College of ^fjpsficiang anb burgeons; Hibrarp Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/treatiseondiseasOOsken TREATISE ON THE DISEASES OF WOMEN FOR THE USE OF STUDENTS AND PRACTITIONERS BY ALEXANDER J. C. SKENE, M. D., LL.D. Professor of Gynecology in the Long Island College Hospital, Brooklyn, N. Y. formerly Professor of Gynecology in the New York Post-Graduate Medical School ; Gynecologist to the Long Island College Hospital ; President of the American Gynecological Society, 1887 ; Corresponding Member of the British, Boston, and Detroit Gynecological Societies, of the Royal Society of Medical and Natural Sciences of Brussels, of the Obstetrical and Gynecological Society of Paris, and of the Leipzig Obstetrical Society ; Honorary Member of the Edinburgh Obstetrical Society ; Fellow of the New York Academy of Medicine ; ex-President of the Medical Society of the County of Kings ; ex-President of the New York Obstetrical Society THIRD EDITION, REVISED AND ENLARGED WITH 290 ENGRAVINGS AND 4 PLATES IN COLORS NEW YORK D. APPLETON AND COMPANY 1900 ^G / u t^J Copyright, 1888, 1892, 1897, D. APPLETON AND COMPANY. ^ en Oi i TO THOMAS KEITH, M. D., LL. D., F. R. C. S. E., ^f^ THIS WORK IS DEDICATED Gi AS A TRIBUTE TO HIS ACHIEVEMENTS IN SURGERY, «-" .. HIS JUSTICE AND COURTESY TO THE MEDICAL PROFESSION OF AMERICA, AND AS AN ACKNOWLEDGMENT OF HIS KINDNESS TO THE AUTHOR. 2: PREFACE TO THE THIRD EDITIOK In no department of medicine have more rapid and greater strides been made during the present decade than in gynecology. During this period many things new and useful have been added to the science and the art, while much that is both old and new deserves to be forgotten. To preserve and present to the student and practitioner that which his own experience and that of the highest authorities in this country and abroad have demonstrated to be worthy of their confidence, has been the author's aim in the preparation of this edition. In the discussion of injuries of the pelvic floor he has en- deavored to rearrange the varieties so that they could be more clearly comprehended. The surgical treatment has been simplified and otherwise improved, and more fully illustrated by drawings from the living subject and the cadaver. Yaginal and abdominal hysterectomy have been brought fully up to date, and complete descriptions and illustrations given of the approved methods of performing these operations. The control of haemorrhage in all surgical procedures by com- pression and electric heat has been made practical and perfect in all its details, so that it now in the author's practice takes the place of the ligature. This contribution to surgery is believed to be of great value not alone to the gynecologist, but to the general sur- geon as well. Tlie surgical treatment of uterine displacements is fully consid- ered and its true value estimated. The use of the endoscope and cystoscope is so described as to bring these instruments more completely within the grasp of the vi DISEASES OF WOMEN. general practitioner, thus enabling him to make diagnoses other- wise impossible. The illustrations have been in charge of Robert L. Dickinson, M, D., who has given up much time to the development of accurate and artistic drawing of medical subjects. Prof. Joseph H. Raymond, who is associated with the author in teaching gynecology, has had entire charge of carrying the work through the press. To these gentlemen, and to the profession at large, sincere thanks are here tendered by The Author. PEEFAOE TO THE SECOND EDITIO:^. The demand for a second edition of this work, and the fact that it is used as a text book in many of the leading medical schools, are very gratifying to the author, who takes this opportunity to thank the members of the medical profession for this evidence of their approbation. Every eifort has been made to improve this edition by a thor- ough revision and the addition of much new material. New chapters have been added on ectopic gestation, diseases and injuries of the ureters, vesical hernia and its surgical treatment, and the latest views of the author have been given in the discussion of laparotomy, ovaritis, and injuries of the cervix uteri and pel- vic floor. The publishers have, at great expense, produced a large number of new and handsome illustrations, and in every respect have made the work a perfect sample of their art. The Author. April 15, 1892. PREFACE. This book was written for tlie purpose of bringing together the f ullj matured and essential facts in tlie science and art of gyne- cology, so ari'anged as to meet the requirements of the student of medicine, and be convenient to tlie practitioner for reference. In the plan adopted, the diseases peculiar to women are, as far as possible, divided into three classes. The first class comprises those which occur between birth and puberty ; the second, those between puberty and the menopause ; and the third, those which come after the menopause. Each subject is briefly described, and histories of cases, typical and complicated, are given as illustrative of the disease or injury under consideration, together with the author's method of treat- ment. The number of illustrative cases given depends upon the practical importance of the subject and the ability to make it more plain by the use of illustrations. In carrying out this plan, the history of gynecology and the discussion of all unsettled questions have been omitted, as being at variance with the plan adopted. Credit has been given as far as possible to those who have made original discoveries, but a vast number of original workers have been passed unnoticed for want of time and space even to name them. To the medical student, history has no value until he has mastered the rudiments of the science and the art, and the prac- titioner can find in the works of reference all the historical facts which he may seek. X PREFACE. The author has ventured to give his own views and methods pertaining to practical matters, believing that while they may differ to some extent from the general literature of the day, they will be found reliable in practice and may be of interest to the spe- cialist. Marginal references have not been made, because all selections from the literature that have been incorporated in this work are those already well established and familiar to the gynecologist, and foot-notes only embarrass the reader who is seeking for the facts alone. Acknowledgments are due to my associates — Dr. J. H. Ray- mond, who has rendered valuable aid in the preparation of the work, and Dr. R. L. Dickinson, who has made the drawings for the original illustrations. The Author. TABLE OF CONTEJ^TS. CHAPTER PAGE I. — Methods of Observation ...... 1 II. — Development op the Fallopian Tubes, Uterus, and Vagina . 22 III. — Menstruation and its Derangements and Chlorosis . . 30 IV. — Flexions of the Uterus . . . . . .54 V. — Diseases of the External Organs of Generation . . 77 VI. — Diseases of the Vagina ...... 100 VII. — Injuries to the Pelvic Floor from Parturition and other Causes ........ 116 VIII. — Fistula in Ano and Coccyodynia ..... 167 IX. — Inflammatory Affections of the Uterus . . . 177 X. — Corporeal Endometritis ...... 207 XI. — Subinvolution . ...... 219 XII. — Sclerosis of the Uterus ...... 225 XIII. — Membranous Dysmenorrhcea ..... 234 XIV. — Lacerations of the Cervix Uteri ..... 247 XV. — Cicatrices of the Cervix Uteri and Vagina . . . 264 XVI. — Inversion of the Uterus ...... 271 XVII. — Dislocations op the Uterus ..... 284 XVIII. — Retroversion of the Uterus ..... 310 XIX. — Abuse of Pessaries ....... 342 XX. — Hypertrophy of the Cervix Uteri .... 351 XXI. — Fibroma of the Uterus ...... 856 XXII. — Malignant Disease of the Uterus .... 403 XXIII.— The Menopause . . . . . . .439 XXIV. — Senile Endometritis ....... 458 XXV. — Diseases of the Ovaries ...... 469 XXVI. — Diseases of the Ovaries (Continued) .... 485 XXVII. — Neoplasms of the Ovaries ...... 506 XXVIII. — Cystic Tumors of the Ovaries — Symptomatology and Phys- ical Signs . . . . , . . . 523 XXIX.— Ovariotomy ........ 544 xii DISEASES OP WOMEN. CHAPTER PAGE XXX. — Illustrative Cases of Ovarian Neoplasms . . . 568 XXXI. — Diseases of the Fallopian Tubes .... 586 XXXII. — Pelvic Cellulitis ....... 596 XXXIII. — Pelvic Peritonitis ....... 620 XXXIV. — Pelvic Hematocele ...... 637 XXXV. — Ectopic Gestation ....... 649 XXXVI. — Diseases of the Urinary Organs — Anatomy and Develop- ment of the Bladder and Urethra .... 659 XXXVII. — Malformations of the Bladder and Urethra . . 672 XXXVIII. — Function of the Bladder ...... 697 XXXIX. — Functional Diseases of the Bladder .... 703 XL.— Functional Diseases of the Bladder {Continued) . . 723 XLI. — Methods of Exploration of the Bladder and Urethra . 743 XLII. — Organic Diseases of the Bladder .... 754 XLIII. — Organic Diseases of the Bladder {Continued) — Treatment of Cystitis — Croupous and Diphtheritic Cystitis — Cystitis with Epidermoid Concretions ..... 788 XLIV. — Non-Inflammatory Diseases of the Bladder — Dislocation OF THE Bladder ....... 812 XLV. — Foreign Bodies in the Bladder ..... 831 XLVI. — Rupture op the Bladder ...... 847 XLVII. — Neoplasms, Hyperplasia, and Atrophy of the Bladder . 858 XLVIII. — Patency of Gartner's Duct — Diseases of the Urethra and Urethral Glands ...... 873 XLIX. — Dilatation, Dislocation, and Prolapsus of the Urethra . 908 L. — Stricture, Foreign Bodies, and Incomplete Fistula of the Urethra ........ 927 LI. — Diseases of the Glands of the Female Urethra . . 938 LII. — Vesical and Urethral Fistula ..... 951 LIII. — Diseases and Injuries of the Ureters .... 968 INDEX TO ILLUSTRATIOI^S. FIO. 1. 2. 3. 4. 5. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 18a 19. 20. 21. 22. 23. 24. 25. 36. 27. 28. 29. 30. 31. 32. 33. 34. 34(1, 35. 36. 37. 38. Examining table Bimanual examination . Sims's speculum Cusco's bivalve speculum Sims's position, seen from above Nurse holding Sims's speculum The movements of the speculum — first movement " " — second movement " " — third movement Hunter's depressor Sims's probe Whalebone sound Jenks's sound Skene's curette Hanks's dilator Goodell's dilator Sponge tents Tupelo tents . Ether inhaler Miiller's ducts Coalescence of ducts Disappearance of septum Appearance of fundus and eemx Infantile uterus (Winckel) Palma plicata . Infantile uterus, antero-posterior section, scant invagination Virgin uterus (Sappey) — anterior view " " — median section " " — transverse section Double uterus and vagina (Eisenmann) Uterus unicornis (Pole) Uterus bicomis unicollis (Winckel) Uterus bifundalis unicollis (Courty) Uterus duplex (Cruveilhier) Double uterus . , Anteflexion of cei'vix — first variety Anteflexion of body of uterus — second variety Anteflexion of body and cervix — third variety Operation for imperfect invagination ; the incision " " " sutures in position xiii 9 11 11 12 12 13 18 14 14 15 15 15 16 17 17 18 18 19 22 22 23 22 23 23 23 24 24 24 35 36 26 27 37 29 57 58 58 66 66 XIV DISEASES OF WOMEN. FIG. 39. Elliott's uterine adjuster 40. Glass stem, with soft-rubber base 41. Extreme anteflexion 42. Skene's hysterotome 48. External genitals of a woman who has borne children 44. The superficial veins of the perinajum (Savage) 45. External genitals of a virgin . 46. Cribriform hymen .... 47. Annular hymen ..... 48. Fimbriate hymen .... 49. Rectum continuous with allantois (bladder) and duct of Miiller (vagina) (Schroeder) ..... 50. The depression has extended inward (Schroeder) 51. The cloaca is dividing (Schroeder) 52. The perineal body is completely formed (Schroeder) 53. The upper part has contracted (Schroeder) . 54. Spurious hermaphroditism (Simpson) . 55. Length of vagina .... 56. Triangular shape of perineal body 57. Sims's vaginal dilator .... 58. The levator ani ..... 59. The muscles of the pelvic floor 60. Diagrammatic sagittal section of the female pelvis 61. Tlie pelvic floor a suspension bridge . 62. So-called rectocele .... 63. Beginning atrophy of perineal body in median line 64. Atrophy in median line, with sagging of posterior vaginal wall 65. Sagging of the pelvic floor 66. Diagram of the sweep of the suture . 67. 68. Sutures properly and improperly introduced 69. Peaslee's needle ..... 70. Tissue forceps ..... 71. Emmet's curved scissors 72. Emmet's scissors .... 73. First step of perineorrhaphy, denudation begun 74. Second step, continuing the strip 75. Vivifying complete .... 76. Needle-forceps ..... 77. Stitch in place ..... 78. The stitches in place .... 79. Laceration with rectocele 80. Perineal body restored (profile view) . 81. Scissors for removing sutures . 82. Complete laceration of perinajum and sphincter ani 83. do. operation ; denudation completed 84. do. " sutures in rectal wall introduced 85. do. " rectal sutures tied ; remaining sutures placed 86. Haeraorrhoid clamp 87. Hard-rubber rectal tube 88. Denudation for restoration of periuffium 89. Sutures in place .... 90. The operation for fistula in ano , INDEX TO ILLUSTRATIONS. XV FIG. 91. 92. 93. 94. 95. 96. 97. 99. 100. 101. 103. 103, 105. 106. 107. 108. 109. 110. 111. 113. 113. 114. 115. 116. 117. 118. 119. 130. 121. 133. 133, 125, 127. 138. 139. 130. 131. 132. 133. 134. 135. 136. 137. 138. 139. 140. 141. 143. Mold of uterine cavity in the virgin (Guyon) " " " " multipara (Guyon) Section of mucous membrane of uterus " through corpus uteri of an infant . '• '• " " of a woman aged eighty-three One of the median columns in the cervical canal (Courty) Section through the mucous membrane of cervix showing cystic degen- eration ...... Elongation of the cervix (Wincltel) . Hypertrophy of the body of uterus (Winckel) General enlargement of uterus (Winckel) Skene's instillation tube .... Sims's curette ...... 104. The two sides of a half membrane from a multipara Half a membrane from a virgin A cast from a virgin ..... Fragments of membrane in the condition in which they are often ex- pelled ...... A cast which might be taken for a product of conception Bilateral laceration ; unequal division of the cervix Bilateral laceration, with thickening of the everted lips Extensive multiple lacerations Multiple incomplete lacerations Incomplete bilateral laceration " '• " in section Crescentic laceration ..... Skene's hawk-bill scissors .... Operation for laceration of cervix ; denudation complete Skene's triangular needles .... Counter-pressure instrument .... Operation for laceration ; sutures in position " " tied Removal of crescentic-shaped piece (seen in section) 124. Method of bringing the sides of the section together 126. Another method of closing the gap Partial inversion (Thomas) Complete inversion (Thomas) . Polypus simulating partial inversion (Thomas) Polypus simulating complete inversion (Thomas) Byrne's method of reduction of inversion Cup pessary to exercise gradual pressure (Thomas) Replacement of uterus by dilatation through abdomen (Thomas). Section of pelvis showing its inclination and tlie axis of the inlet , The normal range of the uterine axis (Van der Warker) Diagram of the uterine ligaments .... Section through right broad ligament Section of pelvis, with the slings of the uterus Diagram of the uterus slung between the broad ligaments The normal inclination of the pelvis and the transmission of force from above ..... The three degrees of prolapsus Prolapsus uteri with cystocele XVI DISEASES OF WOMEN. FIG. 143. The shallow pelvis with lessened inclination of brim 144. Increased inclination of inlet 145. Uterus replaced, with pessary in position 146. Stem pessary, modification of Cutter's 147. The three degrees of retroversion 148. Retroversion of the second degree 149. Retroversion with imperfect invagination of cervix 150. Apparent imperfect invagination 151. The same uterus with its lips drawn back into place 152. The three steps in replacing the retro verted uterus by means of sponge holders ....... 158. Albert Smith pessary ...... 154. Method of measuring the length of the pessary 155. Diagram of pessary in situ on looking through Sims's speculum 156. Slight invagination of cervix posteriorly with suitable pessary 157. Decided invagination of cervix posteriorly fitted with a suitable pessary 158. What the pessary does not do .... 159. How the pessary acts ...... 160. Second step ; the uterus falls into the pessary 161. The knee-chest position ..... 163. Ventral suspension ...... 163. Fibroid on posterior wall of uterus simulating retroflexion 164. Prolapsed and adherent ovary simulating retroversion 165. Overcurved pessary making pressure on angle 166. Extreme retroflexion (Barnes) .... 167. Uterus with defective walls; the supra-vaginal portion of the elongated (after Winckel) .... 168. Stem of pessary ulcerating through cervix . 169. Stem cutting through body of uterus 170. High rectoeele due to improper pessary 171. Displacement caused by a badly adjusted pessary . 173. IIyi)ertro[)hy of the cervix ..... 173. The first stop; splitting the cervix .... 174. The double flaps of the amputation .... 175. Diagram of the pieces removed .... 176. The sutures in place ...... 177. The sutures tied ...... 178. 179. Interstitial fibromata (Winckel). 180. Subperitoneal and submucous fibromata (Winckel) . 181, 182. Enlargement due to subinvolution compared with that from growth of a fibroma (after Winckel) 183. Uterine electrode ..... 184. ficraseur ...... 185. Wall of uterus caught in ecrascur-wire and removed 186. Abdominal hysterectomy (Kelly) ; line of incision . 187. " " " ovarian vessels and round ligament tied 188. Cancer of both lips (Winckel) .... 189. Cleveland ligature forceps ..... 190. Vaginal hysterectomy — clamp operation : Specnhim in place 191. do. Cervix severed from vaginal wall . 192. do. Forceps pushed through pouch of Douglas 193. do. Forceps draws tube forward INDEX TO ILLUSTRATIONS. xvn FIG. PAGE 194. Vaginal hysterectomy — clamp operation : Forceps turns broad ligament . 425 195. do. Tube and ovary rolled forward .... 425 19G. do. Uterine artery clamped ..... 425 197. do. Placing gauze ...... 485 198. Vaginal hysterectomy by morcellement ..... 426 199. Vaginal hysterectomy by author's electric haemostatic forceps : Beef mus- cle seized in forceps ..... 428 200. do. Artery closed . . . . . .428 201-203. do. Hemostatic forceps . . . . . .430 204. do. Transformer for heating forceps .... 433 205. do. Hand-driven dynamos ..... 434 206. do. Cautery incisions about cervix .... 435 207. do. Vagina and wound after removal of uterus . . 485 208. The fundus uteri and ovaries seen through the pelvic brim (His) . . 469 209. The ovary and its ligaments (Henle) ...... 470 210. The ovarian, uterine, and vaginal arteries (Hyrtl) .... 471 211. Cyst-regions of ovary (Bland-Sutton) ..... 473 212. Section of the ovary of a bitch (Waldeyer) ..... 475 213. Ovary displaced and bound down by adhesions * . . . 501 214. Left ovary, one large cyst (Farre) ...... 508 215. Compound and proliferating cyst (Farre) ..... 509 216. Multilocular cyst (Hooper) . . . . . . .510 217. Papillary cystoma of ovary (Winckel) ..... 511 218. Dermoid cyst of ovary (Winckel) ...... 512 219. Fibroma affecting both ovaries (Winckel) ..... 513 220. Area of dullness in large ovarian tumor ..... 528 221. Area of dullness in ascites ....... 529 223. Cautery clamp ........ 548 223. Keith's short compression-forceps ...... 556 224. Keith's long compression-forceps ...... 556 225. Keith's needle ......... 557 226. Keith's ligature-forceps ....... 557 227. Keith's modification of Spencer Wells's clamp .... 557 228. Position of operator, assistants, and accessories in ovariotomy . . 558 229. Diagrammatic transverse section of the pelvis (Luschka) . . . 596 230. Section through sacrum, symphysis, and ischia .... 597 231. Pelvic abscess opening obliquely downward .... 598 232. Pelvic abscess opening obliquely upward ..... 598 233. The pelvic peritonaeum, looking into the brim .... 620 234. The reflections and pouches of the pelvic peritonaeum (Hodge) . . 621 235. Retroverted uterus bound back by peritoneal adhesions (Winckel) . 623 236. Subperitoneal pelvic hsematocele ...... 637 237. Intra-peritoneal pelvic haematocele ...... 638 238. Diagram of the bladder to show corpus and fundus . . . 660 230. Base and neck of the bladder (Savage) ..... 663 240. Urethra laid open with probes distending Skene's glands (posterior wall divided) ......... 664 241. Urethra laid open with probes in Skene's glands (anterior wall divided) . 664 242. Transverse section of urethra with gland on either side . . . 665 243. Longitudinal section of urethral glands ..... 666 244. The meatus everted, showing the mouths of the glands . . . 667 245. The relations of the ureters (Garrigues) ..... 670 xvm DISEASES OF WOMEN. FIG. 246. Extroversion of the bladder .... 247. Linear cicatrix ..... 248. Bladder covered by deep flaps 249. Diagram of the result of the operation 250-252. Slcene's endoscope .... 253. Urethroscope with electric light 254. Principle of the Xitze-Leiter cystoscope 255. Diagram of cystoscope .... 256. Leiter cystoscope ..... 257. Skene's modification of cystoscope . 258. " " " " for ureteral catheterization 259. Skene's bivalve urethral speculum . 260. Fountain-syringe for washing bladder 261. Skene's instillation-tube .... 262. Skene's urinal cup-pessary .... 263. Holt's catheter, with its modification 264. Skene's modification of Goodman's self-retaining catheter 265. Retroversion of the gravid uterus (Schatz) . 266. Skene's pessaiy for prolapsus of the bladder 267. Pessary holding up the bladder 268. Modification of the retroversion pessary, used in prolapsus of the 269. Forward transposition of the uterus . 270. Retrocession of the uterus .... 271. Skene's reflux catheter .... 272. Skene's fissure probe and knife 273. Skene's urethral speculum .... 274. Skene's modification of Polsom's nasal speculum . 275. Allen's polypus forceps .... 276. Blake's polypus snare ..... 277. Dilatation of middle third of the urethra . 278. Skene's button-hole scissors .... 279. Dislocation of upper third of urethra 280. Complete dislocation with dilatation 283. Sims's tenaculum ..... 284. Operation for vesico- vaginal fistula ; paring the edges 285. Sims's sponge-holder ..... 286. Emmet's needles ..... 287. Curved track of the needle .... 288. Operation for vesico-vaginal fistula ; the sutures in place 289. Two sutures tied ..... 290. Kelly's ureteral catheter .... bladder PAGE 688 689 690 691 744 745 746 747 748 750 750 751 792 795 799 801 801 814 819 820 820 827 828 881 892 903 903 904 905 911 919 920 921 956 957 957 958 958 959 959 960 Plate I. Operation for laceration of cervix uteri. II. "Vaginal hysterectomy with the author's hajmostatic cautery forceps. III. Abdominal hysterectomy with the author's hajmostatic cautery forceps. IV. Inflammation of the urethral glands. IV. Operation for prolapsus of bladder and urethra. Note. — All illustrations not credited are from original drawings by Robert L. Dickinson, M. D., or were prepared under his supervision, excepting cuts of instru- ments and Figs. 93, 94, 95, 97, 242, and 243, by J. M. Van Cott, M. D., and Figs. 240 and 241, by A. U. P. Leuf, M. D. DISEASES OF WOMEN. CHAPTER I. METHODS OF OBSERVATION. A THOROUGH familiarity with the means and methods of investi- gation is the first requisite in acquiring knowledge. The art of observation, which is simply the systematic use of the mental and physical faculties to obtain facts, should be made an essential part of the preliminary training of every student of medicine. From this point of view, the subject which we have to consider resolves itself into two divisions : first, the ways and means of investigation ; and, second, the objects to be studied. Before approaching the study of gynecology, it is taken for granted that much experience and practice have been attained by the student in the art of investigation. The experience of every- day life, from infancy onward, and the ordinary school education obtained before beginning the study of medicine, tend to develop and cultivate the perceptive faculties. Still, the physician and surgeon require special training in the art of observation. To accurately note the structure, form, color, general proportions, and expressions of the human body in health, is the first lesson which every student of medicine should learn. This is the most important step toward the attainment of a practical knowledge regarding the functions of the human body, and its deformities, diseases, and injuries. The correct, rapid, and thorough observer has from the outset great advantages. Important and necessary as this branch of education is, it is almost wholly neglected in schools and colleges. The chief occupation of teachers appears to be to impart knowledge already in existence, rather than to qualify the student to observe and think for himself. Special attention should be given to this art of observation, be- cause it is the key to science and the first exercise in practice. The systematic way in which knowledge is presented in books and by oral instruction enables the student to acquire facts in all branches 2 1 2 DISEASES OF WOMEN. of learning, and to classify them. The mental training obtained in the study of mathematics and logic prepares men to make reasonable deductions from the facts obtained ; but in institutions of learning, thorough training in the art of observation is seldom given. This lack of preliminary education adds greatly to the labors of the student, because he is obliged to acquire knowledge while he is not in possession of the means of obtaining it, and it is mainly be- cause of this defect that practitioners of medicine are led into error in making diagnoses. They fail to observe all the facts, and hence their deductions are liable to be incorrect. Acute, clear perception is a gift which all do not possess in a high degree, but it can be cultivated by those of ordinary intelli- gence, and it should be by those who intend to practice medicine. The practical study of the elements of natural science, which should constitute a large share of the early education of those destined for the profession of medicine, aids much in cultivating the faculties concerned in observation. So also the arts, especially drawing, painting, and sculpture, help to qualify for the actual in professional life. The trained eye and hand of the artist are most valuable in acquiring the art of medicine and surgery, and a share of the days of youth spent at an art-school will save much time and perplexity in the medical school as well as in subsequent professional life. The first lesson is to obtain a familiarity with the general appear- ance of the body in health, its structure and the uses of the various organs, the process of development, the slight deviations from the ideal or highest type which occur within the range of health, and finally the relations of the being to his environment or conditions of life. A portion of this subject will be fully discussed in the chapter on the development and structure of the sexual organs of woman, and the conditions of life which are suitable to her development, growth, and maintenance. Subsequently the derangements of the body from disease and injury will come in for the greater portion of time and attention. Here it is that the highest perceptive power is needed, and the most painstaking attention to observation. The fact should be kept clearly in mind that a knowledge of the science of medicine does not give skill in the art of practice, how- ever much it may help in acquiring that art. Men profoundly versed in the science of medicine may be poor practitioners ; and others, whose knowledge of the science is very limited, may attain some reputation in practice ; but the best (qualified physician is he who knows most of both the science and the art. The subject for present consideration is the method of investigation to be adopted METHODS OP OBSERVATION. 3 in practicing the art of gynecology. Before beginning the actual work of examining patients, it is necessary to know how to do so. There are several methods of investigating the sick and injured given in text-books and taught in the medical schools, but most of these are better adapted to general practice than to special depart- ments of medicine. The methods which I desire to present here are circumscribed, and perhaps less complicated, because they are limited to the diseases peculiar to women. In examining patients it is well to first settle definitely in the mind the object to be attained and how to attain it. Some rational system of investigation should be mastered in all its details before undertak- ing actual practice. To engage in clinical study without such prepara- tion is like trying to read a language without knowing its alphabet. The system advised is : first, to obtain all the facts regarding the case in hand ; second, to arrange these facts in their natural relation to one another ; and, finally, to make deductions from the data thus obtained. These suggestions will be easily remembered in the follow- ing order and association : observation, classification of things observed, and conditions indicated by the sum of the information obtained. The examination of a patient should begin by a general inspec- tion ; and, in order to make that inquiry complete and profitable,, certain questions should be raised in the mind of the examiner ; such, for example, as. What is the general appearance of the patient under observation ? What size ? Regular or defective in general outline ? Lean or corpulent ? What temperament ? Is the face pale or flushed ? Languid or vigorous ? Sad or cheerful ? Calm or excited ? Intel- ligent or stupid ? What diathesis is indicated, if any ? In short,^ does the general physiognomy indicate health or disease ? All these interrogations are made while looking critically at the patient. There are so many questions to be answered in this con- nection, that one may find some difiiculty in promptly remembering them ; but by constant practice the mind and eye can be trained to take advantage of a rule of observation employed by critical investi- gators in other arts, which is this : having a type of normal organiza- tion in mind, the observer is able to scan a given case, and detect any deviation from that standard of healthy formation and appearance. The artist, in looking at a picture or statue, does not necessarily question every line of the drawing or form by itself, but his trained eye catches any defects that there may be in the work before him. The classification of facts is simply putting together those which are similar in character. The arrangement of material things in groups is familiar to all. A well-arranged library, in which all books 4: DISEASES OF WOMEN. pertaining to a given subject are placed side by side, is a fair illus- tration of this kind of classification. Facts and ideas can be arranged in the mind upon precisely the same principle. The advantage of classification is that it aids comprehension and memory. By recall- ing one group of facts which have been associated in the mind, the rest will follow in easy and natural order. There are two methods of classifying the information contained in the clinical history' of a patient. One is to obtain all the facts possible, and then to arrange them in order. The other is to classify them at each step of the examination. The former method requires a mental grasp and tenacity which few possess, and therefore 1 would advise the latter. The information obtained by inspection may be classed under four heads : 1. The original character of the organization, M'hether perfect or imperfect in structure and function. 2. If imperfect, whether from imperfect development, causing lesions of form or lesions of structure, or from inherited or acquired disease, and inherited tendencies to dis- ease, known as diathesis. 3. Evidences of disease, expressed in the face, either acute or chronic. 4. The temperament ; which simply means the preponderance of a certain portion or portions of the organization. To illustrate the value of this process of general inspection of patients, the partial histor}^ of a case seen in private practice will suffice. A lady called to consult me regarding her son, a little fel- low seven years of age. After a very brief survey of the patient, I saw enough to satisfy me that he had recently had scarlatina, and that when a child he had suffered from sore eyes, and that his father had been subject to rheumatic pains in years gone by. The mother acknowledged that I was right in every particular. A glance at the boy showed that exfoliation of the cuticle, which occurs after scar- latina, was still going on ; the face was pale and puffy, indicating commencing dropsy from acute nephritis, a sequel of the eruptive fever. I also noticed that he had a scar upon the cornea of each eye, the result of a former keratitis. The form of his nose and the character of his teeth indicated an inherited syphilis ; and from the appearance of his mother and other facts known to me, I presumed that the father was the one who had transmitted the specific disease. The age of the patient should be ascertained, because that sug- gests the possible existence of the diseases which are likely to occur at certain periods of life. Care should be taken to compare the real and apparent age, in order to ascertain if the patient is prematurely old, or well preserved. This interrogation will also serve to keep in mind the fact that, in early life, acute diseases prevail, while degen- erations are usually limited to advanced life. METHODS OP OBSERVATION. 5 It is important to know the social relations of a patient — that is, whether she is married or single. If married, she is liable to the diseases and accidents attendant upon child-bearing. If she has never been pregnant, her sterility may have resulted either from choice, or because of some defect in her organization. Women who are single are, by reason of that fact, limited in the range of diseases of their sexual organs, and this may be taken for granted unless evi- dence to the contrary is obtained. Having made a general inspection of a given case, and ascer- tained the age and social relations, an examination of the various portions of the body should next be made in systematic order. To do this conveniently, one group of organs or one system should be examined at a time. The various systems are classified as follows : THE NERVOUS, NUTRITIVE, MUSCULAR, AND SEXUAL SYSTEMS. The first three are subdivided as follows : The nervous has two grand divisions, the cerebro-spinal and organic. The nutritive lias four subdivisions, the digestive, circulatory, lymphatic, and excre- tory ; and the third has the osseous and muscular. The present purpose is to outline the methods of investigating the sexual system, but, in order to do that successfully, it is necessary to be able to examine the whole body. 'No one can be a trustworthy specialist without having a thorough knowledge of the whole organi- zation. All the parts of the body are so bound together by mutual relations that one can not accurately diagnosticate the diseases of one portion without knowing the condition of all the others. On account of that fact I must refer to the principles upon which the examination is made of parts other than the sexual system. Briefly, it may be stated that the two principal subjects of inquiry are the condition of the functions and the structure of the organs under examination. Perverted function of the cerebro-spinal divis- ion of the nervous system is manifested through derangements of sensation and motion, and abnormal states of the organic nerves are indicated when nutrition is deranged, while the organs of nutrition are free from structural disease. The condition of the circulatory system is indicated by the color of the skin and mucous membranes, the character of the pulse, and the heart-sounds. The general nutrition may be estimated by the appetite for food, the excretions, and the state of the tissues generally. These are meager hints, but, if kept in mind while examining cases in the de- partment of gynecology, will guard against the mistake of overlook- 6 DISEASES OF WOMEN. ing affections of the general system, which might modify or cause diseases of the sexual system. In applying the principles already hinted at in the investigations of special diseases of the sexual organs, we find that morbid action is manifested by symptoms and physical signs. The symptoms may be classed under three heads : First, deranged nerve-action ; second, deranged functions of the organs affected ; and, third, modified loco- motion. First Class (nerve-symptoms). — Pelvic pains not specially local- ized ; sacral pain ; pain of certain pelvic organs ; pains beginning in the pelvis and radiating to other parts of the body. Second Class. — Derangements of function, such as deranged men- struation ; sterility ; abnormal discharges ; deranged function of the bladder and rectum. Third Class. — Aggravation of any or all of the above-named symptoms, by standing, walking, or other muscular exercise. Keeping this classification in mind, questions will suggest them- selves, the answers to which will determine the presence or absence of these symptoms. One should know the symptoms which belong to a given disease, and then ascertain if they are present by asking questions of the patient. Correct testimony will more surely be ob- tained in this way than by depending upon the voluntary statements of the person examined. The following plan will be of service in obtaining the symp- toms referred to in the three classes given above : First, ask if the patient has pain and where it is located. Ascertain also if this pain is connected with any of the functions of the pelvic organs. Then obtain the history of the functions of the sexual organs, in the past and present. These facts can be obtained from the patient herself, aided perhaps by some one who knows her well. Some practice is necessary to acquire skill in taking testimony, the value of which depends largely upon the physician's abilitj' to make the patient answer his questions correctly. Such questions as the fol- lowing regarding the menstrual function should be asked : At what age was the menstrual function first established ? At wliat periods of time has it recurred? IIow long does it continue each time? "What are the quantity and character of the flow ? Is it attended with pain, and if so, where is the pain located, and at what time does it occur in relation to the menstrual flow ? Has menstruation always been attended with pain, or only for a limited period in the history of that function ? And, finally, is menstruation attended with de- rangements of any of the other functions of the body ? METHODS OP OBSERVATION. 7 From the answers to these questions two points can be decided : First, whether menstruation has been performed normally during the whole or part of the patient's menstrual period of life ; and, sec- ond, if any derangement of that function exists, whether it be in character, recurrence, duration, or quantity. Next in order comes the history of reproduction. Has the pa- tient had children, and if so, how many, and when ? Has she mis- carried ? If she has, at what period of gestation, and at what time in relation to birth of living children if she has had any ? "Was there anything abnormal in her pregnancies, confinement, or recov- ery from labor ; if so, what ? The answers to these questions will determine whether the present conditions date back to some of the diseases or accidents of pregnancy or parturition. If the history so far obtained indicates any disease or functional derangement of the sexual organs, and there is any accompanying affection of the general system, the question arises, regarding the relations which they sus- tain to one another. That question can frequently be settled by ascertaining which of the two affections, the local or general, ap- peared first. The one which precedes is frequently the cause of that which follows. Thus far we have been dealing with symptoms which, as a rule, reveal only derangements of function. They are but expressions of disease, and do not in all cases indicate the conditions of the organization which cause the derangement of function. This brings us to the final division of our subject, viz., the phys- ical signs of disease. These are the physical evidences of change of structure. There are exceptions to the general rule that these phys- ical evidences are always present, but they are few in number, and therefore may be omitted in our general consideration of the subject. The changes of structure and organization in the sexual organs, which are expressed by physical signs, are as follows : Changes of position, form, size, consistence, composition, color or appearance, and degree of sensitiveness. The means of obtaining physical signs are the touch — single or bimanual — palpation, percussion, speculum, sound, probe, curette, exploring-needle, uterine dilator, and microscope. The art of employing these means next claims attention. EXAMINATION BY THE TOUCH. This examination is most conveniently practiced when the pa- tient is placed upon a suitable table. One that is thirty-three inches high, forty-three inches long, and twenty-three inches wide. 8 DISEASES OF WOMEN. having a projection on the right-hand corner upon which to rest the feet, answers better than any table or chair that I have ever seen. The patient should be placed upon the back, with the pelvis as near the end of the tal)le as possible, permitting the heels to rest upon the table also, while the thighs are flexed upon the body and the legs upon the thighs. A sheet held by the edge in both hands Fig. 1. — Exaraining table. (The upper part of the foot-rest folds down as the dotted liu-es show, and the support can be pushed in.) is drawn over the liml)s from the feet upward, at the same time that the skirts are pushed up out of the way. This protects the patient from exposure. In this examination the index-finger of the right hand is gener- ally employed, but both right and left should be educated, because it is sometimes difficult to examine that side of the pelvis which faces the back of the hand used. In critical cases, therefore, it may be necessary to employ both hands, first one and then the other, in order to complete the examination. In the majority of cases it is requisite to employ the bimanual method, as it is termed — that is, while one or two fingers are introduced into the vagina, the fingers of the other hand are placed upon the abdomen at the pelvic inlet, and by pressure the parts are brought down to within near reach of the finger in the vagina. Fig. 2 illustrates the mode of making this examination. This method is quite satisfactory in spare patients with lax abdominal muscles ; but when the muscles are tense, and when the walls of the abdomen contain a thick layer of adipose tissue, the examiner will find great difficulty in practicing it. In METHODS OP OBSERVATION. 9 such unfavorable conditions, when the diagnosis is obscure, much will be gained by using an angesthetic. Examination of the pelvic organs through the rectum is of great value. In this method the touch is practiced in the same way as in that already described. There are other methods practiced, such as introducing two fin- gers into the vagina, the index and the middle; and the introduction of the whole hand into the vagina or into the rectum. Simon's method is to first dilate the sphincter-ani muscle, and then pass the Fig. 2. — Bimanual examination. whole hand into the rectum as far up as need be. Extraordinary advantages have been claimed for this method, which brings all the pelvic organs within the grasp of the examiner ; but it has proved to be dangerous, and, owing to the fact that pressure benumbs the hand, it is more difiicult than it appears to be theoretically. It should not be practiced, except in rare cases in which it is of vital importance to make an accurate diagnosis that can not otherwise be made. Dilatation of the urethra sufiicient to admit the finger has 10 DISEASES OF WOMEN. been practiced and advised for the purpose of aiding in the explora- tion of the pelvic organs, but the information gained in this way does not compensate for the suffering and danger ; hence the prac- tice is rarely called for, and still more rarely admissible. Digital Touch by the Rectum. — This method is generally resorted to when some obscure, abnormal condition has been discovered by the vaginal touch. Much satisfactory information can be obtained in this way, especially regarding the posterior wall of the uterus, the ovaries, and the sac of Douglas. The bimanual method of practicing the rectal touch is the same as the vaginal. Pressure upon the hypogastrium with the external hand gives the conjoined aid, as in examining by the vagina. Vesico-Vaginal Examination. — In this method a sound is passed into the bladder while the finger is in the vagina. By this means certain states of the vagina, urethra, and bladder are investigated. Vesico-Rectal Examination. — This is the same as the vesico-vaginal except that the finger is introduced into the rectum. It is the more valuable of the two in exploring all that lies between the bladder and rectum. Palpation. — Whenever the touch discovers anything abnormal^ as a tumor, an enlargement of the uterus, or products of inflamma- tion, additional information can be obtained by abdominal palpation. This is accomplished by manipulating the abdomen so as to outline the part in question, and to test its sensitiveness, mobility, and density. Both hands are usually employed in this examination. Percussion. — It is unnecessary to describe the manner of practicing percussion. Suffice it to say that percussion is practiced in exactly the same way in exploring the abdomen as it is in exploring the thorax, the object being to test the density of the abnormal part and outline its relations to the abdominal organs. Palpation and Percussion Conjoined. — This consists in resting the fingers of one hand at one point on the abdominal walls and making percussion at another point. Its chief object is to ascertain if there is fluid present ; this is shown by fluctuation. There are three ways of accomplishing this : The flrst is to select points on the distended abdomen directly opposite one another, resting the fingers lightly at one part, and percussing at the other. This is known as tlie dia- metrical method. The second, the peripheral method, is to take points on a section of the abdomen and manipulate in the same way. The third consists in resting the fingers at one point and making pressure at tlie other, to see if the part is wholly movable or partially 80. This differs from the others essentially in substituting inter- rupted pressure for percussion. METHODS OF OBSERVATION. 11 Fig. 3. — Sims's speculum. The Speculum. — This instrument is twofold in its use. It is one of the most important aids in the investigation of disease, and at the same time a necessary instru- ment in treat- ment. A great variety of spec- ula are used, l)ut two answer all requirements. Sims's speculum and Cusco's bi- valve, slightly modified, answer every indication. In fact, Sims's speculum is all that is needed, ex- cept when an assistant or nurse can not be obtained to hold the specu- lum, then Cusco's may be employed with advantage in examining the eer vix uteri, and for the purpose of making applications thereto. In using Sims's speculum it is ne- cessary to have the patient upon the table already de- scribed, which should be near a window giving a good light. Oc- casionally it may be necessary to examine a patient upon the bed, but this is difficult, and should not be undertaken until the ex- aminer has acquired by practice great facility in the use of the speculum, and only then, when it is impracticable to place the pa- tient upon the table. A housewife's cutting board placed beneath the mattress will greatly aid in the examination. The position of the patient should be on the left side, semi-prone, with the left arm behind the back, the head upon a low pillow, and near the right-hand side of the table, the limbs drawn up, the right limb above and in front of the left, and the pelvis at the end of the table on the left-hand side. Fig. 5 illustrates this position. In order to place the patient in this position, she should stand upon an ottoman or low chair, with her left side toward the end of the table. The skirts on the left side are then raised, and she is directed Fig. 4. — Cusco's bivalve speculum. 12 DISEASES OF WOMEN. to sit down on the table ; her left hand is placed behind the back, and she is made to lie down on the left side, inclining forward. The i'lu. J. Siiii;'.-; {jofeition, seen from above. Fici. (i. — Nursu huldiiig Siiu.s's .■^lA'cuiuin. limbs are at the same time drawn up and placed in proper position. The skirts are then pushed up on the right side, and at the same METHODS OF OBSERVATION. time a sheet is drawn over the limbs and arranged so as to expose the labia only. The speculum is introduced by separating the labia with the fingers of the left hand, holding the instrument in the right hand by the handle ; the point of the blade is placed upon the posteri- or commissure, and, while backward pressure is made, the speculum is passed into the vagina. Care should be taken not to touch the meatus urinarius. The free blade is then grasped with the right hand by the nurse or assistant, while with the left she raises and supports the natis and labium on the upper or right side. The position of the one who holds the speculum should be with the left side toward the patient, the fingers of the right hand surrounding the blade, while the thumb rests in the inside of the blade. The elbow should rest against the side, as a point of purchase to give ability to make steady traction. The left arm should rest upon the right hip of the patient, while the hand supports the labium and natis to keep them out of the way (Fig. 6). Careful training is required to enable one to hold the speculum properly. The chief and essential requirement is to maintain the instrument for any desired length of time in the position in which the operator may choose to place it. The objects to be at- tained by the use of the speculum are, to distend the vulva by making traction upon the posterior commissure, and at the same time to draw the whole floor of the pelvis or perinseum backward toward the sacrum, away from the pelvic organs above, which, from the position of the patient, gravitate toward the abdomi- nal cavity. By these means the vagina is distended by atmospheric pressure, which gives space for the admission of light, and room for inspection or manipulation in operating. These facilities can be extend- ed by changing the position of the specu- lum in the following manner: The as- sistant who holds the instrument can, by rotating the hand, cause the point of the blade in the vagina to describe the arc of a circle (Fig. 7). By moving the hand forward, the blade is made to point backward Fig. 7. — The movements of the speculum. First movement. Fig. 8. Second movement. 14 DISEASES OF WOMEN. Fig. 9. — The third movement. toward the rectum ; and by moving the hand backward, the blade is caused to point forward (Fig. 8) ; and, finally, by raising or lower- ing the hand, the speculum is made to reflect the light upward or down- ward to either the upper orlower side of the vagina, according to the re- quirements of the examiner { Fig. 9). At the same time that all these changes of position are being made, the required traction upon the per- inseum can be maintained. In using the Cusco speculum, the position of the patient is the same as for examination by the touch. The labia are separated with the left hand, and the instru- ment introduced with the blades closed, the direction of inti-oduction being downward and inward. When the speculum is in position the blades are separated. There is quite often difliculty in bringing the cervix into view through this instrument. This can usually be avoid- ed by getting the point of the posterior blade well under the cervix before separating the blades. This speculum is principally used in the treatment of the simpler diseases of the cervix uteri, when an as- sistant can not be procured to hold a Sims's speculum. As a means of investigation it is quite limited in its use. Hunter's Depressor. — This instrument is used to depress the anterior vaginal wall. It acts like the anterior blade of a bivalve speculum, and is a necessary companion to Sims's speculum. Of all the depressors. Hunter's I regard as the best. TT.t 1 EM ANM-COr Fig. 10. — Hunter's depressor. THE UTERINE SOUND AND PROBE. There are three kinds of sounds : Simpson's, which is made of hard metal, and maintains an unchangeable shape ; Sims's, which is of soft metal, and can be bent or molded to any curve ; and a third, which is elastic and bends on the slightest pressure, but by its elas- ticity regains its original shape. There are two varieties of the lat- ter : that made of elastic material like whalebone or rubber, and a metallic one, rendered elastic by a spiral arrangement in its mechan- ism, known as Jenks's. Simpson's sound is seldom used now, except METHODS OF OBSERVATION. 15 in a modified form. It is difficult to use, because its shape can not be adapted to different cases ; and it is dangerous, from the fact that it will not bend to light pressure. Fig. 11. — Sims's probe. Sims's probe is made of soft copper or pure silver, both of which metals have the quality of being easily molded. It is like the ordi- nary probe used in general surgery, only longer and a little thicker, and is provided with a handle (Fig. 11). The probe which is most generally used, and the one which I prefer for ordinary use, is the same as Sims's, only thicker. It is stiff enough to sustain all requisite pressure, and yet can be easily Fig. 12. — Whalebone sound. molded to any curve. In practice it is well to be provided with this one as well as that of Sims. The elastic probe is the same in form as Sims's, but is made of rubber, gum-elastic, or whalebone (Fig. 12). The sound of E. W. Jenks is hollow and spiral for a distance of two thirds from the pointed end. This spiral arrangement gives it flexibility. It is also graduated and provided with a sliding sheath which is very convenient in measuring the depth of the uterus, the Fig. 13. — Jenks's sound. arrangement being such that the examiner can run the sheath toward or away from him, the figures at the end of the sheath near- est the handle giving the measurement of the distance from the point to the distal end of the sheath (Fig. 13). The sound or probe should only be used after the position of the uterus has been ascertained by a digital examination, and its sensi- tiveness tested as far as that can be by the touch. It is very impor- tant to know the position of the uterus and its relations to the other organs, in order that the sound may be curved to suit the direction 16 DISEASES OF WOMEN. of the canal of the uterus, and to suggest the direction in which the instrument should be guided. There are two ways of probing the uterus : In the one, the jDatient is placed upon the back, and the lin- ger of the examiner is carried up to the os uteri ; the sound is then guided along the linger until it enters the canal, when it is passed to the fundus, the handle being depressed to make the sound correspond to the direction of the canal of the uterus. The other way is to expose the uterus with Sims's speculum, and to pass the sound with the aid of the eye. This latter method is the easier and safer, and gives at least as much information as the one first described. The vaginal walls being distended by the speculum, the instrument is free to accommodate itself to the direction of the canal of the uterus, and, aided by sight, the os uteri can be found at once. Safety in using the sound does not depend so much upon the touch which guides the instrument to the uterus as upon the hand that holds and passes it into that organ. There are few who acquire the perfection of touch to guide the sound into the unseen utenis without using force, which, though very slight, may cause mischief. In sounding or probing the uterus in any way, force should not be used. This rule should never be violated. The Sound and Palpation Combined. — In this method of examina- tion the sound is passed by touch, with the patient upon the back, and, while it is in the uterus, it is held with one hand ; the other hand is placed upon the abdomen, and downward pressure made until the uterus is felt. The uterus is then moved by the sound, and the movements are detected by the hand upon the abdomen. The in- formation obtained in this way will be noted farther on. The Curette.— This instrument is used to explore the cavity of the uterus in order to detect any abnormal growths which may be there, and also to remove portions of such growth for inspection, in order to determine their character. The instrument best adapted to this purpose is made upon the principle of the Recamier curette. It is simply a scoop of small size with a stem of flexible copper or sil- ver, the object of this flexibility being to enable the investigator to bend or curve it to suit the position of the uterine canal, and also Fig. 14. — Skene's curette. G .TIEMANN &C0. that it may bend before doing any damage to the endometrium if undue force is inadvertently used (Fig. 14). The curette is introduced through a Sims's speculum in the same METHODS OF OBSERVATION, 17 manner as the sound, and when once within the cavity of the uterus it is passed over the surfaces of the endometrium, and if any pro- jections are detected a portion can be scraped olf and removed for inspection. The further use of the curette will be again described, in connection with tlie treatment of diseases of the uterus. The Aspirator. — This instrument is employed to investigate the ■contents or composition of tumors formed in the pelvis. When the question arises whether the tumor present is solid or fluid, and if fluid what the character of the fluid is, the use of the aspirator will determine. The aspirator used in general surgery answers well ; still, a hypodermic syringe, larger than the usual size, and armed with a long, slightly curved needle, thick enough at the end nearest the syringe to give it strength to bear pressure, is more convenient. The method of using the exploring aspirator is as follows : The patient is placed upon the back, and the point of the needle is guided to the part to be examined, and is then thrust into the mass or tu- mor ; the piston is then drawn out, and the fluid, if any be jDres- ent, is examined. Uterine Dilators. — "When it is necessary, as occasionally happens, to dilate the cervical canal in order to explore the cavity of the Fig. 15. — Hanks's dilator. uterus, resort must be had to some of the dilators. These are of two kinds : The first consists of graduated dilators, which can be Fig. 16. — Goodell's dilator. j)assed in rapid succession, such as the dilators of Hanks (Fig. 15), and the instruments with expanding blades (Fig. 16). These are in- tended to produce rapid divulsion to the required extent. The other kind acts by the swelling of the material of wliich they are made. Of these tents the compressed sponge (Fig. 17), sea-tangle, and tupelo (Fig. 18) are in general use. It is seldom that tents are required for purposes of examination 3 18 DISEASES OF WOMEN. onlj; the dilators mentioned answer, as a rule. They act mora promptly, and are less likely to cause after-trouble if dilatation is not carried to an extent which is seldom necessary for purposes of ex- amination. Tents are to be avoided if possible, because of the suffer- FiG. 17.— Sponge tents. Fig. 18.— Tupelo tents. ing they causo, and the danger of inflammation and blood-poisoning, l)Otli of wiiich misfortunes have followed their use. They expand slowly, and cause irritation and pain, which must be endured for hours befoi'e they accomplish their work. Acting thus like foreign l)odies and powerful irritants, they are not without danger. The dilators act more promptly, and are less likely to induce inflamma- tion, and, although they cause pain and irritation, these are of short duration. The Concave Mirror. — This is commonlj' known as the head-mirror, and is used in the practice of laryngoscopy. It is also of much use in speculum examinations when a good light can not he obtained. In emergencies oceuri-ing at night, the mirror enables the surgeon to use artificial light with perfect satisfaction. Placing a lamp by the side of the patient in front of the examiner, the light can be reflected into the vagina so as to expose the parts in a very perfect way. Facility in the use of this mirror should be acquired, as it is at times indispensable. The Microscope. — A careful scrutiny of the minute structure of pathological specimens is always necessary to complete diagnosis, hence tlie microscope should be ])laced high in the list of means for exact observation and investigation. All that need be done in this connection is to remind the reader of tlie fact. A knowledge of the microscope and its use must be ol)tained elsewhere. The prog- ress in microscopic investigation has been go great that many men in active practice have neither the time nor the ability to make their own microsco]iic investigations. When such is the case, the duty of the gynecologist clearly is to seek the aid of the microscopist that he may obtain through him the required information. METHODS OF OBSERVATION. 19 Anaesthesia. — When the parts to be touched in examination are very tender great advantage is gained by the use of cocaine. A two-and-a-half-per-cent solution is safe, and can be made efhcient by repeated or prolonged application to the vulva with the McKesson and Robbins glass pyrozone atomizer, and to the cervix uteri with a pipette. When there is great tenderness of the pelvic organs, and the abdominal muscles are in a condition of spasm, which render the examination wholly impossible or sufficiently unsatisfactory to leave a doubt in the mind, then ether should be given to the extent Fig. 18a. — Ether-inhaler. Its principle is the same as that of the nitrous-oxide appara- tus. The reservoir, b, in which the ether is vaporized, is separated from the mouth- piece, A, by the long rubber tube. The valves, e, of the mouth-piece permit the expired air to escape without coming in contact with the ether-vapor. The valve, d, enables the ansesthetizer to administer pure air or pure ether, or any proportion of air and ether, f is the rubber tube and stop-cock by means of which the mouth- piece is blown up. c is a funnel through which the ether is passed, a is the joint uniting tube and inhaler. The advantages of the apparatus are that the ether-vapor is warmed, that reinspiration of expired air is avoided, and that the ether may be diluted with air to maintain the required antesthcsia. The stage of violent excite- ment caused by partial suffocation is avoided, and prolonged anassthesia can be maintained without the slightest imperfection of aeration of the blood. of complete anaesthesia. The relaxation which this affords simpli- fies all investigations in a very marked degree. In the investiga- tion of the pelvic organs of insane women and in virgins who cer- tainly require examination yet can not submit, the nitrous-oxide gas is of great value. It acts quickly and pleasantly, and has none of the effects during or after its administration which are so distressing to those of sound mind and horrifying to the insane. The mode of administering it is with the apparatus used by den- tal surgeons, to whom we are indebted for perfecting the apparatus for giving this anaesthetic. The gas is condensed in a strong cylin- 20 DISEASES OF WOMEN. der which hold8 one hundred gallons. By a valve arrangement it is permitted to escape into a rubber bag, from which it is inhaled. The inhaler is an ingenious arrangement by which the act of inspi- ration opens a valve that permits the gas to be drawn from the bag, while the act of expiration closes the valve in the supply-tube, and opens another valve for the escape of the impure air. There is still another valve under the control of the operator, which admits air with the gas, so that when the patient is fully anaesthetized the gas can be diluted with air in sufficient quantity to keep up the anaesthesia. The cylinder of condensed gas and the inhaler are put up in a case convenient to carry. I have long employed a modifi- cation of this apparatus for ether inhalation and I find it superior to the inhalers in general use. Fig. 18a and the accompanying de- scription shows its mechanism and mode of acting. To be able to recognize the normal and pathological conditions which are revealed by the means described requires much practice. It greatly aids in obtaining that practice — in fact, it is quite neces- sary — to keep clearly in mind what to look for. In order to facili- tate the memorizing of the objects to be investigated, I have ar- ranged the signs under each of the various means of obtaining them as follows : Vaginal Touch. — Position, size, shape, and density of the uterus. Size and shape of the os externum. Presence or absence of discharge from cervix. Condition of vaginal walls, perineal body, and recto-uterine space. State of the rectum and lower portion of sac of Douglas. Position of the bladder and urethra as indicated through the an- terior vaginal wall. Presence or absence of fixation of pelvic organs ; swelling or tumors in the sac of Douglas or broad ligaments. Tenderness at any part. Bimanual Touch. — Size, form, and position of the body of the uterus. Tenderness and mobility of the uterus and other organs and tissues. Position and state of the Fallopian tubes and ovaries. Condition of the bladder. Presence of neoplasms and their relation to the pelvic organs. Products of inflammation, their location and character. Kectal Touch. — Condition of the rectum, posterior surface of the uterus, broad ligaments, Fallopian tubes and ovaries, and utero- sacral liiraments. METHODS OF OBSERVATION. 21 Vesico-rectal Touch. — Absence of the uterus from its normal position in inversion of the uterus, entire absence of the uterus ; aid to diagnosis in women who are too fat to permit the bimanual examination. Vesico-vaginal Touch. — Changes in the position of the bladder and urethra. Results of disease in the vesico-vaginal septum. Palpation. — Form, size, and density of tumors or products of in- flammation felt through the abdominal walls. Percussion. — Density of morbid parts. Normal resonance. Palpation and Percussion Conjoined. — Fluctuation, density, or elasticity of morbid parts. Speculum. — Appearance of mucous membrane of cervix uteri and vagina. Signs of inflammation of mucous membrane. Relations of the cervix to the vagina. Form of os externum. Character of secretions. Signs of injury to the cervix and vagina. Nature of new growths suggested by their appearance. Sound and Probe. — Direction of the canal of the cervix and cav- ity of the body of the uterus, in relation to their normal position in the pelvis. Relation of the canal of the cervix and cavity of the body to each other. Straight, deflected, or tortuous state of the cavity of the uterus. Long and transverse diameters of the cavity of the uterus. Caliber of the cervical canal, os externum, and os internum. Degree of sensitiveness or roughening of the different portions of the cavity of the uterus. Sound and Palpation Combined. — Displaced uterus may be raised up to meet the touch of the hand upon the abdomen for examination. Mobility of the uterus with or without moving abnormal growths in the pelvis or lower portion of the abdomen. Curette.— Presence or absence of growths or tumors in the uterus. Removal of portions of growths from the cavity of the uterus for inspection. Aspiration. — Abstraction of fluid (encysted or otherwise) for in- spection. Dilators, tents, anaesthetics and head-mirror as aids with other means of exploration. CHAPTER II. DEVELOPMENT OF THE FALLOPIAN TUBES. UTERUS, AND VAGINA. The Fallopian tubes, uterus, and vagina are developed from two primary elements known as Miiller's filaments. These iilaments when first visible in the embryo are solid, and are situated on either side of the vertebral column, a little in front of and on the inner side of two other primary elements, the AVolffian bodies. The changes which take place in Miiller's filaments durhig the evolutions of de- velopment are as follows : From solid fibers, slightly enlarged and club-shaped at their upper ends, cavities are formed, and these be- come canals. Their lower ends approximate and coalesce, from below upward, less than half their length. This cliange, which takes place between the ends of the sixth and eighth weeks of foetal life, sented in and 20. stage of ment, Miiller's ducts are separated by a septum fonned from their coalescent walls, so that the united portion shows a right and left cavity. These two cavities are soon converted into one, the septum disappearing from below upward throughout the whole of the united portion of the ducts. The lower single canal thus formed is the rudimentary vagina and uterus, while the two upper ends of Miiller's ducts form the Fallopian tubes (Fig. 21). From this time to the fifth month there IS repre- Figs. 19 At this develop- FiG. 19. — Muller's ducts. Fig. 20.- -Coalescence of ducts. Fio. 21. — Disappearance of septum. Fig. 22. — Appearance of fundus and cervi.x. DEVELOPMENT OF THE FALLOPIAN TUBES, ETC. 28 is an increase of tissue, especially in the upper portion of the canal, which renders the distinction between the vagina and uterus appar- ent. The upper ends of Miiller's ducts exj)and and become slightly fimbriated at their extremities. The upper portion of the uterus at this time is bifurcated and forms the two horns between which the fundus is subsequently developed. Fig. 22 shows the oi-gans at this stage of development. In the sixth and seventh months the utenis increases in size, especially in the cervical portion, wliich at this stage is much larger than the body. There is also an increase of tissue between the horns of the uterus which renders their diverir- ence less marked. The rugose arrangement (palma plicata) of the rudimentary mucous membrane of the cavity of tlie uterus extends very nearly to the fundus, its folds running outward to the uterine oi-ilices of the Fallopian tubes. Ele- vations appear in rows upon the mu- cous membrane of the vagina which are the rudiments from which the transverse folds are subsequently de- veloped. During the eighth and ninth months the thickness of the walls of the body of the uterus increases, the fundus becomes more prominent and rounded, but u]3 to the time of birth the cervix is larger than the body of the uterus. At the time of birth the primary development of the uterus is complete, and it changes veiy little in form from that time until the period of pubei'ty. The size and appearance of the infantile uterus are shown in Fig. 23. The cavity of the uter- us and the arrangement of its mucous membrane are represented by Fig. 24. Fig. 25 gives a side-view of tiie uterus and vagina, and shows their relations to each other. At this time the cervix pro- jects but little into the vagina. From the time of birth, when primary development is complete, up to the period of puberty, the uterus undergoes very lit- tle change exce^^t during the second den- tition. At that time the body increases in size, becoming more nearly equal to the cervix. The palma plicata disappears Fig. 23.— Infan- tile uterus. Fig. 24. — Palma plicata extend- ing nearly to fundus. Fig. 25. — Infantile uterus, an- tero-posterior section, scant mvajrination. 24 DISEASES OF WOMEN. from the body of the uterus, excepting one longitudinal fold. The uterus gradually descends into the pelvic cavity and the cervix is. projected down into the vagina a little farther. From this time na changes occur worthy of notice until puberty, when secondary de- velopment takes place. Secondary development consists in a general increase in the size of the uterus, especially in the body and fundus, which become much larger than the cervix. The length of the uterus is increased. The walls become thicker and firmer. The last trace of the palma pli- cata disappears from the mucous membrane of the cavity of the l)ody, and the mucous membrane becomes thicker by the formation of its glandular tissues. In this way the uterus attains the shape and size of maturity. Together with the changes in size and form comes a change of position. The uterus descends into the pelvis and complete invagination of the cervix occurs. Fig. 26 shows the general appearance of the mature uterus in outline, and Figs. 27 and 28 represent the relations in which the Fio. 26. Fig. 27. Fig. 28. Figs. 26-28. — Virgin uterus (Sappey) : 26, anterior view; 27, median section; 28, trans- verse section. 26. 1, body; 2, 2, angles; 3, cervix; 4, site of the os internum; 6, vaginal portion of the cervix; 6, external os. 27. 1, 1, anterior surface; 2, vesico- uterine cul-di-nac ; 3, 3, posterior surface ; 6, isthmus ; 7, cavity of body ; 8, cavity of the cervix; 9, os internum; 10, anterior lip of os oxternuni ; 11, posterior lip. 28. 1, cavity of body; 4, 4, cornua ; 5, os internum; 6, cavity of cervix; 7, arbor vitue of the cervix ; 8, os externum. cervix and vagina stand to each other. By comparing Figs. 23 and 25, which illustrate the infantile uterus, with Figs. 26 and 27, the difference between the results of primary and secondary develop- ment will be fully comprehended. DEVELOPMENT OF THE FALLOPIAN TUBES, ETC. 25 MALFORMATION'S OF THE UTERTJS. The malformations of the uterus are naturally divisible into two classes : those that occur during embryonic life, and those that occur at puberty, the period when secondary development takes place. The first class embraces the greatest variety. Nearly all of these malformations are due to arrest of development at different stages of that process. The malformations most frequently seen are the uterus a Fig. 29. — Double uterus and vagina from a girl aged nineteen (Eisenmann) : a, double vagi- nal orifice with double hymen. bipartis, uterus duplex, uterus unicornis, uterus bicornis, uterus bi- fundalis unicollis, and rudimentary uterus, generally known as ab- sence of the uterus. A very rare condition has been described as hypertrophy of the uterus, and classed with the malformations. It is really not a malformation, but a complete development of the 26 DISEASES OF WOMEN. uterus during infantile life. When the first evolution in the process of development — i. e., the union or coalescence of Miiller's ducts — Pig. 30. — Uterus unicornis from a young child, posterior aspect (Pole) : b, right Fallopian tube ; c, left Jfallopiau tube exceptionally present ; d d, ovaries ; e, bladder (Courty). is arrested, and each duct grows by itself, the result is the uterus bipartis. The uterus duplex is formed by the coalescence of the ducts, with arrest of absorption of the central wall. The development goes on, so that in time the whole organ is larger than the normal uterus, but it is divided into two by the central wall (Fig. 33). Uterus unicornis is produced by a complete arrest of development of one of the ducts at the part which should form one half of the body and fundus of the uterus (Fig. 30). The uterus bicornis occurs as the result of non-union of that part of the ducts which forms the Tuba Fransen Fio. 31. — Uterus bicornis unicoUis (Winckel). body and fundus (Fig. 31). The uterus bif undalis unicollis is formed by the same error of development as that which produces the uterus bicornis and double uterus with the followino; difference : In the DEVELOPMENT OP THE FALLOPIAN TUBES, ETC. 2Y uterus bifundalis (Fig. 32) the liorns, though not united, are well developed and present outlines more nearly like the normal body of the uterus, while the part which forms the cervix is completely developed. Entire absence of the uterus is per- haps unknown, unless in mon- strosities in whom the lower part of the trunk is wanting. Rudimentary uterus is seen occasionally. As most fre- quently found, it presents a very small cervix slightly, if at all, invaginated, and in place of the body of the uterus one or two small solid masses are found from a quarter to half an inch in thickness and about the same in lenffth. Fig. 32. — Uterus bifundalis unicollis. Fig. 3S — Uterus duplex (Cruveilhier). Left walls developed in consequence of prec:nancy. The effect of malformations as manifested during functional life is quite remarkable. In some there is not the slightest deviation from health in the function of the sexual organs. In others the 28 DISEASES OF WOMEN. results are very disastrous. This practically gives two classes of malformations according to the effect they have upon the health and usefulness of the subject. In the one class the malformation does not materially affect the function of the uterus, while in the other the functional action is always imperfect — sometimes im- possible. The cases of simple deformity, in which there are suffi- cient development and growth of one or both elements of the uterus to make the organ functionally competent, have no ill effect upon the general usefulness and welfare of the individual. The follow- ing case will illustrate this : Double Uterus and Vagina. — A married lady, thirty-two years of age, who had borne three children and nursed them, called upon me for advice regarding a leucorrhoea which had troubled her since the birth of her last child. Her general health had always been ex- cellent. Upon making a digital examination, I found the vagina normal and also the cervix, excepting that one side of the cervix was closely united to the vaginal wall throughout its entire length. On the left side of the vagina high up I found a hard mass which was also noticed on making bimanual exploration. The lirst im- pression was that she had suffered from a pelvic cellulitis, and that the mass on the left side was the remains of its products. This idea was given up at once on finding that the patient gave no history of any pelvic inflammation. I then suspected that there might be a fibroid in the left side of the uterus, which, by extending the entire length of the cervix, had pushed the vaginal w^all before it. A speculum examination revealed a ca- tarrh of the cervical canal. The uterus had the usual appearance of one that had borne children, and the cervix was nonnal in shape and position, except for the peculiar relations of the cervix and vagina on the left side, which were noticed during the examination with the touch. Just within the labium minus on the left side, a pe- culiar fold of the vaginal wall was noticed running • transversely. On raising this fold with the point of the sound it was found to be a septum, and there was also discovered another vagina to the left of it. Using a smaller Sims's speculum to distend this vagina, I found the other cervix which had all the characteristics pertaining to a nul- lipara. The passage of a sound showed that the canal of the uterus on the left side was not quite so long as the one on the right. It was then clearly evident that the patient had a double uterus and vagina, and that the right uterus had borne three children, while the left uterus was a virgin one. She was attended in her confine- ments by three ditfoi-ent physicians, none of whom made any refer- DEVELOPMENT OF THE FALLOPIAN TUBES, ETC. 29 ence to this malformation, and it is fair to suppose that none of them discovered it. This case is of interest as showing the fact that some of the mal- formations do not in any way affect the function of the uterus nor the general health of the subject. When there is malformation, and the growth of the uterus falls so far sliort of the normal type that functional activity is impos- sible, the results are often very unfortunate. The nature of this class of cases bears such close resemblance to those in which there is arrest of secondary development at puberty, that they may be con- sidered together in the following chapter. A Unique Case of Double Uterus. —In this case I found a large uterus with a well-formed cervix, and directly in front of it a very much smaller uterus, the cervix of which was but slightly in- vaginated (Fig. 34). On my first exami- nation I made a diag- nosis of uterine fibro- ma. I thought that I could outline the tumor projecting from the uterine wall toward the bladder. Subsequently I noticed a free dis- charge of uterine leu- corrhoea issuing from a slight elevation on the vaginal wall in the median line, about an inch from the os ex- ternum of the larger uterus. I passed a sound througli the small opening in the wall of the vagina, and found that it entered about an inch and three quarters, demonstrating that the supposed fibroid was a small uterus. I account for this strange malformation on the theory that, during development and after coalescence of Miiller's ducts, these rudiments made half a revolution, thus bringing one in front of the other. Fig. 34. — Double uterus. CHAPTEK III. MENSTRUATION AND ITS DERANGEMENTS, AND CHLOROSIS. Menstruation is the function of tlie uterus that especially claims the attention of the gynecologist, though it is only a subordinate part of the great process of reproduction. Professor Stevenson, of the University of Aberdeen, describes the physiology of menstruation as a nutritive and active innervation wave that periodically runs to the pelvic organs, attaining its height at the beginning of utero-gestation, or, in the absence of gestation, at the beginning of menstruation. This nutritive material is eliminated when the mucous membrane of the cavity of the body of the uterus undergoes degeneration, either wholly or in part, and is exfoliated in a granular state. This degen- eration and exfoliation, according to some observers, involve the whole membrane down to the muscular walls, while others claim that they affect only the epithelial layer. Be this as it may, there appears to be a general agreement among the authorities of the present time that degeneration and exfoliation occur to an extent sufficient to expose the smaller blood-vessels of the endometrium, and to so weaken their walls that they give way and haemorrhage follows. This menstrual flow is composed of blood from the vessels, with at least the dehris of the degenerated and exfoliated epithelium. The flow, which lasts for days, subsides, the mucous membrane is renewed, and the same high state of anatomical completeness and functional capal)ility is restored, when another menstruation takes place, and so this function is repeated over and over again, except when suspended during pregnancy or lactation, until the end of functional activity at forty -Ave years of age or thereabout. During the period of functional activity of the sexual organs, from puberty to the menopause, menstruation is an evidence of health, and is also essential to health. It is an index of the state of the sexual system and also of the general health of mature women. 30 MENSTRUATION AND ITS DERANGEMENTS. 31 Hence its derangements constitute most valuable evidence of the presence of disease, while its normal recurrence is an evidence of health. In practice it is best to study this function by its character- istics, rather than by theories regarding its cause or the reasons for its existence. It is on this account necessary to comprehend its nat- ural history ; therefore, I propose to give here a synopsis of the con- ditions of menstruation. The laws which govern this function of menstruation, as given in our text-books, are so varied by climate, personal peculiarities, and the conditions of life, that a general average pertaining to these laws is about all that can be obtained, and this can be used to very little advantage in practice. Fortunately, there are certain rules which apply to menstruation with great uniformity, and these should be clearly understood. The most important of these are the fol- lowing : 1. Menstruation should begin at puberty — i. e., when the woman is maturely developed, no matter what the age may be. Increase of size may take place by growth after puberty, but all the organs of the body should be completely developed, so far as form and structure are concerned, before the function of menstruation is taken up. 2. It should recur at regular intervals ; about every twenty-eight days is the average time. A regular periodicity is normal, but the duration of the periods often differs in different persons. 3. The discharge should always be fluid in consistence and san- guineous in color. 4. The flow should continue a definite length of time, the dura- tion depending upon the habit of each case ; at least there should not be any great deviation from this rule. 5. The quantity should be about the same each time. There should be no deviation from the first rule. If the menses appear before development is complete, both in the sexual organs and the general system, it is an error which is either the result of disease or of the surroundings of the patient, and generally modifier unfavorably her future life unless it can be corrected. The same may be said regarding those who fail to menstruate when the devel- opment and growth of the body are completed. The other rules re- garding the recurrence, duration, quantity, and character of the men- strual flow, may vary in different women, but they should be uni- form and regular in each person. Whatever the habit may be that is established at puberty in a given case, that habit should be main- tained through life. Some w^omen menstruate systematically from 32 DISEASES OF WOMEN. puberty until after bearing a child, then they take up a different order of menstruation in regard to all or some of the characteristics of that function. That is normal, but it is the only well-marked chansre in habit which is the same in health. Obedience to these laws of the menstrual function implies cer- tain conditions that are necessary to the fulfillment of these laws. These may be briefly stated as follows : 1. Maturity of development of all the organs, both of the general and sexual systems, and a fair degree of health of all. 2. A sufficient and well-regulated supply of normal blood to the sexual organs. 3. Normal structure and functional activity of the nerves which preside over the action of the sexual organs. 4. Conditions of life favorable to general health and reproduc- tion. This includes food, climate, society, and occupation. Allusion has already been made to absence of the uterus and also to its rudimentary states in which the menses never appear, and because of these marked anatomical defects and absence of function nothing can be done by the gynecologist in the way of improve- ment. There remain to be considered cases in which the conditions of menstruation are all present but in an imperfect degree, so that men- struation, although established, is performed imperfectly. ILLUSTRATIVE CASES. uterus Unicornis; Imperfect Menstruation and the Results. — A woman, twenty-nine years of age, of healthy parents, above the average size, and well formed generally, had enjoyed excellent health until she was eighteen years of age. About that time her mammary glands became well developed and she presented all the outward characteristics of woman physical and psychical. She then began to suffer at stated periods from backache, a sense of fullness in the pelvis, and slight leucorrhoea. In a day or two after these symptoms came on, and while they continued, she became dull and sleepy, and had a feeling of fullness in the head and slight headache. These attacks lasted several days, when they passed off and again returned about every montli. In the interval her health was good and she performed her duties as a domestic. Five months after the first time that these symptoms appeared, and while she was suffering from an attack, she had a slight menstrual flow, which lasted less than twenty-four hours, and apjwared to alleviate her suffering. The next month her flow returned in the same way, but MENSTRUATION AND ITS DERANGEMENTS. 33 all her symptoms were increased. From this time on her men- strual flow returned regularly, but did not increase in duration or quantity. At each recurring menstrual period her suffering in- creased in severity until she was obliged to give up her duties at such times. On one occasion when she was trying to do her work while suffering, she was exposed to cold and was seized with an inflammation — j)elvic peritonitis, no doubt — and was taken to the hospital, where she remained for three months. During that time she took morphine liberally. From this time her suffering dur- ing the menstrual period was very great, sufficiently so to keep her in bed, and to require large doses of morphine to make life tolerable. Another attack of pelvic peritonitis came, and again she was sent to the hospital for treatment. She recovered from the acute attack, but her suffering at her periods was far greater than ever before. Epileptiform convulsions came w^ith her pelvic pains, and were repeated frequently until the menstrual period passed by. For several years her time was spent between her home and the hospital, and in occasional efforts to do the duties of a house-servant. Condition when First Examined. — Having obtained the above history from the patient, I observed that she still had all the evidence of fair general health, except that, from pain and the use of mor- phine, her nervous system was decidedly impaired. Physical Signs. — The touch detected a very small cervix nteri which projected into the vagina only half an inch. The organs and tissues were fixed, and on the left side there was an irregular mass "which felt like the products of a former pelvic peritonitis. On the right side the parts were less elastic than normal, and, owing to an exceedingly tense state of the abdominal muscles, the body of the uterus could not be felt, neither could the right ovary be posi- tively made out. From the negative signs, however, I was able to satisfy myself that the right ovary was not enlarged, nor was the body of the uterus as large as it ought to be. The speculum re- vealed nothing of value, but, in using the sound through it, I could pass that instrument into the cavity of the uterus. The canal of the cervix was an inch in length, and in its proper position as indicated by the sound. When the internal os was reached, the sound turned to the right and passed in that direction about an inch. This led me to suspect that the uterus was unicornis. To obtain further evidence, the speculum was removed, while the sound was left in the uterus. The patient was then placed upon the back, and by the rectal and vaginal touch combined, the horn 4 34 DISEASES OF WOMEN. of the uterus above the vagina was reached. While making the combined touch, an assistant rocked the horn of the uterus with the sound, and I could then outline it with the fingers. It was about an inch in its transverse, and only a little more in its long diameter. The upper end, which represented the fundus, appeared to be slightly pointed in place of rounded, as is the fundus of the normal uterus. Treatment. — There was nothing in the case to give the slightest hope that she would derive benefit from any general treatment. The removal of the ovaries to stop the tendency to menstruation was the only indication apparent to my mind, and, owing to the old adhe- sions from the former pelvic peritonitis, the dangers of that opera- tion were fully appreciated. The case was explained to the patient and the friends who brought her for my advice, and they were left to choose between the removal of the ovaries, or no further care on my part. The patient, after thinking of the dangers and the pros- pects, became very anxious for the operation. Her argument was that she was tired of life, and that all her friends were tired of car- ing for her, and, if there was one chance in a thousand of being re lieved, she longed for that chance. The operation was performed with great difiiculty, owing to the adhesions. The right ovary was completely surrounded with inflam- matory products, and was found with much trouble. The left ovary was adherent at several points that were easily broken up. There was no trace of the left horn of the uterus, nor of the left Fallopian tube. The right ovary was located within one inch of the upper end of the right horn of the uterus, and there was no well-defined Fallopian tube on that side. Comments. — This case certainly illustrates fully the great suffer- ing that may arise from this degree of malformation. The presence of well-developed ovaries which excite a demand for menstruation, associated with a uterus incapable of performing that function, is one of the most unfortunate conditions known to the gynecologist. It is evident, also, that the development of the one horn of the uterus sufficient to make a slight effort to menstruate only aggra- vates the difficulty. This patient would perhaps have been better had the uterus been absent altogether. Incidentally, I may remark that the absence of the tubes in this case is evidence against those who claim that they have a leading influence in causing menstruation. Rudimentary Uterus Bicornis; Entire Absence of Menstruation. — AVhen first examined, this lady was thirty years old, below the MENSTRUATION AND ITS DERANGEMENTS. 35 average size, but well formed, and presented, to outward appear- ances, all the characteristics of her sex. As a child she was rather small and delicate, but had good health. At the age of sixteen she passed through all the changes of form common to puberty, but never menstruated. When questioned regarding her health at that time, she remembered only that slie occasionally had slight headache and indisposition, but wliether these symptoms came peri- odically or not she did not know. At no time was her suffering sufficient to interrupt her school duties. She was married at eighteen, and, while she was affectionate and devoted as a wife, sexually she was perfectly negative. Without being very strong mentally or physically, she enjoyed good health, and only called upon me at the time she did because of some temporary^ irritation of the urethra which caused pain on urination. This gave me an opportunity to examine her pelvic organs. The external organs were normal, and the vagina also. The cervix uteri was not more than five eighths of an inch in diameter. The os externum was small but normal. In the location of the body of the uterus two small, oblong, bifurcated bodies were found continuous with the cervix. These bodies were about a quarter of an inch thick and about an inch long, as nearly as could be estimated by the bimanual examination. I regarded them as the rudimentary horns of the uterus, which were retroverted. ]^ear the upper ends of the horns of the uterus, and a little outside of them, two other bodies were found which I presumed to be the ovaries. They were about half the size of a fully-developed ovary and of the usual form of that organ, except that they were not so flat from before backward, and appeared to be more dense than normal. It was evident that the development of the ovaries had progressed further than that of the uterus, because they were relatively much larger than the rudiments of the uterus. Owing to the fact that the patient was of small size, with non-resisting abdominal muscles and the rudiments of the uterus retroverted, the examination was easy, so that I feel some confidence in giving the physical signs and the diagnosis based upon them, believing that they are correct. Comments. — This case apparently shows that the ovaries were sufficiently developed to influence the changes which occur at puberty, but were so much under size that they were incapable of the highest functional activity, while the uterus was not only arrested in its development, but in its growth also ; hence men- struation, even in an imperfect way, was impossible. This case is placed in contrast with the preceding one to show that when arrest 36 DISEASES OF WOMEN. of development and growth is such as to render functional action entirely impossible, a fair degree of health may still be maintained ; while, on the other hand, if the development and growth of the ovaries are complete, and the nterus is developed sufficiently to make an imperfect effort to menstruate, the health and usefulness of such a one is greatly impaired, and a life of suffering generally follows. Small Uterus from Arrested Growth ; Scanty Menstruation improved by Treatment. — The patient was a young woman of full size and well formed, and of a sanguine, nervous temperament, and a re- markably good and well-cultivated mind. She had always enjoyed good health excepting when she was fourteen years old. At that time she was " working hard at school, and became run down." Rest soon restored her, and she began to menstruate at the age of fourteen years and six months. Her menses from that time returned regularly, but the flow was scanty and lasted only forty-eight hours. During the menstrual period, and for several days after it, she suf- fered from fullness of the head, restless nights, and a feeling of discomfort in the pelvis with general mental and physical indispo- sition. She continued in this way until she was mature, the time when she was first examined. By the touch the cervix uteri was found to be rather small, but well formed and in proper relations to the vagina. Owing to the rigid state of the abdominal muscles, the uterus could not be satisfactorily outlined by the bimanual touch. Using the sound through the speculum, the long diameter of the uterus was proved to be one and seven eighths inches ; quite a small uterus for a woman of her size. Her general health was very good indeed, and she would not have sought immediate advice had it not been that she was engaged to be married, and was very anxious to be relieved from the ill feelings which came in connection with her scanty menstruation. Treatment. — At her next period she was directed to take a tea- spoonful every three hours of the following mixture : Ammon. mur., 3ij ; aquse camph., ^ ij, to begin as soon as she felt that the period was approaching, and to continue until six hours after the flow stopped. Xot being used to medicine, she objected to it strongly, and during her subsequent periods she took a teaspoonful of liq. ammon. acetatis every three hours, commencing one day before the flow began and during its continuance. Immediately after the flow ceased, one or more fine punctures were made near the external os, which produced considerable bleeding. This was done to relieve, as far as possible, the congestion M'hich lingered because it was not MENSTRUATION AND ITS DERANGEMENTS. 37 relieved by the menstrual flow. This was practiced after three pe- riods. At intervals of six days during the entire menstrual flow the canal of the cervix, including the internal os, was gently dilated with graduated sounds. This was done in the hope that it would stimulate the nutrition of the uterus. After the third month of treatment it was found that the men- strual flow had increased in quantity and continued for one day longer. A stem-pessary was then introduced, but it caused more irritation than was safe ; so, after it had been worn for three days, it was removed, and not used again. From this time onward the treatment was limited to a mild con- stant electric current. One electrode was passed into the uterus, the other applied alternately over the sacrum and supra-pubic region. This was repeated every six days in the interval between the monthly periods. She continued to take the solution of acetate of ammonia at each period, but with what benefit is not known. At the end of eight months the uterus measured two inches and one eighth in its long diameter, and she menstruated between four and five days at each time, the flow being much more free and her unpleasant symp- toms having all disappeared. She married then, and I lost sight of her for seven months, when she called to consult me regarding amenorrhosa, which had existed for two months and was due to pregnancy. I heard that subsequently she was confined, and was in quite good health. Undersized Uterus from Arrested Growth ; Scanty Menstruation ; Sterility; Incurable. — This woman was thirty years old when this history was obtained. She was of medium size, and had enjoyed fair health most of her life. During her girlhood she had to w^ork very hard in a store, and often sufliered at that time from fatigue. She developed slowly, and did not menstruate until seventeen years of age. During the first four years after puberty the menses lasted only two days and the flow was scanty. At twenty-two she was married, and placed in easier and more comfortable circumstances, and for about one year the menstrual flow lasted from two and a half to three days at each time. She then missed one period, and then the menses returned more freely than ever before, which made her believe she had had a miscarriage ; but of this there was no proof. When she had been married two years she began to have pain of a dull, aching character in the region of the uterus during her menses. This pain became more marked as time advanced, and gradually the pain extended to the ovaries. These pains were never acute, and passed away entirely after menstruation ceased. At 38 DISEASES OF WOMEN. twenty-nine years of age she had sickness in her family and was overtaxed tliereby, and her menses stopped for five months, but again returned. In tlie absence of the menses she had leucorrhoea, but not before nor since. Examination by the touch showed the uterus to be relatively long and narrow ; the body was not much larger than the cervix. The long diameter as measured -with the sound was two inches. There was slight tenderness on pressure over the ovaries. All the pelvic organs were in normal position. Her general health was about as good as it ever had been. Treatment. — Sodium bromide, gr. xxx, was given three times a day in Yicliy water before meals during the menstrual period. This relieved the uterine and ovarian pain very much. Between the periods the hot-water douche was used until all pain had been relieved. The subseipieiit treatment was about the same as in the case last related, with the addition of more extensive dilatation of the cervical canal, and she also wore the intra-uterine stem-pessary for six weeks. !Slie took internally phosphates, iron, and strychnia in various forms, and for several months. At the end of seven months she was free from all pain during menstruation, but the flow was no freer, nor did it last any longer. The uterus had not in the least increased in size. She was dis- missed unimproved, so far as the growth of the uterus was con- cerned. Comments. — This and the preceding case are placed together to show the results of treatment. They demonstrate that the prospects of success in increasing the growth of the uterus depend very largely upon the age of the patient. The earlier in life that the treatment is begun, the more likelihood is tliere of success. Undersized Uterus, its Growth apparently being arrested by Pre- mature Sexual Nervous Excitation; Irregular and Painful Menstrua- tion; all the Symptoms increased by Local Treatment. — This was a single wonuui, twenty-two years old, the daughter of wealthy and educated parents. She was tall, spare, and of nervous tempera- ment. Before puberty she acquired the habit of self-abuse while at school. While her general system was not developed, and while weak, irritable, dyspeptic, and subject to severe headaches she be- gan to give evidences of puberty, and her menses first appeared at twelve years of age. From this time, up to the time of taking this history, she menstruated irregularly, the average time between the periods being five weeks, but often two, three, and on several oc- casions five months elapsed. The flow was usually normal in MENSTRUATION AND ITS DERANGEMENTS. 39 quantity, character, and duration, although the latter was variable. Pain in the back, pelvis, and lower portion of the abdomen always accompanied the menses, and was sufficiently severe to keep her in bed during that period. The severity of the pain was presumably not so great as the patient described. Her extreme sensitiveness inclined her to exaggerate her sufferings. Neither was the chai-acter of the pain so acute and localized as that which occurs in flexion of the uterus. Her general health was poor, slight mental or physical exercise fatigued her, and if she persisted she became so tired that she could not rest. Her sleep was disturbed by dreams that were not all dreams, and in the morning she felt quite exhausted. Be- fore I saw her she had been treated locally and generally by several physicians, some of high standing in the profession, and others of questionable repute, and was invariably worse after being treated. An examination by touch revealed a small uterus slightly retro- verted, though that malposition was, I believe, temporary. The length of the uterine cavity measured with the sound was a fraction less than two inches. With the exception of extreme sensitiveness of the pelvic organs generally, there was no other abnormality found. Local treatment was tried for a short time, but it was found to be injurious. She was then given systematic occupation under the direction of a skilled attendant. Massage and careful dieting were also directed. Her days were fully occupied with short alter- nating periods of mental and physical exercise and rest. Every a,fternoon she took thirty grains of bromide of sodium, and during her menstrual periods thirty grains three times a day with eight drops of tincture of cannabis Indica. Laxatives were given to regu- late the bowels, and tonics occasionally when specially required. It should be mentioned that she gave up her evil habit as soon as she was made to understand its ill effects. Under this general plan of treatment she improved in every respect. She still suf- fers at her monthly periods, and the menstrual function is still irregular. Comments. — This case is given as a representative of that class of cases of delayed or arrested growth of the uterus and the functional imperfection which is sure to follow, the primary cause of all being the premature excitation of the sexual organs. A sufficient number of these cases has been seen and studied to warrant the statement that when the habit of self-abuse is begun before puberty it often arrests the development or growth, or both, of the uterus, and the 40 DISEASES OF WOMEN. consequences are far more disastrous than the same practice when begun after puberty and completed growth. Chlorosis. — Closely associated witli this subject is chlorosis, a condition involving menstrual derangements due to the same de- fect of the uterus, being associated with lesions of the general system. Chlorosis is a condition which has usually been considered as a disease ])er se^ but it appears to me to be rather a peculiar character of organization presenting invariably certain character- istics of structure which are unfavorable to high functional activity, and which predispose to certain forms of disease. Some authori- ties, French mostly, believe that chlorosis is a disease of the organic nervous system which appears at puberty and presents certain changes of nutrition, especially in the character of the blood. There is certainly some reason for this view of the subject. The functions of the body which are under the direct control of the organic nerve-centers are perverted apparently by some obscure derangement of organic innervation, but this appears to come from some imperfection of the nervous system, perhaps mal-develop- ment, rather than from some well-defined disease. The German pathologists hold that in chlorosis there is an arrest of growth of the circulatory and genital systems ; the heart and blood-vessels be- ing undersized and the sexual organs also. This certainly cor- responds to the facts as observed clinically, and if to this be added that peculiar condition of the organic nervous system, which is un- defined but probably structural, a type of organization results which presents all the tangible characteristics of chlorosis. This is the conception which I have accepted regarding chlorosis, which may be defined as an organization in which the circulatory and the genital systems are below the normal type in point of development and growth, and in which there is a state of the organic nervous system which is also below the normal and incapable of exercising the highest functional activity. These constitutional conditions combine the features of a peculiar temperament and a diathesis ; the temperament being so marked as to show a tendency to disease or diathesis. It would siiqplify the subject if the term chlorotic temperament Avere used to express this constitutional condition. Viewing the subject from this standpoint, it is easy to understand that such an organization, while it might act under the most favor- able circumstances of life, would be incapable of sustaining the more complex functional activities of a mature and fully occupied life. It is easy to see, also, that a chlorotic subject, when called upon to take up the functions of reproduction, when thus ill-quali- MENSTRUATION AND ITS DERANGEMENTS. 41 fied to do so by reason of anatomical defects, would naturally tend to derangements of nutrition in the form of impaired appetite, labored digestion, and the ansemia, debility, and mental depression which naturally follow mal-iiutrition. So, also, would the sexual system suffer because of the undersize of the uterus and, pre- sumably in some cases, the ovaries also, together with the im- perfect Ijlood-supply which, sooner or later, comes from the mal- nutrition. This I believe to be the true state of the body knov/n as chlorosis, and that all the phenomena manifested by such sub- jects are the outcome of their anatomical peculiarities. Whether this be the proper description of chlorosis or not, it is the expres- sion in brief of the prominent features of chlorotic subjects, and agrees with the facts observed in practice. The reason, I presume, for the different opinions held has grown out of the fact that some have accepted the mal-nutrition which is so often seen in the chlorotic, and the consequences thereof, as the disease itself ; where- as these derangements of the nutritive and sexual systems are the outcome of the anatomical imperfections. The chief object in dis- cussing the subject here is, because chlorotic women necessarily suffer from deranged and imperfect menstruation, and they natu- rally fall into the care of the gynecologist, and without some defi- nite idea of the nature of this affection its rational management would not be possible. From the very nature of chlorosis, it is clearly evident that the object of the therapeutist should be to aid in the development and growth of the subject while young, in the hope of overcoming the natural tendencies to these constitutional defects. After adolescence the most that the physician can accomplish is to overcome, as far as can be, the mal-nutrition and derangements of menstruation which arise from the constitutional imperfections. Arrested Growth of the Uterus, associated with Small Circulatory- Organs ; Chlorosis. — This patient stated that when a girl she was of medium size and quite fleshy, and was said by her friends to look strong and healthy, but she was never able to endure much muscu- lar exercise. Her appetite and primary digestion had generally been good, yet she never required a large quantity of food. Her face was rather pale while a girl, and remained so. She never was in- clined to take active exercise, and, when obliged to do so, respira- tion was labored, and she soon became tired. At the age of fifteen she began to show the general form of womanhood, but did not menstruate until eight months later. From that time onward she menstruated regularly, but the flow lasted only 42 DISEASES OF WOMEN. three dajs, and was not at all free. On several occasions, when obliged to exert herself sufficiently to slightly lower her general health, the menstrual flow was almost colorless, and lasted only two days. At twenty-one she was married. Her general health re- mained as before, and she proved to be sterile. I saw her when she was twenty-eight years of age, seven years after being married. She then consulted me regarding her sterility. In general appearance she was a typical chlorotic subject. She was of medium height, quite fleshy, but not inordinately so ; her hair was intermediate in color, being neither dark nor light — in fact, it might be said to be colorless ; too light for a brunette, too dark for a blonde. If this dark shade had been removed, it would have been hair of a dark-flaxen color ; the eyes were a gray-blue and very clear ; the sclerotic coat pearly white ; the skin remarkably smooth and white. The face was pale, with that greenish-yellow hue which must be seen to be fully appreciated. This color of the face differs from the yellow, dry skin of the cacliectic subject, the pallor of ansemia, and the bronze of sunburn. Few blood-vessels were visible on the face or hands, and these were very small. The pulse was about eighty, but small, more like that of a child. The heart-sounds were very clear and distinct, but the impulse was weak. The area of cardiac dullness was apparently smaller than usual, but this was difficult to make out, owing to the mammary glands being large. At the time of my first examination she was feeling more than usually languid and weak because of indigestion and constipa- tion, which had troubled her for several weeks. Her tongue was coated, and her appetite poor. On walking up-stairs quickly she suffered from " want of breath." If she stooped down and rose suddenly, she had vertigo. Toward night her ankles became slightly swollen. Her sleep was often disturbed by dreams. In dis- position she was a little sluggish, good-natured, and generally cheer- ful, with occasional attacks of mental depression, which occurred usually at the menstrual period. The pelvic organs were normal as regards general nutrition, ex- cept that the mucous membrane was anaemic. The position of the uterus was normal. The sound showed the cavity of the uterus to be a fraction under two inches in length. There was a slight leucor- rhcea. The menses were regular, lasting from three to four days, until four months before she was first seen by me. During that time she had had a leucorrhoeal discharge' at the menstrual period, but nothing more. Treatment. — Pil. hydrarg., gr. x ; pulv. ipecac, gr. j, were given MENSTRUATION AND ITS DERANGEMENTS. 43 at bedtime, followed by a saline laxative in the morning. After this, a teaspoonful of the following mixture was given, well diluted, before meals : Strychnife sulphatis, gr. ss. ; acid, hydrochlor., 3j; tinct. cardam. comp., 3 j ; aquse font., 3 ij. This improved her appetite, and her strength increased. When she had finished the first mixture, the following was given : Ferri iodid., ±)j ; quinia3 sulph., gr. X ; ext. belladonnas, gr. ij, in pil. No. xx, one before each meal. These pills were taken with apparent benefit for three weeks, when they were stopped, and the following was ordered : Tinct. iodin., 3 ij ; potass, iodidi., 3 ss. ; syr. simp., 3 j ; aquse font., 3 ij ; one teaspoonful, after meals, in water. During the follow- ing six weeks she took the pills one week, and the next week the tincture of iodine mixture, alternating regularly. The menses ap- peared at the fifth month after they stopped, but were scanty, and lasted only two days. The appetite and digestion were improved, and the anaemia was less marked. She also felt much stronger. I then prescribed ferri pyrophos., 3 jss. ; strychnise sulph., gr. ss. ; liq. potass, arsenit., 3 j ; tr. colomb., 3 j ; aquse font., 3 ij. Teaspoon- ful, in water, after meals. This mixture she continued to take for six weeks longer, omitting it occasionally for a few days. Dur- ing the treatment she was relieved, as far as possible, from all care, took light exercise in the open air, and had a good supply of nu- tritious food in great variety, being restricted only in the quantity of fluids, sugar, and fats that she took. The menses continued from this time onward to be regular, and the character and duration of the flow were the same as they had been in her best former health, but were not improved. For several years, indeed up to the present time, w^iich is now five years since she was first seen, she has been in fair health, but on several occasions, when she ventured to do more than usual, her digestion became deranged and her appetite poor. Anaemia has become more marked, and the menses have diminished, but she has promptly applied for treatment, and the use of tonics has restored her to her usual rather low standard of liealth. Comments. — This history shows that the patient was not cured of her chlorosis, but only relieved from intercurrent attacks of malnutrition and the consequent imperfect menstruation which she had. This is the history of the great majority of such cases when they come under observation and treatment after puberty. This shows that the whole character of the organization is below the highest standard, and hence there is a tendency to break down under oi-di- 44 DISEASES OF WOMEN. nary taxation, and the physician can do no more than restore the patient to her nsnal decree of health. Chlorosis treated before Puberty with apparently Good Results. — A schoolgirl, fourteen years old, large enough for her age, and un- usually fleshy, was brought to me on account of loss of appetite and constipation. There was no evidence of puberty, except that her breasts were large, but they were mostly made up of adipose tissue. Her general appearance, color of li^ir and eyes, small heart and blood-vessels, white skin, jiale face, and disinclination to active exer- cise, indicated chlorosis. Nothing was lacking but the usual anaemia and peculiar color of the face to make the case a type of chlorosis. She was directed to give up some of her school duties and devote more time to systematic muscular exercise and out-of-door life, to abstain from fat meat, sugar, and butter, of all of which she was un- usually fond, and to live upon lean animal food, fish, eggs, oatmeal, fruit, and brown bread. To relieve her constipation I prescribed quin. sulph., 3 j ; ext. belladonna, gr. ij ; ext. colocynth. comp., gr. X, in pil. No. xx ; one immediately before each meal. At the end of two weeks the bowels were acting too freely. One pill, night and morning, before meals, was ordered. These answered for a time, but in three weeks it was found that one pill was all that was required, and at the end of two months from the time she came under treatment, pills were given up altogether. She was then put upon tlie following : ]^ Ilydrarg. chloridi corrosivi gr. j. Liquor arsenici chloridi f 3 j. Tr. ferri chloridi. Acid, hydrochloric, diluti ilil f 3 iv. Syrupi simplicis 3 ij. AqutB q. s. ad § vj. M. Sig. : A dessertspoonful, well diluted, after each meal. This is known as the mixture of the four chlorides, and is said to have been first used by Tilt, of London, and was introduced to the jirofession of Philadelphia by the late Dr. A. II. Smith. This medicine was given for one month, then omitted for two weeks, and again taken for one month. After this, she was given iodide of iron in small doses for two months. In summer she was sent to the mountains, and encouraged to ramble in the open air, to drive, and occasionally ride on horseback. The diet that was first recom- mended was continued, except that she occasionally indulged her fancy for sweets. MENSTRUATION AND ITS DERANGEMENTS. , 45 Under this course of treatment she lost flesh, and grew taller and stronger. Her pulse was markedly improved, and her appetite con- tinued to be very good. At the age of fifteen years and three months she showed evidences of maturity, and simultaneously her appetite became somewhat capricious ; backache and headache occa- sionally troubled her, and she was at times depressed. The mixture of the chlorides was resumed and continued for one month. Her usual order of life was continued, except that she did not ride on horseback, and was carefully guarded from overtaxation, mental and physical. The menses appeared and continued for four days normally, and were not attended with great pain. In six weeks the flow returned, and lasted the same length of time. From this on- ward for one year the menses were normal. After that, she went to a higher school, and tried to make up for lost time in her studies. During this time she was not seen, i. e., for about one year and four months. Then she called upon me, and the following history was obtained : Her appetite was capricious,- and her bowels constipated ; she had headache often ; slept in a restless, dreamy way ; had pain in the prsecordial region and dorsal portion of the spine ; was easily frightened, and had palpitation of the heart on taking exercise. The menses were delayed for two weeks, and when they returned the flow was scanty, and lasted only three days. At this time she had a more marked chlorotic appearance of the face than at any time before. The pills previously prescribed were given to keep the bowels regular, and the mixture of chlorides was given for one month, and after that she was given twenty minims of the sirup of the iodide of iron three times a day. The thought of falling behind in her studies grieved her so much that she was placed under the care of a governess, who interested her in her studies but did not harass her. The menses became normal again, and she regained her general health, and has since continued well. She is at this time married, and the mother of one child. Comments. — It is not possible to prove that this patient would have become a well-defined chlorotic subject, but I believe that she would, had she been neglected, as most of these cases are. In my clinical records I find several cases of this kind, and most of them have been greatly aided by care and medication similar to that used in the management of this case. The benefit of treatment has been most marked in those who came under care early in life. Those who had no treatment until after puberty, and were suffering from all the symptoms of typical cases were improved by treatment, so 46 DISEASES OP WOMEN. far as obtaining relief from deranged digestion and neuralgia, and to some extent from anaemia, but tbej still maintained their consti- tutional peculiarities, with a tendency to recurrence of the anemia and menstrual derangements. In those who married early and bore children (a not unusual thing for those in whom chlorosis is not marked), there was a notice- able predisposition to albuminuria and puerperal convulsions. Snch cases also tend to inertia of the uterus and post-partum hsemorrhage. Thev very generally suffer from aniemia and nervous exhaustion during lactation. A Marked Case of Chlorosis, complicated with Gastric Derange- ment. — The patient was a domestic, twenty-three years of age, and presented all the characteristics of chlorosis in a typical degree. She had suffered repeatedly from amenorrhcea, but had always responded to tonics sufficiently to resume her duties in a few weeks. She was attacked with vomiting, her strength failed rapidly, and she was unable to leave her room for weeks. When she took food it gave her distress, until it was rejected. Sometimes food would be vomited after having been retained in the stomach nearly an hour, but it was not in any degree digested. Gastric ulcer was suspected, although she had never vomited blood. She was given peptonized milk as the only food. This^ she retained in increasing quantity, and gradually regained her usual health. Comments. — This case shows the strong characteristics of ex- treme ansemia in chlorotic patients. I believe that the stomach is unable to digest food because of the anaemia, and this causes the vomiting. In such cases the peptonized food is of the greatest possil)le value. Menstrual Derangements from Causes independent of the Sexual Organs.— This class of menstrual disorders is closely related, in the matter of diagnosis, to those deranged functions of the uterus due to anatomical lesions ; hence the subject may appropriately be dis- cussed here. It is only necessary to call to mind all the condi- tions necessary to menstruation to see plainly that constitutional diseases, acute and chronic, as well as functional disturbances of the nervous system, would act unfavorably upon the functions of the genital system. As a general rule, any constitutional affec- tion wliich impairs nutrition and reduces strength very decidedly will affect menstruation. This is certainly the case when the gen- eral depression continues for any great length of time. The best MENSTRUATION AND ITS DERANGEMENTS. 47 example of tliis is seen in phthisis puhnonahs. In the advanced stages of this disease the menses usually stop altogether. The uterine function ceases under these circumstances, simply because the general system is unable to sustain it. In acute diseases, such as pneumonia or typhoid fever, menstruation may be interrupted for a period or two, but it usually reappears when the patient fully re- covers from the constitutional disease. On the other hand, in degen- erative diseases, such as organic diseases of the liver, lungs, heart, or kidneys, the menses often become irregular and scanty or profuse, and finally stop altogether during the remainder of the invalid's life. So, also, severe shocks or over-taxation from shock, exposure to cold, fear, grief, and extreme mental work, may cause the menses to temporarily cease. Again, either of the constitutional conditions referred to above may retard the first appearance of the menses if they are active at the period of puberty, even though the develop- ment and growth of the genital organs may not be arrested. Amenorrhcea, or delay of the advent of the menstrual function, is the rule when these causes exist. There are exceptions to this rule, as, for example, valvular lesions of the heart and cirrhosis of the liver, may cause menorrhagia, and nervous derangements may cause premature menstruation. The diagnosis in such cases is usually easy. By the time that the uterine function becomes deranged, the constitutional disease is so far advanced as to be easily recognized. One is greatly aided in diagnosis when the menses have for a time been regular, but become deranged without any disease of the sexual organs being present. When amenorrhcea occurs as the result of some constitutional disease that is incurable, the special interest of the gynecologist ends when the diagnosis is made, because no special treatment is of any avail. On the other hand, in menorrhagia, when due to chronic affections of the heart, liver, or kidneys, something may be accom- plished in the way of modifying the trouble, and thereby prolonging the life of the patient. Here also the management is general, not special, and hence does not come within the scope of the present work. Premature Menstruation from Deranged Conditions of Life and Deranged Innervation. — The rule that the menses should appear after the completion of development which occurs at puberty is violated in the cases now under discussion, because the uterine function is taken up before the general development is completed. In determining the question of premature menstruation it is necessary to ascertain whether the patient is suflSciently mature in development to render 48 DISEASES OF WOMEN. lier capable of taking up this uteiiae function. She may be old enough, but not developed enough in her general system. The causes of this too early appearance of the menses are various. It seems that opposite conditions of life produce the same results. Bad air, poor food, overwork, and impure social surroundings, have this ill effect ; at least, cases frequently occur among those who are so poor that they fail to obtain all that is necessary to health. This fact regarding the premature activity of the sexual system appears to arise from a law in Nature, which is that all plants and animals placed in unfavorable environments devote more of their energies to reproduction than those that are more favorably situated. It would appear as if they appreciated their danger of being crowded out of existence, and hence struggle more vigorously to procreate. Yiewing the subject in this light it may be said, to speak figurative- ly, that girls and plants while stunted by living in poor soil run to seed. The same premature menstruation occasionally occurs among those who are favorably situated in regard to the necessities of animal life. Those who have the means of supplying all their wants, real or imaginary, and lack intelligence and culture, which would enable them to profitably occupy their minds, suffer like the poor. This would indicate that the real cause of the sexual precocity was deranged innervation. Delay of the advent of menstruation occurs among those who are situated apparently like those just described. The girl who labors out-of-doors and develops great muscular strength may fail to menstruate until past the usual age. So, also, the same thing occurs to some who live in luxury. In such cases the cause is, no doubt, imperfect innervation. In the class first described attention is given to the genital system prematurely, M'hile in the second class the social element of life is neglected. The general management of these patients consists in removing the cause, if possible, by placing them in such healthful surround- ings as will prevent the evil. This, however, is not always in the power of the physician, and he has to meet the wants of those really in suffering. When the menstrual function has been established, though prematurely, no effort should be made to sto]) it. Attention should be given wholly to building up the general system. The overworked should obtain rest and good food. The nervous system should have attention. The perverted mind-action should be cor- rected by wholesome brain-occupation. The indolent should be stimulated to greater activity. Society is desirable for those in MENSTRUATION AND ITS DERANGEMENTS. 49 "whom the menses are delayed, and quiet country life should he pre- scribed for those who have suffered from premature social excite- ment. ILLUSTRATIVE CASES. Premature Meastruation from Deranged Innervation, produced by Luxurious Surroundings and Over-Stimulation of the Nervous System. — The patient was an only daughter of wealthy parents, and was al- ways a bright child and greatly indulged by her family and friends. She was treated at home and at school more like a young lady than a child, and was almost constantly in company. In the parlor and drawing-room she associated with her elders, and was devoted to the opera and theatre from the time she was big enough to visit such places of amusement. She often suffered from headaches and indi- gestion, and was always excitable mentally, and at times peevish and irritable. She menstruated first at eleven years quite freely, and the How lasted four days. At this time she had all the ap- pearances of girlhood. The mammary glands were slightly de- veloped, but her foi-m had not attained anything like maturity. Trom this time onward she menstruated regularly and normally. She was first seen during her first menstrual period, and then her parents were advised to change all her habits of life. She was taken to a quiet country home in summer, instead of a fashionable hotel at which she had previously passed her summers, and permitted to spend her time in the fields with her attendant, who was a woman of good common sense and experienced in the proper care of chih •dren. All excitement was kept from her, and her habits of life xnade regular and natural. In winter she was permitted to attend school for half the time, and the rest of the day was devoted to draw- ing, reading, and gymnastic exercises. Abundance of sleep in the early part of the night was directed, and cold bathing every morn- ing. No medicine was given. Under this general management she grew in size quite rapidly, and by the time she was sixteen years old she was a well-developed young lady, and enjoyed very good health. Premature Menstruation occurring in a Poor, Ill-cared-for Girl, "from the Lowest Grade of Society. — This patient, a hospital one, was ten years and five months old when she first menstruated. She lived in one of the poorest tenement regions of the city. Her father was :a drunkard, and left his family to the care of the mother, who was a washer- woman. This girl lived by begging while very small, and when older worked in a tobacco-factory. She was thirteen years old when seen in the hospital, and had menstruated regularly from the -age mentioned. Her general health was poor, very poor ; she had 5 , 50 DISEASES OF WOMEN. the appearance of an undersized, ill-fed, undeveloped girl, quite ignorant, and doubtless of low moral nature. She was in the hospi- tal to be treated for specific vaginitis. Delayed Menstruation in a Girl who was large, strong, and in good health. — The daughter of a poor farmer had spent most of her life in doing out-door farm-work. Her food was milk, oatmeal, and potatoes. She was large, muscular, and full-blooded. Between six- teen and seventeen years of age she developed the characteristics of womanhood, but at the age of seventeen years and six months the menses had not appeared. She was then suffering from occasional headaches, backache, drowsiness, constipation, and general indisposi- tion. These symptoms, with delay in the appearance of the menses, caused her to seek advice. She was very muscular and tine-featured. The pulse was full and strong, the mammary glands well developed, and her figure was markedly of the female type. A teaspoon ful of sulphate of magnesia and half a teaspoonful of table-salt in a goblet- ful of water were ordered every morning an hour before breakfast. The liberal use of animal food was directed. She was advised to take a vacation from her hard labor on the farm, and visit her rela- tions who were more comfortably situated. These directions were followed out for a month, with no effect, except to relieve her con- stipation. The saline mixture was stopped and the following or- dered : Quinine sulph., 3i; ext. belladonnae, gr. ij ; ext. aloes aq., gr. iv. Pil. no. xx : one before each meal. When the headache and general feelings of malaise returned, I prescribed spiritus ammon. arom., 5«^s; aquae camph., 3 i jss — a dessertspoonful every three hours. At the end of two months, she began to menstruate. There was considerable pain accompanying the flow, which was rather dark in color. The pills were continued, but she was soon able to give up one a day, and then two, and finally ceased taking them altogether. At each period, which recurred regularly, she took the ammonia and camphor mixture. Six months after her first men- struation she reported that she was regular and (piite Avell. Delayed Menstruation in a Patient of Marked Phlegmatic Tem- perament and Indolent Habits. — The daughter of wealthy parents, of average height but quite stout, and presenting all the evidences of the phlegmatic temperament, was brought to me at the age of six- teen, because she had not menstruated. I learned that she lived well, slept much, and took but little exercise, mental or physical. She had all the appearance of having arrived at puberty, and for one year had had a slight leucorrhrea, but no menstrual How. She was ordered to take lessons in horseback-riding, and to walk for half an MENSTRUATION AND ITS DERANGEMENTS. 51 hour twice a day. A Turkish bath with thorough massage three times a week was also directed ; I prescribed potass, permanganat., gr. XXX, in piL no. xxx : one three times a day, before meals. This treatment was contiinied for about three months, excepting that at the end of one month the pills were omitted for three weeks and again taken up, and continued until the end of the three months. At this time she menstruated, and continued to do so regularly after- ward. The ilow was never very free, but it continued about live days each time. Irregular Menstruation from Deranged Innervation and Anaemia. — This patient was twenty-live years of age, of sanguine, nervous tem- perament, and had been in good health up to the time that she was nineteen. She menstruated first at iifteen, and continued to do so regularly, until the year that she graduated in school, when nineteen years old. Dm-ing the latter half of her last year in school her menses became irregular, six weeks or two months in- tervening between the periods. At this time her health became much reduced, but after leaving school she improved generally, and the menses became regular. At twenty-four years of age she began to indulge to excess her love for music and painting, which had always been favorite studies with her. Dyspepsia and general debility fol- lowed, and the menses became again irregular. She first came under my care at twenty-five, and at that time the menses had been absent for three months. She was quite anaemic, and her nervous system much exhausted. She was ordered to give up her favorite studies, and devote herself to regaining her lost health. She was directed to take three regular meals a day, and in the forenoon a cup of beef- tea or a glass of milk, and in the afternoon extract of malt, or else peptonized milk and a glass of claret. Before her regular meals she was given tr. nucis vom., ^^, iij ; vini ipecac, ^J ij, in a wine-glass of warm water. This improved- her appetite. After meals she took a teaspoonful of the following: Tr. ferri chlor., 3 iij; lic[- ai*- senic. hydrochlor., 3 j ; spiritns limonis, 3 ss ; syr. simp., ^ j ; aquae font., ^ij. This treatment was continued for three weeks, with the effect of improving her general condition, but the menses did not return. In place of the iron-mixture she was given the permangan- ate of potash pills, but without any apparent effect. Iron was again given, and the menses returned after she had been six weeks under treatment. She continued to be irregular, some five and six weeks between the periods, but, as her general health improved, the inter- menstrual, periods became shorter, until the normal time was estab- lished. Altogether she was under observation for one year, and 52 DISEASES OF WOMEN". during most of that time she took tonics containing some form of iron. Citrate of iron and quinine, iodide of iron and whisky, po- tassio-tartrate of iron and wine, were the chief preparations given. Suppression of the Menses from Acute Derangement of Innervation. — A hidy, twenty-one years of age, of excellent physique, who had menstruated with great regularity from the time that she was lifteen years of age, left home for the lirst time in her life to visit some friends in a far-distant city. On the day that her menses should have appeared, she was alone and not accustomed to traveling, and she hecame much excited over her journey, and was greatly fatigued when she reached her friends. She could not sleep on the cars, and her appetite left her almost altogether. I was called to her on the third day after she left home, and a few hours after her arrival. The menses had not appeared ; her head ached very acutely ; her face was flushed ; skin dry and pulse excited. The temperature was 100° Fahr. I ordered a hot foot-bath and the forehead bathed with alcohol, and prescribed ammon. bromid., gr. xv, tinct. aconit. rad., tt], i], every three hours in a small glass of Vichy water. She was kejit quiet in bed. After taking three doses of the medicine, she slept fairly well during the night. Next morning her headaclie was almost gone ; her pulse was quiet ; flushing of the face less notice- able, and she had an appetite, but the menses had not come. I pre- scribed camph., gr. v ; ext. lupul., gr. x ; ext. valerian, gr., x : in cap- sul. Xo. X. One to be given every three hours during the day and following night if awake. She slept well in the night and next morning began to menstruate. Amenorrhcea from Chronic Derangements of Innervation. — This patient was twenty-four years of age, of good constitution, and had menstruated normally until six months before the taking of this his- tory. In that time she lost her motlier, to whom she was greatly devoted. This prostrated her with grief, and about the same time her father suffered reverses in business, so that my patient, who had up to this time lived in luxury, was obliged to seek employment to support herself. From the death of her mother she failed to men- struate until nine months aftei'ward. She was greatly depressed \\\) to the time that she began treatment, and, although her general health was good, she was melancholy, and was greatly annoyed by her new occupation and changed social position. The amenorrluini was a great source of anxiety to her, because some of her friends had told her that it was sure to lead to consumption. I fully assured her that she was in no danger, and that her recovery was certain. This alone was a decided tonico MENSTRUATION AND ITS DERANGEMENTS. 53 I ordered the following : Strychnise sulphatis, gr. ss ; tr. cannabis Indie, 3 ij ; tr. card, comp., ^ j ; aqnge font., § ij- Teaspoonful be- fore meals. This she continued for two weeks. I tlien ordered Parrish's compound sirup of phosphates, a teaspoonful, after meals, in water. This was taken regularly for three weeks, when the fol- lowing was given instead: Quin. sulph., 3ij; ext. valerian., 3j; ext. cannabis Indic, gr. v : in capsul. No. xxi. One before meals, and a glass of red wine after meals. This was continued for over a month. During this time she was induced to take more out-of-dooi- exercise, and divert her mind by light amusements. General gym- nastic exercise was taken, but not systematically nor regularly. When this course of treatment had been employed she menstruated, and from this time on was regular and well. In general spirits she began to improve considerably before the menses returned, but after- ward her progress was rapid, and recovery complete. This case will suffice to illustrate this cause of amenorrhoea. Imperforate Hymen causing Non-appearance of the Menstrual Flow. — This affection should be classed with atresia of the vagina, but is given here because the history of such cases resembles delayed men- struation from some of the causes just given. This condition is usually unnoticed until puberty, when all the evidences of menstrua- tion appear except the flow, which is arrested by the imperforate, thickened hymen. The fluid which accumulates at each menstrual period distends the vagina first and then the uterus, the distention increasing at each period. Pelvic tenesmus, a feeling of distention of the vagina, and enlargement of the abdomen are the chief symp- toms and signs presented. In course of several months the suffering causes the patient to seek relief, when a diagnosis can be made by physical examination. The treatment is to evacuate the fluid by opening through the hymen. This is attended with great danger, owing to the tendency to inflam- mation and septicaemia. The fluid is dark, thick, and tarry in char- acter, and decomposes quickly on exposure to air. This and the irritation of the vagina and uterus may account for the tendency to inflammation and blood-poisoning. The method of treatment found, in past times, to be the safest was to make a small opening, evacuate very slowly, and subsequently enlarge the opening, or exsect the hymen entirely. Another method is to make a free incision with the incandescent knife of a thermo-cautery, evacuate rapidly, and wash out the uterus and vagina. This method has proved to be safer since the days of antiseptic surgerj^, and may be adopted. CHAPTER IV. FLEXIONS OF THE UTEKUS. I coNsroER flexion of the uterus as a deformity, and it certain- ly belongs to that order of pathological conditions. The pathol- ogy, cause, symptoms, physical signs, and treatment of flexion, all differ from version, hence a clear distinction between the two should be made in order to avoid confusion. Anteflexion of the uterus is most frequently a congenital deform- ity, some arrest or derangement of development giving rise to the malformation. Occasionally it results from disease, inflammatory or degenerative, which weakens the uterus at a certain point and permits it to become bent upon itself. I shall limit myself to the consideration of flexion occurring as the result of these two causes, and shall purposely omit all deformities caused by pre-existing affec- tions, such as adhesions of the uterine body to other pelvic organs, tumors in the walls of the uterus which by their weight bend the uterus, and pressure of abdominal tumors which crowd the uterine body to either side. Whenever flexion is produced by some such antecedent disease, I prefer to consider it as a complication of the primary affection, rather than to discuss it as a distinct condition. The point of flexion is at the junction of the body and cervix. It may occnr above or below that point, but only as a very unim- portant exception to the rule. The several forms of flexion I have denominated first, second, and third. The first is flexion of the body ; the second, flexion of the cervix ; and the third, flexion of both l)ody and cervix. Taking the ground that flexion is a deformity, it may naturally be attributed to some defect of development ; and in order to un- derstand the lesions of form and structure arising from arrest or derangement of development, it becomes necessary to restate the essential points in that process as relates to the uterus. At l)irth the uterus and vagina are joined in such a manner that 54 FLEXIONS OF THE UTERUS. 55 tlie cervix uteri projects into the vagina but a very short distance, and about equally on the anterior and posterior walls of the vagina. After birth the uterus remains without change until puberty, ex- cept during the time of second dentition, when the palma plicata disappears from the body of the organ, with the exception of one fold which runs lengthwise. The body increases a little in size, so that the body and cervix become more nearly equal. At the same time the organ settles down into the pelvic cavity, and the cervix elongates and becomes more prominent in the vagina. At puberty the uterus undergoes secondary development. The ■organ increases in size, this being especially true of the body. Un- til puberty the uterus differs but little in shape from that of the new-born babe, which has been already described ; but at the time when menstruation or functional activity of the reproductive organs is about to be established, it assumes the form and structure of the mature organ. Suffice it to say that, as the tissues are developed, they become denser, giving to the organ the firmness necessary to support it and keep it from bending in any direction by its own weight. There are two anatomical points bearing upon the subject now under consideration to which I desire to call particular attention : 1. The position or relations of the uterus to other pelvic organs at birth, during girlhood, and after puberty. 2. The relations of the cervix uteri and the vagina at the com- pletion of 23rimary formation and after secondary development. The infantile pelvis is relatively narrower, deeper, and less curved than the adult ; hence the canal formed by the uterus and vagina is straighter than after puberty. The small size of the infantile uterus, the thinness of its walls, and flaccid condition of its tissues, render it capable of bending forward or backward according to circumstances. This fact may account for the variety of opinions regarding the position of the uterus previous to puberty. At birth the uterus is high up in the pelvis, but settles down during the second dentition, as has been already stated, and forms with the vagina the arc of a smaller circle, having its concavity forward ; hence the greater liability of the uterus to be antefl.exed or anteverted during girl- hood, if it deviates at all ; but, according to Klob, the uterus is neither bent forward nor backward until puberty. From the information obtained by the study of embryology and the anatomy of the reproductive organs, one must necessarily con- sider the uterus and vagina as forming one canal. The peculiar ar- rangement at the junction of these organs appears as if formed from 56 DISEASES OF WOMEN. an invagination, the upper part of the vagina receiving the dupli- cation of the uterus which forms the vaginal portion of the cervix. This invagination is very slight at birth, as may be seen by referring to any normal infantile uterus. The projecting portion of the cervix at this period is about equal, anteriorly and posteriorly. During the period of second dentition, when the uterus settles down, this portion of the cervix becomes more apparent still. It will also be observed that the posterior wall of the cer\dx projects a little farther than the anterior. At puberty, when the sexual organs undergo secondary development, invagination progresses still further, and the cervix and vagina assume the relation of adult maturity. It should be noted that the poi'tion of the cervix which projects into the vagina is much longer posteriorly than anteriorly. This must neces- sarily be so, to some extent, from the fact that the uterus and vagina form an arc of a circle corresponding to the curve of the pelvis ; but the difference is slightly greater than is necessary to make the curve form part of a circle. Perhaps it would be more correct to say that the junction of the cervix and vagina forms an obtuse angle. I am thus particular in describing these relations of the uterus and vagina, because I hope to show hereafter that arrest or derange- ment of the process of invagination of the cervix uteri has much to do in causing flexion. Anteflexion of the Uterus. — I prefer to consider anteflexion of the uterus a deformity, although it is usually called a displacement, because it certainly is a lesion of form rather than position. The pathology, cause, symptoms, physical signs, and treatment of flexion all differ from those of displacements of the uterus, hence the clearer that the distinction between the two can be made the better. The deformities which occur at pul)erty are perhaps more fre- quently lesions of size or quantity from arrest of growth than lesions of form from arrest of develo]^ment. Daring secondary development the infantile uterus is transformed into that of the adult chiefly by the increase in the size of the body and fundus, and the dipping down of the cervix into the vagina. When these changes do not take place properly, especially if the invagination of the cervix is arrested, the uterus becomes flexed upon itself. Other causes of this malformation there are which will be again re- ferred to. Anteflexion of the uterus is usually a congenital deformity, caused by arrest of development occuri-ing during the later stage& of that process. It is inferred from the clinical history of flexion FLEXIONS OF THE UTERUS. 57 that it is congenital, but this is not perhaps strictly true of all the cases that occur as primary lesions. I presume that most frequently the malformation takes place during secondary development at puberty. Occasionally it comes from some pre-existing disease, in- flammatory or degenerative, which weakens the walls of the uterus at the junction of tiie body and cervix and permits it to become bent upon itself. Retroflexion often, perhaps generally, is devel- oped from retroversion, the one holding a causative relation to the other, but this form of acquired flexion will most conveniently come uiider the head of retroversion and its complications. Clinically considered in relation to causation there are two classes : the congenital, called so because it is usually first recognized at pu- berty ; and acquired, because it generally appears after puberty and follows some previous uterine disease either inflammatory, or a mal- nutrition which reduces the quantity of tissue at a given point, and permits the uterus to bend upon itseK. Flexions from these two causes constitute a class by themselves, and therefore they alone will be treated of in this connection. Flexions occur in connection with other affections, such as adhesions of the body of the uterus to other pelvic organs ; tumors in the walls of the uterus, which, by their weight, bend the uterus upon itself ; and pressure from ab- dominal tumors which crowd the uterine body out of place ; but flexion in such cases is only a complication of the affection which causes it, and does not belong to the subject of flexion as a primary lesion. Theoretically, the uterus might become flexed in either direction ; but practically the forward and backward, anteflexion and retroflexion, are the only two forms that occur as uncom- phcated affections. The later- al flexions are, as a rule, sec- ondary to the diseases already mentioned. Anteflexion, which occurs as the result of imperfect de- velopment, and which is oc- casionally acquired from mal- nutrition, is by far the most common. There are three varie- ties of anteflexion : First, anteflexion of the cervix (Fig. 34a) ; Fig. 3-la. — First variety ; anteflexion of cervix. 58 DISEASES OF WOMEN. second, anteflexion of the body (Fig. 35) ; and, third, ante- flexion of both body and cervix (Fig. 36). Pathology. — Flexion of any form necessitates some defect in the structure of the uterus. This constitutes one of the essential differ- ences between flexion and version, which latter is sim- ply an error of location without, necessarily, any change of structure of the uterus. The flexion is usu- ally at the junction of the body and cervix, the point corresponding to the inter- nal OS. Flexion at any point in the body or cervix oc- curs only as an exception, At the point of flexion the On the side to which On Fig. '■'>'■). — Seconi variety ; anteflexion of body of uterus. which need not be noticed here, tissues of the uterine walls are deficient the organ is bent the wall is com])ressed and attenuated the other side the loss of tissue is not so marked, the thickness being but slightly diminished by the stretching. The sub- mucous, fibrous stratum of tissue, which is said to give firmness and support to the organ, is absent or deficient on the side to which the uterus is bent. The effect of flexion on the uterine canal is to produce constriction or occlusion of the internal os. The external OS is sometimes more open than in health, owing to trac- tion being made on the pos- terior lip. The stricture thus formed gives rise to accumu- lation of the secretions of the uterine cavity, and to partial retention of the menstrual i)roducts. The circulation in the uterus, as will be Fig. \'^\. — Tliiril varici y ; antctUwiuii of body and cervix. FLEXIONS OF THE UTERUS. 59 readily understood, is interfered witli. Tlie obstruction tends to keep up congestion, and this may eventually lead to oedema and a predis- position to endometritis. The menstrual fluid, in place of escaping passively, is expelled, perhaps, by spasmodic contractions. The submucous stratum of fibrous tissue is in some cases abnormally dense aiid resists the swell- ing of physiological congestion and this causes pain. These patho- logical conditions increase with time. The pressure at the point of flexion produces anaemia and atrophy of that part, and the intrinsic support of the uterus being thus diminished the flexion increases. Hence, anteflexion of the flrst two varieties often pro- gresses to the third. The anatomical appearances in flexion are well described in ISTie- meyer's '" Text-Book of Practical Medicine." I quote that portion which applies to anteflexion of the body of the uterus : " On autopsy, flexion of the uterus may be readily recognized, as part of the pos- terior wall of the body, instead of the fundus, forms the highest part of the uterus. Generally, we may restore the sunken fundus to its position, but it sinks back again to its former place when we let go of it. If we remove the uterus from the body, and hold it erect by the vaginal portion, the fundus sinks down anteriorly ; if it be held horizontally, it not infrequently holds its weight if the flexed side be upward, but it bends together if we reverse it." To this I would add that in the first variety the cervix projects into the vagina much farther on the posterior wall than on the anterior ; indeed, in marked cases, the anterior lip of the cervix uteri is very little below a line corresponding to the point of union between the cervix and the an- terior vaginal wall. Natural History of Anteflexion. — Symptomatology. — Derangement of uterine Junction constitutes the principal point in the natural his- tory of flexion. Menstiiiation, from its first establishment, is often painful — there is dysmenorrhoea. The severity of the pain bears some relation to the extent of flexion. The greater the deformity the more marked is the pain, though there are exceptions to this rule. The character of the pain is of the greatest importance. It is inter- mittent, and always precedes the flow. When the flow begins, the pain either subsides or becomes much less. The pain closely resem- bles that which occurs in abortion in the early months of pregnancy. The reason, I presume, is that while the fluid is accumulating in the uterine cavity, pain is excited by distention ; but the flow when once started, continues with less expulsive eftbrt. Painful men- struation often occurs without flexion, but in such cases the piain 60 DISEASES OF WOMEN. continues throughout the whole period, or during the early part of it, and is not relieved by dilatation of the cervix ; while in flexion it precedes the flow, and is relieved temporarily by dilatation. This pain, at the commencement of menstruation, is the most prominent symptom in the history of flexion as it occurs in the young girl. The trouble tends to increase gradually. If the patient gets married, all the symptoms usually increase. Should she become pregnant, there is great liability to miscarriage during the early months. The effect of the pregnancy, however, in part at least, is to remove the deform- ity, even wlien miscarriage occurs, so that pregnancy is likely to occur again, and go on to full time, and the deformity is cured completely. Checking the menses by exposure to cold, or any cause which will produce hypersemia of the uterus, or endometritis, promptly increases the dysmenorrhoea, and gives rise to new symptoms. Leucorrhoea, backaclie, local tenderness, deranged digestion, and nervous disturb- ances, are all added to the original symptoms. Sometimes in ante- flexion frequent micturition is a marked symptom. There are all varieties and degrees of prominence of the symp- toms in the natural history of flexion. The dysmenorrhoea which begins at puberty may continue, and increase but little through life. This is most likely to be the case if the individual remains unmar- ried, and can avoid all the conditions which tend to aggravate uter- ine disease. On the other hand, the dysmenorrhoea may increase in severity during each succeeding menstruation, and after marriage become intolerable. In the intervals between the menstrual periods the patient in her early life is free from trouble, but eventually symptoms of uterine and vaginal inflammation are manifested. Constitutional derangements, especially of the nervous system, fol- low, and in time we have the broken-down, miserable patients, famil- iar to all practitioners. Such patients often seek relief in the use of stimulants and opium, which only soothe for a time, but eventually aid in undermining the health and strength of the unfortunate suf- ferers. Owing to the fact that all imperfectly developed organs are less able to resist the causes of disease, the subjects of flexion are very liable to pelvic peritonitis and diseases of the ovaries and Fallopian tubes, with all the suffering which these affections give rise to. Physical Signs. — Although the history alone might lead one with a tolerable degree of certainty to suspect the presence of flex- ion, the physical signs must be depended upon for an accurate diag- nosis. The physical signs of flexion arise from the changed relations of the body and cervix to each other. These signs are detected by FLEXIONS OF THE UTERUS. 61 the touch and the uterine probe. The touch may indicate that the cervix is in its normal position, or is anteflexed, the os pointing toward the introitus in the same way that we find it in retroversion. The vaginal portion of the anterior wall of the cervix is much shorter than the posterior. Carrying the finger along the anterior vaginal wall, the body of the uterus can usually be felt bending for- ward. The bimanual examination reveals the deformed condition of the uterus in lean patients, whose abdominal parietes are yield- ing ; but in fleshy subjects with rigid abdominal muscles, very little can be learned by this mode of exploration. When rigidity of the parts is the obstacle to exploration, an ansesthetic may be used with great advantage, as practiced by Sir J. Y. Simpson. When the signs thus obtained point to flexion, the diagnosis should be confirmed by using the sound. Much trouble is often experienced in introducing this instrument. Indeed, it is impossi- ble in extreme flexion to carry the sound into the uterus without first straightening the bend at the junction of the body and cervix. To do this, the cervix should be seized by a tenaculum, and gently drawn downward, while at the same time the fundus is pressed up- ward and backward with a probang. In this way the canal is par- tially straightened, and the sound can be introduced. There are cases where it is only necessary to curve the sound properly and manipulate with care, and the point of flexion can readily be passed. When the sound passes into the body of the uterus in the direction indicated by the touch, the diagnosis is complete. While there are many conditions which might present the signs of flexion as obtained by the touch, the combined testimony of the touch and sound are sufficient to make the diagnosis sure. Causation. — There are several causes of flexion, and this may account for the different opinions held by authors on this subject. The errors, I presume, come from investigators accepting the cause found in a limited number of instances as applying to all cases of flexion. Some of the more important causes assigned may be briefly noticed. Rokitansky considered that the peculiar density and arrange- ment of the mucous membrane of the cervix and lower part of the corpus uteri formed one of the chief supports of the organ, and gave it its slight anterior inclination ; consequently, he looked upon the pathological state of this layer as the basis in the development of uterine flexions. He thought the uterus bent upon itself, from cir- cumscribed atrophy of one of its walls, arising from inflammation. He claimed that the glands of the mucous membrane, becoming dis- 62 DISEASES OF WOMEN. tended from imprisoned secretions, so pressed upon the other tissues as to cause atrophy at that part. When the distended glands rupt- ured and collapsed, the part rendered thus defective permitted the uterus to bend upon itself. Several eminent writers on this subject, Dr. Ludwig Joseph being the most recent, after careful observa- tions, have been unable to discover this peculiar condition of the mucous membrane and its submucous layer to which Rokitansky alludes. If they are correct, further discussion of this supposed cause is useless. Should Rokitansky be right, the cause he favors would chiefly aifect cases of acquired flexion ; while the majority of cases occur before we have any evidence that inflammation pre- ceded it. Virchow attributes the primary cause of flexion to congenital shortness of the anterior uterine ligaments, which drag the body of the uterus forward, or flex it. The uterus being held in this posi- tion, pressure results, which leads to atrophy of the tissues, and thus all the conditions of flexion are present. Klob, who is one of the best authorities on uterine pathology, doubts the views expressed by Yirchow, and states that with the nor- mal flrmness of the tissues the uterus is not likely to be deflected by the cause in question. He also calls attention, as a reason against the theory of Yirchow, to the fact that false membranes or short liga- ments, which would incline and fix the fundus forward, would ne- cessarily cause pressure on the fundus of the bladder. This would cause the bladder to distend more in its lowest portion, which would press the lower part of the cervix uteri backward, and in place of producing flexion would cause anteversion. Klob admits that the cause assigned by Yirchow may produce or maintain flexion, but only when there is defect of tissue in the uterus itself, arising from some preceding cause. The relation of the bladder to the uterus is looked on by some writers, including Yirchow and Ludwig Joseph, as of some impor- tance in the etiology of flexion. The uterus is known to make a descent corresponding to the variations in the shape of the bladder, which in fcetal and infant life changes from the elongated fusiform to the short ovoid shape, and its fundus, thus approaching the floor of the pelvis, draws the attached uterus with it. As the cervix uteri is closely attached to the posterior surface of the bladder, it will be readily understood that perverted development in the con- nections of the two organs might lead to flexion. The only causes which I consider worthy of discussion in con- nection with anteflexion, when it occurs as a primary or uncompli- FLEXIONS OF THE UTERUS. (53 cated disease, are : 1. Malformation resulting from arrested or im- perfect development. Flexion arising from this cause may be classed among the congenital deformities. 2. Deformities arising from in- flammation and degeneration of the uterine walls on one side. This will include atrophy of the anterior uterine wall at the os internum from inflammation and distention of the cervical glands ; also fatty degeneration in advanced life, and excessive involution after parturi- tion, by which one of the uterine walls is weakened at the junction of the cervix and body. These may be called acquired flexions. I purposely omit a number of conditions usually given as causes of flexions, such as metritis, enlargement of the corpus uteri, preg- nancy, uterine tumors, abdominal tumors, accumulations of fluid in utero, ascites, fecal accumulations, and adhesions from inflammatory exudations. Several of these causes, such as pregnancy, produce flexion so very seldom that they may be treated as exceptions to the ordinary laws of jjathology, and are of no practical importance. The others named are more important than the flexions which they pro- duce, and I should prefer to discuss flexion occurring under such circumstances as a complication of the prunary affection. It is, to say the least of it, objectionable classification, to discuss the primary and most important disease as the cause of a consecutive affection, and one which does not always follow. Regarding the first cause— imperfect development — I can readily see how flexion might occur therefrom. During the time when in- vagination of the lower portion of the cervix and upper part of the vagina takes place, the process is liable to progress farther on one side than on the other. Should the posterior vaginal wall become reflected much higher than the anterior, the attachment of the vagi- na, being lower on the anterior surface of the cervix, would naturally pull it forward. From the fact that this malformation at the junc- tion of the uterus and vagina is present in the vast majority of cases of anteflexion of the cervix, I have looked upon it as one important cause. If this arrangement should tend, as it probably does, to bring the cervix forward so as to flex the uterus to a slight degree previ- ous to its complete development, the pressure at the point of flex- ion would arrest the growth at that point, and then the wall would become more attenuated still, and flexion of the body would be produced. Imperfect development may cause flexion in another way. The infantile uterus, having little strength of tissue to support itself, might readily become flexed, and so remain during the period of secondary development. I am aware that good authorities, such as €4 DISEASES OF WOMEN. Klob, state that previous to puberty the uterus is neither bent back- ward nor forward ; but other observers have found the infantile uterus anteflexed in many cases, and one can readily understand why the organ might remain so. The position in sitting at school and in sewing so often maintained by girls, constipation, and improper cloth- ing, all tend to retard development and hence produce flexion. The uterus might readily increase in size at all parts except the portion compressed at the point of flexion. Flexion occurs also from excessive development of the cervix. The unnaturally long cervix pressing upon the posterior wall of the vagina is inclined forward, while the body of the uterus remains in its normal axis. This produces slight flexion, which in time becomes greater, on the principle that the deformity, once established, tends to increase. When flexion is caused by inflammation, the explanation given by Rokitansky and already referred to, applies in some cases of ac- quired flexion. Irregular involution is doubtless one of the causes of flexion when it occurs after confinement or miscarriage. If press- ure was brought to bear on the cervix, fundus, or both, so as to favor flexion, involution might go on beyond the normal limits at the point of pressure. Treatment. — A brief review of the various plans of treatment will, I believe, show that while they are of great value, and capable of giving relief in many cases, still it will be found that they do not fully equal all demands. The use of extra-uterine pessaries will re- lieve some of the prominent symptoms, but will not overcome the deformity. Intra-uterine pessaries, while they sustain the uterus in its normal shape, are objectionable in some respects ; they are often diflicult to introduce, are not easily held in position, and are liable in some cases to cause so much irritation as to make their prolonged use dangerous to life. The surgical methods which have for their object only to relieve the symptoms or evil consequences of flexion, are chiefly dilatation and division of one wall of the cervix. Dilatation is certainly of much value, but the improvement is often, indeed generally, only temporary. Division of one side of the cervix answers the same purpose as dilatation, and the effect is not more lasting. But neither of these modes of treatment overcomes the deformity altogether, and seldom permanently cures the troublesome symptoms. The merit of dividing the cervical wall appears to me to be, that it may correct the conditions of the flexion which cause sterility, and when that is accomplished, and pregnancy follows, the development of the uterus FLEXIONS OF THE UTERUS. 65 •during gestation permanently cures the malformation as a rule. If pregnancy does not follow, the patient is not always imj^roved, ex- cept temporarily, by the treatment. The objects to be attained in the treatment of flexions of the uterus are, to straighten the organ and to keep it so until the defect- ive portions of its walls become developed sufficiently to render it self-sustaining. Should the means used fail to overcome the de- formity, the next aim should be to relieve the patient from the con- sequences of the flexion by other means, such as dilating the canal of the uterus, or dividing the posterior wall of the cervix after the manner of Sims. The means to be used in the management of flexion must be adapted to each case, and hence the subject resolves itself into, lirst, the treatment of flexion of the cervix ; second, flexion •of the body of the uterus ; and, third, flexion of both. It follows, naturally, that the treatment of flexion of both the body and cervix — i. e., the third form mentioned — should include the treatment of the first and second forms. The treatment of flexion is as follows: When the vaginal por- tion of the cervix is unusually long and conical, amputation may be •called for, and is often followed by very satisfactory results. In the majority of cases a less important operation will answer. By clip- ping out a Y-shaped piece in each lateral edge of the os, and extend- ing upward from an eighth to a fourth of an inch, a few of the circular fibers are divided. This permits the longitudinal fibers to contract, and thus shortens the vaginal portion of the cervix. By far the most frequent and important lesion that occurs in the connection of the uterus and vagina is the imperfect invagination of the anterior wall of the cervix, which has been described under the head of pathology. To overcome this deformity, I have adopted the following plan of treatment : The patient is placed on her left side, and Sims's speculum is introduced. The anterior lip of the •cervix uteri is seized with a tenaculum, and the cervix drawn back- ward toward the hollow of the sacrum. This puts the anterior column of the vagina on the stretch, at the point where it is reflected on the cervix. The vaginal wall is then divided transversely with the scissors, about three fourths of an inch from the os uteri, the incision being from a quarter to three eighths of an inch deep (Fig. 3Y). The vaginal wall is dissected up, so that when the incised portion is put upon the stretch the sides will come together. In other words, the upper and lower edges of the incised central por- tion of the vaginal wall are drawn apart, and the sides brought together to flU the space, so that the transverse incision now ap- 6 66 DISEASES OF WOMEN. pears as a longitudinal one. Sutures are introduced, to keep the parts together till they unite (Fig. 38). 37. — (->peratiou for imperlect invagination. The incision. If the uterus is slightly below its normal level, and inclined to retroversion (a condition not uncommon in anteiiexion), much benefit will be obtained by introducing a double-lever pessary, largest at its posterior extremity. This will hold up the uterus, and, by making Fig. 38. — Operation for imperfect invaji^ination. Sutures in position. pressure in the posterior vaginal eul-'l<-.sa<\ draw the cervix back- ward, and thus hold the edges of the wound together and favor union. The effect of this simple and safe operation is to bring^ the anterior wall of the cervix farther down into the vagina, and permit it to extend backward more toward the axis of the pel- vis, where it ought to \)l\ Tliis ])Ian of treatment I have found to be sufficient for the relief of fiexion of the cervix uteri in many cases. FLEXIONS OF THE UTERUS. The treatment of flexion of the body of the uterus requires first that the organ should be made straight, and then that it should be kept straight, as already stated. The first ob- ject can be accomplished most easily by the use P; of EUiott's uterine adjuster (Fig. 39). I am in- 1 1 debted to Dr. T. G. Thomas for the knowledge j i of the method of using this instrument. It is ! '• similar to a uterine bougie, with a round metallic disk at its end. By turning this disk, the point of the instrument can be bent forward or back- ward at the will of the operator. In using it to straighten the flexed uterus the instrument is carried forward and passed into the uterus ; the disk at the end is then turned in the reverse di- rection, and the Itistrument, carrying the body of the uterus with it, is bent in the opposite direction until the body and cervix uteri are brought into line with each other. There are certain precautions necessary in using this instru- ment to straighten a flexed uterus, but these will be brought out in the history of cases which fol- low. In straightening the uteras with Elliott's ad- juster it is useful to bend the uterine body back- ward beyond the line of the cervix when this can be done without causing much pain. The stretch- ing of the wall of the uterus at the point of flex- ion stimulates nutrition and gives strength to the weak part. By repeating this treatment many times, much relief is given, and much progress I I made toward finally overcoming the defoiTaity. To keep the uterus straight in antefiexion of the body, two of the many methods commended I have found useful — the first being the use of a retroversion pessary to draw the uterus back- ward, as suggested by Emmet, in order to bring the cervix on a line with the body of the uterus. The other means is the intra-uterine stem with a vag-inal pessary to keep it in position ; the glass or hard-rubber stem and a closed ring pessary of soft rubber answers very well (see Fig. 40). In using the intra-uterine stem the greatest possible care should Fig. 39.— Elliott's uter- ine adjuster. 68 DISEASES OF WOMEN. be employed because of the great danger of exciting inflammation. Before resorting to the use of this instrmnent all congestion and irritability should be subdued as far as possible, and the uterus should be trained to tolerate a foreign body in its cavity. To accomplish this, all the ordinary means for the relief of metritis should be employed. Cocaine, which has proved to be of great value in other departments of surgery, is a great help to the gynae- cologist, especially in the management of the class of cases now under consideration. By the use of this agent the extreme hyperaesthesia, which renders the use of the sound not only painful but dangerous, can be completely overcome. When I first began to use cocaine I was fearful that, while the sound or adjuster could be used without pain under the effects of this local aiuEsthetic, there might be as much danger of causing inflammation as there would be without it ; but experience has proved that my fears were groundless. I prefer a two-per-cent solution, and depend upon repeated applications to produce the desired effect. This is a safe way of using cocaine. At the time of using the solution it should be at about the temperature of the body, and it should be introduced with a pipette. I apply it to the canal of the cervix and os internum, and in a few minutes pass the sound just beyond the internal os. If this causes much pain, I make another application and try the sound again ; and if it can be easily introduced, I permit it to remain in the canal for a minute or two. At the next treatment I repeat the application and use a larger sound, and, if this is well tolerated, I pass the pipette into the cavity of the body and apply the cocaine. If that causes no pain, I use the Elliott adjuster and straighten the uterus, if I can do so without causing suffering. At each subsequent use of the adjuster I apply cocaine until the tenderness disappears. Then the cocaine is omit- ted, and if the sensitiveness does not return I feel sure that the stem pessary will be tolerated. I am inclined to think that cocaine aids in relieving inflannna- tion. Its immediate effect is to reliev'e congestion, and although the hypersemia returns after the effect passes off, I do not believe that it does so to the original extent. Defects of the canal of the uterus are frequently associated with flexion. In some cases the whole canal of the cervix is too nar- row, and in others there is a stricture at the internal os. To over- come these defects, and to aid in correcting the flexion, several methods have been employed, tlie chief among them being incision and dilatation. When the constriction is at the external os uteri, FLEXIONS OF THE UTERUS. 69 Fig. 40. — Glass stem, with soft rubber base. I prefer incision followed hy dilatation, easy and gradual, or forci- ble. The first consists in passing graduated sounds, the other in using the uterine dilator (see Fig. 16). I prefer the forcible dilatation when there are no contra-indica- tions, such as extreme sensitiveness; but I do not approve of carry- ing the dilatation beyond that which is sufficient to admit a No. 12 or 16 English sound. The extreme dilatation practiced by some, which is carried to a point sufficient to ad- mit the index-finger, is dangerous and un- necessary. In cases complicated with endo- metritis, adenoma, or stenosis at the internal OS, I employ free dilatation, curetting, and packing with gauze. This treatment has been successful in so many cases that I now give it first place. If the flexion returns after this the stem pessary can be employed. A fuller account of this is given in the treat- ment of corporeal endometritis. Finally, it may be noted that success in the treatment of flexions depends upon the careful use of the means suggested, avoiding, as far as possible, the ever-present danger of exciting inflammation, which may make matters far worse. And much depends upon the age of the patient. It is always more easy to correct deformities in the young than in those of more advanced life. It should also be borne in mind that there is a tendency for the flexion and all con- sequent symptoms to return unless utero-gestation follows. On this account I have classifled the results of my treatment in married women under two heads, viz., relieved, and cured. The former em- braces those who have been relieved from dysmenorrhoea, but have remained sterile, and the latter those who have been relieved and have borne children. Ninety per cent have been relieved or cured of dysmenorrhcea, and about fifty per cent cured of sterility. Comparing my results with those of other gynecologists, I have reason to be quite in favor of the treatment that I have employed. Sims's operation — that is, dividing the cervical wall posteriorly and keeping it open — was the treatment of anteflexion years ago, and I followed that practice for a long time, but abandoned it in favor of the methods given above. Hearing very little about it now and for ten years past, I presume that it has fallen into disuse. About seven years ago Professor E. C. Dudley, of Chicago, in- 70 DISEASES OF WOMEN. troduced to the profession a modification of Sims's operation that found favor with many. The doctor's description of his operation is as follows : " Under ether the uterus is exposed by Sims's speculum. The uterine canal is dilated by means of Palmers or a light Ellinger's dilator sufficiently to permit the introduction of a dull spoon curette. The object of the curettement is to remove any granula- tions that may give rise to hypersecretion or menorrhagia. " The endometrium is then thoroughly irrigated with hot ster- ilized water. Then the cervix is divided backward in the median line considerably past the utero-vaginal attachment. The cut sur- faces are held apart by means of two tenacula — one in the hand of the operator and the other in the hand of an assistant — while the incision is somewhat deepened by means of a scalpel, especially on the side of the cervical canal. " On each side the surface thus incised is now folded upon itself and secured by silkworm-gut sutures. These sutures are not intro- duced in such a manner as to stitch the intra-cervical to the vaginal margin of the cut surface, but the cut surface is folded upon itself in a direction at right angles to this — i. e., on either side of that point at the margin of the os externum where the backward incision is commenced — and is stitched to the very angle of the incision so that the cut surface is folded upon itself, not from within outward, but from before backward. Thereby the os externum is carried directly back to the angle of the incision. " Already the cervix has commenced to point backward in its normal direction toward the hollow of the sacrum, instead of foi-- ward toward the vaginal outlet. Then the anterior lip of the cervix is caught with a tenaculum and partially removed. "■ This incision should extend to the os externum, but not into it. " Sutnres are used for the purpose of folding the exposed sur- face upon itself from side to side. The removal of a portion of the anterior lip is not only not a mutilation, but it may even correct a deformity, because in antefiexion the anterior lip is often elongated in consequence of the relatively greater pressure exerted upon the posterior lip by the posterior vaginal wall." While I know that this o])eration is a great improvement upon the Sims operation, I must say that I prefer the methods of treat- ment already given. FLEXIONS OP THE UTERUS. 71 ILLUSTRATIVE CASES. Anteflexion of the Cervix Uteri, Sims's Operation. (Relieved.) — This patient was a strong, healthy lady, who began to menstruate at the age of fourteen years. She continued in good health, and the menses were normal, except that she had more discomfort than be- longs to perfect health. About the age of eighteen menstruation became more painful, and she had some backache and occasional leucorrhoea. These symptoms increased but little until she was married, at twenty -two years of age. Then she began to have dysmenorrhoea, and occasional menorrhagia. The leucorrhcea and backache became more persistent and her strength failed. The pain at the menstrual period was not very severe ; in fact, it was not at all like the violent pain often present in flexion of the body of the uterus, but it made her life quite miserable at that time. About eighteen months after her marriage she first applied for treatment, when the above symptoms were related. The OS externum pointed toward the vulva, and the vaginal por- tion of the cervix was slightly flattened from below upward. The invagination of the cervix anteriorly was nearly normal, but not in proportion to that of the posterior wall, which appeared to be ex- cessive. The body of the uterus was in its normal position ; the sound could not be passed until the cervix was dragged backward and brought in a line with the body. She was treated for a time to relieve her congestion and cervical endometritis, and then the posterior wall of the cervix was divided according to Sims's method. When the edges of the wound healed, there was considerable inversion of the mucous membrane, showing that it was redundant. The protruding portions were trimmed off, and then tlie results of the operation were quite satisfactory in ap- pearance. She was relieved of all her symptoms, for a time at least, but remained sterile, although the canal was large enough, and the sound could he passed. Three years afterward she was seen, and then she was complaining of leucorrhcjea and occasional pelvic pains. This case was treated fifteen years ago, and is the last one in which I have performed Sims's operation or any of its modifications for flexion. Extreme Anteflexion of the Cervix Uteri; Dysmenorrhoea. (Re- covery.) — The patient was first seen at the age of twenty-five. Her past history was that of good health. Menstruation occurred first at fifteen, and from that time onward was normal, except that it was accompanied with pain. During the first few years after puberty 72 DISEASES OF WOMEN. the pain was slight, but it gradually increased until it was suffi- ciently severe to unfit her for everything during the menstrual period. Her general health began to fail ; she lost flesh, and became very nervous and irritable, and it was on this account that she sought relief. I found that the anterior wall of the cervix uteri was on a line with the anterior wall of the vagina, and the os pointed toward the pubes. The posterior wall of the cervix projected into the va- gina far more than normal ; in fact, the cervix was hooked upward. The body and fundus were in the normal position. Fig. 41 will give an idea of this form of flex- ion. It gave the impression that in the descent of the uterus the anterior wall of the cervix had been arrested in its progress by the vaginal wall, while anteflexion*^ ^^^® posterior wall of the uterus descended beyond the normal extent. It was very difficult to pass the sound ; to do so, the uterus had to be raised up in the pelvis and partially retroverted. Drawing the cervix forcibly backward toward the sacrum developed a band of the anterior wall, which ran from the extreme end of the cervix upward and forward about an inch and a half, and there blended with the vaginal wall. It was easily seen that this abnormal attachment of the vagina was the cause of the flexion of the cervix. Preparatory treatment was employed for a short time, to reduce congestion, and then the operation, already described, to correct the invagination of the cervix, was performed. The ridge of anterior vaginal wall was divided a little less than an inch from the cervix, and then very gentle traction was sufficient to draw the cervix back into its proper relations with the body of the uterus. The wound, which was made at right angles to the axis of the vagina, became parallel to it, when the cervix was carried back into its normal po- sition. It was closed with silk sutures, carried deep down into the wall of the vagina, to make sure that the deeper portions of the wound were coaptated. When the sutures were tied, the invagina- tion was seen to be complete, and the cervix was carried well back, quite as far as it should be; there was also a noticeable traction on the sutures, because the cervix inclined to flex forward again. To correct this, a stem-pessary was introduced, which extended about half-way up the cavity of the body of the uterus. This w^as held in position at first with a marine lint tampon, and when the wound healed the stem was held in place by the retaining pessary. The FLEXIONS OF THE UTERUS. 73 operation was done witliout ether, and the patient did not complain of pain, except wlien the stem was introduced into the uterus. Ten dajs after the operation the sutures were removed and the union was complete ; the stem was still left in place. After another week had gone, there was considerable congestion in the canal, indi- cated by a free discharge. The stem was removed, and an applica- tion of tannin and glycerin made. After the sutures were removed, the douche of borax and warm water was used daily, and once a week the stem was removed and the canal painted with tannin and glycerin. The next menstrual period was without the severe pain which she suffered before the treatment. Still there were backache and pelvic tenesmus. The stem was left in place during menstrua- tion and for three weeks after, but during that time it was removed every week, and the application of tannin made. The second menstruation after the operation, the first after the removal of the stem, was painless. Subsequently there was no re- currence of the flexion, and her menstruation has continued regu- lar and without pain. It is now three years since she was treated, and she remains well and free from dysmenorrhoea. I may add here, that in all cases of anteflexion of the cervix, due to imperfect vagination, the treatment given above has been suc- cessful. Anteflexion of the Body and Cervix Uteri with Prolapsus. (Eecov- ery.) — This patient was a little below the medium size, but was strono; and active. She be^an to menstruate at thirteen, and con- tinned to do so rather irregularly. She generally went over time a varying number of days. From the first, menstruation was painful, the pain gradually increasing from month to month and year to year. This pain was characteristic of flexion ; it began before the flow, diminished when the flow was well established, and subsided entirely on the second day. The pain was referred to the uterus, and was intermittent. From puberty to about twenty-one years of age her health was perfect between the menstrual periods. She then began to sufter from backache, leucorrhtea, occasional ovarian pain, and gradually her digestion became impaired, and the nervous system fretted. She was first seen at the age of twenty-four, when the above history was obtained. It was evident that all her symptoms were increasing in severity ; general congestion and tenderness of the vagina, uterus, and ovaries, were found at the examination. The OS externum pointed toward the vulva, and the fundus could be felt through the anterior wall of the vagina. The cervix was normal in 74 DISEASES OF WOMEN. size, and projected into the vagina in due proportions, anteriorly and posteriorly. The uterus rested low down in the pelvis, and the cer- vix appeared to be bent forward by the pressure upon the pelvic floor. These signs, obtained by touch, were all confirmed by the sound and speculum. The sound was passed through the os internum with difficulty at first. There was no change in the structures of the uterus except the flexion ; the congestion was well marked, and there was slight leucorrhcea, indicating that cervical endometritis was being developed. The treatment of this patient consisted in remedies to improve digestion. Bromide of sodium was given to quiet her nervous sys- tem. Locally, the hot-water douche was employed ; the os exter- num was dilated, and tincture of iodine applied to the cervical canal ; the uterus was raised to its proper elevation, and held there at first wnth a tampon, and afterward with a small Peaslee's pessary. The following week the internal os was dilated, until it admitted a No. 10 sound, and the iodine was also repeated. This caused much pain, and compelled the patient to rest in bed a few days, during which time the hot douche was continued. After this, the uterus was made straight by using Elliott's adjuster once a week. The douche and iodine were continued, and this completed the plan of treatment. For six months this course of local treatment was followed out, the constitutional treatment being varied as the symptoms changed. The tenderness and congestion first disaj)peared, and the pain dur- ing menstruation gradually became less and less, and finally ceased entirely. The patient remained under observation two months longer, and then married, and seven months later her physician reported to me that she was four months pregnant. Anteflexion of the Body of the Uterus ; Stenosis at the Os Inter- num, treated with Stem-Pessary. (Recovery.) — This patient had good health, l)ut was of a highly nervous temperament, a condition which had been increased by a severe and prolonged education. She be- gan to menstruate at fifteen, and had dysmenorrhea from the beginning. She managed to get along by resting at the menstrual periods, and bearing her sufiiering as best she could, but at the age of twenty-eight gave up, and sought advice. Her general health at that time was impaired, and she was quite despondent. When first examined, the usual signs of anteflexion of the body of the uterus were found. The cervix was also slightly bent forward. The canal of the uterus was of full size, except at the internal os ; FLEXIONS OF THE UTERUS. Y5 a small probe only could be passed at that j:)oint. The uterus was quite tender, and there was some catarrh of the cervical mucous membrane. Tonic and sedative treatment was begun, and the strict- ure was incised on two sides, with the hysterotome. After this, a sound was passed twice a week for a time. The pa- tient was much relieved by this treatment, but still suffered pain at the meustraal periods. The pain returned to a certain extent, at each menstruation, and at the end of a year treatment had to be re- FiG. 42. — Skene's hysterotome. newed. At that time the patient appeared to be as badly off as when first seen. Dilatation of the canal and straightening the uterus with Elliott's adjuster gave some relief. More thorough treatment was advised, but she would not consent to give her whole time to it. Four years later the patient returned in much worse condition than when first treated. The tissues of the uterus were much hard- er, and there was more tenderness. Great pain was experienced upon passing the sound, and any effort to straighten the uterus was un- bearable. Sleeplessness was now a prominent symptom, and she was obliged to take morphine at the menstrual periods. I prescribed the rest-treatment, with tonics, bromides, massage, and the hot-water douche, and the application of tincture of iodine to the cervix uteri and the upper part of the vagina. When the general health had been improved by two months of this treatment, the cervical canal was dilated, under the use of cocaine, until it ad- mitted a ]S"o. 12 sound. The uterus was then straightened with the Elliott adjuster, and a glass stem-pessary introduced. Although she was kept quiet after the introduction of the stem, the suffering was so great that at the end of two hours it had to be removed. The general treatment was resumed for about four days, and the stem was again used ; this time it was worn for five days, but had to be again removed, owing to the pain it caused. The irritation was again subdued by the hot douche and cocaine applied to the canal of the cervix, and occasionally an application of iodine and carbolic acid was made. A week later the stem was used again ; it then caused Y6 DISEASES OF WOMEN. less pain, but she had to remain in bed, and there was still consid- erable distress. There was also a marked leucorrhoeal discharge. It was necessary to remove the instrument about every five days, and treat the cervical endometritis. Three weeks passed before the patient could be trusted to walk around, and it was two months longer before she could walk out and nde without causing pain. The dysmenorrhoea was less severe each month, and finally subsided entirely. The stem was worn altogether about four months ; during all that time the case had to be watched and treated for a recurring endometritis, but finally tlie recovery was complete. Two years have passed since the treatment was completed, and the patient remains well. The chances are, however, that the flexion will recur. It will be noticed that the stem caused much irritation, and re- quired constant watching. This I find is the case very often. There are few patients who will tolerate the stem unless great care is tak- en, and they are treated the moment that symptoms appear. The longer the trouble has existed, the more difiicult it is to use the stem. The uterus becomes more dense in structure and more sensi- tive in old cases, and the results of treatment are not very satisfac- tory. This is the rule, and there are not many exceptions to it. The patient whose case I have just described is one of the oldest that I have ever successfully treated for flexion. All the cases here given are intended to show the different forms of flexion, and the various methods of treatment employed. It will be seen that my object is not to use one method of treatment in all forms, but to adapt the treatment to the peculiar requirements of each case. Finally, I may add that I have succeeded in relieving all cases of flexion, of whatever form or degree, temporarily at least, by the treatment described, excepting when there were complications, such as ovarian disease, or the results of old inflammations. A consider- able number have entirely recovered, and borne childi'en. CHAPTER y. DISEASES OF THE EXTERNAL ORGANS OF GENERATION. ANATOMY. The Pudendum. — The pudendum, comprises all those parts that are situated at the outer and lower portion of the pelvis. It is bounded above by the lower part of the abdomen, on either side by the thighs, and below by the perinseum. In general outline it is wedge-shaped, the edge being downward. The several parts are the mons veneris, the labia majora and minora, the clitoris, and the hymen. The mons veneris is a mass of tissue which covers the sym- physis pubis, and occupies the triangular space formed by the junc- tion of the abdomen and thighs ; it is composed of fatty tissue and rather thick integument, which, after puberty, is covered with hair. At its lower border it is divided into two folds by the upper por- tion of the urogenital fissure. The labia majora are two prominent rounded folds of integument, continuous above with the mons vene- ris, which extend downward to the perineeum. They are formed by integument covered with hair on the outer side ; the inner sur- face is more like mucous membrane in general appearance, but it contains sebaceous glands instead of mucous follicles. The tissues of the labia beneath the skin are, connective tissue, elastic elements, and fatty lobules with underlying adipose structure. The vascular supply is abundant, forming a venous plexus. The labia minora, also called the nymphse, are two small folds of mucous membrane, situated upon the inner sides of the labia majora, and extending downward until they meet posteriorly, and form the thin circular band, the fourchette or frgenidum vulvce, which extends across at the posterior part of the opening of the vagina outside of the hymen. The outer surfaces of the labia minora are continuous with the labia majora, and the inner surfaces with the mucous mem- brane of the vestibule. 77 78 DISEASES OF WOMEN. The clitoris is analogous to the penis, but possesses neither corpus spongiosum nor urethra ; it is erectile in structure, and is described as having three parts — the crura, corpus, and glans. The crura are :*• Fig. 43. — The external genitals of a woman who has borne children. oblong, spindle-shaped processes, formed by the bifurcation of the corpus ; they are attached to the rami of the ischium and pubos. The corpus is located in tlie median line beneath the pubic arcli, and terminates anteriorly in a rounded extremity, the glans. Tlie relations of the clitoris and the labia minora are as follows: Each labium divides anteriorly into two folds, which surround the glans clitoridis, the superior folds meeting to form the preputium clitoridis ; the inferior folds being attached to the glans, and forming the fnemim. The vestibule is the triangular, smooth surface, bounded above by the clitoris, on either side by the nymphoe, and below by the an- DISEASES OF THE EXTERNAL ORGANS OP GENERATION. 79 terior vaginal wall. Jast above the junction of the vestibule and vagina the meatus urinarius is situated. It is distinguished by its projection beyond the general surface of the vestibule. The hymen, is a thin semi-lunar fold covered on both external and internal sur- faces with mucous membrane, and stretches across the posterior part of the orifice of the vagina. It is a continuation of the vagina (Budin). In fact, the hymen covers the orifice of the vagina, closing it completely, except a small, crescentic opening just below the mea- tus urinarius. It varies in different subjects in regard to its shape, hence the above description can only be taken as that of the typical form — the deviations from this type will be referred to in connec- tion with the pathological conditions of the hymen. The meatus urinarius is situated in the median line, at the junc- tion of the lower margin of the vestibule and the margin of the an- terior wall, about three quarters of an inch below the clitoris. It is kept closed by the muscular tissue of the urethra, and presents a puckered appearance and projects slightly beyond the general plane of the vestibule. The line of junction between skin and mucous membrane runs along the base of the inner aspect of the labium majus, passes down beside the base of the outer as23ect of the hymen, and through the fossa navicularis. The deeper structures of the external parts of generation are mostly glands and blood-vessels with connective tissue — the arrange- ment of the two latter giving the characteristics of erectile tissue. The glands are of two kinds, the sebaceous and mucous. The sebaceous glands are abundant in the tissues of the nymphse ; they furnish a yellowish-white secretion, which has a peculiar odor. In those who are not quite cleanly in their habits this secretion accumu- lates beneath the upper folds of the nymphse, around the glans cli- toridis. The mucous glands are of two varieties — the glandul?e vestibu- lares majores and the gland ulae vestibulares minores. The glandulge vestibulares minores are about six in number, and are situated about the meatus urinarius ; they are of the compound racemose variety, and have short ducts with large orifices. Some- times one or more of these ducts is found, much enlarged, and look- ing like a cul-de-sac, large enough to admit the point of a small catheter. The glandule vestibulares majores are two in number and about the size of a pea, and are of a reddish-yellow color. They are situ- ated at the posterior extremity of the buibi vestibuli, and are par- 80 DISEASES OF WOMEN. tially included in the bulhi, or, more properly speaking, the glands and the bulbi overlap each other. They, like the glandulse minores, are of the compound racemose variety, and their acini open into a duct, more than half an inch in length, which is wide where it leaves the gland, but becomes nar- YiG. 44. — The superficial veins of the perinaMim (Savajjc); c, corpus clitoridis ; 1, 2, 3, corpus cavernosum urethra; ; 5, anterior supcrfical perineal veins ; 7, dorsalis clito- ridis vein ; 8, 9, 10, pudic vein and primary liranclies ; d, tuberosity of iscliium ; o, coccyx ; 6, vulvo-vafiinal jrland ; «, anterior border of gluteus raaxiinus muscle ; b, superficial sphincter and muscle; ff, erector clitoridis muscle; h, left crus cli- toridis. rower toward its orifice. These duets, in tlieir course, run along the inner side of the vaginal bulbs, and terminate in front of the hymen, about midway from the base of the vestibule and the posterior border of the hymen, or its remains. DISEASES OF THE EXTERNAL ORGANS OF GENERATION. SI The remaining deeper structures of the pudendum of special in- terest are celkilar tissue and two masses of blood-vessels, known as the bulbi vestibuli vaginoe. These bulbs of the vaginal vestibule are, w^hen distended with blood, about an inch long; they are located on each side between the vestibule and the pubic arch. They are composed of reticulated veins and erectile tissue. The upper ends Fig. 45. — External genitals of virgin. of these bulbs are pointed, and communicate, by an intervening small plexus, the pars intermedia, with the vessels of the glans cli- toridis (Fig. 44). The orificiura vaginae differs greatly in size and general appear- ance in the virgin, in those accustomed to sexual intercourse, and in those who have borne children (see Figs. 43 and 45). 7 82 DISEASES OF WOMEN. In virgins the hymen is present, as a rule, and its upper crescen- tic border, with its concavity looking toward the urethral opening, forms the vaginal orifice. There is a considerable variation in the shape of the hymen, and, though there are deviations from the nor- mal type, they are not of necessity morbid states, but rather pecul- iarities of formation. The most common of these are the hymen cribriformis (Fig. 46), which has a number of small openings ; the Fig. 46. — Cribriform hymen. Fig. 47. — Annular hymen {{). Fig. 48. — Fimbriate hymen. hymen annularis (Fig. 47), which has one small central opening; the hymen fimbriatus (Fig. 48), so called because it is fringed some what like the extremity of a Fallopian tube. The hymen is usually lacerated in several places during the first coitus, but in some instances this does not take place. Cases have been seen in married women in whom the hy- men is very elastic and distensible. Hyrtl men- tions one specimen, in the museum at Ilalle, where the hymen is perfect though the woman had given birth to a seven-months' child. The carunculfe myrtiformes are a number of iso- lated elevations of mucous tissue about the ori- fice of the vagina, which most authors claim to be the remains of the lacerated hymen. Schroeder has pointed out that these elevations or carunculiv are ])roduced by child-bearing, and not by simple laceration of the hymen. Clinical observations confirm the views of Schroeder. Development aud Malformations of the Vulva. — During the second month of fetal life tlie rectuiii. allaiiti>is, and Miiller's ducts com- municate, but there is as yet no opening of these to the exterior (Fig. 49). Fig. 49. — B, rectum, con- tinuous with All, al- lantoi.s (bladder) and .»/ duct of Miiller( va- gina) ; X, depression of skin which grows inward and forms the vulva (Schroeder). DISEASES OF THE EXTERNAL ORGANS OP GENERATION. 83 Fig. 50. — The depression has extended inward and become continuous with the rectum and allantois, forming the cloaca (CI). Fig. 51-. — The cloaca i8 dividing: into urogen- ital sinus (fom(it()logi/. — The patient will usually detect the inflamma- tory condition l)efore the physician is consulted. This portion of the pudendum will be hot, sensitive, and painful ; pruritus may also be present. PJnjsical Signs. — By inspection of the parts, redness around the mouths of the ducts will be found. The openings of these ducts are to be sought for, about the middle of the ostium vagimij. one or DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 87 €ach side, just in front of the hymen, or the cariinculse myrtiformes. By palpation a hard, circumscribed tumor will be found at the loca- tion of the gland. Prognosis. — The inflammation may gradually subside, or result in the formation of an abscess. If an abscess forms it will pursue the same course, and be recognized in the same manner as an ab- scess elsewhere. The pus may discharge through the duct, or it may require surgical interference. Rarely the pus remains encysted for a long period. The inflammation may conflne itself to the duct and not extend to the gland. In this case it will cause but little trouble, pain and pruritus being present for a short time, and disajipearing with the subsidence of the inflammation, or the inflammation may result in adhesion of the wall of the duct, and, by occluding its lumen, prevent the escape of the secretion of the gland, and cause a cyst by its retention. JSTot infrequently the walls of such a cyst become inflamed, and an abscess results. Treatment. — The inflammation of these glands is to be treated in the same manner as is recommended for the treatment of in- flammation of the labia majora. When a cyst forms, and its contents can not be evacuated through the duct by pressure, it may be dissected out. Although the great- est care may be exercised, this can not always be done ; in that case, the cyst-wall, after being exposed by dividing the mucous mem- brane, may be opened freely, the contents of the sac removed, the wall of the sac thoroughly cauterized Avith carbolic acid, and the cavity permitted to heal from the bottom by granulation, its walls being kept separated by packing with cotton in order to prevent its closino;', and ao-ain flllino;. Inflammation and Abscess of the Labia Majora. — This inflamma- tion occurs in the connective tissue, which constitutes the greater part of the labia. It is often associated with vulvitis, or may be due to the secretions of the vagina, which are of an irritant char- acter. Blows or other injuries may also excite an inflammation in these tissues. This inflammation is characterized by redness and swelling; the latter is not circumscribed, as in the inflammation of the vulvo-vaginal glands, but is more diffuse. Like that, however, it is painful, and accompanied with pruritus. AYhen a swelling is fonned in one of the labia, it niay be due to simple inflammation, or it may be a hernia, an ovary, or a hematocele. Treatment. — The means employed for the treatment of inflam- mation of connective tissue elsewhere are indicated here. These are rest, evaporating lotions containing opium for the relief of the 88 DISEASES OP WOMEN. pain, salines, and flaxseed-poiiltices if the inflammation does not subside. If an abscess forms, it should be opened as soon as the presence of pus is determined ; the opening of the abscess, and the subsequent treatment of the wound, should be managed on strictly antiseptic principles. Varicose Veins of the Vulva. — The veins about the vulva, like those in other portions of the body, may take on a varicose condi- tion. This commonly occurs in those who have borne children ; and, indeed, pregnancy appears to stand in a causative relation thereto, although cases undoubtedly do occur in tliose who have never been, pregnant. Causation. — Anything which obstructs the venous circulation -will, by increasing the intravenous pressure, tend to produce this varicose condition, whether it be a pregnant uterus, a tumor, or, as mentioned by Winckel, the straining at stool, in case of obstinate constipation, Symytomatology. — A patient may have well-marked varicose veins of the vulva, and yet be entirely unaware of the fact. Or a sense of heat and irritation may be experienced of so disagreeable a nature as to cause her to consult a physician, when the presence of varicose veins may be recognized. In still other cases the full- ness due to the swelling is so great as to attract her attention, though other symptoms may be absent. Physical Signs. — Upon examination, in slight cases, the varicose condition of the veins is observed. There may, however, in more aggravated cases be so much tumefaction of the labia and other parts as to mask this peculiar condition of the veins. Holden describes a case in which a tumor existed as large as the head of a child. Tlie diagnosis in these cases is to be made by excluding the other affections, by the methods which are elsewhere described. Treatment. — But little can be done in the way of radical treat- ment for this condition. The bowels should be attended to, so that tliere may not be constipation and the accompanying straining at stool. If the varicosity is marked, and shows a tendency to increase^ some relief may be obtained by a pad, so applied as to give the veins the support which they lack by reason of the weakness of their walls. It should be constantly borne in mind that, wlien these veins assume a marked varicose condition, there is a possibility of their becoming so distended during pregnancy as to rupture at the time of deHvery. Wounds of the Pudendum. — These injuries are of three kinds — in- cised, punctured, and ccjiitused. They are of great interest, owing DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 89 to the profuse haemorrhage which usually occurs when the vessels of the bulbi vestibulares are wounded. Superticial wounds of the labia are not usually important ; it is only when the larger vessels of the bulbi are opened that profuse and dangerous haemorrhage occurs. Incised and punctured wounds are usually caused by falling upon cutting instruments. I have not had any personal experience with such injuries. All I know about them I have gathered from Sir James Y. Simpson's obstetric work. Pie calls attention to several fatal cases of this injury, death occurring from haemorrhage. He also states that several of these fatal cases were supposed to be caused by criminal intent. I remember, when a boy, reading an account of a gypsy woman, in Scotland, who died from pudendal haemorrhage, and her husband was tried for her murder. The defense set up was, that the wound was caused by striking against a stick while squatting down to urinate, in the woods, where they were encamped. Thomas records a case, not fatal, I believe, which was caused by a piece of china, from the breaking of a ])ot de chamhre. Symptomatolocjy . — The symptoms are pain and profuse haemor- rhage, following an injury to these parts. The bleeding is suffi- ciently alarming to require an examination, when the character of the injury is at once detected. Causation. — The causes are traumatic, and need not be discussed. Treatment . — The treatment, commended by most authors, is to use cold applications and astringents, such as persulphate of iron and tannin, and if these are not sufficient, to enlarge the wound, pack it with antiseptic cotton, and appl}^ pressure. To make the pressure effectual, the vagina should be tamponed, and a compress and band- age applied. I am satisfied that this kind of treatment must prove very un- satisfactory. Although I have had but little experience with acci- dental injuries of the pudendum, I have repeatedly encountered pro- fuse bleeding from vessels of the bulb, wounded while removing morbid gro\vths from the pudendum. In such cases I have found it most satisfactory to ligate the bleeding points, taking up the ves- sels en masse when several of them were wounded ; when it has been difficult to find the vessels and secure them in the deep wounds, 1 have passed a strong suture from the outer side of the labia into the vagina, and returned it so that it would include the bleeding vessels in its grasp when tightly tied. This controls the bleeding for the time, but occasionally it will start again, when the ligature becomes loosened, which it is likely to do in a few hours. When 90 DISEASES OF WOMEN. this occurs, the ligature should be tightened. If there is no subse- quent bleeding, the suture can be removed at the end of twenty-four hours. I am sure that this is the most surgical as well as the most satisfactory way of managing haemorrhage in this region. Styptics and pressure, in some cases, will only conceal the bleeding, but not arrest it ; the blood will burrow in the soft tissues and complicate the injury, and also make ligature of the vessels more difficult. Contused Wounds of the Pudendum. — These are of two degrees of severity. A slight bruise, causing rupture of only a few small ves- sels (which very soon stop bleeding), gives rise to an ecchymosis, which quickly disappears. Occasionally inflammation follows and an abscess develops, which is managed in the usual way. Contused wounds, which rupture the large vessels of the bulbi vestibulares, or varicose veins of the labia, if any such exist, produce pudendal h?ematocele — i. e., an accumulation of blood in the loose cellular tissue of the parts. The pathology of this injury is the same as that of bruises or contused wounds generally. There are lacei-ation of the vessels, and haemorrhage into tlie cellular tissue. In contusion of the pudendum there are two conditions which conspire to make the injury grave in character — the large size of the vessels wounded, and the loose character of the cellular tissue, which admits of a very large accumulation of blood. The size of the hfematocele depends upon the size of the vessels lacerated. In case the vessel is small, the bleeding may be controlled by the pi-essure from the blood in the tissues ; but when large varicose ves- sels or the vessels of the bulb of the vestibule are lacerated, the size of the hsematocele is very great. I have seen one nearly as large as the two fists. The course and termination of luematocele vary. If the blood- clot is small, it may disapi:)ear by absor])tion, without causing much discomfort, after the first ])ain of the injury subsides ; but when the accumulation of blood is large, then infiammation follows, which may terminate in sloughing or suppuration, and filnally septica?niia. SijmptohiatoJofjy. — The symptoms are pain following the injury, and then a feeling of fullness, heat, and sometimes throbbing. In one case that came under my observation the ]n'essure was sufficient to prevent unnatioii, and it was very difficult to pass the catheter. The attentio7i of the patient being directed to tlie location of the injury, the swelling is discovered by the touch. Physical Sigm-t. — The ])hysical signs vary in the different stages of the disease. At first, the tumor is elastic and like a local oedema, except that it does not pit on pressure. After the blood has coagu- DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 91 lated the parts are denser and slightly irregular, or slightly nodu- lar ; discoloration of the skin occurs in twenty-four hours, or less. (Edema of the skin also appeais. Diagnosis. — In regard to the diagnosis, it may be said that pudendal hsematocele can hardly be confounded with any of the diseases of the pudendum, except pudendal hernia, and the mode of development and piiysical signs of the two affections are so unlike that the differentiation is easy. Causation. — The causes of pudendal haBmatocele are predispos- ing and exciting. Varicose conditions of the vessels, degeneration of the vessel-walls, and marked engorgement from any cause which interrupts the venous circulation, render the vessels more liable to rupture when subjected to any injury. Pregnancy predisposes to rupture of the pudendal vessels, and labor is one of the most prominent of the exciting causes, but the present discussion of this affection is limited to causes occurring in the non-puerperal state. The reader will find a very full account of this affection, as it occurs in labor, in a monograph by Prof. Fordyce Barker. In regard to the exciting causes of the affection, it may be said, in brief, that they are always traumatic. Direct blows are the usual means by which the vessels are ruptured ; indirect injuries — from a fall, for instance — might produce rupture of the puciendal vessels, but I have not seen any cases in which the injury was caused in that way. Treatment. — When the patient is seen immediately, and while h?einorrhage is still going on, an effort may be made to arrest the bleeding by pressure ; but if this fails after a short trial, it is best to lay the parts open, and secure the bleeding vessels in the way already described. This is quite an important operation, and requires that the patient should be anaesthetized, but the results fully justify the means. The advantages of this treatment are threefold : the bleed- ing is controlled effectually, and in the safest way, providing the surgeon is called while the bleeding is still going on ; the extent of inflammatory action is greatly lessened or wholly avoided ; and the dangers of septicaemia are guarded against by clearing out the blood- clots and securing free drainage. The rule is, however, that the surgeon is not called until the stage of bleeding is past ; it is then well to wait till the patient has recovered from the loss of blood, and reaction from the shock, if there has been any, has set in, and then lay open the hematocele, turn out the clots, tie any vessels that may bleed, secure free drainage, and use ordinary surgical dressing, I 92 DISEASES OF WOMEN. am sure that tliis course of treatment is the 1)est, being by far the safest in guarding against fatal septicjpmia, and securing a more prompt convalescence, with iniinitelj less danger to the tissues of the pudendum, ILLUSTRATIVE CASE. Pudendal Haematoma. — A dissipated woman, about forty years of age, was brought into the Long Island College Hospital, after having received a brutal beating from her husband. She had a number of bruises about her head and face, and complained of pain in the puden- dum. On examination, an enormous swelling was found in the region of the right labium. Pressure was made by means of bandages, and the swelling, due, no doubt, to haemorrhage, was controlled so that it did not increase. She had considerable fever and depression from her injuries, but was rallied by means of stimulants and quinine. At the end of forty-eight hours after her admission the ecchymosis was so marked, and pressure upon the tissues so great, that slough- ing was apprehended ; even if that should not take place, the exten- sive inflammation and suppuration, which necessarily must follow, would have placed the patient's life in great danger from septicaemia, and made convalescence, at least, very tedious. It was tlierefore decided to operate, which was done as follows : An incision al)out four inches long was made on the inner side of the tumor with the thermo-cautery knife. Proceeding slowly with the insti-ument at a dull-red heat, no hsemorrhage was excited by the incision. The clot, a very large one, was turned out, and, just as soon as the pressure was removed, bleeding started at several points in the deeper portion of the wound. The bleeding vessels were caught up by compression-forceps and ligated, and the general oozing which ke])t up was controlled by the cautery. The wound was then j^acked with lint, which was held in place by a bandage ; the dressing was changed night and morning, the quantity of lint being reduced as the cavity contracted. She made an excellent recovery, and left the hospital in two weeks from the time of the operation. Hernia of the Pudendum. — Two varieties of hernia ma}' occur in the vulva — one known as anterior-labial, and the other as poste- rior-labial. The former, which is sometimes described as inguinal labial hernia, consists in the passage of the dislocated organ by the side of the round ligament into a labium majus. The sac may con- tain intestine, omentum, ovary. Fallopian tube, or uterus. AVinckel found six cases of this variety of hernia in .5,000 private patients ex- amined by him ; in one case an ovary was found in the left side ; DISEASES OF TILE EXTERNAL ORGANS OF GENERATION. 93 in a second, eacli ovary in a hernial sac ; in a third, the utenis ; and in a fourth, the pregnant uterus. The second variety, known also as vagino-labial hernia, occurs much less frequently, Winckel has seen but two cases, and says that the hernia passes down in front of the broad ligament into an open- ing in the pelvic fascia and levator ani, and appears at the posterior extremity of one of the labia majora. Diagnosis. — This is not difficult, if due caution and care be ex- ercised. If the patient bears down, the size of the tumor will be increased. If she be placed in the knee-chest position, the hernia can be readily reduced, going back with a gurghng sound. When she assumes an upright position, the reduced tumor will again return. Treatment — This consists in reducing the hernia, and retaining the organ in place by means of a properly -applied truss. Vaginal Enterocele. — This is a form of hernia in which the intes- tines descend into the pelvic cavity, and may pass down either in front of or behind one of the broad ligaments. The hernia is usually composed of small intestine alone, though it may contain omentum alone, or both intestine and omentum to- gether. Cases have been recorded in which the large intestine came down instead of the small one. Vaginal enterocele is usually explained in the following manner : The intestine, having found its way into Douglas's ciil-de-saG, pushes it downward, and gradually causes the vagina to bulge inward. This may increase to such a degree that, finally, the tumor may appear at the vulva and even protrude from it. Diagnosis. — This is not difficult if the examination is made with care, though serious errors have been made by surgeons, the tumor being considered an abscess, and opened by the knife. A vaginal enterocele may be recognized by the following char- acteristics : It becomes smaller on pressure ; increases in size when the patient coughs or bears down ; is resonant on percussion — though, if the contents are omentum, this sign would not be present — and is easily returned if the patient be placed in the knee-chest position. It may be mistaken for an abscess, a prolapsus of the vagina, an ovarian cyst, or a dropsy of the Fallopian tubes. Causation. — Parturition is considered as the most common cause of the hernia, the intestines being pressed down against the relaxed pelvic tissues by the expulsive pain of labor. When occurrhig in nulliparous patients, it is usually due to falls or to violent straining efforts. 9J: DISEASES OF WOMEN. Treatment. — Inasmuch as the sac of this variety of hernia is not liable to constriction, strangulation rarely occurs. The tumor will disappear if the patient is placed in the knee-chest position, and its retention may usually be accomplished by a pessary that will keep the vaginal wall tense. This will at least prevent the protrusion of the hernia from the vulva, though it is doubtful if any treatment will prevent entirely the entrance of the intestines into the pelvic cavity. The existence of this hernia should be borne in mind in case the patient becomes pregnant, for under such circumstances labor is often impeded by the enterocele, which, coming down in advance of the presenting part, olf ers a serious obstacle to its progress. Hydrocele of the Round Ligament. — In order to understand the condition which is present in hydrocele, it is necessary to recall the anatomical relations of the round ligaments and the labia majora. The labia, it will be remembered, are the analogues of the male scrotum, and the round ligament of the spermatic cord. These liga- ments terminate in the labia majora, and are covered by an offshoot from the peritonaeum, the increased serous secretion formed by this membrane constituting hydrocele. Althougli the peritoneal sac does not ordinarily extend into the inguinal canal, still it may do so, and intestine or an ovary may en- ter tliis pouch. Hydrocele of the round ligament is liable to be confounded with hernia. The tumor will be translucent if it be hvdrocele, and this, together with the history, will be sufficient to make the diagnosis. An aspirator needle may be employed to make the diagnosis more certain. It is an exceedingly rare disease, and one that I liave never seen. Treatment. — The fluid contents of the sac should be withdrawn by aspiration, and tincture of iodine injected. Hyperaesthesia of the Vulva. — This disease, as the name implies^ is characterized l)y a supersensitiveness of the vulva. Pruritus is absent, and on examination of the parts affected no redness or other extenial manifestation of the disease is visible. When, however^ the examining finger comes in contact with the hyi^erassthetic part, the patient complains of pain, which is sometimes so great as to cause her to cry out. Indeed, the sensitiveness is occasionally so exaggerated as to keep the patient from consulting her physician until it becomes absolutely intolerable. Sexual intercourse is equally painful, and becomes in aggravated cases impossible. This affection must not be confounded with vaginismus, or with other conditions of increased sensitiveness of the vulva due to in- flammatorv conditions. DISEASES OF THE EXTERXAIj ORGANS OF GENERATION. 0.> Caumtloii. — The causes which produce this hypersesthetic con- dition of the vulva, when not due to inflammation or the presence of urethral tmnors, are difficult to recognize. At the menopause the affection seems more likely to oecm- than at any other period of life, and women of weak mental and physical powers are more often its siiljjects than those who are strong both in mind and hody. Treatment. — Various methods of treatment have been suggested, but so far as my own experience is concerned they have been iu most instances unsatisfactory. The sensitive tissue has been dis- sected off and relief obtained for a time, the hyperaesthesia return- ing, however, as before the operation. Nitric acid has been ap- plied, but without a cure resulting. The best that we can probably do for our patients is to bnild them up with tonics and nutritious food, and, if possible, to send them away so that they can have tlie benefit of a change of air and of scene, and at the same time be re- moved from the irritation of sexual intercourse, which of necessity aggravates and perpetuates the hypersesthesia. I have repeatedly- been able to relieve the hyperagsthesia, temporarily, by the applica- tion of cocaine in a four-per-ceut solution. This will also be found useful when making examinations in cases of sensitive vulva, or in passing the sound into a sensitive uterus. Pruritus Vulvae. — This condition is a symptom rather than a dis- ease in and of itself, and yet it is such a prominent one in many cases, as to justify its description as an independent affection. Pathology. — Pruritus consists essentially in an irritable condition of the nerves of the part affected. Although this is ordinarily the vulva, it may be and often is the vagina and the anus, and even the integument of the abdomen and thighs may be involved. SymjytomaAology . — The patient notices an itching of the parts- affected, which is at first relieved by scratching or rubbing, but later this relief is but temporary, and the friction aggravates the original trouble, until an eruption of an irritating nature appears, from which at a still later period there is an exudation, which, by the nails used in scratching, or in other ways, is carried to other portions of the body, and seems by its irritant nature to excite a similar trouble there. The itching and the burning sensations become at times in- tolerable, and the patient is debarred from the society of her friends. In some instances the annoyance and suffering are increased at night, and in order to obtain sleep hypnotics have to be administered. Physical Signs. — The signs vary according to the affections which cause the irritation. These are described above in speaking of the pathology. In some cases there are no definite signs present. 96 DISEASES OF WOMEN. Causation. — It is more than probable that pruritus is always secondary to some other trouble. A due appreciation of this fact is necessary for the institution of ])roper treatment, as, if it is lost sight of, and that which is in reality only a symptom is regarded as a disease, the pruritus will continue ahnost indefinitely, and in its chronic form will resist all remedial measures. Leucorrhoea is very commonly as- sociated with pruritus, and appears to stand in a causative relation thereto. Other irritating fluids may also produce the same result. Of these the most common are diabetic urine and the discharges from an ulcerating cancer of the uterus. The leucorrhoeal discharge which is most likely to produce pruritus is that from a uterus which is the seat of endometritis, either cervical or corporeal. The presence of parasites may also account for the existence of pruritus. Treatment. — From the principle already laid down that pruritus is to be regarded as a symptom of some pre-existing disease, the de- tection of this disease will first demand attention, and when discov- ered treatment appropriate thereto should follow. If there be an endometritis, the discharge from which irritates the vulva or other parts, and causes pruritus, the inflammation should be treated as advised elsewhere. A pledget of absorbent cotton placed against the os, to receive the discharge, will be of great benefit ; this should, of course, be renewed sufficiently often. Yaginal douches containing acetate of lead or carbolic acid will often give great relief. Subnitrate of bis- muth may be dusted on to prevent friction of the labia against each other ; this sometimes I'elieves the pruritus. I have found this to be one of the best local applications in the pruritus caused by diabe- tes ; in such cases I direct the patient to keep the urine from coming in contact with the parts, as far as possible, when urinating, and to dry the pudendum and dust it over with subnitrate of bismuth. By adding an equal quantity of prepared chalk to the bismuth, it makes a powder that is more easily used. Very satisfactory results can be obtained in the management of cases where the pruritus is caused by some appreciable disease of the organs. The greatest difficulties are experienced, however, in the treatment of that form of pruritus which occurs without any lesion of structure or accompanying affections to account for it. That there are some morbid changes in the tissues, in the violent pruritus which is experienced, is no doubt true, but so far they have not been demonstrated by pathologists, and hence the majority of authors con- sider that this affection is a neurosis. DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 97 111 the majority of cases of this kind that have come under riij observation, the skin has been bleached, in spots appearing whiter than the normal skin. It has also lost the normal elasticity. Tu the touch it seems harder and less liexible, but what these changes are, and whether they are related to the pruritus, are questions which have not yet been answered. The pathology and causation of this affection are both obscure, and the treatment is equally unsatisfactory. Many of these cases prove to be incurable, and in some it is not possible to give the patient complete relief by any local treatment. This has led to the use of a great variety of agents, but none of them has proved to be reliable in all cases. The remedies that have given the best results in ray practice are bichloride of mercury and emulsion of bitter almonds, one grain to the ounce ; this is applied to the parts affected twice a day. A powder composed of one grain of morphine to two grains of chalk, to be applied night and morning ; equal parts of tincture of opium, iodine, and aconite, and eight per cent of carbolic acid, applied once a day — all of these have been tried, and each one has proved serviceable to some extent, but there are cases which resist all these remedies. The bichloride of mercury mixture, used alone, has been of the most service in the largest number of cases. Where it fails, I have used a solution of iodoform in ether ; this is applied by means of an atomizer, and by using strong air-pressure the solution is forced into all the folds of the mucous membrane ; the ether soon evaporates, and leaves a fine coating of the iodoform over the whole surface. This nearly always relieves, and if applied frequently is curative in some cases. I have also used carbolic acid and tincture of iodine, equal parts, and this nearly always gives relief for a day or more. In the following case this application relieved the pruritus permanently : The patient had passed the menojDause, and, although she had not borne children, her health had always been good. Dr. Fordyce Barker, whom she consulted, sent her to me, telling her at the same time that I could not cure her, but would give her as much relief as possible. I tried the usual remedies, with no benelit. I then used the carbolic acid and iodine, but found it difficult to apply to all the irregularities of the surface. I applied it with the atomizer, using a high pressure, so that the solution was forced into the tissues, and a deeper effect obtained than I had expected. The result of this was, that the patient suffered greatly. The first effect was sharp pain, followed very soon by relief from the itching, and numbness of the parts; in short, the anaesthetic effect of the carbolic acid was 8 98 DISEASES OF WOMEN. obtained in a marked degree. Following this there were great irri- tation and pain ; the epithelial layers of the skin and mucous mem- brane came oil" as if they had been blistered, and there was much sensitiveness. During this, while the patient was suffering the most pain, she said that it caused far less suffering than the itching. When she recovered from the treatment the itching did not return for several weeks, and then only in a slight degree. I made the same application once again to several spots where there was severe itching, being careful not to cover more than a very small area. It was not necessary to apply the remedy the third time. She completely recovered, and remained well for one year at least ; and I presume she has had no 2-e lapse, as I should probably have heard from her if she had. Eruptions of the Vulva. — The vulva may be the seat of eczema, either acute or ciironic, herpes, prurigo, erysipelas, and diphtheria. Eczema here as elsewhere consists of vesicles, or a somewhat reddened skin, from which a serous fluid escapes. This dries, and oftentimes a thick crust forms, under which pus may accumulate. If the attack does not become chronic, this crust falls off in one or two weeks, exposing a new and tender epidermis beneath. If, on the other hand, the affection becomes chronic, the tissues become thickened by exudation, and at the same time dry, and lose their suppleness. This condition is very liable to extend to the thighs and to the integument about the mons veneris and anus. In herpes, vesicles are also present, but they are not accompanied by any redness or inflammation of the surrounding tissues. These vesicles may rupture and scales result, but, like herpetic eruptions on the lips, they are of short duration, and soon disappear. In prurigo, small papules are seen on the affected parts. Kiilm describes them as having a small, dark spot in the center, which is depressed, and containing a tenacious, reddish, gland-like mass at- tached to the bottom of the papilla. Treatment. — In the acute form of eczema, in which there is free transudation of serum, I use subnitrate of bismuth or powdered soap- stone, with three to Ave per cent of carbolic acid. When the parts are dry, I employ oxide-of-zinc ointment, carbolic-acid ointment, or glycerine and borax. In chronic forms of eczema, applications of nitrate of silver, twenty grains to the ounce of water, may be made. This may be done once or twice a week. The herpetic eruption will disappear without treatment, and the only indication is to keep the affected parts protected from friction. Prurigo may be cured, according to Xiihn, by removing these DISEASES OF THE EXTERNAL ORGANS OP GENERATION. 99 tenacious masses which have been described as situated at the bottom of the papillffi. The vulva is sometimes the seat of erjsipeLatous and diphtheritic inflammation. Erysipelas is rare in adult life, and indeed may be said to occur most frequently in the very earliest infancy. In its local treatment sugar-of-lead lotions may be applied, and internally tonics and stimulants. The prescription which has given me the most satisfaction is as follows : Borax, one drachm ; tincture of opium, one ounce; glycerin, three drachms; and water, three ounces. The parts should be kept constantly moistened with this. Diphtheria of the vulva occurs in some cases when the exudation exists in the pharynx or larynx, and rarely as an independent disease. Its treatment is constitutional. Noma, or gangrene of the vulva, is perhaps best considered in connection with the eruptive diseases. The first indication is a swelling of one of the labia majora, which becomes of a grayisb- green color, followed by vesicles ; the color changes to brown, and gangrene rapidly sets in. Causation. — Noma occurs in children whose general health is poor, either from insufficient and improper food, or from having lived in squalid tenement-houses ; or, indeed, from both combined. It may also occur as a complication of one of tbe contagious diseases — scarlet fever, measles, or small-pox. The prognosis in noma is very grave. Treatment. — This should be directed to sustaining the failing powers of the patient. For this purpose quinine, iron, and stimu- lants should be freely administered, and antiseptic dressings applied to the affected parts. It has been recommended to excise the gan- grenous tissue, and to apply the actual cautery to the underlying parts. CHAPTER YI. DISEASES OF THE VAGINA. Anatomy of the Vagina. — The vagina is the continuation of the genital tract from the uterus to the vulva. It is curved to coincide ■with the axis of the pelvic excavation ; this, to some extent, i-enders it much shorter in front than behind. The anterior wall is about two inches long, while the posterior is nearly twice that length. The anterior wall is further shortened by the cervix uteri, which joins the vagina much nearer to the vul- va in front. Fig. 55 shows the comparative length of the vagina in front and behind. The vagina is attached above to the cervix, about midway be- tween the body of the uterus and the termination of the cervix uteri. Below, it unites with the floor of the pelvis and the structures Avhich form tlie vulva. Anteriorly, it is united to the bladder and urethra ; to the former loosely, and to the latter so firmly that it is almost impossible to separate these structures even by dissection. Posteriorly, the vagina and rectum are united and form the recto-vaginal septum. Below, they are se])a- rated by the sphincter-ani and tranversus-perinei muscles and cellular tissue. Fig. 56 shows the triangle formed by the bifurcation of the two canals and the divided muscles between them. The vesi CO- vaginal septum is the most resist- 100 Fig. 55, — Length of vagina, less in front than behind. Fig. 56. — Triangiilar shape of perineal body. DISEASES OF THE VAGINA. 101 ant portion of the vaginal walls, and, when put upon the stretch, feels like a cord lying beneath the mucous layer ; this is called the anterior column of the vagina. The vaginal walls are composed of three coats — an external, mid- dle, and internal ; the external consists of fibrous, elastic, and areo- lar tissue ; the middle of unstriped muscular fiber ; and the inter- nal of mucous membrane. The muscular coat is continuous with the middle coat of the uterus, and the two are alike in structure, and in the fact that they both undergo extraordinary hypertrophy during utero-gestation. The mucous membrane of the vagina is continuous with the endometrium, but differs from the latter in structure to a marked extent. It is arranged in transverse folds, which are most prominent anteriorly, and is studded with papillae and covered with pavement epithelium. In general structure the mucous membrane of the vagina resembles very much the skin. This is noticeable in cases of prolapsus, in which the membrane, by being exposed, be- comes dry and its epithelium hardened. The stnicture of this membrane is like the skin to some extent — its secretion is serous and of acid reaction. There has been some discussion among anatomists regarding the presence or absence of muciparous glands in this vaginal membrane. The fact is that they are abundant in the lower third, but nearly absent in the middle and upper thirds. The vagina is developed like the uterus, from Muller's ducts, and is hable to malformations from arrest or defects of development. Malformations of the Vagina. — Imperforate hymen has been al- ready discussed under the head of menstrual disorders due to mal- formations of the sexual organs generally. Double vagina usually occurs in connection with double uterus, and in such cases no harm to the patient is likely to result. Perpetuation of the septum between the most dependent por- tions of Miiller's ducts has been found. In one patient who came under my observation a thick septum extended from just within the hymen upward about an inch and three quarters. This malforma- tion gave rise to no symptoms, and was not recognized until the birth of her first child, when the attending physician found that it caused some obstruction to delivery. I examined the case about two months after her confinement and found this septum, about a quarter of an inch thick and quite resistant. It was divided by two incis- ions parallel to the axis of the vagina, and about three quarters of an inch apart. The strip thus removed was not the whole of the septum, but it was sufficient, as the ends remained contracted. The 102 DISEASES OF WOMEN. divided edges were brought together Mith sutures, and healing took place very promjitly. Imperforate Vagina. — Absence of the vagina has been described as one of the malformations, but it is doubtful if there is not in these cases a rudiment of vagina, M-hich is imperforate, and hence absent to all intents and purposes. In the most complete case of the kind that I have seen the rectum and bladder were near together. With the linger in the rectmn. and a large sound in the bladder, a rather dense cord running upward from the vulva could be felt. The uterus was also rudimentary, and although the patient had passed the period of puberty, and had the outward characteristics of her sex, she had never menstruated. This was evident from the absence of menstrual flow in the uterus and Fallopian tubes. In cases like this nothing can be gained by treatment. So long as there is no excessive menstrual molimen, which would endanger the life of the patient, there should be no interference. Atresia of the Vagina. — This is the more common affection. It may be either complete or partial, congenital or acquired. In the congenital form the atresia may extend the whole length of the vagina, and that condition is generally associated with an un- developed uterus. The incomplete, or partial, atresia is usually at the lower third, but it may occm' at the upper or middle portion of the vagina. Congenital atresia occurs under two different conditions. The one is associated with defective development of the uterus or ovaries, or both, sufficient to prevent menstruation altogether. In the other, menstruation takes place, but the flow being obstructed, accumulation occurs in the uterus and sometimes in the Fallopian tubes. These differing conditions require different management. I will therefore consider them separately. Atresia of the vagina, with defective develojiment of the uterus and ovaries, is only of interest with reference to the diagnosis. Noth- ing can be done, nor is there any active demand for treatment. The patient does not suffer, as a rule, except from the consciousness of her deformity, which would only cause mental distress in case she intended to get married. Two such cases have come under my observation. The most typical one was of a good family, strong, but inclined to flesh. She did not cliange much in general appearance at puberty, but main- tained considerable of the masculine type. She never showed the slightest disposition to menstruate. She Avas asked by a Avorthy man to marry, but she was afraid to do so without advice, kno^ving DISEASES OF THE VAGINA. Ifl3 that she was " unlike other women." She sought advice, and on ex- .amination there was found atresia of the vagina, and a])parentlj the uterus and ovaries were rudimentary. Nothing could be done to help her. She took up nursing as a profession, and has succeeded remarkably well. This case is briefly given in order that this variety may be contrasted with the next form. Atresia associated with fully developed uterus and ovaries may be complete or incomplete. Usually, there is no notice taken of the deformity until puberty arrives, unless the attention of the mother or physician is directed to the pelvic organs for some other reason. There are no symptoms until puberty. Tlien the patient, after hav- ing undergone the changes characteristic of the period, has all the symptoms of menstruation without the flow. The symptoms, or menstrual molimen, as they are called in tbeir totality, are more marked than in normal menstruation, and great pain, fullness, and tenesmus, come on during the period. The tirst ■effort at menstruation is not usually attended with such severe suf- fering, but each succeeding period is worse, and very soon the evi- dences of the accumulated fluid become tangible. Physical Signs. — Inspection of the parts shows a complete closure ■of the vulva. Combined touch with a straight sound in the bladder and a finger in the rectum, reveals the fact that in absence of the vagina the rectal and vesical walls come together, and are thin and ■elastic. If the vagina is present, but closed, it is felt between the sound and finger as a firm cord. When the uterus is distended with menstrual fluid, the accumulation causes a tumor, which is elastic and -obscurely fluctuating. The signs of partial atresia differ according to the location of the occlusion. When the atresia is in the upper third of the vagina the lower portion of the canal ends in a cul-de-sac. If the atresia is at the lower third, the obstruction is found below, and, by means of the sound in the bladder and the finger in the rectum, the upper portion of the vagina is found distended with menstrual fluid. Causation. — Congenital atresia is produced by some arrest of development or disease during embryonic life. When it is acquired between birth and j)uberty, it is usually due to acute inflammation occurring in connection with some constitutional disease, such as scarlatina, diphtheria, or measles. Gangrenous vulvitis and vaginitis, which may occur in the course of any of the above-named diseases, may also terminate in atresia. I have seen two cases of partial atresia, caused by some acute inflam- mation during the course of typhoid fever, occurring near the period of puberty. 104 DISEASES OF WOMEN. In the cases which have been acquired after puberty and child- bearing, one was a soldier's wife, who was confined of her first child at a military post on the frontier. Her labor was of three days' duration, and she was finally delivered by craniotomy ; there was subsequent sloughing of the vaginal walls, and consequent atresia. Another case of partial atresia was caused by amputation of the cervix for cancer. There was at the time of the operation deep cau- terization of the vaginal walls, wdiich resulted in atresia. One other case was caused by the accidental use of pure carbolic acid, as a vag- inal injection. In this case the adhesions of the vaginal walls were not very firm, and the canal was restored by operation, but there was much trouble exj)erienced in preventing the recurrence of the atresia — a constant tendency to which remained. Prognosis. — In complete atresia there is great diflBculty in tlie operation for its relief, and a constant tendency to contraction of the parts ; hence, the hope of complete recovery is, to say the least, very limited. Treatment. — The indications are to restore the vagina by surgical means. This is a difficult procedure, and one that is not very suc- cessful in all cases. The difficulties in the operation, and the ulti- mate success, depend upon whether the atresia is partial or complete. If the portion of the vagina which is closed is limited to a third of the whole canal, reasonable hope of success may be entertained, but I doubt if the vagina was ever fully restored and maintained when complete atresia existed. When there is associated with the atresia imperfect development of the uterus and ovaries, and there is no tendency to menstruation, treatment is not indicated. Such malformed subjects often live quite comfortable and useful lives. There is another class of cases, already referred to in treating of absence of the menstnial function, in which the uterus and vagina are rudimeutarv', but the ovaries are well developed. In these there is a recurring menstrual molimen, and the general nervous system may become greatly deranged. Ovaro-epilepsy may occur under these conditions. The removal of the ovaries might become neces- sary in such cases in order to arrest the inclination to menstruation, and relieve the constitutional disturbance caused by such unsuccessful efforts. The following is a description of Dupuytren's operation for atresia of the vagina, as described by Courty, with the modifications which ]\[. Puesch has added, which I quote from the work of Dr. Thomas : DISEASES OF THE VAGINA. 105 " After having arranged the woman in a convenient position, the bladder is emptied by means of a male catheter, which is given to an assistant, who holds it turned upward. It is not removed during the operation, except where the obliquity of the part would render it troublesome. The index-linger of the left hand is then carried into the intestine as far as jDOSsible, in order to serve as a guide for the bistoury and at the same time as a protection to the rectum. After these preliminary steps the operator, placed between the thighs of the patient, makes a transverse incision at the center of the obsta- cle, or in the vulvar orifice, if the vagina is completely wanting ; if the cellular tissue is lax, he can tear with his finger, the sound, or the handle of the bistoury the vesical and rectal walls till he reaches the tumor ; if it is tense or too resistant, the surgeon dissects by gentle efforts, separating the tissues with the handle or the finger rather than cutting them, and, if it be necessary, breaking them down at the edges with a button bistoury. In each case he proceeds slowly and carefully, stopping from time to time to examine with the finger and be certain at what distance those organs are situated which it is necessary to avoid. When the canal which has been reopened will admit the index-finger easily, and when a more distinct perception of fluctuation announces the proximity of the sanguineous collection, the operator is warranted in plunging a trocar into this, and the pouring out of a sirupy, bro^vn liquid, like the lees of wine, will show that the end has been reached. The pressure upon the uterus is then stopped, a large part of the fluid is allowed to flow away through the canula, and then, substituting for this instrument a per- forated sound, the operator increases the size of the opening by nu- merous incisions upon its sides, and thus renders certain the final result. Afterward he carries a gum-elastic sound into the uterine cavity, and throws through this, but with very httle force, several injections of warm water. The dressing having been finished, the parts are sponged and dried, and the patient is placed in bed, pro- tected with cloths, so as to prevent the bedding from being soiled by the mucous and sanguinolent discharges which flow during the first days." To keep the canal open after this operation is exceedingly difii- cult ; all surgeons testify to this fact. Many things have been tried to accomphsh this object, but the best is the glass plug or dilator of Sims (Fig. 57). In one case — the case of acquired atresia referred to under the head of causation — I found that the glass instrument caused much pain, and I used elm-bark cut in fine strips, made into a roll of suitable size, and moistened with carbohzed water. This 106 DISEASES OF WOMEN. Fig. 57. — Sims's vaginal dilator. was removed daily, and, as it expanded after being introduced, it answered in that case very well. The tendency in all these cases is to contraction and return of the atresia ; in fact, I have never seen a case of complete atre- sia permanently cur- ed. In view of all these, I have been guided in practice by the valuable sug- gestions of "West, The following is from his work on " Diseases of Women," page 34 : " The operation for atresia is performed by the bistoury or guarded bistoury, or Pouteau's trocar. The bistou)'y is to be gener- ally preferred. Pouteau's trocar is resorted to when a considerable part of the lower vagina is absent, and the sac is punctured some- times pretty high up per rectum. This operation is in such cases preferable to vain, painful, and dangerous attempts to bore the thin tissues between the urethra and rectum to make and maintain a new vagina. Such a proceeding results only in vexation. It is far better for the malformed woman to discourage all hopes of maternity. The artificial j^assage into the rectum is easily kept open, and the men- stnial Huid runs oft" through it." INFLAMMATORY AFFECTIONS OF THE VAGINA. Vaginitis. — The vagina is seldom if ever affected with idiojiathic inflammation ; vaginitis, therefore, always occurs as the result of some speciflc cause, or is secondary to some contiguous inflammation, such as endometritis. There are several varieties of vaginitis. Clas- sifled according to the intensity and duration of the aft'ection, there are the acute and chronic forms ; when classified according to the causation, there is a number of forms, the most important of which are gonorrhreal, erythematous, sometimes called eiysipelatous, and diplitheritic. As a rule, the inflammation is general, involving the whole canal ; occasionally it is circumscribed, and then it is found just within the vulva, or else at the u"i>per part. J^athology. — Owing to the anatomical peculiarities of the vagina it is not suscej^tiblc of the catarrhal form of inflammation, so com- mon to mucous membranes elsewhere. From the fact that the vag- inal mucous membrane resembles in structure the skin, and that DISEASES OP THE VAGINA. 10 7 there are few mucous follicles found in it, vaginitis, in its pathology, is more like dermatitis than like the ordinary iuHammations of mu- cous membranes. Congestion, transudation of serum, premature ex- foliation of the ejDithelium, and, in well-delined cases, the formation of pus, are the characteristic results of acute vaginitis. In the subacute form there is less congestion and less pus, other- wise the inflammatory lesions are the same. This ma}' all be more briefly stated in another form, as follows : Vaginitis occurs either as erythematous, purulent, or exudative — never as purely catarrhal. The morbid appearances in these forms differ. Erythematous vaginitis is characterized by great capillary congestion, which gives the intense redness of this form of inflammation in the first stage. Then, as the disease advances, there is exfoliation of the epithelium. Sometimes the epithelium comes off in thin flakes, resembling in this respect the exfoliation of the cuticle in dermatitis. This leaves the mucous membrane denuded of its epithelium, and gives a glazed appearance to the whole canal. During this time there may be a free serous secretion and some pus found, but these are not profuse in all cases. In purulent vaginitis the lesions are the same as already described. In the exudative forms the characteristic lesions are present ; the diphtheritic membrane as in diphtheria, the croupous in that form of inflammation. There are other forms of vaginitis mentioned by some authors, but they are peculiar in regard to causation, while in tlieir pathol- ogy they do not differ materially from those described. Bymjptomatology . — The symptoms in the acute form are a feeling of internal heat and fullness. These increase in intensity, and pain in the vagina and uterus come on. Vesical and rectal tenesmus are present in severe cases, and urination and defecation are painful. The urine causes violent smarting of the inflamed parts aliout the vulva w^th which it comes in contact. So severe is the pain in some cases during and after urination, that the patient resists the inclina- tion until the power of evacuation is lost, and there is retention. There are constitutional disturbances also. kX first there is fever, and following that loss of appetite and debility. The discharge is profuse, and sero-purulent in character ; it causes excoriation of the external parts, which often extends to the limbs. If great cleanli- ness is not observed, the discharge decomposes and causes a very dis- agreeable odor. In the subacute and chronic forms of vaginitis the symptoms are the same in character, but less in degree ; in fact, the annoy- 108 DISEASES OF WOMEN. ing discbarge is the only symptom observed in many of these mild eases. Physical Signs. — By inspection of the parts when the labia are separated the characteristic discharge can be seen and recognized. It differs from that of vulvitis in being less tenacious. The mucous glands about the vulva give to the discharge of vulvitis a cohesive- ness which is not found in that of vaginitis. The use of Siras's speculum will show the inflamed appearance of the membrane and the discharge which is present. The anterior and lateral portions only of the walls of the vagina are seen through the Sims speculum, but by watching the folding together of the posterior and anterior walls, as the speculum is with- drawn, the whole canal can be thoroughly inspected. The difference betw^een the signs of acute and sub-acute inflam- mation is simply in the intensity of the congestion, the extent of the canal involved, and the quantity and character of the discharge. To distinguish gonorrhceal vaginitis from the non-specific forms the microscope alone is sufiicient. When there is a question regard- ing the nature or the cause, specimens of the discharge should be examined for the gonococci. Causation. — There is a predisposition to vaginitis in those of delicate health and strumous diathesis, but it is not marked. Judging from my own observations, the common causes of vagi- nitis are gonorrhosal virus, metritis, especially puerperal, and ery- thematous affections. This applies to the acute form of the affec- tion. Sub-acute and chronic vaginitis may be caused by any inflam- mation in the neighborhood of the canal. Dysentery, for example, causes vaginitis not infrequently. Different fungi have been credited with causing vaginitis, but this is not well settled. When it occurs in connection with the eruptive diseases the cause is, of course, the specific morbid material which produces the constitutional disease. Prognosis. — With proper care vaginitis can be arrested and re- covery secured without any permanent lesions. It is liable to re- cur if caused by gonorrhosa. Sometimes permanent damage is done to the canal when the vaginitis is due to any of the eruptive diseases or diplitheria. Treatment. — In the past, treatment of vaginitis has consisted mainly of the frequent use of medicinal douches. The agents used, and the means and ways of using them, have varied greatly with different practitioners. Very recently a new method of treatment has been brought to the notice of the profession by Dr. Engelmann, DISEASES OF THE VAGINA. 109 of St. Louis. His method he terms the dry treatment, which consists in the use of medicinal powders and medicated tampons. A number of years ago I tried this method, in an imperfect and limited way, in the treatment of vaginitis among the insane, and obtained ex- perience enough to know that it is of great value. I find even now, however, that while using certain agents in powdered form, and also the tampon, the discharge from the inflammation and the powder used lodge in the folds of the mucous membrane, and that it is necessary to use a vaginal douche occasionally in order to make the treatment effective. In acute vaginitis I employ what may be called a mixed treat- ment, using the medicinal agents and powder with tampon, and oc casionally employing the douche in the following way : After cleans- ing the mucous membrane thoroughly with a douche of warm water and borax, a drachm to the quart, I then thoroughly apply sub- nitrate of bismuth and prepared chalk, equal parts, and introduce a tampon of borated cotton, the tampon being so arranged as to thor- oughly keep the vaginal walls apart ; at the end of twenty-four hours the tampon is removed, and any accumulation of the discharge and powder is thoroughly removed and the tampon replaced. At the end of the next twenty-four hours the tampon is removed and the doLiche of borax and water employed, and the dry treatment re- peated. In acute cases where there is much pain, and especially if due to specific cause, I employ iodoform in place of the bismuth. If the trouble does not yield promptly to this treatment I give up the dry dressing, and every third day apply to the entire canal, by means of the atomizer with strong pressure, a solution of nitrate of silver, one grain to the ounce, or sulphate of zinc, one half grain to the ounce. I find that such mild solutions, applied with considerable force with the atomizer, diffuse the application very thoroughly, and produce a far more marked effect than much stronger solutions used as a douche. The method of application or spraying the canal is as follows : A Sims's speculum is introduced, and when the canal is distended by pressure, the spray is thoroughly applied to the upper portion of the canal and to the anterior and lateral walls, and the posterior wall is sprayed as tlie speculum is gradually withdrawn. In the inter- vening days between these applications I employ daily, or t'^ace a day, a vaginal douche of a solution of sulphate of zinc, sixty grains to the quart of warm water. In cases that can not be so carefully watched and treated, I rely 110 DISEASES OF WOMEN. almost wholly upon the siilphate-of-ziuc solution, used as a vaginal douche twice a day at first, and subsequently once a day. This an- swers remarkably well in a great majority of cases, but there is a constant liability to miss a portion of the canal, especially the upper and posterior fornix. To overcome this, an application of the nitrate of silver or sulphate of zinc is to be made to these neglected parts once or twice a week through the speculum. This simple treatment is usually sufficient in all ordinary cases, but whenever the disease is specific in its origin, and is complicated with urethritis and endometritis, then these affections should be treated simultaneously in the ordinary way. If treatment is neglected or discontinued too soon, the vaginitis will recur in a very short time. Vaginismus. — Since the time when Sims first described this affec- tion and its treatment it has been considered by most writers as a distinct affection, and is usually classed as a neurosis of the vagina or hymen. In all the cases which have come under my observation the trouble has been due either to some affection of the muscles of the pelvic fioor, or to a hypertesthesia of the mucous membrane of the vagina. The former will be spoken of in connection with in- juries of the pelvic floor. Hypereesthesia due to affections of the other pelvic organs, I have always looked upon as a symptom of the preceding disease of the utei'us, rectum, or bladder. Yiewing the subject from this stand- point, little need be said about it in this connection. The removal of the affections which give rise to it is the chief indication, and is generally sufficient in the way of treatment. It may be mistaken for anal fissure, urethral caruncle, or vaginitis. Occasionally, it is necessary to give relief while the treatment is being employed to reniove the cause ; and, in those cases in which the cause can not be removed, efforts shcndd be made to relieve the hyper- sesthesia. This can usually be done by the judicious use of cocaine. Neoplasms of the Vagina. — Many of the neoplasms of the vagina are the same in character as those found elsewhere ; as, for example, sarcoma, carcinoma, fibroma, and lipoma. All these are very rare. The diagnosis and treatment of these neo]>lasms are based upon the same principles as those which guide the j^ractitioner in dealing with such affections when located in other parts of the body. I will, however, give a T)rief account of some of the more com- mon neoplasms of the vagina : Cysts of the Vagina. — These vary in size from that of a buck- shot to that of a child's head — one case, at least, being on record, DISEASES OP THE VAGINA. HI in which the tumor was of the hitter size, and so seriously interfered with hibor as to necessitate the evacuation of its contents before the labor could proceed. Nelaton reported a case in which, on analysis, the cyst contents were found to be made up of water, eighteen parts ; albumen, one part and a half ; and salts, a half part. Micro- scopical examination has shown the presence of epithelium, pus, cholesterine, nucleated and lymphoid cells in these cysts. Occa- sionally blood and pus are found in the contents. AYinckel, who has examined these cysts with great care, states that their walls are made up as follows : The external surface is covered with the ordinary pavement epithelium of the vagina ; the thickness of the walls varies between one twenty -fifth and two fifths of an inch — the thinnest portion being formed of connective tissue alone, the thicker with the addition of smooth muscular fibers. The internal surface is usually perfectly smooth, but may show papillae covered with epithelium, which in the majority of cases is cylindri- cal, more rarely simple, or stratified pavement epithelium, or, still more rarely, stratified pavement and cylindrical epithelium in the same cyst. These cysts of the vagina are caused in some cases by a closing and subsequent distention of the vaginal glands. They may also be due to dilated lymph-vessels, to oedema, and to the accumulation of blood after an injury. C,ysts most frequently have their origin in distended Gartner's ducts. This has been clearly pointed out by Amand Routh in his most interesting article in Volume XXXY of the " Transactions of the Obstetrical Society of London." Their recognition is not difiicult, provided that a careful inspection is made of the vaginal canal. Their treatment is exceedingly simple. It consists in emptying them by an incision through their walls. To prevent refilling, the cyst wall should be removed if possible, and the wound closed. If that is not possible, the portion of the cyst wall left should be destroyed with cautery or caustic, and the cavity packed with gauze to cause healing by granulation. The following case, illustrative of this form of vaginal cyst, I quote from Dr. Routh's article : " Miss C. C, aged twenty-five, first saw me in 1889 for coccygo- dynia and bearing down, due to pelvic congestion. She improved rapidly, but over- walked herself in January, 1890, and for a few weeks suifered as before. Two years and a half afterward — Xovem- ber, 1892 — she consulted me again for pain over the right ovarian region, and a profuse yellow watery discharge, which was occasion- ally offensive. Walking caused great pain down the right leg and 112 DISEASES OF WOMEN. in the right side. The abdomen was somewhat distended, and the muscles resistent over the right half of the abdomen. Per vaginam tlie uterus was m^obile, but pushed over to the left by a somewhat elastic mass on the right side of the pelvis, situated apparently be- tween the layers of the broad ligament. Bimanually this mass could be felt to be partly mobile, elastic, tender, and separate from the uterus, which by means of the sound could be moved to some extent independently of the broad-ligament tumor. " In the vaginal wall, running from the base of the right broad ligament, starting from a spot slightly to the right side of the cer- vix, there was an elastic ridge, somewhat irregular in outline, which passed forward and toward the middle line, becoming lost a little to the right of the urethra, about three quarters of an inch behind the base of the vestibule. I could not find out where the discharge came from, though I noticed that the upper part of the vagina was free from discharge, while the vulvar orifice was always moist, and soiled by a somewhat viscid, yellowish, offensive secretion. " A fortnight later the patient suffered severe throbbing pain, and the temperature rose nightly to 101° or 102° F. The vaginal ridge had then become larger, tenser, and more elastic, and evi- dently contained fluid reaching very nearly to the vaginal outlet in the middle line of the vaginal roof. " In a few days the portion of the vaginal cyst near the cervix was found to be more swollen, being about the size of a thumb, but the rest of the vaginal ridge seemed to consist of several cysts, ap- parently intercommunicating. There seemed also to be definite communication between the vaginal cyst and the broad-ligament tumor, from the fact that pressure upon the vaginal cyst caused its contents to pass backward, while straining or coughing immediately refilled it. " The patient went into a nursing home, and was examined under ether. The vaginal cyst was then found to be collapsed along its whole length ; the broad- ligament tumor was very distinctly made out, and was thought to be a broad-ligament parovarian cyst, the vaginal cyst being presumably a patent Gartner's duct communiciit- ing with the cyst cavity. At the end of the examination, as the patient was regaining consciousness, she coughed, and bore strongly down, causing a quantity of yellowish offensive pus to come out of a minute hole not previously seen, just beneath and to the right of the urethral orifice at the base of the vestibule. A small probe passed down this al)normal orifice for three quarters of an inch, and the passage was laid ojien as a rectal fistula would be. The DISEASES OP THE VAGINA. 113 openings of Skene's ducts just within the urethral orifice were quite perceptible. " I then opened the main vaginal cyst about two inches up the vagina, but w^as not able to pass a probe for any distance either backward or forward. " Offensive pus continued for some days to come away from both of these places, but mainly from the anterior orifice ; indeed, I do not think I really opened the main cyst posteriorly on the first occasion. A few days later I succeeded in passing a probe along the whole canal from the anterior orifice, and subsequently a direc- tor ; and, under ether, freely laid open the vaginal cyst by means of a Paquelin's cautery knife, letting out much pus, which welled freely out of the upper end of the incision at the base of the broad liga- ment. "The duct thus laid open was lined by smooth membrane, but no microscopic examination was made. " A sound passed into this upper opening near the cervix went a distance of five inches upward and outv^^ard, and was evidently inside a cyst cavity in the broad ligament. " The opening was enlarged to admit the finger, which could be passed into the cyst behind the vagina, and could make out that the lining membrane was smooth, and that the cyst was between the layers of the broad ligament. Per Tectum the examining finger passed well behind the cyst cavity, and could then detect a sound passed into the parovarian cyst from the vagina. The cavity was washed out with iodized water, and a drainage tube inserted. " For nearly five weeks the purulent fluid continued to come away, speedily losing its offensive odor and becoming daily more watei'y, and at the upper end the sides of the vaginal cyst tended to unite again over the drainage tube, which was gradually shortened and finally removed, leaving a canal in the vaginal wall about an inch long (March, 1893) on the right side of the cervix. " liovember 7, 1893. — A rut or trough is to be felt in the vagi- nal wall to the right of the vaginal portion, leading into a short canal an inch long. The canal now only admits a large sound, and ends in a cul-de-sac. It is lined by a bright red membrane. The uterus lies in its central position, and nothing abnormal can be felt in the right broad-ligament region. The patient feels perfectly well. " This is believed to have been a case of distended Gartner's duct, where the contents finally suppurated. It is probable that at first the vaginal part of the duct was impervious, but had become grad- 9 114 DISEASES OF WOMEN. ually opened up by the pressure of the contents of the distended portion in the broad ligament where the pain first began." Dr. Routh has been able to find but two other cases of associated broad-ligament and vaginal cyst, one described by Watts in 1881, and a second by Veit in 1882. J^hese are as follows : " Watts's patient had a vaginal cyst which bulged from the an- terior vaginal wall in the position of a urethrocele. The urethra was, however, quite normal. " He laid open the cyst per vaginam^ and to his surprise was able to pass a probe several inches without the slightest resistance. The probe passed to the patient's left side, and its tip was easily felt at a point midway between the umbilicus and the left anterior superior iliac spine. Watts thought this probe had penetrated to the perito- neal cavity, but I think it pretty clear that, as in my case, it was really between the layers of the broad ligament, where there was almost certainly some distention of the duct not noticed at the time, as it doubtless speedily collapsed when the vaginal cyst was opened. " Yeit's case (1882) was that of a married multipara, aged forty- seven, who had a large vaginal cyst, which made micturition diffi- cult, owing to pressure upon the urethra. The cyst bulged out between the labia majora as large as a child's head. " The uterus was pushed over to the left by a tense elastic swell- ing in the right broad ligament, which clearly communicated freely with the vaginal cyst. " The case was treated by incision of the vaginal cyst, draining both it and the broad-ligament cyst, and by cutting out a large piece of the lining membrane of the vaginal cyst to prevent reclosure. Cholesterine crystals were found in the fluid. The epithelium was flattened in type. " The finger could be passed into the broad-ligament cyst, and the ovary could be felt on its posterior and outer surface." Fibroma, Myoma, and Fibromyoma. — These growths occur but rarely. Like the cysts of which T have already spoken, they vary very much in size ; some being so small as only to be recognized by the most careful examination, while others may be so large as to in- terfere seriously with micturition or defecation, or even to so dimin- ish the caliber of the pelvic canal in pregnant women as to prevent the delivery of the child through the natural passage, and to necessi- tate laparotomy. These tumors are readily recognized by their den- sity. If there is any doubt in the mind of the practitioner, an aspi- rating needle will at once exclude a cyst or an abscess. If the tumor attains aiiy considerable size so as to interfere with any of the func- DISEASES OF THE VAGINA. 115 tions it should be i*emoved ; or if, though small, it is increasing in size, this would constitute sufficient indication for its removal. This may be done by Paquelin's cautery, if the tumor is sufficiently pedun- culated, or if not, it may be enucleated. Sarcoma. — This is so rare as to need Init the simple mention. Its treatment should, of course, be prompt removal as soon as recog- nized. Carcinoma. — All that I think it necessary to say on this subject has been said in the chapter on Cancer of the Uterus, to which the reader is referred. CHAPTER VII. INJURIES TO THE PELVIC FLOOR FROM PARTURITION AND OTHER CAUSES. In order to comprehend fully the nature of the injuries to the pelvic floor and their varied and important pathological relations, it is necessary to review briefly the anatomy and physiology of this structure. The pelvic floor, which is also known by the somewhat indefinite name of perinseum, comprises the tissues which together occupy the space between the bones of the pelvic outlet. It is composed of muscles, fascia, areolar and elastic tissues. The muscles, which are the chief element in the structure and perform its function, have their origin from the ischium, the pubes, and the coccyx. From these points they extend downward, inward, and backward to the median line, and are united to the terminal ends of the rectum and vagina and to each other from the opposite sides. The levator-ani muscle arises from three points : the first sec- tion from the posterior surface of the os pubis on each side of the symphysis, the third section from the spine of the ischium, and the second or middle portion from the tendinous arc swinging between these two points, this thickening of the obturator fascia being called the " white line." The three parts converge to be inserted into the coccyx, or the recto-coccygeal raphe, though a few fibers are given off to the vagina, perineal body, and sphincter ani. The general course of the muscle is backward in a nearly horizontal direction. It is lined by the anal or levator fascia beneath, while above it is attached to the strong recto-vesical fascia. According to Dr. W. W. Browning (Medical News, June 12, 1S97) the first part also has its origin from the posterior layer of the triangular ligament, where it blends with the obturator fascia along the descending ])ubic ramus. Fig. 58 shows the position and attachment of this mnscle. The transversus-j)erinji'i muscle arises fi'om the ramus of the ischium, and passes across to the median line, where it joins its fel- low of the opposite side. The coccygeus arises from the spine of 116 INJURIES TO THE PELVIC FLOOR. 117 the ischium, and is inserted into the side of the lower part of the sacrum and side and front of the coccyx. It is understood, of course, tliat there are two of each of the muscles thus far described, one on each side. The bulbo-cavernosus muscle can be most easily traced Fig. 58. — The levator ani, seen from the right after removal of much of the ischium. Lp, first section arising from the rear of the pubes ; Lr, second part arising from the fascia, or white line ; Li, third, or ischial portion. The sphincter surrounds the anus, and is attached to the coccyx. by taking as its orio-in the space between the sphincter ani and the orifice of the vagina. From this point its two halves pass upward, one on each side of the vagina. The upper anterior end of each slip of muscle divides into three parts, which are inserted as follow^s : One into the lower surface of the corpus cavernosum of the clitoris, a 118 DISEASES OF WOMEN. second into the posterior portion of the bulb, and the third unites with its fellow of the opposite side in the mucous membrane of the vestibule ; and all of them are, through tiie medium of tendon and fascia, connected to the pubic bones. If this muscle is traced from above downward to the center of the pelvic floor, it will be seen to Fig. 59. — The muscles of the pelvic floor ; on one side the superficial muscles, on the other the three parts of the levator (semi-diagrammatic). The ischio-rectal fascia is shown beyond the nmscle. have an origin and insertion like that of the anterior libers of the levator ani ; hence the bulbo-cavernosus and levator ani may be con- sidered as one muscle. This view is justifiable from the fact that they also contract together, having a similar function. The sphincter-ani muscle, which has a function peculiarly its INJURIES TO THE PELVIC FLOOR. 119 own, is closely united to all the other muscles of the pelvic floor by uii interlacing of the muscular flbers and by tendinous and fascial attachments. This muscle arises from the end of the coccyx, and divides to surround the end of the rectum, while its deeper fibers are inserted in the tendinous raphe in the median line between the rectum and vagina. The superficial fibers of this muscle are circu- lar, and attached to the integument. Taking the muscles of the pelvic floor in the aggregate, they form one complete diaphragm of muscular tissue which fills the pel- FiG. 60. — Diagramtnatic sagittal section of the female pelvis. U, uterus ; R, rectum ; S, symphysis ; P, perineal body ; B, is beneath bladder. This is the position of the uterus when the bladder is moderately full. vie outlet. By this arrangement the rectum and vagina are held in position, and their terminal ends controlled in the performace of their functions. The muscular attachment of the muscles and va- gina is in part shown by the preceding figures, 58 and 59. The normal elevation of the pelvic floor is illustrated by Fig. 60. 120 DISEASES OF WOMEN. This position of the pelvic floor and the relations of the rectum and vagina should be noted because they become changed in most of the injuries of this structure. The muscles of the pelvic floor are surrounded by the deep and superficial fascia, which in some parts becomes ligamentous in char- acter ; for example, the ischio-perineal ligament — that dense portion of the fascia which stretches from one side to the other through the space between the rectum and vagina. This fascial structure accom- panying the muscles is characteristic of all muscular structures which have to afford continuous sustaining power, like the muscles of the back, of the neck, abdomen, and thigh. Function. — These anatomical facts regarding the floor of the pel- vis suggest that its functions are to sustain the rectum and vagina, and to aid in their functions. The arrangement of the muscles is such that they close by sphincteric action the terminal ends of the rectum and vagina, yet also permit the distention of their orifices during the acts of parturition and evacuation of the rectum. When pressure is made downward by any body in the rectum or vagina, the levator muscles act to draw the orifices of these canals upward, and hence supply a resisting force to the downward pressure which effects dilatation of the vagina and rectum. This action of the mus- cles in resisting downward pressure is well demonstrated during par- turition. AYhen the child's head presses upon the floor of the pel- vis, the muscles, by retraction, distend the sphincter ani to a great extent. The dilatation of the vagina is produced by a more passive giving way to the forces above, and yet the muscles exert a well- defined power in retracting that portion of the pelvic floor. This function of the muscles should be noted because it enters into the mechanism of most of the injuries to be discussed. Tiegarded as a mechanical structure, the pelvic floor resembles a diaphragm com- posed of muscles and fascia which close the pelvic outlet. Its bor- ders are attached to the bony walls of the pelvis, and it is held at its proper elevation by strong fascia and the levator-ani muscle. Its mechanism is based upon the principles of the suspension bridge, the anchorage being represented l>y the pelvic bones, the floor representing the bridge and the levator-ani muscle with the powerful fascial layers corresponding to the sustaining cables (see Fig. r,i). This brief statement i-egarding the function of the ])elvic floor embodies the essential points in its chief offices. There remains something to be said regarding its relations to the pelvic organs. Up to the present time the attention given to this subject by INJURIES TO THE PELVIC FLOOR. 121 gynecologists has been almost wholly confined to laceration of the so-called perineal body — an injury frequently seen, but not by any means the only one that occurs to these parts. This concentration of attention on one portion of the subject has given rise to great diversity of opinions regarding the function of the perinseum and Fig. 61. its relations to the displacements of the pelvic organs, one party to the controversy believing that the perineal body has much to do with sustaining the pelvic organs in position, the other holding that it has very little power in this respect. Without summing up at great length the arguments on both sides, the facts bearing on the practical side of the subject may be briefly stated. In all injuries of the pelvic floor which impair its supporting function to any extent, prolapsus of the pelvic organs will follow in time, except in three conditions : 1. Where the injury is compensated for by the muscles (which still maintain their attachment to the vagina and rectum) drawing the remaining portion of the pelvic floor upward, forward, and toward the pubes, thereby closing the vaginal orifice and supporting the pelvic organs. 2. Where by reason of some intra-pelvic inflammation the organs have become fixed by adhesions ; and, 3. Where the patient is abundantly supplied with adipose tissue, and takes very little active exercise. Excepting under the circumstances here named, prolapsus of the pelvic organs invariably occurs after important injuries of the pelvic floor. The displacement does not follow the injury immediately, but, as a rule, comes on slowly. This conclusion has been arrived at from a large number of clinical observations, and it helps to defi- nitely settle the question regarding the value of the pelvic floor as a means of support for the pelvic organs. From these facts one may obtain the key to the differences of opinion which have been 122 DISEASES OF WOMEN. held by gynecologists regarding the functions of the pelvic floor. Those who believe that it plays a secondary part in maintaining the pelvic organs in position argue that there are anatomical structures which sustain the pelvic organs in place without aid from the pel- vic floor, and, in proof of this, point to the fact that the removal of the pelvic floor is not followed by displacement of the pelvic organs. This is often seen in cases in which lacerations sufficient to largely impair the function of the pelvic floor have existed for years in women in active life without the occurrence of prolapsus of the pelvic organs. And, more than all this, it is said, prolapsus of the pelvic organs occurs where there is no apparent injury of the pelvic floor — i. e., no laceration of the perina^um. The fallacies of this argument are that, although the pelvic oi-gans are held in position by supports that are sufficient to resist ordinary taxation for a given time, they are not able to do so under extraordinary pressure for any length of time unaided by the pelvic floor. Again, the cases cited in which prolapsus does not occur when the perineum is lacerated belong to one of the three exce])tional states which I have already given. And, finally, the cases in which there is prolapsus while the pelvic floor appears to be uninjured are, as a rule, cases of mistaken diag- nosis, the floor of the pelvis being i-eally imperfect, although not apparently so on examination by the sense of sight alone. Some observers look for a laceration of the perinteum by inspection of its mucous and tegumentary surfaces, and, if injury to these surfaces is not found, they pronounce the pelvic floor perfect, while the fact is that laceration of the perinannn in the median line is only one of many injuries of the pelvic floor which render it functionally imper- fect. But granting that the pelvic floor takes no part in supporting the pelvic organs under ordinary taxation, it certainly aids in doing so in case there is extraoidinary downward pressure from lifting lieavy weights, violent coughing, and the like. Again, when the pelvic floor is injured — say l>y laceration — and loses the power to support itself and the vagina and rectum, prolapsus, esj)ecially of the vagina, occurs. This causes a dragging upon the pelvic organs wliich in due time will cause them to descend. In view of these well-known facts, the most enthusiastic advocate of the independent supports of the pelvic organs must admit that the pelvic floor is at least indi- rectly concerned in su])]K)rting the structures above it. The injuries of the ]U'lvic floor are of two classes : 1. Lacerations of the pelvic floor in the median line. 2. Laceration of the levator-ani muscle and separation of the INJURIES TO THE PELVIC FLOOR. 123 muscular coat of the vagina from the pelvic floor. This injury is an internal transverse laceration. The flrst class is divided into lacerations extending from the vulva down to the sphincter-ani muscle ; subcutaneous separation of the muscles and fascia; and lacerations extending from the vulva into the rectum, involving the sphincter ani and less or more of the recto-vaginal septum. The tirst of these — laceration of the pelvic floor in the median line — is the injury most frequently sustained during parturition. Several degrees of this injury are described by authors, but in re- gard to the pathology and treatment there are only two which, in this connection, require attention : the one which extends through the muscles of the anterior portion of the pelvic floor — that is, from the vulva to the sphincter-ani muscle — and the other which extends through the sphincter-ani muscle and into the rectum. The former of these is the injui-y which is most frequently recognized, and is there- fore presumed to occur most frequently, although this point is not yet settled. Certainly it is the least grave in its consequences if properly cared for, because it is the most easily remedied by surgical treatment. In its simplest form the laceration extends through the mucous membrane of the vagina, the integument, and the junction or union of the bulbo-cavernosus with the transversus-perinsei muscle, a few fibers of the levator ani and the fascia, elastic and areolar tissues which constitute the perineal body. AVhen this injury is uncomplicated with laceration of the muscles of the pelvic floor elsewhere than at the median line, the separated ends of the muscles involved in the rupture still retain their union with the divided side of the perineal body and with each other. This is very clearly shown by the fact that the bulbo-cavernosus, trans- versus perinsei, and anterior fibers of the levator-ani muscles hold the separated sides of the perineal body and the posterior, unin- jured portion of the pelvic floor upward. At the same time that the posterior portion of the pelvic floor is maintained at its nor- mal elevation, it is often brought forward to compensate for the loss of support caused by the laceration. This compensation does not occur in all cases, but usually does so unless there is damage done to the muscles other than at the median rupture alone. I have observed in some cases suflieient drawing forward to lessen the dis- tance between the meatus urinarius and anus very perceptibly. This is familiar to all who have studied the subject with a view to operat- ing, from the fact that, in order to estimate the depth of the lacera- tion, to determine how extensive the vivifying of tissue need be, it 124 DISEASES OF WOMEN. is necessary to retract the posterior portion of the pelvic floor with the tinger or sound in order to press the rectum or anus backward into its place. This compensation prevents prolapsus of the pelvic organs for a long time, in some cases for many years, and is one rea- son why rupture of the perineal body is not always followed by pro- lapsus uteri. In this condition the vulva is not enlarged from dis- tention by the partially inverted vaginal walls, nor is the uterus necessarily displaced. Many such cases are seen ajnong patients who seek relief for other affections, but have no symptoms which can be traced to tlie laceration, except occasional pain in the scar tissue in the injured part. In cases of long standing the posterior vaginal wall becomes prolapsed. Tiiis condition has been described as rectocele. The diagnosis is made by inspection. The second form of injury given in the classification is subcu- taneous separation of the nmscles and fascia in the median line, usually limited to the transversus perinsei muscle and fascia, but in rare cases involving the sphincter-ani muscle. Years ago, when I first called attention to this subject, I was not aware that the sphincter ani was ever involved in this form of in- jury, but I have seen since then at least three cases in which the sphincter ani was lacerated completely while the integument and mucous membrane of the vagina remained uninjured. The evi- dences that my observations were correct are that there was incon- tinence, the integument on either side was depressed where the lower fibers of the retracted muscles had drawn it inward, and the most careful examination proved l)eyond a question that the integu- ment had never been lacerated. I am aware of the fact that a com- plete laceration in the median line may unite by first intention, leav- ing the sphincter ani ununited, and that the scar may be so faint as to be easily overlooked, but in the cases I have referred to I am posi- tive fmm my own examination, and that of my associates, that no such injury to the integument ever occurred. Furthermore, I found in operating that when the integument was divided some thickening of the cellular tissue was apparent, due no doul)t to a reparative exudate which occurred at the time of the injury. I also found the ends of the muscle far apart, the lacerated ends being completely healed over by natural ])rocesses. In looking back I recall several more cases of this kind, but not having studied them witli sufticicnt care, they are not available for my present purpose. The mucous membrane of the vagina and the skin covering the perinaeum remain normal, but the transversus-perinaei muscles aie INJURIES TO THE PELVIC FLOOR. 125 torn apart in tlie median line. The bull>o-cavernosus muscles are separated from their insertion at the center of the perinaeum, and possibly some of the libers of the levator-ani muscle ai"e also lacer- ated. There is, in short, a complete laceration of the deeper struc- tures of the perinseum, the skin and mucous membrane alone re- maining uninjured. The result of this injury is falling of the pelvic floor, and usually prolapsus of the pelvic organs. The func- tion of the pelvic floor is destroyed or impaired as iu the injury first described. I believe that this condition has generally been mistaken for functional imperfection of the perinseum, or relaxation, as it has been called. The fact is, that it is a well-defined anatomical lesion, which can be demonstrated quite easily by passing the finger into the vagina and pressing downward and outward. In this way the absence of the muscles, fascia, and connective tissue is discovered. It is found also by this examination that all muscular resistance is lost in the parts. Again, while the index-finger is in the vagina the parts anterior to the sphincter-ani muscle can be grasped between the finger and tlmmb, which will show that where the perineal body should be there is only skin and posterior vaginal wall. There is still another method of examination, and perhaps the most critical one — that is, to pass one index-finger into the vagina and the other into the rectum, when it will be found that the only resisting mus- cular tissue felt between the two fingers is the sphincter ani. These examinations by the touch are quite sufficient ; but if fur- ther evidence is desired, it may be obtained by trying to excite con- traction of the muscles which act as a sphincter vaginae. This can be done by the interrupted electric current, or by irritating the labia. In making a vaginal examination, one can observe how actively the muscles of the pelvic floor contract and close the introitus vagi- nae in the normal state; but in this injury no such contraction oc- curs, nor can it be produced by pricking the labia with a needle, or by any such means used to excite reflex action. In case the levator-ani muscle remains intact, the posterior por- tion of the pelvic floor remains in its normal position, except that the end of the rectum may be displaced backward, but it rarely is, as a rule, because the vagina and uterus are not prolapsed. The coun- terpart of this lesion is often seen in cases that have been operated upon with the intention of restoring the pelvic floor or perinaeum, the operation having failed in its object. Union of the skin and mucous membrane is obtained, but the muscles are not united, and hence, although upon removing the sutures the result is pronounced 126 DISEASES OF WOMEN. to be perfect, and to the superficial observer appears to be so, the muscular function of the pelvic floor has not been restored, and the operation is, in fact, a complete failure. When the two forms of injury just described have existed for a long time prolapsus of the vaginal vi^alls takes place. The posterior vaginal wall is most frequently displaced and is usually described as a rectocele, but that is incorrect, as will be pointed out in discuss- ing transverse internal lacerations. The third form of injury in the njedian line extends from the vulva into the rectum, and includes in the solution of continu- ity the sphincter-ani muscle and less or more of the recto-vaginal septum. Rupture through the sphincter ani is the most unfortunate of all injuries of the pelvic floor, owing to the incontinence which follows. The unhappy subjects of this accident are debarred from taking much active exercise, and usually avoid society. Strange as it may appear, they do not all suffer from prolapsus of the pelvic organs ; in fact, I think that prolapsus following this injury, to any great degree at least, is the exception. This is, no doubt, due to the fact that such patients are unable to do much walking or standing, and therefore the pelvic organs are not submitted to much downward pressure. It might be supposed that relief from this distressing condition would be sought before sufficient time had elapsed for prolapsus to occur, but this is not always the case, for I have seen several such injuries of many years' standing, and yet there was very little displacement. There is indeed very little falling of the pelvic floor or of its divided sides. This is accounted for by the fact that the laceration extends through the greater por- tion of the pelvic floor, leaving little remaining to settle down- ward. In most cases the two halves of the floor are held well up in position by the muscles which are attached to them. When the laceration is through the sphincter-ani muscle only, and does not extend upward into the anterior wall of the rectum and the poste- rior wall of the vagina, there is a little control of the rectum still retained. This retaining power is sometimes favored by a band of scar tis- sue, which lies between the upper fibers of the divided sj)liincter, and gives a fixed point toward which the muscle can contract in an imperfect way. There is usually ]>r()lHpsus of the mucous membrane of the rectum in cases of long standing, and the prolapsus is almost always greater if the wall of the vagina and rectum are also lacer- ated to any great extent. INJURIES TO THE PELVIC FLOOR. m Injuries of the second class, which are transverse, and have been described as internal lacerations, consist in laceration of the anterior fibers of the levator-ani muscle and fascia, and this is usually attended with separation of the muscular layer of the vaginal wall from the pelvic floor. In some cases the laceration is complete, involving the mucous membrane as well as the muscular coat of the vagina, and in very rare cases the laceration reaches upward and outward as far as the laceration of the levator-ani muscle extends, but as a rule the laceration of the levator ani is subcutaneous — that is to say, not attended with laceration of the mucous membrane of the vaginal wall. The injury of this muscle, I believe, was first described in my early writing on the subject, but if this is an unjust claim on my part I shall be happy to have it corrected. The pathological changes which ultimately take place in the trans- verse lacerations are : A marked sagging of the pelvic floor, which in itself may be perfectly normal in structure. This sagging is appar- ent upon inspection, and, as I have elsewhere pointed out, the diag- nosis of this lac- eration is made ^ ^ /" from the fact that under stimula- tion the levator- ani muscle fails to perform its function. The action of this muscle is to a large extent vol- untary, and this voluntary power is lost and stimu- lation fails to call it into action. Of course, the continuation of this sagging gives rise to or permits prolapsus of the vaginal walls, uterus, and bladder. Rectocele is also said to follow in this injury, and possibly it may in rare cases, but I am fully assured from careful observation that the so-called rectocele is not a rectocele at all, but a prolapsus of the vaginal wall and a varicose condition of the veins lying between the vagina and the rectum just within or above the pelvic floor. This I have been able to demonstrate, in a vast majority of cases, by an examination which proved that there was no rectal diverticulum pointing toward the vulva, and that pressure upon the so-called rec- FiG. 62. -The so-called rectocele, being a prolapse of the vaginal wall, with varicose veins beneath it. 128 DISEASES OF WOMEN. tocele caused it to disappear as soon as the blood was pressed out of the enlarged veins. This is shown in Fig. 62. An argument which has been made against this by one of my friends, to whom I have explained my views on the subject, is that he has noticed in faecal accumulations the rectocele protruding through the vulva, especially on voluntary eiiorts being made to evacuate the rectum. This is offset by the fact that in most of such cases I have found that when the rectum is emptied its muscular walls contract and there is no diverticulum left. Of course, the rectum loses its support when the levator-ani muscle is lacerated, and is easily overdistended, and the distention must be toward the vagina and vulva, but is temporary, not permanent, and hence not a rectocele. I may say further in reference to this form of injury that it is followed by pathological changes which give rise to more distressing symptoms than any other. It is in this form of injury that prolapsus more frequently occurs, not only of the uterus and vaginal walls, but also of the bladder ; and there is greater liability than in any other injury to the formation of varicose veins around the lower portion of the vagina and rectum, which give rise to no small degree of suii'ering. In this injury, too, subinvolution of the vagina and uterus most fre- quently occurs. More than that, I believe that there is in addition to the subinvolution of the vagina a certain degree of areolar hyper- plasia, which accounts for the extraordinary thickening of the vagi- nal walls seen in this class ; still more, if relief is not obtained there comes a time when atrophic changes of the vaginal walls take place which cause fur- I ther changes in the venous cir- culation, and if the injury goes many years with- out repair, atro- phy of the leva- tor - ani muscle occurs, and such changed struc- tures become ab- FiG. 6.3. — Beginning atrophy of perineal Iwdy in the median line. Solutcly incura- ble by any meth- od of operating. It is quite a number of years (sixteen or eighteen) since I called attention to the atrophic changes in the muscles which take place in cases of long standing, and though a certain amount INJURIES TO THE PELVIC FLOOR. 129 ■of temporary relief is obtained by operating, prolapsus of all the pelvic organs recurs. I formerly believed that in connection with transverse lacera- tions a subcutaneous laceration in the median line (Fig. 63) some- times occurred, but I am satisfied now, after more extended obser- vation, that in n ^^1' Fig. 64. — Atrophy in the median line, with sagging of the pos- terior vaginal wall resembling subcutaneous transverse laceration. place of a lacera- tion there is a thinning out and •absorption of the tissues in the me- dian line which produces a con- dition similar to that of subcuta- neous laceration. This absorption is brought about by the sagging of the pelvic floor, which makes undue traction upon the transversus perinsei muscles and fascia, and as the posterior wall becomes prolapsed additional pressure is made at that point, and hence the absorption or atrophy which takes place in the median line. This change of structure resembles in every particular the lesion of subcutaneous laceration (Fig. 64), but it is only found in cases that have existed for a long time, in which there is marked prolapsus of the vaginal walls and, •of course, great sagging of the entire pelvic floor. These facts in regard to pathology have a very important bearing upon the ques- tion of treatment, as will be noted further on. Symptomatology. — The symptoms which are developed by inju- ries to the pelvic floor are not sufficiently diagnostic, or else they have not yet been sufiiciently studied, to make them of decided value to the diagnostician. Patients have a feeling of want of support of the pelvic organs, or, as they express it, a dragging-down feeling, and some derangement of the functions of the rectum and bladder, but, as these symptoms occur in all the forms of injury named, and as they also in like manner occur in displacement of the pelvic organs, but little reliance can be placed upon them. When the function of the levator-ani muscle is lost from injury or atrophy, there is usually much difficulty in evacuating the rectum. This is, of course, most marked when the patient is constipated, but it is noticed also when 10 130 DISEASES OF WOMEN. the bowels are free, though to a less extent. When there has been a laceration in the median line the scar tissue is often tender to the touch, and occasionally causes some general nervous disturbance. The sensitiveness of this scar tissue is sometimes so great as to pro- duce reflex muscular contraction when touched while the patient is aniiesthetized. The admission and expulsion of air from the vagina (flatus vaginalis) is said to occur frequently in these injuries, and it is no doubt one of the most reliable symptoms of injuries of the pelvic floor, as it rarely occurs in any other condition. In cases complicated with prolapsus of the vaginal walls, blad- der, and uterus the symptoms belonging to these affections are pres- ent. In cases of laceration in the median line involving the sphincter- ani muscle the control of the rectum is lost. This symptom points to the nature of the lesion directly. Physical Signs. — Inspection reveals the structural changes that have taken place in the lacerations in the median line, so that the diagnosis could be easily made by direct examination. Subcutaneous lacerations of the muscles and fascia in tlie median line are detected by muscle and fascia. These escape notice at the time when they occur unless carefully looked for. They are easily detected, however, by grasping the pelvic floor in the median line between the thumb and finger. By this manipulation it will be found that all the structures, except the mucous membrane of the vagina and integument, have been divided and retracted, and there is noth- ing left of the fascia and muscular structure in the median line excepting the sphincter-ani muscle. The transverse internal laceration, when entirely confined to the muscular structures of the vagina and levator-ani muscle, is not an easy lesion to detect, owdng to the fact that a similar condition is produced by sagging of the pelvic floor, following delivery and temporary paralysis. One of the pathological changes which take place in transverse laceration is a marked sagging of the pelvic floor, which in itself may be perfectly normal in structure. This sagging is apparent upon inspection, and the diagnosis of this laceration is made from the fact that under stimulation the levat(»i--ani muscle fails to per- form its function. Tlie action of this nniscle is to a large extent voluntary, and this voluntary power is lost and stimulation fails to call it into action. Fig. 65 shows the downward disjilacement resulting from the injury to the muscles. This displacement can be demonstrated upon the subject by placing one finger upon the pubes and the other on INJURIES TO THE PELVIC FLOOR. 131 the tip of the coccyx, and observing the extent to which the pelvic floor projects below these two points. Again, by placing the pa- tient upon the side and flexing the thighs at right angles with the trunk, the downward displace- ment becomes apparent. In the most pronounced cases the parts project downward almost on a line with the nates. The physical signs of this condition will be re- ferred to again in connection with atrophy of the muscles, and the differential points will be noted. In the diagnosis of all these injuries, the all-important ques- tion is to determine whether the paralysis is due to overdistention of the muscles and is temporary only, or due to atrophy, and hence permanent. This can not always be settled at once and positively. If the tissues of the pelvic floor appear to the touch to be lacking muscular fiber, and no muscular contraction can be induced by stimulation, it is presumptive evi- dence of muscular atrophy ; and yet it may be only a temporary loss of muscular power. It is necessary, then, to support the pelvic floor and let the patient rest in the recumbent position to remove all downward pressure from the parts, and, by the use of astringents and electricity, endeavor to restore the muscular function sufliciently to prove that there is still muscular tissue present. If by such means the muscular function is even partially restored, the diagnosis is completed, and the indications for further treatment are estab- lished. It is then, and only then, that surgical treatment may be employed with the hope of obtaining complete recovery. Should all well-directed efforts fail to give evidence that the muscles still retain their true anatomical characteristics, it is useless to hope for success in operating. Causation. — The causes of these injuries of the pelvic floor are traumatic (excepting the last one described), that is, overdistention or stretching of the parts during parturition. The exceptions to Fig. 65. — Sagging of the pelvic floor. The sweep from A to B denotes the sagging portion of the pelvic floor. The bulging posterior vaginal wall (rectocele) shows white between the labia. 132 DISEASES OF WOMEN. this have already been mentioned, viz., long-continued overdistention from prolapsus of the pelvic organs, extreme constipation, and mal- nutrition in old age. There are, no doubt, certain states which predispose to these in- juries. Phlegmatic women who have failed to take exercise sufficient to develop these muscles are liable to lacerations during parturition. In such cases the muscles of the pelvic floor are poor in quality, and rupture easily under extreme pressure. The very opposite of this apparently predisposes to the same accidents. In vigorous muscular women the pelvic floor is often unyielding because of the great strength of its muscles. They resist the pressure of the child as it is forced against the pelvic floor by a powerful uterus, and, seemingly, rather than relax and stretch, their union at the median line gives way; it is in such cases that complete laceration in the flrst degree is most likely to occur. Again, in those in whom the pelvis is shal- low and wide in the straits, the child passes easily through the pelvic canal, when rather sudden, unrestrained pressure comes upon the parts and they are very liable to give way. In others still, either from habits of life or the position of the uterus in relation to the pelvis, the return circulation is retarded, the vessels become overdistended, and a deranged nutrition, with softening of the tissues of the pelvic floor, renders them easily torn. The immediate cause of lacerations, whether subcutaneous or complete, is distention during delivery. The tissues in the median line give way, in the great majority of cases, because the greatest pressure is brought to bear at that point. That the laceration ex- tends to, but not through, the sphincter-ani muscle, as a rule, is no doubt due to the strength of this muscle. In fact, it is a matter of surprise that the sphincter is ever lacerated when its position is con- sidered in relation to the force brought to bear upon it. The only rational explanation of the laceration which I have been able to ob- tain from a careful clinical study of the matter is as follows : The transversus-perinnei, levator-ani, and bull^o-cavernosus muscles are so strongly attached to the s]ihincter-ani muscles that, during de- livery, when the head distends the pelvic floor they hold the sphinc- ter ani upward and forward. If the size of the head is out of pro- portion to the distensibility of the pelvic floor, one of two injuries must occur : either the muscles attached to the sphincter must give way and permit the sphincter to recede downward and escape injury, or else the sphincter must be torn through. This eftect of the other muscles upon the sphincter ani during delivery of the child's head can be seen by the way in which the sphincter ani is INJURIES TO THE PELVIC FLOOR. 133 drawn upward until the anus is distended an inch or two. While the fetal head was unusually distending the pelvic floor, and while the hand was placed upon the parts to "support the perinseum," I have felt, or fancied that I could feel, the muscles attached to the sphincter ani give way and permit the rectum to recede and escape injury. Regarding the causes of injuries to the levator-ani muscle, one has but to recall the phenomena of labor as related to it to under- stand how it may be freely lacerated in ordinary labor. It cer- tainly is as fully exposed to injury as the other muscles which we know are frequently lacerated subcutaneously. In delivery with for- ceps, the levator-ani muscle is frequently injured, I believe. While the child's head is in the grasp of the forceps and during traction, I have noticed, by passing the finger into the rectum, that the levator ani was drawn so tightly over the edges of the blades of the forceps that it appeared as if it must be torn, and I feel sure that it often is. I am the more fully convinced of the truth of this by having care- fully watched patients that I had delivered with forceps, and have found in some of them evidence of injury of the levator ani above its lower attachment. That evidence was obtained by finding, on subsequent vaginal examination, that the resistance of the levator muscle usually found was wanting, and also that there was pro- lapsus of the pelvic floor, and loss of contractility upon irritating the parts. Ti'eatinent. — The object in treating these injuries should be to restore the lacerated muscles by securing union of their severed fibers. In the ordinary or most commonly recognized injury, lacera- tion in the median line down to, but not through, the sphincter, the immediate treatment usually employed is to close the wound with sutures at once, or to cleanse the wound from blood clots and coapt the parts, carefully bind the patient's limbs together, and trust that union may follow. The treatment by the immediate use of the suture will be made plain by the following : Primary Operation. — The wound, if seen when it occurs, is tri- angular, the base running parallel to the rectum and the apex being at the posterior part of the vulva. The sides of the wound come to- gether quite easily, and only require well-adjusted sutures to keep them in position. Much care is necessary in using the sutures. If they are imperfectly introduced they do harm by preventing the union which often takes place without surgical aid. If one is not accus- tomed to this simple operation of closing the wound with sutures, it w^ould be infinitely better for the patient to trust to nature than to 134 DISEASES OF WOMEN. IIUICOLIS shin QQ. The center lines ^^^- 66.-Diagram of the sweep of the suture. have tlie surgeon employ sutures in a bungling way. The sutures should be introduced as follows : The needle, held in the groove at right angles to the forceps, should be entered in the skin exactly at the edge of the wound, and as far down as the deepest part ; it is then carried into the tissues and made to describe the arc of a circle and emerge at the margin of the mucous membrane of the vagina. The needle is again introduced on the opposite side and cari'ied through as before, and brought out at the point in the skin opposite where it was first introduced. If this is properly done, the position of the suture in the tissue will be as repre- sented in Fi^ repi'esent the sides of the wound, and the dotted line shows the suture, which describes a circle, the point at which the suture is tied and the opposite point of its circumference being at the upper and lower angles of the wound. There are three advantages in using the suture in this way : First, the ends of the suture coming out at the edges of the wound hold the parts exactly together without the aid of superficial sutui-es ; second, the curve which the suture takes deep under the tissues brings the central portions of the wound together, whereas, if the suture is passed straight through the tissues, the edges of the wound would curve inward, while the cen- FiGs. 67, 68.— Sutiires prop- tral parts would not meet. Fig. 67 shows erly and improperly intro- tj^e parts adjusted by a proper suture, while Fig. 68 shows the effect of the imperfect one. Again, the suture running deep into the tissues gives addi- tional surety of catching the ends of the muscles so as to reunite them, which is the chief object of the operation. In the primary operation — i. e., the introduction of sutures immediately after the injury occurs — Peaslee's needle is easier to use than the ordinary 71 Fig. 69. — Poaslee's needle. perineal needle. Fig. 69 shows the instrument. This needle, with a handle, and an eye near the point, is armed with a thread and passed through the tissues as already described, and the end of the suture is passed under the thread in the needle ; this is then withdrawn and INJURIES TO TPIE PELVIC FLOOR. 135 TDrings one end of the suture into the tissues. The operation is re- peated on the other side, wliich completes the introduction of the suture. The only advantage of this needle is that it is easier to man- age than the ordinary one. It can only be used, however, in the primary operation. The silk suture properly prepared is by far the best for the immediate operation. Silver wire, which at one time was the only suture which could be relied upon, has been ■superseded by others that are vastly superior for tliis purpose. It is impossible to keep the parts clean after confinement without causing pain while the ends of silver-wire sutures are projecting from the parts. Catgut sutures are employed by some, but they are most unsatisfactoi'y. They decompose, and by causing suppuration prevent healing. Apfelstedt recommends the method proposed by Yeit of confin- ing the suture to the perinyeum in the closure of recent tears, on the ground (1) that needle holes in the vagina or rectum favor infection of the wound ; (2) that too many stitches destroy too much tissue ; and (3) that when they are knotted a cavity is likely to be left in the wound. He uses two needles to each thread of silkworm gut or silk ; these are inserted where the wounded surfaces meet, so as to emerge near the perineal wound. The first needle passes two milli- metres below the junction of the two wounded edges of mucosa, and the lowest in the same way, two millimetres above the point where the edges of the wound in the rectal mucosa meet, the lines of the stitches spreading toward the perineum like a fan. Six or eight sutures are enough. The middle ones are drawn quite tight, the others but moderately so before being knotted. This method has been used by Apfelstedt since 1892. All the vagino-perineal lacera- tions have healed, and three out of four total lacerations. This constitutes the whole primary treatment of injuries of the pelvic floor, as given in our text-books — a kind of management gen- erally sufficient in central lacerations, but that can have little influ- ence in restoring the other forms of injury. To secure the reunion of the muscles that have been lacerated subcutaneously, especially the levator ani, the parts should be well supported and kept at rest. If the pelvic floor is permitted to remain in its relaxed and displaced position there is but little chance of the lacerated muscles uniting, nor, in case they are simply overtaxed by distention, will they regain their tonicity promptly if left unaided by support. Especially is restoration likely to be prevented if the patient is permitted to as- sume the erect position too soon, and if, to increase the injurious effects of this unwise liberty, the uterus is crowded down into the 136 DISEASES OF AVOMEN. pelvis by a compress and tight bandage applied around the body. In all eases of injury in which concealed laceration of the muscles ia suspected, the pelvic floor should be well supported with a compress and bandage fastened to the abdominal binder. By these means the severed ends of the muscular libers are brought nearer together, so that they have a better chance to unite. An objection would natu- rally be raised to this treatment on the ground that it would obstruct the free flow of the lochia. This can be overcome by making the compress of absorbent cotton, antiseptic gauze, or marine lint, and draining the vagina with a drainage-tube or a strip of gauze or lint. I believe that in this way the vagina can be drained and kept as clean as it can be by occasional douching. In fact, I am inclined to think that the very frequent use of vaginal injections so generally employed in this age of antiseptic obstetrical practice often tends to retard the restoration of injuries of the pelvic floor. It is well, also, to let the patient rest upon either side after the first twelve or twenty-four hours. This position takes ofE all pressure from above, and favors the upward inclination of the pelvic floor. Great care should be taken to avoid distention of the bladder and rectum. Con- stipation after confinement is almost sure to prevent or, at least, retard recovery. By attending to these siiiiple means much can be done toward preventing that incurable condition, permanent paraly- sis from atrophy. After convalescence from confinement, in case it is found that, although there is no complete loss of muscular action in any part of the pelvic floor, there is a muscular weakness shown by the impaired power of resistance to pressure, the supporting treatment, with judi- cious rest and exercise well regulated, should be kept up until strength is restored. The restoration of the function of the muscles, as already stated in speaking of general treatment, is the great object of all surgical operations for the relief of these injuries of the pelvic floor. It matters not how mucli tissue may be gathered together and united in the region of the perineal body, it will have no functional action if destitute of muscular tissue. The success of all surgical proced- ures depends upon the restoration of the muscles, elastic tissue, and fascia, and not the mere uniting of the tegumentary and areolar tissue. In this plastic operation, known as perineorrhaphy, or restoration of the perinaeuin, much surgical skill is necessary in order to succeed. This is true of all operative surgery, and yet special care is necessary in this operation, because union l)y first intention must be secured INJURIES TO THE PELVIC FLOOR. • 137 or else the operation will fail. In many operations in surgery, if the wound does not heal by tirst intention, union may be secured by granulation and a perfect result obtained ; but in the operation under consideration, if the whole or any part fails to unite promptly, partial or complete failure is the result. This calls for the employ- ment of all known surgical means most favorable to prompt healing. On this account, then, some general considerations regarding plastic operations in gynecology will be in place before describing the methods of operating. What will follow on this subject will apply equally to all operations about the pelvic floor and pelvic organs, especially lacerations of the cervix uteri. The following may be given as the conditions necessary for the healing of the wounds in question : 1. A condition of the wound and of the general system favorable to the repair of injuries. 2. Perfect coaptation and retention of the parts to be united, and protection of the parts from extrinsic and otEending agents during and after coa^Dtation. If these conditions are all secured, success must of necessity fol- low. The management of wounds is not a matter of blind chance. The process of repair in living tissues is governed by definite laws which are always the same under identical circumstances. To ob- tain the conditions necessar}- to the fulfillment of these laws is often difficult and sometimes impossible; still, the nearer we come to all the requirements the more surely will the desired ends be accom- plished. The first of these conditions, viz., good general health, may be found wanting in many ways and degrees which are too familiar to require notice, but there are some of these which may be mentioned because they are very often overlooked — preoccupation of the sys- tem by some highly taxing function, like lactation, for example, and certain deranged states of the nervous system. These certainly have an important bearing upon the healing of wounds, although little if anything is said in our works on surgery regarding them. In fact, there is good reason for believing that enfeebled states of the nerv- ous system have much to do with retarding the healing of wounds, even when the general nutrition appears to be normal. We fre- quently hear surgeons say that patients recover from injuries much more promptly when they have courage and hope without fear ; but exhausted and irritable states of the nervous system retard the pro- cess of repair, although the patient may be indifferent or perfectl,y satisfied in regard to recovery. 138 DISEASES OF WOMEN. Regarding the unfavorable conditions of the tissues generally met with, the following are the most important : Contusions. — Contusions accomj^anying wounds caused by par- turition. Lacerated wounds of the pelvic organs often heal promptly if well coaptated immediately after they occur, but no such union should be expected in case the tissues are greatly contused. While this is true of the immediate treatment of wounds sustained during labor, it is pretty definitely settled that operation wounds made dur- ing the process of involution — that is, within four or six weeks after confinement — often fail to unite. From this we learn that while tissues are undergoing involution they are not in the best condition to heal ; and also that, when involution is delayed beyond the usual time, treatment should be employed to complete the process before undertaking plastic operations. Scrupulous care is also required in preparing the tissues by mak- ing clean, accurate incisions which will give smooth surfaces to the parts to be united. Old scar tissue should also be removed from all wounds where union by first intention is desired. These are rules in surgery which are well known, but they are sometimes overlooked in practice. Ihemorrhage. — Hsemorrhage in these operations is often a source of difficulty and delay to the operator, but, worse than that, it is sometimes the cause of failure. In the vast majority of surgical operations all that is required of the surgeon is to arrest the haemor- rhage, by any of the ordinary means, in order to secure a good re- sult ; but in the operations in question, if some kinds of styptics are used, they prevent union. Cases differ so very much in regard to haemorrhage that I have given much thought to the predisposing causes of this bleeding tendency, so marked in some patients. The haemorrhagic diathesis in its most typical form is generally found in men, but a less marked haemorrhagic tendency is common to many women, and these are very unpleasant subjects to operate upon. During the past few years it has been my misfortune to meet with quite a number of cases in which the bleeding tendency was noticeable. The cause of this in most of them, I think, was im- paired general health, due to exhausting conditions of life rather than to any congenital imperfection of the blood itself. Another very important element I have found to be mechanical inteiTuption of the circulation, the pelvic organs becoming congested from re- tardation of the portal circulation, induced by hepatic disorders, sedentary habits, tight lacing, and so forth. The products of former pelvic inflammations, such as pelvic cellulitis, also tend to maintain IIJJURIES TO THE PELVIC FLOOR. 139 a liypersemic state of the pelvic organs ; this we often find long after all evidence of active iiiHannnation has subsided. The condition at the time also is often favorable for bleeding ; the well-defined vas- cularity which exists in conditions such as imperfect involution in- sures hcTemorrhage in all operations undertaken during such unfavor- able states. The possible haemorrhage from such causes can be avoided by the proper selection and preparation of cases before oper- ating. The rule which should be followed in this matter is to secure the best possible state of the general health of the patient, and to reduce all hyperfemic states of the pelvic organs as far as possible. This is generally possible to a great extent, because the object of plastic operations is to restore the organs to their original form and struct- ure, differing in this regard from many other operations in surgery which have for their object the removal of diseased parts. In carrying out this plan of treatment, however, there is one difiiculty encountered in practice ; when patients are ill and suffer- ing they will gladly accept any operation which promises them relief, but, when they are free from pain and have gained in health, they hesitate about undergoing any surgical treatment which is designed to keep them from suffering in the future. This, however, does not prevent the surgeon from advising that which is best. There are patients — fortunately very few — who have the hseraorrhagic diathesis sufficiently marked to debar them from operations, and it is doubtful if any preparatory treatment will change this constitutional pecul- iarity. Such subjects should be let alone ; to operate in these cases is dangerous, and almost always ends in failure. I have had three such cases in the past five years ; two of them were operated ujDon before discovering their peculiarity, the result being depletion of the patients without any benefit from the operation, and the devel- opment of extreme caution on the part of the operator in selecting cases in future. The third case was diagnosticated earlier, and I declined to operate. The management of bleeding vessels in these operation wounds is of great importance. All haemorrhage should be arrested before bringing the parts together, because a slight oozing, which would do no harm in a wound to be treated by open dressing, may jDrevent union in wounds in which drainage should not be emplo^'ed, or, at least, should not necessarily be required. This often requires an amount of time which the surgeon reluctantly bestows, but success in treating this class of wounds depends largely upon attention to this matter. Still more, the means used to arrest haemorrhage should 140 DISEASES OF WOMEX. be such as will not interfere witli tlie process of healing. Hitherto the means employed have been ligation or torsion of the large vessels, and for minor bleeding the use of ice or cold water. Moi'e recent experience has pointed out objections to these means. Chilling the tissues by cold is injurious, it is said, and no doubt the statement is true. It has, fortunately, been found that hot water is more efficient in controlling haemorrhage, and its eftects upon the tissues are not unfavorable — hence its use as a styptic in these operation wounds is strongly commended. Torsion is objectionable, because it is less certain to control bleeding than the ligature, and quite as liable to give rise to suppuration. In view of this fact, it may be said without doubt that the antiseptic ligature is the best means of controlling the vessels in these wounds. Regarding the material to be used as a ligature, it may be said that that which can be inclosed in the wound without giving subsequent trouble is the thing required. The prop- erly-prepared catgut ligature fulfills the indications. Some recent expei'ience indicates that the Japanese ligature, made of whale-sinew, is the best, owing to its being absorbed with great facility. Occa- sionally, in deep lacerations, a small artery on each side may require to be ligated ; the chief arterial bleeding, however, comes from the upper portion, the small vessels coming apparently from above down- ward in the areolar tissue, between the rectum and vagina. These sometimes bleed quite freely, and they are not controlled by tighten- ing the sutures, which arrest the heemorrhage at points lower down. Such vessels I control by passing a needle through the vaginal mu- cous membrane above the denuded surfaces, and thus carry a ligature under the bleeding vessels, tying it over the free surface, checking the bleeding on the principle of acupressure. The sutures can be left in position until the perimBum has completely healed ; they can then be removed wnth the aid of the speculum. Occasionally it be- comes necessary to ligate some of these vessels which bleed persist- ently and can not be controlled in the way I have previously de- scribed ; it is then well to ligate them with a tine catgut ligature, the ends being cut off short and inclosed in the wound. In spite, however, of all precautions, secondary hsemorrhage will occasionally occur after this operation. I have met with four such cases in my practice ; in one of them it occurred on the seventh day after the operation. In all of them the bleeding took place fi-om the upper or vaginal portion of the wound, the blood flowing into and widely distending the vagina before appearing externally. In my first case I was obliged to remove the sutures, empty the vagina of blood-clots, and ligate the bleeding vessels. This resulted INJURIES TO THE PELVIC FLOOR. 141 in spoiling mj operation, for, although I reintroduced the sutures, union did not take place. This haemorrhage occurred on the sec- ond day. In my three subsequent cases I secured much better results. In- troducing a Sims's speculum on the anterior side of the vagina, I removed the clots and blood by sponging, and then, throwing light into the vagina by means of a concave reflector, 1 was al>le to see that the blood welled up from the upper portion of the wound. In ])lace of pulling the edges of the wound apart and searching for the bleeding vessels, I passed a cmwed needle and ligature down and around the place where the bleeding came from, and was able, by tightening my ligature moderately, to control the bleeding entirely. These eases subsequently did well, and the result of the operation was good. Sutures. — The coaj^tation of the tissues by means of sutures re- quires more than a passing notice. The success which J. Marion-Sims obtained with the silver-wire suture led at once to its general use in gynecological operations. There is, however, good reason for believing that the results obtained by that great surgeon depended as much upon, his skiU in using sut- ures as upon the material which he used. To-day we know that it matters little whether silver- wire or pre- pared silk sutures are used, provided they are properly introduced. The silk selected should be braided, and not the twisted variety, for the reason that the braided silk retains wax much better, and does not unravel on being handled. The wax in the twisted silk breaks and separates from the silk, and the silk thereby becomes porous and will absorb blood-serum which readily decomposes. The reason why surgeons formerly failed in the operation for vesico-vaginal iistula, when they used silk, was because the organic matter, ab- sorbed by the unprepared silk, decomposed and caused septic inflam- mation. The braided silk, properly saturated with wax, overcomes this completely. The parts to be united should be brought together and held there without any straining upon the sutures. It is equally important to introduce the sutures so that they will prevent the in- curving of the undenuded edges of the parts to be united, and, finally, a sufiicient number of sutures should be employed to secure uniform retaining pressure at all parts of the wound. These are facts which every one is supposed to know before en- gaging in surgery, but in practice a large number of failures are seen because of neglect in regard to them. The management of these wounds during the healing process 142 DISEASES OF WOMEN. differs somewhat from the modern treatment of wounds in gen- eral. Dressings. — The antiseptic dressings which surgeons use in some form or other are difhcult of application in the operations for restor- ing tlie cervix uteri and jDerinseum. So fully is this the case that some of our highest authorities on gynecology make no pretensions to using antiseptic treatment in such wounds, unless frequent bath- ing of the parts with water and carbohc acid may be called such. No doubt some of our best operators get good results with this kind of after-treatment, but it is more than probable that still better re- sults can be obtained by treatment more in accordance with the rules of antiseptic surgery. Viewed in the light of modern investigation, it appears that the frequent douching of wounds with carbolized water is a practice at least ten years behind the surgery of to-day. In treating wounds of the perinaeum there are many perplexing difficulties in the way of obtaining a proper antiseptic dressing. Here, also, the vaginal douche has been freely used, for the purpose, it is said, of removing vaginal secretions which might irritate the wound and prevent its healing. Such treatment is generally un- necessary, if not injurious. In all operations for repairing old injuries of the periniieum it is better to first cure all uterine and vaginal dis- eases which give rise to abnormal discharges. That is the only sure way of protecting the operation wound from that source of disturb- ance. This, of course, can not be accomplished in the treatment of lacerations immediately after confinement. Then it becomes a very important question how to protect the perineal wound from the lochia. Various means have been suggested for this purpose, such as coating the vaginal surface of the w^ound with collodion, placing carbolized lint or borated cotton upon the inner portion of the wound, and, the most common of all, the frequent use of vaginal injections. It is hardly possible to say, at the present time, which is best. The collodion has not been tried often enough to speak positively regard- ing it. In using the lint or cotton there is danger of separating the edges of the wound, the very thing of all others to be avoided. Perhaps the best treatment, after carefully cleansing the parts and bringing them accurately together, is to let the wound alone for about two days, trusting that during this time it may become sufficiently protected, by a coating of fresh lymph, to resist the subsequent dis- charges. After the lochia begin to decom))ose, the frequent use of the vaginal douche is advisable, and should be continued until the union is completed. In the secondary operation for restoring the perinseum, the vag- INJURIES TO THE PELVIC FLOOR. 143 inal portion of the wound may generally be left alone. It is pro- tected from the air by the anterior vaginal wall, which makes a suit- able dressing provided the uterus and vagina are in a normal condition, as they should be, before the operation is done. If suppuration takes place and pus is discharged into the vagina, it should be disposed of by injections. The outer portion of the w^ound may also be left without dressing, but it is better to apply lint or cotton upon each side of the sutures ; if silver wire is used, or if silk is employed, the lint can be placed over the wound and retained in place by keeping the limbs together. The advantage of this kind of dressing is that it absorbs any discharge that there may be. Perhaps the most important point of all in the management of such cases is to keep from dropping urine upon the wound. The most scrupulous care should be taken to close the end of the catheter in withdrawing it. If this is neglected, a few drops of urine will escape from the eye of the instrument, and, falling upon the wound, will cause trouble. The nurse should be carefully instructed to use the catheter in this way, and, to make doubly sure of cleanliness, a httle absorbent cotton should be placed between the meatus urinarias and the wound every time the instrument is used. Notwithstanding all this care, suppuration wdll sometimes occur^ and then the question arises how to manage this complication. If the suppuration is limited to the track of one suture, that one may be removed and the remaining ones trusted to keep the parts to- gether. It sometimes happens that a cellulitis which begins in the region of the sutures extends outward and ends in suppuration. This should be treated by a free incision and drainage, which may save the operation. On the other hand, if suppuration takes place between the surfaces to be united, there is very little hope of obtain- ing union at all by any kind of treatment. A partial or even com- plete success may be obtained in such cases if the suppurative process is detected early, and drainage from the lower edge of the wound is established. This can be effected by loosening one or more of the sutures, and then introducing carbolized silk thread to secure the free escape of the inflammatory products. DESCRIPTION OF THE OPERATION FOR RUPTURE IN THE MEDIAN LINE. The first part of the operation consists in denuding the sur- faces to be united. The extent to which this should be carried depends upon the character of the injury. If there is no prolap- 144 DISEASES OF WOMEN. sus of the pelvic floor of the posterior vaginal wall (see Fig. 65), it will suffice to denude the surfaces as far as the original laceration extended and no farther. This can be done by tracing the out- line of the scar tissue formed by the healing after the laceration. This scar tissue contracts and brings the normal tissues toward each other so that the portion to be exsected, as indicated by the rule given here, appears to be very small and insufficient ; but, when the scar tissue is removed, the skin and mucous membrane retract and make the denuded surface large enough — much larger, in fact, than the piece of tissue taken away. If more tissue is removed in such cases and good union is obtained, the introitus vaginae is made too small. When the sides of the laceration are drawn outward and the pel- vic floor is prolapsed, and the distance from the meatus urinarius to the anterior portion of the sphincter ani is increased to an abnormal degree (see Fig. 65), the denudation should be made high enough on either side to make sure, if possible, to unite the loose ends of the bulbo-cavernosus muscle. To do this the original scar tissue should G.T\tV^^^^^^^- Fig. 70. — Tissue forceps. not be taken as a guide in vivifying the parts. On the contrary, the vivifying should be carried upward on either side to within an inch or less of the lower side of the vestibule. In this condition there is usually prolapsus of the posterior vaginal wall, and when such is the case the denudation should be carried upwai-d a little higher. The instruments for denuding the parts are a number of sponges fixed in holders, a tissue forceps (see Fig. 70), and Emmet's curved scissors, four in number, two with lesser curves and two with greater (see Figs. 71 and 72). These instruments can not be described ; they must be seen to be understood. INJURIES TO THE PELVIC FLOOR. 145 The method of operating is as follows : The jMtient is placed upon the operating-table in the lithotomy position, and the limbs held in a Clover crutch or a sheet arranged according to Dickinson's method. An assistant on each side separates the labia to fully expose the parts ; the operator, seated in front of the patient, seizes the tissues with the forceps on the left side as high up as the denudation should ex- tend, and with the scissors removes a strip at the junc- tion of the skin and mucous membrane across to a corre- sponding point on the right. The end of the strip should be left attached, the other scissors taken, and the strip continued back to the left again. In this way the con- tinuous strip may be taken out from one side to the oth- er and back again until the wliole surface is denuded. The three figures will give a better idea of the mode of procedure than this descrip- tion. In case there is prolapsus of the vagina — and it is there- fore necessary to carry the denudation high up on the vaginal wall — the scissors with the greatest curve should be used at that part of the procedure. When the whole surface has been denuded in the manner de- scribed, it is necessary to make sure that the edges of the wound 11 First step ; denudation begun. 146 DISEASES OF WOMEN. are straight and alike on both sides, and that the surface is smooth. This can be accompHshed by causing the assistants to put the parts upon the stretch, when care- ful sponging will show any irregularity which needs to be trimmed off. By passing the linger over the fresh sur- face, any scar tissue that re- mains can be detected by its density and resistance com- pared with the softness and elasticity of the normal tissue. At this stage of the op- eration attention should be given to haemorrhage. If there are any spurting vessels in the wound they should be controlled by suture or ligature. Fortunately, when such vessels are encountered they are generally at the up- per margin of the w^ound, and may be controlled by passing a fine suture through the mucous membrane of the vagina and under the ves- sel and then tying it tight enough to stop the bleeding. This has been already noticed under the head of general obser- vations. Next in order comes the introduction of the sutures, and just here it may be stated that for all plastic operations I use silk sutures prepared as follows : The ordinary braided silk is immersed five or six hours in wax containing six per cent of carbolic acid and six per cent of salicylic acid; The wax is kept all the time at a tempera- ture high enough to licpiefy it. Tliis long immersion in the melted wax is necessary to thoroughly saturate the silk. When this is ac- complished, the silk is drawn through a carbolized sponge to remove any excess of the wax. It is then put on a reel which is placed in a close-stoppered bottle and kept until required. Nos, 4 and 5 are the sizes used ; No. 5 for the lower suture and No. 4 for the upper ones. The needles employed are like the ordinary darning needles, but Fig. 74. — Second step ; continuing the strip. INJURIES TO THE PELVIC FLOOR. 147 curved. The larger needles are armed with No. 5 thread and the smaller with No. 4. To manipulate these needles it is necessary to have a suitable forceps, and for this I have devised the instrument rep- resented by Fig. 76. It is a double forceps. The central portions of the two blades wliich form the handles are made of spring steel. The halves cross each other at about an inch from each end to form the jaws. At one end the jaws are file-faced on the upper tip and grooved on the lower; at the opposite end the jaws are copper-faced. The latter are used to grasp the point of the needle in drawing it through. The elastic spring of the handle portion opens the jaws at each end, the needle is intro- duced into the desired groove, the handle is grasped, which closes the jaws and holds the needle perfectly immovable, no matter how much pressure may be brought to bear upon it. When the jaws are closed there is a stop-catch that holds the two halves of the handle together and keeps a firm hold upon the needle. The needle is carried into the tissues while it is held by the grooved and file-faced jaw ; it is Fig 75. — Vivifying complete ; the vaginal su- tures on one side are inserted. Fig. 16.— Needle-forceps. then unfastened by drawing back the catch, the forceps is reversed, and the point of the needle seized in the copper-faced jaws and withdrawn. The advantage of the copper-faced jaws is that they 148 DISEASES OF WOMEN. Fig. 77. seize the point of the needle lirmly enough to draw it through the tissues without injuring the point — a vahiable feature in such an instrument. The sutures are introduced as follows : The needle — placed in the forceps at right angles to it, should be entered in the skin exactly at the edge of the wound at the lowest external angle of the denuded tissue. It is then passed outward deep into the tissues, then curved round in the tissues in front of the rectum and deep into the tissue of the other side, and made to emerge at a point corresponding to the one where it was entered. If this is properly done, no part of the suture will be seen. Its position in the tissues will be as represented in Fig. YY. The dotted line represents the suture which describes a circle, and the straight line shows the sides of the wound as they are brought together where the suture is tied. Sometimes when the tissues are rigid it is difficult to introduce the first suture with one sweep of the needle. It is then better to pass the needle in through half of the vivified portion, to draw it out and re-insert it at the same point, and carry it around through the other side. If there is sufficient tissue between the base of the vivified part and the rectum, the second and third sutures may be intro- duced like the first ^ — each one being passed at a higher point. The fourth suture (see Fig. 78) is introduced through the side. It is then carried through about three eighths of an inch of the vivi- fied portion of the vaginal wall, and then passed through the other side. The last suture is passed through both sides, as shown in Fig. 80, the position of the sutures being viewed in profile. Fig. 78. — The stitches in ])lace ; the vaginal sutures tied. INJURIES TO THE PELVIC FLOOR, 149 When more than live sutures are used, the fifth is passed hke the fourth, only a Httle above it. Most operators introduce the in- dex-finger into the rectum, to guide the introduction and passing of the needle. This should not be done under any circumstances, be- cause, by so do- ing, the rectal wall is crowded forward, and is sure to be includ- ed in the suture, and, besides, it is a violation of the rules of antisep- tic surgery to op- erate with dirty fino-ers, ■^'^^- '^^- — Laceration with rectocele. (The Fig. 80. — Perineal ^ dotted line gives the normal location body restored. in many cases of perineal body.) (Profile view.) there is very little tissue left in the perineal body after the vivifying is completed. The muscular coat of the vaginal wall having become atrophied, or torn fi-om its attachments to the floor of the pelvis, there is only the mucous membrane left, and, when that is removed in denuding the parts, the wall of the rectum is all that is left above the skin and sphincter-ani muscle. When such is the case, the first suture only should be carried through the tissue, as already described ; the others should be introduced as shown in Fig. 78. The great advantage of this is, that the sides of the wound are brought together in front of the rectum, the place where the perineal body should be. Furthermore, the sutures introduced in this way avoid the rectal wall — a very important desideratum, as we know from the fact that when any of the sutures are, intentionally or by accident, passed into the wall of the rectum, they cause much pain and rectal tenesmus, and greatly distress the patient, especiallj^ when the bowels move. When the sutures are all in place, the wound should be carefully cleansed of all blood-clots, and, if there is still some oozing of blood, traction should be made upon the sutures ; if that controls the bleeding, the sutures should be tied in the ordinary way. While they are being tied the sides of the pelvic floor should be pushed up by the assistants, to bring the wound together. The after-treatment and other points, such as the removal of the sutures, will be brought out in the history of the following cases : l^Q DISEASES OF WOMEN. Case of Central Laceration extending to the Sphincter Ani ; Uncom- plicated. — The patient, a spare, small woman, in good general health. She had been married nine years, and had one child eight years old. Her labor was easy and rapid, and her convalescence uninterrupted, excepting that she had a leucorrhoea which began after the lochia stopped, and continued until the time when she sought medical ad- vice. Her menses returned ten months after her confinement and one month after her child was weaned. Six years after her conline- ment she overtaxed her strength, and then her leucorrhoea became more profuse, and she began to suifer from backache and slight pel- vic tenesmus, especially upon standing or walking. She was consti- pated, but in all other respects was well. She sought medical advice because of these symptoms and her sterility. An examination showed a laceration, but no other injury to the pelvic floor. The posterior and lateral parts of the floor were well sustained, and there was very little separation of the sides of the laceration. There was commen- cino- prolapsus of the posterior vaginal wall, luit it was only apparent upon separating the labia and causing the ])atient to cough or make downward pressure. The uterus was below its normal elevation, but not changed in its axis. The leucorrhoea was due to a cervical ca- tarrh, which promptly yielded to treatment. Five days after a menstrual period her bowels were freely moved in the morning by a dose of pulv. glycyrrhizse comp., given at bed- time the night before. On the following evening the l)Owels moved spontaneously, and, an hour later, an enema of borax and warm water was given to wash out the rectum. Early next morning the vagina and pudendum were thoroughly cleansed and disin- fected and she was anaesthetized with ether, and the operation was performed according to the method already described. The bleeding was easily controlled by the sutures. A small pledget of marine lint was placed over the wound and the knees bandaged to- gether. Soon nausea followed, but no vomiting, and late in the even- ing she was comfortal)le, having only a feeling of slight burning in the region of the wound. She took a small cup of tea, and slept several hours during the night. Next day she liad milk, soup, and gruel. The catheter was used for the first forty-eight hours, and after that, when necessary, she was rolled over upon her face, and, with a bed-pan placed under her, she urinated without further help. On the morning of the third day she took a Seidlitz powder, and at noon an enema of castile soap and water, which moved the bowels freely and easily. After this the bowels were moved dailv witli an enema and she had her usual food. INJURIES TO tup: pelvic floor. 151 The marine lint was kept upon the outside of the wound for five days, changing it daily. There was no discliarge from the vagina or wound. There were no vaginal injections used, and the wound was not washed at any time. In fact, after the fifth day she had no local treatment. Fig. 81. — Scissors for removing sutures. On the eighth day the sutures were removed in the following way : She was placed in Sims's position on the bed ; the nurse separated the nates, which exposed all the sutures without making any traction upon the parts; each suture was seized with a forceps, and, with the tenaculum blade of the scissors, one side of the thread was caught up and divided. Fig. 81 shows the scissors used for the removal of sutures. It answers the purpose well, and guards against clipping off both ends and leaving the suture in the tissues, an accident which not unfrequently happens. This method of removing the sutures is very much simpler than trying to remove them with the patient upon the back. The patient was kept in bed until the twelfth day after the opera- tion, but during that time she was allowed to change her position from the back to either side without help. On the thirteenth day she was permitted to sit in a chair, and on the fifteenth day she was allowed to begin to walk. Two months after the operation she was examined, and the space between the rectum and vagina was found to be normal to the touch — i. e., the lines represented by the lower portion of the posterior vaginal wall and the outer surface of the pelvic floor, running from before backward, formed an angle as represented in the accompanying diagram. Furthermore, when the introitus vaginae was re- tracted with a Sims's speculum and the instrument removed, the muscles promptly contracted and firmly closed the vagina, showing that the muscles had been restored. This I consider to be the only reliable evidence of the success of this operation. Subcutaneous Laceration in the Median Line. — The first step in the operation for this injury is to make an incision in the skin from the posterior commissure down to the sphincter-ani muscle, and then remove the scar in the cellular tissue and proceed as in the com- 152 DISEASES OF WOMEN. plete laceration just described. In case there is prolapsus of the pos- terior vaginal wall, the redundant skin and mucous membrane should be removed and the vivifying of the tissues completed by removing all scar tissue. Laceration of the Pelvic Floor, Sphincter-Ani Muscle, and Recto- Vaginal Septum. — In this extensive injury, in which the laceration of the walls of the rectum and vagina extends upward bevond the internal sphincter ani, it is necessary to restore the septum before operating upon the perinaeum. As a rule, the laceration does not extend beyond the sphincters, and the parts can all be restored at one operation, but in the rare injury now under consideration two separate operations are required. I will describe lirst the operation for restoration of the septum. The patient should be placed in the lithotomy position, and the anterior wall of the vagina elevated by a Sims's or otlier retractor, which exposes the parts to be treated. The tissues on each side of the laceration are vivified well out on the vagina, in order to obtain a broad surface for coaptation. Only enough of the mucous membrane of the rectum is removed to dispose of the scar tissue that may be present. Silk sutures are introduced wdth a round-pointed, curved needle, such as Emmet uses for vesico-vaginal fistula. The needle should be introduced at the outer edge of the vivified surface of the vaginal mucous membrane and be carried deep into the tissues, and should emerge just within the edges of the rectal mucous membrane. By refer- ring to Fig. 82 an idea may be obtained of the sutures in posi- tion, with this difference, that in this operation silk sutures are used, and are tied upon the vaginal side, whereas in the operation of restoring the sphincter-ani muscle and perinaeum, catgut sutures are employed, and these are tied upon the rectal side. The in- troduction of the sutures is begun above, and each one tied when introduced. The sutures should be No. 8 silk, and not more than an eighth and a sixteenth of an inch apart. They should be removed on the eighth day, and one month allowed to elapse before the next opera- tion is ])erformed, in order to give tlie })arts a chance to become firmly united. OPERATION FOR THE RESTORATION OF THE SPHINCTER ANI AND PERINEUM. It has been already stated that the chief object of all plastic operations upon the ])clvic floor should be to restore the muscles INJURIES TO THE PELVIC FLOOR. 153 that have been injured. This is pre-eminently so in the operation to be described, because the sphincter ani is the most difficult to restore, and the results of failure are so apparent that neither the surgeon nor patient can possibly believe that the operation is a Fig. 82. — Complete laceration of the periuseum and sphincter ani. The depressions on either side of the rectal opening show the separated ends of the torn sphincter. Between the two runs a thin bridge of dense scar tissue. The rectum is drawn toward the pubic arch by a strong levator. Moderate cystocele and rectocele are present. success when it is not — a delusion often indulged in regarding the plastic operations to repair the lesser injuries of the pelvic floor. In order to comprehend the position and relations of the surfaces 154 DISEASES OF WOMEN. to be viv^lied, it must be borne in mind that when the sphincter ani is ruptured the severed ends are drawn outward and backward by the retraction of the muscle until they lie on either side nearly on a line with the posterior walls of the rectum. This may be better Fig. 83. — Complete laceration of pi'iin;i\nii. Dciiinliitiuii ronipletcd. Here the vulva is shown drawn apart much more widely than in Fijr. 8tl. The flap (R) left from the rectocele is raised. The scar tissue between the sphincter ends has been re- moved. The depressions indicate the ends of the sphincter. understood by referrinir to ¥\s;. 82. The depressions on either side of the anus are the ends of the mn.scle which are drawn down below the surface. The process of vivifying should be begun by seizing the end of the muscle on the patient's left. AVith the scissors a strip of tissue INJURIES TO THE PELVIC FLOOR. I55 should be removed from tliat point around the tissues between the rectum and vagina, and downward and outward to and includincr tlie end of the muscle on the right. AYhen this is done, it will some- times be found that the softer tissues rise above the depressed end of the muscle, so that a fossa is formed on each side. Should this occur, more of the most prominent tissue should be removed. The denudation is then carried upward upon each side to the point where the laceration began. If there is much relaxation of the rectal and vaginal walls, the denudation may extend even higher on the sides. At this stage of the vivifying there are two broad denuded sur- faces (one on each side), connected by an isthmus formed by the recto- vaginal walls. In this septum all scar tissue should be cut away, and then the rectal and vaginal walls should be separated with the handle of a scalpel or blunt-pointed scissors. The object of this dissection is to give a broader surface to be united, and to permit the vaginal wall to be raised up and attached to the inner side of the perineal body, as it is called. When the vivifying is completed the parts appear as represented in Fig. 83. There are ordinarily two sets of sutures used, one to coaptate the rectal wall and sphincter-ani muscle, and the other to do the same for the perinseum. The rectal sutures are introduced first. I used 'No. 2 catgut and the curved Emmet needle. The needle is entered at the margin of the rectal nmcous membrane on the patient's right side, and is carried upward and out- ward in the tissues about a quarter of an inch. It is then withdrawn and entered on the left side, and brought out in a manner corre- sponding to the course which the needle traversed in the right side. This leaves the ends of the sutui*es to be tied on the inside of the rectum. In introducing the first perineal suture, the point of the needle should be entered at the inner and lower point of the vivified sur- face, then carried outward around the end of the muscle, then in- ward through the recto-vaginal wall, and finally around the other end of the muscle to a point directly opposite the one where the needle was introduced. This requires skill and practice, and is often difficult ; and I have found it easier to pass the needle around the ends of the muscle and bring it out in the median line, reintroduce it, and carry it around the other end of the muscle. The objection made to this method is that the central portion of the suture is ex- posed, but the suture is completely buried in the tissues when it is tied. Certainly it is better to introduce the first suture accurately in this way than to attempt the more difficult way and fail to get it 156 DISEASES OP WOMEN. right, a result usual to those who are not accustomed to this operation. The second suture may be introduced in the same way. The remain- ing sutures are employed in the way described in the operation for restorins: the laceration in the first deg^ree. Fiars. 84 and 85 show the sutures in place. Certain changes are necessary to be made in the details of the operation in those rare cases in which the laceration of the recto- FlG. 84. — Complete laceration of i)ciin;i'uiii throut^li s|>liiiicter. The sutures in the rectal wall introducotl. For the sake of cli'arness soiuo have been omitted. vao-inal septum has extended so high up that an operation for its restoration is necessary before restoring the sphincter-ani muscle and the perin5T3um. Another condition recjuiring similar treatment is found in cases in which the scjitum has been extensively lacerated, INJURIES TO THE PELVIC FLOOR. 157 but has united by intervening scar tissue, which has to be removed to secure a perfect restoration. Under such circumstances, and also in cases in wlncli the rectal and vaginal walls can not be separated by dissection, it is better to unite the vaginal wall in the median line by a special row of sutures running parallel to the axis of the vagina. In such cases three sets of sutures are necessary : One to unite the rectal wall, one to unite the Fig. 85. — The rectal sutures have been tied on the rectal side and the ends cut short. The remaining sutures are in place. The flap from the rectocele is lifted by a tenaculum. perinseum, and one to unite the vaginal wall. In performing this modified operation, I usually vivify the edges of the laceration of the septum the entire length and then introduce the rectal sutures and be- 158 DISEASES OF WOMEN. fore tying tliem vivify all the rest of the parts to be united. The stitches are introduced into the vaginal wall and the perineal stitches placed last. The patient is put into Sims's position and the rectal sutures are tied. She is replaced upon the back and the vaginal sutures are tied, and lastly those in the pelvic floor. I have obtained the very best results from this method of opera- ting, and in suitable cases prefer it to all others. Further details of the operations will be brought out in the following history of cases : Typical Case of Laceration extending through the Sphincter Ani. — The patient was twenty-six years old when she was confined with her first child. The labor was tedious, and she was delivered, with forceps, of a very large child, which died during delivery. She made a rather slow recovery, owing to the extensive injury to the floor of the pelvis. Five months after confinement I saw her for the first time. She was then in very good health, but suffered pain in the region of the injury, especially when she walked, and she had very little control of the rectum. When constipated, she suffered very little ; but, when the bowels were free and when there was flatulence, she was obliged to remain secluded. I found that the laceration involved the sphincter-ani muscle, and evidently had extended upward into the wall of the rectum and vagina ; but union had taken place, by a little intervening scar tis- sue, down to the sphincter, or within a quarter of an inch of it. The muscles of the pelvic floor, excepting the sphincter and transver- sus peringei, acted well, and held the divided sides well up. The end of the rectum was also drawn upward and forward, so that the distance from the vestibule to the posterior margin of the anus was less than normal. This brought the posterior wall of the vagina up to the anterior, so that the vagina was closed. It was only by plac- ing the finger in the rectum and pressing it backward that the full extent of the laceration became apparent. She was constipated, and her tongue slightly coated, at this time. Pil. hydrarg., gr. x, and pulv. ipecac, gr. j, were given at bedtime, and a wine-glass of Hun- yadi-Jauos water an hour before breakfast next morning. This moved the bowels freely, and they were kept free for the subsequent two weeks with the following : Fluid extract of pod(»j)hyllum 3 j I Tincture of colocynth 3 ij 5 Tincture of belladonna 3 j ; Glycerin 3 ss. ; Syrup of acacia and compound tincture of cardamom, of each 5 j- INJURIES TO THE PELVIC FL(XJR. 159 A teaspoonful of this noon and evening before meals. When this acted too freely, only one dose was given. During these two weeks the nurse passed the finger every day into the rectum and pressed the parts back toward the coccyx, main- taining the traction steadily for several minutes. This was done for the purpose of restoring the elasticity of the tissues, and also elon- gating the divided sphincter muscle as much as possible. Menstrua- tion then began, and no further local treatment was employed mitil after it stopped, when it was resumed. Four days after the menses ceased, the operation was performed in the prescribed way, silk sutures being used. For twenty-four hours before the operation, and for three days after, the patient had only fluid food — beef-tea, strained soups, whey, and water. After the third day, peptonized milk, strained oatmeal and barley gi*uels, and raw oysters were added to the diet list. There was sufficient pain during the first three days to require ten drops of liquor opii comp. to be taken every four hours. On the fourth day she suffered from flatulence, which was relieved by catheterizing the rectum, using a silver catheter ; this had to be re- peated the following day. On the eighth day (and before the su- tures were removed) half an ounce of sulphate of magnesia in peppermint-water was given before breakfast and toward noon ; when the patient felt the bowels inchned to move, half a pint of solution of ox-gall and water were used as an enema. When this had been retained about twenty minutes, the nurge assisted the evacuation of the bowels by making pressure upon each side of the wound opposite the hrst suture, and, with the index-finger of the other hand in the vagina, she made gentle and interrupted pressure downward and outward. In this way it was hoped that the rectum would be evacuated without disturbing the wound. There was not the slightest trace of haemorrhage, which gave reason for believing that no harm had been done. On the ninth day all the sutures were removed, and on the tenth day the bowels were moved in the same way as before. During all this time the catheter was used to draw the urine. After this the patient was permitted to urinate in the prone position. Every second day until the twentieth the bowels were moved, the same care being taken by the nurse to guard the wound during the evacuation. On the twentieth day the wound was carefully examined, and there was apparently perfect union throughout, including the mucous mem- brane. The function of all the muscles of the pelvic floor was re- stored, except that of the sphincter ani. The function of that mus 160 DISEASES OF WOMEN. cle was, however, sufficiently restored to give the rectum retaining power, but it did not act as a perfect sphincter muscle. When it acted, the contraction was not equally toward the center, but rather toward the point of rupture that had been restored. The posterior portion of the perineal body acted like a fixed point, toward which the muscle contracted. I am inclined to believe that this is the best result that can be obtained by this operation. After the new repara- tive tissue which is developed during healing has fully contracted, the function of the muscle becomes more nearly restored. Indeed, it is in many cases quite perfect so far as controlling the rectum is concerned, but it rarely, if ever, acts exactly as it did before injury — i. e., by a perfect concentric contraction. A Case illustrating Partial Failure of the Operation; a Second Operation completing the Cure. — The patient was thirty-five years old, and had had three children. The youngest was eighteen months old at the time when this history was taken. Her first labor, five years and a half ago, was comj^licated. The patient stated that the doctor in attendance said that there was a shoulder presentation, that the child was turned and delivered feet first, and that the forceps was used to deliver the after-coming head. From that time onward she had no control of the rectum, and the only way she w^as able to take care of herself was by being extremely constipated, the bowels never moving except in response to medicine, a dose of which she usually took about once ever}' week. The extent of the injury was exactly like the case last given, excepting that there was union of a thin band of vaginal mucous membrane, which extended outward to the upper margin of the sphincter-ani muscle. There were also two hiTemorrhoidal tumors, formed by hyperplasia of the rectal mucous membrane, located at each side of the anus. These haemori'hoids, which are not uncommon in this injury, were removed one month before the restoration of the lacerated parts was undertaken. The mode of operating was by seizing the tumors in a Pean forceps and making traction sufficient to raise the mucous membrane, then pass- ing the haeniorrhoid-clamp (Fig. 8G) beneath the forceps, and slowly Fig. so — Iltcinorrlioid tlaiup. INJURIES TO THE PELVIC FLOOR. 161 constricting the pedicle by tightening the clamp. A ligature of prepared silk was applied to the pedicle under the clamp. The for- ceps and clamp were then removed, the tumor clipped oft" far enough outside of the ligatui-e to prevent its slipping, and the stum]) touched with carboHc acid. The ligatures came oft in less than a week, leav- ing a very minute spot to heal. She was then submitted to about the same preparatory treatment as in the last case related, and the operation was performed as before described. The diet was gruel and peptonized milk, with beef-tea. On the second day half an ounce of Roclielle salt was given, followed in three hom's by an enema of half a pint of a solution of ox-gall, and, one hour later, a large ene- ma of soap-suds. This did not move the bowels ; on the following morning half an ounce of castor-oil was given, and in the afternoon the enema repeated as on the previous day ; the enema came away, but the bowels did not move. The next day, she was ordered a mixture composed of a decoction of senna, one ounce to a pint of water, with one ounce of Rochelle salt. Of this, two ounces were given every hour until she had taken three doses. It pi'oduced a free evacuation, without causing pain in the wound or doing it any harm. The mixture was repeated in the same way with a like effect, and was again ordered a third time, but, by an oversight of the nurse (the case was in a general hospital), it was not given. Another mistake was made the following day, the nurse giving two drachms in place of two ounces of the medicine. On the eighth, day after the operation the medicine was given correctly ; but, when the bowels were about to move, the nurse, who should have sujDported the parts, was absent, and the patient got out of bed to use the commode, and had a free movement, attended with pain and some bleeding. Up to this time the wound had progressed quite well in healing, but that unfortunate movement of the bowels, unaided by the nurse, tore the ends of the sphincter-ani muscle apart, and spoiled the operation to that extent. On the tenth day the sutures were removed. There was perfect union, excepting the ends of the muscle. The opera- tion was a complete failure, so far as its main object was concerned. She was kept in the hospital for two days more, when it was found that, although her bowels were easily kept regular — a great improve- ment on her former state — she had very little more control of the rectum than before the operation. Three months after this she was again persuaded to try to obtain relief, and she was placed under the care of a more competent nurse, who followed directions regarding preparatory treatment, including the manipulation daily of the sphincter ani, and at the end of a week 12 162 DISEASES OF WOMEN. another operation was performed to restore the sphincter. The stretchinor of the muscle backward with the finder in the rectum as practiced bj the nurse was more effectual than in cases in which the rupture is complete. The part of the pelvic floor which was restored by the operation gave some support to the severed ends of the sphinc- ter, so that when traction backward was made the muscle became considerably elongated ; and when the second operation was under- taken the parts were sufficiently relaxed to facilitate the necessary manipulations. The patient, well anaesthetized, was placed in Sims's position, a small speculum introduced into the rectum posteriorly, and traction made backward, while with a strong tenaculum, fixed in the margin of the anus anteriorly, the ends of the muscle and the intervening tissues were brought into view. The end of the muscle of the left side was seized in the tissue forceps and denudation made from the left to the right end of the nmscle. The vivifying included both ends of the muscle and extended upward on the anterior rectal wall about half an inch. The sutures, three in number, were introduced in the same way as in the first operation. Some trouble was ex- perienced in curving the needle around through the tissues, but with the aid of an assistant, who passed his index-finger into the vagina and everted the rectum in front, all the sutures were accurately in- troduced. On the third day after the operation a dose of senna and salts was given in the morning, and at noon the bowels were moved in a rather novel way. An apparatus constructed upon the principle of that used by Professor Bigelow for expelling fragments of stone from the bladder was employed to wash out the contents of the rec- tum (Fig. 87). Fig. 87. — a is a hard-rubber rectal tube bifurcated at b c; b, wliieli is the supply tube, is attached to a fountain syringe, anserved in the ordinary forms of cervical endometritis. Occasionally the discharge Fig 9"^ — H\pertrophv of boih of uterus fol- low ino; coiporcal endo- metntife (Winckel). Fig. 100. — General enlarge- ment of uterus, contrasting with the two preceding fig- ures (Winckel). Fig. 98. — Thickening and elongation of the cervix, as a result of cervical endome- tritis (Winckel). may be muco - purulent, at times it is sero-muco-purulent ; but this occurs only in extreme cases, and usually is due to some specific cause, and hence need not be considered in this con- nection. The ordinary form of cervical endometritis, described above, occurs in parous and imparous alike. There is another form of cer- vical endometritis which occurs only in the imparous, and has some peculiar characteristics which should l)e noticed here. In these cases the changes in the vessels already noted may or may not be present ; usually they are not. The discharge from the cervical canal is not usually profuse, but it is peculiar in character. In place of the clear, translucent secretion we find a very thick and exceedingly tenacious material of the consistency of thick glue, and of a darkish color not unlike pneumonic sputum, though more solid and dense, and not usu- ally so bright-red in color. Associated ^Yith this peculiar discharge 188 DISEASES OF WOMEN. there are usually marked tenderness and dysmenorrlioea, which are not accounted for by any other condition of the uterus than the state of the cervical mucous membrane. I am inclined to think that this form of cervical disease is due to some malformation or arrest of de- velopment of the glands of the mucous membrane. I have been led to believe this because it occurs in those in whom the uterus is im- perfectly developed generally, and also the same peculiar secretion is observed in some women after the menopause, when the uterus and its mucous membrane have undergone final involution. In other cases of this class the mucous membrane of the cervix becomes prolapsed, causing dilatation and inversion of the lips of the external os, so that the cervix appears as if it had sustained superficial, bilateral laceration. In such cases the ai:)pearance is such as to lead to the belief that the patient has borne children, or had a miscarriage ; but I have found it associated with unruptured hymen, showing that it could not have come from injuries during parturition. Dr. Emmet describes cases of laceration that he has seen follow- ing criminal abortion in those who have not borne children. In the cases to which I refer the anatomical appearances are the same as he describes, but I am satisfied that in those that have come under my observation the laceration was apparent, not real. As soon as the membrane is reduced to its normal dimensions by exsection of a portion of it, and relief of the inflammation by treatment is accom- plished, the external os contracts, and the cervix resumes its original virgin form, showing that no injury to the muscular coats of the uterus has ever occurred. Symptomatology. — Cervical endometritis does not necessarily give rise to marked constitutional disturbance ; when it does so the symptoms usually appear in the form of general debility, especially of the nervous system. The patient may become easily fatigued and somewhat changed in disposition, and less inclined to mental activity. (Sometimes there is considerable mental disturbance, but much of all this is usually due to the fact that the patient is annoyed by the presence of a more or less profuse leueorrhoea, which gives her discomfort, and leads her to suppose that she is suffering from a serious affection. The constitutional effects of this local affection depend very much upon the sensitiveness of the patient. The menstrual function is not necessarilj^ affected. In cases of long standing there may be irregular menstruation, and the flow may be inclined to diminish, but this is not the rule. The character of the leucorrlueal discharge is diagnostic. It is dense, thick, opaque, and tenacious, while the vaginal leucorrhoea is INFLAMMATORY AFFECTIONS OF THE UTERUS. 189 serous, non-tenacious, and usually purulent. If the disease is long continued backache comes on, the pain being located in the sacral region, which distinguishes it from the lumbar pain characteristic of general debility and some of the acute diseases. There is often, also, some pelvic tenesmus. All these symptoms are usually very much aggravated by muscular exercise; the symptoms alone, how- ever, are not sufficient to enable one to make a diagnosis. All that can be learned from them is simply that there is some uterine affec- tion which, if it does not yield promptly to constitutional treatment, demands further investigation in order to settle definitely its char- acter. Physical Signs. — These, as obtained by the touch, are usually rather unsatisfactory. Upon making pressure upon the cervix there is sometimes tenderness, but not always ; in some cases a roughened condition of the mucous membrane around the os externum can be detected by the touch. ]^ot infrequently there is a little relaxation of the vagina, and the uterus rests lower in the pelvis. Speculum examination affords the best means of ascertaining the lesions. We can usually see enough of the mucous membrane within the OS externum to determine the presence of the inflammation. This is rendered more positive when the redness and erosion of the membrane extend outward upon the vaginal surface of the cervix, and also when there is eversion of the membrane. There is usually a free leucorrhoeal discharge from the cervical canal. Sometimes this hypersecretion is the only evidence of the disease present. Passing the sound into the cervical canal shows that it is more sensitive than in health, and the membrane bleeds more easily on touch than it should. It will be seen that the physical signs, as well as the symptoms, are not by any means marked in cervical endometritis, yet they are sufficient for diagnostic purposes. Whenever the con- stitutional disturbance and the local symptoms are severe, it may at least be suspected that the membrane of the cavity of the body of the uterus is also involved. This will be more fully discussed under the head of corporeal endometritis. In the form of cervical endometritis referred to, in which the secretion of the glands is opaque, dark in color, and exceedingly te- nacious, the discharge is not at all times very profuse, but enough can be obtained by using a small curette to show its character. This in itself will be sufficient to determine the diagnosis. Causation. — The predisposing causes of endometritis are imper- fections in the general organization, and in the development and growth of the sexual organs. Scrofulous and tubercular diatheses 190 DISEASES OF WOMEN. incline to chronic inflammation of the mucous membranes generally, and the membrane of the uterus is no exception. When the uterus is under size or malformed in a slight degree, so that menstruation is imperfectly performed, an inflammation of its mucous membrane is very likely to come on sooner or later. Sed- entary habits and unsuitable clothing, over-fatigue in standing or walking, or anj'thing which interrupts the return circulation from the pelvis, predispose to this aifection. So, also, deranged nutrition, from insufiicient nutriment or over-taxation, mental or physical, which leads to impoverishment of the blood. Frequent child-bearing and prolonged lactation also predispose to the same trouble. All these causes act to produce derangement of innervation and circulation, and so favor the development of inflammation. The exciting cause which plays the jnost important part in endo- metritis is imperfect involution after confinement or menstruation. The great majority of cases take their origin from this imperfection of the menstrual or parturient involution. Other exciting causes which may be mentioned are injuries to the uterus from displacements, the use of ill-fitting pessaries, injuries during confinement, causing puerperal inflammations: abortion, es- pecially if produced, intemperate coition, and efforts to prevent con- ception, and finally gonorrhceal virus. This specific cause of endo- metritis no doubt produces a form of inflammation which difters from the non-specific forms, and hence we will refer to it at another time. So far as I know the same causes produce both cervical and corporeal endometritis, so that in the present state of our knowledge I am not prepared to state any difference in the causes of the two affections, if any such exists. I am inclined to think, however, that as cervical endometritis is beyond doubt much more common than corporeal, it may be inferred that the one tends to the development of the other. Prognosis. — Of the uncomplicated cases of cervical endometritis the great majority yield to the proper treatment. There is in some a tendency to a recurrence of the disease, even after recovery has apparently been perfect. In those cases of imperfect development there is not the same certainty of giving eomjilete relief. Treatment. — The constitutional treatment of inflammatory affec- tions of the uterus should be based upon the principles of the gen- eral management of local inflammations. To correct any defect in the general health, to improve menstruation, and to calm any excite- ment of the nervous system, comprehends the whole subject. The sexual organs being dependent upon the nutritive and nervous sys- INFLAMMATORY AFFECTIONS OF THE UTERUS. 191 terns for support, general therapeutic agents can only affect tlie one by action through the other. There are a few medicines wliicli act especially upon the sexual organs, through the circulatory or nervous systems, such as ergot, hydrastis canadensis, and the bromides, but their effects are not al- ways efficient in controlling inflammation. Constitutional remedies, as already stated, act upon the uteras only so far as they improve general nutrition and innervation. In view of these facts, little need be said on this part of the subject ; every means which can improve the general health should be em- ployed in connection with the local treatment. To save repetition, the reader is referred to the section on menstrual derangements, third chapter, for details of constitutional derangements which usu- ally accompany diseases of the uterus. Local Treatment. — Local treatment of the diseases of the uterus — the one organ of the sexual system which is most amenable to local treatment — will be given in the history of cases. Some general re- marks, however, on the principal facts in uterine therapeutics may be submitted in this connection. That which is said now will apply in great part to all forms of metritis. Local treatment should be employed with the view of accom- plishing two objects : first, to remove the disease, and, second, to restore the organ to its normal condition. It will at once be inferred that if the first object is attained, the second will follow as a natural consequence ; but it may or may not, according to the character of the treatment employed. I am satis- fied that in times past, and even at present, much of the treatment of uterine disease, while it arrests the inflammatory trouble, proves so destructive to the normal structure of the organ as to render the last condition of the patient worse than the first. In the management of uterine diseases one may be guided by some of the accepted rules laid down by surgeons for the treatment of infiamraation generally, viz. : Place the diseased organ at rest ; quiet irritation by sedatives, and relieve the congestion by depletion, astringents, alteratives, and sedatives. To accomplish these objects, it is necessary to employ all the improved means brought forward by modern investigation, changing and adapting them so as to meet the peculiarities of each case. First, then, rest should be secured by having the patient abstain from long-continued standing or walking, and from over- excitement of the sexual function. If the uterus is displaced, it should be replaced, and sustained in its normal position by the support of a well-fitting pessary, if need be. 192 DISEASES OF WOMEN". To relieve pain and quiet the irritation a vaginal or rectal sup- pository made of extract of belladonna, one eighth to one half grain, with cocoa-butter, and used at bed-time, will often give great relief. Suppositories of iodoform and of conium are also of service when used in the same way. I desire to call attention specially to the next agent, namely, deple- tion, because I regard it is as a remedy of some value. In making this statement I am aware that I encounter much professional prejudice. Bloodletting has ceased to be the fashion of the day. The lancet is condemned as a " little instrument of mighty mischief." Few of the younger members of the piofession have ever seen a patient bled. Local depletion held its own some time after general venesection was to a great extent abandoned, but even this has gradually given way to the popular prejudice of the day ; nevertheless, the fact in surgical therapeutics remains as true as ever, that the removal of blood directly from the vessels of an iuilanied or congested organ gives some temporary relief. Frequent repetition of bloodletting should be avoided, but when a case is first seen in which there is marked congestion, the abstrac- tion of a httle blood by a few punctures around the os externum, or the superficial scarification of the mucous membrane in this region will pave the way for other applications. To practice depletion exclusively and persistently, as some of the older gynecologists did, is certainly injurious ; but, as a means to be employed in suitable cases, it is worthy of consideration. Hot water, used as a vaginal douche, is an antiphlogistic which was first popularized in this country by T. A. Emmet. It depletes the parts by stimulating the circulation, and is at the same time something of a local sedative. It is an exceedingly jjopnlar remedy at the present time, and is used rather indiscriminately in all diseases of the pelvic organs, and with heroic persistency. If properly used it gives relief in congestion of the vagina and uterus, and in cellulitis when the inflammation is limited to the cellular tissue about the cer- vix uteri. It is also of service in the passive congestion which often accompanies imperfect involution, but in pelvic peritonitis, salpin- gitis, and ovaritis it is often harmful. It is also very liable to do harm when used, as it often is, after plastic operations about the cervix uteri and perinaium. Another means of depletion was introduced by J. Marion-Sims. He employed a small vaginal tampon of cotton saturated with glyc- erin, which caused free exosmosis from the mucous membrane, there- by relieving capillary engorgement and oedema. INFLAMMATORY AFFECTIONS OF THE UTERUS. 193 Position has much influence in modifying the circulation in the pelvis, and hence patients should avoid the too common habit of sit- ting all day in a chair because they suffer when they walk. Short periods of walking or riding, followed by rest in the recumbent po- sition, should be directed. In the treatment of endometritis with the applications of cura- tive agents, two very important questions arise : First, what agents shall be used, and how shall they be applied. Bearing in mind that the uterus should not be injured in its structure, the therapeutist is bound to reject all the more powerful and destructive agents, such as nitric or chromic acid, caustic potash, and the actual cautery. All these have been used, and are now, though less extensively, I trust, than formerly, in the treatment of simple chronic endometritis, or hypersemia of the mucous membrane of the cavity of the uterus. Leaving out of account the value of these potent agents in the treatment of malignant diseases of the uterus, I desire to be distinctly understood as opposed to their use in the treatment of the benign uterine diseases. I readily admit that inflammation of a mucous membrane can and may have been " cured," as the expression is, by such means. The oculist could " cure " a chronic conjunctivitis by destroying the membrane with strong caustic, but I fear the eye would be hardly presentable afterward, and it would surely fail to perform its func- tion. There are those who treat the same affections of the mucous membrane of the uterus with these destructive agents, and the results which follow can be easily imagined. It may be argued, I am aware, that strong caustics are being used less and less by the profession in the treatment of uterine disease, and I am glad to believe that such is the case. Nitric and chromic acids, and other caustics, are being laid aside, but only, I fear, to give place in some cases to new but none the less destructive agents. I allude to the galvano-cautery and the thermo-cautery. These have become the " fashionable " caustics or cauteries of the day, and I trust I most thoroughly appreciate their value in the treatment of malignant disease, when the destruction of tissue is called for ; but, in the treatment of inflammation, they can not fail to work great and uncalled-for destruction, like the agents used in the past. The treatment of the cervical canal is fortunately simpler, being m.ore easy to reach, and much more tolerant of irritation. The only difficulty in the way of making applications is the presence of a tena- cious secretion which fills the canal. This should be removed with a small curette before the application is made. 14 19-1: DISEASES OP WOMEN. The method of applying these agents is by using the pipette (Fig. 101). Regarding the agents to be used, a long list might be ^_ given, but it will -^ r■T^i:^^AN^l ,&■^.u■^.^^^^^^ suffice tO say that ^J^^"^ ^ the safest and most Fig. 101. — Skene's instillation tube. . emcient are mild solutions, one or two grains to the ounce, of sulphate of zinc, chlo- ride of zinc, nitrate of silver, tannic acid, and bichloride of mer- cury ; mv own preference for general use is tincture of iodine two parts and carbolic acid one part. The frequency with which these local applications should be made depends upon the nature of the lesions. In ordinary cervical and corporeal endometritis, once every five or six days will answer. This gives time for the tissues to fully profit by the application before it is repeated. I am aware that the practice with some is to make local applica- tions every day or every other day, but I know that this constant manipulation is irritating, and does more harm than good. Mucous Polypi of the Cervix Uteri. — In connection with erosion of the cervix the glands of the cervical canal sometimes become cystic, and project from the eroded surface. The amount of this projection is occasionally so great that the cysts escape from the canal and hang by pedicles in the vagina. They are not unlike nasal polypi, and are called mucous polypi of the cervix. They are red in color and are semi-transparent. ILLUSTKATIVE CASES. A Typical Case of Uncomplicated Cervical Endometritis. — A lady, thirty-two years of age, was married at the age of twenty-one, had borne six children, and had nursed all of them. Her health had always been very good, and her menstruation regular and natural, showing that her general health and organization were excellent. She nursed her last child for eighteen months, her menses returning when her child was ten months old. From that time she had a slight leucorrhojal discharge, which gave her no trouble and was not re- garded. Before weaning her child she became quite debilitated, com- ]ilaining of occasional dizziness, shortness of breath in active exer- cise, considerable backache, constipation, and occasionally impaired appetite. Her leucorrhoea about this time increased in amount and alarmed her, because she attributed her general ill-feelings to this discharge. This was her condition when she first applied for advice. On digital examination the uterus was found to be normal in size INFLAMMATORY AFFECTIONS OF THE UTERUS. 195 and position, the external os was larger than normal, and there ap- peared to be slight roughening of the membrane immediately around the OS. A specuhim examination revealed an areola of a deep-red color around the os externum, and a profuse leucorrhoeal discharge from the cervical canal. The cervix appeared to be a little larger than normal, but this increase in size V7as wholly due to enlargement of the cervical mucous membrane, which was decidedly congested, and possibly somewhat thickened. The internal os appeared to be normal ; the mucous membrane of the cervix bled when touched rather gently with the uterine sound. From the fact that her men- strual flow was quite regular and normal, and that the internal os was not unduly dilated, nor the body of the uterus enlarged or ten- der, the diagnosis of endometritis limited to the cervix was made with positiveness. Her general debility was no doubt due to fre- quent child-bearing and lactation, and not wholly to her uterine dis- ease, as she had supposed ; in fact, I believe that the cause of the endometritis was largely, perhaps entirely, due to her exhausted and debilitated condition. , She was directed to wean her child as promptly as possible, and to rest from all her taxing household duties ; to spend some time every day in the open air, riding mostly, and to take an abundance of good nourishing food. The following prescriptions were given to her : A teaspoonful of comp. liquorice-powder at bed-time, to be repeated every night, the quantity to be increased or diminished in order to keep the bowels regular. Two grains of the pyrophosphate of iron were given after meals, well diluted, and a glass of claret. Locally, she was directed to use a vaginal douche of borax and wanii water twice a day. This was continued for about two weeks, M^hen it was found that she did not apparently derive very much benefit from it, and she was directed to use it only once a day, which seemed to answer quite as well, and relieved her from the trouble of using it twice a day, which she complained of as a considerable annoyance. Locally, the treatment consisted of a careful removal of all secretions from the cervical canal with a dull curette. In doing this consider- able hseraorrhage was produced at first, and it was necessary to wait until this had subsided before making any local application, but as this only occurred a few times it was soon possible to remove the secretions without difficulty, and a preparation of equal parts of tincture of iodine and carbolic acid was applied thoroughly to the entire canal with the glass pipette (Fig. 96). A few drops of this mixture was drawn up into the tube by compressing and releasing the bulb. The pipette was carried up to the internal os, and while 196 DISEASES OF WOMEN. it was being slowly withdrawn pressure was made upon the rubber bulb, which gently expelled this mixture and thoroughly applied it to the entire raucous membrane. This local treatment was repeated every five days during the next two succeeding inter-menstrual pe- riods, and the general tonic and sustaining treatment continued, varying the chalybeate tonics from time to time. From this time onward local applications were made after each menstrual period, and again in about two weeks, making two local treatments between each menstrual period. Her general condition greatly improved ; the cervix diminished in size by a marked contraction of the cali- ber of the canal ; the leucorrhoeal discharge almost entirely disap- peared, and at the end of five months from the time that the treat- ment was first begun she was dismissed quite well. She was di- rected, however, to return after the menstrual period for two or three months, to ascertain if there was any disposition to a recurrence of the cervical endometritis. It was found that she remained well, and hence recovery was considered to be complete. Cervical Endometritis, with Hyperplasia of the Mucous Membrane. — This patient was twenty-eight years of age, rather small and deK- cate-looking, but had enjoyed good health up to her last confinement. She had been married eight years and had three children, the last one being ten months old at the time when I saw her first ; she had nursed all her children, the first two for about a year, but the last one she weaned when it was eight months old, because she did not feel well, and had not sufficient milk for it. When her baby was about four months old she began to suffer from leucorrhoea, back- ache, and pelvic tenesmus — the latter symptoms being very much aggravated by active exercise. She had also lost considerable flesh, was easily fatigued, and somewhat nervous and depressed ; her gen- eral nutrition appeared to be fair, and her appetite was good ; her bowels were regular, and, although her pulse was not strong, she had a good, clear, healthy complexion. Digital examination revealed slight relaxation of the vagina, especially of the upper portion ; the uterus was rather low in the pelvis, and, while the body was normal in size, the cervix was considerably enlarged. The cervical canal was dilated, and the lips of the external os everted. Around the os, and extending outward to about half the thickness of the cervical walls, the mucous membrane was quite granular and rough to the touch. Through the speculum a very free leucorrhoeal discharge from the cervix was observed, and the first impression was that there was superficial bilateral laceration of the cervix, but on more careful investigation it was found that the mus- INFLAMMATORY AFFECTIONS OF THE UTERUS. 197 cular wall of the uterus was very little, if at all, injured, and that the enlargement of the os externum and the eversion of its lips were due to the enlargement of the mucous membrane. The corrugations of the thickened mucous membrane were so marked as to give a papillomatous appearance, and the congestion was such that the parts bled freely on being touched with a sponge. The patient was put upon a systematic course of rest and exercise, simple but nourishing food, and the citrate of iron and quinine as a tonic. Locally, she was ordered a vaginal douche of two quarts of water, two drachms of borax, and a half drachm of tannic acid to be used twice daily. A number of the more prominent points of the mucous membrane, which projected from tlie os externum, were removed with the scissors. A borated tampon was introduced and removed on the following day, and two days afterward the iodine and carbolic acid mixture was applied to the whole length of the cer- vical canal with the pipette. One week afterward that portion of the cervical mucous membrane which could be seen was smooth, less re- dundant and less vascular ; the canal was still dilated, and the rugosi- ties of the mucous membrane were abnormally prominent. The more prominent portions of the mucous membrane of the canal were touched with a fifty-per-cent solution of chloride of zinc applied with a camel's-hair brush. Considerable pain followed this applica- tion, and continued until late in the evening. From this onward the vaginal douche was employed once a day, borax and water only being used, the tannic acid being omitted. The carbolic acid and iodine were applied to the canal of the cervix with the pipette, the secretion being carefully removed with the curette before the appli- cation. This local treatment was employed once a week during the inter-menstrual periods for about five months, after that one appli- cation after each menstrual period for three months longer. At this time her general health had been considerably restored, the canal of the cervix had returned to its normal size, the leucorrhoeal discharge had entirely disappeared, and the mucous membrane around the os externum was perfectly normal. She had no further trouble from backache or pelvic tenesmus, and she was dismissed perfectly well, locally and generally. Cervical Endometritis, Stenosis of the External Os, and Cystic De- generation of the Mucous Membrane. — This patient was an English lady, thirty-nine years of age. She had two children, the youngest one being five years old. She had an excellent constitution, and her health had always been quite perfect. After her second confinement her convalescence was interrupted for a short time by some local 198 DISEASES OF WOMEN. trouble, the nature of which I coukl not exactly determine. She recovered from this, but afterward suffered from uterine leucorrhoea. This gave her very little trouble, and as she hoped that it might dis- appear she did not seek medical advice until two years afterward, when she called upon a physician, who told her that " she had ulcer- ation of the womb." He treated her for about six months by apply- ing nitrate of silver, making the applications with a swab through a cylindrical speculum. This I learned from the patient herself, who stated that the doctor told her he was using nitrate of silver. The treatment diminished the leucorrhoeal discharge, but she began to have backache and pelvic tenesmus, with an occasional sharp pain in the region of the uterus. She also had slight dys- pareunia. She was told by her physician that the ulceration was cured, and that her symptoms would all probably pass away, but after wait- ing for six months and finding that they did not she came under my observation. Her general health was still fairly good, but the local symptoms caused her considerable nervous disturbance, and the leucorrhoea had returned, but not so profusely as before. The touch revealed an enlargement of the cervix uteri, and around the os there was a number of quite hard points, some of them projecting a little above the general surface, giving an impression that there was a number of shot imbedded in the cervix. The os externum could not be very clearly made out by the touch. The entire cervix ap- peared to be a little denser than normal, and on speculum exami- nation the mucous membrane seemed to be red in spots, while the cysts had a whitish or pearly appearance, some of them showing a deep-yellow color. The os externum was somewhat puckered from scar tissue, one well-marked scar running from the posterior lip of the 08 outward and backward. This was lighter in color than the general mucous membranCo The os admitted a small uterine probe. The canal of the cervix, above the contracted os externum, was found to be considerably dilated, and contained quite a large accumulation of a thick, tenacious, leucorrhoial secretion. The cervix was tender to the touch, but not extremely so ; the body of the uterus appeared to be normal in every way. The conditions here found illustrate a very common class of cases in which there has been ordinary cervical catarrh, which has been treated by the application of a caustic to the vaginal surface of the cervix and the lips of the os externum. The frequent and long-continued use of nitrate of silver almost always produces stricture, scar tissue, occlusion of the Nabothian glands, and the formation of cysts. The treatment in this case INFLAMMATORY AFFECTIONS OF THE UTERUS. I99 was to first take out a triangular piece of the scar tissue from each side of the os externum, which enlarged it sufficiently. The cysts were then all carefully torn open, and the contents evacuated by pressure ; the secretion in the cervical canal was removed with the curette, and an application of the tincture of iodine was made to the canal and the vaginal portion of the cervix. A hot-water douche was directed to be used twice a day. The patient was examined three days after, when the os externum was observed to be contract- ing somewhat as the healing process was going on. A small tampon of cotton was introduced into the os externum, and maintained there for twenty-four hours by means of the vaginal tampon. It was then reintroduced without the vaginal tampon, and again removed at the end of the next twenty-four hours. This tampon, while it pre- vented the contraction of the os, interfered at the same time with the process of healing, so it was given up. At the end of a week after the tirst treatment there was found still a number of cysts, some of them within the cervical canal. These were all opened and the leucorrhceal secretion removed from the canal with the curette, and the mixture of iodine and carbolic acid applied ; and tincture of iodine alone applied to the vaginal portion of the cervix. These applications were repeated once a week, and the warm- water douche continued for four months. During this time all the local symptoms disappeared except the leucorrhoeal discharge,, and this diminished in quantity and became less opaque in character, but it did not wholly disappear. The size of the external os remained ample, while the canal con- tracted very decidedly, so that it was almost of its normal caliber. The scar tissue became less dense, and all tenderness disappeared. After the first four months' treatment the patient was seen for an- other three months, just after the menstrual period, when the iodine and carbolic acid were applied to the cervical canal, and the iodine to the vaginal portion of the cervix. Seven months from the time that she first came under my observation she was found to be preg- nant, and hence was dismissed as recovered. I subsequently learned that she passed safely through her confinement, but 1 have had no opportunity of examining her since, although I believe that she re- mains quite well, and hence it can be inferred that the cure was permanent. Cervical Endometritis treated by Caustic, which produced Con- traction of the lower two thirds of the Cervical Canal. — This lady was twenty-eight years of age, of remarkably strong organization, and had always enjoyed good health until the birth of her third 200 DISEASES OP WOMEN. child. At that time she had some difficulty in her labor, and sus- tained a slight laceration of the perinaeum ; after this she had pelvic tenesmus and leucorrhosa. When she first came under my observa- tion she had slight prolapsus of the uterus, with retroversion in the first degree ; there was cervical endometritis, indicated by the deep- red color of the mucous membrane and free leucorrhoea, but there was no other pathological change in the mucous membrane. An application of tannin and glycerin was made to the cervical canal, the uterus was replaced, and she was told that it would be necessary to restore the perinaeum in order to give complete relief. The thought of an operation somewhat disturbed her mind, and a friend advised her to place herself under the care of her physician, a homoe- opathist. This she did, and at the second visit he told her that he had introduced a pencil of nitrate of silver into the womb, and had applied some cotton to keep it there, and desired her to return to his office the next day so that he might remove the cotton. On the way home she suffered severe pain, and was obliged to go to bed as soon as she reached the house. She suffered considerably during the night, and the following day sent for the physician, who removed the cotton, and told her that she would be all right. She continued, however, to have a good deal of pain and pelvic tenesmus, especially when she tried to stand or walk. For the next two or three days she had a discharge which differed from the former leucorrhoea ; it was less tenacious, yellow in color, and at times quite offensive in odor. She returned to the physician for further treatment as soon as she was able. The discharge became very much less, and finally disappeared entirely. She was encouraged to hope that she would get well without any further treatment. In this, however, she was misled. Her backache and pelvic tenesmus increased in severity, especially when standing or walking, and she began to have painful menstruation. About a year from the time she had the caustic ap- plied she returned to me. I found the displacement about the same ; there was no leucorrhoeal discharge whatever, and no external evidence of the former endometritis. The os externum was con- tracted, and its lips curved inward ; the tissues around the os were extremely hard, and to the touch and inspection appeared to be mostly scar tissue. The cervical canal was contracted in its lower two thirds, so that a small uterine sound could be passed with difficulty ; there was none of the elasticity of the normal canal left, but a hard, almost cartilaginous condition existed. The passing of the sound caused considerable pain, and some haemorrhage. The patient was then INFLAMMATORY AFFECTIONS OF THE UTERUS. 201 sent to mj private hospital, and an effort was made to dilate the cervix by the use of graduated sounds. This gave pain, and was not effectual. Then the whole length of the contracted portion of the cervical canal was incised on the two sides, the incisions being made with my hysterotome (Fig. 42) through the scar tissue, and the canal was then dilated sufficiently to admit a No. 23 sound ; a tent made of marine lint and dipped in carbolic acid and glycerin, one part of the former to three of the latter, was passed up into the canal and retained there by a vaginal tampon ; this was left in po- sition for twenty-four hours, when it was removed. A short, hard- rubber stem-pessary, which reached beyond the line of contraction, but not up to the internal os, was introduced and worn for nearly three weeks. During that time it was repeatedly removed and tinct- ure of iodine applied to the cervical canal, and a vaginal douche of borax and warm water was used. The treatment was continued throughout with all antiseptic precautions. After the operation on the cervix the uterus was kept in place, first by means of a tampon, and subsequently by means of the pessary, which answered the purpose while the patient remained in a recumbent position. The perinseum was then restored, and the patient dismissed after two months of treatment in the institution. She subsequently returned to me once a month, when I passed the uterine sound and applied the tincture of iodine, in order to prevent any recurrence of the con- traction. Six months from the time that she was operated upon she became pregnant, and, although some trouble was anticipated in the dilatation of the cervix during her labor, there was none. Prof. Charles Jewett attended her in her confinement, and all went well, and she has remained free from uterine trouble ever since. Cervical Endometritis in an Imparous Woman. — This was a cul- tivated lady, with an excellent constitution, who began to menstruate at fourteen, while she was a school-girl, and continued to do so nor- mally until she had been teaching several years in a high school. She taught many hours daily, and being strong and very ener- getic she preferred to stand, as a rule, while drilling her class. This overtaxation brought on dysmenorrhoea, backache, and leucorrhoea. These symptoms were not marked at first, but as she kept on at her work they gradually increased. When she was twenty-eight years of age she came under my care. She had then been married about one year, and although her symptoms had not increased — in fact, she had enjoyed better health after being relieved" from her arduous duties as a teacher — still she had backache and leucorrhoea, especially on taking active exercise ; and she was sterile. I found the men- 202 DISEASES OP WOMEN. strnal function perfectly normal, except that she had backache and some pelvic tenesmus during the flow, but these were relieved to some extent if she kept quiet. Her chief symptom at that time was a rather free leucorrhoea. A digital examination found the pelvic organs well developed. There was no tenderness nor any evidence of disease that could be obtained by the touch, except that the os externum appeared to be larger than is usually found in the virgin cervix. On speculum examination quite a free leucorrhoeal dis- charge was observed, and there was a ring of deep-red color in the mucous membrane around the os externum. The cervix was rather large in proportion to the body of the uterus, and was of a deeper color than normal, and the uj)per portion of the vagina also was congested. The canal of the cervix, including the internal os, was normal in size, so that the uterine sound could be passed to the fundus without dithculty or causing much pain. As her health was quite good, no constitutional treatment was necessary. During the succeeding two months six applications of iodine and carbolic acid were made to the cervical canal. The next month three applications were made of iodine alone, and the next month after that glycerin and tannic acid were applied. At the end of that time the leucorrhoeal discharge had entirely subsided, the patient suffered much less from backache, and had no pain or discomfort at her menstrual periods. She was then dismissed, and nothing more was heard of her until four years afterward, when she returned to inform me that she was two months pregnant. I have not seen her since, but have heard through her family that she was delivered of a healthy child after a somewhat tedious labor. Cervical Endometritis in an Imperfectly Developed Uterus. — This lady appeared to be rather frail, but had always enjoyed good health. She beffan to menstruate first at thirteen, and for the first vear was rather irregular, and always had some pain the first day. The flow lasted only from two to three days, and the dysmenorrhoea increased somewhat from month to month ; and she began to have backache before and after menstruation, with occasional leucorrhoea. When she was twenty-four years old she was married, but from that time onward her dysmenorrliGea increased ; she had almost continuous backache, and a good deal of tenesmus, with occasional attacks of frequent urination. One year after her marriage she came under my observa- tion, and I found the uterus rather below the normal size ; there was slight anteflexion of the cervix, but the body of the uterus was in its normal position. The uterus was tender to the touch, and there was also some hyperaesthesia of the vagina. A speculum examination INFLAMMATORY AFFECTIONS OF THE UTERUS. 203 revealed a general congestion of the cervix and vagina, the cervix being smaller than it ought to be ; the os externum was small, and while there was a slight vaginal leucorrhoea there was no discharge from the cervix. The canal of the cervix was quite large in jDropor- tion to the size of the external os, and the os internum was so small that an ordinary-sized uterine sound was passed with difhculty, and caused pain. The canal of the cervix contained a plug of very thick, dark- colored, and very tenacious secretion. This was removed with the curette, but with great difficulty, and quite a free haemorrhage oc- curred during its removal. After removing this secretion very care- fully, and waiting until all haemorrhage had subsided, a mixture of carbolic acid, glycerin, and water was carefully applied to the entire canal for the purj)ose of neutralizing any septic material which might exist there. A small V-shaped piece was removed from each side of the cervix at the os externum, and four very superficial incis- ions were made at the os internum. The uterine dilator was then introduced, and the os internum and externum dilated until a No. 9 sound could be easily introduced. The patient was kept quiet in bed for several days, and as there was no constitutional or local disturbance at the end of that time she was allowed to get up and go about again. From this time onward for about three months the uterine sound was passed once a week to prevent contraction of the cervical canal. At the same time the secretion was carefully removed from the ca- nal, and carbolic acid and tincture of iodine — one part of the former to two of the latter — were thoroughly applied. A vaginal injection was ordered of one quart of warm water and forty grains of sulphate of zinc, to be used once a day. The effect of this treatment was to relieve the dysmenorrhoea, backache, and general feeling of discom- fort in the pelvis. The leucorrhoeal discharge became more free, somewhat lighter in color, and less tenacious. The application of iodine and carbolic acid was continued for two months longer, when all treatment was sus- pended for three months. At the end of that time she returned, and stated that her leucorrhoea remained the same, although other- wise she felt tolerably well. In passing the sound the canal of the cervix was found to be ample, but the character of the secretion had returned to what it was when she first came under my observation. I made applications of the tincture of iodine to the cervical canal for about two months, without apparently improving the condition ; I then tried a 10-per-cent solution of chloride of zinc, applying it once a week, but without improving the case. I then decided to remove a longitudinal strip from each side of the mucous membrane 204 DISEASES OF WOMEN. of the cervical canal ; this was accomplished by seizing the cervix with a tenaculum, and then passing a small-sized Sims's curette (Fig. 102) up to the internal os, and under strong pressure draw- ing it down and cutting out a deep strip of the mucous membrane. Fig, 102. — Sims's curette. This was repeated on the opposite side. The idea of removing the two sections rather than removing the entire membrane, as recom- mended by Sims, Thomas, and others, was to leave a portion of the membrane, which would expand as healing took place, and in that way compensate for the loss of tissue, and thereby prevent the oc- currence of stricture of the canal by contraction. During the heal- ing process the uterine sound was cautiously passed about every third day. This at first caused some haemorrhage and pain, but soon it could be done without trouble of either kind resulting from it. The applications of iodine were again begun and continued for about two months, six applications in all being made. The final effect of this was to control the leucorrhoea, and the little discharge that remained became more transparent and less tenacious — more like the normal secretion of the Nabothian glands. She was then dis- missed apparently well, and she remained so, but continued to be sterile. I have treated a large number of cases of this class in the same way, except that I have not lost time in trying different applications, but have removed the sections of the mucous membrane at the out- set. Two of my patients have subsequently borne children ; several of them have had some contraction of the canal, which had to be relieved by dilatation. In quite a number of them the leucorrhoea has returned, and while I have been able to keep them comfortable by occasional treatment, they have never completely recovered. Cervical Endometritis in a Young Girl, with Marked Thickening of the Mucous Membrane of the Cervix, Dilatation of the External Os, and Eversion of the Mucous Membrane. — This girl was rather small, delicate, of marked nervous temperament, and highly cultivated. Her circumstances were such that she had been able to obtain an excellent education and every advantage and accomplishment that she could desire. She was precocious, and began to menstruate when she was eleven and a half years old. She had always suffered slight pain during her menses, and also had leucorrhaa, which was trivial at first. She had suffered much from backache, headache, and general debility, but was able to attend to her education until INFLAMMATORY AFFECTIONS OF THE UTERUS. 205' she was sixteen years old. Her leucorrboea at that time became quite profuse, and her backache and pelvic tenesmus so severe that she was obliged to give up muscular exercise almost altogether. During this time she had been treated with tonics, and change of air. At the age of eighteen she was placed under the care of a physician in New York, who said that she had some falling of the womb, and treated her by tamponing the vagina with cotton, after the method of Boseman, who, I believe, calls this method of treatment " column- ing the vagina." She derived no benefit from this, although it was continued for several months. In fact, she became much worse. She was then placed under my care, when she was nineteen years of age ; her general condition at that time was one of marked neurasthenia. Her extremities were cold and clammy, her pulse was feeble and rapid ; her pupils were widely dilated, and, while she was naturally of a pleasant and happy disposition, she became apprehensive of trouble, and spent most of her time in thinking and talking about her symptoms. Some times she was dull and sleepy, at other times wakeful and sleepless ; her appetite was capricious — at times good, and at other times poor ; her bowels were constipated ; she was quite emotional, and easily affected to tears by either pleasant or unpleasant mental impressions. The uterus was found in its normal position, its body normal in size and shape, and not especially tender ; the ovaries were tender ; the cervix was quite enlarged, and to the touch gave the usual phys- ical signs of a cervix that has sustained a bilateral laceration super- ficially, or sufiicient to give rise to ectropion, as it is now called. The vagina and vulva were quite relaxed, due, I presume, to the long-continued use of the tampon ; at least, I know of no other rea- son for this condition, although she was evidently of an amorous disposition, and no doubt suffered from physiological congestion of the sexual organs. I have no reason to believe that she had ever abused herself or been abused, unless this tamponing treatment under the circumstances may be called abuse. The speculum revealed a large cervix, looking quite like that of a woman who had borne children. There was well-marked eversion which brought into view anteriorly and posteriorly about half an inch of the cervical mucous membrane, which was easily recognized as such by its rugous arrangement, and the presence of the Na- bothian glands, which, though they could not be seen, were proved to be present at that point by the secretion which was freely poured out on the exposed surface. 206 DISEASES OF WOMEN. The most careful examination failed to find any injury of the muscular walls of the cervix showing that the case was one of ever- sion of the cervical mucous membrane. This patient entered my private institution, and was treated generally by rest, massage, baths, and careful attention on the part of the nurse, with a view to im- proving her mental condition by diverting her mind from herself, and fully occupying her time with the treatment. The bowels were kept regular with a laxative pill ; sleep was secured by a dose of bromide in the afternoon, and another at bed-time when necessary ; and one ninetieth of a grain of the hydrobromide of hyoscine was given three times a day, with the effect of improving her nervous system. A vaginal douche was given once a day, consisting of sixty grains of sulphate of zinc to a quart of warm water. This had the eifect of overcoming the vaginal relaxation after a time. Three weeks after she came under my care her general health had improved noticeably, and she passed through her menstrual period with less pain. I then removed the everted portion of the mucous membrane, being careful not to make the exsection entirely circumscribe the OS externum. (Jn the sides, where the eversion was less marked, portions of the membrane were left untouched. This was done to avoid stricture, which I presumed might occur after healing. The exsection was made with the scissors, and though there was consid- erable htemorrhage, this was controlled by the application of pledgets of cotton dipped in chloride of iron, and kept in place by tampon- ing. When the tampon was removed the douche of zinc solution was resumed, and once a week thereafter iodine and carbolic acid were applied to the cervical canal. As the healing progressed the external os contracted, and the caliber of the canal diminished ; the leucorrhceal discharge also subsided, and at the end of three months the local trouble had entirely disappeared, and the cervix looked like a virgin cervix, except that the os was somewhat larger and oblong instead of circular. Her general health greatly improved, and she was soon able to take gymnastic exercise and cold baths, and to walk and ride in the open air. She was dismissed quite well, and has remained so. CHAPTER X. COI?POKEAL END0METKITI8. The most conflicting views are to be found in the literature of medicine regarding the relative frequency of corporeal and cervical endometritis. Much of this division of opinion comes, no doubt, from imperfect knowledge regarding the diagnosis of corporeal endo- metritis. The facts appear to be as follows : Tliat corporeal endometritis is not so often seen as cervical ; that either may occur alone ; that they may occur together ; and that corporeal endometritis alone is most rare of all. These facts have been obtained from long- continued observation in a very large field, and I feel confident of accuracy in the facts, because I have given due attention to the means and methods of diagnosis — the only way to arrive at correct conclusions. There is another cause of confusion on this subject growing out of imperfect methods of investigation, and that is, classing under the head of endometritis some widely-differing pathological conditions, such, for example, as the changes in the tissues following the acute puerperal affections of the uterus. It will be seen by what follows that, although the diagnosis of endometritis is difiicult, careful attention to that part of the subject will secure a degree of accuracy which has not been heretofore gen- erally attained. Pathology. — The pathology of corporeal endometritis is doubt- less the same in character as that of cervacal endometritis, but un- fortunately there are not the same opportunities of observing the changes which take place in the mucous membrane as in the cervi- cal form. On this account post-mortem examinations are the chief sources of knowledge of the pathology, and as this disease is never fatal an opportunity of examining the uterus only occurs when patients with endometritis die of some other affection, hence the inexact knowledge on this subject. 807 208 DISEASES OF WOMEN. There is also a marked liability to error in post-mortem investi- gations of the endometrium. In constitutional diseases, which prove fatal, there are certain changes in the mucous membrane of the ute- rus which resemble those of endometritis, yet they are not exactly the same, and do not represent the anatomical lesions of uncompli- cated endometritis, and should not be taken for such. The facts regarding the pathology of corporeal endometritis which appear quite deiinitely settled are as follows : In some cases there is a general congestion and thickening of the entire membrane, the lesions of vascularity extending to the glands of the uterus. This gives rise to increased nutritive activity on the part of these glands, and hypersecretion. I am not at all satisfied, however, that the dis- charge from these glands is exactly the same as it is from the cervix. I am inclined to think that it is more serous, less tenacious, and more frequently contains blood than that from the cervical glands. The whole mucous membrane may be denuded of its epithelium, or it may be so only in parts ; and, again, the congestion appears to be greater in spots, and in these places there is thickening of the mem- brane. These thickened red patches are generally found at the mouths of the glands. Not infrequently there are proliferations of the mucous membranes, polypoid in character — a condition which is sometimes called " endometritis polyposa." This new product is one of the most common results of endometritis of long standing. Sometimes the walls of the uterus are found thickened so that the whole uterus, as well as its cavity, is enlarged. In other cases the walls of the uterus have been found diminished in thickness, and changed in structure by fatty degeneration. These changes in the walls of the uterus may or may not be due to the endo- metritis. Corporeal endometritis belongs to that class of inflammations in which the process does not pass through its various stages, and then end in recovery, with or without permanent changes of structure. In this it differs from acute inflammations, which begin and run through all their stages, and end in recovery. If once well established, the inflammation shows very little tend- ency to recover without treatment ; hence it is that the cases are often found that begin in early life, and continue up to the meno- pause. There is very little tendency in the natural history of these affections to become worse or change their character ; they often re- main the same, excepting that the constitutional disturbance may increase, and the patient fail in general health. Symptomatology. — Owing to the fact that the diagnosis of cor- CORPOREAL ENDOMETRITIS. 209 poreal endometritis is difficult, it is very necessary to give close atten- tion to the evidence presented. The symptoms of this affection are well marked, and, although not diagnostic, they are of great value when taken in connection with the physical signs. They naturally arrange themselves into two classes — constitutional and local. The constitutional symptoms are manifested by the nervous sys- tem and digestive organs. There is frequently capricious appetite, flatulence, and constipation. The derangement of the stomach is irregular, often varying in a day, showing that it is a reflex nervous disturbance, not unlike that which occurs in gestation. Tlie mam- mary glands are often sympathetically affected, becoming enlarged and tender, and the areola takes on a darker color. These symp- toms, taken in the aggregate, resemble very closely those found in spurious pregnancy, excepting that the mental obliquity is absent. It will be seen that the symptoms, including the derangement of the digestive organs, are all such as might be expected from reflex nerv- ous derangement, and such, no doubt, is their explanation. I am aware that the symptoms here given have all been said to occur in cervical endometritis, but, while there may be some slight constitutional disturbance from this affection, it is never so well de- fined as in corporeal endometritis. Symptoms referable to the general nervous system, which occur in this affection, are not diagnostic, yet they are valuable when taken in connection with the rest of the history. Headache, sleeplessness, mental depression, and pains in the spi- nal cord, are often present, but I know of no special nerve symptoms peculiar to corporeal endometritis. Among the local symptoms the most important, b}^ far, is derangement of the menstrual function. This I consider the symptom by which the differential diagnosis be- tween cervical and corporeal endometritis can be made, and therefore it should be borne in mind at all times. One would naturally expect that in inflammation of the corporeal endometrium the function of the membrane would certainly be de- ranged, and such is the fact. The catamenial discharge may be pro- fuse, scanty, irregular, and attended with pain, or the function may be suppressed altogether ; the rule is, however, that profuse, pro- longed, and painful menstruation is present. When either of these menstrual derangements occurs, and there is no constitutional or other local cause to account for it, we may reasonably infer that the mu- cous membrane of the uterus is at fault. It may appear strange that opposite conditions, like menorrhagia 15 210 DISEASES OF WOMEN. and amenorrhoea, sliould occur in the same affection ; but this is ac- counted for by the condition of the mucous membrane in the differ- ent stages of the disease. The same peculiarities of behavior are noticed in inflammation of other mucous membranes ; for example, in bronchitis the membrane at first may be unduly dry, and at an- other stage of the disease there may be a profuse secretion. In ad- dition to these changes, in the menstrual function there usually is marked backache, not different in character, but being more severe than in cervical affections. There is also more pain in the uterus, pelvic tenesmus, vesical and rectal irritation. Leucorrhoea is a marked symptom also. The character of the discharge, as already noticed, is more serous, less tenacious, and more frequently contains a few blood- and pus-corpuscles. When cervical and corporeal endo- metritis occur together, the discharge shows the characteristics of both affections. Physical Signs. — The physical signs of endometritis are the same in character as those indicative of inflammation elsewhere. There is tenderness detected by the bimanual touch, which usually shows that the body of the organ is sensitive. After thoroughly cleansing the vagina with a douche, a small tampon of cotton should be placed against the cervix and allowed to remain for two or three hours. If pus is found on the cotton, it is a valuable sign of cor- poreal endometritis. By the use of the sound, four indications of the disease can be obtained. First, the abnormal tenderness ; second, the enlargement of the uterine cavity, as detected by actual meas- urement ; third, dilatation of the os externum ; and, finally, the great vascularity of the membrane, as shown by bleeding on touch. In using the sound for diagnostic purposes in corporeal endome- tritis, much skill and practice are necessary in order to make the ex- amination with advantage to the diagnostician and safety to the patient. Moreover, care should be taken to make a disinfectant ap- plication before using the sound, and to be sure that the sound itself is thoroughly aseptic. Many of tho difficulties following the use of the sound, related in the books, I believe to be due to lack of care and attention to these points, thus permitting the carrying of septic material into the uterus. The density of the uterine tissues is a valuable sign in determin- ing the existence of endometritis. As a nde, the body of the uterus is less dense than normal, excepting in cases of long standing, in which there is sometimes induration or hardening of the uterus. Prognosis. — Corporeal endometritis is more difficult to manage CORPOREAL ENDOMETRITIS. 211 than cervical, and hence this has led many of the writers in the past to state that the affection is incurable in many cases. At the pres- ent time I believe that a more favorable view of the matter may be taken. The disease in itself is not dangerous to life, and, when un- complicated, will usually yield to appropriate treatment. There is a decided tendency in many cases for it to return, but even then it can be relieved by removing the cause. Recovery takes place at the menopause or senile endometritis follows. The affection is not in itself self-limited, but is limited by the period of functional activity of the uterus. There is a prevailing opinion that endometritis, when it continues up to the menopause, complicates " the change of life," and favors the development of malignant disease. The former opinion is true, the latter doubtful. The results vary with the different kinds of treatment used. I have never seen a case cured by certain methods, which have been commended to the exclusion of all others ; for example, hot-water douching, and the application of the tincture of iodine to the vagina. ]^either does endometritis yield to treatment so long as there is a displacement of the uterus, or a laceration of the cervix ; but, when all the conditions necessary to recovery are secured, then endometritis will yield to local treatment in the vast majority of cases. Causation. — The causes of corporeal endometritis have been re- ferred to in discussing cervical endometritis ; hence, to save repe- tition, it will suffice to say that there are certain conditions oi the general system which predispose to the affection. The strumous diathesis, imperfect general nutrition from either gross living and sedentary habits, or exhaustion from overtaxation, are the chief pre- disposing conditions. The direct or exciting causes are complicated labors, miscarriages, derangement of menstruation, and sepsis. The vast majority of cases of corporeal endometritis, which have come under my observation, were clearly due to the causes given above. In fact, if those caused by gonorrhoea are excluded, nearly all the others can be ascribed to lesions of parturition and derange- ment of menstruation, which arrest the post-partum and post-men- strual involution. Treatment. — The constitutional treatment of inflammatory dis- eases of the uterus was briefly referred to while discussing the treat- ment of cervical endometritis, so that it is only necessary to repeat the general statement, that every means should be employed to re- store the general health. The treatment must, as a matter of coursCi 212 DISEASES OF WOMEN. be adapted to the nature and degree of tlie impaired state of the general organization in the given case. The local treatment, such as the hot-water douche, already de- scribed, apph'es in part to cervical endometritis, and therefore need not be repeated here. It will suffice to give directions regarding topical applications to the corporeal mucous membrane. I will first consider the indications for intra-uterine medication, the remedies to be used, and the means of employing them. This question is still with many an unsettled one, both as regards the curability of corporeal endometritis, and the value and safety of intra-uterine medication. The literature on the subject of intra- uterine treatment is not very definite, hence I shall confine myself to a few points, which I regard as fairly well established, and likely to be of service in the treatment of this disease. The important questions which come up for consideration on this subject are, first, is it safe and advantageous to make intra-uterine applications ? Second, if so, what curative agents shall be employed ; and, third, how shall they be applied ? Turning to the text-books or the current literature on the sub- ject in search of an answer to the first question, I find the greatest diversity of opinions. The pioneer gynecologists of Europe, such as M. Gendrin, M. Jobert de Lamballe, Bennet, and Simpson, rarely, if ever, made ap- plications beyond the os internum, believing that endometritis could be cured by treating the cervix and the cervical canal. On the other hand, we find that Aran, Scanzoni, and Gantillon, and Dr. Henry Miller (who, by the way, was the first to employ intra-uterine medi- cation in this country), Kammerer, Nott, Peaslee, and many others, relied to a very great extent on intra-uterine applications for the relief of corporeal endometritis. Many more names might be mentioned to show the want of har- mony among physicians on this point, but no useful knowledge would be gained thereby. All that can be learned from a review of the Uterature is that intra-uterine medication is more extensively employed now than formerly. Believing that time tends to drift the profession to the side of correct therapeutics, it may be inferred that local applications to a part or to the whole of the lining mem- brane of the uterine cavity are sometimes necessary, if not indispen- sable, in treating endometritis. In seeking an answer to the second question, one encounters a variety of medicinal agents, ranging from the actual cautery to the blandest anodynes. CORPOREAL ENDOMETRITIS. 213 Bearing in mind, however, the second object to be gained, name- ly, to restore the organ to health, and leave it uninjured, it is evident that all destructive agents should be avoided. This has already been stated in discussing the treatment of cer- vical endometritis, and all that was then said applies with greater force in regard to corporeal endometritis, because that portion of the mucous membrane is more delicate in structure. In my own practice I employ either bichloride of mercury, one grain to an ounce of water ; tincture of iodine ; tincture of iodine, two parts, and carbolic acid, one part ; or suppositories of iodoform and cocoa-butter. There is so much risk in treating the mucous membrane of the cavity of the body of the uterus that there are certain precautions which should be kept in mind. These may be formulated as fol- lows : Tliat intra-uterine applications, excepting to the cervical canal, should not be used until other means have been thoroughly tried and have failed. The uterus should be in or near its normal posi- tion. The cervix uteri should be sufficiently dilated to allow any excess of the fluid to escape from the cavity of the body. After having carefully freed the cervical canal from the secretion, the easiest and most effectual way of making applications is to use the glass pipette, already described. The solution to be employed is drawn up into the glass tube by the rubber bulb ; the instrument is then passed up to the os inter- num or to the fundus uteri, if desired, and, as it is withdrawn, press- ure is to be made upon the bulb which forces out the solution and brings it in contact with the entire lining of the canal. The method generally in use of dipping a probe wrapped with cotton into the solution, and passing that up into the canal, is very unsatisfactory. The cotton on the probe injures the mucous mem- brane, and the solution is deposited about the os externum — very little, if any, getting into the canal. The injections by means of a syringe and a reflux catheter, com- mended by many, I have tried, but I have abandoned the method because it is dangerous and unnecessary. It is well to use some bland fluid, such as warm water and salt, to test the toleration of the uterus before using the more potential agents. A small quantity of the agent used is all that is necessary. Six to ten drops is sufficient to cover the surface to be treated, and more than that is useless. When from long-continued congestion the mucous membrane of the cavity of the uterus has become hypertrophied, giving rise to 214 DISEASES OP WOMEN. that condition now known as endometritis polyposa, the use of the curette gives the most prompt rehef. The blunt instrument should always be used, because it is perfectly eflEective and free from danger. Method of Curetting. — The pathological conditions which demand the use of the curette have already been referred to. The instru- ment which I employ has also been described, and the advantages which I consider that it possesses have been clearly pointed out. There is still something to be said regarding the method of using it. Dilatation of the cervical canal should be made rapidly, under anaes- thesia, with Goodell's dilator. This method of immediate dilatation is greatly in advance of the old way of dilating by sponge or sea- tangle tents, which always caused great pain, and sometimes inflam- mation and septic infection. The patient is placed in Sims's position and the cervix caught and held with a tenaculum curved on the flat (see Fig. 6) and the cervix dilated. The curette is then curved so that it will pass into the uterus and to one side, and, while the to-and-fro motion is being made, the instrument is also moved slowly toward the op- posite side. I find that, Mdth my curette, fungosities or decidua can be pushed off or detached with the upward as well as with the downward or scraping motion. When the anterior wall has been thoroughly treated, the instrument is withdrawn into the cervix, bent a little in the opposite direction, and turned around so that it will face the posterior wall, which is then treated in the same man- ner as was the anterior. From a large experience I have come to look upon this operation as one of the safest in gynecology, and very satisfactory in its results. Of course, the usual surgical cleanliness should be observed, and the uterus should be washed out with an antiseptic solution and packed with gauze. ILLUSTRATIVE CASES. The patient was thirty-two years of age, who had been married ten years, and had given birth to two children. She made a slow recovery from her last confinement, and nursed her child for about six months. Her health then began to fail, and the child was weaned. Two months after this the menses returned, and at the time were quite scanty and only lasted for a day or two. After this she suffered from backache, pelvic tenesmus, and irritable bladder, with free leucorrhoea, at first like an ordinary cervical secretion in character. Her general condition also became disordered. The CORPOREAL ENDOMETRITIS. 215 appetite was capricious ; the bowels constipated, and distended from flatulence. She also liad occasional attacks of nausea, and at times headache ; she became quite nervous, and her sleep was broken. Her menstruation became irregular, generally coming on at the end of two or three weeks and continuing longer than normal, and was too free. When Jirst examined I found the uterus large, the in- crease in size being mostly of the body and fundus. Bimanual pressure being made upon the body of the uterus gave rise to a dull pain. A speculum examination revealed considerable redness around the OS externum. The discharge, as seen coming from the canal, was dark in color, as if stained and streaked with blood ; around this tenacious material there was a little sero-purulent discharge noticeable. The sound entered two and a half inches, and could be moved about considerably in the cavity of the body, showing that the cavity was enlarged. Gently touching the fundus and sides of the uterus with the sound gave rise to pain, and the patient com- plained of a little nausea and faintness. From the general history and the physical signs the diagnosis of inflammation, involving the entire mucous membrane of the uterus, was made. The subsequent history fully corroborated the diagnosis in every respect. At this time the patient's tongue was coated, her appetite poor, atid she was constipated. A dose of blue mass with a grain of ipecac was given at night, followed by a Seidlitz powder in the morning ; and after this a bitter tonic of Colombo and wine of ipecac before meals. A teaspoonful of Parish's compound syrup of phosphates, well diluted, was given after meals. The constitutional treatment consisted simply of iron tonics, a laxative pill, plenty of nourishing food, and a very little exercise. Once a week I removed the secretion from the cervix, then applied carbolic acid and iodine, and ordered a hot-water douche night and morning. The local application caused pain for several hours, and did not appear to do any good. I passed a medium-sized curette into the uterus, and gently curetted the entire mucous membrane of the body ; this brought away considerable serum and blood, some of which, from its dark color, had evidently been retained for a considerable time. There was also muco-purulent material which came away at the same time, but this may have come from the cer- vix. On carefully examining all that was removed from the uterus, several little masses of fungous material were found, and several shreds that looked like portions of the epithelial layer of a thickened and softened membrane. The curetting seemed to be a failure, so far as obtaining any 21Q DISEASES OF WOMEN. large-sized f ungosities which I had been led to suspect existed from the frequent and profuse menstruation. Considerable pain was caused by the use of the curette, and it lasted for several hours, but finally passed away. The patient also complained of being faint and having nausea, and, as she appeared pale after the operation, I have no doubt that her suffering was very great, though she was a brave lady, and did not complain without cause. There was con- siderable oozing of bloody serum from the uterus after the curet- ting. About five days afterward an examination revealed a copious discharge of cervical secretion, which was rather dark in color and slightly yellow, as if it contained pus. Very small clots of blood were also found entangled in it. The cervix was then freed from the secretion, and iodine and carbolic acid again applied. The next menstrual flow came on at the proper time and was quite free, but it did not last quite as long as usual. Two days after the flow had subsided I again used the curette, with the result of bringing away some blood and muco-serous material, but no shreds of membrane nor fungosities. The patient suffered much less this time from the treatment. From this onward, once a week, a pencil made of cocoa-butter, and as much iodoform as the butter would take up (about four grains in all), was passed up into the cavity of the uterus as near to the fundus as possible ; carbolic acid and iodine were applied to the cervical canal. This treatment seeming ef- fectual, it was repeated once a week for about two months ; during this time the uterus diminished in size, the discharge also became less, and changed to the character of that usually found in cervical endometritis. The menstruation then became regular as to time and less profuse, and did not last longer than the usual time. The intra-uterine applications were then suspended, except the applica- tion of iodine and carbolic acid, which was continued once a week to the cervical canal for about two months longer. She had then improved so much in her general condition, and the uterus appear- ing to be normal, except that she still had sliglit cervical leucorrhoia, I unwisely told her that she was quite well, and she did not return for any after-treatment for six months. Her leucorrhtea at this time became again rather troublesome, and she came back for further care. I then found that her general condition was entirely satis- factory ; her menstrual flow was regular and normal ; the internal os had contracted to its natural size ; the uterus measured three inches only in its longest diameter, and all that remained of the former trouble was a hypersemic state of the cervical mucous membrane, with leucorrhoea ; this was treated for about six weeks with one part CORPOREAL ENDOMETRITIS. 21Y of carbolic acid to three of iodine, and then slie was dismissed per- fectly well. I have been informed that she has given birth to a child since she was under my care. Chronic Corporeal Endometritis. — The patient was twenty-nine years old, and had one child when twenty-three, and a miscarriage when twenty -live years of age. Up to the time of her miscarriage her health had been very good, but from this time she began to suffer. The menses, formerly normal, began to be too free, and were attended with pain. In fact, from the time of the miscarriage she had menorrhagia and dysmenorrhoia, and both became more marked as time went on. The pain in the uterus at the time of the menses was not acute, but was continuous and aching. It began a day or two before the flow and continued until the flow ceased, and some- times for several days after. There was some irregularity about the recurrence and quantity of the menses, and she observed that when the flow was very free the pain was not so severe. At some of the menstrual periods the flow would begin and go on for a day and then stop for hours, and then come on again quite freely. When these interruptions took place there usually were clots passed, which evidently came from the uterus, because they were expelled after pains which differed from the usual pain in being more acute and intermittent. The menorrhagia and dysmenorrhoea became gradually worse, the pain being greater when the flow was less. She became much exhausted at each period, either from pain, loss of blood, or both. Throughout the whole course of the affection she had a discharge from the uterus which was sero-purulent. At times, especially before the menstrual period, there was a cer- vical leucorrhoea, but the discharge from the body of the uterus was most marked and continuous. It was more yellowish in color, less tenacious than cervical leucorrhoea usually is, and oftentimes it was tinged with blood and quite offensive in odor. There was much backache, pain in the pelvis, and wandering pains in the abdomen. The appetite was capricious ; at times fairly good, and at other times very poor. She often had nausea, which lasted for a short time. The bowels were constipated, and she was greatly tormented with flatulence. Her ultimate nutrition was poor ; she had lost flesh, and on her face there were many large blotches. The nervous system was very considerably disturbed. Originally of a cheerful disposition, she became irritable and emotional. Sleep 218 DISEASES OF WOMEN. was often broken at night, and she had unpleasant dreams. During the day, especially after eating, she became drowsy, but seldom could sleep, if she tried to do so. In other words, she was anaemic and neurasthenic. She suffered at times from a spasmodic cough, due evidently to deranged innervation. There was no organic disease of the lungs or bronchi. The general treatment was tonic and sedative. Mild lax- atives were also given. Locally, the hot-water douche was used, and equal parts of iodine and carbolic acid were applied to the cervix. This did not give any relief to the local symptoms, and her general condition improved very little. The menstrual flow was as free and painful as before. The curette was used, and some fungous material removed ; after this she felt better, and the menstrual flow was more natural. Sub- sequently she neglected her treatment, and in a few months all the old symptoms returned. She was anesthetized, the cervix fully dilated, and curetting employed. A large quantity of polypoid material was removed, the uterus washed out with a five-per-cent solution of carbolic acid and thirty per cent of glycerin and then packed with gauze, which was removed at the end of three days. Tlie corporeal endometritis was completely relieved. The constitutional treatment was kept up, and an application was made after each menstruation for three months, which arrested the slight catarrh of the cervix. CHAPTER XI. SUBINVOLUTION. Subinvolution of the Uterus after Parturition. — The great in- crease in the size of the uterus during gestation, and its rapid reduc- tion after delivery, are among the most remarkable phenomena in the animal economy. The uterus during nine months increases from about two ounces to two pounds in weight during the evolution of gestation, and it is reduced by involution in the short space of two or three weeks. This process of involution (by which the uterus is reduced to its original size) is a transformation and absorption of the tissues. The structural elements of the uterus, which are no longer needed, un- dergo fatty degeneration and absorption, and are in that way dis- posed of. The time required for this involution to take place, and the causes which may interrupt it, have been clearly pointed out by Dr. Alexander Sinclair, of Boston, in vol. iv of the " Transactions of the American Gynecological Society," 1879. Dr. Sinclair gives the re- sults of careful measurements of the uterus in one hundred and eight cases. These measurements were made from twelve to thirty-six days after delivery, the average being sixteen days. In the great majority of these cases the uterus had been reduced to its normal size at the end of three weeks. In one the uterus measured two and one haK inches on the twelfth day. This shows the wonderful ra- pidity with which this involution goes on. In all the cases in which the involution was retarded, there were present certain morbid states, such as laceration of the perinaeum or cervix uteri, metritis, or septicaemia. These observations of Dr. Sinclair's are of the highest value in showing the time required for the process of involution, and also the conditions which interrupt, retard, or arrest it. Pathology. — In uncomplicated cases there are no inflammatory 319 220 DISEASES OF WOMEN. products, nor are there any new tissue formations. The structures of the uterus are the same as in the normal state, but developed by gestation. In Dr. Snow Beck's case the microscopical appearances were like tliose found in the middle period of uterogestation. In other cases evidences of fattv degeneration have been observed in the muscular tissues. AVhen the involution has been arrested bv puerperal metritis, the products of the inflammation are found. According to Dr. Xoeg- geratli, these products are inflammatory exudations and hyperplasia of the cells of the areolar tissue. Syinptomatology. — I have never observed any symptoms which were specially characteristic of imperfect involution. The history of the delivery and subsequent progress usually presents some fact which would suggest possible subinvohition. There are usually present leucorrhoea and backache, and pelvic tenesmus upon standing or walking, but all these symptoms occur in other affections. Physical Signs. — Digital examination shows that the uterus is enlarged and softer than normal. Very often it is low down in the pelvis. The vagina also is found to be enlarged and relaxed. The rule is that if involution is arrested in the uterus it is also arrested in the vagina and in the uterine ligaments. There are many ex- ceptions to this rule, however ; as, for example, a laceration of the cervix uteri and perinaeum will arrest involution of the cervix and vagina, while the body of the uterus may return through involution to its normal size. This can be made out easily by the touch in most cases. The sound, used through the speculum, shows the exact size of the uterus, and when that abnormal size occurs after confinement, and is not otherwise accounted for, it is a reliable sign of subinvolution. The cerN-ix and vagina are usually of a deep, bluish-red color, and there is dilatation of the cervical canal, and usually some eversion of the lips of the OS externum. Prognosis. — Recovery may be expected under proper care if treatment is begun early and can be fully carried out, and there are no complications which can not be removed. In case that the tissues are damaged by metritis the case may go on to sclerosis, and become incurable. AVhen the subinvolution is due to injuries of the cervix, the restoration of the injured parts is usually followed by a comple- tion of the involution. Causation. — Injuries, such as laceration of the cervix and peri- naeum, and septic infection causing either cellulitis, lymphangitis, or SUBINVOLUTION. 221 metritis, are the chief causes. Getting up too early after confine- ment, and engaging in hard work in the erect position, are also liable to arrest this process. All the cases that 1 have seen were traced to some of the above-named causes. Treatment. — The management of subinvolution usually falls to the obstetrician in case he is on the watch for it. When not com- plicated with any well-defined puerperal affection it is apt to pass for a time unnoticed, because it does not give rise to suffering until the patient is about her duties again. When the patient begins to go about after her confinement, and there is pelvic tenesmus, backache, and leucorrhcea, imperfect invo- lution should be suspected ; and, if the physical signs confirm the diagnosis, the patient should be put back to bed, and kept there for a time. If the recumbent posture is not sufficient to restore the uterus to its normal position, artificial support should be used, either by pessary or tampon. The hot-water douche should be employed, and if there is imperfect involution of the vagina and pelvic floor, tannin or sulphate of zinc may be occasionally added to the douche. In the past, antiphlogistic measures were employed as the chief treatment. Leeches were applied to the cervix, and puncturing and scarifying were employed to abstract blood from the uterus. This depletion is doubtless beneficial when there is well-marked engorge- ment, and the general state of the patient is good — not anaemic, as is generally the case with these patients. Local bloodletting should not be employed unless there is extreme congestion, neither should it be repeated more than once or twice. A certain degree of hypersemia is necessary to the process of involu- tion, and anaemia will arrest the process. Depletion is only admissi- ble in morbid hyperaemia. That it is useful in such cases is beyond doubt. The value of depletion is seen in those who resume the func- tion of menstruation soon after delivery. A profuse menstruation is generally followed by improvement. I have generally relied upon less depressing measures. While taking care of the general health, I have advised rest, the hot douche, and tincture of iodine applied to the cervix, cervical canal, and upper portion of the vagina. When these have failed, I have used elec- tricity in the same way as in the treatment of uterine fibroids, but not with so strong a current. This agent is one of the most valuable that we have. Massage of the uterus will also be found useful. In cases of long standing there is usually some injury of the cer- vix uteri or the pelvic floor ; when such is the case, the lacerations must be repaired before involution will be completed. 222 DISEASES OP WOMEN. It 1*8 almost needless to add that all complicating conditions, such as endometritis, should have due attention. Superinvolution of the Uterus after Parturition. — This affection was iirst described bj Sir James Y. Simpson, and illustrated with cases which occurred in his practice. I presume it must be a very rare condition. I have not seen a case about the diagnosis of which I felt sure. Premature atrophy of the uterus I have seen, due to destructive disease of the ovaries, re- moval of the ovaries, and certain peculiar states in which the meno- pause occurred prematurely, but a case not so accounted for has not occurred in my practice. I saw a patient once in consultation, six months after her confinement, who suffered from pain in the abdo- men, which was due apparently to adhesions from an old peritonitis. The uterus was very small for one who had borne children, in fact it was below the size of a virgin uterus. The menses had been scanty. I made a diagnosis of superinvolution, and gave the attending phy- sician a brief clinical lecture on the subject. He examined the uterus afterward, and confirmed my statement regarding the size of it. While I felt sure that the ]3ain present, and for which I was con- sulted, was in no way connected with the small uterus, I took occasion to say that the patient would remain sterile ; and I also predicted an early menopause. To my surprise she gave birth to a healthy child, of full size, about one year after I had made the diagnosis. Perhaps superinvolution, to a certain extent, may not necessarily cause sterility, and my diagnosis may in this case have been correct, but I do not believe so. Owing to my lack of personal knowledge on this subject, I will here give in full the case reported by Sir James Y. Simpson, in his work on "Diseases of Women" : " The subject of this rare pathological affection began to men- struate at the age of thirteen, and the catamenia recurred regularly every four weeks till she became pregnant when eighteen years old. Utero-gestation went on without any unusual phenomena to the full t3rm ; and her parturition was natural but tedious, a male child being born after a labor of seventeen hours. Nothing unusual occurred during her puerperal convalescence and lactation. But subsequent to delivery she never menstruated. She was, however, subject to frequent attacks of diarrhea, which she herself believed to be gener- ally most severe at recurring monthly intervals ; and the dejections were then sometimes tinged with blood. " Two years after accouchement she became a patient in the fe- male ward of the Royal Intirmar}^, complaining of the state of amenor- SUBINVOLUTION. 223 rhoea, with attendant broken health. She suffered from pain in the back and hypogastrium, with a sensation of weight and pressure in the pelvic region ; dysuria ; a furred tongue ; and a weak compressi- ble pulse, generally beating from 80 to 90 in the minute. She was thin, feeble, and ansEmic in appearance. The mammae were shrunk and flat. For some time before admission she had suffered much from occasional headaches and giddiness ; frequent nausea and vom- iting ; palpitation and occasional rigors. " On making a vaginal examination, I found the uterus small and mobile. The cervix uteri was much atrophied, and the vaginal por- tion of it scarcely made any projection into the canal of the vagina. The OS uteri was so much contracted as to admit a surgeon's probe with difficulty. It was dilated by a slender bougie being left in for two or three days ; and, when the uterine sound was subsequently used, the uterine cavity was found to be only one and a half inch in length, or about an inch less than normal. " A variety of means was employed with the view of benefiting the general health of the patient, and of exciting action in the uterine system, but with little or no effect. " Diarrhcea repeatedly occurred during the three or four weeks she remained under my care, requiring the free use of opiates for its restraint ; and as the uterine symptoms did not at the time seem to admit of special attention and treatment, the patient was transferred to one of the general wards of the hospital, where she was placed under the care of my colleague. Dr. Bennett. " During the following month the diarrhoea recurred from time to time very severely. At last anasarca in the lower extremities and albuminuria supervened ; ascites followed ; and shortly afterward her face and arms became oedematous. About a month after these symp- toms appeared delirium at last came on, the f^ces passed involun- tarily, and ultimately she died in a state of prolonged coma. " On post-mortem inspection some crude tubercles were found in both lungs, especially in the left. The liver was enlarged, and showed some fatty transformation. The kidneys presented also some stearoid degeneration, and in the right there was in addition a small tubercu- lar abscess. The large intestines were very much thickened in their parietes, and contracted in their caliber, while their mucous mem- brane was ulcerated in various parts. Along the lower end of the ileum several large ulcerations were seen running circmnferentially around the interior of the bowel. One or two ulcerations were also found in the stomach. The uterus was very small, and atrophied in its length and breadth, its size being diminished about a third below 224 DISEASES OF WOMEN. the natural standard in all its measurements, and its parietes were correspondingly thin and reduced. The whole length of the uterine cavity from the os to the fundus was not more than one inch and a half, while the normal uterus usually measures in this direction two inches and a half. When a section was made of the posterior wail of the organ, the thickness of its parietes at their deepest or moct developed point was not above three Hues, instead of the normal measurement of five or six lines. The tissue of the uterus appeared dense and fibrous, and the section of it presented the orifices of nu- merous small vessels. The ovaries seemed also much atrophied, and smaller than natural. Their tissue was dense and fibrous, and pre- sented no appearance of Graafian vesicles. There was no inflamma- tory deposit on the peritoneal surface of the uterus or its appendages ; but some thick pus, or tubercular matter, existed in the distended cavity of the right Fallopian tube." CHAPTER XII. SCLEROSIS OF THE UTEEUS. Fifteen years ago I employed this term to designate an affection of the uterus, which up to that time had been known by a variety of names — such as chronic interstitial metritis, hypertrophy, chronic inflammatory hypertrophy, and areolar hyperplasia. Subsequently Gallard used the same term in the same way. This affection of the uterus is a change of structure produced by a pre-existing inflammation or derangement of nutrition, and may be more properly considered as the product of morbid action, rather than active disease. The term which I have selected, therefore, more clearly indicates the true nature of the affection than the names of the affections or processes which produce it, and by which it has heretofore been designated. Pathology. — This comprises certain changes of structure, mostly of the middle coat of the uterus, which, as already stated, have been caused by preceding morbid processes. This change of structure consists in an excess of connective tissue, the result of an areolar hyperplasia. This element in the structure of the uterine walls rapidly increases, encroaching upon the mus- cular element, and more especially upon the blood-vessels in the connective tissue. The result is marked increase in the density of the tissues, and anaemia from pressure upon the vessels. There is frequently an increase in the size of the whole organ, but in some cases the uterus is not enlarged. In fact, the uterus may notably diminish in size, when the hyperplasia is suflficient to cause atrophy of the other tissues of the uterus. The histological composition of the tissues differs in different cases, and in different stages of the development of the affection. In those cases which have their genesis in puerperal metritis there is generally at first, in addition to hyperplasia of connective tissue, a fatty degeneration of the muscular tissue, which has not IG 225 226 DISEASES OF WOMEN. been disposed of by the process of involution. There are, also, in some cases, some of the products of the inflammation in the form of exudation into the tissues. All these give the uterus its increase in size, which to some extent is permanent, although the organ may diminish very much in time. The hyperj^lasia of the connective tissue causes atrophy of the other tissues, and to that extent the uterus is reduced in size. When tlie sclerosis follows non-puerperal metritis the uterus, which dur- ing the stage of inflammatory engorgement was larger than normal, may become reduced to, or even below, its normal size. This is more likely to occur when the hyperplasia is extensive, and involves all the tissues of the uterus and their blood-vessels. Sclerosis may be general or local. When due to puerperal or chronic metritis, or to deranged nutrition from long-continued con- gestion, the whole organ shares in the morbid process. Wlien it is due to some injury and inflammation, or deranged nutrition of the cervix, the body may remain normal. Circumscribed patches of sclerosis in the body or cervix have not been found. Finally, this is a permanent affection. When once the changes of structure have taken place they remain, to a certain extent at least. There is no tendency to complete restoration of the normal tissue. There may be a slight diminution of the size of the uterus. I am inclined to think that even at the menopause, the period at which almost all uterine affections subside, this lingers, and possibly remains always. I have had an opportunity of observing several cases some time after the change of life, and the uteras in all of them was lai'ger than it should be. Dr. Noeggerath claimed that sclerosis, or chi'onic me- tritis, as he called it, predisposed to cancer of the uterus. This may be so. There is in this affection a change of structure, and, accord- ing to the rule in pathology, a consequent lowering of the vitality of the part, and a predisposition to further degeneration, Sjinptomatology . — The clinical history of this affection differs in many points from that of other forins of uterine disease, but there are no symptoms that are diagnostic. There is more marked constitutional disturlmnce in the pro- nounced eases than is found in the average inflanmiatory affections. This may be due largely to the exhausting effect of the disease which preceded the sclerosis — this being quite sufiicient to keep up the general ill-health. There is derangement of menstruation, usually anienorrhcea. In well-marked cases neuralgic pains in the uteras are frequently pres- SCLEROSIS OF THE UTERUS. 227 ent, which are much worse at the menstrual period. The pain at this time often begins before the How and continues throughout the whole period, and sometimes a day or so after. In some cases the pain is acute and irregular, in others of a dull, aching character, and in a few both varieties of pain coexist. The form of suffering may be likened to a very great aggravation of all the disagreeable feelings of an ordinary menstruation. The clinical history (so far as symptoms are concerned) in the inter-menstrual period closely resembles that of corporeal endome- tritis. Physical Signs. — These are briefly as follows : Ansemia of the uterus, indicated by the pale appearance of the cervix, as seen through the speculum, and suggested by amenorrhoea ; enlargement and in- duration of the uterine walls, as detected by touch and sound ; in- creased length of the cavity of the uterus without increase of the lateral and antero-posterior diameters ; slight retraction of the lips of the OS externum, and the small size of the cervical canal compared with the size of the walls of the cervix. The hardness of the uterus is a most valuable sign, but one that is not easily detected. To the touch, the uterus does not in all cases appear to be more dense than the virgin uterus, but where it is en- larged it is softer in consistency, except in sclerosis ; hence, when there is an increase in size and induration, not due to fibroma, the evidence is in favor of sclerosis. In the great majority of cases the uterus is more tender than in any other affection, except acute metritis, and endometritis with flex- ion. The touch excites this sensitiveness, and the passage of the sound causes marked pain. Prognosis. — Sclerosis being a permanent change of structure, recovery with or without treatment is the exception. By reheving any complication which may be present, such as displacement, the patient may be made sufficiently comfortable to reach the menopause, and then recovery may take place. Sclerosis of the cervix may be relieved to a great extent, some- times completely, by trachelorrhaphy, if the cervix has been lacer- ated. In case the cervix has not been injured its size can be reduced, and the tissues may become softened and the nutrition improved by taking out a V-shaped piece on each side, and bringing the parts to- gether, as in the operation for laceration. Causation. — The causes of this affection, given in the literature of medicine, are che same as those of almost all other inflammatory 228 DISEASES OF WOMEN. diseases of the uterus. In the cases which have come under my own observation, they were either acute metritis following child-bearing, or miscarriage or long-continued general endometritis, and injuries to the cervix during labor. This leads me to believe that these are the only causes of this affection. In fact, as sclerosis is the result of a deranged nutrition of an inflammatory nature, it follows that the cause must be a pre- ceding metritis, partial or general. Treatment. — Sclerosis is, of course, a preventable disease in the majority of cases. If the inflannuatory affections which lead to it are carefully managed the structural changes will be avoided, except- ing in severe puerperal metritis. When once the changes in the tissues which constitute true scle- rosis have occurred, it is still a question whether any known treat- ment can entirely relieve it. As already stated in the prognosis, benefit may be obtained by removing complications, such as lacera- tion of the cervix. In xhe hope of causing absorption of the areolar tissue, mercury, iodine, copper, and belladonna have all been em- ployed ; and, it is needless to say, that the hot- water douche has also been frequently tried. Dr. Noeggerath, of New York, recommends amputation of the cervix, permitting the stump to heal by granulation instead of cover- ing it over with vaginal mucous membrane. This he deems advisa- ble, not only in the hope of relieving the sclerosis and to counteract the effect of the operation, but also to prevent the development of malignant disease. So far as my own personal observation goes, I am obliged to say that I have not seen much benefit from any such treatment, and have come to look upon ths disease as an incurable one. There is one remedy which promises to be useful, and that is electricity ; but I have not had experience enough in its use to enable me to speak definitely regarding it. I may say, however, that it promises more than anything else that I am familiar M'ith, but more extensive observation is necessary to determine its true value. ILLUSTRATIVE CASES. Sclerosis of the Cervix Uteri. — This case, M^hose history I give, is one of the very few that I have seen of sclerosis of the cervix, not accompanied with laceration. It is possible that the cervix had been lacerated during one of the patient's confinements, and that the M'ound had healed, but I could not find any trace of such injury. The patient was thirty-one years old, and had borne four chil- SCLEROSIS OF THE UTERUS. 229 dren ; tlie last one three years before the time when this history was taken. Slie did not recover from this confinement as well as she had in previous ones, but I could not get any history of serious puerperal disease at that time. After the confinement her health was poor, and she gave the history of some uterine disease. Her menstruation was normal, but attended with more pelvic pain than formerly. She had suffered from leucorrhoea, but this had gradually diminished. At my first ex- amination I found the body of the uterus normal, but the cervix was much enlarged and hard to the touch ; the os was circular and small in proportion to the size of the cervix — it was an inch and three quarters in diameter. To the touch the cervix appeared to be as large as the body of the uterus. There was no other lesion found except that there was prolapsus in a slight degree. She was treated with the hot douche and applications of tincture of iodine, but without effect. I then removed, with the hawkbill scissors, a large V-shaped piece from the lateral walls of the cervix, and closed the wound with sutures, making an operation like that for bilateral laceration. Healing was prompt and complete, and the size of the cervix — at least the vaginal portion of it — was much reduced. She was better for the operation, and at the end of one year I found that the whole cervix was nearly of its normal size, and that the tissues were soft and more vascular. The operation had the effect of changing the nutrition of the parts, and causing absorption of the new tissue. In sclerosed tissue due to laceration of the cervix, I have fre- quently seen such favorable changes after operations. Sclerosis Uteri, following Puerperal Metritis. — This patient was thirty-five years old, had been pregnant five times, and given birth to four living children. While pregnant at the seventh month with her fourth child she received an injury which caused her to give birth to a dead foetus a few days afterward. During her fifth pregnancy she received a shock from seeing a friend in a convulsion ; labor came on immediately, and she was de- livered of a seven months' child. Soon after her confinement she complained of pain and tenderness in the region of the uterus, fol- lowed by fever. These symptoms extended over a period of three weeks, and there can be little doubt, from the history given, that she had acute puerperal metritis, which left her health permanently impaired. Since that time her menses have been irregular, scanty, and attended with pain. At times she has a menstrual molimen, 230 DISEASES OF WOMEN. but no catamenial flow. During the last year she has menstruated twice, the last time three months ago. This is the previous history of the case. She now suffers from extreme debility and anaemia, which is shown by her general appearance ; she also complains of ill-deiined aching pains throughout the pelvis, and in the sacral region ; occa- sionally she has very slight leiicorrhoea. Her digestive organs are also very much deranged, and her nervous system, from the joint action of disease and drugs, is a miserable wreck. By physical exploration I find that the uterus is enlarged, being three quarters of an inch longer than normal. The body and cervix are tender to the touch, and the sound carried into the cavity gives extreme pain. The cervix is indurated and smooth, and the os is smaller and more circular than is usually found in those who have borne children. Exploring the cavity with the sound, I find that while the longer diameter is considerably increased the antero-posterior and lateral diameters are shortened. The uterine walls appear to lie in close contiguity, so that it is impossible to turn the sound far in any di- rection. These signs obtained by the probe are of vast importance, for they indicate clearly that the enlargement of the uterus is due to an actual increase in the walls of the organ, and not a mere ex- pansion of its cavity. In other words, the growth is concentric, not eccentric. The cervix, as seen through the speculum, is notably pale ; the OS is small, with its lips curved inward. This retraction, or di*awing inward of the os, is confirmatory of the opinion that the walls of the cervix are enlarged more than the mucous membrane of the cavity. When the mucous membrane of the cervix is swollen, and the walls remain normal, the lips are enlai'ged or pouting. Briefly, then, the j^hysical signs indicate that there exists a con- dition of unusual hardness and enlargement of the uterine walls, while the relative size of the cavity is lessened. The uterus is also anaemic, as can be seen from a glance at the cervix. It should be noted that this patient has amenorrhoea — a condition that is much more common in the young than in those who have borne children, and is seldom found in connection with enlargement of the uterus. This form of sclerosis presents many points of resemblance to that of general endometritis, but they are essentially different. Contrasting sclerosis with endometritis gives results as follows : The one begins with acute inflammation of the uterus, the other SCLEROSIS OF THE UTERUS. 231 does not ; in tlie one tliere is amenorrhoea, in the other menorrhagia ; in the one the nterine walls are enlai-ged and the cavity diminished, while the reverse of this obtains in the other ; the utenis in the one is indurated and anaemic, in the other it is relaxed and highly con- gested. These are plain outline distinctions, easily recognized, and characteristic of almost opposite pathological conditions. Treatment and Prognosis of the Case. — After each menstruation an effort was made, either with leeches or puncture, to supplement the flow by depletion. This was not successful. It was ditticult to extract blood from the aniiemic tissues, and what was accomplished did not even relieve the patient. Blistering the cervix was tried with some apparent benefit ; cantharidal collodion was applied, and a tampon used to protect the vagina until vesication should take ])lace. This was repeated several times at intervals of two weeks, and the patient had less pain in the uterus and gained a little, but whether from the blistering or tonics and general supporting treat- ment, could not be stated with certainty. Iodine was next tried ; it was applied to the canal and vaginal surface of the cervix thoroughly twice a week, but she did not seem to improve much. About this time some one in England reported good results in obstinate uterine affections from vaginal suppositories containing mercury. I tried these until slight salivation was produced. Some harm, but no benetit was the result. Finally, I may state that some relief was obtained, but not much. She profited from constitutional treatment, but not much if any from local medication. Considera- ble relief was obtained by wearing a Peaslee's ring-pessary, which gave a little support to the uterus, but it caused irritation, and had to be removed. "When she was greatly fatigued, and suffered more pain than usual, a cotton tampon gave relief also. I lost sight of the patient for a number of years, but recently she returned to the city and called to see me about some trouble of her digestion. She told me then that she never fully recovered until the menopause, which occiu-red at forty-six. Since that time she had been fairly well. The uterus, though larger than it should have been at her age, was smaller than when under observation, fourteen years before. Sclerosis Uteri, resulting from Endometritis and General Congestion. — The patient was twenty-four years old when flrst seen. She was highly refined, and of a well-marked nervous temperament. She beffan to menstruate at the as'e of fourteen, and had contimied so to do regularly, but had always had slight pain at the menstrual peiiods, 232 DISEASES OF WOMEN. and was unusually nervous and irritable at such times. She was married at twenty-two, and soon after began to have backache, leu- corrhoea, and more pain than formerly during menstruation, and the flow was more free. These symptoms gradually increased, and her general health failed considerably. Pain in the uterus and general pelvic tenesmus were added to her other symptoms, and after suffering for two years in this way she came under my care. I then found the uterus larger than it should have been, and its tissues softer than normal, especially those of the cervix. The canal of the cervix was larger than normal, and the whole uterus was tender to the touch. Passing the sound caused severe pain. There was considerable erosion of the cervix, the os externum was di- lated, and the mucous membrane was highly congested. There was a free muco-purulent discharge which irritated the vagina and vulva. The usual local treatment for endometritis was employed, and the ordinary means were used to improve her general health. Appli- cations of nitrate of silver (which I used at that time, according to the advice of my former teachers) caused great pain, and were given up for milder means, such as tincture of iodine, and tannin and glyc- erin. She improved very slowly, and about ten months after she came under my care she went to Europe with her husband, who was called there on business. She remained in England for about five years, and occasionally was treated by a distinguished physician there. Excepting various kinds of vaginal injections she had no local treatment while in England. Her general health improved very much, and she bore her local troubles without complaint. Upon her return to this country, I found that her menstrual flow had diminished until she had less than before her marriage. There was very little leucorrhoea, and less pelvic tenesmus. There was quite as severe dysmenorrhoea, and she had intermittent pain in the uterus of a neuralgic character. The uterus, taken as a whole, was a little smaller, and indurated to the touch ; the canal of the cervix and the cavity of the body were decidedly diminished in caliber, and still tender to the touch of the uterine sound. The os externum was contracted, and its lips in place of being everted as formerly were now slightly curved inward. In place of the soft vascular conditirm of the cervix, present when she was first examined, it was now round, well defined, and rather anaemic in appearance. It was only by referring to my notes of the case, taken at the SCLEROSIS OF THE UTERUS. 23S first examination, that I could fully realize the change which had taken place. I treated her for a short time in the hope of relieving her dys- menorrhoea and uterine pains, but without much benefit ; and, as she was able to get along by resting at her menstrual period, she was dis- missed with the advice to await the menopause, when in all proba- bility she would be relieved CHAPTER XIII. MEHIBR ANGUS DYSMENOEKHCEA. I SHOULD i^refer to call this affection membranous menorrhoea, believing that the term would be more appropriate, but as the original name has been longer in use, and is familiar to the profession, I shall not attempt to change it. This is an affection which, although rather rare, commands very urgently the attention of the gynecologist, because of the dreadful suffering which it gives rise to, and the obstinacy with which it has heretofore resisted treatment. There is a marked uniformity about this disease. In its j)athology and clinical history it varies but little in different cases. A number of affections resemble it to a limited extent, but it stands out well defined, and is easily detected by the experienced diagnostician. Pathology. — An exfoliation in mass of the mucous membrane of the cavity of the body of the uterus at the menstrual period is the chief lesion in this affection. Microscopically, the mass presents all the histological elements of the true mucous membrane of the uterus, including the utricular glands, unchanged by any new or abnormal elements. When it is expelled entire, it represents a complete cast of the cavity of the uterus, and is triangular, with an irregular open- ing at each of the angles, the one representing the internal os uteri, and the others corresponding to the ostia of the Fallopian tubes. This membrane is rather ragged on the outer surface, but smooth on the inner, and looks exactly as the lining membrane of the uterus does when in position. The size is usually about an inch long and less than that in width, and is generally somewhat larger than the normal proportions of the cavity of the uterus ; but this is not always the case. In this respect it is like the decidua of pregnancy ; in fact, in general appearance it closely resembles the decidua vera, but there is a decided difference in its microscopic elements, sufficient at least to distinguish, This similarity of the two membranes has le^ 234 MEMBRANOUS DYSMENORRHCEA. 235 to their being called the decidua gravida and the decidua menstru- al is, the former being the mucous membrane as seen in abortion at a very early stage of gestation, the other the membrane as thrown off at menstruation in this morbid form, ' Comparing the changes \7hich the mucous membrane undergoes in membranous dysmenorrhoea with its changes in normal menstru- ation, the difference is as follows : In normal menstmation, if we accept the views of Dr. Williams, of London, the whole mucous membrane undergoes fatty degeneration, disintegration, and elimina- tion ; whereas in membranous dysmenorrhoea the mucous membrane becomes separated from the walls of the uterus without being changed or disintegrated ; exfoliation and expulsion simply occur. The way in which the separation of the mucous membrane takes place is not positively known. It is presumed, however, that fatty degeneration in the deeper structures of the membrane takes place, and thereby it becomes detached from the uterus. It is possible, also, that the capillary haemorrhage, instead of occurring on the free surface of the membrane, takes place in the deeper structures, and in that way dissects off the membrane. This, however, is hypo- thetical, and needs confirmation. Sometimes the membrane is ex- pelled in shreds, which suggests that the exfoliation either occurs in spots or sections, or else that the membrane is completely sep- arated from the uterus, but becomes broken up either during ex- pulsion or in handling it afterward. It is much more probable that it is completely exfoliated and broken up subsequently than that it is separated in circumscribed patches. All these facts lead to the conclusion that the affection is a perversion of nutrition and func- tion rather than an organic disease, inflammatory or otherwise, which gives rise to this peculiar condition of the mucous membrane at menstruation. It is clearly evident that there is nothing pathologi- cal in the condition of the mucous membrane itself, but that the whole morbid process consists in the separation of the membrane in mass, in place of disintegration, which is the normal character of the mucous membrane in menstruation. There are other views regarding the pathology of this affection : one, that it is the result of gestation, which is arrested at a very early stage, and that the membrane thrown off is really a decidua vera. That this theory is fallacious will be seen when the physical signs of this affection are discussed. The idea that it is an inflammatory affection is not well sustained. No such product or result of inflammation is found elsewhere in the mucous membranes of the body, nor is it necessary that inflammation 236 DISEASES OP WOMEX. of any part of the uterus should be present in order to produce membranous dysmenorrhea. Associated with this membranous dysmenorrhcea we occasionally find inliammatory conditions, but not of tlie mucous membrane of the cavity of the body. There may be, and often is, a general hy- pertemia of the uterus and vagina, but usually it is not greater than that which is seen in normal menstruation. There is occasionally, in cases of long standing, cervical endome- tritis, but this does not extend to the body of the uterus. In fact, I believe that a well defined endometritis can not occur at the same time as membranous dysmenorrho?a. This affection, then, is cer- tainly srii getieris, and is not the result of inflammation in any form or in any stage of the inliammatory process ; neither is it a utero-ges- tation ending in abortion at a very early stage of pregnancy, as some have maintained ; neither does the membrane partake of the nature of any of the morbid neoplasms which occur in mucous membranes elsewhere in the body. The mucous membrane in this affection is developed in the nat- ural manner after each menstruation, and the gross appearances and histological comj)osition of this structure sliow that it is normal, and differs in no way from the mucous membrane of the uterus up to the time when the menstrual flow is about to begin. Perhaps there is, in some cases, an increase in the quantity of the membrane, but only to a very limited extent, if at all. In short, the only pathol- ogy connected with this affection is in the manner in which the meml)rane is thrown off. Symptomatology. — This affection occurs in single and married women — about as often in one class as the other, perhaps. It also occurs in those who have borne children, but in most of the cases that I have seen in married women the patients have been sterile. The recurrence of the menstruation is generally regular ; sometimes it is delayed, and sometimes there is a sense of pelvic discomfort before the menstrual flow, but not always. The chief symptom is the pain which comes on usually during the first day, sometimes later, and increases in severity, and is somewhat intermittent in character until the meiiil)rane is expelled, when it i-ather al)rui)tly subsides. The flow sometimes is scanty jirevious to the expulsion of the membrane, and after that it is generally quite free; at times abnor- mally so, and occasionally small clots are passed. Sometimes there is a leucorrhteal discharge succeeding the men- strual flow, the discharge being occasionally tinged with blof)d. In MEMBRANOUS DYSMENORRHCEA. 237 other cases the menstrual flow subsides after the expulsion of the membrane, and no leucorrlnjea of any account occurs afterward. There is really nothing in the clinical history of this aifection by which it can be positively distinguished from dysmenorrhrea due to Figs. 103, 104. — The two sides of a half-membrane from a multipara; from the cavity of the body. The slight puckering present is due to alcohol. other causes. Hence the diagnosis must always depend upon the physical signs. Physical Signs. — In order to make a diagnosis, it is absolutely necessary that the membrane expelled should be preserved and examined. The gross appearances of the speci- men are usually all that is necessary to satisfy the diagnostician regard- ing the nature of the affection, but in cases where there is a doubt the microscope must be called in to aid in the diagnosis. The morbid materials expelled from the uterus which simulate the membrane produced in this affection are the decidua expelled in abortion in the earliest stages of pregnancy ; the masses of fibrin which have formed in the uterus in menorrhagia ; very dense masses of secre- tion from the cervix ; and the membranous-looking shreds expelled from the cervix and vagina after astringent or caustic applications. Fig. 105. — Half a membrane from a virgin ; from the body of the uterus only. 238 DISEASES OF WOMEN. ^■^ H '-^H Hit ' ' '''"^H ^^HL*'- 1 I'l^H ■P^' ''^^ ''i^^^H ^^^^^^^E^MF l.,j 1 ■| 1 ^^^^^^^^B^^ 1 Fig. 107. — Frag- ments of mem- brane in the con- dition in which they are often expelled. The decidua in early abortion is most ditiicult to distinguish from the menstrual membrane. In the early abortion the mem- brane expelled is usually larger and more ovoid or round, and not so mark- edly triangular as the decidua of menstruation, and is also thicker, and usually is accompanied with villi of the cho- rion. If there is still a doubt, the microscope reveals the fact that the menstrual membrane pos- sesses only small cells, while those of the de- cidua-vera membrane are so great as to be easily distinguished. There is a de- cided microscopic difference in the epi- thelium, the tubes, and the inter-glandular tissue. This difference between the two membranes is not only in the decidua of early abortion, but also in the decidua of extra-uterine pregnancy. In being thus able to distinguish be- tween the decidua of pregnancy and the membrane of menstrua- tion, the only great difficulty in the diagnosis is overcome. Inspection will enable one to dis- tinguish shreds of fibrin, masses of unusually dense secretion of the cer- vix, and shreds from the cervix and the vagina after astringent ap- plications from the menstrual mem- brane. The diagnosis can l)e made with great certainty. Causation. — Discarding the cur- rent views regarding membranous dysmenorrhfea — that is, that it is due to inflammation, or else the re- sult of gestation — one is left with out any very rational view to offer Fig. 106. — A cast from a virgin, where the cervix is also involved. Fig. 108. — A cast which might be mistaken for a product of concep- tion : w, shaggy interior ; «, film of niiMnbrane covering it; c, fila- ments from cervix. MEMBRANOUS DYSMENORRHCEA. 23^ regarding its causation. While it is not, perhaps, the part of wisdom to discredit the accepted views on any question in medicine until one has souiething more reliable to offer, still, if the causes assigned can be readily shown to be incorrect, it is iniinitely better and safer to be entirely in ignorance of the causes of things than to attribute them to the wrong causes. Foi'tunately, however, while I find my- self at variance with most of the recent authorities regarding the cause of this affection, I am in perfect harmony with the views of Dr. Oldham, vvho was the first to discover " dysmenorrhcea mem- branacea." Dr. Oldham distinctly pointed out the characteristics of this affec- tion, and stated that the membrane is formed under abnormal ovarian stimulus ; and I am fully satisfied that he was not only the discoverer of the disease, but also conceived the true idea regarding the cause of it — viz., some undue ovarian influence or sexual excitation. In other words, it would appear to be some derangement of innervation and nutrition. Taking this view of the causation, I expect to find myself in har- mony with the neurologists at least. This class of specialists mani- fests a willingness to trace many diseases originally to some derange- ment of the nervous system, when they find anything like good reasons for so doing. Hence, I expect their support in choosing, as 1 do, to believe that the starting-point in the pathology of this affec- tion must be some derangement of innervation produced by disease or functional disturbance of the ovaries. Confirmation of this view regarding the cause of membranous dysmenorrhcea may be found in studying the agencies which give rise to other morbid states of the uterus, like the fibroid growth, for example, which in its anatomical elements does not differ especially from the tissues of the uterus from which it springs ; and, if we could find the cause of this devi- ation from healthy nutrition, it might be applicable to the disease under discussion. But, unfortunately, the causes of fibroid tumors given in our literature are unsatisfactory, and by no means well sus- tained. From the fact that uterine fibroids are more common in sterile women than in others, it would appear that sterility predisposes to their development, and perhaps no better explanation of the cause of these growths has ever been given than that of my somewhat hu- morous friend, who said that "the uterus, being prepared for normal work and not finding it to do, took up the development of fibroids as a sort of occupation for its formative powers." May it not, then, be that a well-defined predisposition to reproduction, uncalled for by 240 DISEASES OF WOMEN. gestation, excites this morbid action on the part of the uterus which leads to this abnormal exfoliation of its mucous membrane ? This view might at least be entertained, because in other cases, when we are unable to detect the cause of a disease in something that is tan- gible, we usually attribute it to deranged innervation and conse- quent malnutrition. This view of the causation is, to some extent, sustained by the etfect of medicines upon the lesions. This ailec- tio!i has always been recognized as one that is often difficult to cure, many times incurable, in the hands of the most competent phy- sicians and surgeons. This possibly may have been due to misap- prehension of the nature and cause of the disease, and hence falla- cious therapeutics, rather than to the incurable character of the disease. In favor of this line of thought I may state that the patients whom I have treated in years ])ast, on the theory that the cause was inflammatory, have derived little benefit, while those who were treated for deranged innervation, malnutrition, and undue ovarian excitation, have made very much better progress. I am inclined to attribute most of the trouble to ovarian influence, the condition of the ovaries being that of an undue nerve excitation and possible congestion. I have been led to this belief by two facts : that the majority of the patients that I have seen have been subjects of a highly nervous organization, and in most of them there has been tenderness of the ovaries, and pain at times, without there being any evidence of ovaritis. The rheumatic diathesis is said to favor this affection, and it is possible that tliis may be so, although I am unable to recall any of my patients as l)eing rheumatic ; neither have I been able to trace it to the tubercular or strumous diathesis, nor to syphilis. It is certain, however, that, if either of these conditions existed, it would have its influence in helping to keep up the uterine trouble, and every effort should therefore be made to relieve it by treatment. Treatment. — The treatment of this affection is necessarily both palliative and curative. While the patient is suffering during the expulsion of the membrane, it is very necessary to relieve the pain as far as possible. This, of course, can be most promptly done In the use of opium, which should be avoided if jjossible, however, be- cause of its after-effects. Sodimn salicylate and antipyrine, Ave grains each, may be given when the stomach is empty. Chloral hydrate answers fairly well in some cases. I am not sure that it has any advantages over chloroform, camphor, and belladonna, or conium and cannabis Indica ; in fact, in the major MEMBRANOUS DYSMENORRHCEA. 241 ity of cases one has an opportunity to try several agents, and, of course, the patient will decide which gives most relief. Indications for general treatment are to quiet all nervous disturbance and to improve the general nutrition of the mucous membrane. It so happens that when the first part is attended to the latter will follow in due order. To quiet the nervous irritation and disturbance there is nothing that equals the bromide of sodium. This should be given in twenty- or thirty-grain doses three times a day for ten days or two weeks before the menstrual period. And, if the pain is not severe enough to require the addition of some of the remedies already named to re- lieve it, the bromide may be continued throughout the menstrual period and several days after. From this it would appear that the bromide is to be used continuously ; but one or two weeks in each month it can be omitted. When the bromide has been employed for some time, and it seems desirable to give it up, conium may be administered in moderate doses combined with camphor, if the pa- tient is weak. If there is any evidence of the rheumatic diathesis, the bromide of lithium should be given. Next to quieting the nerv- ous system, any debihty that may exist should be overcome by nerve tonics. Undue nervous excitation so often goes hand in hand with nervous depression that in many cases it is necessary to combine the tonic and sedative treatment. All the remedies which may be used need not be here mentioned. In regard to the modification of nu- trition, it need only be said that any accompanying derangements of the digestive organs that may be found should receive careful atten- tion ; but this hardly need be mentioned in this connection. My rule of treatment has been, after subduing all nervous dis- turbances, to put the patient upon the iodide of sodium in case she is in fair strength and inclined to flesh. If there is anaemia, I prefer the iodide of iron. If these do not accomplish the object, I employ mercury, giving it in small doses, never continuing it long enough to produce salivation, carefully watching to avoid this. In cases of aneemia, where I have feared the debiEtating eifect of this alterative, I have given the bichloride of mercury with iron. After keeping them upon this treatment until I could see some evidence of its effects, I have then put them upon iodine and arsenic. In regard to local treatment, I have been entirely guided hy the ^niews of the pathology as expressed above, and have therefore em- ployed alteratives and sedatives almost exclusively. Of these I have found iodoform most effectual. I have also used iodine and mer- cury with advantage. In cases where I have found any complications 242 DISEASES OF WOMEN. I have carefully attended to them, restoring displacements and cor- recting flexions, and so on. When the canal has been constricted, free dilatation and jjacking with gauze have been efficient. "When the congestion which occurs at the menstrual period has not subsided in a few days, I have employed the warm-water douche. After this, 1 have applied to the cavity of the uterus small bougies of cocoa-butter with as much iodoform as they would take up. Three or four grains of iodoform mixed with vaseline that has been lique- fied by heat, and introduced through the pipette, is perhaps the best method of applying it. This has been introduced once a week or once every live days. When there has been much tenderness, and the use of the pencils has caused pain, I formerly used aconite and opium and iodine ; this I have introduced into the cavity of the uterus. I am now trying cocaine to subdue the tenderness as a pre- paratory means to the use of the iodoform. But so far this new remedy has not been a perfect success. In cases where this has failed and the uterus was not especially sensitive to intra-uterine medication, I have instilled into the uterine cavity a few di'Oj)s of a S-jDer-cent solution of carbolic acid, making one application a few days after the menstrual flow and not repeat- ing it until the next period. In the interval I have used the iodo- form. I have also used the fluid extract of conium and hydrastis Canadensis ; but this I have found gives more pain than any of the other applications that I have used ; and so of late I liave used an infusion of the hydi'astis alone, which appears to answer as well and gives less pain. HISTORY OF CASES. Case I. Membranous Lysmenorrhcea in a Married Lady who was never Pregnaat. — This patient was forty-one years of age, of good constitution, and had been married eight years. She began to men- struate at thirteen, and continued to do so regularly and normally until slie was twenty-one ; then she began to have occasional pain, about the menstrual ])eriod, in the region of the ovaries. About a year after this she began to have severe uterine pains during the menses, and states that she occasionally passed masses that looked like membrane fi'om the uterus; they were small, however, and did not apjiear at each period. After her marriage the pain at the menstrual periods became worse, and almost every month she passed a membi'anous cast of the uterus. The usual history of each menstruation is that the flow he- gins not very free, and, after continuing for about five hours, the pain becomes very intense and lasts from three to eight hours, when MEMBRANOUS DYSMENORRUCEA. 243 she expels the membrane and the pain subsides, the flow continuing for a day or a day and a half after the membrane has been expelled. The flow, taken altogether, is not profuse, and only lasts from two to two and a half days, while formerly — that is, before her dys- menorrhoea began — it used to continue from four to Ave days. When flrst seen, her general health was good, but she was rather hysterical and nervous, and was somewhat depressed and disappointed because she had not had children. She described the suffering at her menstrual periods as some- thing unbearable, although it did not last more than a few hours at a time. She was flrst examined midway between the menstrual periods. The uterus was then found to be normal in size and in good position. The internal os was rather sensitive and appeared to be slightly contracted ; there was also a distended Nabothian gland in the middle third of the cervical canal, but the uterus pre- sented a normal appearance in every other respect. There was no congestion ; in fact, at this time the mucous membrane appeared rather anaemic. The diagnosis was left an open question until the next menstrual period, when I obtained the membrane expelled and had it examined by my friend Professor Frank Ferguson. His report stated that the specimen was uterine mucous membrane unchanged in its histological composition. This settled the question of diagnosis. Careful inquiry elicited the fact that she had never been preg- nant, so far as I could rely upon her testimony, which I believe to be accurate because of her great desire to have children. I also learned that on several occasions she had lived apart from her hus- band, who was of necessity absent on business for several months at a time, and that she suffered just the same, and at each month there was an expulsion of membrane, showing conclusively that there was no possibility of mistaking this affection for pregnancy and abortion. The ti-eatment consisted, flrst, in placing her upon the following- mixture : Half a grain of the bichloride of mercury, one drachm of the solution of the chloride of arsenic, three drachms of the tincture of iron in a three-ounce mixture of sirup and water. A teaspoonful of this was given, well diluted, after each meal. At the same time the internal os was incised superflcially in three places, dividing equally the circumference of the canal, and the distended ISTabothian follicle was punctured and evacuated. A week after this a sound was introduced of full size, and there was less tenderness ; the tincture of iodine was then a]:)plied from just within the internal os outwai-d. At the next menstrual period 2-I-4 DISEASES OF WOMEN. she had less pain, but it lasted just as long, and she passed a mem- brane uuchanged, except that it did not appear so thick as formerly. From this onward the local treatment consisted in passing a full- sized sound just beyond the internal os directly after the menstrual period, and again in two weeks, and in nearly every six days about two grains of iodoform mixed with vaseline were passed into the cav- ity of the uterus, well up toward the fundus. This local treatment was continued without interruption for three months, and the iirst prescription, after it had been taken for two wxeks, was followed by the iodide of iron, a grain and a half three times a day. After the second month, and at the third menstrual period from the time that treatment began, she had no pain and passed no mem- brane. At the next period she passed several shreds, but nothing like a complete cast of the uterus. The constitutional treatment, that is, alternating between the first prescription of mercury and arsenic and the iodide of iron, giving first one for two weeks, and then the other, was continued for two months longer. The application of the iodoform was continued for one month longer, once every week, and once after her menstru- ation, at the end of the fourth month of the treatment. Since that time she has had no further trouble ; her menses are regular, lasting about three days, and entirely without pain or any discharge of membrane. That was her record at least one year after she gave up treatment, since which time I have not heard from her. Cast: 11. Membranous Dysmenorrhoea occurring after Treatment for Anteflexion and One Miscarriage. — A lady of very high culture and over-refinement, of a well-marked nervous temperament, but otherwise of good constitution, came under my observation when twenty-eight years of age ; she had then been married a year and a half. She menstruated first at fourteen years, and continued to do so regulai'ly, but with pain from the very l)eginning. The pain usually began a day or so before the flow and gradually diminished after. Her suffering at each period gradually increased until her marriage, when it l)ecame more severe. This, and the fact that she remained sterile, induced her to seek advice. I found her suffering from anteflexion of the body of the uterus and cervical endometritis ; there was also tenderness of the left ovary on pressure. She was treated for the flexion, and completely recovered. The dysmenor- rhoea was entirely relieved, and she became pregnant. During her pregnancy she suffered very much from morning sickness, and at the end of the third month began to show some signs of septi- MEMBRANOUS DYSMENORRIICEA. 245 coemia; she then miscarried, and the ovum was found to be macer- ated, and probably had been dead in uUro for two weeks. She recovered from this and was quite well for about a year, when her dysmenorrlujea returned ; she then returned to be treated for wliat she supposed to be a recurrence of her former trouble, but I found no evidence of the former flexion. But, on inquiry, I found that she passed at each period a membranous cast of the uterus. The patient thought little of this, because in former years, while suffering from the dysmenorrhoea caused by flexion, she occasionally passed small clots which looked somewhat membranous in character, but no doubt were simply blood-clots. She was placed upon treatment similar to that employed in the lirst case reported, except that there was no necessity for enlarging the internal os as in the former case, the only difference in the local treatment being that I used iodine in place of iodoform during the last two months of the treatment ; and once, immediately after the menstrual period, I applied a mild solution of carbolic acid to the uterine cavity. She did not again pass any membrane after the third month of treatment, and her pain from menstruation entirely disappeared. She was dismissed at the end of four months, and two months afterward reported that she was pregnant. Three months after that time she was examined and found to be so, and was progressing well. Since that time I have not seen her, but have heard that she gave birth to a healthy child. Case III. Membranous Dysmenorrhoea treated by Dr. Fordyce Barker, of New York; Complete Recovery. — I give the history of the following case for two reasons : First, to show that iodoform was employed in the local treatment, and that the patient's recovery was complete ; and also to take the opportunity of stating that I believe that Dr. Barker was the flrst to employ this agent. The history is not altogether complete, because I obtained it from the patient herself, who was unable to tell all that was done for her; but I know positively that slie suffered from dysmenorrhoea, and that she entirely recovered under the care of Dr. Barker, and has remained well for a number of years. This was an educated lady of a well-marked nervous temperament ; she began to menstruate at thirteen, and continued to do so normally until she was twenty-six years of age. At that time she was said to have had an acute attack of ovaritis, and after recovering from that she had dysmenorrhcea. The character of the pain at her menstrual periods then appeared 246 DISEASES OF WOMEN. to be ovarian. After suffering in this manner for about four or live years she noticed the expulsion of membranous casts of the uterus at the menstrual periods. During this time and for a year afterward she was regularly treated l)y her family physician, but without relief. She then consulted Dr. Barker for her general ill-health, but did not call his attention to her derangement of the menstrual function. She improved in her general condition under his care, but found no relief from the memljranous menstruation. She consulted him again and called his attention to the uterine trouble, and he immediately placed her under treatment. The constitutional remedies employed I do not know, but the local treatment consisted in dilatation of the cervical canal and the application of iodoform to the uterine cavity. She continued to pass membrane for several months ; then the trouble ceased, and has not returned. She now menstruates regularly and naturally, and has done so for over two years. Several other cases might be added, some showing failure of treatment, and others where the patients were really made worse l)y being treated for inflammation of the uterus which w^as supposed to be the cause of the affection, but undoubtedly was not. Other cases might be given, also, in which recovery took place, and after several months or years the trouble returned, but they would add nothing to the views already expressed regarding the pathology and treat- ment of this affection. CHAPTER XIV. LACEKATIONS OF THE CERVIX UTERI. Regarding this subject Dr. Thomas Addis Emmet says : " Its importance can not be exaggerated, since one half of the ailments among those who have borne children are to be attributed to lacera- tions of the cervix." This estimate of the frequency and consequences of laceration of the cervix uteri is quite sufficient to introduce the subject and secure for it special attention. Sir James Y. Simpson pointed out the fact that lacerations of the cervix uteri frequently occurred, and Dr. Gardiner also described such lesions and their results ; but to Dr. Emmet is due the credit of describing fully the pathology of lacerations of the cervix and their causative relations to many other uterine diseases. He also devised efficient surgical means for their relief. This is certainly the most brilliant of all Dr. Emmet's achievements. The disturbing influences of this injury upon the sexual organs and the general health are usually marked, but depend to some extent upon the magnitude and location of the laceration. The first eifect noticed is to retard recovery after confinement. The lacera- tion exposes raw surfaces to the lochial discharges which, when these are decomposing and offensive, may give rise to septicaemia. Even where this does not occur the injury interrupts, more or less, the process of involution and produces all the troubles which usu- ally follow therefrom. There is more or less inflammatory action set up in the parts, and the efforts at healing the laceration develop much scar tissue and not unfrequently enlargement and hardening of the parts fi'ora areolar hyperplasia. The scar tissue thus formed and the sclerosed tissues beneath and around the scars are often tender and painful. All this proves to be a source of local irritation, and sometimes causes much general disturbance through reflex action. The inflam- 247 248 DISEASES OF WOMEN. matory action which immediately follows the injury does not entirely subside when cicatrization is complete. The inflammation in the cervical mucous membrane lingers there, and hence old lacerations are generally accompanied with marked catarrh of the cervical mem- brane. This is kept up and often aggravated by the eversion or rolling outward of the divided walls of the cervix, which exposes the cervical mucous membrane to fiiction and the acid secretions of the vagina. Therefore, the cervical endometritis accompanying lacerations has no natural tendency to disappear. It is also rebel- lious to treatment, and finally, if it is subdued, it soon returns unless the original injury is repaired. In lacerations of long standing, and especially those that have been treated by caustics, the mucous folli- cles become closed and distended, assuming the form of small cysts. The presence of these distended cysts increases the size of the cer- vix and gives an irregular outline to the surfaces under which they are situated. By pressure they cause absorption of the tissues of the cervix, so that when they are punctured or ruptured and their con- tents are evacuated the cervix becomes diminished below the original size. The several forms of laceration of the cervix uteri most fre- quently seen in practice are : 1. Lateral lacerations of one or both its walls. 2. Antero-posterior laceration ; usually found in the posterior wall, but occasionally involving botli. 3. Multiple lacerations, usually three in number, but occasionally more. 4. Incomplete lacerations, in which the solution of continuity extends from within outward through the mucous membrane and muscular walls of the cervix, but not through the mucous membrane of the vagina. This form of injury is generally bilateral, but occa- sionally the lacerations are multiple, involving the two walls laterally and the posterior and anterior walls also. Sometimes two of these forms of injury are found together, as, for example, a complete bilateral laceration and an incomplete lacer- ation of the anterior wall of the cervix. The first, and by far the most common of these injuries, lateral laceration, presents several varieties. The bilateral laceration, in its typical form, divides the cervix into two equal parts, and extends up to the vaginal junction. As seen at times, the laceration is superficial, extending not more than half way up to the vaginal junction ; again, the laceration may extend on one side up above the vaginal junction, while on the other LACERATIONS OF THE CERVIX UTERI. 249 Fig. 109.- it is mucli less extensive. In other cases the bilateral laceration divides the cervix into two unequal parts, the anterior portion usu- ally being tlie larger (Fig. 109). The morbid states of the cervix uteri which accompany this form of injury and are caused by it vary greatly. In the simplest forms the cervix, in the aggre- gate, is not much en- larged ; the divided halves rest nearly to- gether, and protect the mucous mem- brane of the cervi- cal canal. Under these circumstances a slight hypersemia of the cervical mu- cous membrane and a slight leucorrhoea are all the lesions present in many cases. Even these are not always found. In other cases the halves of the cervix are widely separated. The mucous membrane of the canal is everted, and is generally de- nuded of its epithelium, markedly congested, often thickened and irregular, and covered with a profuse leucorrhoeal discharge. In still other cases there is, in addition to the above e version, a marked hy- perplasia of all the tis- sues, especially on the inner surfaces. The new tissue fills in the space between the halves of the cervix, so that the opposite sides of the laceration can not be brought togeth- er (Fig, 110). „,^. , - Fig. 110. — Bilateral laceration, with thickening of the llus SUperabund- everted lips. -Bilateral laceration ; unequal division of the cervix. 250 DISEASES OF WOMEN. ant tissue is produced by arrest of involution and areolar hyperplasia. The tissue is denser than normal, and, in fact, presents a trne sclerosis. ^_____ Lacerations of the an- tero - posterior walls, while they are said by Emmet to occur frequently, are comparatively less often seen, because they generally heal promptly and com- ])letely of their own accord. Where they are found, they are generally complicated with all the lesions de- scribed in connection with lateral injuries. Multiple lacerations vary greatly in number and ex- tent. A trilateral laceration is most frequently met with. The cervix is usually di- FiG. 111. — Extensive multijjle lacerations. vided into three unequal parts, as seen in Fig. 111. This may be called a complete multiple laceration, because all the tissues of the cervix are divided. There is another form of tins injury in which there are a number of lacer- ations which extend from within outward, but do not involve the vaginal mucous membrane (Fig. 112). The lateral incomplete lac- eration may be unilateral or bilateral. CTenerally, both walls are divided from within outward to the outer mucous coat. This injury is over- looked quite often by gynecol- ogists. At least, I infer this from the fact that Dr. Em- met is the only writer of all those whose works I have consulted who mentions it. Fi,;. il2.— Multii)lc incomplete lacerations. LACERATIONS OF THE CERVIX UTERI. 251 Fig. 113. — Incomplete bilateral laceration. It is usually described as a patulous or dilated condition of tlie cervix, and to the toucli and inspection it appears to be so, but a careful examination shows that the cei"vix is divided into two parts that are held together by the outer coat, or mucous membrane. Fig. 113 shows the lesion. This lesion can be most con- veniently demonstrated by pass- ing the uterine sound into the cervical canal, and then carrying it outward in the line of the laceration, when it will become apparent that the outer coat of the cervical wall is all that re- mains intact. There is usually no e version of the mucous mem- brane, but almost always there is a marked catarrh of this membrane, which is peculiarly resistant to treatment. In a number of these cases I have found enlargement of the anterior half of the cervix whicli gave a crescentic appearance to the OS externum, Fig. 115. Causation. — Laceration of the cervix is usually cansed by parturition, either natural or in- strumental. In a great majori- ty of first labors the cervix is injured to some extent, but in many the laceration either unites or, being very superficial, gives no trouble and passes unnoticed. Certain conditions of the tissues of the cervix predispose to lac- eration. Irregular development of the cervix either before or during pregnancy, in which one wall is thicker than the other ; induration from previous dis- ease, which lessens the elasticity of the tissues ; and a softened a?dematous condition of the cervixj produced by pressure in tedious labors— all these favor laceration. In abnormal labors requiring manual and instrumental aid be- fore the cervix is dilated there is additional liability to injury, and Fig. 114. — The incomplete bilateral lacera- tion shown in Fig. 113, as seen by sec- tion of the cervix. 252 DISEASES OF WOMEN. y^.MiM4i^^ A ^^■' , :;,,. jw:*^f?P^ i ■w this frequently occurs ; but it is also a fact that lacerations often take place in perfectly easy and natural labors. Indeed, it appears that in easy and rapid labor lacer- ations are very likely to oc- cur, such frequently showing that precipitate delivery is a cause of this accident. Dr, Emmet states in his book that he has seen laceration of the cervix in cases of criminal abortion. I have never seen laceration of the cervix after abortion from any cause at or before the third month of gestation. There is a condition of en- largement of the cervix with eversion of the mucous niem- braue of the cervical canal which presents all the phys- ical signs of a superficial bilateral laceration, and this I have seen after abortion in the first pregnancy, but I have also seen the same condition in the virgin uterus. This alfection is described under the head of cervical endometritis, and, therefore, need not be discussed here. From what has been said, it will appear certain that this injury can not at all times be prevented by any skill and care on the part of the obstetrician. This should always be borne in mind and freely stated where the injury is attril)uted to carelessness on the part of the attendant during lalxjr, a mistaken criticism not unconnnonly heard anions the laitv. The effect of this injury n\)(m the uterus and the general health of the patient, together with the symptoms and physical signs, will be brought out in full in the histories ofi llustrative cases which follow. The treatment of tliis injury includes the j)rimary and secondary management. It has been suggested that when the injury takes place the laceration should be immediately clossd with sutures, but this is impracticabk'. First, because it is impossible to fully estimate the extent of a laceration in the relaxed condition of the cervix im- mediately after delivery ; and, secondly, the difficulty of accurate- ly adjusting sutures under the circumstances would subject the pa- FiG. 115. — Crescentic laceration. LACERATIONS OF THE CERVIX UTERI. 253 tient to exposure, wliicli is unwarranted. Besides this, the intro- duction of sutures and the disturbance of the tissues necessary to their introduction would tend to interfere with spontaneous union, a favorable termination not infrequently attained. The primary treatment then must be limited to the usual means employed by the competent obstetrician to secure noi'raal involution of the pelvic organs. The secondary treatment should embrace three objects : First, to overcome the consequences of the injury ; sec- ond, to improve the nutrition of the parts injured, and thus pre- pare them for the third step, the repair of the laceration by surgical means. When an improvement in the condition of the tissues of the uterus is attained, the general health of the patient is usually bene- lited by securing the best conditions for success in the operation for restoring the laceration. In order to do this it is necessary to overcome as far as can be the endometritis which usually accompa- nies the injury. The means used for this purpose sometimes suc- ceed in relieving the subinvolution which usually is present in those cases. Where there is much enlargement of the cervix from areolar hyperplasia, which makes it impossible to bring the divided edges together, and all ordinary treatment fails to reduce this enlargement, it is sometimes necessary as a prej)aratory measure to remove a por- tion of the tissue on the inner sides of the divided halves of the cer- vix and allow the parts to heal before performing the final opera- tion. This I have usually accomplished by taking out a section on each inner side of the halves and bringing them together with a couple of sutures. These are left in place for a week or two, and in the mean time the hot-water douche should be used, and such local applications as may be necessary to relieve catarrh or hyper^emia. The sutures are then removed, and after a few weeks the operation for the restoration of the cervix is performed. When there are a number of cysts in the cervix (a condition known as cystic degenera- tion) they should all be opened and evacuated. Sometimes the everted mucous membrane becomes very much thickened, and pre- sents a granular or papillomatous-looking surface. When such is the case, it is best to trim off the more prominent points on the surface, and subsequently make such application as will reduce the thicken- ing and vascularity of the membrane. It has been suggested by some that whenever there is a laceration it should be at once restored. Such authorities are of the opinion that if the operation is successful the other pathological lesions which were caused originally by it will disappear eventually. This is not 254 DISEASES OF WOMEN. by any means to be relied upon, and I much prefer to remove, as far as possible, all local complications before operating. The objects to be obtained b}' the operation are to remove the scar tissue formed by the healing of the ununited edges of the lacer- ation, and thereby relieve the pain and reflex disturbances which it may have given rise to, and also to close in the mucous mem- brane and protect it from further irritation. There is still an- other important benefit gained by the operation — viz., when the uterus is larger than normal, owing to subinvolution, a marked reduction in its size will follow after this operation. I beheve that the completion of involution generally follows successful res- toration of the cervix, excepting in those who have had puei-peral metritis. In recent superficial lacerations I have operated without anaes- thetizing the patient. The pain of the operation is trivial compared with the distress from the after-effects of an anaesthetic. As a rule, however, it is necessary to administer an anaesthetic, especially in deep lacerations of long standing, where there is much scar tissue and consequent tenderness. The operation for the restoration of the cervix uteri must vary a little in detail according to the nature of each form of injury, but the operation, as performed on the bilateral, uncomplicated form of laceration, illustrates in the most perfect way the mech- anism and details of the operation. I will, therefore, describe the operation in this form of laceration, and give cases the histo- ries of which will illustrate the necessary modifications in the other forms. The operation is performed as follows : The patient is placed upon the left side, and a Sims's speculum introduced and held by a trained nurse or assistant. A tenaculum forceps, curved upon the flat side, is fixed in the anterior half of the cervix, at the point which makes the lip of the os externum. The posterior half of the cervix is seized in the same way with a similar forceps, and the operator, taking a forceps in each hand, brings the two flaps together, in order to see exactly where the parts are to be united. The forceps which holds the anterior flap is then given to an assistant, while the one attached to the posterior flap is held in the left hand of the operator, and the surfaces ai"e denuded by the hawk-bill scissors. Fig. IIP). The points of the scissors are made to seize the angle formed by the junction of the two flaps as far up as appears necessary to denude them. The flaps are brought together by the aid of the forceps on PLATE I. FIG. 117 PAGE 255. FIG. 120 PAGE 258. FIG. 121 PAGE 258. R.L. D.DEL riug tit witiiii The blades of tL ^^^^jjsijtte** '/•ic' .-^-Z'>*. \ "'^'S*^^ the sail pleted. d the most PLATE I. i )n ifi cmii- Operation.for Lacekation of the Cervix Uteri, sides "h"^ Figure 117. Page 355. i:>u iijK easily ' sci^jsons ,, uvPenudation complete. the iiniii ■ a!i'''^'> of thc^ 111' che op; -\\u\ . ■'"■ 1 " Figure 120. Page 258. ^ . ' , • , ■ 1 The sutures in position. tiuUti of til" ■■'■' ..---'■■I ■ .,v..... ,.M ', A, cmvince u. ^. .o-. t. ^^o Figure 121. Page 258. tissue can not be rt- 1 ti^o+ T . .,., .... ,1,,., ,ThQ sutures tied. ■^'vTi ire ii'ood ITT'- I ii:. ii7, colored plate, oi t^'- '■■• ■■- '• - 1 TL eunveiiU-ur ccuratei i\ \ 4 ■< fl t 1 .•an be made to ans^v he shape ;;^ '' ^ " ''e shown iv. c needli ■^'on \vi;ii lion of ' is used tor this Tlir : thof.' .1 ,>.,.., m3TU xiyaaD an'i lJ aoq yionAaaiO >, silT LACERATIONS OP THE CERVIX UTERI. 255 each side, so as to bring the tissues more within the grasp of the scissors. The blades of the scissors are then closed, and a strip is removed from above downward on each flap. The other side is treated in Fig. 116. — Hawk-bill scissors. the same way, and the most important part of the denudation is com- pleted. It frequently happens that a portion of the tissue to be so removed escapes from the scissors at the lower portion of the flaps on one or both sides ; but when this happens, the denudation is easily completed with the ordinary curved scissors. If the curved scissors only are used, much difficulty is experienced in vivifying the upper angles of the laceration, but with the hawk-bill scissors this portion of the operation can be accomplished accurately and with facility. The hawk-bill scissors, while saving time and trouble, give smoother surfaces for coaptation than can be otherwise ob- tained. A faithful trial of both methods by myself, and observa- tions of the old method as practiced by the most expert surgeons convince me of this fact. It has been said that all the cicatricial tissue can not be removed with the hawk- bill scissors. In regard to that, I can say that I have always succeeded in removing all that was necessary to secure good union and satisfactory ultimate results. Fig. 117, colored plate, shows the two denuded surfaces on each side of the laceration and the strip of the mucous membrane between. The needles used are triangular and pointed. Three lengths are convenient to have, but the medium one can be made to answer for all. The shape and length of these are shown in Fig. IIS. The needle-forceps described in connection with the operation for restoration of the pelvic floor is used for this operation. The sutures are introduced in the following mannei : The nee- dle is placed in that groove of the Fig. 118.— Triangular needles. needle - forceps which will give 256 DISEASES OP WOMEN. the desired angle, and is held immovable there, while the operator grasps the handle and closes the catch. The needle is then passed into the tissue, and left there while the forceps is unclasped and reversed. Its other end is then used to grasp the point of the needle and draw it through. The iirst two sutures are introduced at the lower end of the tiaps, at points corresponding to the sides of the OS internum. In some cases, when the parts do not come together easily, it is M'ell to introduce first a suture on each side at the upper end of the wound, and then the two lower ones. While introducing the first two sutures the parts are held by the tenaculum forceps, which were used during denudation. As each suture is introduced, the ends are united by passing one around the other in a loop-knot. This keeps the sutures from being tangled. The tenaculum forceps is then removed, and, while an assistant steadies the ceiwix by holding the ends of the first sutures, the others are introduced, a tenaculum being used to make counter-pressure while the needle is passed. The sutures are tied as follows : One or two turns of the ends are made to form the first half of the knot, the assistant takes hold of one end, the other is passed through the loop of a counter-pressure instrument, and then seized by the left hand of the operator. Trac- tion is then made on both ends of the suture, and, at the same time, the loop of the instrument is pushed down along the thread to make the knot slip to its destination. Repeating this manceuvre completes the knot. The instrument used is about the size and shape of an ordinary Sims's tenaculum, but, in place of having a hook-^^oint, it terminates in a ring (Fig. 119). G.TIEMANN hCO. Fig. 119. — Ring-tenaculum or counter-pressure instrument. By this method the sutures can be tied about as easily and rap- idly in the cavity of the vagina as upon a free surface. The ends of the sutures are then cut off, and a small tampon of well-dressed fiax, saturated with pine tar (marine lint), is carefully packed in, first around the cervix, and then below it. This tampon makes a good antiseptic dressing. It promptly absorbs serous oozing, and pre- vents any motion of the uterus which might strain the sutures. At tlie end of forty-eight hours it sliould be removed, and, if the parts are then in a healthy condition, no further local treatment is required. If there is any suppuration, a fresh tampon should be introduced, and allowed to remain for forty-eight hours longer. From my experience in a large number of cases, I am satisfied LACERATIONS OP THE CERVIX UTERI. 257 that the use of the tampon is a reliable after treatment in this opera- tion, and is preferable to the daily injection of carbolized water, which so many employ. The patient should rest in bed, with the privilege of turning upon either side. The bowels and bladder should be evacuated upon the ])ed-pan. The sutures should be removed upon the eighth or ninth day. If union is imperfect, the lower ones may be left in for two weeks. The simplicity of the after treatment is its chief merit. Keep- ing the patient perfectly still in bed is a great punishment to one in good general health, and tends to prevent union ; hence, giving the patient the j)rivilege of tossing about on the bed is a great com- fort. I am inclined to think that I could give the patient liberty to get out of bed to evacuate the bowels and urinate, if the tampon was employed continuously. As bearing on this point I may refer to the case that I operated upon in my office, and sent home in the street-cars. She made a perfect recovery. Another case shows what can be done with impunity. A patient of Dr. George W. Baker's, a, very strong, active lady, was operated upon for a bilateral lacera- tion in the usual way. She refused to stay in bed, but rested on the sofa, and visited the water-closet when necessary. Her menses came on prematurely and profusely. A large coagulum formed in the vagina and was passed while straining in the water-closet, ^ot the shghtest hope of success was entertained, bat on removing the sutures the results were found satisfactory in every way. These cases convinced me that the absolute quietude usually insisted ujDon is not necessary, and hence since then I have given more liberty of action. Much discomfort is avoided in this way, and the patient gets up better and stronger. ILLUSTRATIVE CASES. Typical Case of Bilateral Uncomplicated Laceration of the Cervix "Uteri. — The patient was twenty-four years of age, and had her lirst child fourteen months before she was first examined. Her general health was fairly good, but she had backache and profuse leucor- rhoja. Walking or standing gave her pelvic tenesmus, and she was more easily fatigued than in former years. She began to menstruate ten months after her confinement, and gave up nursing her child when it was a year old. The menses were normal, but more free than formerly, and lasted a day longer. She was sterile. Physical examination showed that the uterus was a little larger than it usually is in a person of her size. The cervical mucous membrane was 18 258 DISEASES OP WOMEN. hyperaemic, and denuded of epithelium in certain places. There was a profuse leucorrhcea. The cervical canal was cleared of the leucorrhcEal discharge, and an application of equal parts of tincture of iodine and carbolic acid was made. This was repeated at the end of a week and after the succeeding menstruation. The cervix was restored in the way al- ready described without using an anaesthetic. Figs. 120 and 121, colored plate, show the cervix with the sutures in position. A marme-lint tampon was used and kept in position for forty-eight hours. No after-treatment was needed. The sutures were removed on the tenth day, and the union was complete. The patient was kept in bed two weeks in all, and during that time was given a good, generous diet, and her bowels were moved daily. She had no pain during her rest in bed, and, although weak when she first tried to walk, she soon regained her strength. After the re- moval of the sutures a vaginal douche of borax and water was used up to the time of the next menstrual period. Three months after the operation she was free from all her former symptoms. The cervix then appeared like that of an imparous uterus. Bilateral Laceration complicated with Enlargement of the Cervix from Hyperplasia. — This patient had her only child when she was twenty-six years old. Her labor was tedious, but otherwise normal. From the time of her confinement until I first saw her, four years afterward, she had not been well. She suffered from backache, pel- vic tenesmus, and profuse leucorrhoea. Her general health, which was formerly very good, became impaired. The appearance of the cervix when first seen is shown by Fig. 110. It was impossible to bring together the edges of the os exter- num, owing to the enlargement of the halves of the cervix. Con- stitutional treatment was employed, and the hot-water douche and tincture of iodine used locally, but at the end of two months there was only a slight improvement in the condition of the cervix. A pre- liminary operation was then performed as follows : A crescentic- shaped piece of tissue was removed from the inner side of each half of the cervix sufiiciently deep to permit the halves to be brought together with very little traction. Fig. 122 shows the por- tions removed ; the dark lines indicate the lines of incision. Two sutures, one on each side of the os externum, were introduced to hold the parts together while healing was going on. Figs. 123 and 124 show the parts brought together with the sutures, and Figs. 125 and 126 show a different method of doing the same operation. Before tying the sutures a piece of muslin saturated with wax was LACERATIONS OF THE CERVIX UTERI. 259 placed between the halves of the cervix, and left there for four days to keep the coaptated parts from meeting. The sutures were Fig. 122. Fig. 123. Fig. 124. Fig. 125 Fig. 126. Figs. 125 and 126. — Another method of closing the gap. Fig. 122. — Removal of crescentic shaped piece (seen in section) when the everted lips are thickened. Figs. 123 and 124. — Method of bringing the sides of the sections together. removed at the end of two weeks, when it was found that the parts where the exsections were made had nearly healed over. Three weeks afterward the cervix was restored in the usual way, and good union was obtained, and the patient subsequently recovered. In cases like this I have sometimes removed the re- dundant tissue of the cer- vix at the time of perform- ing the final operation for the restoration of the cervix. Wlien this is done, it is necessary to keep a plug in the cervical canal during the healing process in order to prevent the vivified portions from uniting. I much prefer to do the preliminary operation, believing that I can get better results by so doing. Laceration of. the Posterior "Wall of tlie Cervix TJteri, complicated with Ealargement of the Cervix and Cystic Degeneration of the Mucous Membrane. — The patient was first seen when thu'ty-foiu' years of age, and had been married thirteen years. The injuiy of the cervix oc- curred twelve years before, when she had her only child. She got up from her confinement with leucorrhoea, backache, and pelvic tenesmus, and continued to suffer from these for about one year, when, becoming tired of being told that her pelvic symptoms would disappear when she gained her strength, she consulted another phy- sician. Local treatment was then employed with benefit, but it proved to be temporary. The leucorrhoea and other svmptoms re- turned in an aggravated form. She continued in this way. getting a little temporary relief from treatment and again going uncared for- 260 DISEASES OF WOMEN. up to the time that she came under my care. For three months she was treated for cystic degeneration, catarrh, and hypertrophy of the cervix. The latter appeared to be due to imperfect involution and hyperplasia combined. The laceration extended up to the vagi- nal junction, and there were erosion and eversion, but not to any great extent. In restoring the cervix, its sides were seized with the tenaculum forceps, and the upper angle of the laceration vivilied with the hawk-bill scissors. The denudation was carried down- ward to the OS externum with the curved scissors. The introduc- tion of the sutures and the after-treatment were conducted as usual. The union was satisfactory in every way. There was no return of the former symptoms, and she was classed among the suc- cessful cases, although she remained sterile without any apparent cause for it. Multiple Laceration of the Cervix. — A large, muscular lady had her first child when she was twenty-six years old. Her labor was tedious, the membranes rupturing before the cervix was fully dilated. Man- ual dilatation was resorted to, and the forceps used to deliver before the bead had fully descended into the pelvis. This much of the history was obtained from the physician who attended her in confine- ment. Four years subsequently I first examined her and found a multiple laceration of the cervix. The irregular nodulated state of the cervix and its density to the touch suggested the thought that there might be malignant disease present. This suspicion was still further aroused by a speculum examination, which revealed a profuse leucoiThoea and a rough, vascular, papillomatous state of the mucous membrane. The fact that the parts improved promptly on treat- ment settled the diagnosis. The cervix was divided into three un- equal parts (Fig. 112). For two months she was treated for the in- flammation of the cervix, and at the end of that time the laceration of the posterior wall was operated upon in the usual way. It was not necessary to anaesthetize the patient, as the operation required only a short time and was not very painful. She was kept in bed for a week, and good union was obtained. This left the patient with a simple bilateral laceration, which was successfully operated upon five weeks afterward. Multiple Laceration incomplete, complicated with Endometritis Poly- posa. — The patient was thirty -seven years old, married seventeen years, and had borne three children, the youngest of whom was two years of age. It was impossible to ascertain when the cervix was injured. The history showed that her health l>egan to fail after the birth of her second child, and that she broke down completely after LACERATIONS OF THE CERVIX UTERI. 261 her third one was born. When she came under my observation she had menorrhagia, a poor appetite, and constipation. She was ema- ciated, very ansemic, irritable, sleepless, and suffered much from headaches — in short, was perfectly useless, and a great sufferer. She had free leucorrhoea, backache, and ovarian pain, which was at times quite annoying. The physical signs indicated that there was a polypoid state of the endometrium. There were four lacerations of the cervix. Two lateral, the largest, and one in the anterior wall and another in the posterior wall These latter might be called fissures. They did not extend through the whole of the middle coat of tlie cervix. The lateral lacerations were complete, involving the entire wall of the cervix for about a quarter of an inch below and were incom- plete above. The fungosities of the endometrium were removed with the curette. This relieved the menorrhagia and improved the general health of the patient to some extent. The restoration of the cervix was effected by operating upon the lateral lacerations in the prescribed way, i. e., first making complete lacerations of them, and then vivifying the parts and closing them with sutures. The antero-posterior lacerations or fissures were treated by vivifying their sides as well as could be done before closing the lateral ones. When the sutures were tightened in the lateral lacerations it was found that the traction appeared to hold the antero-posterior lacerations together. The result proved that such was the case. There was good union, and the patient gained in strength rapidly and was quite well at the end of three months. Typical Case of Bilateral Incomplete Laceration of the Cervix Uteri. — The patient, a lady of excellent physique, married at thirty- one years of age, and had her first child three years later. Her labor was tedious in the first stage, but her recovery was without any marked interruption. When her child was twenty months old she became pregnant again, and miscarried at the third month. Six months after her miscarriage she was first examined. She then suffered from menorrhagia, pelvic tenesmus, and profuse leucor- rhoea, which caused some general depression — but not to any great extent. The utenis was retroverted, and the cervical canal admitted the index-finger nearly to the internal os. The uterus was a little larger than normal, and its mucous membrane congested and irrega- lar to the touch of the sound. The uterus was restored to its position and retained there with a pessary. The canal of the cervix was touched with tincture of iodine. This gave her relief from tenesmus, but did not control \ 262 DISEASES OF WOMEN. tlie menorrliagia nor the leiicorrh(ea. Subsequently the cavity of the uterus was curetted, and carbolic acid and iodine were apj^lied to the canal of tlie cervix. From this time on the menses were nor- mal, but the leucorrhoea returned again and again. Treatment would arrest it for a time, but it returned, and she proved to be ster- ile, Eestoration of the cervix was proposed in the hoj)e that the operation would give her permanent relief. The operation was performed as follows : Taking hold of the anterior and postei'ior walls of the cervix with the tenaculum for- ceps, a straight scissors was passed into the cervix half its entire length, and the mucous membrane of the vagina (the pcjrtion of the cervical wall which escaped laceration) was divided. The other side was treated in the same way. The halves of the cervix were drawn apart, so that the extent of the internal laceration could be clearly seen, and then the angle on each side was vivified with the hawk- bill scissors. After this there still remained a little redundant vagi- nal mucous membrane at the lower portion of the cervix, and Ije- tween the vaginal and cervical mucous membrane the site of the laceration, the muscular walls remained modified. The redundant vaginal membrane was removed and the middle walls of the cer^ax were vivified with the curved scissors. This modification of the method of vivifying the parts to be united became necessary because of the lacerations being incomj^lete. In some cases of incomplete laceration when the cervix is large, it is best to divide the vaginal mucous membrane first. By using the hawk-bill scissors a V-shaped piece can be taken out on each side which completes the vivifying with a single clip of the scissors on each side. The sutures were introduced and the operation com])leted in the usual way. The case progressed favorably, union was complete, and there has been no return of the leucorrhoea nor any of her for- mer symptoms. Incomplete Laceration with Hypertrophy of the Anterior Half of the Cervix. — The ]iatient had suffered from a profuse leucorrhoea since the birth of her child five years before, ^he had been treated oc- casionally, and derived only temporary relief, the symptoms return- ing again when treatment was suspended. The enlargement of the anterior half of the cervix was confined mostly to the mucous mem- brane. This gave a crescentic appearance to the os exteriuim (Fig. 115). The treatment consisted of exsection of the hypertrophied portion of the mucous meml)rane in the antei'ior wall, and when the ])arts had healed the laceration was operated on in the same LACERATIONS OF THE CERVIX UTERI. 203 manner as in the case of incomplete laceration preceding this ■one. The exsection was made by seizing the part to be removed with A tissue forceps, and with a sHghtly-curved scissors, clipping oft: the whole of the mucous membrane on that side up as high as the hy- pertrophy extended. There was some bleeding, but that was very ■easily controlled by packing the cervical canal with cotton, and using a vaginal tampon to keep it there. The Results of the Surgical Treatment of Lacerations of the Cervix Uteri. — There are some points that remain to be settled by reliable ■observations regarding the results of the surgical treatment of these injurieSo More statistics by reliable observers are needed to deter- mine definitely all the benefits which may be reasonably expected from this form of treatment. It may be fairly claimed that successful restoration of the cervix -will relieve the inflammatory troubles of the cervix, including the -suffering from scar tissue in the great majority of cases. Sterility due to the injury of the cervix and the consequent le- gions is cured in many cases. Labor is not, as a rule, retarded by the condition of the cervix ^fter the operation. Kor does laceration necessarily occur again. I have been able to compare the dilatability of the cervix after "tracheiorraphy with that of lacerated cervix with scar tissue, and I have found that the results are greatly in favor of those patients in -whom the cervix has been restored. CHAPTER XV. CICATRICES OF THE CERVIX UTERI AND VAGINA. Cicatrices, the results or products of diseased action aud inju- ries, are of pathological importance according to their size and loca- tion. They derange the conditions of health and comfort by the tender and painful character of scar tissue, and by its inelasticity, which interferes with the free motion of the pelvic organs. The slow, persistent contraction of this abnormal tissue, by which the adjacent normal parts are united, causes pain by making pressure on the terminal nerve-libers. Tenderness, also a characteristic of scar tissue, is developed in the same way, or perhaps from the excessive irritability or imperfect protection of the nerves found in cicatrices. This tenderness is most marked in scars at or near the introitus vaginae, and varies according to the age of the new tissue. When an uninterrupted cicatrix surrounds the cervical canal, the os ex- ternum, or the vagina at any point, stenosis is produced, and all the derangements consequent thereon, according to the partial or com- plete development of the stricture. Causation. — The causes which lead to the formation of cicatrices are familiar to all, and require only to be named in order to I'ccall them for present consideration : Injuries during parturition suffi- cient to cause sloughing or loss of tissue ; lacerations which heal over without uniting the divided parts, or which are united by interven- ing new tissue ; amputation of the vaginal portion of the cervix ; exsection of a portion of the vagina, es])ecially where healing takes place by granulation ; destruction of the mucous membrane and sub- jacent structures by the free use of caustics, and extensive ulceration either simple or sjiecitic. These are the chief affections which give rise to the conditions now under consideration. Syraptoinatology. — The principal symptom developed by cica- trices is pain, which is often intermittent or remittent, and is usually increased by exercise. When the scar involves the circumference of 204 CICATRICES OF THE CERVIX UTERI AND VAGINA. 265 the cervix, and the caHber of the canal is reduced below the normal size, dysnienorrhoja occurs in some cases. When the vagina is ex- tensively involved, the functions of the bladder and rectum are occa- sionally deranged so as to give rise to frequent and difficult urination and painful defecation. This is due, doubtless, to the tenderness of the scar tissue and diminished mobility of the parts. For the same reason, coition is painful, and in some marked cases impossible. It will be observed that the same derangement of the sexual function occurs in vaginitis, vaginismus, and in that rare neurotic affection in which there is extreme hypersesthesia without any apparent change of structure or circulation to account for it. In short, any or all of the symptoms caused by cicatrices may arise from other pathological conditions, such as are found, for example, in conva- lescence from pelvic peritonitis or cellulitis. On that account the diagnosis must be based chiefly on the physical signs. Physical Signs. — These I may briefly mention. They are the presence of abnormal tissue, which is usually tender, always indu- rated, less elastic than healthy parts, and sometimes lighter in color, and having a smooth surface. Cicatrices of the vagina are easily detected ; those of the cervix are liable to be confounded with sclerosis and incipient malignant disease. The points of distinc- tion are the increase of tissue and abnormal vascularity found in the latter. Treatment. — Knowing the evils which cicatrices give rise to, the first duty of the practitioner is to guard against their formation. This can be accomplished to a great extent, I am sure, by observing certain lines of practice. Lacerations of the pelvic floor, occurring during natural or artificial delivery, should be immediately brought together by sutures, when it is possible to do so, in place of leaving them to heal as best they may, which is the usual practice. In many such cases the patient is anaesthetized when the injury is sustained, and, if the obstetrician has the requisite instruments at hand — as he ought to have — the operation of closing such wounds with sutures is practicable ; if such wounds can be made to heal without the inter- vention of much new tissue, the cicatrices are very unimportant com- pared with the large scars which are sometimes formed where healing takes place by granulation. In making these statements, I am aware that the ground taken may be questioned. In opposition to this practice, it may be said that such wounds often heal promptly without the aid of sutures, and even when sutures are employed there is no certainty that good union will take place. On the other hand, it can be fairly claimed 266 DISEASES OF WOMEN. that, if the edges of a lacerated wound are held together, the chances of their uniting are better than if left alone. Ev^en should healing take place by granulation, the sutures, preventing the wide separa- tion of the parts, will tend to lessen the size of the cicatrix. When there is so much to be gained by good union, and so much suffering entailed by bad, the use of sutures in such cases is surely good surgery. The formation of troublesome cicatrices following the use of caustics may be prevented by carefully circumscribing the space to which they are applied, and by avoiding their use to an extent suf- ficient to cause destruction of the deeper structures of the mucous membrane. When it is necessary to apply a caustic — say nitric acid — to the OS externum or cervical canal, a portion of the membrane should be left untouched if possible, so that the eschar, if one is formed, will not completely circumscribe the canal. By attention to these points cicati'ices may be prevented, or, if they follow, they will be less troublesome in character. In the treatment of cicatrices the chief indications are to relieve the pain and tenderness of the parts, prevent contractions, and, where deformities exist, to correct them. These requirements cr.n be most promptly and perfectly fulfilled by removing the whole of the cicatrix and bringing together the normal tissues, and obtain- ing as near immediate union as possible. But this radical treat- ment is only called for in rare cases, and is not always practicable, owing to the size, depth, and unfavorable location of the cica- trix. Exsection should not be undertaken in any case unless the scar is movable on the subjacent tissue. It is necessary to wait until this molulity is established, which usually occurs sooner or later. When the scar can not be removed altogether, contrac- tion should be guarded against by preventing it from shortening. In oblong cicatrices, contraction in width rarely gives trouble, while shortening causes deformity. This can often be prevented by dividing the scar at one or more points, and then putting the parts on the stretch by the tampon or pessary. The divided edges thus held apart are united by intervening new tissue, and the scar is lengthened, while the process of narrowing still continues. Some- times the contractility of the normal tissues is sufficient to draw the divided edges of the scar apart, so that incising the scar is all that is necessary. When a cicatrix surrounds the os externum it should l)e divided on two sides, tbe lateral being ]>ref(M'able in most cases; a tent of sea-tangle should then be introduced and worn during the process CICATRICES OF THE CERVIX UTERI AXD VAGINA. 267 of liealing. The tent slioulcl be short, so as not to enter the internal OS, and it can be held in position by a pessary by stitching it to the walls of the cervix. The frequent use of the sound or dilator will answer the same purpose. In the management of cicatrices of tlie vagina, very satisfactory results are obtained by the treatment proposed. After dividing the cicatrix, the parts are put upon the stretch by the glass dilator em- ployed by Sims and others in the treatment of atresia vaginse. I have also used for the same purpose elm-bark, made into a roll of the proper length and thickness and beaten until it is soft. It is then dipped in carbolized water and introduced like a pessary. This has the advantage of being agreeable to the tissues, and by expand- ing very slowly it causes distention, which is easily borne. By en- larging from day to day the size used, the vagina can be distended slowly and without pain. I am satisfied that this method of treatment has another advantage, which is, that by slow, continuous dilatation the normal portions of the vagina can be developed so as to compen- sate for the contraction of the cicatrix to a very considerable extent. When there is no marked deformity, and pain and tenderness are the only symptoms, great relief will often follow an incision of the cicatrix at a number of points. I have also been led to believe that softening of the scar and relief from pain were obtained by the frequent application of equal parts of tincture of opium, aconite, and iodine. A word might be said about complications, such as vaginitis, cervical endometritis, etc. They are to be treated in the usual way, of course. I need only add that, so far as my observations have ex- tended, it has been found that by relieving trouble caused by cica- trices, recovery from accompanying affections is facilitated. This is as might be expected. ILLUSTRATIVE CASES. Scar Tissue producing Stenosis of the Vagina. Primary Cause : Acute Inflammation during the Course of the Fever. — A lady, thirty years of age, large, well formed, and in general good health, men- struated first at fifteen vears of ao'e, and has continued to do so regularly and normally ever since. She has been married twelve years, and during that time coition has been impossible. Before marriage she had no symptoms of uterine disease, but soon after she developed uterine and vaginal leucorrhoea, which have continued in- termittently ever since. She has also suffered occasionally from backache and irregular pains in the pelvis. Examination by the 268 DISEASES OP WOMEN. touch revealed contraction of the whole vagina, so that the index- finger could w^ith difficulty be introduced, and at the upper portion there was a stricture through which the finger could not be passed. In a pocket beyond the stricture the cervix uteri was subsequently found. The stricture was due to scar tissue, which formed a circular band about a quarter of an inch wide. P^rom this ring, extending downward, there was another cicatrix which terminated at the re- mains of the hymen. There was subacute vaginitis, and the papillae of the mucous membrane were enlarged and exceedingly tender. The examination caused intolerable pain. At another time an anaes- thetic was given and the stricture divided. The uterus was then found to be normal in size and shape, but there was a little erosion about the os externum, and congestion of the cervical mucous mem- brane and hypersecretion. Nothing in the history of the case, nor in the local lesions, gave any clew to the cause of the trouble, but on re-examination it was found that when the patient was a child she had what was called typho-malarial fever followed by pelvic inflammation and the forma- tion of abscesses. From this much of the history obtained from the patient's mother, I presumed that the cicatrices of the vagina were the prod- ucts of the disease of her childhood. The treatment employed in this case was such as has been de- scribed, and marked improvement has followed. At the end of four months after beginning the treatment the vagina admitted Cusco's speculum ; the tenderness was reduced, but not wholly relieved. The patient went to the country for the summer, to return in October for further treatment, and finally recovered. Scar in the Vaginal Wall resulting from an Injury sustained during Labor. — I was called to see a lady two months after her con- finement with her first child. I learned that she had had a tedious labor and was delivered by forceps. She made a good recovery, ex- cept that when she undertook to stand or walk she suffered from sharp pains in the vagina and a feeling of dragging and weight, especially on the left side. On examination I found a recent cicatrix on the left side extend- ing from the lower portion of the labium majus up the vagina for about three inches. The scar, which was about half an inch in width, was quite tender to the touch, and in the center of it, here and there, a few granulations remained and bled on being roughly touched. The patient, although very healthy and strong, had not been able to go up or down stairs or leave the house for two months CICATRICES OF THE CERVIX UTERI AND VAGINA. 269 after her confinement, the time when I saw her. No otlier uterine or pelvic disease could be found. This case shows the trouble which wounds of the vagina, sus- tained during confinement, will cause, and it is reasonable to suppose that if the parts had been united by sutures at the time of injur}^ a more prompt recovery would have followed. Scar Tissue between the Posterior Wall of the Cervix Uteri and Vagina, caused by Former Treatment. — This lady was fifty years old and had passed the menopause several years. Her health had been very good during most of her life. She had some uterine inflamma- tion and leucorrhoea after the birth of her last child, and was treated with caustic applications which relieved the leucorrhcea. After this she began to have pelvic pain of a neuralgic character, which in- creased gradually. This pain was greatly aggravated by exercise. The effect of the local suffering and inability to take active exercise upon her nervous system was very marked. A vaginal examination by the touch detected a thin band of scar tissue extending from the posterior wall of the cervix to the vaginal wall. The scar was quite tender, and when touched with the probe or finger gave rise to the neuralgic pain from which she generally suf- fered. The patient was placed on the side, and a Sims's speculum introduced. The cervix was caught with a tenaculum and drawn forward. This put the scar tissue on the stretch and made it promi- nent. The whole scar tissue was removed with one sweep of the curved scissors, and the edges of the mucous membrane of the vagina were united with a few catgut sutures. The parts healed without delay, and all the local pain and general disturbances promptly subsided. The relief was so prompt, complete, and per- manent, that there can be no doubt about the scar tissue being the whole cause of the patient's suffering. This case is a fair sample of a class, now fortunately diminish- ing in number, in whom scars are produced by the use of caustics. The general practitioner using a Ferguson speculum and a swab in treating diseases of the cervix uteri, usually does very little to cure the disease, but much to destroy the tissue of the cervix and vagina. The swab, charged with a strong caustic solution and pushed up into the canal, is compressed so that the caustic runs down on the poste- rior wall of the cervix and vagina. While the diseased tissues get very little of the application, the normal tissues at that point are destroyed. This is often repeated, and results in forming scar tissue such as that presented in this case. Such results of treatment were often seen years ago, and at the present day they are far too common. 270 DISEASES OF WOMEN. A Band of Scar Tissue just within the Introitus Vaginae, and extending across from Side to Side of the Vagina, due to Forceps De- livery. — ^Tlie patient was undersized, but a strong, Liealtby lady. She was confined with her first child five months before I saw her. Her physician told me that the child was large in proportion to the mother, and that he was obliged to deliver with forceps while the head was high in the pelvis. In the delivery much damage was done to the cervix and vagina, but the pelvic floor was not torn. She recovered slowly from her labor, and continued to have a dis- charge, and pain mostly of a neuralgic character. I found a semicircular band of scar tissue running from the ramus of the pubes, high up and around the vagina to the opposite side. The scar was unyielding, so that the finger could only be introduced with difliculty into the vagina. It extended deep down below the mucous membrane of the vagina, and at the upper ends was fixed to the pubic bones. It appeared to me that in the original injury the whole of the vaginal wall, together with the bulbo-caver- nosus muscles and the anterior fibers of the levator-ani muscle, had been torn away from its attachments to the floor of the pelvis. I have never before nor since seen an injury exactly like this, and hence I do not know positively how it was produced, but pre- sume it occurred as I have stated. About half an inch from the median line of the posterior wall of the vagina the scar tissue was divided on each side. Traction backward was then made with a narrow-bladed Sims's speculum, which distended the vulva and at the same time brought the ends of the incisions, which were made parallel to the axis of the vagina, together. The sides of the incis- ions were held together with sutures. The immediate effect of this operation was to relieve, in a marked degree, the pains from which the patient had suifered. It also restoi'cd the dilatability of the vulva, so that the jiatient could resume her sexual duties when the incisions had healed. CHAPTER XVI. INVEESION OF THE IJTEEUS, Inversion may be defined as a turning inside out of the uterus, in which its walls descend into its cavity. The external surface be- comes the internal, and the fundus uteri, which should be highest in the pelvis, becomes lowest. There are several de- grees of inversion, varying from a mere depression of a portion of the uterus, to a complete inversion. In practice two degrees can be made out, and these can be easily comprehended by a reference to Figs. 127 and 128. In the first form there is a depression of one side or partial inversion ; the second form is a com- plete inversion. When the vagina is also inverted, the condition is known as inversion and prolapsus. This complication occurs as a rule in the puer- peral state only. In all cases of inversion, at least at the time when this accident occurs, enlargement and relaxation of the tissues of the uterus are found. This is particularly so in the puerperal state, when inversion oc- curs most frequently. Symptomatology. — The severity of the symptoms depends upon the extent of the inversion and the sudden- ness with which it occurs. Partial inversion, brought about gradually, may not cause sufi&- cient disturbance to attract attention. The symptoms of shock are present when the in- version occurs suddenly, as it does in the puer- peral state. The shock and pain are more marked, as a rule, when the inversion is accom- panied with prolapsus. In a few recorded cases, the shock alone proved fatal. Fig. 127.— Partial inversion (Thom- as). If there is great Fig. 128.— Complete version (Thomas). 272 DISEASES OF WOMEN. haemorrhage as well as shock, the patient is more likely to suc- cumb. Haemorrhage occurs when the inversion is incomplete as well as when complete, especially at the time when the accident takes place. Tlie presence of the uterus in the vagina causes disturbance of the bladder and rectum, by pressure. These are the symptoms which occur in acute inversion, and if the patient passes safely through this stage then the symptoms of chronic inversion aj^pear. In complete inversion after the uterus has fully contracted, the haemorrhage is not profuse, except at the menstrual periods, when there may be menorrhagia. This is generally a sero-sanguinolent discharge for the iirst week or even later, then the irritation may cause congestion, ulceration, and general inflammation of the vagina and mucous membrane of the uterus, and a consequent leucorrhoea and purulent discharge. If the uterus remain outside of the vagina it usually becomes dry from exposure to the air, but it also becomes abraded in places and finally ulceration occurs. Whether the uterus remain in the vagina or becomes completely prolapsed, the inflammation, ulcera- tion, haemorrhage, and the purulent discharge which arise there- from may break down the general health of the patient and the case terminate fatally. Throughout all this there is pelvic pain and tenesmus. Physical Signs. — The diagnosis (which is not by any means easy in all cases) depends largely upon the physical signs. These differ somewhat in recent cases and in those of long standing. When the inversion occurs after labor, the bimanual touch will reveal two very important facts. The uterus is not found in its position behind the pubes, but occupies the pelvic cavity, and can be outlined in the vagina. By moving the uterus between the two hands, the fundus and body will be found below in the true pelvis, while instead of the fundus being found above, a depres- sion in the uterus can be felt at the superior strait. If the vagi- nal touch alone is relied upon, the condition will be taken for the coming placenta. The placenta being attached to the uterus, as it usually is at this time, obscures the uterus, but upon trying to re- move it from the vagina by hooking down one of its edges with the finger, the solid uterus will be found above the placenta, the two being united, but easily separated. While this exploration and re- moval of the placenta — if it is present — are going on, the left hand is placed upon the abdomen, and the absence of the uterus above is INVERSION OP THE UTERUS. 273 observed, as already stated. Passing the linger above the mass in the vagina, in search of the walls of the cervix and the os uteri, a furrow is felt which shows that the walls of the vagina and uterus are continuous, and that there is no opening into the cavity of the uterus. These signs will suffice for any one who is familiar with the normal condition of the parts in labor, to make a diagnosis. In fact, there are only two things which could easily be mistaken for inversion, a fibrous tumor and the presenting membranes in a case of tmns. The latter could be made out by palpating the abdomen and finding the large uterus with the child, and the other, though less easily, could be detected by the presence of the uterus behind the pubes and the presence of the uterine canal which could be fol- lowed by the touch beyond the tumor. These physical signs should be sufficient to suggest the diagnosis, which can be confirmed by restoring the inversion. This is easily accomplished by any one familiar with obstetric manipulations. When there is complete prolapsus, as well as inver- sion, the diagnosis can be made by inspection. The form of the tumor, the appearance of its mucous membrane, the presence of the j)lacenta, or, in case that it has been detached, the irregular appearance of the placental site compared with the rest of the membrane, and the contractions of the uterus, which can be noticed while handling the parts, are quite sufficient to settle the diagnosis. In old cases, in which the uterus has become reduced to its origi- nal size by involution, the diagnosis is not so easy as in recent cases, and yet, by the aid of the sound and the bimanual touch, the diag- nosis can be made with certainty in the great majority of cases. By the touch the round tumor is found projecting into the va- gina, and the lips of the os externum can be distinguished surround- ing the tumor. The fornices can sometimes be made out also. In most of the cases that I have seen the cervix was thinned out so that its walls felt as if continuous with the vagina, and the fornices were also obliterated. In either condition the evidence is in favor of inversion, but when the cervix can be found the evidence is more valuable, especially if the finger can be passed up into the cervix between its walls and the body of the uterus. There the mucous membrane of the cervix can be felt reflected upon the tumor to the same extent all around. These signs can be made out by the vaginal touch. The biman- ual touch is still more satisfactory. By that method the uterus can be raised up in the pelvis by the finger or fingers of one hand in the 19 274 DISEASES OF WOMEN. vagina, while with the other hand a body with a depression in its center can be felt through the wall of the abdomen. In spare pa- tients with relaxed abdominal muscles the bimanual touch will usu- ally suffice to make the diagnosis quite positive. In doubtful cases the uterus may be drawn down with a tenacu- lum or pressed down by a hand upon the abdomen, while a rectal examination with the index-finger of the other hand is made. In this way the fingers of the two hands may be made to meet above the uterus, and at the same time the finger in the rectum may detect the cup-shaped end of the uterus above. In case the bimanual touch is not practicable, owing to the patient being very stout, or the abdominal muscles unyielding, the same signs can be obtained by passing a sound into the bladder and turning it backward until it meets the finger in the rectum above the uterus. To facilitate either or both of these methods of examination by the touch, the uterus may be drawn downward by a noose made of tape or rubber passed around the cervix, as recommended by Barnes. Chronic inversion is likely to be mistaken for fibrous polypus of the uterus. A number of mis- ^^)- takes of this kind are on record, but most of them occurred before the time when the uterine sound and the bimanual touch were employed for diag- nostic purposes. The diiierentiation can usually be made by the methods of examination already de- scribed. In polypus, the uterine sound can be passed be- yond the tumor into the uterus above, whereas, in inversion, the progress of the sound is arrested at the neck of the uterus. The bimanual touch, rec- tal touch, and vesico-rectal examination, reveal tlie uterus above the tumor. The inverted uterus is tender, the polypus is not. This sign is of much value. By seizing the tumor and turning it around it will move in the cervix if it is a polypus. The two surfaces will glide backward and forward upon each other, Init in inversion no such motion can be produced. Incomplete inversion is not easily diag- nosticated under the most favorable circumstances. To distinguish partial inversion from an intra-uterine fibroid of small size is next to Fig. 129.— Polypus siraulating partial inversion (Thom- FiG. 130.— I'ohpus simulating com- plete inversion (Thomas). INVERSION OF THE UTERUS. 275 impossible. Fortunately, sucli a diagnosis is not imperative, because active treatment is not often called for in these incomplete and doubtful cases. Prognosis. — Inversion is always a grave condition. If it does not prove fatal at first from shock and haemorrhage, it becomes a continuous trouble, which either gradually undermines the general health, and thereby shortens life, or else keeps the subject in a state of impaired usefulness and ill health. There is no certain tendency to natural recovery, and although quite a number of cases have been recorded in which spontaneous replacement of the uterus was said to have taken place, such an occurrence must be very rare. From the fact that most of these cases are recorded by the older authors, it is possible that in some of them the diagnosis was incorrect. One thing is certain, no such fortunate termination should be exj^ected or rehed upon. Without treatment the condition wiU probably continue. The prognosis is rendered more grave by the fact that the treatment is not without danger. There are several methods of treating inversion, but neither of them is wholly safe. This statement applies to chronic inversion. When the inversion occurs during labor, immediate replacement is easy and not attended with any great risk. The dangers in restor- ing an old inversion are from inflammation and septicsemia, pro- duced by the injuries to the uterus, vagina, and adjoining parts during the violent efforts necessary to accomphsh the object. These dangers are greatly increased hj unskillful operating, still unfortunate results have occurred in the practice of the most skillful surgeons. Causation. — The conditions which predispose to inversion are enlargement of the uterus and relaxation of its tissues. These are best illustrated in the puerperal state. Inversion can not take place in a normal non-puerperal uterus. The condition of the uterus im- mediately after the delivery of the child is most favorable to the accident, and it is at this time and under these circumstances that inversion most frequently occurs. Predisposing causes, other than pregnancy or parturition, are known, but they are oj)erative in bringing about a condition of en- largement of the uterus and relaxation of its tissues. These are distention of the uterus from tumors or fluids. The relaxation of tissues which is found in imperfect involution and prolapsus is also given as a predisposing cause, but I have not seen the record of any case which could be clearly traced to this cause. To briefly restate this matter, the tendencies to inversion depend upon enlargement, distention, and relaxation. The exciting causes 276 DISEASES OF WOMEN. are traction or pressure upon tlie fundus uteri when it is in a con- dition favorable to inversion. The direct causes are traction upon the umbilical cord or pressure upon the fundus uteri at the moment when the child is expelled, or sudden delivery of the child, either by traction or the natural muscular efforts. Muscular efforts, when there is relaxation of the uterus, are mentioned as a cause, and cases are recorded in which inversion is said to have occurred in that way, but that cause must be seldom operative. Prolapsus uteri is also credited with having some causative relation to inversion, but I liave no knowledge on this subject. Next to parturition come intra- uterine tumors in the causation of inversion. All the cases which have come directly under my own observation, or that have come to my knowledge indirectly through competent contemporary authori- ties, have been clearly traceable to parturition or fibrous polypi. The conditions are alike in pregnancy and intra-uterine tumors, so far as the uterus is concerned in the predisposition to inversion. There is enlargement of the uterus with relaxation followed by muscular contraction. During the growth of the tumor the uterus increases in size, and finally endeavors to expel the growth, and when the muscular contractions are going on the fundus uteri is dragged downward by the pedicle of the tumor. In this way all the predisposing and mechanical conditions are j^resent which are most competent to cause inversion. Treatment. — There are several methods of managing inversion. Of course the indications are to restore the uterus to its proper rela- tions. This is often difiicult in chronic inversion, and sometimes impossible, hence other means must be employed to give all relief possible. In case replacement can not be accomplished, the most promi- nent symptoms should be relieved by treatment ; hiemorrhage should be controlled by astringents and inflammation should be reduced by appropriate care. Inversion can be successfully treated if seen im- mediately after it occurs. The method of operating is to grasp the uterus in the right hand, and carry it upward until the cervix can be felt with the left hand through the abdominal wall ; counter- pressure is then made while the fundus uteri is being forced upward with the right hand in the vagina. The abdominal walls being thor- oughly relaxed, as they are immediately after confinement, the bi- manual manipulations are comparatively easy. The os uteri can be felt with the left hand, and by pressing the abdominal wall down into it with the fingers it is dilated, and when the fundus is restored far enough to engage in the os, the lips of the cervix can be pushed INVERSION OF THE UTERUS. 277 over the fundus, in the same way that they are pushed over the head of the child in delivery. Cases of Recent Inversion. — I have seen four cases of inversion soon after they occurred, one in my own practice and three in con- sultation. Two of these were inversion with complete prolapsus, and the other two were uncomplicated. My own case was that of a strong young woman in her second confinement. The pelvic outlet was rather narrow, and the perineeum rigid, so that the pains which ex- pelled the head were most powerful, especially the last one. The moment that the head passed the perinseum the whole child was expelled with extraordinary force. While the nurse rested her hand upon the abdomen I tied the cord, and then I found the placenta presenting at the vulva. I passed my finger up to bring the edge down and then deliver it, but I found a hard body above to which it was attached. I then passed my left hand over the abdomen, and found that the uterus was not there. Inversion was suspected, and I at once separated and removed the placenta, which was very easily done in this case, and then with bimanual manipulation restored the uterus with the greatest facility. The removal of the placenta and the reduction of the uterus occupied but a moment. The patient did not apparently suffer, but I think that there was slight shock and consequent anaesthesia, so that the reduction was painless and finished before she reacted. I found I could grasp the fundus easily, and by making firm press- ure upon one comer with my thumb and upon the other with the middle finger, and thus raising the whole uterus up until I could feel the OS with the fingers of the left hand, the pressure and counter- pressure effected the reduction with ease and rapidity. I found that the reduction of one horn first, as recommended by Dr. Noeggerath, answered well, first because the horn was more easily brought under pressure, and also because it appeared to yield most readily. In grasping the uterus the thumb naturally rests upon one horn, and by making firm pressure at that part, which is more convenient than to press upon the center of the fmidus, it appears to be the natural way of effecting reduction by the unaided hand. The hand was made to follow up the reduction, so that when it was completed the hand was fully within the utenis, and it was left there, and pressure upon the uterus with the left hand upon the abdomen was made until the uterus contracted and the hand was expelled. This was the part of the procedm-e which required the most time, owing to the uterus being slow to contract. 278 DISEASES OF WOMEN. The three other cases were seen in the practice of others. One that I saw with Dr. A. R. Matheson, was a complete prolapsus as well as inversion. I saw the patient in about half an hour after the inversion occurred. There was considerable shock, and the doctor was obliged to liold the uterus with the placenta attached in the firm grasp of both hands to prevent hsemorrhage. The prolapsus was reduced first and then the inversion, in the same waj and in about the same time as the case just described. I saw another case of in- version and prolapsus with Dr. Bliss. It was of three days' stand- ing. The doctor did not attend in confinement, but was called to see the j)atient because of the inversion. When I saw her she was exceedingly weak. The pulse 140, and feeble. She was anaemic, and the abdomen greatly distended and tender to the touch. The uterus was resting between the limbs, and parts of the mucous mem- brane here and there were in a sloughing condition, and other por- tions were dry and glazed looking. Vaseline was applied over the whole surface, and the uterus first pushed up into the vagina and then grasped with the hand, and the inversion reduced. The opera- tion in this case was more difiicult and prolonged. Owing to the tympanitic state of the abdomen it was difiicult to make proper pressure upon the lips of the cervix, and that was a cause of delay. The extreme depression of the patient (while it raised a doubt as to her being able to stand the operation of reduction) gave that com- plete relaxation and general anaesthesia which was favorable. No anaesthetic was given. In about ten minutes the reduction was effected. The patient recovered. One other case I saw with Dr. Bodkin. The inversion occurred at two o'clock, and three hours later it was reduced. There was some excitement of the pulse, and the patient had pelvic ])ain. There was very little haemorrhage, but there had been considerable at the confinement. Chloroform was administered, and the reduc- tion was accomplished by the same method. More time was required than in either of the other cases, because there was more contraction of the uterus, but by means of upward pressure and counter-pressure upon the lips of the cervix the reduction was accomplished in a short time. Chronic inversion is far more difficult to manage than recent in- version. In fact, when the inversion has existed long enough to permit the uterus to regain its original size, or nearly so, by involu- tion, and has contracted firmly, its reduction is always difficult, and sometimes impossible. This has led surgeons to devise several methods of reducing this inversion under these circumstances. INVERSION OF THE UTERUS. 279 Dr. Thomas has classiiied tliese methods as follows : Methods of effecting gradual reduction and methods of effecting rapid reduc- tion. The method of reduction by taxis is the oldest and most re- liable, and should be tried first in all cases, because, if it fails, the gradual reduction may be tried subsequently, providing that the taxis is not so violent and prolonged as to cause fatal inflammation. There are several ways of applying taxis, but only two ways of attaining the desired end. The principle of the one is to reduce first that portion which was last inverted, and the other is to reduce the fundus first and dilate the cervix at the same time, so that the portion first inverted is first reduced. To some extent both objects may be attained at the same time by so manipulating that both changes of position may go on together. The method of operating is as follows : The patient should be placed upon the operating table in the dorsal position, and the surgeon's hand carefully in- troduced into the vagina. It is necessary to dilate the vagina, in the great majority of cases, in order to admit the hand. Some- times the dilatation is difiicult to accomj^lish with the hand without rupturing the vagina. When this is the case, dilatation as a pre- liminary measure should be accomplished by stretching with the speculum and the inflatable rubber bag. The right hand is introduced into the vagina and the uterus grasped with the thumb and fingers. The uterus is compressed and at the same time carried upward, and held against the left hand, which makes the counter-pressure. The manipulations with the right hand should be so directed that one or both horns should be reduced first. The cervix should be dilated, and reduction begun at that point at the same time that reduction of the horn is effected. Fortunately, the efforts to accomplish the one favor the other. This method of ]^oeggerath's, which has already been discussed, is that which I prefer, but there are certain modifications which are of value in certain cases, and should be employed when failure of the one method makes the trial of the modified methods necessary. For example, Dr. Thomas has employed a cone of wood in place of the left hand for dilating the cervix. In thin patients this can be inserted into the ring of the cervix, which can be felt through the abdominal walls, and gradually forced into the cervix until suflicient dilatation is obtained. Barren placed the fingers around the body of the uterus and the thumb upon the fundus, and forced the cervix against the sacrum to secure counter-pressure. Courty's method consists in using the index and middle fingei's of the left hand in the rectum, to dilate the cervix and make coun- 280 DISEASES OF WOMEN. ter-pressnre. This method of using the left hand combined with the method of Dr. Noeggerath is highly commended by Dr. T. G. Thomas. Dr. Emmet describes his method as follows : " In 1865 I succeeded in effecting a reduction by passing my hand into the va- gina, and, with the fingers and thumb encircling the portion of the body close to the seat of inversion, the fundus was allowed to rest in the palm of the hand. This portion of the body was firmly grasped, pushed upward, and the fingers were then immediately separated to their utmost ; at the same time the other hand was em- ployed over the abdomen in the attempt to roll out the part form- ing the ring, by sliding the abdominal parietes over its edge. This manoeuvre was repeated and continued. At length, as the trans- verse diameter of the uterine cervix and os was increased by lateral dilatation with the outspread fingers, the long diameter of the body became shortened, and the degree of inversion proportionately less- ened. After the body had advanced well within the cervix, steady upward pressure upon the fundus was applied by the tips of all the fingers brought together." This method, which appears to me like Yandel's, is natural in theory, but in trying it I have found that I could not separate the fingers to any extent, owing to the fact that the extensor muscles are feeble in their action, and not capable of doing more than resisting the pressiu'e of the vagina. Dr. Emmet also commends the closure of the cervix with silver sutures in cases where the reduction can not be completed. He gives a diagram representing the cervix as being about three times as long as the body, and drawn over the fundus and held there by sutures. I have never practiced this treatment for the reason that in all the cases in which I have been able to get the body and fun- dus reduced wholly within the cervix, the complete reduction has been easily and speedily accomplished. Again, I can not see how sutures of any kind would resist the pressure of a partially inverted uteras, w^th a strong tendency, which there always is, to become further inverted. Repositors have been used to aid in the taxis by De Paul, Avel- ing, White, and others. The most useful of these, and one that fulfills the requirements is that invented by Dr. John Byrne, of Brooklyn. It consists of a cup and stem with a movable plug or button in its center. The button forms the bottom of the cup when it is placed over the uterus, and while the cup is in place the plug is pushed forward by the screw in the handle against the fundus, and in that way makes the required upward pressure. INVERSION OF THE UTERUS. 281 Fig. 131. — Byrne's method of reduction. Fig. 131 shows Dr. Byrne's repositor as used, and its cup or bell-shaped instrument with the plug and screw adjustment for making counter - pressure and dilatation of the cervix. A piston in the lower cup pushes the fundus up. There are a number of ad- justable cups which can be adapted to the require- ments of different cases. Cases are sometimes met which can not be restored by taxis. Resort must then be had to such means as gradual reduction by con- tinuous pressure. This is effected by a cup and stem (Fig. 132) which are held in place by a perineal band of rubber or elastic fastened to a bandage applied around the pelvis. When using this instrument care must be taken to keep the uterus in the line of press- ure. When the va- gina is relaxed the uterus may fall backward or for- ward out of the line of pressure ; this can be avoided by using a tampon around the uterus, which may be worn for two days if no great distress is caused by it. It should be examined from time to time, and if there is much Fig. 1 32.— Cup pessary to exercise gradual pressure (Thomas) 282 DISEASES OF WOMEN. irritation the instrument should be remoyed and vaginal injections used until relief is obtained, and the use of the instrument may be again resumed. The rubber bag tilled with water answers a very good purpose. To apply this, the patient should be placed in Sims's position, and through the speculum, the upper portion of the space between the uterus and vagina should be tilled with prej^ared wool ; then the bag should be introduced between the fundus uteri and the pelvic floor, and distended with water. A firm perineal band is then used to support the pelvic floor. Dr. Thomas recommends a strip of adhe- sive plaster for the perineal band, one end being fastened to the sacrum and the other to the abdomen, with two openings, one for the tube of the bag, and the other opposite the urethra to permit urination. I prefer the ordinary muslin or elastic band, because it is more easily removed and readjusted. The degree of pressure and the time which it should be continued must depend upon the re- sults. If there is much pain or irritation the treatment must be sus- pended. The combination of elastic pressure and taxis has been employed with advantage. After the pressure has been used for a time taxis should be tried, and in case this fails the elastic pressure should be again attempted. Care must be exercised in the use of taxis — it should not be too violent or long-continued ; this must be de- cided by the operator in each case. Dr. Charles Martin, of France, succeeded by using a stream of odd water projected against the fundus uteri, through the speculum. This he employed twice a day. The stream was thrown wdth con- siderable force ; he also filled the speculum with cold water, and kept the uterus in it three or four minutes. Dr. T. G. Thomas, from whose work I take the above statement, approves of this method. Dr. Thomas has devised another method, wdiich I understand he employs or advises where other methods fail. The following is taken from his work on diseases of women : " Thomas's method consists in abdominal section over the cervical ring, dilatation Avith a steel instrument, made like a glove-stretcher, and reposition of the inverted uterus by any one of the methods mentioned, by the hand in the vagina. Fig. 133 will render this clear. " Tliis procedure, let it be remembered, is not offered as a method of treating inversion of the uterus, but as a substitute for amputa- tion. Few cases will, I think, resist elastic pressure and judicious taxis ; but that some will' do so can not be questioned. It is to INVERSION OF THE UTERUS. 283 save these few cases from amputation that I suggest abdominal section. " One of the cases operated on in this way has proved fatal. Let it not be forgotten that a certain number of these cases treated by elastic pressure and by taxis likewise do so, for, as in my second case, these operations are often performed upon exsanguinated women whose blood is impoverished. One instance of death after reduction by elastic pressure is recorded by Dr. Tait in the eleventh volume of the ' London Obstetrical Transactions,' while one of the earliest cases on record reduced by taxis — that of Dr. White, of Buffalo, likewise ended fatally." One other method is worthy of mention, name- ly, that of Dr. Brown, of Baltimore. He makes a free incision in the fun- dus uteri, and through the opening thus made he stretches the cervix and then reduces by taxis. In case of failure of all ef- forts, hysterectomy may be performed. This, I consider advisable, if the patient is near to or past the menopause, but it should not be un- dertaken until all other methods have failed. There are several methods of amputating the inverted uterus. Dr. McClintock applied a string ligature around the highest portion which strangulated the uterus, and in two or three days when de- composition of the tissues began, he amputated. Hegar accom- plished the same object by j)assing strong sutures through the cer- vix, and after drawing them tight enough to close the vessels and close the peritoneal cavity, the body was amputated. It will suffice to simply mention amputation without giving elab- orate details. It was frequently practiced in the past, but is sel- dom heard of now. Other methods succeed, and with the method of Thomas in reserve — in case pressure and taxis fail — amputation will seldom, if ever be called for. Cases might be quoted to illus- trate the treatment of chronic inversion, but they would add noth- ing of value to the methods of operating given above. Fig 133. — Replacement of uterus by dilatation through abdomen. (Thomas.) CHAPTER XVII. DISLOCATIONS OF THE UTEKUS. The uterus is peculiarly subject to pliysiological changes of position. The bladder in front causes the uterus to move forward and backward according to its dilatations and contractions. In a similar but much less extensive way, distention of the rectum acts to push the uterus forward. The abdominal pressure from above is constantly changing, and is, therefore, constantly affecting the posi- tion of the uterus less or more. The movements of the uterus under the influence of the ever varying degrees of abdominal press- ure are easily observed by watching the anterior vaginal w^all and uterus through a Sims's speculum in the living subject. There is an up and down motion, very limited but constant, caused by ordi- nary respiration, and under extra exertion, such as coughing, the displacement becomes very marked. Below there is the pelvic floor, which has least of all to do with changing the position of the utenis, and yet much to do in counter- acting the inclinations to displacement produced by other influ ences. These changes of position, when limited in degree, are physio- logical, the organ promptly returning to its original position as soon as the displacing influence is removed. It is only when the uterus remains displaced permanently or is carried. far beyond the physio- logical limits that the dislocation is to be regarded as pathological. When this occurs, the malposition gives rise to suffering from de- ranged menstruation, circulation, and innervation, and in some cases to sterility. Usually, the functions of the bladder and rectum are disturbed and the general system suffers from reflex influences. It is oftly when such symptoms as these are present that displacements of the uterus claim the attention of the gynecologist. In order to fully comprehend displacements of the uterus it is very necessary that the normal position of the uterus should be 284 DISLOCATIONS OF THE UTERUS. 285 clearly understood, and this can only be attained by a knowledge of the anatomy of the pelvic organs. Anatomy. — In discussing this subject attention will be chiefly directed to the position of the uterus in the pelvis, its relations to neighboring organs, and the position and character of the structures which keep it in position. One would naturally turn to the cadaver in the hope that by careful dissection the exact position of the uterus could be deter- mined, but after life is extinct the uterine supports lose their firm- ness, and changes of position usu- ally take place. Moreover, it fre- quently happens that the pelvic or- gans are less or more displaced toward the end of life, so that a normal state of the parts is not often found in the cadaver. Dis- section also tends to displacement, no matter how carefully it may be performed. To obviate this, sec- tions of the frozen subject have been made, and much valuable in- formation obtained from them. Still, the greater part of useful in- formation on this subject must be obtained from careful and oft-repeated examinations of the living subject. With information obtained from all these sources there are still diflierences of opinion among authors on certain points. Under the circumstances, in place of giving a number of conflict- ing opinions, it will be better to give the views which I have adopted as the result of my own observations on the living subject, and after a careful investigation of the views of others. In the first place, it may be said that the uterus is wholly within the true pelvis. The line on the diagram running between the symphysis pubis and the promontory of the sacrum divides the true pelvis from the abdomen, and all the pelvic organs, the uterus included, are below this plane, the superior strait, as the obstetricians call it (Fig. 64). The long diameter of the uterus in the pelvis corresponds very nearly to the axis of this plane, as represented by the line (Fig. 134), and it is equidistant from the sides of the pelvis. The position of the uterus varies from time to time, as already Fig. 134. — Section of pelvis, showing it inclination and the axis of the inlet. 286 DISEASES OF WOMEN. stated, but in all its changes it returns to the axis of the inlet of the pelvis, slightly behind the center of the true conjugate. This is not mathematicallv correct, but is sufficiently so to form a basis from which further studies, both anatomical and clinical, may be con- ducted. In order to obtain some idea of the position of the uterus and the influences which the other pelvic organs have in changing this posi- tion, reference should be made to Fig. 64, which shows a section of the normal pelvis. Fig. 135 shows the changes in the position of Fig. ] 35. — The normal range of the uterine axis, varying according to the distention of the bladder ; a, with bladder empty ; i), with bladder full (Van der Warker). the uterus during the several degrees of distention of the bladder. These physiological changes should be noted and the causes which give rise to them, in order that they may be recognized clinically. Next in the order of inquiry are the anatomical structures by which the uterus is held in position. This requires a consideration of the DISLOCATIONS OF THE UTERUS. 28T structural associations of the uterus and all the other pelvic organs and tissues. The position of the several pelvic organs may be given in a general way as follows : The uterus in the center, Fallo- pian tubes and ovaries on either side, the. bladder in front, rectum behind, and the vagina below. Covering all of these, except the vagina, is the peritonaeum, which is the chief bond of union be- tween the upper portions of the pelvic organs, and out of which are formed the ligaments which have much to do in keeping the uterus in place. The peritonaeum, while it covers the pelvic organs, is attached to the bony walls of the pelvis through the medium of the periosteum and areolar tissue, so that one end of each liga- ment may be said to have an attachment to the inner side of the pelvic bones. The round ligaments are anatomically an exception to this rule. They contain muscular tissue in considerable quan- FiG. 136. — Diagram of the uterine ligaments as seen on looking into the brim. B, bladder. tity, and are really outgrowths from the uterus in the form of round cords, which start from the uterus near the proximate ends of the Fallopian tubes, and sweeping round the outside of the pelvis, pass out through the inguinal rings into the labia majora. These ligaments, as well as all the others, can be seen by looking down upon the pelvic organs in situ. The uterus is seen in the middle of the pelvis, and extending across on either side of it are the two broad ligaments made up of the two folds of peritonreum, which unite after covering the uterus. Running backward from the uterus 288 DISEASES OF WOMEN. to the sacrum are those peritoneal folds known as the utero-sacral ligaments. Between the uterus and the bladder, on the sides of the latter, the folds of peritonaeum form the utero-vesical ligaments. These ligaments are so called not because they are composed of ligamentous tis- sue, but rather be- cause tliey perform a function similar to that of liga- ments. With the exception of the round ligaments which are com- posed of muscular tissue covered with peritonfeum, the others are made up of double folds of peritonaeum con- taining between these folds areolar tissue and some fibers of the pelvic fascia. An idea of the position of these ligaments and their relations to the uterus may be obtained from Fig. 136. I have noticed that, in the dissecting-room, gentlemen are not able at all times to find the utero-sacral and utero-vesical ligaments ; the broad and round ligaments they easily note. The others can be brought into view in the following manner: If the uterus be drawn well forward by a tenaculum, two tense bands will be seen, the utero- sacral ligaments, extending from the side of the uterus back to the sacrum, and as they are thus raised up a pouch of peritonaeum ap- pears between them. This is the sac of Douglas. By reversing this manipulation, and drawing the uterus backward, the utero-vesical ligaments will be seen running forward on either side of the bladder. The utero-vesical ligaments, in addition to their attachments to the uterus and bony walls of the pelvis, are also connected indirect- ly to the anterior vaginal wall by intervening areolar tissue. The Fig. 137. — Section through tlie right broad ligament showing its relation to the uterus, tube, ovary, round ligament, and the vessels in its base. DISLOCATIONS OP THE UTERUS. 289 utero-sacral are connected in the same indirect way with the upper portion of the posteiior va(:;inal wall, and also to the rectum, on tlie left side at least. At the junction of the supra-vaginal jjortion of the cervix and body of the uterus all the ligaments, except the round ones, are attached. Here also the anterior and posterior vaginal wall and a portion of the bladder join these other structures. The union of these structures at this point is not direct, but is through the in- tervention of areolar tissue which is found in considerable quantity in this reo-ion. From this it will be seen that these lio-aments are continuous from side to side, and also from befoi'e backward. The chief function of these ligaments, aided by the anterior vaginal wall, is to keep the uterus and bladder in position. This is clearly evident from the mechanical princi- ple apparent in the an- atomical arrangement of the parts in ques- tion, and from the fact that the uterus remains in place for a considerable time when the pelvic floor is defective, and the abdominal pressure more marked than nor- mal. In short, many cases have been seen clinically in which all the other means that Fig. 188 — Section of pelvis,with the antero-posterior slings <>nnld nossiblvcontrib- "^ ^he uterus; behind, the utero-sacral ligaments; in COUia pOSSlDiy COniriO ^^^^^^ ^^^ anterior vaginal wall (after a frozen section). ute to supporting the uterus were removed by disease and injuries, and yet the uterus was maintained in position under ordinary circumstances. The most rational idea of the means and ways by which the uterus is main- tained in the pelvis I obtained from the following statement by Dr. Frank P. Foster. Speaking of the supports of the uterus, he says : " Ordinarily, they consist wholly of the anterior wall of the vagina in front, and the utero-sacral ligaments behind, which together con- stitute what may be called a beam traversing the pelvis antero- posteriorly on wdiich the uterus rests, being interposed between them, firmly attached to the one anteriorly and to the other pos- 20 290 DISEASES OF WOMEN. teriorlj, making them, so far as mechanical effect is concerned, one structure.'' Tliis is a clear and comprehensive statement of the prin- ciples upon which the ntero-sacral ligaments and the anterior vaginal wall act in supporting tlie uterus. I would go one step further than Fin. 1S9. — Diagram of the uterus slung between the broad ligaments in the true pelvis. The round ligament, tube, and ovary are shown on one side only. Dr. Foster, however, and claim a like function for the other uterine ligaments. The hroad ligaments, firmly attached to the bony walls of the pelvis, and holding the uterus in their folds, make a continu- ous structure extending across the pelvis in its transverse diameter. These structures, taken together, act like '^ beams " or (to be more mechani{uilly accurate) cables of a suspension bridge, which support to a large extent the uterus in its center. The utero-vesical liga- ments also su])plement the anterior vaginal wall as a sup]')()rting medium. According to this view of the subject, the chief supports of the uterus are the anterior vaginal wall, utero-sacral, vesico-uterine, and I)road ligaments. Fig. 138 shows a section of the ])clvis with these ligaments and the anterior vaginal wall with the uterus resting upon them. Fig. 139 shows a ti'ansverse section of the ])clvis just in front of the uterus and broad ligaments, and represents these structures and the uianner in which they support the uterus. A similar func-tion may be claimed for the round ligaments, at least so far as their effect in preventing the backward displacement DISLOCATIONS OP THE UTERUS. 291 of the uterus. Some have chiiuied that the round ligaments have but Httle supportini^ power to sustain the uterus in place, while otliers give it much credit in this direction. Those who believe in Alexander's operation of shortening the round ligaments for the relief of retroversion of the uterus certainly claim great supporting- power for these ligaments, and with good reason, I think. Finally, I may add, that I believe that the ligaments, the vagina, and the other pelvic organs all aid in keeping the uterus in position, and are sufficient to do so under ordinary circumstances. Still, when extraordinary strain is brought to bear upon the pelvic organs, the pelvic floor supplements these supporting structures. Moreover, the relation of the trunk to the pelvis lias much to do, if not in keeping the pelvic organs in place, certainly in freeing them from pressure from ahove. The pelvis is so placed that, in the erect posture, its cavity is be- hind rather than beneath the abdo- men, and the abdominal muscles partially divide the greater cavity from the lesser. This is shown in Fig. 140, where the arrow indicates the direction of the force trans- mitted to the pelvis through pres- sure from above. There is very little direct ab- dominal pressure upon the pelvic organs in the erect posture. The axis of the pelvis is backward and downward, while that of the abdo- men is perpendicular, so that the pressure is indirect from above. Some claim that a suction power is exerted upon the pelvic con- tents by the diaphragm. It is said to act like a piston in the cylinder of a pump. There is reason to believe there is something in this ex- planation from the fact that, on examination through a Sims's specu- lum, the uterus is seen to rise and fall with respiration. This motion is to a large extent arrested when the patient is in the erect posture. If it is a fact, as it apjiears to be, that the abdominal organs are fixed by suspension in their normal position, and that in their descent during this limited motion the pressure upon the pelvic organs is indirect, then this relationship contributes to maintain the position of Fig. 140. — The normal inclination of the pelvis and the transmission of force from above. 292 DISEASES OF WOMEN. the pelvic organs as surely as if there were some traction or suction action of tlie diaphragm tending to draw these organs upward. In regard to the pelvic floor and its i-elations to the displacements of the uterus, that subject has been fully discussed under the head of injuries of the pelvic floor. It is only necessary to repeat my belief already expressed to the effect that, while the pelvic floor does not directly support the uterus, it indirectly aids in doing so, and if it is lost from injury prolapsus of the pelvic organs follows as a rule. DISPLACEMENTS OF THE UTERUS. There are a great many forms of displacement of the uterus, if every change of position of that organ be taken into account, but of those that occur as ])rimary affections there are only two that are often seen, and one that is very rare. These are downward, back- ward, and forward — that is, prolapsus, retroversion, and antever- sion. Prolapsus and retroversion are really the only forms of displace- ment which practically claim attention in this connection. These the gynecologist is called upon to treat daily as primary affections. Occasionally, a case of anteversion may be seen which apparently is not caused by some other affection more important than the conse- quent displacement, but this is exceedingly rare. Again the uterus may be anteverted to a considerable extent without causing the slightest trouble. This form of displacement (quite a rare one) is generally produced as a consequence of some other disease, either of the uterus itself or the organs and tissues around it, or else when it does occur it gives no trouble ; and, as a rule, very little can be done to relieve it by the ordinary methods of treating uncomplicated dis- placements. Taking all this into account, it is evident that the downward and backward displacements alone demand special atten- tion, either in practice or in the discussion of the subject. The other forms of displacement of the uterus, described in text- books, are the right and left lateral anteversions and retroversions. These displacements are always due either to some lesion of develop- ment or to some ]:)revious affection, the products of which either push or pull the uterus out of place. There is also a retrocessioK of the uterus and an antecession, which are not described in books. Perha])s better names for these would be transposition backward or forward. In these dislocations the uterus is found either behind or in front of the axis of the pelvic cavity, or superior strait. These, like the lateral dislocations, are secondary to some abnormal state DISLOCATIONS OF THE UTERUS. 293 which caused them, and hence they are to he looked upon as signs and consequences of tlie primary disease. By adopting this classification it simplifies the subject very much, and leaves one free to give attention to the downward and backward dislocations and their pathology, diagnosis, cansation, and treatment. Again, the two forms of displacement in question are the only conditions of malposition that can be directly treated with favorable results. In the other forms, such as lateral versions, treat- ment must be employed to remove the morbid states which push or pull the uterus out of place, and therefore, the discussion of such displacements should be confined to the diseases which cause them. PROLAPSUS OF THE UTERUS. This is a downward displacement of the uterus commonly called falling. It is of necessity always associated with. disjDlacement of the other pelvic organs and tissues, to a greater or less extent, according to the degree of descent of the uterus. There are several de- grees of prolapsus uteri which have been various ly described. While au- thors designate the most important stages of de- scent by degrees, it should be understood that practi- cally there is no line of demarkation between the degrees. According to this arrangement, when the uterus sinks so that the cervix rests entirely on the pelvic fioor, it is named prolapsus of the first degree ; when the uterine axis has be- come vertical or coincides with the axis of the outlet, the cervix ap- pearing at the vulva, the second degree is present ; while in the third degree the organ is partly or wholly outside the introitus. Fig. l-il shows the three degrees, and may convey a clearer idea than further description. Fig. 141. — The three degrees of prolapsus. The upper outline is a little above the normal position. 294 DISEASES OF WOMEK By some authorities all the degrees of prolapsus in which the uterus still remains within the vulva are termed incomplete, while those in which it protrudes partially or completely beyond the vulva are called complete. This latter arrangement of the subject is perhaps as easily com- j)rehended and as useful in practice as any other. The complete degree is often spoken of as procidentia. Pathology. — Prolapsus of the uterus takes place slowly, as a rule. Sudden prolapsus may possibly occur, but it nuist be a rare thing, ex- cept in the first degree. In the few cases that I have had an oppor- tunity of watching from beginning to completion, the displacement has been gradual. At first the uterus descended to the first degree of prolapsus, and then to the second, and finally to the third or com- plete stage. The time occupied in making the complete descent varies from months to years. The changes which take place in the supports of the uterus and the other pelvic organs during the pro- gressive development of the prolapsus are usually the same in all cases with few exceptions, but the order in which they a]>pear differs according to the cause of the descent. This again depends upon the point in the structures at wliicli the lesions l)egin to develop. There are three methods of development of prolapsus. In the first, the uterus begins to descend because it is too heavy and makes too great demands upon its innnediate supports, or else these supports become defective from pathological changes. This is a descent of the uterus from loss of direct support. The second order of descent is by loss of the pelvic floor, which permits the vagina, bladder, and part of the rectum to descend, and then the uterus follows. The third in order is made up of the two others, the first and the second, all the conditions mentioned in those being operative at the same time. The changes in the supports are elongation from imperfect in- volution after parturition, or stretching pi'oduced by enlargement of the uterus, or pressure on it from above by long standing, stoo])ing, or lifting. In the former condition the supports are too long ; in the latter they are attenuated as M'ell as elongated. In l)otli states the upper portion of the vagina is distended and the bladder slightly prolapsed or drawn backward. There is also, in some cases, loss of the areolar tissue, and the pelvic fascia has lost its strength of fiber. This traction upon the rectum, bladder, and the blood-vessels is pre- sumed to interrupt the return circulation. Whether that is a fact as regards the causation or not, there is usually a ])assive hypera'mia of the parts in these dis])lacenienis. These changes of the positior DISLOCATIONS OF THE UTERUS. 295 and relations of tliese parts are gradually developed. In case the prolapsus proceeds to the third degree, the pelvic lioor gives way under the influence of the continued pressure. The perineal mus- cles become overdistended and the vulva enlarged, until the uterus is permitted to protrude without resistance. In the second order of the development of prolapsus — that is, where the loss of the pelvic floor is the starting-point of the mal- position, the first lesions appear in the vagina. The walls of the vagina at the introitus begin to protrude and their descent is gener- ally attended with increase of tissue. Usually both w^alls prolapse together, but in many cases one or the other takes precedence. As the prolapsus progresses the bladder and anterior wall of the rectum descend, producing rectocele and cystocele. In due time the uterus follows with all the changes in its supports already described above. There are cases in which the prolapsus begins at the lower part of the vagina, while there is no apparent injury of the pelvic floor. This has been accounted for by imperfect involution of the vagina after child-bearing. The large, heavy, and lax walls of the vagina make undue pressure upon the pelvic floor and it gives way before them. A similar state of things occurs, so far as appearances are concerned, where there has been subcutaneous laceration of the mus- cles of the pelvic floor which impairs its function. Prolapsus of long standing changes the sti-uctnre of all the tissues. Atrophy of the muscular tissue of the vagina and pelvic floor occurs, and the ligaments of the uterus lose their character- istics so that they can not he restored to their original state by any means. There is a prolapsus which occurs as the result of degeneration of the supports of the uterus. It occurs in feeble old women in whom general nutrition is greatly impaired. The perinaeum and vagina lose their elasticity, the adipose and areolar tissue disappear, and the vaginal walls, bladder, and atrophied uterus descend. Such patients are also subject to prolapsus of the rectum and sometimes prolapsus of the mucous membrane of the urethra. I have called this senile prolapsus to distinguish it from the ordinary descent of the uterus which usually occurs in middle life. I believe it to be due to the general atrophy of the pelvic viscera because of the time of life when it occurs, and the fact that I have seen it in those who have not borne children. The first case that I carefully studied was in an old maiden of seventy years of age. Syinptomatology. — The natural history of prola])sus uteri as manifested by symptoms and physical signs, differs to some extent 296 DISEASES OF WOMEN. in different cases, though the pathological conditions appear to be the same in all. The suffering caused varies according to the general health and nervous sensitiveness of the subjects affected. What is more strange still, is the fact that incomplete prolapsus often causes more suffering than the more advanced stages. It is not an uncom- mon thing to see a patient with complete prolapsus of the uterus who complains less than another in whom the uterus is still within the pelvis. The symptoms indicative of prolapsus uteri maybe classed under two heads : First, the derangement of the functions of the other pelvic organs, and, second, the disordered nutrition of the tissues of the pelvic viscera generally. The dragging of the uterus upon the bladder and rectum, and the abnormal pressure cause irritation, which gives rise to rectal and vesical tenesmus. The constant desire to evacuate the rectum and bladder, is often very distressing. These symptoms are greatly aggravated by walking, lifting, coughing, and especially by standing, and they are all relieved in a very marked degree, often completely so, by lying down. This difference in the feelings of the patient, when in the erect or recumbent posi- tion, is a diagnostic point of very great value. The recumbent po- sition generally gives relief in the majority of the diseases of the pelvic organs, but not so markedly as in displacements of the uterus. The malnutrition produced by irritation and deranged circula- tion leads in time to inflammatory affections of the uterus and other pelvic organs. This is not an acute inflammation which can be seen, but a hypercemia accompanied by tissue changes such as areolar hy- perplasia and catarrhal states of the mucous membrane. It is prob- able that the endometritis so common in prolapsus uteri may, in many cases, precede the displacement, but the displacement certainly tends to keep it up. The symptoms of these affections need not be given here. The symptoms manifested by the general system in this affec- tion are not marked nor s])ecial. Beyond the backache and deranged digestion which often accompany prolapsus, and the depression which comes from a consciousness of having some chronic ailment which impairs locomotion and general usefulness, there is not nnich that need be mentioned. Physical Signs. — In prolapsus in the first degree, the uterus presses the posterior vaginal wall downward, and encroaches upon the rectum to some extent, at the same time it inclines backward. In some cases the cervix rests so heavily upon the floor of the pelvis that it becomes flattened. This is easily detected by digital exam- DISLOCATIONS OF THE UTERUS. 297 ination, which reveals the descent of the utei-us. The space from tlie piibes to the anterior wall of the body and fundus uteri is en- larged and remains so when the bladder is empty. The u])per por- tion of the vagina is often relaxed and wider than normal. cervix Fig. 142. — Prolapsus uteri with cystocele. In the second degree of prolapsus, the os points toward the os- tium vaginse, and is at or near the vaginal outlet. The fmidus uteri lies back toward the sacrum but not usually so far as in marked re- troversion. In complete prolapsus the uterus protrudes from tlie vagina, and can be easily recognized by inspection. In this third degree of prolapsus, the bladder and anterior wall of the rectum are usually drawn with the uterus, and in extreme cases, the urethi*a also. The extent to which these organs accompany the uterus in its descent varies considerably. This may be determined by passing a sound into the bladder and ascertaining its direction, and the same means will show the extent of the prolapsus of the rectal walls. 298 DISEASES OF WOMEN. Diagnosis. — The affections which simulate prolapsus uteri are h}q)ertrophic elongation of the cervix, librous polypus, and inver- sion. A polypus and an inverted uterus may be excluded by the absence of the os and cervical canal, and by the fact that they are covered with the mucous membrane of the uterus, while the pro- lapsed uterus is covered with the mucous membrane of the vagina. The elongation of the neck of the uterus can be detected by passing the sound, and at the same time pushing the uteras up into the pelvis, until the fundus can be detected by palpation of the ab- domen ; that is, by making the bimanual examination. The fact that this hypertrophy of the cervix occurs, as a rule, in those who have not borne children, will also aid in the diagnosis. There are cases of prolapsus in which the uterus is greatly relaxed, and be- comes elongated, so that the sound, when passed to the fundus, shows a great increase in its long diameter. By replacing the uterus it becomes shortened very considerably ; the shortening, I presume, is due to contraction or condensation of the tissues. This has been described by Emmet as a process of telescoping, but I think the term is ill chosen. One can not "^Z conceive of portions of the uterus being pushed into each other like sections of a tele- scope. In the physical examination of prolapsus, care should be taken to discover any compli- cations which may exist, such as neoplasms of the uterus, which greatly increase its size, abdominal tumors which crowd ••, ; .. ' the uterus downward, and atro- l\ \\ \ pliy of the muscles of the pel- i W / vie floor and vagina. I \ \ I Causation. — The fine ad- 4 '■'' / justment of the uterus and the means which keep that organ in its place, and yet permit con- siderable motion, are such that any increase of weight of the one, or loss of strength of the other will cause displacement. The formation of the pelvis, and its position in relation to the vertebral column : the character of the '-...> .■•■■■' Fig. 148. — The shallow pelvis with lessened inclination of brim. The direct action of tlie pressure from above is shown by the arrows. DISLOCATIONS OF THE UTERUS. 299 fiber of the uterine supjiorts, the quantity and consistence of the areolar and adipose tissue ; one's habits in regard to clothing, posi- tion in standing and sitting, if main- tained unduly long, character of oc- cupation, strength or weakness of general organization ; and the acci- dents and injuries incident to child- bearing, all have certain influences in causing dislocations of the uterus. A shallow and wide pelvis (Fig. 143) which is more than sufficient for the accommodation of its con- tents, while it is favorable to easy parturitions, predisposes to descent of the uterus. Again, if the pelvis is tilted forward, so that it is brought more immediately under the axis of the abdomen (Fig. 143) the pelvic organs are constantly under greater pressure than normal, and prolapsus and retroversion are likely to occur. These facts regarding the form and position of the pelvis are factors of great importance in the problem of uterine displacement, and deserve more attention than has been given to them. The habit of walking erect has the effect of maintaining this favorable relation of the abdomen and pelvis, while stooping distm'bs this harmony of relative positions. In this, both in regard to forma- tion and habit of standing and walking, there is the greatest diversity among women. The tissues of the uterine supports, when defective in quantity or quality, are incapable of performing their functions. These effects may be the result of imperfect development such as occurs in those of sedentary habits in youth, or they may come from debilitating diseases. In the one case they have never been well de- veloped, and in the other they have become atrophied. Standing and walking to an extent that is fatiguing, bring undue strain upon the pelvic organs, and if persisted in, will in time produce prolapsus. Active exercise, with liberal periods of rest, will tend to strengthen the uterine supports, but fatigue will overcome their power of re- sistance. Stooping forward while in the sitting position has a two- fold injurious influence — it interrupts the return-circulation in the pelvis and impairs the nutrition of the organs and brings increased Fig. 144. — Increased inclination of in- let. Pelvic organs escape pressure. 300 DISEASES OF WOMEN. downward pressure to bear on them. The position of the girl at tlie sewing-machine and that of the lady of leisure, bent over in her easj-cliair while reading a novel, are alike hurtful, but worst of all, the school-girl, bending over her desk all daj, while her body is, or should be developing, suffers the most injury. Among the errors in the use of clothing, the abuse of corsets does the most harm. I would not be understood as condemning corsets. Long use has ren- dered that kind of support necessary to highly civilized women, but tight-lacing forces the abdominal viscera out of place and in time displaces the j)elvic organs. Heavy lifting, if persisted in, is a cause of displacement. This is noticed among the poor who do heavy work. The women of In- dia, who were at one time supposed to bear children with ease and impunity, and to suffer less from uterine affections than our Ameri- can women, are very subject to complete prolapsus uteri, caused no doubt from their want of cai"e after confinement and in carrying heavy burdens. General weakness, induced by exhausting diseases and extreme old age, affects the pelvic organs very decidedly. This, no doubt, is the cause of prolapsus uteri in women with consump- tion and in the veiy aged. The most important, certainly the most frequent, causes of uter- ine displacement are the injuries and improper management incident to child-bearing. The condition of the uterine supports after partu- rition is that they are all greatly enlarged through the growth of gestation, and, while they are competent to maintain the large uterus which rests in the abdominal cavity, they must undergo involution in conjunction with the diminution of the uterus. If this involu- tion fails in the uterine ligaments and vagina while it goes on in the uterus the supports fail, because they are too long and relaxed. Im- perfect involution, not only of the uterus but of all the other tissues and organs of the pelvis, is seen to give rise to displacement. This imperfect involution may be due to post-partum inflammation or to the patient resuming the active duties of life before involution is completed. In regard to the injuries of the pelvic floor and their effect on the position of the uterus the reader is referred to the chapter on that subject. Finally, enlargement of the uterus, whether from imperfect in- volution, inflaiimiation, or the presence of neoplasms, will cause prolapsus. This will occur although all the supports may be nor- mal ; the balance between the supports and the organs to be sup- ported being disturbed by the increased weight of the uterus, de- scent will occur. DISLOCATIONS OF THE UTERUS. 301 It should also be borne in mind that the abnormally large uterus will prolapse in spite of the normal supports, while, on the other hand, defective suj^poi-ts which permit a normal uterus to descend will give rise to enlargement of the uterus hj congestion, swelling, and, finally, hyperplasia, and by this increase of weight will incline it to remain displaced. TREATMENT OF PROLAPSUS UTERI. There are four important objects to be attained in the treatment of prolapsus uteri : to restore the displaced organ, to keep it in place, to restore the supports of the uterus, and to remove complications and accompanying affections if any such exist. The restoration of the uterus to its proper place is performed as follows : The patient is placed in Sims's position, and, if the pro- lapsus is comj^lete, the uterus is grasped in the lingers, and, while compression is made, it is pushed upward in the axis of the pelvic cavity. By these means the displacement is reduced from the third degree to the second ; then the perinaeum should be retracted with Sims's speculum, and with two sponges in holders the uterus should be raised to its normal elevation. Difficulty in accomphshing this is sometimes caused by the fundus uteri turning backward while the upward pressure is being made, so that, in place of overcoming the displacement, the prolapsus is changed to a retroversion. This can be guarded against by making the pressure mostly on the posterior side of the cervix. Passing the sound and making it guide the uterus in the right direction while upward pressure is being made is another way of managing difficult cases. While these manijjulations are being made the patient should relax the abdominal muscles by avoiding all straining. Many patients fail to obey orders in this respect ; they continue to hold the breath, and strain as if preparing to resist the pain of some injury about to be inflicted upon them, I have overcome this annoyance by causing the patient to take long regular respirations while being treated. In rare cases, in which much difficulty is met in replacing the fallen uterus, the patient should be placed in the knee-chest position, and then the chances are that the uterus will slip back to its position mthout much hel]?. If any aid is needed it can be given by the sponges in holders, or what is quite as good, if not better, in manipulating with the patient in this position, is to use one or two fingers in place of the sponges. With a very limited experience and a knowledge of the methods described any one can manage this portion of the treatment. To 302 DISEASES OF WOMEN. keep the uterus in place is the question which is not easily settled. The object of all the mechanical means which may be employed is, first, to keep the organ in position and thereby give relief; at the same time, through the agency of the artificial support and otlier means, to restore the natural supports. If the prolapse is not beyond the second degree, and is due to relaxation only of the uterine supports, and not associated with any injury that destroys the integrity of the pelvic floor, the uterus may be retained by means of a pessary or tampon until the supports recover their original strength. In connection with these mechani- cal means, rest in the recumbent position is one of the most im- portant factors in bringing about the desired result. The material used for the tampon should be absorbent cotton, wool, or lint. To simply keep the uterus in place wool is no doubt the best. It is soft and least irritant to the tissues. When there is any vaginitis or endometritis causing a free discharge, ma- rine lint does better. It takes up the discharge, disinfects it, and prevents decomposition. This it does better than either cotton or wool. In some cases lint is irritating to the tissues and can not I)e long continued. Sometimes I have used wool and lint alternately with much satisfaction. Since the introduction of antiseptic material for dressings, the tampon has been far more useful in surgery. In the past when sponges, not well prepared, were used, they could be retained in place but a few hours without causing decomposition. Now the marine lint or l)orated cotton can be worn twenty-four or forty-eight hours without being offensive. •For those who have vaginitis or any inflammation of the uterus I direct that the tampon be applied in the morning after having used the douche of hot water, plain or medicated. At night tlie tampon is removed and the douche again used and afterward the tampon re- placed, if the uterus will not stay in place without it, but omitting it for the night if the recumbent position will overcome the tend- ency to displacement. When there is no inflammatory complication the tampon may be left in place two days and a night. At the end of the second day it should be removed at bed-time and replaced next moniing, the douche being used after removal and before intro- ducing it again. Astringents of various kinds have been employed with the tam- pon, the cotton being saturated with the solution to be used, or tlie agent may l)e employed in ])()wder. The latter is much the prefer- able way wlien the milder astringents are selected. As a rule I pre- DISLOCATIONS OF THE UTERUS. 303 fer the borated cotton or marine lint alone, using sucli astringents as may bo re(juirecl in tlie douche. In many cases there is some loss of the pelvic floor from pre- vious injury. This structure should be restored as soon as the tis sues are in a condition to warrant surgical treatment. As a rule, in those cases oi prolapsus which have existed for some time, the nu- trition of the tissues is impaired and needs treatment preparatory to operating. For a more complete discussion of this subject the reader is referred to the chapter on injuries of the pelvic floor. Keeping the uterus in its position by the tampon and other means of support has the effect of not merely relieving the prolapsus, but also of giving the uterine Ugaments every chance to regain their nonnal condition. Artificial support is palliative and curative as well. The mechanical supports used in the treatment of prolapsus include a variety of devices. The pessaries used are of two kinds^ those that are placed in the vagina and are held in position by the pelvic floor, and those that are held in place by being attached to a strap round the waist. The former are applicable in the first and second degrees of prolapsus while the pelvic floor remains normal or nearly so. The latter are used in complete prolapsus, and in those cases where there is so much loss of the pelvic floor that it will not keep the pessary in position. When the perinseum is sufficient to support the vagina and the prolapsus is limited to the first or second degree, the instrument known as Peaslee's pessary answers very well. It is a simple ring made of whalebone and covered with soft rub- ber. When in position it rests upon the pelvic floor. It should admit the cervix without making pressure upon it, and should fit the upper portion of the vagina without distending it to any appre- ciable extent. It acts by carrying the upper portion of the vagina and the cervix backward into the normal position, and at the same time raises the uterus to a very slight but sufficient extent. If well adapted it takes off the pressure from the lower part of the vagina and permits it to contract and regain its tonicity. Fig. 142 represents prolapsus in the second degree. Fig. 145 shows the pes- sary in position after the uterus has been replaced. When there is relaxation of the pelvic floor due to the prolapsus it is necessary to keep the patient at rest much of the time during the first week or two that the pessary is worn. If this is not prac- ticable a perineal band should be worn to support the pelvic floor while the patient is exercising. In the progress of the treatment the vagina should contract when the uterus is supported by the pessary. This, in time, requires that a smaller instrument should be 304 DISEASES OF WOMEN. used. The rnle is that the smallest instrument should be employed that will keep the uterus in place. If too large a pessary is used it Uterus replaced, with pessary m pusiiiuh will keep the uterus in place, but will overdistend the vagina and weaken the supports of the uterus in place of restoring them. One great advantage which the ring pessary has is in being easily introduced or withdrawn, and that it does not become displaced except to settle downward, and this can be easily corrected by tlie patient assuming the knee-chest position from time to time. When tlie uterus inclines to retrovert after having been elevated, a common occurrence, a retroversion pessary will act better than the ring, but the use of that instrument will be more fully discussed under the head of retroversion. Prolapsus occurring after the menopause when the uterus has undergone final involution, may bo relieved in some cases by the old glass-globe pessary. It certainly is the best instrument that I have DISLOCATIONS OF THE UTERUS. 305 found for old patients having prolapsus of the vaginal walls, bladder, and the remains of the atrophied uterus, if the pelvic floor remains sufficient to support tlie pessary. It simply keeps the uterus and bladder up in the pelvis by distending the vaginal walls. The ute- rus may be anteverted or retroverted, but is so small that it makes no difference what position it occupies so long as it is kept high enough up. The globe is easily used. In fact no mistake can be made with it except to use one that is too large. This must be avoided, be- cause one that is too large will cause vaginitis and ulceration. It is a fact also that the pessary which answers when first used will be too large when the parts regain some of their original tonicity. For a time the patient should be kept under observation and the in- strument changed to suit. This globe pessary is the most trouble- some instrument to remove. I have usually succeeded by using a small Sims's speculum and a Sims's vaginal depressor, and seizing the instrument between the two and making traction. When this fails, a pair of miniature obstetric forceps should be made out of strong copper-wire, by doubling it to form loops and twisting the ends to make the handles. "With this the globe is very easily grasped and removed. The intra- vaginal pessaries, such as the ring and globe already mentioned, and all others that rest wholly within the vagina are liable to slip down and give the patient great dis- comfort, and sometimes they come away entirely. This is especially the case when first introduced. To obviate this, a perineal band should be worn until the perinseum, upon which the pessary de- pends for support, regains its tonicity. By this arrangement the same results are obtained as by the use of the cup and stem pessary, to be noticed hereafter — in fact, better results so far as the comfort of the patient and the final effects are concerned ; therefore, I have always endeavored to relieve prolapsus when possible by the intra- vaginal pessary. Several uterine supporters have been devised to meet the require- ments of cases in which the pelvic floor is relaxed from long disten- tion, so that it has not power to sustain a pessary in position, and the patient's circumstances will not permit long rest in the recum- bent position and the use of the tampon. They are all constructed on similar principles of mechanism and action — namely, cup and ring to receive the cervix uteri, and a stem attached which projects from the vagina and is fastened to a perineal band, which in turn is attached to a waistband. The advantages claimed for this kind of uterine supporter are that if properly ad- 21 306 DISEASES OF WOMEN. justed it will certainly keep the uterus in place, and the patient can remove and readjust it when desirable. These are valuable features no donbt, and may be fairly claimed for the instrument as a rule, but not without many exceptions. There are cases where this form of instrument, while it will keep the uterus at its proper elevation, Avill not keep it in its proper axis without very great care in its ad- justment. Under such circumstances the patient can not remove and replace the pessary with any satisfactory results. While pushing up the uterus, during the introduction of the pessary, a retroversion takes place, and wearing the instrument only aggravates that form of displacement. The further objections which may be placed over against the advantages of this kind of pessary are that it can not be worn for any great length of time without doing harm and caus- ing great discomfort, and where in a given case the patient can not adjust it properly herself it will do more harm than good, and should not be employed on any account under these conditions. Again, in the most favorable cases, it is a constant source of irritation, less or more. The vulva is irritated by its presence and usually becomes inflamed in time ; the pressure of the cup against the cervix and upper end of the vagina causes inflammation and ulceration, if the patient takes much active exercise. The reason for this is that the pessary is firmly fixed by its support outside of the body and the movements of the pelvic organs against this fixed instrument cause great friction. The intra- vaginal pessary moves with the pelvic organs, but the stem pessary does not accom- modate itself to the requirements, and hence its power to do harm. From the little that has been said, it will appear that the use of the vaginal stem pes- sary for the relief of prolapsus is most unsat- isfactory. All that can be said of such means of support is, that in some cases they may be used for a time in the hope of helping to restore the natural uterine supports. Dr. Paul F. Munde has truly said, " The ideal pessary for complete prolapsus uteri is yet undiscovered." The instrument which I have found to answer best of the stem pessaries is a modiflcation of Cutter's (Fig. 140). These pessaries should be fitted with care, and just here another difficulty is encountered in the fact that they are all made of one size and shape, so that it is difficult to change them to suit special Fig. 116. — Stem pessary. Modification of Cutter's. DISLOCATIONS OF THE UTERUS. 30T cases. This I have tried to overcome by making the stem flexible, or rather so that it can be molded, and capable of being shortened, so that it can be made to suit each case. Fortunately, stem pessaries are rarely needed, and, I may say, that every year I tind less need for them. By a careful and judicious use of the ring and the tampon, aided by the T-bandage to suj)port the pelvic floor, one can accomplish nearly all that can be done by these artificial supports. The important facts in connection with pessaries already men- tioned, may be recapitulated here, and they should be borne in mind. They are as follows : First, these means of relief for prolapsus most- ly are temporary and palliative, and can only keep the uterus in place until the tissues are prepared for the operation of perineor- raphy when the pelvic floor has been injured ; second, they keep the uterus in place till the normal supports are restored ; and, third, they reduce a complete prolapsus to an incomplete, when an intra- vaginal pessary will answer the purpose. While these artificial means of support are being employed, ef- forts should be made to strengthen the parts and to remove all com- plications which tend to keep up the prolapsus, astringent injections should be continued, standing and walking should be hmited to an amount which is sufiicient for exercise, and lifting Jieavy weights and wearing tight and heavy clothing should be avoided. The bow- els should be kept free, so that straining at stool may be unneces- sary. This last point should be carefully attended to. Constipation is a potent cause in producing and keeping up prolapsus. The gen- eral health should be cared for, and if there is any debility it should be met by the proper tonic treatment. In some of the most favorable cases complete relief will be ob- tained by the means described, so that all mechanical supports can be given up. Care should be taken not to remove the pessary too soon. I have found in cases of prolapsus that it is best to reduce the size of the pessary by changing from time to time to a smaller one. Martin, of Berlin, has reported one hundred and ninety-two cases in which he has operated for the cure of prolapsus. In all but six he was obliged to perform an operation upon the cervix ; in three instances it was necessary to extii'pate the entire uterus. In one hundred and seventy-one cases silk sutures were used, in seventeen the continuous catgut, the latter being highly commended, al- though it is noted that it is not safe to depend entirely upon these, as secondary haemorrhage may occur if they are not re-enforced with 308 DISEASES OF WOMEN. silk. Relapses occurred only eleven times, and those, too, in old subjects. The operations performed were anterior and posterior kolporrhapliy, with perineorrhaphy. In comparing my own results with the above, I find that I have succeeded as well by the combined use of mechanical supports and surgical operations. That in the treatment of prolapsus, where op- erating upon the cervix uteri and pelvic floor has failed, kolpor- rhaphy has also been useless. I have, therefore, abandoned tliat op- eration. TREATMENT OF PROLAPSUS BY GALVANO-CAUTERY. Dr. John Byrne, of Brooklyn, has treated successfully nine cases of prolapsus of the uterus by galvano-cautery. In three, the cervix uteri was completely amputated with the galvano-cautery. The other six were treated by partial amputation of the cervix. The de- scription of the operation is given by Dr. Byrne as follows : " A diverging double tenaculum was passed into the cervical canal and fixed in the tissues so as to secure complete control of this part. The entire mass was next returned within the pelvic cavity, and the uterus elevated sufficiently to show the line of vaginal in- sertion in its entire circumference. While in this position, a small platinum knife, brought to a red heat, was slowly carried around the base of the cervix, close up to the vaginal fold, and to a depth suffi- cient to accommodate a platinum loop, and to insure it against slip- ping. The latter was next adjusted, and the amount of battery im- mersion being duly estimated to guard against overheating of the wire, the loop was slowly and with intermissions contracted, until about one quarter of an inch in depth had been reached. The wire was now removed, and a firmly-rolled tampon, one and a half inch in diameter and four inches long, smeared with glycero-tannin, having four per cent of carbolic acid, was passed into the vagina, and a T-bandage applied." Two of the six cases required linear cauterization of the vagi- nal walls as well as partial amputation. The following is Dr. Byrne's description of the operation : " The parts having been returned as in the former case, the line of vaginal insertion was noted, and merely marked in spots by the cautery knife. The entire mass was then brought down and out, and with the same instrument a deep, circular fissure about three eighths of an inch in depth was made around the entire circumfer- ence of the cervix, the knife being carried upward and inward in DISLOCATIONS OF THE UTERUS. 309 the direction of the os internum, and precisely as I am accustomed to do in suitable cases of carcinoma. This being done, three diverg- ing fissures were made, one central, one toward either side on the anterior, and one only on the rectal surface, starting from and con- necting with the circular incision for a distance of about three inches ; care being taken that the entire depth of the hypertrophied vaginal membrane should be incised." I am unable to speak from experience regarding this method of treating prolapsus of the uterus. The histories of the cases given by Dr. Byrne in the " Transactions of the American Gynecological Society " for 1886, axe very satisfactory. CHAPTEE XYIII. EETKOVEESIOX OF THE UTEEU8. Retroteesiox of the uterus is a change in the axis of that organ in which the fundus points toward the sacrum and the cervix turns toward the symphysis pubis or vaginal outlet. This displacement varies in extent in different cases ; three degrees are usually de- scribed. In the tirst degree the fundus points toward the promon- tory of the sacrum ; in the second the uterus lies almost transversely in the pelvis ; and in the third the fundus is low down in the pel- vis, while the cervix is thrown upward at a higher elevation than the fundus. Retroversion is usually progressive, except in the first months of pregnancy and in the puerperal state. In these conditions retrover- sion may occur abraptly, and so it may under other circumstances, but usually it comes on gradually, passing from the first degree to the second, and on to the third. It is exceedingly rare to find retroversion in the first degree ex- isting for any length of time, the displacement usually passing on to the second and third degrees. The anatomical changes which take place in backward displace- ments are to some extent the same as those found in prolapsus. The same changes in the supports of the uterus are found, and though differing in detail are the same in kind. This arises from the fact that nearly every case of prolapsus is associated with more or less retroversion, and in nearly all cases of retroversion there is also a slight prolapsus. These changes have been discussed under the head of prolapsus, hence it is only necessary for me to point out here the anatomical features which are ^particularly concerned in retroversion. In retroversion there is shortening of the posterior vaginal wall by contraction. The exceptions to this are when there is rectocele, and in recent cases in which the vaginal wall is apparently short- 310 EETROVERSION OF THE UTERUS. 311 ened, but in reality is thrown into folds. The anterior vaginal wall is generally distorted rather than displaced. Its upper end is Fig. l-i'Z. — The three decrees of retroversioii. crowded upward and sometimes forward by the cervix uteri, and its lower part is sometimes pressed downward and forward, giving it the appearance of a urethrocele. The relations of the cervix and vagina are changed more or less in the majority of cases. In some the projection of the cervix into the vagina is apparently very much increased posteriorly. To the touch the vagina appears to be attached to the whole length of the cervix. This is apparent, not real, and is usually found so when the vagina has still maintained its tonicity. In other cases, with marked shortening of the vaginal wall, the invagination of the cer- vix is lessened. IN early always the invagination of the cervix ante- riorly is less than normal. The position of the uterus as regards elevation varies greatly in diiJerent cases. This may be normal in the pelvis, simply changed in its axis, or it may be prolapsed so that the cervix is close to the vulva, the anterior vaginal wall being much shortened. Again, the posterior wall of the uterus may rest upon 312 DISEASES OF WOMEN. the pelvic floor and altogetlier be placed far back in the pelvis, so that the fundus presses upon the rectum, while the bladder may not, Fig. 148. — Retroversion of the second decree. as a rule, be much affected, either in its position or function, though it sometimes is. The pressure of the uterus being removed from behind, there is nothing except the vesical ligaments to prevent the bladder from extending backward when distended. It then rests upon the retrovertcd uterus instead of rising up toward the abdomi- nal cavity, and the ovaries and Fallopian tubes are to some extent carried backward and downward with the uterus. The extent of this displacement varies greatly. In some cases there is complete prolapsus of one ovary, or of both of these organs, so that they lie in the sac of Douglas and the uterus rests upon them. In other cases the ovaries rest upon the retrovertcd uterus. One case of this kind KETROVERSION OF THE UTERUS. 313 I well remember to have operated upon. The ovaries were diseased and gave so much trouble that I decided to remove them. One was in its normal position, the other, the right one, was adherent to the side of the uterus. This prolapsus of the ovaries is one of the worst complications of retroversion. There is a strongly-prevailing opinion that the circulation in the pelvic organs is much deranged by retroversion, and that changes of structure of these organs follow in consequence. How far this is a fact it is difficult to determine. It is true that in nearly all cases of retroversion are found some congestive inflammatory trouble and structural changes, either from degeneration or hyperplasia, but whether these changes preceded the version and perhaps aided in producing it, or whether they resulted from the change of position, can not at all times be ascertained. There is good reason for be- lieving that all malpositions cause deranged nutrition which in time lead to organic changes, and still such pathological conditions are found when there is no displacement, showing that these relations of cause and effect are interchangeable in displacements and some other diseases of the uterus. COMPLICATIONS. There are cases of retroversion so complicated that they are per- manent and incurable. These should be clearly understood ; hence I refer to them briefly in this connection. There are two classes of such cases : Those which have had pel- vic peritonitis while the uterus was retro verted, the adhesions made by the products of the inflammation permanently fixing the uterus in its malposition. I presume that a similar result is sometimes produced by pelvic peritonitis, the products of which (behind the uterus) will by contracting drag the uterus into the position of re- troversion. This complicated form of retroversion has been con- sidered incurable, but recently encouraging efliorts have been made to relieve it by surgical treatment. This subject will be referred to and discussed at the end of this chapter. The other class is one in which a similar condition occurs as the result of malfor- mation or congenital malposition. In cases of this kind the uterus is retroverted, the posterior vaginal wall short and rigid, the utero- sacral ligaments are short and rather unyielding, and although the uterus is slightly movable it can not be restored to its proper place. In such case the pelvis is wide and shallow, and there is often a lack .of cellular tissue around the pelvic organs. When I first had my attention directed to this class of cases I presumed that they 314 DISEASES OF WOMEN. must have had pelvic peritonitis, but in many of them there was no evidence obtained from the past history to warrant any such conclusion. Further investigation satisfied me that the lesions were the result of perverted development and growth. Some of these cases do not suffer much, but they are sterile as a rule. Symptomatology. — The clinical history of retroversion, so far as the symptoms are concerned, is not sufficiently definite to be diag- nostic. Many of the symptoms are common to prolapsus and cer- tain other affections of the utems. Another curious fact is that the suffering caused by retroversion varies greatly in different pa- tients. The rule is that retroversion causes much discomfort, but I have seen one patient who had retroversion for many years and yet was one of the most active women I have ever known, and was per- fectly free from all symptoms of any affection of tlie pelvic organs. The symptoms which belong more especially to retroversion are rectal tenesmus and the feeling of obstruction to a free action of the bowels. Backache, general pelvic tenesmus, aching of the limbs, irritation of the bladder and rectum, neuralgic pains in the pelvis, and the fact that these symptoms are aggravated by walking and standing and are relieved in the recumbent position, are all evidences of re- troversion, but also occur in prolapsus. Menstniation is frequently deranged and monorrhagia, dysmen- orrhoea of a mild form, and irregular recurrence of the menses, have all been traced to this form of displacement ; but all these are more frequently caused by other affections. In several cases that I have seen, the menstrual discharge was offensive and very distressing to the patient. This symptom I have noticed more frequently in retro- version and retroflexion than in any other affection of the uterus. Physical Signs. — The physical signs are obtained by the touch and uterine sound. The vaginal touch reveals the os uteri pointing toward the introitus vulvae, or in extreme cases, toward the sym- physis pubis. The anterior vaginal wall is often found projecting doA\Tiward in front of the cervix. The upper portion of the pos- terior vaginal wall is found to be pressed downward and forward, so that the junction of the posterior cervical wall of the uterus and the vagina are much nearer to the vulva and more easily touched with the finger. In some cases this prolapsus of the posterior vaginal wall is very marked, and appears to aggravate the version by push- ing the cervix against the bladder. If the bladder is empty and the muscles of the abdomen are re- laxed, the bimanual examination will show that the uterus is not in RETROVERSION OF THE UTERUS. 315 its normal position, but must be retro verted, as indicated by the signs obtained by the vaginal touch. These signs of retroversion, while quite reliable, might, in rare or complicated cases, be misleading, so that it is well to confirm or correct by the use of the sound the evi- dence obtained by the touch. Placing the patient on the left side and using Sims's speculum, the sound can be passed with ease, and its direction will show the dislocation of the uterus. In doubtful or complicated cases, when all the evidence is needed that can be obtained, the rectal touch may be employed. The finger in the rectum can be swept all around the fundus and body of the uterus while it lies low down in the sac of Douglas in the reti-o- verted state. The rectal touch can be made more eifective still by making the abdominal or vaginal touch at the same time. By these means of examination a diagnosis can be made with the greatest cer- tainty, and proof of the accuracy of the diagnosis may be obtained by replacing the uterus. Regarding the conditions which may be mistaken for retroversion and the differentiation little need be said. The question which most frequently arises is whether there is retro- version or retroflexion. This can always be settled by the evidence obtained from the physical signs already obtained, and the fact that in flexion the uterus is bent upon itself, a fact that is noticed by the touch and conflrmed by the use of the sound. Causation. — The causes which produce prolapsus uteri are ap- parently the same as those which give rise to retroversion. The reader may refer back to the causation of prolapsus for the facts re- garding this matter. This will save repetition. It is clearly evident, however, that while there may be much in common in the causation of the two forms of uterine displacement, prolapsus and retrover- sion, there must be some difference in the causes which produce such different effects. This appears to have been quite an obscure sub- ject, for I find that the text-books are very indifferent in regard to it. My own observations lead me to believe that the causes of re- troversion are the loss of support from morbid states of the uterine ligaments occuring while the pelvic floor remains normal or not wholly useless as a means of support, and that prolapsus is due to defects in the uterine supports and loss of the pelvic floor also. This may bs stated in another way, which will show what this view is based upon. In the great majority of cases of retroversion which I have seen, the pelvic floor has not been wholly wanting, in fact, in some of the cases it has been quite normal ; while in prolapsus it is usually defective. It will be easily understood that when the sup- ports of the uterus are defective, especially the anterior ligaments, and 316 DISEASES OF WOMEN. the vagina and pelvic floor are in their normal condition and keep the cervix uteri in place, the tendency would be for the uterus to fall backward into the retro verted position. Changes in the condition of the cervix uteri and in its relations to the vagina have some influence in the causation of retroversion. In those who have had cellulitis, after confinement, in the tissue around the cervix above the vagina the invagination of the cervix is lessened — indeed, sometimes obliterated. The vagina to the touch is like a cul-de-sac^ the entire uterus being above the vagina. This condition favors retrover- sion. Fig. 149 shows retrover- sion with imperfect invagina- tion of the cervix uteri in a patient who- has had cellulitis. Laceration of the cervix bilaterally produces a similar condition of imperfect invagi- nation, which is often associated with retroversion. The anterior half of the cervix becomes lost in the anterior vaginal wall, and the posterior part of the cervix is apparently less prominent in the vagina, if not really so. This is more frequently seen where the lateral lacerations extend above the vaginal junction. Fig. 150 shows this condition. Fig. 149. — Retroversion with imperfect invag- ination of cervix due to inflammatory products about it. Fig. 150. — Apparent imperfect invagination due to bilateral laceration of cervix : c, c, lips of the cervix. Fig. 151. — The same uterus with its lips drawn back into place by tenacula. In such cases the state of the cervix has much to do with keeping up the retroversion, as well as causing it. This I have demonstrated RETROVERSION OP THE UTERUS. 317 by trying to keep the uterus in place before restoring the cervix, and finding it very difficult, while it was quite easy to do so after the cervix was restored. The immediate effect of operating was to bring the cervix prominently into the vagina and sustain it there. Fig. 151 shows the change effected in the case represented in Fig, 150, after the restoration of the cervix and before restoring the retroversion. Further evidence is also obtained to show that these raal-relations of the vagina and cervix, just mentioned, favor retroversion of the uterus, in the fact that in those cases in which the cervix has been amputated the uterus is generally retro verted. These points I consider to be of much importance and of special interest because they are not, so far as I know, discussed in medical works with reference to the causation of retroversion of the uterus. Treatment. — The indications are, to replace the uterus and keep it there, and, by so doing, the supports of the uterus may regain their normal condition and complete relief follow. The methods of replacing the retroverted uterus are to place the patient on the left side, and through Sims's speculum to raise the body of the uterus up with two sponges in holders, used as in Fig. 152. By upward press- ure the uterus can be raised as far as need be, or as far as possible, and then one of the spong- es should be with- drawn or placed in front of the cervix, and backward press- ure made there. This helps to com- plete the replace- ment, and at the same time holds the uterus in place, while the sponge is removed from its position behind the uterus. To succeed in this operation, it is ne- cessary to have the Fig. 152. — The three steps in replacing the retroverted uterus by means of sponge-holders. 318 DISEASES OF WOMEN. bladder empty, and that the patient should not resist the efforts of the suj-geon to replace the uterus. Wlien there is any difficulty met in the practice of the method described, the patient should be placed in the knee-chest position (see Vig. 150), and the Sims's speculum used. This alone is sufficient in some cases to effect re- placement. When it does not do so, the upward pressure of the sponges behind, or drawing the cervix back with a tenaculum, will accomplish the object, or both sponge and tenaculum may be used. It is sometimes difficult to replace the uterus in cases of long standing, owing to the contraction of the posterior vaginal wall. The changes in the parts which have taken place to accommodate the malposition, can not always be immediately overcome. In such cases all that can be accomplished is to raise the uterus as far toward its normal place as possible, and then hold it there by means of a temporary support. By the use of the cotton tampon or a pessary, all that is gained by the first and succeeding efforts to replace the uterus is kept, and if the pessary is used properly it will make con- tinuous upward pressure upon the fundus uteri, and thereby con- stantly gain more and more. In cases of long standing the displace- ment becomes completed by slow degrees, as the tissue changes in the support of the uterus and vagina have taken place as the result of long-continued influences, and they can not be abruptly rectified. It takes time to undo that which it has required months and years to do ; hence, the process of restoration must be accomplished by degrees and by repeated efforts. The details of this method of treatment will be given in the clinical histories of cases to be related hereafter. The next object to be attained is to keep the uterus in position. This raises the question of the mechanical supports of the uterus. I think that Dr. Frank P. Foster, of New York, has given the most rational discussion of the subject that I have seen, and I will quote his views later on. THE TREATMENT OF RETROVERSION BY THE USE OF PESSARIES. There are a great many kinds of pessaries em])loyed in treating retroversion of the uterus. A few of them can be made to do much good when skillfully employed. The great majority of them are useless, and all of them are capable of doing much harm if used without a clear idea of how they should be used. During a discus- sion of displacements of the uterus at a meeting of the American Gynecological Society held in Boston, in 1877, Dr. E. R. Peaslee RETROVERSION OF THE UTERUS. 319 expressed, himself in favor of the use of pessaries, claiming, at the same time, to have obtained very gratifying results from their use in his own practice. In the same discussion. Dr. "VV. L. Atlee said : " I have had no experience vi^ith pessaries, at least with their intro- duction, but I have had a very long experience with theii* removah I do not think that there is a day when I am at home and in my office, that I do not have the privilege of taking out a pessary. I have removed pessaries of all forms and sizes, and pessaries intro- duced by the most distinguished men of the profession." Peaslee and Atlee were certainly two members of the profession of this country, equally distinguished in abihty, profound judgment, and thorough honesty, and why they should hold such opposing views upon a subject so practical may not be capable of explanation by any one. It has appeared to me, however, that the one came to his conclusions from a careful investigation of the utility of pessaries when properly used, while the other based his opinions upon the fact that as generally employed, pessaries do very great harm. Viewing the subjects from these two stand-points, both conclusions are perfectly rational, and ample proof may easily be obtained of the good and evil which come from the use of these instruments. At the present day, I presume that if the harm done should be placed opposite the good accomplished by all the pessaries in use, the results would be about equally balanced. It follows, then, that as matters stand at this moment, it is a question whether the human race would be better or worse if all the pessaries were j)ut out of ex- istence. The all-important fact remains, however, that pessaries are of great value, and capable of giving relief to those who suffer from some of the forms of uterine displacements, if properly used. The same may be said of nearly all valuable agents employed for the re- lief of suffering. That any agent, capable of giving relief when skillfully employed, is likely to be as potent for evil when misused, is a well-known fact ; hence, the object should be to attain to a more perfect and general knowledge of how to make and use pessai'ies in order to promote the good results, and lessen the evil. There are many difficulties which naturally arise in the investi- gation of the use of pessaries. Not only do authorities differ very widely in their views regarding their use, but one's own experience is oftentimes misleading. For example, a pessary may be used to correct a displacement, and marked rehef is obtained. The patient testifies to the fact that her symptoms are relieved and her useful- ness extended while wearing a pessary, and yet that instrument may 320 DISEASES OF WOMEN. be doing harm by still further damaging the supports of the uterus. These may appear like contradictory statements, and yet such are the facts observed many times in practice. The same thing is seen in the abuse of corsets. The lady who has contracted her waist by tight lacing suffers great discomfort when she goes without corsets, and is relieved by wearing them, and yet no one doubts the fact that great injury is caused by this article of wearing-apparel. The mechanical action of pessaries must necessarily be clearly understood in order that they may be employed with favorable re- sults ; misunderstanding on this point is no doubt the cause of much unsatisfactory practice. Judging from the many errors made in the use of pessaries, as seen in practice and from the various opinions expressed by writers, I am fully satisfied that this part of the subject is not as clearly understood as it should be by the profession gener- ally. My own views are so fully in accord with those of Dr. Foster, that I shall quote his article : " It can not be said that opinions are wholly agreed as to the way in which vaginal pessaries most commonly effect changes in the sitTuation, form, and attitude of the uterus. Those who have given any considerable amount of thought to the matter will probably ad- mit (1) that a pessary may operate by virtue of mere lateral disten- tion of the vagina, being itself too bulky to escape readily from the pelvic outlet, and thus preventing the parts resting upon it from so escaping ; (2) tliat the pressure exerted by a pessary may be trans- mitted directly to the body of the uterus, lifting it up when ante- verted or retroverted, as the case may be ; and (3) that such pressm'e may operate by dragging the lower portion of the organ in a certain direction, thus causing its upper portion to move in the opposite direction. " Wliile there can scarcely be a doubt that each one of these methods of action may explain the work done by pessaries under certain circumstances, it may be not only interesting as a mere matter of cunosity, but prolitable as tending to greater precision in practice, to inquire into the relative frequency with which the one or the other actually operates, which of them is therefore of the greater practical im])ortance, and which of them should be specially emphasized in teaching. The question as to whether certain pes- saries act as levers, or whether they are merely forced bodily in a certain direction, and so fulfill their purpose, is quite foreign to this inquiry, and, therefore, I shall not enter upon its considerations. " In regard to the method of action first mentioned — that of lateral RETROVERSION OF THE UTERUS. 321 or transverse distention of the vagina — it may simply be said to apply only to special forms of pessaries, which, although in common use before Hodge's time, have now almost fallen into disuse — deservedly, I may be allowed to add. " The second method, that of pressure transmitted directly to the body of the uterus, is undoubtedly the one that is most prominent in men's minds, most taken into account in practice, and most ap- pealed to in teaching. And yet, it seems to me, its scope is really quite limited, and its practical importance almost nil. If an ex- treme mal posture of the uterus is corrected by the act of inserting a pessary adapted to the case, as may often enough be done, the in- strument may act at iirst, I admit, by direct transmission of its press- ure to the body of the organ lifting the latter from a state of ex- treme anteversion or retroversion, as the case may be. But such action is only momentary ; long before it could restore the uterus to its normal attitude another agency is called into play, so that when the full action of the pessary is attained, its pressure is no longer transmitted to the body of the organ. In any case, then, this direct action on the body of the uterus is of but momentary duration, and accomplishes but a partial result ; and, if the malposture is not originally very decided, or if it is corrected before the instrument is inserted into the vagina, it does not come into play at all. " These statements embody no novelty, but they are so at variance with the views that seem to be held by the most influential teachers of gynecology, that it seems best to put forward som-C reasons for them. To illustrate, then, suppose a case of retroversion. In order that a pessary may fully restore the uterus to its normal attitude, and hold it in such attitude (acting all the time by direct pressure on the body of the organ), its pressure must be exerted not only upward, but forward, and that, too, at a point situated high in the pelvis. Now, from my own experience, from observation of the practice of others, and from the drawings employed by authors to illustrate the action of pessaries, I believe that pessaries long enough to fulfill these conditions are seldom if ever used. Granting, however, that I may be mistaken in this respect, it will scarcely be disputed that either such a pessary, besides being very long, must have a very pronounced curve in order to enable its middle portion to lie wholly below the face of the cervix while its upper end exerts the pressure in question (in which case its introduction, supposing the periniBum to be intact, would be well-nigh impossible) ; or else its limbs must diverge to such an extent as to accommodate the cervix between them, making the instrument very broad, in which case it would not 22 322 DISEASES OF WOME?^. pass between the two utero-saeral ligaments without stretching them apart to such a degree as practically to shorten them, thus causing them to pull the lower poiiion of the uterus backward, and conse- quently throw its upper portion forward. The result of this latter state of things would be that the retroversion would be corrected before the upper end of the instrument had been forced high enough to restore the body of the uterus to its normal position by direct pressure upon it, or by pressure directly transmitted to it. Further than this, I believe that in the great majority of instances the mere upward and backward pressure upon the posterior vault of the vagina would suffice to drag the cervix backward in the same way before the instrument had penetrated at all into the space included between the utero-sacral ligaments. This, however, would depend upon the degree of tonicity with which the vagina was endowed. " With regard to anteversion the case is even stronger, while at the same time it is simpler, for the anterior wall of the vagina is naturally tense, and its tension is usually heightened by the mere fact of the uterus being in a state of anteversion. In this tense condition of the anterior vaginal wall we have a marked contrast with the posterior wall ; the latter is much longer than a straight line drawn between its two extremities, and its lower end is con- nected with parts that are comparatively mobile ; the former is firmly attached to the pubic arch. By reason of this tension of the an- terior wall of the vagina, its virtual shortening occurs almost at once whenever any noteworthy pressure is made upon it : hence, any of the various forms of anteversion pessaries that are supposed to act by lifting the body of the utenis directly up, really accomplish its ascent by stretching the anterior wall of the vagina, and thus drag- ging the cervix forward. In proof of this statement, witness the insignificant size of the anterior projections of these instruments — projections utterly incapable of reaching to the height that they would have to reach in order to make direct pressure upon the body of the uterus, even with the bladder intervening, when the organ had approached anywhere near its normal position. The great sen- sitiveness of the anterior vaginal wall to pressure, the well-known liability of ulceration to occur upon it under the pressure of a pes- sary, both point to its greater tension as compared with the posterior wall. " Passing now to the third of the various methods of action that I have attriliuted to pessaries — that of traction upon the lower portion of the uterus — but little need be said about it, for the considerations brought forward to show the limited scope of the direct-pressure RETROVERSION OF THE UTERUS. 323 theory, all conspire to advance the traction theory to the most im- portant position. Such I believe it ought to occupy, unless the statements I have put forth are shown to be erroneous. I will simply add that always in anteversion, and usually in retroversion, it is throuajh the medium of the vaginal wall, in my opinion, that pes- saries make traction upon the cervix. " I will briefly mention some of the practical applications of the doctrine I have sought to uphold. In cases of retroversion it is usually sufficient if pessaries are to be used at all, to employ an in- strument simply with the idea of making backward pressure upon the posterior wall of the vagina, directing the pressure somewhat upward, unless there are special reasons for not doing so, but not resorting to pessaries with such an exaggerated pelvic curve as to render their introduction difficult. If the instrument is curved rather sharply at a point very near its upper end, the pressure wiU be distributed more evenly over the posterior vault of the vagina, and, therefore, will be borne better. " The usual forms of retroversion pessaries (the Hodge instrument and its various modiflcations, including those with external support) seem to me to act in this way, and to be as unobjectionable as any we are likely to hit upon. More or less stretching of the posterior vault of the vagina is apt to re- sult, but it is of little consequence even should it prove pei-manent, for it in no wise interferes with the natural functions of the parts. Broad pessaries, penetrating between the utero-sacral ligaments, should never be used, for these ligaments form a part of the mech- anism by which the normal situation and attitude of the uterus are maintained, and anything that stretches and relaxes them interferes with the permanent cure of retroversion." Fig. 153. — Albert Smith pessary. ADAPTATION OF PESSARIES. The adaptation of pessaries for the relief of retroversion, is facili- tated by keeping in mind the object to be accomplished, and the way in which the instrument acts in fulfilling these requirements. All that remains, then, is to shape the pessary to the case in hand, and to place it in position after the uterus has been restored to its place. This is an easy or difficult task, according to the artistic and me- chanical skill of the surgeon. Badly-adjusted pessaries are not so 324 DISEASES OE WOMEN, common as badly-fitting shoes and clothes, because they are not so generally used. No one who is destitute of some knowledge and skill in mechanics, will ever succeed in the treatment of displace- ments of the uterus by means of mechanical supports. The gravest errors are committed every day by using pessaries without under- standing the principle of their action or the methods of adapting them. This lack of knowledge and of the required ability lead to the too frequent use of certain kinds of pessaries known by the names of their inventors. The prevailing idea being that a certain form of pessary recommended by some one in authority will answer for all cases, a slight variation in size being all that is necessary. This is certainly a great mistake. The only pessary which can be of service is one that is correctly adjusted to the patient who is to wear it ; not a ready-made one with a distinguished name and repu- tation. An abundant experience, so far as seeing and treating many cases goes, and some practical knowledge of the mechanical art, en- ables me to say, that no two cases of displacement are alike, and, therefore, each one must be fitted with a pessary of the special form and size required. This really simplifies practice greatly, because it enables one to reject the vast number and variety of ready-made pessaries in the market, and to choose the simj)lest forms and adaj)t them according to certain principles and the requirements of cases. In the books there is no end to the number of instruments com- mended, and the directions to introduce and remove them are ample and sufficient, but there is a conspicuous absence of any definite and useful directions regarding the manner in which such instruments are to be fitted. In the simpler cases when the uterus can be restored to its posi- tion completely, and when thus restored the vaginal walls assume their normal shape, the pessary is easily adapted. The length of the vagina should be obtained from the posterior fornix to a point cor- responding to the upper end of the urethra, and the width of the vagina at that part indicated by a line bisecting the center of the cervix uteri should be taken. These measurements give the size of the pessary required in length and width, and are usually taken through a Sims's speculum, with the patient on the left side. The longitudinal measurement is easily obtained by a sponge and holder (Fig. 154), which are carried up by the side of the cervix to the upper termination of the vagina, and there marking, with the finger resting on the stem of the sponge-holder, the point opposite the junction of the bladder and the urethra. The transverse meas- urement may be taken by sight, or, if the eye is not trained suffi- RETROVERSION OF THE UTERUS. 525 ciently for this, by a pair of long dressing-forceps liaving a mark on the handles the same distance from the lock as the point of the blades. The for- ceps are passed up and the blades ex- panded until they reach the lateral walls of the vagina, and, while held in this position, the measurement is ob- tained from the ex- tent of separation of the handles. The size being obtained, the shape next de- mands attention. The outlines of the Albert Smith pes- sary (Fig. 153), are adapted to the lat- eral vaginal walls in a general way, and any change to suit special cases is easily made. The curves for the antero-posterior walls are slight modifications of the ogee curve of the mechanic, which is two seg- ments of a circle joined and reversed. This shape may be taken as a basis from which changes of form must be made in every instrument used. The guide for the form of these curves I have ob- tained in this way : I first ascertain by touch and in- spection the length of the invagination of the cer- vix posteriorly, and then make the posterior up- ward curve of the pessary a little short of the extent of this in- FiG. 154. — The method of measuring the length of the pes- sary ; p, retracted perineal body. anterior vaginal Wdll Fig. 155. — Diagram of pessary in situ on looking at it in Sims's position, through Sims's speculum. 326 DISEASES OF WOMEK Fig. 156. — Slight invagination of cervix posteriorly with suitable pessary. vagination. The ante- rior downward curve is made about equal to the posterior, subject to shght variations to meet special cases. Figs. 156 and 157 show two cases dif- fering in the extent of invagination, with pessaries adajjted to them. These rules for the adaptation of pessaries are only useful as a basis to start from ; each case requires one deviation or more from these rules. This ne- cessitates a material for a pessary which is easily molded, and this is happily now afforded in the instrument made of whale- bone and fine copper-wire, and then covered with soft rubber. This kind of a pessary can be modeled with the greatest facility to any form. To restate briefly the most important points in the manage- ment of mechanical supports in the treat- ment of retroversion, I would say that my method is as follows : Sims's position and his speculum are used in replacing the uterus, and when it is restored the measurements are taken, a pessary se- lected of the proper size and modeled to suit as nearly as ])ossi- t^ ,,„ t^ •, i • ■ ,■ r • . • i , •■' .' Jig. 157. — Dccidoil iiivaginsition of cervix posteriorly ble. It IS then intro- litted with a suitable i)cssary. RETROVERSION OF THE UTERUS. 327 duced and careful observations made to see if it fulfills the require- ments. If it does not it is removed, altered, and reapplied, care being taken never to Lave tlie instrument large enough to make general pressure on the vaginal walls, nor of such shape that it will make undue pressure at any one point. Where possible, I prefer to introduce and remove pessaries through Sims's speculum. The method of doing this is very sim- ple. In the introduction the perinseum is retracted, and the pessary turned up on the edge is passed beyond the vulva and then turned half round, which brings it into position. It is usually the case that, in the treatment of retroversion, the pessary requires to be changed in shape quite frequently during the first two or three weeks that it is in use, but with the material de- scribed this is easily done. When the utenis is well in place, and the vagina no longer appears to be undergoing any changes from involution and contraction, then a hard-rubber pessary is made, using the soft one, which has been made to answer the purpose, as a model. The hard rubber, of course, can be worn a much longer time than the soft, and is much more agreeable to the tissues. In regard to the modifications to be made in pessaries, to suit cases as they present themselves, all that is necessary will be said when giving the histories of cases. It is important, however, to keep in mind what has been said in regard to the cases in which the uterus can not be fully restored to its normal position, owing to changes in the posterior vaginal wall and the uterine ligaments. In such cases the restoration to the normal position must be gradual, and hence the use of the pessary is to keep the uterus in the posi- tion in which it is placed by the efforts at restoration, and by the support of the instrument to favor a tendency toward the normal position on the part of the uterus. In the management of such cases the posterior part of the pessary should not be much curved upward, if at all, be- cause the object is to have the pessary carry the posterior vaginal wall backward behind and below the uterus to support the body and fundus, while the cervix resting be- tween the bars of the pessary is unsupported and free to sink downward and backward Fig. 1 58.— What the pessary as the body of the uterus rises. Here the principle of the lever acts to change the axis of the uterus. This is shown in Figs. 159 and 160. The lever action of the pessary is made more effective by the 328 DISEASES OF WOMEK post, wall ant. pressure of the bladder and the anterior vaginal wall upon the ante- rior part of the instrument, which inchnes to raise the posterior j)art upward, and so bring the pessa- ry into a more oblique position as the uterus rises. See Fig„ 159. The pessary being wedge- shaped — that is, narrower in front than behind — is held up- ward by the contraction of the lower portion of the vagina, and the wedge-action helps the lever-action of the pessary to raise the uterus and throw it forward. In regard to the surgical operations employed in the management of retroversion, I may say that, where the cervix uteri is lacerated, it should be restored, and also that the pelvic floor, if injured, must be operated upon in order to care retroversion. In fact, very little progress can be made in the treatment of retroversion, unless the pelvic floor and uterus are normal or nearly so. This is all the surgical treatment that I now employ, besides mechanical support, in the management of these displacements. Fig 159. — How the pessary acts — shown by the arrows in the diajiram. Alexander's Operation. — In recent times, Alex- ander, of Liverpool, has devised a plan for the correction of uterine displacements, which con- sists in shortening the round ligaments. In his presentation of the subject to the British Gyne- cological Society, he said that the operation has now been performed in nearly all prominent cities in the world, and by most operators with more uniform success than generally liefell any new operation. He never found any difliculty in finding and drawing out the ligaments. An in- cision was to be made upward and outward from the pubic spine, in the direction of the inguinal canal, for one and a half to two or three inches, according to the fatness of the subject. A considerable thickness of subcutaneous fat was then met witli, which must be cut through by subsequent incis- ions, until the pearly, glistening tendon of the external oblique muscle was reached. Midway through the fatty tissue an aponeu- rosis sometimes appeared, so firm and smooth that it might cause the operator to think he was deep enough, l)ut he would find no liga- 1 CO. — Second step ; the uterus falls into the pessary. RETROVERSION OF THE UTERUS. 329 ments at tliis spot. The first stage of tlie operation consisted simply in cutting down upon tlie tendon of the external oblique muscle, until it appeared clean and shining at the bottom of the wound. Fig. 161.- -The knee-chest position — air enters the vulva, and distends the vagina, and the fundus falls in the direction of the arrow. The external ring was then found. The finger passed to the bottom of the wound detected the spine and the ring outside. Having iso- lated the external wound, and tied any little vessels, the next step was to find the end of the ligament. By everting all the structures upward, the round ligament could be seen, generally at the lowest part, and with the white easily distinguished genital branch of the genito-crural nerve along its anterior surface and close to it. The ligament at this stage was more or less rounded in shape. It was an easily recognized flesh-colored structure. When the ligament was identified, the small nerve on its surface was to be cut through without dividing any of the ligament. Then gentle traction was to be made, either by the fingers or by broad, blunt-pointed forceps. Bands holding it to neighboring structures were cut through with scissors. As soon as it began to peel out, it was left, and the oppo- site side begun. The final stage of the operation consisted in placing the uterus in position by the sound, and pulling out the ligaments until they were felt to control that ]30sition. A curved threaded needle, with fine catgut, was used to stitch each ligament to both pillars of the ring and the external abdominal ring was closed with- out strangulating the ligament as it lay between them. The ends of the ligaments were now cut o£F, and the remainder stitched into the wound by means of the sutures that closed the incision. A fine drainage-tul)e was inserted, and the wound washed out with carbolic or other lotion before these sutures were tied. 330 DISEASES OF WOMEN. The after-treatment consisted in rest. The tubes were removed on the second day, when the wound was dressed. The mortality of the operation might be set down as nothing. Three deaths had oc- curred, but they were due to preventable causes. As mortality did not seriously enter into any consideration of the results of this opera- tion, the real question at issue was whether it fulfilled the intentions of the operator and satisfied the expectations of the patient. The operation was designed to correct certain uterine displacements, and these alone. Whether the discomfort of the patient would be there- by relieved, entirely depended on whether or not the symptoms were due to the displacement. To secure success the operation must be properly performed, and the after-treatment must be rational, so that no strain might be placed on the ligaments until sound union had taken place. Most excellent results from this operation have been reported by many surgeons. I have not practiced it very often, for the reason that most cases are curable by the means which I have described, and the cases that are incurable by such means are also incurable by Alexander's operation. In estimating the merits of any surgical procedure one must always bear in mind its disadvantages. I especially call attention to this subject because we hear enough about the success of Alexander's operation and not enough, perhaps, of limitations of its usefulness, if we rely for all our information upon the strongest advocates of this treatment of retro-displacements of the uterus. During my investigations of retro-displacements of the uterus I found the round ligaments defective in some cases. This led me to the conclusion, early in my teaching days, that atrophy or imper- fect development of this ligament was a frequent cause of backward dislocations of the uterus. I have also found that retroflexion oc- curring among nullipara was sometimes accompanied \vith a defect in the round ligaments, due, I presume, to a lack of development. In those who liad acquired retroversion or flexion, I presume, the defect was due to atrophy. Recently I have seen two cases tliat fully illustrate the point in question. One was a married lady about thirty years of age who had borne two children. For six years she had suffered from a retroflexion of the uterus. For two years she had been tormented with a painful left ovary. She had been treated by several practi- tioners during the six years before coming to me. Finding it im- possible to keep the uterus in place by any support, I determined at once to do a temporary ventral fixation of the uterus. In my bi- RETROVERSION OF THE UTERUS. 331 manual examination I could not feel the round ligaments, and on direct inspection, after opening the abdomen, no trace of them could be found. I subsequently removed the uterus and ovaries at niy clinic, and no evidence of the presence of round ligaments could be found. This case was a very fortunate one for investigation. Be- tween the folds of the peritonaeum where this ligament should be found there was nothing but areolar tissue. These two cases were much the same as others that I have examined heretofore. I have consulted with my associates on this subject and have found that their experiences coincide with my own. I have asked Prof. Browning, Professor of Anatomy at the Long Island College Hospital, about this ligament, and he has told me that he finds it ill defined in some of his subjects, and so difficult to demonstrate to his classes that he often ignores it altogether. Dr. Lewis, formerly Professor of Anatomy, and Dr. F. H. Colton, at one time Demon- strator of Anatom}^ give me the same account of their observations reo-ardino; this liffaraent. I have observed that in cases of retroversion the round liga- ment is at first stretched, and then atrophy begins first in the mid- dle of the ligament and becomes complete there, while the uterine and abdominal ends are the last to give way. This explains the fact that in doing Alexander's operation the end of the ligaments is sometimes found in the inguinal ring fairly well developed, while there is not a trace of it left in the abdominal cavity except within an inch of the uterus, where a few fibers may or may not be found. Further confirmation of this opinion has been obtained in having seen expert surgeons of large experience fail to find the round liga- ment in a most careful dissection. This, I presume, is a reasonable explanation of the failures that occasionally come to light. There is still another, objection to Alexander's operation, namely, that hernia follows in a number of cases. I am fully satisfied that, no matter how carefully one may do an Alexander's operation, the abdominal wall is sometimes weakened at the point where the incision is made and the patient is predisposed to hernia. There is no trouble immediately after the operation, but in after years when the scar tissue is absorbed the wall of the abdomen is weakened and hernia is likely to follow, and it does occur in some cases. I have seen three patients who had hernia following this operation. These cases having been operated upon by experts and having such results compel me to believe that there are many others, for it is hardly possible that all the cases with imperfect results should have come under my observation. 332 DISEASES OF WOMEN. The advocates of this operation claim that it has one great ad- vantage that I have not referred to, and that is, the short time re- quired to cure displacements in this way. I have never found that patients saved time or money by Alexander's operation, if they were curable in the old way. In treating a retroversion the patient is under observation longer, but she is not so long off duty as in undergoing Alexander's operation, and hence does not lose as much time. To the surgeon who likes to operate and does not very well understand other ways of treating displacements, this operation has a wide range of application, and is popular with patients who like to be cured quickly. Still, in all this I find no good reason for modifying my opinion regarding the indication for the employment of Alexander's operation. I am fully satisfied that this operation is valuable, but limited in its usefulness. I now employ it in one class of cases, namely, retro- version or retroflexion accompanied with prolapsus of the ovaries and without adhesions. In such cases the uterus can be restored to its normal position, but can not be held there by mechanical sup- port, owing to the ovaries being in the way. Such cases are in- curable by the old method of replacement and support, but are promptly relieved by Alexander's operation, providing the round ligaments are all right. To this extent I indorse this operation in the cases referred to, and commend it as a most valuable procedure. It has been brought into disfavor, like many other good things, by being: overdone. Ventral Fixation. — This is the name given by Sanger to the operation of fixing the fundus uteri to the abdominal wall. Kelly called it hysterorrhaphy, and later has used the term ventral suspen- sion, but I like the first name best, as it is most comprehensive. The indications for this form of surgical treatment are retroversion or retroflexion complicated with adhesions, atrophy at the junction of the body and cervix, or disease of the ovaries that require ovariotomy. The operation was first performed by Koeberle, as follows : Having had occasion to remove an ovary and tumor, he fixed the stump in the abdominal wound. This is known as the indirect method, and having been found defective has been aban- doned, I believe, in favor of the direct method — that is, stitching the uterus directly to the abdominal wall. A number of different ways of doing this fixation have been practiced by various surgeons. Some vivified the peritonaeum at the points to be united by scrap- ing ; others omitted this. Various ways of introducing the sutures have been practiced. Pozzi's method is the simplest, and as efii- RETROVERSION OP THE UTERUS. 333 cient as any. lie uses a continuous suture, which he passes through the muscular layer and peritoneeuin of the abdominal wall and through the peritonseum. The rest of the abdominal wall is closed in the usual way. He uses fine silk. I prefer chromicized catgut. Operating in this way the fixation is permanent, at least it re- mains for a long time, and hence I have looked upon this procedure as objectionable, first, because it is an abnormal condition, and on theoretical grounds it is not good surgery to produce one morbid state to cure another if it can be avoided ; and, in the second place, this fixation of an organ that should be movable quite often causes suffering as bad as, or worse, than the displacement. For these reasons I have not been fully satisfied with this ven- tral fixation described in the books and practiced by surgeons gen. Fig. 162. — Ventral suspension. The uterus is swung to the peritonaeum of the anterior abdominal wall by sutures passed under the utero-ovarian ligaments. To the right, beneath, is shown the incision, with one stitch ready for tying ; above this, the usual method of passing the stitches through the peritonseum of the fundus. (From photo- graphs of a cadaver.) erally. I have therefore made the fixations so delicate that in time they give way and leave the uterus free, as it should be. The way of doing this operation is very simple in principle, hut requires consider- able skill and care to do it well. The object is to fasten the utero- ovarian ligaments (at their junction with the uterus) to the inner side of the abdominal wall with a chromicized catgut suture. Adhesions are formed between the surfaces thus held together that are strong enough to hold the uterus in place for a while, but will give way in the course of time. During the period of fixation the natural sup- 334 DISEASES OF WOMEN. ports of the utei'us regain their strength and hold the organ in place after the artiiicial fixation has given way. Much care is necessary in selecting the place upon the peritoneal surface where the sutures should be introduced. First, one should measure the width of the uterus at the point where the sutures are to be introduced, and a little more than half of that represents the distance that each suture should be from the median-line incision ; then the distance from the pubic bones upward to where the lower part of the suture should be, about the thickness of the uterus, plus three quarters of an inch from the pubes. This is difficult to illustrate, but Fig. 162 may help to make the description more clear. The uterus should be supported with a properly adapted pessary, and the cervix kept in proper position until union is completed. In fact, I have deemed it advisable to keep the pessary in position for two months, in order to prevent a recurrence of the displacement when the ventral fixation gives way. With this kind of after-care my cases have remained well. That is more than I can say of per- manent fixation, for all the cases occurring in my own practice and seen in the practice of others have suffered less or more when the uterus remained firmly fixed to the abdominal wall. This includes all the surgical treatment of retro-displacements of the uterus that I have found necessary to relieve curable cases. Some other surgical procedures have been tried, but so far as I can discover they possess no advantages over the operations already described. Neither have they been adopted by the profession gen- erally. Dr. AVilliam R. Pryor unites the uterus to the bladder by scarification and sutures. I quote the following description of his operation : " The patient being in Trendelenburg's position, the incision should be carried well down to the pubic articulation. For suture material I would not use silkworm gut because of its permanency, but silk or catgut. The bladder should l)e empty. The anterior surface of the uterus from its bladder junction to the level of the tubal openings should be scarified in the middle for a width of half an inch. Beginning at a point from the posterior border of the sym- physis not greater than an inch, the peritoneal surface of the bladder should also be gently scarified for a space equal to and opposite that on the uterus. The scarification on both bladder and uterus should be so done as to cause no bleeding. Even though the dimensions of the bladder be greater than those of the uterus, so as to necessarily leave a portion of the bladder undenuded, it matters not. But as the contracted bladder about equals the uterus in length, it will not RETROVERSION OF THE UTERUS. 335 often happen tliat much surface on the bladder will be left unscari- fied. The suture should then be introduced with a curved needle without cutting edge. Three or four sutures at most will suffice. These are to be all passed under the bladder peritonaeum first, and then the lowest suture under the uterine serosa, and tied to one side. The same with the other sutures in turn. About half an inch apart will suffice to secure accurate coaptation. The sutures are tied in a flat knot and the ends cut short. The abdominal wound is closed in the usual way." Shortening the round ligaments within the peritoneal cavity has been practiced by A. Palmer Dudley, Polk, Mann, Wylie, and Bode. The former two gentlemen unite the round ligaments in front of the uterus by first vivifying the peritonaeum and then introducing one or more sutures. One very objectionable result in this operation is that the Fallopian tube is bent at an acute angle to the uterus so that it is liable to be occluded at that point. The latter surgeons fold the round ligaments upon themselves, and, having scraped the surface brought in contact, unite them with sutures loosely tied. Many attempts have been made to fix the uterus by the way of the vagina when it could be brought into position. Some of these operations I shall mention here, though I can not recommend them as having any advantages, or even meeting the indications as well as the surgical procedure already described. Metro-elytrorrhajyhy . — Byford united the wall of the cervix uteri to the vaginal wall (in front or behind, according to the displace- ment) by vivifying the tissues and uniting the parts with sutures. According to Pozzi, Doleris practiced pre- or retro-cervical colpor- rhaphy, but I have not discovered that the results were satis- factory. Pelvic Colpo-hysteropaxy.—Th.h is the name given by Pozzi to Freund's operation, which consists in opening through the posterior vaginal wall into the sac of Douglas and suturing the supra-vaginal portion of the cervix to the peritonaeum near the utero-sacral liga- ments. Uniting the Bladder and Uterus hy the Way of the Vagina. — Mackenrodt opens the vaginal wall in front of the uterus, and, after dissecting up the peritonaeum and opening it, he removes a portion and unites the remainder to the uterus by a continuous suture run- ning from one tube to the other. The bladder wall is then stitched to the uterus. The operation is the same in principle as Dr. W. R. Pryor's, already described. 336 DISEASES OF WOMEN. Shortening the Round Ligaments through the Vagina. — "Winter and Schauta opened into the peritoniieiim through the vagina be- tween the uterus and vagina, and fastening the round ligaments where they are given off from the uterus to a point seven or nine centimetres distant. AVortheim called this operation the vaginal Alexander method. Yineberg and Polk have practiced this procedure in a modified form. BETROFLEXION OF THE UTERUS. In the chapter on anteflexion of the uterus the pathology of flexions generally was discussed, and the classification adopted was that flexion was a de- formity and not a sim- ple dislocation. In fact, a very broad dis- tinction was made be- tween displacements and flexions. It was observed at the same time that retroflexion of the uterus was fre- quently — in fact in the great majority of cases — produced as a result of a retroversion. The uterus first becomes displaced backward, and, in consequence of the deranged forces acting upon the uterus, it becomes bent upon itself — that is, flexed as well as displaced. Owing to this close asso- ciation of retroversion and retroflexion, and the fact that the treat- ment of l)otli has much in common, I have placed them together. In practice I have made out two degrees of retroflexion, and the flexion is confined to the body, the cervix maintaining its normal relations to the vagina. At all events, the cervix is never bent backward. Pathology. — This is the same as in anteflexion, so far as the uterus is concerned. There is a want of snfiicient tissue at the junc- tion of the cervix and body of the uterus, the point where the flexion Fig. 163. — Fibroid on posterior wall of uterus simulating retroflexion. RETROFLEXION OP THE UTERUS. 337 occurs. In the majority of cases the cervix and upper part of the vagina are farther forward in the pelvis than they should be, and the cervix points forward more than it should, but less so than in re- troversion. This gives rise to a little short- ening of the anterior vaginal wall, or else an undue invagination of the anterior wall of the cervix. Symptomatology. — The symptoms present in retroflexion are very much the same as those of retroversion, hence it is only necessary here to note some few that are more marked in flexion than in ver- sion. In retroflexion the menstrual function is more frequently disturbed. Dysmenor- rhcea is often present, and although the pains are less acute than in anteflexion, they are far more marked than in retroversion. In many of those having retroflexion the menstrual discharge is often quite offensive ; this also occurs in other conditions, but, taken in connection with other signs and symptoms, it is valuable as a means of diagnosis in this affection. Physical Signs. — The points of difference between retroflexion and retroversion are, as observed by the touch, that the cervix in flexion does not point toward the vulva or pubes, but is nearly in its normal position. There is less relaxation of structure of the upper portion of the vagina. Behind the cervix the rounded fundus can be felt by the examining finger to be pointing downward and back- ward, instead of directly backward as in retroversion. Between the cervix in the vagina and the fundus uteri the angle of flexion can be felt. All this can be made out by the vaginal touch, and in favorable cases the bimanual examination will help to verify the signs obtained. When the abdominal muscles are very lax and the vagina long and elastic the uterus can be carried upward with the finger which 28 Fig. 164. — Prolapsed and adherent ovary simulating retroflexion. 338 DISEASES OF WOMEN. is in the vagina, and brought within reach of the hand on the abdo- men — i. e., the uterus can be grasped and examined bimanually. In that case the deformity of the uterus can be clearly made out ; but it is rare that this is practicable. It is usually impossible to reach the anterior wall of the uterus by the hand placed upon the abdomi- nal muscles. In the great majority of cases I have been obliged to depend upon the vaginal touch and the uterine sound to make a positive diagnosis. The two conditions which I have found simulating the physical signs are a large and prolapsed ovary and a subperitoneal fibroma on the posterior wall of the uterus. These are shown in Figs. 163 and 164. In either of these affections the touch gives the signs of retro- flexion, and it is only by using the sound and proving that the uterus is in its proper position and form that they can be distin- guished from flexion. While the sound is not absolutely necessary to differentiate between retroflexion and such conditions as those named, I find that it gives confidence in the diagnosis in retroflexion to pass it and see that the canal runs backward and is not distorted by the flexion. Sometimes it is very difiicult to pass the sound around the point of flexion, and in order to do so it may be necessary to raise the fundus and also the cervix, in order to straighten the canal. When the uterus is very tender, much care should be exercised in using the sound. The application of cocaine is useful in relieving the hyperfesthesia. Causation. — Retroflexion occurs in single women, and also in those who have borne children. In the former I have found it much more frequently. For practical purposes, this affection might be divided as regards causation into two forms, congenital and ac- quired. From the history of those cases in which this flexion is found in early life, I believe that it is brought about by some lesion of development. It may not be, strictly speaking, a con- genital malformation. It is more likely that the infantile uterus becomes retroverted before puberty, and then when secondary development takes place the increase in weight of the body and fundus causes dis^flacement of the upper part of the uterus, and the cervix being held in place by the resistant vagina, the flexion is produced. This is the only explanation of the production of these cases at puberty. When it is acquired after bearing children, I believe that retroversion occurs first, and if the cervix meets re- sistance from the anterior vaginal wall and bladder in front, the RETROFLEXION OP THE UTERUS. 339 flexion is produced. If the uterus is made to bend a little at the point of flexion, tlie pressure will cause atrophy at that point, and thereby the flexion will gradually increase. It is possible that in some of the acquired cases there is some lesion or excess of involution at the junction of the body and cer- vix, and the walls of the uterus being thus weakened at that point, permit the uterus to fall over backward. Prognosis. — In acquired cases, and uncomplicated, appropriate treatment will usually give relief if persisted in long enough. In the so-called congenital forms there will be found cases which do not yield to treatment. Relief from the most distressing symptoms may be obtained, but as soon as the mechanical support is removed the flexion will return. The resistance of some cases to treatment I have found due to a rigid state of the posterior wall of the va- gina, which prevents the use of a pessary which would extend far enough back to throw the fundus forward. In such cases the use of a pessary often aggravates the trouble. Treatment. — The principles of treatment in retroflexion are the same as in retroversion, and hence need not be discussed here fur- ther than to note some of the additional means necessary in flexion. To restore the uterus to its normal form and position it is often necessary to use the Elliott adjuster, and to repeat its use a number of times ; then a pessary should be employed as in retroversion. In adjusting the pessary care should be taken not to curve the poste- rior bar too much, but to shape it so that it will carry the posterior vaginal wall back behind the body and fundus so as to support both. This can be made clear, perhaps, by showing the effect of a pessary which is not of proper shape, and which in- creases the flexion by making press- ure upward in place of backward (Fig. 165). Alexander's operation is suggest- ed to the mind by those cases which do not yield readily to treatment, and I presume it would be useful. How- ever, the only cases which resist the usual treatment are those in which the posterior vaginal wall is un- yielding and the uterus can not be straightened by Elliott's adjuster. In such cases there is reason to suppose that the uterus is fixed in its malposition by some old cel- lOvcrcurved ^v"'' pessary (after pi- Barney) 340 DISEASES OF WOMEN. lulitis or peritonitis ; and, if so, Alexander's operation would not succeed. It is rather rare that the treatment prescribed fails. In obstinate cases, in which the frequent straightening of the uterus does not stimulate tlie growth of tissue at the point of flexion, the stem pessary should be tried. The canal of the cervix should be dilated sufficiently to admit a 'j fair-sized glass or hard-rubber stem. The stem is then introduced to over- come the flexion and keep the uterus straight, and the pessary is used to keep the stem in place. The same kind of stem and pessary as are used in the treatment of anteflexion are employed, with this diflPerence, that FiQ. 167.— Uterus with defective walls; the pessary is adapted to keep the the supra-vaginal portion of the cer- uterus in position as Well aS to hold vix 18 elongated (after VVinckel). . ^ the stem in place. To recapitulate, the stem corrects the flexion, and the pessary corrects the retroversion besides keeping the stem in place. Atrophy of the Uterine Walls at the Junction of the Body and Cer- vix. — This is a condition which causes anteflexion and retroflexion, which may alternate by turning the body of the uterus backward or forward. I have found it in those who have borne children, and also in those who have not. Pathology. — There is a defect in the middle layer of the ante- rior and posterior walls of the uterus at the internal os which per- mits the uterus to bend forward or backward with equal facility. Fig, 167 shows the appearance of such a uterus. Such cases are rare, and have a clinical history very much the same as anteflexion. I can give the best description of the affection by relating the his- tory of a well-marked case. ILLUSTRATIVE CASE. A dressmaker, single, and in fair general health, twenty-seven years old, came under my care in the hospital, giving the following history : She began to menstruate at flfteen, and from that time until she entered the hospital had suffered from dysmenorrho^a. The pain at her periods became progressively worse, until she was entirely unfitted for her duties. RETROFLEXION OF THE UTERUS. 341 She sought relief in medicine, but only large doses of opium sufficed. Becoming wholly useless, she entered one of the hospitals of this city, and remained under treatment there for four months. During that time she had violent hysterical convulsions at her men- strual periods, and deriving no benefit from treatment was dismissed as incurable. Upon examination, I found marked anteflexion of the body of the uterus, and owing to slight stricture of the internal OS and the extreme tenderness of the uterus the sound could not be passed until she was anaesthetized. I then found that the os internum was constricted. I incised it and dilated until I could pass a No. 9 English sound. At the same time I used Elliott's ad- juster to straighten the uterus, and carried the fundus backward. This was accomplished with unusual facility, the uterus making no resistance to bending in any direction. The instrument was with- drawn, and the patient placed in bed to rest ; there was no pain or inflammation following this treatment. Three days afterward I made a digital examination, and found the uterus retroflexed. By using again the Elliott adjuster I was able to change the retroflex- ion back to the original anteflexion, which remained so for several days. It being necessary to pass the sound every third day to pre- vent the recurrence of the stricture at the internal os, I took advan- tage of the opportunity by changing the flexion a number of times, and found that whatever position I placed the body of the uterus in it would remain there. The dilatation of the os internum gave the patient great relief from the dysmenorrhoea. The usual treatment for congestion and hypersesthesia was continued, and the canal kept dilated by the use of the sounds. A stem pessary was tried, but she could not tolerate it except by keeping in bed. She improved so much in two months that she left the hospital, and only returned occasionally as an out- patient. For two years I kept her under observation, and although she was not entirely free from pain she was able to make her living. In this case I feel sure that the trouble originated in an imper- fect growth at the time of secondary development. In one other case, of which I have full notes, the flexion came after the patient's second confinement, and, perhaps, was due to a derangement of involution. CHAPTER XIX. ABUSE OF PESSAKIES. Injuries to the Pelvic Organs Caused by the Improper Use of Pessaries. — The dangers of stem pessaries have already been referred to in the chapter on flexions, so far as their liability to canse acute inflammations of the uterus, pelvic cellular tissue, and peritonfeum. There are still other injuries which they may give rise to. When the stem is small and badly adjusted with reference to the character of the flexion, the point of the instrument may become imbedded in the wall of the uterus, or the lower part of the stem may divide the posterior wall of the cervix. Both of these injuries I have seen in practice. In one case, an anteflexion of the cervix, a small stem of steel with a hard-rubber disk at its end was introduced by a general practi- tioner, and left in place for three months. ^; ^^"^ The patient soon began to suffer from a ) purulent discharge, which gradually in- creased, and there was much pain, greatly aggravated by walking. When I saw her the relations of the stem and uterus were as shown in Fig. 1C8. After the removal of the stem, the cervix presented exactly the same appearance as that seen after Sims's operation for flexion, except that there was more thickening of the edges of the wound and more inflammation than I have ever before seen after discision of the cervix by the surgeon. The inflammation subsided under ordinary treatment, and she was at least none the worse for having worn the stem. Another patient came under my observation while wearing a stem pessary, which had been introduced six weeks before by her medical Fig. ifi8. — Stem of pessary ul- cerating through cervix. a-12 ABUSE OF PESSARIES. 34-/ attendant. Slie bad suffered pain and tenderness from the time that the stem was introduced, and for a week before she came under my care the sutfering was so great that she was obliged to stay in bed and take opium fi-eely ; she had also a purulent discharge, and at times bleeding. The stem was about the thickness of a No. 9 catheter. It was made of hard rubber, and was held in place by a cup pessary in the vagina. While the stem was still in place (the vaginal pessary having been removed) the body of the uterus was found to be markedly antefiexed, and its anterior wall near the fundus was unusually prominent, as if it contained a small fibroid tumor. The flexed shape of the uterus led me to suppose that the stem must be curved, but on removal it proved to be straight. I then passed with some difticulty, owing to the tenderness of the uterus, a much-curved sound into the cavity of the uterus, and then after straightening the sound, it was passed into the groove made in the posterior wall by the stem. One might sujDpose that the cavity of the uterus was simply dilated so that the sound could be curved forward and then straightened and passed along the posterior wall, but I am confident that such was not the case. The posterior wall of the body was flexed forward and rested upon the anterior wall on either side, and the sul- cus made by the stem was in the center. Fig. 169 shows the conditions as they ap- peared to me during ray examination. There was considerable bleeding after the removal of the stem, and the uterus be- came more flexed apparently as soon as the support was withdrawn. There was relief from the acute symptoms and inflammation caused by the instru- ment, but the dysmenorrhoea was worse than before. Atrophy of the muscular tissue of the vaginal walls from over- distention by pessaries that are too large is quite frequently seen. Practitioners who are not skilled in the use of pessaries, yet never- theless use them, produce this injury of the structures of the vagina. The same unfortunate results are effected by those who believe in tlie theory that in order to keep the uterus in place, in retroversion, for example, it is necessary to use a pessary large enough and suf- ficiently curved to force the posterior wall of the vagina far up in the pelvis above its normal elevation. Fig. 169.— Stem cutting through body of uterus. 344 DISEASES OF WOMEN. The following case will illustrate this : The patient had children, and was said to have had a displacement ; probably retroversion. She was treated with a variety of pessaries, so she told me, but did not get well ; when she came to me, she had much backache, pelvic pain, and vaginal leucorrhoea ; she was then wearing a pessary nearly large enough to till the pelvis, and much curved both in front and behind. The uterus was in about its proper place in the pelvis, but the vagina was greatly overdistended and its walls were thin, especially the posterior wall behind the cervix. On removing the pessary, a difficult task owing to its size, the vaginal wall, and the rectal wall also, I think, fell downward and formed a rectocele high up. Fig. 170 will give an idea of the state of the parts as they appeared to the touch, after the j^essary was removed. The part of the thin wall of the vagina bulged down- ward, and felt to the touch exactly like the ordinary rectocele, except that the protmding mass was at the upper part of the vagina in- stead of the lower ; when seen through the speculum introduced about an inch and a half, this was confirmed by the eye. The first impression ol)tained by the touch was that of a portion of intestine distended with gas lying behind and below the cervix uteri. The patient felt a little more distress, strange to sa}', after the pessary was removed ; when she tried to walk without it, she suffered from pain and tenesmus very severely. This I have found to be the case in all instances of overdistention of the vagina; patients suffer witli the support, and for a few days suffer more without it. This is much the same experience as ladies have who can not go without corsets, and the tighter they lace them and the more damage they do, the more they miss them when they discontinue their use. This patient was kept rather cpiiet for a time, and astringent in- jections were used, which, after a long time, restored the vagina more Fig. 1 70. — High rectocele due to improper pes sary. ABUSE OF PESSARIES. 345 nearly to its normal caliber. There remained for over a year, when I last saw her, and perhaps ever since, a sagging of the upper part of the posterior vaginal wall. Another case, somewhat of the same character, came to me from the West. She was forty, and single ; her health and strength had been good until she was thirty-six years of age, when she began to have a variety of nervous symptoms clearly due to general debility. She was treated by several reputable physicians, but not recovering as fast as she desired, she consulted still another, who told her that she had falling of the womb, which caused all her troubles. There was not a symptom that pointed to any disease or displacement of the sexual organs, but a Cutter pessary was introduced and the patient wore it about two years. Her general health improved very little, and the pessary soon caused her trouble ; still she persisted in wearing it because the doctor said she must do so ; her condition be- came so wretched that she came East, in the hope of gaining relief. When she came to me she had some vaginitis and vulvitis caused by the pessary, but the uterus was perfectly normal in every way. The Cutter pessary had pushed up the posterior vaginal wall far beyond the cervix, which lay on one side of the instrument, not between the bars as it should have done. The condition of the posterior vaginal wall at the upper part was about the same as in the case just related. The lower part of the vagina was normal, excepting the inflammation caused by the pes- sary. The vulva was also inflamed, and she suffered greatly from this, especially in taking exercise. This patient also felt the want of the pessary when it was removed, but only for a short time. She was examined seven months after the removal of the instrument and was found to be perfectly well. Injury of the Posterior Vaginal Wall by the use of Pessaries in Cases of Incurable Retroversion. — This case illustrates a class which, though not large, deserves notice. In retroversion with fixation of the uterus, either from a congenital state or because of adhesions or shortening of the post-uterine ligaments, there is sometimes a slight mobility of the uterus which admits of its being partly restored. This leads the practitioner to hope that, by the use of the pessary, the displacement can be corrected. The result is that the posterior portion of the pessary makes too great pressure upon the vaginal wall and produces inflammation and abrasion. This usually causes a free vaginal discharge and pain enough to make the patient seek relief before much permanent injury is done. In all such cases pes- saries should not be used at all, but if one is employed in the hope 346 DISEASES OF WOMEN. of doing good, it should be abandoned as soon as it causes any irri- tation. In these incurable cases, a slight relief may sometimes be given by using a Peaslee's ring, or a Smith's pessary very little if at all curved posteriorly. Either of these instruments will hold the uterus a trifle higher in the pelvis, and this will, in some cases, give a sense of support and relief to tlie patient. Overdistention and Atrophy of the Anterior Vaginal Wall from the use of Anteversion Pessaries. — This condition is rarely seen ex- cept among the patients of those who look upon anteversion as a morbid state of importance whenever it occurs. In order to raise the body of the uterus up when it is anteverted, it is necessary to elevate the anterior vaginal wall far beyond its normal position. In order to do this, the instrument must make well-marked pressure upon tlie parts, and, if this is continued, the muscular wall becomes atrophied and overdistended, and this can be carried on to a very great degree, the whole length of the vagi- nal wall becoming double that which it originally was. When the pessary is removed in such a condition, there is at once observed a well-defined and large prolapsus of the vaginal wall, and if the instrument is left out, cystocele will soon follow. This is the rule, but the final results depend to some extent upon the length of time that the pessary has been worn. The stretching of the vaginal walls caused by pessaries can be overcome by removing the instrument, and prescribing rest and astringent injections. But if the overdistention has been kept up long enough to cause atrophy of the muscular tissue, the injury is pennanent and can be very little improved by treatment. There is also danger to the bladder and urethra from the ante- version pessary. The following case Mall show how this comes about : Frequent Urination associated with Slight Anteversion of the Blad- der. — The lady was about thirty, and had a child seven years old. She gradually developed a pelvic tenesmus and some irritability of the bladder. She consulted her physician, who diagnosticated ante- version of the uterus, and stated that the disturbed function of the bladder was due to the malposition of the uterus. Thomas's ante- version pessary was introduced by the physician in charge ; this gave the patient a sense of support which was agreeable, but more disturbance of the bladder M-as caused. The physician urged the patient to wear the pessary, telling her that she would get used to it, and the unfavorable effects would pass off ; but this proved not to be the fact. The patient then came under my care, having worn AliUSE OF PESSARIES. ?A7 the pessary for two weeks ; 1 at once removed it, with the result of giving some relief, but there was still more impatience of the blad- der than before the instrument was used at all. The true state of affairs proved to be that the patient had a slight catarrh at the neck of the bladder, not due to the malposition of the uterus at all, and the pessary only increased the original affection. In proof of this, the symptoms all disappeared when the disease of the bladder was removed, and without changing the position of the uterus in the least. Cup Pessary with an Extra- Vaginal Support, causing Vulvitis and TJlceration of the Vagina. — All the pessaries having a stem attached to a band around the body have given trouble when worn for any length of time. The evil caused by the one used in this case, is typical of most of them. The patient lived in the country, and, while suffering from pel- vic tenesmus, called in a physician who adjusted a Babcock's uterine supporter for " falling of the womb." She was directed to remove it at night and introduce it in the morning. For a short time she felt some relief, but soon began to suffer from a profuse vaginal dis- charge and great tenderness about the vulva. The suf- fering increased until she was unable to walk, and the introduction of the support- er gave great pain. When I examined her I found the relations of the uterus and supporter as rep- resented in Fig. 171. The uterus was retroverted and the cup and stem were situ- ^"'- 171--Di8placement^causedbya badly adjusted ated in front of the cervix and held the anterior vaginal wall high above its normal position. There was some ulceration of the vaginal wall and general vaginitis and vulvitis. The apparatus was removed, vaginal injections of borax and water employed, and in a short time the inflammation was relieved. The uterus was then restored to its normal position, and retained there with a pessary such as I use in such cases, and she did very 348 DISEASES OF WOMEN. well. But for several months there was a tendency to prolapsus of the anterior vaginal wall, owing to the overstretching of it by her former supporter. The Upper Rim of a Cup Pessary partially imbedded in the Vagina, around the Cervix Uteri. — This patient had a prolapsus uteri, and the physician who had her in care used a cup and stem of soft rub- ber ; the cup was quite a large one and its edges were rather sharp. I think it was called the Barrington supporter. She was much re- lieved by this instrument, being able to do her duty as a laundress, but she began to have a vaginal discharge and occasional bleeding, with pain and tenderness. I saw her with the doctor and found a ring of raw tissue in the vagina, around the cervix uteri, correspond- ing to the size and shape of the cup. The uterus was large, measuring nearly five inches. Evidently the pressure upon the instrument was more than the tissues of the vagina could stand. The patient rested for a time and used vagi- nal injections ; the parts healed promptly, but the scar tissue re- mained tendei', and gave way under the pressure of the instniment, whenever she wore it for any length of time. I think that this patient conld have been cured by rest in the recumbent position until the enlargement of the uterus and I'elax- ation of the vagina had been overcome, and then the pelvic floor restored. But she could not give the time to this, being poor, and obliged to work to live. She was directed to wear a perineal pad fastened to a waist-l)elt, and slie got along fairly well in that way. A Pessary imbedded in the Posterior Vaginal Wall. — In the cur- rent literature there have been many extraordinary cases recorded of pessaries having passed through the vaginal walls into the rectum and bladder. Some of these cases have been very remarkable, and have been recorded as matters of curiosity. Little has been said about the causes of such accidents or how to manage them. The following case illustrates the most common forms of this ac- cident : The patient was a widow who had borne several children, and had been well until the menopause, vvhen she became insane. At the outset of her mental derangement, her physician suspected that she had some uterine disease, and, on investigating the case, found the uterus larger than it ought to be and retroverted. He restored the organ to its normal position and introduced a pessary which hold it there ; the instrument was well adapted and answered the purpose well. After this his attention was wholly directed to her mental condition, and she recovered her mind in about one year. The pessary was forgotten by her physician, who introduced it ABUSE OF PESSARIES. 349 while she was in the asylum. When she came home, or soon after, she began to have a discharge from the vagina and occasional bleed- ing. I then was called to examine her, and found all that portion of the pessary which rested behind the cervix uteri, imbedded in the vaginal wall. The tissues to the extent of nearly a quarter of an inch had united in front of the pessary bar. Traction was made upon the pessary until the tissues inclosing it were made tense, and they were then divided down to the instru- ment ; there was much bleeding, but the parts healed well, leaving a large scar in the posterior vaginal wall. This case is one the like of which is not infrequently seen ; they differ from most of those already mentioned, in the important fact that they occur in cases in which the instrument is well adjusted and answers its purpose for a time, causing no trouble until the vagina begins to contract during the final involution at the menopause. The vagina contracts so much that the pessary, which, at the time of its introduction was small enough and had plenty of room, becomes altogether too large and must imbed itself in the vaginal walls. I have seen a sufficient number of these cases to satisfy my- self that they occur in the practice of the most competent gyne- cologists, sometimes, perhaps, from neglect in giving specific direc- tions to the patient to report from time to time, so that the behavior of the pessary may be watched, but more often from the fact that the patient having been relieved of all her symptoms, either forgets the pessary, or else feels secure and safe, so long as there is no suf- fering which she can not, in her own opinion, attribute to the meno- pause, the time when there is the greatest danger of the accident in question. Pessary entirely imbedded in the Vaginal Walls, except about three quarters of an inch. — This patient came to me when she was forty-six years old ; she was still menstruating, but irregularly, and on one or more occasions had menorrhagia. She was suffering from a prolapsus of the uterus which caused her much trouble when she was on her feet. I restored the uterus, and used an instrument to keep it in place. This gave her relief at once, and she was able to take up her duties as in times past. She came to see me several times and I made some applications to the uterus which caused a slight endometritis. I directed her to continue her visits from time to time, in order that I might see how the pessary was acting ; this she did not do, for feeling perfectly well, she concluded that there was no need of further treatment, and she acted accordingly. Ten years passed, and though she began to have a purulent discharge 350 DISEASES OF WOMEN. and occasional bleeding from the vagina, still she neglected her self. After a time she cahed a physician, who made a superhcial examination, and told her that he suspected that she might have can- cer ; he advised her to place herself again under my care ; this she did, and I found the vagina almost completely closed. On the right side anteriorly, I fomid a small portion of the pessary exposed, but the rest was imbedded in the vaginal walls and covered over by considerable tissue. The granular and highly-vascular character of the tissues sug- gested that the doctors suspicion of cancer might be correct. The pessary could be felt through the wall of the rectum which appeared to be quite thin at that point. Passing a sound into the bladder, a part of the pessary appeared to be encroaching upon it. With ditficulty the finger could be passed between the free portion of the pessary and the vaginal wall until it reached the cervix uteri, which was normal. The pessary had to be removed, yet the task appeared to be a ditficult one. There was so much haemorrhage caused by the examination that I dared not divide the tissues which enclosed the pessary, neither did I feel that I could with safety rapidly and forcibly tear the instrument out of its place, fearing that I might do damage to the rectum and blad- der, I finally adopted the following method with success : Using a Sims's speculum, I seized the part that was exposed in the anterior part of the vagina with a very strong forceps, and with a small finger-saw cut out the section within reach. I then laid hold of an end and by traction caused the pessary to revolve until another por- tion came into the place of the one removed ; this was sawed off, and piece after piece was taken out in this way until the whole was removed. The sinns was washed out for the purpose of cleaning it and stopping haeraorrlmge, but there was so much bleeding that I had to use a tampon to control it. The patient did quite well, and beyond a marked tliickening of the vaginal walls, has now no trace of the injiu-y. Since my experience with this case, I have seen quite a number of cases of imbedded pessaries, and have removed them in the way described. Two cases I have in mind now in wliich the pessaries were imbedded in the posterior vaginal wall, which were treated by sawing out the anterior half or third of the pessary, and then by turning the remaining portions around they were removed without breaking down or dividing the tissues surrounding it. CHAPTER XX. HYPERTROPHY OF THE CERVIX UTERI. This is a peculiar and rather rare affection. It differs from the enlargement of the entire uterus, which occurs in pregnancy and in some of the inflammatory affections. The hypertrophy is confined to the vaginal portion of the cervix, and is distinct from the enlarge- ment of the supra-vaginal portion, which occurs in connection with metritis, subinvolution, and pregnancy. Pathology. — The only change in structure of the cervix is in quantity. The length of the cervix is increased, which is the main point in the pathology. Sometimes it is thickened, but not in pro- portion to the elongation. It is characterized by great increase in length without increase in the diameter of the cervix, and no changes occur in the composition of the tissues. This is a true hypertrophy, which occurs from causes wholly different from the ordinary conditions which produce hypertrophy. The extent of hypertrophy differs in different cases ; this is due, to some extent, to the stage of progress when the first examination is made. In some cases the cervix projects from the vulva one or more inches, while in others the cervix rests just behind the hymen or in the vulva (Fig. 165). The cervix is generally conical and the os externum is generally small, as it should be in the virgin cervix. It occurs in the unmarried most frequently, but occasionally in those who are married but sterile. Symptomatology. — The symptoms are exactly the same as those due to prolapsus. In the first stage there is pelvic tenesmus, and a sense of overdistention of the vagina. The presence of this large cervix causes irritation of the vagina and consequent leucorrhoea. Owing to the great increase in the length of the uterus, it becomes doubled up in the pelvis, and this often affects the menstrual func- tion, giving rise to dysmenorrhoea. In the last stage of the affec- 351 352 DISEASES OF WOMEN. tion, in which the cervix protrudes from the vulva, there is much discomfort ; and the feehng of distention causes great irritabiKtj of Fig. 172. — Hypertrophy of the cervix. (-J.) the general nervous system. Excoriations and ulcerations of the mucous membrane are produced. Physical Signs. — The bimanual touch reveals the fact that while the fundus uteri is at its normal elevation, the cervix is either down at the vulva or protruding beyond it. At the same time the firmness of the vaginal walls, occupying their normal position, shows the great length of the extra-vaginal part of the cervix. This sign is diagnostic when the cervix is still within the vulva, but when the cervix has escaped through the vulva there is prolapsus of the vagina which obscures the signs to some extent. Emmet claims that elon- gation from prolapsus of the uterus has been mistaken for hyper- trophic elongation. This does not seem possible for one who knows anything al)Out the rudiments of gynecology. By restoring the pro- lapsed uterus, any little elongation which may have come from stretching will disappear, while no change of position will make any difference of length in hypertrophy. The use of the sound also HYPERTROPHY OF THE CERVIX UTERI. 353 helps greatly in determining the extent of the hypertrophic elon- gation. Causation. — The fact that this affection is limited to the virgin cervix makes it appear as if the hypertrophy might be due to neg- lected functions, but tlie fact is that its cause is not known. Prognosis. — The hypertrophy yields to surgical treatment very promptly. All the cases that I have treated, five altogeth- er, have been com- pletely relieved by amputation of the cervix. Treatment. — The removal of the super- abundant intra-vagi- nal portion of the cervix by amputa- tion, is the only meth- od of treatment which gives satisfaction. Several methods of operating have been employed, such as the circular method, made with the knife or scissors, the ecraseur., and the galvano-cautery wire. Originally, in all of these methods the stump was left to heal by granula- tion. J. Marion Sims greatly improved the operation by covering the stump Avith mu- cous membrane. Simon and Marckwald made a double- flap operation, and I have adopted a modification of this method. The details of the '^ -' '. /' operation, as I perform it, are Fig 175. — Dia- as follows : _ Sjam^ reLvld^ A rubber cord is passed around the cervix and drawn tight enough to control the haemorrhage ; the ends of this cord are then seized with a fixation- fojceps, which keeps them from slipping, and also holds the cervix in the desired position. The cervix is divided from the canal outward on either side a£ 24 Fig. lYS.— The first step; splitting the cervix. Fig. 174— The double flaps of the amputation. 354 DISEASES OF WOMEN. high lip as tlie amputation is to he made (Fig. 173). The double flaps are then made with the scalpel in such a way that the two short flaps are on the in- side (Figs. 174 and 175). The portions removed are wedge-shaped. Two middle sutures are then introduced from the cervical mucous mem- brane, or short flaps, to the outer mucous mem- brane, and the lateral sut- ures are used in the same way as in restoring a bilat- eral laceration. Fig. 176 shows the sutures as intro- duced, and Fig. 177 shows them when tied. Before tying the sut- ures the rubber cord should be loosened, and if there are any vessels that bleed freely they should be controlled. Slight ooz- ing is controlled complete- ly by tying the sutures. There are two things which have been brought out by experi- ence, and these should be kept in mind. The flrst is, that the cer- vix after amputation retracts or shrinks, so that it should not be amputated too high up, but left a quarter or three eighths of an inch longer than it should apparently be. It will be found short enough two or three months after the op- eration. The next point is, that the middle and outer layers retract after the operation far more than the mucous membrane of the cervix ; especially is this the case when there is a cervical endometritis present. In several of my cases I found, several months after the operation, tliat the mucous membrane protruded from the os externum, and had to be clipjied Fig. 176. — The sutures in place. Fig. 177. — The sutures tied. HYPERTROPHY OF THE CERVIX UTERI. 355 off. This is a simple, thing to do, but by observing the directions this item of after-treatment will not be required. The after-treatment is the same as that employed in the op- eration for restoring a lacerated cervix uteri, and need not be de- scribed here. In a certain number of cases I have noticed that the outer walls of the cervix retract more than the mucous membrane after this operation. Immediately after the parts have healed, the cervix is quite perfect, but in a few months the mucous membrane protrudes beyond the muscular wall. This is more likely to occur. I think, in case there is a cervical endometritis accompanying the hyper- trophic elongation. When this condition of protrusion or prolapsus of the cervical mucous membrane is found subsequent to amputa- tion, the easiest and quickest way is to draw the superabundant tis- sue and clip it off. Just here I may mention that hypertrophic elongation of the anterior half of the cer\dx occasionally occurs in bilateral laceration. When this elongation is very great, I have found it best to amputate the redundant part as a preliminary to the operation for the lacera- tion. This is done in the same way as taking off a finger by the flap operation. CPIAPTEIi XXI. FIBROMA OF THE UTEKUS. This fonn of neoplasm, which frequently appears in the wall of the uterus, differs materially from growths generally. In many re- spects it is unlike any other neoplasm in genesis, pathology, and natural history. Observations made in recent years have led me to reject the hitherto accepted opinion that fibroma of the uterus is developed during middle life. I am now convinced that it is congenital, and has its genesis in lesions of arrangement of the tissue elements of the middle layer of the uterine wall. The only essential difference in the histological composition of the middle layer of the wall of the uterus and fibroma is in the arrangement of the tissues. The muscular coat of the uterine wall is arranged in three layers, longitudinal, circular, and oblirpie ; but these are all interlaced, so that they form one structure or continuous muscle. In the filjroid neoplasm the fibers are arranged in circular form around a given center, and are cut off" or separated from the wall of the uterus by a thin layer of areolar tissue, and do not form part of the uterine wall. It may be said that this tumor is in, but not a part of, the wall of the uterus. Another difference between the structui-e of the uterus and fibro- ma is, that in the developmental changes that take place in the uterus during gestation the rudimentary muscular cells are formed into muscular filaments, while the tissue elements of fibroma in- crease in quantity but do not change in form or character. It is more of the nature of hyperplasia than degeneration. The evidence that uterine filiromata have their origin in derange- ment of embryonic evolution consists in their having been found, in a rudimentary state, in the infantile uterus and in young subjects, and before their presence had been announced l)y any signs or symptoms. They are also found occasionally with other congeni- tal lesions of development, such as anteflexion of the uterus. 350 FIBROMA OF THE UTERUS. 60( Figs. 178, 179. — Interstitial fibro- mata (Winckel). Furthermore, if they orig'inate in a lesion of arrangement of tissue elements (and this, I believe, is a fact), this must of necessity take place during embryonic life. One can understand how transformation of cell elements and the development of new tissue can take place in the forma- tion of tumors ; but lesions of arrange- ment of musculo-fibrous tissue, such as occur in the formation of uterine fibro- mata, is possible only during develop- ment in the embryo. Fibroid, fibrous myoma, fibromyo- ma, and hysteroma are the names that have been used to designate this varie- ty of tumor. I prefer the term fibroma, believing that it is as com- prehensive and indicative of the character of this neoplasm as any. Fibromata grow usually in the body and fundus of the uterus, but in rare cases they have been found in the cervix. All of these growths originate in the middle coat of the wall of the uterus, but the direction they take while growing varies in different cases, and this has led to a very clear and useful classifi- cation of fibromata. AYhen the tumor remains imbedded in the middle coat of the wall of the uterus it is called interstitial (Figs. 178 and 179) ; when it grows toward the outside, sub- peritoneal ; and when it grows toward the cavity of the uterus, submucous. Figs. 178 to 180 will show the three forms classed accord- ing to location. The subperitoneal variety might well be divided into two classes, those that are situated outside of the broad ligament and those that are within its folds. Though very little has been said in books about the fibromata which grow within the folds of the broad ligament, the history of such differs so much from the ordinary subperitoneal variety that a special notice is (juite necessary. Fibromata situated in this position, instead of becoming pedunculated, extend outward between the folds of the broad ligament and drop down deep into the pelvis. It is not until they become quite large that they extend up out of the pelvis. Beine: surrounded by the folds of the broad ligament thev are more firmly fixed in the pelvis than other subperitoneal tumors, and con- sequently cause more displacement of the pelvic organs. The uterus Fig. 180. — Subperitoneal and submucous fibro- mata (Winckel). 358 DISEASES OF WOMEN. and the bladder are usually pushed far over to the opposite side of the pelvis, and the pressure upon the ovaries and pelvic nerves causes the most pain and suffering of all of this class of tumors. They are more likely to cause cellulitis than when located elsewhere. In some cases the tumor drops down very low in the pelvis behind all the pelvic organs. In one case, unusually large, which came under my care, there was a considerable mass behind the rectum which extended down to the perinaeum. It appeared to be a part of the tumor, but I presumed that it nmst be something else. Dr. Thomas Keith saw the case, and pointed out that the tumor had split up the broad ligament in its growth, and, extending down- ward beneath the peritonaeum, necessarily got behind the rectum. The location of fibromata has a marked influence upon the his- tory and treatment ; the classification should be clearly understood and kept in mind on this account. Those that grow toward the inside of the uterus may remain broadly attached to the uterine wall, or they may become pedunculated. They may be single, conglomerate, or multiple. The single tumor consists of one mass, the multiple of several masses situated apart and at different places in the uterus, and the conglomerate consists of a number of masses growing close together and sur- rounded by one capsule. Fibromata vary greatly in shape. When very small they are usually round, but as they grow they sometimes become irregular ; especially is this true of the conglomerate variety. In all cases the tumor is in a sense distinct from the wall of the uterus. The tumor is in the uterine wall, but not a part of it. There is in almost all cases a clear line of demarcation between the tumor and the tissues of the wall of the uterus. The tissues which surround tlie tumor and separate it from the neighboring tissues are chiefly cellular, and form what is called the capsule. This, after all, is only a separation in the arrangement of the tissues of the uterine wall and tumor which shows the difference between the two. Were it not for this the morbid growth would be very much like a cir- cumscribed hypertrophy of the uterus. As it is, the development, growth, and decay of fibroids are influenced by the uterus, from which they take their origin and nutrition, and are governed by the same laws. They increase in size during pregnancy, and generally diminish after confinement, and after the menopause they disappear with the final atrophy of the uterus. Even in the absence of pregnancy the growth of a fibroma resembles the normal growth of a pregnant FIBROMA OF THE UTERUS. 359 uterus, in the respect that there is simply an increase of tissue with- out change of structure. The I'ule is that fibroids do not increase by growth before puberty, and they usually disappear after the menopause, but not immediately after the cessation of the menstrual function. Usually the menopause is postponed in cases of fibroma, the patient continuing to menstruate until fifty years and over. Neither does the decrease in the tumor begin as soon as the menses stop in all cases. On the contrary, the organic forces which main- tained the menstrual function being no longer called for are devoted to the growth of the fibroma, and this growth may go on for some time after the menopause, but the rule is that in time the process of atrophy begins, and the tumor diminishes and finally disappears alto- gether, or returns to its primitive size. During the growth of these tumors they frequently change their position and relations to the uterus. The submucous tumor extends more and more into the cavity of the uterus. This change in posi- tion diminishes the area of connection between the tumor and uterus. It becomes pedunculated, and in this condition is sometimes de- scribed as a fibrous polypus of the uterus. This process of expul- sion of the tumor from the uterus may go on until separation is com- plete, the tumor being expelled as is an ovum in miscarriage. The same changes occur in the reverse direction in subperitoneal fibro- mata. They frequently become pedunculated, and it has happened that they have become detached from the uterus altogether. When this has occurred (which has not been often) there are usually found adhesions of the tumor to the abdominal viscera, and a vas- cular communication between the tumor and the parts to which it has become attached has been established. Sometimes such adhe- sions occur in tumors which are not pedunculated, though it is a notable fact that fibromata are the least liable to form adhesions of all the neoplasms. These changes of fibromata in relation to the uterus are aided, perhaps effected wholly, by muscular contraction of the uterus. The process is in the nature of an expulsion, and is the natural way by which the uterus endeavors to free itself from such morbid growths. The density of fibromata differs in different cases, and occasion- ally changes in the same case. They sometimes, especially if large, become soft and oedematous. Sometimes collections of serum, blood, or pus are found in the tumor. These give a feeling of softness and ill-defined fluctuation. When this condition is found the tumor is usually called a fibro-cyst, but there is a difference in pathology be- 360 DISEASES OF WOMEN. tween a libro-cyst and a fibroma with cjst-like cavities containing blood, pus, or serum. I have seen two cases of fibroma which gave the pliysical signs of fibro-cysts. They were both large submucous fibroids, and situ- ated in the body of the uterus, leaving the fundus free. The tumor closed the lower part of the cervix uteri, and the menstrual fiuid and secretions of the mucous membrane accumulated in the fundus and upper part of the cavity of the body, and formed what appeared to be a fibro-cyst. After the menopause these fibromata usualh^ diminish or remain stationary, and give no trouble except by mechanical action upon neighboring organs. The rule is that they either disappear or at lea.st give no further trouble. At one time it was believed that fibromata were capable of being converted into cancer. That is a mistake, I believe. INfalignant disease may appear in connection with fibromata, but I have not yet found any reliable evidence that the one is converted into the other. Perhaps fatty transformation is the usual change which takes place ; occasionally calcareous or osseous degeneration occurs. Tumors which have undergone calcareous degeneration I have seen several times, but I have not seen anything like true osseous forma- tions. Perhaps it would express the facts better in most cases to call this material bone-like rather than to convey the idea that it is true bone. These changes or degenerations in fibromata usually are conservative. First the tumor stops growing, and then undergoes atrophy, or is transformed into osseous-like or calcareous material, but in either case the rule is that the patient is relieved. In some rare cases the tissues soften and suppurate, and septicsemia is pro- duced. One such case occurred in my practice and i^roved fatal. CHANGES IN THE UTERUS FROM THE EFFECTS OF FIBROMATA. The pathological changes which take place in the uterus dur- ing the presence of a fibroma are of much interest. It becomes enlarged in all cases, but most of all in the submucous and inter- stitial varieties, less so in the subperitoneal, and least in the pedunculated subperitoneal. Cei-tain changes in the mucous mem- brane of the uterus usually occur. There are, in many cases, poly- poid growths developed, and endometritis is almost always present. In regard to the changes in tlie mucous membrane which occur in connection with fibroma, Dr. Wyder, of Berlin, makes the follow- ing statement : FIBROMA OF THE UTERUS. 301 " Fibromyomas are said to be likely to give rise to malignant diseases of the mucous membrane. . Martin has formerly maintained that these conditions furnish an indication for total extirpation. The writer, having examined a number of cases, does not share this view. " "With subperitoneal myomas the mucous membrane was found much thickened ; the most important alteration was a very perfect glandular endometritis. In one case adenomatous J^olypi were present ; in another, on one side glandular, on the opposite side interstitial, endometritis. " For interstitial myomas three groups must be formed : " 1. Where the tumors are separated from the uterine cavity by a wall one half to one centimetre thick. " 2. Where the tumor is beneath the mucous membrane but does not project. " 3. AVhere the tumor projects largely into the uterine cavity. " Of seven cases in the first group, in one no alterations were found ; in two, glandular endometritis (mucosa four to ten milli- metres thick) ; in three, interstitial endometritis. In most cases the vessels were very numerous and their walls very thick. " In the second group, the deeper layers of the mucous mem- brane were completely transformed into connective-tissue trabeculse ; at the surface was a greatly dilated capillary network with thick- walled vessels. " In the third group, interstitial endometritis was found. " The thicker the wall separating the tumor from the uterine cavity the more is the glandular structure developed (glandular en- dometritis) ; the closer the tumor approaches the mucous membrane the more pronounced becomes the connective-tissue character of the proliferation in the mucosa (interstitial endometritis). We then find the mucosa on one side atrophied into connective tissue, and on the other in a state of glandular proliferation. As regards the source of the haemorrhages, it should be remarked that no vascular changes are to be expected in subperitoneal tumors. It was found that where glandular endometritis was alone present no haemor- rhages had gone before. In the case of interstitial tumors associated with glandular endometritis exclusively there was likewise no pre- ceding haemorrhage. It was present only with interstitial en- dometritis. Therefore haemorrhage will not take place where the interglandular tissue is quite intact ; but it will occur where both structures proliferate equally (endometritis fungosa), or where one or the other form develops predominantly, or where glandular en- 362 DISEASES OF WOMEN. dometritis exists on one side and interstitial endometritis on the other. Compression of the numerous vessels causes venous con- gestion ; hgemorrhage will set in, especially when glands and tissue have proliferated equally. The glands exert no influence on the under surface ; their character is usually benign. The border line between mucosa and muscle is intact. Endometritis glandularis is of a benign nature." These pathological changes in the mucous membrane and the increase in its extent by the great enlargement of the uterus cause a marked increase in the vascularity. To this state is due the menor- rhagia and hemorrhage which are so generally present in cases of fibromata. Deformity of the uterus is produced in many cases, but in some even large tumors the uterus presents the form present in pregnancy. It is simply enlarged but not changed in form. There is often displacement of the uterus, especially in the interstitial and subperitoneal varieties. The tumor either drags the uterus toward the side upon which it is located, if it is small, or pushes the uterus in the other direction, if the growth is large. The cervix uteri may be disturbed in many ways. It is some- times greatly elongated and far out of its normal position. Many times it is spread out on the tumor so that it appears to be a part of it. The canal of the cervix is often tortuous and its caliber lessened. Pressure of the uterus upon surrounding organs may cause derange- ment of function. These effects depend upon the size and location of the tumor, with reference to the degree of the derangement. When the tumor is still small enough to remain in the pelvic cavity and make pressure to a limited extent only, the symptoms produced resemble those caused by uterine displacements and small ovarian cysts. The rectum may be pressed upon and its function perverted. The bladder uiay suffer from pressure which may prevent it from distending, or it may be rendered irritable and tender. In some cases the pressure may become so great that the function of the bladder and rectum may suffer, and even the ureters themselves may be affected in the same way. I have seen several cases — three in all, I think — where the ureters were obstructed from the pressure of fibromata, and the kidneys were affected in consecpience. The pressure may become so great that the function of the rectum or bladder l)ecomes arrested, and infiammation of the cellular tissue or peritomeum may occur and prove fatal. I have repeatedly seen slight attacks of pelvic infiammation caused by pressure of fibromata; one case ])rove(l fatal from pelvic inflammation and rectal obstruction. I saw the patient first when she began to have infiani- FIBROMA OF THE UTERUS. 303 mation, and I found the tumor impacted in the pelvis and it could not be dislodged by any means. The inflammation progressed, and the obstruction of the rectum became complete by the addition to the tumor of the products of the inflammation. In most cases the tumor can be raised up out of the pelvis when it be- comes large enough to give much trouble. The pressure may be upon the pelvic nerves so as to cause very great pain. When fibromata escape from the pelvic to the abdominal cavity they do not cause so much trouble unless they become very large. They may cause peritonitis and intestinal obstruction, but that is rare. They were formerly supposed to cause ascites, because fluid in the peritoneal cavity was found in a certain proportion of cases. Keith believes that this fluid is a transudation from the tumor rather than from the peritonaeum, as in ordinary ascites. The quantity of the fluid is seldom sutiicient to cause much distress. Symjytoriiatology. — The symptoms of uterine fibromata are natu- rally of three kinds : First, those manifested by the general system, which are also called constitutional or remote ; second, those which originate in the uterus itself ; and, third, those that are produced by the pressure of the tumor upon neighboring organs. The severity of the remote symptoms depends upon the size and location of the tumor. There are a great many patients who do not suffer in general health from fibromata of the uterus until the growth has advanced to a considerable size. Sooner or later, according to the extent of disturbance which the growth causes, the general health becomes impaired. The patient becomes anaemic and is generally debilitated, because of either the loss of blood or deranged nutrition, or both. These symptoms are not by any means diagnostic, but may come from a variety of affections. In the most marked cases, when the patient is extremely anaemic, the skin becomes slightly bronzed, and gives to the patient the appearance of having malignant disease. The symptoms which are manifested by the uterus are pain and haemorrhage. The pain is not always pronounced, in some cases it is not at all persistent. It is irregular, spasmodic in character, and is most marked when the tumor is submucous, and least so in the interstitial variety. The haemorrhage is the most prominent symp- tom of all. It usually comes on periodically, and is therefore in some cases a menorrhagia. Menstruation is too free, and lasts too long and recurs too often. Bleeding may come at any time, there being no regularity whatever in some cases. This sj'raptom is so constantly present, that Dr. J. Mathews Duncan called fibroma the bleeding disease of the uterus. 364 DISEASES OF WOMEN. This name is well deserved, for certainly no other affection gives rise to so nnich haemorrhage of the uterus as does this. The size of the tumor does not intiueuce the severity of the bleeding. In some small tumors the bleeding is greater than in others of mon- strous size. It is the location of the tumor and the complications, such as endometritis in various forms, which determine the ha^mor- rhagic symptoms. It is greatest in the submucous, less in the interstitial, and least in the subperitoneal, as a general rule. The submucous pedunculated variety is the most liable of all to cause bleeding. A very small tumor of this kind may cause the most persistent and exhausting lui^morrhage. The symptoms produced by the pressure of the tumor upon neighboring organs are generally most marked when the tumor occupies the pelvic cavity ; then the pressure upon the bladder and rectum causes irritation and func- tional obstruction of these organs, and less or more pelvic tenesmus of a general character. The elfect upon the bladdei- is to render urination very frequent and sometimes difficult or impossible. I have seen three cases in which there was retention of urine. The tumor was pear-shaped in all of them, and large enough to extend above the brim of the pelvis. The urethra and bladder were car- ried upward, so that the urethra was caught between the tumor and the piibic bones and compressed. Urination in these cases was for a time difficult, and then retention came. All voluntary efforts to evacuate the bladder only made matters worse, by forcing the tumor downward and wedging it into the superior strait. Ilelief was given first by the catheter, and then by pushing the tumor up- ward, the patient being placed in a knee-chest position. Pressure upon the pelvic nerves and ovaries often causes much pain. Pain in the back and limbs, which is often present, no doubt comes from the same cause. Pressure upon the ui-eters may cause obstruction and hydro- nephrosis, and all the unfortunate results to the kidney which must follow. In such cases there is at first ])ain in the region of the ureters, and subsequently the symptoms of renal disease appear. Fibromata large enough to occupy the cavity of the al)domen give very little trouble, as a rule. A^ery large tumors interfere with fi-ee res])iration, and the action of the stomach and bowels to some ex- tent. The ascites which sometimes accom])anies fibromata of the uterus was supposed to be due to irritation of the pcritomeum. It is more likely that it is a transudation from the tumor itself, as already stated. This is sugi^ested by the fact that hydro-peritonaeum is usually found in connection with oedematous tumors. FIBROMA OF THE UTERUS. 365 Figs. 181 and 182. — Enlargement due to sub- involution compared with that from growth of a fibroma (after Winckel). Physical Signs. — The positive signs of iibroiiia are tlie increase in size, change in form and consistence of the uterus, and the dis- placement or distortion of the canal, as related to the body of the uterus. The touch discovers the fact that the uterus is enlarged, apparently, and by the bimanual touch it usually can be proved to be really so. The shape of the uterus is changed in nearly all cases. It is irregular in out- line, one side being much larger than the other. In the subperi- toneal variety this deformity is quite marked. The tumor pro- jects from the surface of the uterus so boldly that it can be instantly detected. In some of the cases of submucous fibroma, and occasionall}^ in the inter- stitial, the uterus is uniform in shape and appears like a uterus enlarged by gestation ; and even when there is some irregularity of form it is not unlike that which is often found in pregnancy, but the uterus is very hard in the one case, while in the other it is very soft. The hard character of the tumor and uterus is a very reliable sign of fibroma. In all conditions which cause enlargement, the uterus is softened except in fibroma and in very rare cases of cancer. "Whenever the uterus is enlarged and indurated, fibroma may be strongly suspected. Deflection of the canal of the uterus from the center is a very important sign of fibroma. The relations of the canal of the uterus to the axis of the pelvis, as shown by the sound, are changed in all forms of displacement, but the canal is still in the center of the uterus. In fibroma the canal is excentric and very often tortuous. The use of the sound, by which this displacement of the uterine canal can be detected, gives this most valuable evidence of the ex- istence of a fibroma. Figs. 181 and 182 will show this point very plainly. The one shows a uterus large, owing to subinvolution, the other about the same size from enlaro'ement due to a fibroid. In not a few cases the canal is so deflected, displaced, or com- pressed, that the sound can not be passed. A flexible bougie may be used under these circumstances, and although it will not posi- tively show the position of the canal, it gives valuable indications of it. When the sound can not be used at all, this valuable sign is not 366 DISEASES OP WOMEN. obtainable, but the fact that the canal in a large uterus will not ad- mit the sound is evidence of fibroma. There is no other condition of enlargement of the uterus in which the sound can not be passed, as a rule. Sm.all fibromata, which occupy the pelvic cavity, present some physical signs which resemble displacements of the uterus, ovarian tumors, tubal pregnancy, the products of former inflammations and diseases of the Fallopian tubes. The differentiation between flexions and versions of the uterus and fibromata is based upon the following facts : In flexion and version the uterus is not much enlarged, and, as a rule, can be re- stored to the proper position when all signs suggestive of fibroma disappear, and then, too, the sound shows that the cavity of the uterus is not displaced nor enlarged. Ovarian tumors are distin- guished from fibromata by being less dense and not usually fixed to the uterus ; one can be moved without the other. Early pregnancy is usually distinguished from a fibroma by the history and symp- toms, but the physical signs differ. The uterus is soft in pregnancy, while it is unduly hard in fibroma. The enlargement and softening extend to the cervix in pregnancy, but not in fibroma. Should a doubt exist, the differential diagnosis can easily be made in a short time by watching the progress of the case. The signs of pregnancy will soon become sufficiently pronounced to settle the question. The most difficult cases to deal with are those in which preg- nancy takes place while there is a fibroma present. I have seen sev- eral cases of this kind. Two of these were pregnant when first seen, and in both the diagnosis of fibroma was made and in only one did I suspect pregnancy at my first examination. In the others I was aware of there being a fibroma present, but I did not detect the pregnancy until several months had elapsed. Fibromata situated within the folds of the broad ligament are not easily distinguished from the products of a pelvic cellulitis, extra- uterine pregnancy, and disease of the Fallopian tubes. The history of the case, taken in connection with the physical signs, will usually suffice to enable one to make the diagnosis. Large fibromata which occupy the abdominal cavity have to be differentiated from fibro-cysts of the uterus and ovarian tumors. In regard to the distinctive signs by which the diagnosis between ovarian tumors and fibromata is made the reader is referred to the section relating to the diagnosis of ovarian tumors. The solid hard fil)roma is easily distinguished from a fibro cyst of the uterus by its density, as recognized by the touch, but a soft FIBROMA OF THE UTERUS. 357 fibroid may be so elastic as to give the signs of an imperfect fluctua- tion, and simulate a cyst with a thick wall. In such cases of doubt the chances are in favor of the tumor being a soft fibroma, but if it is very necessary to make a diagnosis it may be done by aspiration. The accumulation of fluid in the upper part of the cavity of the uterus, occurring as a complication of a uterine fibroma, gives the physical signs of a fibro-cyst so perfectly that one must certainly be led to make a false diagnosis. I have seen two such cases ; one was a very large intra-uterine fibroma which closed the canal of the uterus below by pressure in the latter stages of its growth. The secretions of the mucous membrane accumulated at the fundus and gave distinct fluctuation. One of the most distinguished gyne- cologists of this age saw the patient with me, and thought, as I did, that it was a fibro-cyst, but it was not. The histories of these cases, especially one which is given further on, will show more fully the peculiar character of the pathology and the dilficulties of diagnosis. Causation. — The causation of uterine fibromata remains as ob- scure as ever. Granting that they are the results of lesion of evolu- tion leaves the question of the derangement of development unset- tled. Heredity may probably have something to do with it. A lesion in the arrangement of the fiber of tissue might be transmitted as surely as the distribution of colors. The fact that these neoplasms prevail in certain families and races favors this theory. Certain facts in regard to age, race, and social relations have been ascer- tained which favor the growth of these neoplasms. The age when fibromata grow is between thirty and thirty-five years. There are many exceptions to this, however, but it is rare to have these growths appear before puberty or after the menopause. It may be more correct to say that they never attain any appreciable size befoi-e pu- berty and rarely after the menopause. In regard to race, the negro is more liable to fibromata than the white, although no good reason has been discovered why this is the case. The influence of the so- cial relations is stated by Thomas Addis Emmet as follows : " The development of these growths is retarded by child-bearing, and even by marriage, for the sterile M^oman is less liable than the old maid, but in turn she is more so than the woman who has borne children." These facts are deductions from large tabulated observa- tions of cases by Dr. Emmet. He also gives his views regarding the social state as related to the causation of these neoplasms in the following woi'ds : " Between the ages of thirty and forty years the unmarried 368 DISEASES OF WOMEN. woman is fully twice as sul)ject to fibrous tumors as the sterile or the fruitful. I have already referred to this subject, when treating of the causes of disease, and pointed out that this is one of the tributes which an unmarried woman pays for her celibacy. It seems as if it were the purpose of jS^ature that the uterus should undergo the changes dependent upon pregnancy and lactation about once in three years throughout the child-bearing period, and that if the uterus is not physiologically occupied in child-bearing there is greater liability to the development of fibrous tumors as the woman advances in life. This will also be the case with the married woman who has taken means to prevent conception, as well as with her who has been sterile from some cause beyond her control, but to a less degree in the latter case. I think I have had occasion to note that the sterile woman who has earnestly wished for children does not have her liability to fibrous tumor increased by the fact of her sterility — an instance, probably, of the remarkable effect of mind upon the body. Finally, the woman who may have been fruitful in early life, but remained sterile long afterward from some accidental cause, may have a tumor developed, but is less liable thereto from having once borne a child." From my point of view, the statements of Dr. Emmet given above refer to the growths of fibromata, not to their genesis or de- velopment. Prognosis. — Fibromata of the uterus, while the most frequently seen of all the neoplasms of the sexual organs, are the most harmless so far as their tendency to destroy life. They occasion suffering, but rarely prove fatal. Many patients are unable to live on until the menopause, when the tumors disappear altogether, or become reduced during the final involution of the uterus so that they are harmless. The complications are, first, haemorrhage, which recurs so often in many cases that it endangers life. Very few patients bleed to death directly, but some become so reduced by the long-continued loss of blood, which impairs nutrition, that death comes as the result of some secondary affection which would not have occurred except for the exhausted state of the patient. Peritonitis and cellulitis are liable to be set up by fibroma, and of the fatal cases peritonitis is a not infrequent cause. Softening of the tumor and decomposition may cause a fatal septicemia. Blood-poisoning sometimes occurs during the expulsion of intra-uterine fibroma. The tumor, being in part cut off from the circulation, undergoes necrosis before its expulsion is completed, and causes septica3mia, and death takes place when FIBROMA OP THE UTERUS. 369 relief and recovery appear to be within the immediate reach of the sufferer. Pressure upon the pelvic organs may cause death by arrest- ing the functions of these organs. This is most likely to take place when the tumor grows in the broad ligament and is therefore fixed in the pelvis. I have also seen death occur from pressure upon the ureters causing obstruction to the llow of urine, renal disease, and Anally uraemia. Although there are dangers from all of the com- plications named above, the number of fatal cases is very small even when left without treatment ; and by judicious management a large number can be relieved entirely, or helped sufiiciently to be able to pass through life in comparative comfort. Within the past few years such means as ovariotomy, hysterectomy, and electrolysis have been employed in the treatment of uterine fibroma, with results which raise the hope that the great majority of these neoplasms will be controlled, and the death-rate from this cause reduced to a minimum. Treatment. — The size and location of uterine fibromata, and the conditions and complications produced by them, differ very greatly, and hence the treatment must vary with each case. Uterine fibro- mata, when discovered in the rudimentary or latent state, are amen- able to treatment. A careful study of many cases has convinced me that these tumors are disposed to remain in a latent state until they come under conditions favoring their growth, such as sterility, deranged menstruation, and endometritis. In other words, it is more easy to keep a fibroid from beginning to grow than to arrest its growth after it has begun. It is evident that any derangement ■of the functions of the uterus favors growth of fibromata. It natu- rally follows that the relief of any diseases of the uterus which de- range or interrupt any of its functions will indirectly control the growth of fibromata. This I have demonstrated many times. I have on record a number of cases of imperfect development with small fibi-oids of the uterus, manifested by irregular and painful menstruation, that upon being relieved of the malformation and impaired nutrition have suffered nothing from the fibroids. Sev- eral patients after being cured have become pregnant, and while the fibromata appeared to increase in three of them during gestation, they reduced in size during post-partum involution of the uterus. In eighteen cases of pregnancy with fibroma of the uterus, seven miscarried and eleven were delivered at full term ; two of them were twice delivered safely. The subsequent histories of ten were kept for periods varying from one to four years, and in only one did the fibroma grow to any appreciable extent. 3Y0 DISEASES OF WOMEN. In some of my cases the tumors had attained considerable size before gestation took place, and as they remained stationary, for some time certainly after confinement, it appears that gestation re- tarded their growth. The indications for treatment (when fibromata are rudimentary and latent, and also when they are growing but are small) are to remove all malformations, malpositions, and inflammations, or other curable lesions that may be present ; in short, to restore the uterus to its normal structure so that it may perform its functions. When this is accomplished the growth of fibromata is prevented in the great majority of cases. The above may be called the preventive treatment — that is, treatment which prevents growth. When this fails, or in cases hav- ing progressed far enough to cause trouble, the treatment required is of an entirely different character. The ways and means may be said to vary from the simplest medication to the most daring surgery, and each method, if judi- ciously adapted to the requirements of cases as they come, gives satisfactory results. Medicinal agents have been employed in great variety, but ergot alone has been found of real value. The action of ergot upon fibromata may accomplish beneficial effects in two ways. By excit- ing uterine contractions, it may produce expulsion of the tumor if its relations to the uterine wall are such that it can be expelled. On this account ergot does its best work in the submucous variety of uterine fibromata. In the same way the ergot, by causing con- traction of the uterine walls, may lessen the area of attachment of a subperitoneal fibroma, and arrest or retard its growth by lessening its blood-supply. This view of the beneficial effects of ergot upon the progress of subperitoneal fibromata is based upon the fact that when such tumors are pedunculated they do not, as a rule, grow so fast as when they arc attached to the uterus by a broad base. In this respect the action of ergot is simply to aid in the natural method of disposing of these growths — viz., by expulsion, which in the submucous or intra-uterine variety is often complete, the growth being wholly expelled from the uterus. Ergot also acts in another way to arrest the growth of such tu- mors. By keeping the uterus in a condition of permanent contrac- tion, and by contracting the blood-vessels, the size of the tumor is diminished, and atrophy takes place. In order to obtain the good effects of ergot in this way, it must be given in liberal doses, sufii- cient at least to produce all the contractions of the uterus that the FIBROMA OF THE UTERUS. 371 patient can endure the pains of, and it must be continued for a long time. It sometimes happens that the patient can not take ergot for any length of time without having indigestion and loss of appetite ; occasionally, also, the uterus fails to contract in response to full doses of this drug. In either case it is useless, and should not be con- tinued. In some cases the use of ergot, while it does not diminish the size of the tumor nor aid in its expulsion, appears to retard its growth, and it also controls the bleeding, which is a great gain. When the patient can be guarded against the great loss of blood, she may be enabled to live in comparative comfort and usefulness until the menopause. Electrolysis. — This method takes a high rank among the means of treating fibroma of the uterus. In order to fully comprehend this subject, some knowledge of the elements of electro-physics should be obtained. For this we must refer our readers to the text- books on this subject. Method of applying Electrolysis in the Treatment of Fibroid Tu- mors. — The method of using the current which I have adopted is to pass an electrode into the cavity of the uterus, and insulate that portion of the instrument which rests in the vagina. The other electrode — a broad one — is applied over the abdominal surface where the tumor is located. The electrode in the uterus is con- nected with the negative pole of the battery, and the other with the Fig. 183. — Uterine electrode. positive. The current is then gradually turned on, until it is as strong as the patient can tolerate and is continued for eight or ten minutes. This is repeated every third or fourth day. The electrode which is introduced into the uterus is shaped like a uterine sound. The portion of it which occupies the cavity of the uterus is made of platinum. The rest is copper covered with hard rubber, and over this there is a sheath of rubber, which can be moved for- ward or backward to regulate the length of the portion to be insu- lated, which varies, according to the depth of the canal of the uterus in different cases. Fig. 183 shows this instrument. The electrode which Apostoli uses for the outside of the tumor is composed of sculptors' clay, rolled, cut to a size sufficient to cover the prominent part of the 372 DISEASES OF WOMEN". tnmor, and about half or three quarters of an inch thick. The clay is covered with some thin fabric, like cheese-cloth, to keep it to- gether. This is applied over the abdomen, and then a broad me- tallic plate applied over the clay. This answers very well so far as fitting the rounded abdominal surface, and by its own weight it keeps its place and also protects the skin from irritation. It is not very convenient, however. The clay has to be kept wet all the time, in order to be ready for use when needed. It also requires to be made M-arm in cold weather, and is not very clean to handle. Owing to these inconveniences of the clay, other materials have been used. I employ a sheet of absorbent cotton about half an inch thick when wet, and gently compressed, and over that an electrode made of a number of small metallic plates fastened together with wire. In this way the electrode fits the irregular curves of the ab- dominal walls. Even this is not exactly what I desire. While it is free from the objections of the clay, it does not adapt itself to the body as well as the clay. This leads me to believe that something more convenient than anything now in use may yet be devised. This is the method of using electrolysis in the way which appears to me to be most acceptable, but there are modifications as practiced by some which should be noticed. Some prefer to anassthetize the patient and use a current stronger than the patient could otherwise bear. This may insure more rapid progress in the treatment, but it is perhaps more dangerous and disagreeable to the patient. I prefer a current which the patient can tolerate, and continue it longer at a time and repeat the treat- ment oftener. It not infrequently happens that the cervix uteri is displaced, so that the electrode can not be introduced into the uterine cavity. In such cases a needle-pointed electrode should be thrust into the tumor and the current passed in the usual way. Apostoli speaks of this as making an artificial canal in place of the normal one of the uterus. In order to maintain this canal made by the first puncture, the current used must be strong enough to destroy the tissues in imme- diate contact with the instrument. Should the opening close, another puncture can be made at the next treatment. In cases where there is severe menorrhagia Apostoli recommends the introduction of a positive electrode into the uterus, and the use of a current strong enough to slightly char or dry the mucous mem- brane, and in that way arrest the bleeding. This is no doubt good practice when the bleeding can not be arrested by other means, such as curetting or the application of astringents. FIBROMA OF THE UTERUS. 37i Menorrhagia, when it is present, can sometimes be helped by treating tlie endometrium. The endometritis is often attended witli fungous growths which greatly increase the tendency to haemorrhage. The removal of such fungosities with the curette will often give relief, and the subse- quent application of tincture of iodine to the uterine mucous mem- brane at regular intervals is of service. In order to use the curette and apply the iodine, it is necessary that the cervical canal should be sufficiently large to permit an entrance to the uterine cavity. In some cases the cervical canal is so narrow and the cavity of the uterus so deflected that to reach it is sometimes impossible. In such conditions sufficient drainage after treatment is not obtainable, and hence the very great danger. When expulsion, with or without the use of ergot, has advanced far enough to pedunculate an intra-uterine tumor and dilate the cer- vix uteri, the tumor can be separated from the uterine wall by dividing the pedicle. When the dilatation of the cervix is complete. TOP VIEW. Fig. 184. — Ecraseur. and the tumor is expelled from the uterus and lodged in the vagina (the pedicle still remaining attached to the uterus), the separation and removal of the tumor are quite easy. There are several methods of dividing the pedicle. I prefer to use the wire ecraseur . The galvano-cautery ecraseur has been used, but it is difficult to apply, and it is impossible to avoid burning the uterus and vagina ; it has no advantages over the wire or chain. The ecraseur which I use is modified to suit the wire. The por- tion to which the wire is attached is so arranged that each end of the wire is held fast by a pinching screw, so that the loop of wire can be lengthened or shortened in a moment (Fig. 184). I employ the steel wire used for piano or zither strings, the thickness of the. wire being adapted to the size of the pedicle. The wire has one very great advantage over the chain in being easily applied. It is elastic, and yet stiff enough to be easily made to slip over the tumor to be snared. 374 DISEASES OP WOMEN. Objections to the wire or chain eci^aseur have been raised. There is danger, it has been claimed, of the uterine wall being drawn into the grasp of the chain and a part of it removed, and an opening made directly into the peritoneal cavity. The fact is, that as the wire is tightened around the pedicle the tissues are forced out of its grasp equally on both sides. There is no drawing of the tissues into the grasp of the wire. If there is inversion of the uterus at the point of attachment of the pedicle, the wall of the uterus might be included in the ecraseur wire and removed. This happened once in my own practice, and I believe the same thing has been done by other operators. Fig. 185 shows the condition referred to as it oc- curred in my own patient. The inversion of part of the uterus was not detected before the operation was completed, but an ex- amination of tlie tumor showed that the inverted portion of the uterine No harm came from it. The patient did well, but the greatest anxiety was felt for some time. Sometimes it happens that the tumor, while it protrudes into the vagina to a slight extent, is grasped by the cervix so firmly that the wire of the ecraseur can not be applied. The same difficulty has been encountered when the tumor — the size of a fetal head — is lodged in the vagina. Under such circumstances, the tumor should be reduced by rapidly taking sections of it away with a strong scissors, and then the ecraseur can be used, or if the haemorrhage is not great the base of the tumor should be enucleated. Much care and gentle handling of the enucleating instrument should 1)0 employed, because the muscular wall of the uterus at the point of attachment of the tumor may be absorbed, and the base of the tumor rest upon the peritonaeum. This state of affairs I have found in two cases wliich I treated by enucleation, the histories of which will be given. Fig. 185. — Wall of uterus caught in ec/-«seMr-wire and removed. wall was completely removed. FIBROMA OF THE UTERUS. 375 Intra-uterine fibromata have been treated by enucleation l^efore tliey became pedunculated, and before the cervix was dilated. Dila- tation or descision of the cervix was made and the tumor enucleated. When the tumor was high up the capsule was incised, and ergot given to bring the tumor within reach of the operator. At one time this treatment was quite in vogue in this country. The operation is difficult and dangerous, and the results so unsatis- factory that it was abandoned years ago. Removal of the ovaries for the relief of small fibromata which cause exhausting haemorrhage has given satisfactory results. This plan of treatment was suggested by the fact that these neoplasms disappear, as a rule, after the menopause. Reasoning from this, it was pi'esnmed that by removing the ovaries, and thereby inducing the cessation of the menstrual function prematurely, the same effect upon the fibromata would be obtained. It was found to be so, and hence in properly selected cases the removal of the ovaries gave ■excellent results. Since hysterectomy has been perfected the re- moval of the ovaries for the cure of fibroids has been abandoned by the vast majority of surgeons. Supra-vaginal Hysterectomy. — The evolution of this operation is most interesting, and were this work in any degree historical a <3hapter on the subject would be required. In the beginning, the uterus proper was removed, and the cervix left as a pedicle, which along with the broad ligaments was included in a clamp and left in the lower end of the wound. It was impos- sible in this way to apply the clamp at the junction of the body and ■cervix without including a part of the bladder or making extreme traction of the outer portion of the broad ligaments. The stump formed in that way was very large and very unsatisfactory. Keith overcame this difficulty by clamping the broad ligaments and sepa- rating them from the uterus, and also dissecting off the bladder in front, when necessary, so that the uterus could be raised up and the clamp applied at the upper portion of the cervix uteri. The broad ligaments, being freed from the fundus uteri, were included in the ■clamp without traction. Many modifications of this extra-peritoneal method of treating were introduced by Hager, Treub, Martin, and •others, but none proved sufficiently satisfactory to stay. Though most excellent results were obtained in this way the convalescence was slow, and Keith and others sought for some way of treating the pedicle by the intra-peritoneal method, the same as in ovariotomy. Schroder, Martin, A. Palmer Dudley, and others, after ligating the broad ligaments, amputated at the junction of the body and the 376 DISEASES OF WOMEN. cervix uteri, and sutured the stump and covered it witli the peri- tonaeum. The results were not equal to those obtained by subsequent im- provements, such as the method of B. F. Baer. His method of operating is so much in advance of the older ways that I quote his own description of it : " After the required abdominal incision is made, all existing ad- hesions of omentum, intestines, etc., are separated in the usual way, and the tumor lifted out of the abdominal cavity. If the incision has been an unusually lengthy one, several sutures are placed at its upper end for the better protection of the intestines. The patient may now be elevated to the Trendelenburg posture, if deemed best, and the parts thoroughly studied, so that a clear idea as to the char- acter and location of the tumor and pedicle may be obtained before the ligation and separation are begun. The first step in the opera- tion is the passing of a single silk suture through the broad ligament, near the cervix. This ligature is again made to transfix the broad ligament near its outer edge, to prevent slipping ; it is then tied. A stout pedicle forceps is next placed under the Fallopian tube and ovary, and made to grasp the broad ligament for the purpose of preventing reflux from the uterus. The ligament is now severed just below the forceps, the incision being carried close to the tissue of the tumor. If deemed necessary, another ligature is now passed through the broad ligament farther down along the side of the cervix. This ligation and cutting are now repeated on the opposite side. The knife is then run lightly around the tumor an inch or two above the peritoneal reflexion of the bladder in front, probably a little lower behind, and the severed edges of the peritonaeum strii)ped down with the handle of the scalpel for the purpose of making peritoneal flaps. The next step is a most important one : it is the ligation of the uterine arteries. This is done in the broad ligaments, outside of but close to the cervix. Care must be taken to avoid the ureter on the one hand and the cervical tissue on the other. The ligature may either be placed within the folds of the severed ligament, or, which is preferable, made to encircle the double fold of the ligament and artery in one sweep ; action here will de- pend upon the size of the pedicle and the consequent separation of these folds. The constant traction which is made- upon the pedicle by the assistant, who is holding the tumor, serves to draw out and elongate the cervix after the peritoneal covering has been incised, and thereby to permit deeper incision into the neck, which is next amputated with the knife by a sort of cupped incision. The stump FIBROMA OF THE UTERUS. 377 is now grasped with a small volsella forceps, and further trimmed and reduced, if necessary, so that the entire supra-vaginal portion is removed before it is dropped back into the pelvis. The cervix being now released, it immediately recedes, and is drawn deeply into the pelvis by the retractive and elastic properties of the vagina, where it is buried out of sight by the peritoneal flaps covering it. These flaps have been rendered so taut by the ligatures which have been placed that usually, as the cervix recedes into the pelvis, they close over it like elastic bands. The cervix is now in its natural position, and without a ligature or suture in its tissues. The operation is finished by infolding the edges of tlie peritoneal flaps, which may be secured by Lembert sutures, if necessary. I have not found this necessary if the ligatures which secured the uterine arteries have also grasped the several folds of the broad ligaments, for this so tightens them that the sides are brought forcibly together when the cervix is drawn under. If any other vessels are found spurting, they are, of course, ligated." Abdominal Hysterectomy. — The operation which I have adopted is that practiced and described by Prof. Howard A. Kelly, of Balti- more. I quote his description in full : " The operation consists in the following steps : " 1. Opening the abdomen. " 2. Ligation of the ovarian vessels near the pelvic brim, either on the right or on the left side, clamping them toward the uterus, and cutting between. " 3. Ligating the round ligament of the same side near the uterus, cutting it free, and connecting the two incisions, in order to open up the top of the broad ligament. "4. Incision through the vesico-uterine peritonaeum from the severed round ligament across to its fellow, freeing the bladder, which is now pushed down with a sponge, so as to expose the supra- vaginal cervix. " 5. Pulling the body of the uterus to the opposite side to ex- pose the uterine artery low down on the side opened up. The vagi- nal portion of the cervix is located with thumb and forefinger, and the uterine artery, seen or felt, is tied just where it leaves the uterus. It is not always necessary to tie the veins. " 6. The cervix is now cut completely across just above the vaginal vault, severing the body of the uterus from the cervical stump, which is left below to close the vault. " Y. As the last fibers of the cervix are severed or pulled apart, while the body of the uterus is being drawn up and rolled out in 378 DISEASES OP WOMEN. Fig. 186. — Showing line of incision through peritonfcum from left to right, through left broad ligament, round ligament, utero-vesical peritonEEum, right round ligament, and ending with right broad liga- ment near the pelvic brim. (Kelly.) the opposite direction, the other uterine artery comes into view and is caught with artery forceps about an inch above the cervical stump. " 8. Rolling the uterine body still farther out, the right round ligament is clamped and cut off, and lastly the ovarian vessels are clamped at the pelvic brim, and the removal of the whole mass, con- sisting of uterus, tubes, and ovaries, is com- pleted. " 9. Ligatures are now applied in place of the forceps holding the uterine artery, round ligament, and ovarian vessels ; if the surgeon prefers, these may be tied as they are exposed without using forceps. " 10. After the enucleation the operation is now finished in the usual way — {a) by closing the cervical tissue over the cervical canal, and then (b) by drawing the peritonaeum of the anterior part of the pelvis (vesical peritonaeum and anterior layers of broad liga- ments) over the entire wound area, and attaching it to the posterior peritonaeum by a continuous catgut suture. " The continuous transverse incision should always be started on the side where the ovarian vessels and the ovary and tube are most accessible. If the case is one of a fibroid uterus, and the tumors are developed under the pelvic peritonaeum or in the broad ligament of one side, this side should be opened up last, from below upward, when the tumors can be rolled up and out with surprising facility. " Displaced ureters will not be injured, for on the side on which the enucleation is started such a ureter is pushed down with the loose peritonaeum as the uterus and tumors are pulled up and toward the opposite side ; and on the other side, no matter how much the ure- ter is displaced out of the pelvis, as tlie tumors caught from below are rolled up and out, the ureter drops down with the peritonaeum and cellular tissue to the pelvic floor, and the operator need not even see it or be aware of its displacement to avoid the risk of in- juring it. " If the ureter is found to be displaced only on one side, the op- eration should begin on the opposite side. FIBROMA OF THE UTERUS. 3Y9 " To escape the danger of tying the ureter on the side on which the uterine artery is caught after dividing the cervix, I am careful to put tlie forceps on the artery well above the cervical stump and to tie there. " The abdominal incision is always closed without drainage by using a continuous catgut suture for the peritonaeum, interrupted Ov.ves. ilouncL lig. Fig. 18*7. — Left ovarian vessels tied, left round ligament tied, vesical peritonfeum divided and pushed down and left uterine vessels ligated. Cervix amputated and uterus pulled up and out, exposing right uterine artery, which is clamped an inch above the cervical stump. The two following steps are clamping the right round ligament and right ovarian vessels, when the mass is removed. (Kelly.) silver- wire sutures for the fascia, a buried continuous catgut suture for the subcutaneous fat, and the subcuticular catgut suture for the skin. " The important points accomplished by this method of operat- ing are {a) the great saving of time, and (b) the simple way in which certain serious complications are met. " {a) Time saved. — According to other methods of operating, half an hour or an hour, or even more, may be consumed in enu- 380 DISEASES OF WOMEN. cleating the tumors and in getting ready to close up the pelvic and abdominal wounds, while by this method the enucleation is often effected in three or four minutes, and in difficult cases in from ten to fifteen minutes. " The experience of every surgeon will bear me out in insisting upon the importance of saving time at this particular stage of the operation — that is, the stage of enucleation — which is most likely, when prolonged, to produce shock and to be accompanied by ex- cessive loss of blood. " Furthermore, when the enucleation of the disease is completed^ all important questions affecting the vital interests of the patient have been answered ; adhesions have been severed, important vessels controlled, intestinal complications dealt with, and tumors developed in situations difficult of access have been removed. In other words^ those factors in the case which often demand an alert judgment and the highest surgical skill have all been dealt with ; the rest of the operation, closing the pelvic wound and the abdominal incision, fol- lows a certain routine which may with safety be left in the hands of a well-trained assistant. '' {b) Complications met. — I have insisted particularly upon the novel way in which serious complications are simplified by this plan of treatment, and I would refer chiefly to two kinds of complica- tions : " First, fibroid tumors located under the peritonseum of the pel- vic floor ; and, " Second, inflammatory masses situated behind the broad liga- ments, with dense adhesions to the pelvic peritonseum, to the rec- tum, and often to the small intestines. " In the case of the subpelvic peritoneal fibroids, it is astonishing how difficult they are to get at from above, and how easily, on the other hand, they roll out when handled from beneath by this pro- cedure. " I would say the same of the inflammatory cases. Matted masses adherent in all directions which resist enucleation from above are often removed with ease when rolled up from the pelvic floor from below. The adherent structures seem to be unrolled in a natural and easy way, in surprising contrast to the difficulties experienced and the injuries inflicted in gaining the slightest finger-hold in pro- ceeding from above. " To recapitulate : Abdomirial hysterectomy by the continuous incision down through one broad ligament across cervix and up through the other broad ligament, is contrasted with hysterectomy FIBROMA OF THE UTERUS. 381 lay an incision down to the cervix through one broad figaraent, and then down througli the other, followed by amputation of the cervix. " The special advantages offered by this method of operating are : " 1. The saving of from sixtj^ to eighty per cent of the time in the enucleating stage of operation. " 2. The ease with which intra-ligamentary myomata and myo- mata beneath the pelvic peritonaeum may be enucleated. " 3. The ease with which inflammatory masses posterior to the broad ligament may be enucleated by attacking them from below after dividing the cervix. "4. The control of a displaced ureter, on the side last opened up, keeping it out of the. way of injury by the simple mechanism of the operation.'' Traction and Morcellation. — Dr. Emmet, I believe, was the first to operate by the method which he calls traction and morcellation, lutra-uterine tumors that have, in the progress of expulsion, di- lated the cervix, but are sessile — that is, attached to the uterus by a broad base — should be removed, be enucleated. That operation is performed as follows : The patient is placed in Sims's position or in the lithotomy position, according to the preference of the operator, and the parts exposed. The capsule is divided at the presenting portion of the tumor with the knife, or, if very vascular, with the cautery. The tumor is seized with a double tenaculum forceps, and, while making traction, the tumor is separated from its attachments by enucleation. A variety of instruments have been invented and used for enucleating, but I have found most of them poorly adapted to the purpose. I use with satisfaction the dry dissector, well known in general surgery, but made larger and longer. The blades are wedge-shaped and rounded on the sides, and one is blunt and the other provided with very fine saw teeth. The blunt blade or end of the instrument is used in operating upon hard tumors when the capsule is easily separated. The blade with the teeth is required when the capsule is more firmly attached to the tumor. It is always easier and better to enucleate the tumor in mass, and yet when one is too large for this it can be reduced by morcellation. Having completed the enucleation, the capsule should be removed if it does not retract but remains dangling in the cavity of the uterus. That is done by gathering together the edges of the opening at its lower part, seizing it in a forceps, twisting it, and then passing the wire loop around its upper portion and removing it with the ecraseur. This is a most important part of the operation. If the capsule 382 ■ DISEASES OF WOMEN. is left it may slough, and give much trouble. Again, packing suffi- cient for drainage is used. This part of the operation should be done quickly, because the uterus contracts in time and makes it diffi- cult to place the packing. ILLUSTRATIVE CASES. Fibroma of the Uterus ; Recovery without Treatment. — This case illustrates a class, not by any means large, in which the disease runs its course without causing much discomfort or impairing the health to any great extent, and without being influenced by treatment. The patient was highly nervous and very active, had a good consti- tution, and enjoyed good health. When she was about thirty years old her menstrual flow became more free than formerly. She had up to that time been quite regular and normal in regard to menstru- ation. This slight menorrhagia continued, and occasionally was quite profuse. She also had backache and pelvic tenesmus, which rendered her less active and enduring than in her earlier life. I flrst saw her professionally when she was thirty-one years of age. She was then single and enjoying fair health. I supposed that she might have a fibroma of the uterus from the history, and suggested that I should find out by examination the exact condition. This she objected to. From this onward she continued about the same. The menor- rhagia continued, and she had at times dysmenorrhoea and leucor- rhoea, but all of these did not impair her health or usefulness suf- ficiently to make her willing to submit to treatment. At forty years of age she married, and then her symptoms increased consid- erably, but in the intermenstrual periods she was fairly well. Four years after her marriage she had an attack of malarial fever of a mild order, and then the menorrhagia and dysmenorrhoea became worse, and I then had an opportunity to examine her, and found that there was a fibroma in the posterior wall of the uterus, probably inter- stitial. She soon recovered from the malaria and its effects, and then her uterine troubles became as the}" had been formerly. About this time I made an application of iodine to the cavity of the uterus, but as she improved she did not return for further treatment. I saw her occasionally while visiting other members of her family, and heard that she was about the same as formerly. According to her own statement, she was not at any time quite well, but not ill enough to be willing to be treated. When she was forty-nine she again consulted me, and I then found that the men- strual flow had been diminished for over one year, and had been ab- sent altogether for three months. She was quite nervous and resf; FIBROMA OF THE UTERUS. 383 less, just as many are at the menopause. I examined tlie uterus, and found that the fibroma had almost disappeared. The uterus was much larger, at least twice as large as it should be after the menopause, but not one third the size that it was when I first ex- amined the case. I have seen her since, and find that she is quite well. Interstitial Fibroma of Large Size, complicated with Endometritis ; treated by Tincture of Iodine to the Endometrium, Ergot during the Menstrual Period, and Mild Continuous Current of Electricity. — A strong and vigorous lady who had always enjoyed good health until after she was twenty-five years old, was first seen when she was thirty-one. She was married at twenty-six, and soon thereafter began to menstruate too freely ; she never was pregnant. When first seen she was prostrated with a severe menorrhagia. I then ob- tained the facts given above, and also learned that she had sufliered from pelvic pain, leucorrhoea, backache, and a gradually increasing menstrual flow until the time I saw her, when she was quite ex- hausted. The uterus and tumor extended upward to half-way be- tween the pubes and umbilicus. Stimulants and ergot were given, but the flow continued, and then the tampon was used, which stojjped it. She improved from this time, quite perceptibly, but was pulled down at the next period, though not to so low a point as before. She was then put under treatment for the endometritis. The hot-water douche was tried, and the whole endometrium touched with tincture of iodine. In order to do this it was necessary to dilate the os exter- num, and then by using the pipette, the application could be made very thoroughly. There was at first considerable catarrh of the cer- vix, and for that a few applications of tincture of iodine and carbolic acid, equal parts, were made. Under this treatment the menstrual flow became less free, although the tumor increased slightly in size. After remaining under treatment intermittently for about two years, she was induced to place herself under the care of a physician who made the acquaintance of her husband. This gentleman treated her twice a week with a mild continuous current of electricity, which he passed through the tumor by placing one electrode upon the ab- domen and the other upon the back. Three quarters of a year were occupied in this way, but without any improvement ; she neither gained nor lost, except that her flow was more free. She returned to my care again, and I resumed the treatment of the endometritis with iodine ; I also continued the elec- tricity, but did so by procuring a battery for the patient, and having one of my assistants teach her how to use it. In place of applying 384 DISEASES OF WOMEN. it twice a week, as the doctor had done, she used it every day, and I am satisfied that she used it as effectually as the doctor. This treatment was kept up for two years. Whenever her menses became very free, or if the leucorrhoea returned, she came for treat- ment, otherwise she used the electricity alone. The tumor had diminished perceptibly, but her general improvement was out of proportion to local changes, excepting that the endometritis was re- lieved. After this she went to live in the country, and was not seen again until she was forty -six years old. I then found that the menses were normal, and that the tumor was very much reduced. When first seen, I could with ease introduce the sound into the uterus seven and a half inches, while at the age of forty-six the cavity of the uterus measured less than four inches. Interstitial Fibroma of the Uterus treated with Ergot ; Eecovery. — This patient was thirty-four years old, married, and had one child when she was twenty-three years old. After its birth she suffered from leucorrhoea and backache, but did not have any treatment until she was twenty-seven years of age. She then began to menstruate too freely, and was treated by her physician, but without effect. The menorrhagia, while it depressed her, did not disable her alto- gether, so she went about her duties until she noticed a tumor in the abdomen ; she then came to me for advice. I found the uterus en- larged, extending upward to within two inches of the umbilicus. The cavity of the uterus was detiected to the right and backward, and the sound passed to the depth of seven inches. The fibroma occupied the left anterior wall and projected considerably to the left, giving to the whole mass (uterus and tumor) an irregular out- line. There was some endometritis, and the patient was slightly anae- mic, but otherwise her health was good. Half a drachm of fluid extract of ergot was given before meals, for about a month, in the hope that it might incline the tumor toward the cavity of the uterus, and by partially expelling it bring it within reach for the operation of enucleation. At the end of a month there was no change in the position of the tumor ; ergot was then used hypoder- mically about twenty minims every third day. This excited strong uterine contractions, which lasted for about an hour or more each time. This treatment was continued for three weeks, but without changing the position of the tumor, though it diminished in size. The hypodermic use of the ergot was then given up, because the patient became tired of the pain it caused. She continued to take the quantity first given by tlie mouth for seven or eight weeks, and FIBROMA OF THE UTERUS. 385 the tumor continued to decrease in size. The hypodermic use of the ergot was tried again for nearly a month, but was only used every fourth day. At the end of three months all treatment was stopped because the patient's digestion became impaired. She was kept upon tonic treatment for a time until her general condition improved, and again the ergot was resumed, using it hypodermically and by the mouth alternately. The menorrhagia gradually subsided, and at the end of six months the tumor had diminished over two thirds of its former size. The cavity of the uterns was only three and three quarter inches in depth. No further treatment was deemed neces- sary. Three years after the treatment was suspended the patient was in good health, and her menses were regular. The uterus was above the average size, but not much so. The left wall was more than twice the thickness of the other, so that there was a trace of the fibroma remaining, but it was harmless. "While the object for which the ergot was originally given was not attained a happier result followed. The ergot so influenced the nutrition of the growth as to cause dropsy. This is a rare effect of ergot, and yet it sometimes is pro- duced in certain cases. Submucous Fibroma ; Expulsion by the Natural Efforts ; Separation of the Pedicle with the Ecraseur ; Recovery. — The patient was un- married and thirty-five years old ; she was large, strong, and had always had good health. She began to menstruate at fourteen, and continued to do so in a perfectly normal way until she was twenty- eight years old. At that time the menstrual flow became more free and lasted a little longer. From this time onward, the menstrual flow gradually but not regularly increased, until she established a well-marked menorrhagia. This undermined her health consider- ably. She lost flesh, and became quite anaemic. She had charge of a branch of a large business establishment, and was an efficient and trusted employe, but her duties became very trying to her, espe- cially at her menstrual periods, at which times she was obliged to stay at home occasionally. Still she persisted in her work until she was taken ill and confined to her bed. She called in a poorly-quali- fied physician who failed to relieve her ; subsequently her employer requested me to take her in charge. I found the uterus enlarged from the pressure of a fibroma, which was evidently intra-uterine. She also had all the signs and symptoms of a pelvic cellulitis in the left, broad ligament. This terminated in resolution, and in about two weeks she was able to be around again. Although still weak, she returned to her duties, but her menorrhagia continued. Every 20 386 DISEASES OF WOMEN. effort was made by tonics and good food to improve her strength. She was requested to rest at her menstrual periods, and to take ergot and cannabis Indica in moderate doses at such times. She con- tinued to be quite anaemic, but dragged along with her work as best she could. I saw her only occasionally, and found that the tumor did not grow very fast, and she did not lose much in general strengtli. This went on for six years, when she began to have se- vere pains from uterine contractions ; for this I saw her and sug- gested that she should give up the use of ergot. I did not see her again for about five months, when I was called in haste to her, and found her suffering from great expulsive pains. She told me that it was time for her to menstruate, but she had had very little flow, but instead these extreme j^ins. Examining the abdomen, I found that the size of the uterus* was greatly increased, and that in the absence of uterine contractions, there was distinct fluctuation at the upper third of the uterus. I presumed that the fluctuating mass was a cyst which had rapidly developed since the time that I had seen her before. On making a vaginal examination, I found the cervix dilated about two inches and a solid fibroma protruding at the OS externum. Opium was given to ease the pain which was ex- hausting her, and at the end of twelve hours I found that although the pains had modified a little, they had continued. The dilatation of the cervix had progressed. The opium was continued in large doses. It was then night, and I desired her to sleep. The night was passed fairly well, she had pains, but slept between them. Next day the opium was suspended and the pains returned with renewed vigor. Toward evening, after having several violent pains, they ceased, but were followed by the most distressing pressure upon the rectum and bladder. There was no cessation to this suffering, and I was called in haste to see her. I found the tumor the size of a fetal head, pressing upon the perinseum and firmly impacted in the pelvis. The fluctuating mass was still felt in the pelvis but lower down. Her sufferings were such from the complete obstruc- tion of the rectum and bladder that immediate relief was de- manded. She was at once conveyed to a private room in the hospital, and the removal of the tumor effected. The operation was as follows : It was impossil)le to determine the location or character of the attachment of the tumor, nor could I pass the chain of the ecraseur over it, so firmly was it fixed in the vagina. To avoid incision of the pelvic floor and delivery of the tumor en masse — a very bad method which has been practiced — I determined to diminish the FIBROMA OF THE UTERUS. 38Y size of tliG mass bj exsection with tlie scissors and forceps. It was nic^lit, so I liad to use artificial light reflected from the head-mirror. Through Sims's speculum it was easy to cut away enough to enaljle me to determine that the pedicle was not large, and that the chain of the ecraseur could be passed. While making this examination, and also while adjusting the chain, there was considerable discharge of dark blood from above the tumor. The pedicle was easily di- vided, and the remains of the tumor were further reduced, so that it could be brought through the vulva without laceration. The re- moval of the mass was followed by a gush of dark blood, at least a pint in all, and there were several clots which remained in the vagiua. These were raj)idly removed, and then I could see the distended and empty uterus. The blood had accumulated in the uterus above the tumor, and given rise to the fluctuation and rapid increase in the size of the uterus which I had observed. "With the hght reflected from the head-mirror I was able to ex- amine the entire cavity of the uterus most thoroughly. By holding the lips of the os externum apart with an elevator and sponge-holder, the view of the interior of the uterus was complete. The site of the attachment of the tumor could be clearly seen, and the gradual contraction of the uterus was also noted. There was nothing of interest in the after-history of the case. The patient made a good recovery, and gradually regained her health and strength. It is now four years since the operation, and she has continued in perfect health. Uterine Fibroma, supposed to be a Uterine Fibro-Cyst ; Death from Septicaemia during the Process of Expulsion. — An unmarried lady of somewhat delicate organization came under my observation when she was thirty years of age ; she said that five years previously she began to suffer from menorrhagia, and soon afterward began to ob- serve a gradual increase in the size of the abdomen. When first seen, the tumor was about the size of the uterus at the seventh month of gestation ; all the physical signs of a submucous fibroma were obtained. Her general health was somewhat impaired, she was anaemic, owing to the menorrhagia, which was not excessive ; otherwise she was in fairly good health, and, as her circumstances in life were good, she was able to be around and enjoy life. She was placed upon a general tonic treatment, with the use of ergot and cannabis Indica, which were given at the menstrual period. She continued for three years to do fairly well, occasionally having an attack of menorrhagia, which pulled her down a little, but she readily recovered from this, and went about in her usual way. 388 DISEASES OP WOMEN. She was seen only occasionally, and the general plan of treatment was not changed. About the fonrth year after she came mider my observation, she had an attack of menorrhagia which was rather more severe than usual, and she took larger doses of ergot, and continued the remedy longer than was her habit. This controlled the menorrhagia but produced severe uterine pain, for which I was called to prescribe. I then carefully examined the tumor and found that it had increased in size considerably from the time 1 had seen her before — about four or five months. I found that the upper portion of the tumor was quite elastic, and that there was distinct fluctuation extending through an area of about five inches. I then suspected a fibro- cyst. Soon after this she was seen by my distinguished friend, Dr. T.-G. Thomas, who, without knowing of the patient's history or my own opinion, made the diagnosis of fibro-cyst. During the remainder of that winter and the next spring she had more menorrhagia, and was kept more continually under the influence of ergot; when summer came she had regained some of her former strength, and went to the country, where she remained for several months. She returned in the autumn slightly improved, but about a month afterward began to suffer from severe pains, due to uterine contractions. These pains increased in severity and frequency, until she was unable to leave her room. She then sent for me, when to my surprise I found the cervix uteri fully dilated and the tumor partially expelled from the utenis, occupying and completely fiUing the vagina. The ergot was suspended, and she was relieved from her severe pain by the use of opium, but the pressure upon the pelvic organs became so great that it was necessary to try and relieve her. The lower por- tion or capsule of the tumor began to slough, and I then determined to remove all of the tumor, or as much of it as possible. In the mean time the uterus as examined through the abdominal wall had not diminished very much in size, and the fluctuation was more marked and more extensive. She was at this time very anaemic, and so weak that I dared not anaesthetize her. So I proceeded without doing so, with the patient in Sims's position, and with the aid of Sims's speculum I rapidly removed all that portion of the tumor which occupied the vagina, using the tenaculum forceps and ha?rao- static scissors. There was very little haemorrliage, and the patient derived very great relief from the removal of this portion. She wap permitted to rest for a few days and ergot was again given, which produced expulsion of another mass about as large as the one that FIBROMA OF THE UTERUS. 389 had been expelled, this was removed in the same waj as the other 5 while removing a portion which extended up into the cervix uteri, about five or six ounces of lluid escaped from the cavity of the uterus. Immediately after this it was found that the fluctuation was greatly lessened, and the size of the tumor, as observed through the abdominal walls, had markedly diminished. She had after this con- siderable fever and disturbance of the stomach, and this, along with her marked anaemia, prostrated her so that nothing could be done for nearly a week but to sustain her. At the end of that time her temperature diminished somewhat, she was able to take nourishment and stimulants, and as considerable more of the tumor had been ex- pelled, a third attempt was made to remove it. I was able to re- move all that portion outside of the cervix ; I then endeavored to remove a portion that was still within the grasp of the cervix ; as soon as I did this, about four ounces of putrid matter w^re discharged from the uterus. Although there was not much haemorrhage, and the patient did not complain of pain, she was so much exhausted and her pulse was so feeble that I was obliged to desist, feeling confident that if I undertook to remove the remainder of the tumor, the patient would succumb. The cavity of the uterus was carefully washed out with carbolized water, and the patient put to bed and stimulated and nourished as well as possible. Two days afterward, when she had rallied considerably, I found that the lower por- tion of the cervix had contracted around the tumor, and that it was breaking down and decomposing. I thoroughly and repeatedly washed out the inner cavity of the uterus, and hoped by so doing to control the septicaemia from which she was suffering in a most marked degree. I also felt confident that if I could bring her strength up again that I might be able to remove the whole of the tumor. But this proved to be impossible, although the uterus con- tracted again, in fact, sufiiciently expelled the tumor to partially dilate the cervix. She at no time was in any condition to bear so formidable an operation as' completing the enucleation of the tumor. The septicaemia still proceeded, and she died about five years from the time that she first came under my observation. On post-tnortem examination it was found that a portion of the fibroma as large as a fetal head remained, and was attached at the posterior and right lateral wall of the uterus, and that it closed the cavity very thoroughly by pressure, and that there was still a little fluid in the fundus uteri. It was clearly evident from this, that this obstruction of the canal below and the distention of the cavity of the uterus above, which gave rise to the fluctuation obtained at her 390 DISEASES OF WOMEN. examination, explained the resemblance of the physical signs to those obtained in the uterine libro cysts. It is a number of years since this case came under my observa- tion, and I am satisfied that had I known then as much as I know now about the management of such cases I should probably have been able to save her. As it is, I still think that had she sent for me when she returaed from the country, and before her strength became so much exhausted from the efforts at expulsion, I might have been able to remove the whole of the tumor ; but it was otherwise. A Case of Submucous Fibroma m which Pregnancy progressed to Full Time, and the Tumor was completely expelled about a Week after Confinement. — This case was seen in consultation with Dr. Bodkin, who, when called to attend her in confinement, found a soHd tumor which so completely filled the pelvis that he could not reach the os 'uteri. The labor-pains continued, the membranes ruptured, and the cord became prolapsed. The tumor was recognized as a fibroma which extended down into the cervix and at the same time upward toward the fundus. It was a long, naiTOW tumor which may have assumed that shape by stretching during the growth of the pregnant uterus. We agreed to try to deliver by version. Accordingly, when the patient was anaesthetized the doctor succeeded in pushing up the tumor out of the pelvis, and passing his hand past the tumor and through the os, which was quite dilatable, he turned and delivered. I then took charge of the placenta, which was retained for some time. To facilitate its delivery and at the same time to investigate the tumor, I passed my hand into the uterus and was able to make out by bimanual touch the size and location of the tumor. It was oblong, as already stated, and situated in the anterior wall a little to the left side, and extended from the cervix nearly to the fundus, and evidently was immediately beneath the mucous membrane. The patient did very well considering all things ; she had con- siderable hsemorrhage at the time, and the discharge afterward was free and at times offensive, and she had long-continued after-pains. About seven or eight days after her confinement she had an at- tack of tenesmus, and in the hope of obtaining relief she got up to the commode, and by vigorous expulsive efforts expelled the tumor. It was much shrunken, no doubt, but even then the doctor estimated that it was about seven inches in length and three inches in diam- eter. She subsequently did well. In this connection it may be stated that uterine fibromata cause sterility, as a rule, owing perhaps to the endometritis which is usu- FIBROMA OF THE UTERUS. 391 ally present, and when pregnancy takes place miscarriage generally occurs. Still, I have seen at least four cases that went to full time. In all except the one recorded above the tumors were subperitoneal and not large. Extreme Dilatation of the Cervix Uteri and Expulsion of a Sub- mucous Fibroma while only Slightly Pedunculated; The Case diag- nosticated as Inversion of the Uteras; Operation and Recovery. — This patient came to my hospital clinic and gave a history of menor- rhagia for years, and for several months past a metrorrhagia and uterine pain. She was quite anaemic, but had always been w^ell and strong until the excessive menstruation came. She also stated that she visited the outdoor department of the Woman's Hospital of Kew York, and the gentleman who saw her said that her womb was turned inside out, that she should enter the hospital for operation, and that her case was a dangerous one. I presumed that the diagnosis made was inversion of the uterus, and on asking, the doctor about the case he told me that he beheved it to be so. On my first examination I found a tumor in the va- gina which, in size and shape, was exactly like an inverted uterus. The mass was covered with uterine mucous membrane. Absence of the fundus and body of the uterus in the upper part of the pel- vis was observed by the bimanual touch. That portion of the mass which was uppermost was larger than that which is usually found in inversion of the uterus, but in the center of it there was a slight depression which is generally found in inversion. Passing the sound around the tumor gave evidence that the vagina was at- tached to the upper part of the tumor, but by pressing the tumor to one side and separating the vagina from it, I could see that there was uterine mucous membrane above the vagina, which extended upward, inward, and over the tumor. By seizing the tumor and twisting it round upon its axis, I also observed that the upper part of the vagina did not move with it as would have been the case if there had been inversion of the uterus. From these signs I con- cluded that the tumor was a fibroma, with a small but very short pedicle attached to the fundus uteri, and that the cervix and lower portion of the uterus were so completely dilated that the vaginal and uterine walls were continuous. I presume, that in time, the tumor would have dragged the fun- dus uteri downward and produced inversion. This has occurred. In fact, it is not an unusual thing to find a partial inversion of the uterus caused by fibromata during their expulsion. The pedicle was divided with the ecraseur and the tumor re- 392 DISEASES OF WOMEN. moved. The cavity of tlie uterus then appeared like a cup-shaped dome at the termination of the vagina. A sjDonge, in a holder, was gently pressed against the fundus uteri, and held there until the uterus contracted^ which it did quite slowly. This was done to pre- vent a possible inversion from taking place. The j^atient recov- ered very promptly. Soft Fibroma ; Atrophy of the Muscular "Wall of the Uterus at the Point of Attachment of the Tumor ; Enucleation after Dilatation of the Cervix Uteri and Partial Expulsion; Recovery. — The patient was forty-nine years old, married, and had had two children, the last one sixteen years before the time when she came under my care. She was a strong, healthy lady, and had been wel. until she was about forty-live years of age. At that time she began to menstruate more freely than at any previous time in her life, but being told that it was due to " change of life " she did nothing for it, until she became so weak that she sought advice of a practitioner who treated her locally for ulceration of the cervix which he said she liad. She grew worse, the bleeding was more free and lasted longer at each period, and she had a profuse watery discharge at other times. Then uterine pains came on, which she said were like the first pains of labor. This was the history which I obtained when called to see her the first time. On examination I found the cervix well dilated, and part of a soft fibroma occupying and filling the upper part of the vagina. The pressure gave her much discomfort, and I found that the por- tion in the uterus was quite as large as that Avhich occupied the vagina. Without giving the patient an anaesthetic, I removed all that was outside of the uterus with the ecraseur. There was no pain and very little bleeding caused by the operation. The patient being fatigued by remaining in Sims's position I did nothing more for two days, and at the end of that time the larger part of the mass was expelled from the uterus. It was oblong but not pedun- culated. All that was protruding from the os externum was re- moved with the ecraseur, and the stump was seized with a double tenaculum forceps and enucleated. Traction being made with the forcejis the mass was separated from the capsule with a blunt cu- rette. There was very little pain caused until the mass was sepa- rated all round and the deepest attachment w-as reached. Then the patient began to conij)lain. This was fortunate, because it made me very careful. I simply made steady traction and counter-pressure with the curette. When the mass came away I could see the peri- tonaeum very plainly at the bottom of the cavity. My assistant FIBROMA OF THE UTERUS. 393 also observed it, and recognizing what it was, lie naturally was quite anxious. A space, about the size of a twentj-hve cent piece was ex- posed. It had not been wounded at all, but appeared as if it had separated from the tumor very easily. To make sure that there was no mistake I examined by the touch and found the parts exactly as tliey appeared to be on inspection. Submucous Fibroma of Large Size extending through the Uterine Wall to the Peritonaeum ; treated first by Partial Exsection with the Galvano-Cautery and Several Years after by Enucleation ; Recovery. — This was a hospital case which I saw with Dr. Gushing. The tumor was large, and extended down into the cervix on one side and could be easily reached. The patient was suffering greatly from bleed- ing. Partial excision was made by passing two large curved needles through a section of the tumor, and then passing the wire be- low the needles, and cutting it off by heating the wire. Section after section was removed in this way, until all that portion which could be reached conveniently was removed, about two thirds of the whole, perhaps. The operation was long, and I did not think it prudent to continue the efforts to remove the whole mass. Recov- ery from the operation was without interruption, and the patient was much improved. The menorrhagia subsided, she gained her former strength, and was able to make her living as a laundress. In a few years the tumor had grown again, and all the old symptoms returned and were worse than ever. Dr. Gushing had to see her for several attacks of menorrhagia, which nearly proved fatal. She then came into the hospital. The tumor was nearly as large as it was before, and she was extremely feeble and angemic. There was a cardiac mitral murmur. The officers of the hospital strongly advised that I should not operate, and I would have gladly followed their advice, but the patient begged that I should try again to help her, and I agreed to do so. The tumor was low down in the pelvis and projected beyond the opposite side of the cervix. Ether was given, and the pulse improved a little under its influ- ence. The capsule was divided with the thermo- cautery, and sepa- rated from the tumor over its exposed portion. A strong forceps was fixed in the mass, and while strong traction was being made the enucleation was performed with the spoon-saw of Thomas. When I had nearly completed the separation, I noticed that there was very little resistance on the part of the uterine wall at the upper part ; I then made a bimanual examination and found that I had passed through the muscular coat of the uterus entirely. I was fearful that if I made any further effort to complete the 394 DISEASES OF WOMEN. enucleation I might wound the peritonaeum. The detached por- tion was separated from the rest, and the operation stopped. The portion left was about the size of a hen's egg. There was not much bleeding, but I can only saj that the patient was living when she was put to bed. The uterus contracted fairly well. There was no further haemorrhage, but a free disci large of serum continued for a number of days. I felt sorry that I had not been able to remove the whole of the tumor, but was glad that her life had been spared. She improved slowly in strength, and was able to leave the hospital in three weeks. The heart-murmur, which was presumed to be largely due to her extreme anaemia, proved to be due to mitral in- sufficiency, and although she had no more trouble from menorrhagia, she did not fully regain her strength. She took up her old occu- pation, but it was more than her strength could endure. A little over two years after the operation she died suddenly of heart-fail- ure. The post-mortem revealed the heart lesions which proved fatal. The part of the tumor which was left had not grown, in fact, it jDrobably had diminished. The scar at the point of the deepest enucleation showed that there was no middle coat of the uterus at the side of attachment of the tumor. These facts proved conclusively that in operating I had gone through to the perito- naeum, as I thought I did at the time. The following cases, treated by hysterectomy, are from the work of Dr. Thomas Keith : Large Solid Fibroid, Weight, Forty-two Pounds ; Supra-Vaginal Hysterectomy; Recovery. (Keith).— Mary C, aged twenty-eight, was sent into the Royal Infirmary by Dr. Robertson, of Ardros- san. She had sought relief in many quarters in vain. The tumor was very large, and was fii'st noticed five or six years before. She was wasted about the chest and arms, like a case of old ovarian disease. The abdomen measured forty-nine inches at the umbilicus ; the tumor was firm and solid throughout. The ensiform cartilage was turned upward, and the growth extended under the sternum and ribs; close to the sternum there was a large projection the size of a child's head. No trace of the ovaries could be detected. The greater part of the pelvis was occupied by the tumor. There was no dis- tinct cervix, only a small triangular projection drawn to the left side, almost beyond reach of the finger. For several years no great inconvenience had resulted ; menstruation was nevQr in excess, and for the last fifteen months it had entirely ceased ; since then, the increase in the tumor had been rapid, and she could do little or noth- FIBROMA OF THE UTERUS. 395 ing owing to its weight. She sat all day knitting ; at twenty-eight, her life-prospects were anything but bright. For obvious reasons, this j)atient was not taken down to the large tlieati-e, but was operated on in the ward, on the 18th of April, 1881. Sulphuric ether was given, and the operation was performed under carbolic-acid spray. The sponges, thirty in number, had been lying for a long time in a five-per-cent solution of carbolic acid ; they were washed in hot water, and then put into a two-per- cent solution, and wrung almost dry. These were used over and over again, and were not washed in any fresh solution during the operation. Dr. Wilson was present from Glasgow, and there were about twenty visitors and students. The first incision measured twelve inches ; it terminated four inches above the pubes, so as to avoid the bladder, which was to be elevated on the tumor. On the right side, the broad ligament rose as high as the crest of the ilium. The left broad ligament was largely spread over the half of the tumor as high up as the ribs. The opening was then enlarged to twenty-two inches, and, by dint of hard pushing and patience, the huge mass was slowly moved forward as far as its connection on the left side would permit. The right ovary was easily seen. On searching for the left, it was found to be transformed into a long, tense, umbilical -like cord, seven or eight inches in length. Here and there along this tense band were several small cysts. It was so imbedded in the tumor that it never could have been removed. The right, broad ligament was transfixed by soft-iron wires, secured and divided ; all bleeding from the tumor was prevented by a series of strong-locking forceps. The fibroid was now more easily dealt with. It was drawn for- ward, so as to put on the stretch its enormous connection on the left side. About a dozen powerful-locking forceps, ten inches in length, were now applied to the broad ligament before and behind. The whole was then cut downward, and the mass enucleated as low as possible. A strong, soft-iron ligature embraced the base, which was of great thickness. The tumor was then cut away, the stump showing a section of the cervix in the centei. The forceps were removed one by one, and all bleeding vessels separately tied. Some of these were large, and one threw blood over the assistant's head. There was much trouble in finding some bleeding points among the loose cellular tissue of the huge gap now left. The haemorrhage was mostly venous. All present could see that the condition was full of danger, and that secondary hiwmorrhage 396 DISEASES OF WOMEN. into this loose tissue was not one of tlie smallest risks of the opera- tion. When all oozing seemed to have ceased, the stump (the thick- ness of the leg) and the end of the right, broad ligament were se- cured, with much tension, outside; a glass drainage-tube was iixed in above the stump, and the wound closed by forty silk sutures. The operation lasted one hour and three quarters. After much blood and serum had escaped from the tumor, its weight was forty- two pounds. Ten hours after the operation, five ounces and a half of sirupy blood were removed from the pelvis through the tube. The pulse was 94 ; the temperature 102*2° ; rising two hours afterward to 103'4°. During the night, back-pain was relieved by injections of morphia. The first day was passed fairly well. In the evening the pulse was 126, and the temperature 102'2° ; flatulence was troublesome. She felt w^eak, and had whisky and water to drink. There were only four ounces of bloody serum from the tube. On the third morning, the pulse was 120, and the temperature 104°. On the fourth day, the pulse was 114 to 125 ; the temperature ranged from 101° to 103-5°. On the fifth day, after a restless night, the temperature had risen to 106° ; it fell to 104°, and again in the afternoon it rose to 105-5.° There was OBdema of the labia, and much cellular infiltration in the pelvis. She looked very ill during these days, not caring for food, though taking stimulants freely ; on the sixth day the pulse dropped to 92, and the temjDerature also fell to 101-6°. The tube was re- moved, there being only a tablespoonful of reddish serum in the pelvis. On the ninth day the wound was found healed throughout. The stump was dry and sweet. The pulse and temperature almost normal. In the tliird week there was again a rise of pulse, and of tem- perature from 101° to 103.° This continued for ten days, and caused some anxiety. On the eighteenth day, the wii-es were loose and were removed. The loop was two inches and three quarters in diameter. Seven weeks after the operation she left the hospital. She is now a strong woman, in ]ierfect health, and can do anything. Soft Bleeding Fibroid; Intra-Peritoneal Treatment of Pedicle; Recovery. (Keith).— In 1876, Dr. Kidd, of Alyth, sent me an un- married woman — a domestic servant — with a fibrous tumor, low in the pelvis and extending to the umbilicus. She was no longer able for FIBROMA OF THE UTERUS. 397 her situation, partly from pain and partly from excess at the menstrual periods. She was twenty-nine years of age, and of fairly healthy appearance. I advised her to delay interference, unless such be- came absolutely necessary. After three years she came again, very anxious for relief. She was much changed ; the tumor now tilled the abdomen ; she was extremely anaemic, and quite unfit to make her living in any way. The tumor varied much in size : very large and tense before menstruation, much smaller and softer after this was over. The loss of blood was sometimes very great. Operation was on July 16, 1879. Carbolic spray was used. An incision not exceeding ten inches was made ; by taking time, the tumor molded and could be pushed through the opening. Both broad ligaments extended up to the fundus of the tumor on a level with the ribs. The portion containing the ovarian vessels was first transfixed and ligatured, locking-forceps being put on close to the tumor, before the ligament was divided. The same process was repeated on the other side. The tumor was then separated down- ward all around from its cellular attachments, and a soft-iron wire, secured quite low down — in this case, almost round the top of the vagina — by Koeberle's instrument. There was thus left a large cavity, from which the pelvic portion of the tumor had been shelled out. Koeberle's instrument — five and a half inches in length — was left dipping into the pelvis, as it could not be secured outside. There was little bleeding from the separated surfaces, and the wound was kept as open as possible around the instrument, to allow of the escape of serum. The operation lasted one hour and a quarter. There was a good deal of pain, and several opiates were required during the afternoon, There was very free perspiration for some days. The highest pulse reached was 124, about thirty hours after the operation ; the highest temperature was 100*5°. Recovery was uninterrupted. The serre- noeud came away with the slough in ten days ; she returned home thirty-two days after the operation, the wound being quite cicatrized for some days. The tumor was a soft, oedematous fibroid, and weighed nineteen pounds. This patient has enjoyed perfect health since the operation. Fibrous Tumor of Uterus, containing an Inflamed, Suppurating Cavity; Operation; Recovery. (Keith). — An unmarried woman, aged forty-four, was admitted into the Royal Infirmary in February, 1874, under Dr. Matthews Duncan. She was a pale, thin, un- healthy looking woman. She had granular, everted eyelids, and was half -blind from inflammation of the cornea. Up till the pre- 398 DISEASES OF WOMEN. vioTis June her health was fairly good. She was then obh'ged to give up her situation as cook in London, where she had hved for more than twenty years. Menstruation was regular and normal. Five weeks before ad- mission a tumor was detected. It was hard, elastic, quite fixed, and reached to the umbiHcus. The cervix was drawn to the left side of the pelvis ; it was almost beyond reach of the finger, and felt as if lost in the tumor. This was supposed to be ovarian. I never had any doubt that the case was one of uterine fibroid, and declined to operate on it. After two months' residence in the hospital she was dismissed, and went to her friends in the north. In the course of the summer she began to write letters to say that she suffered severely, and that the tumor had increased. She was importunate, and wished something tried. At last, wearied by her importunity, she was allowed to come back. The tumor had certainly got much larger ; its appearance was changed. It was very tender now, and had become prominent on the right side, push- ing the loin outward. There was some free fluid. The feeling of elasticity was less marked, while that of a deep, obscure fluctuation was pretty distinct. The relations in the pelvis were the same, the tumor filling the whole upper pelvis. It was everywhere fixed and immovable. On September 5th, a needle was put in at the umbilicus, and sixty ounces of a dark-brown fluid were removed. This was pronounced to be ovarian. There was little apparent diminution of the tumor. Much irritation followed the puncture, and in ten days the tension was greater than ever. The aspirator was again used ; the same quantity of fluid, which was again said to be ovarian was removed. This time much relief followed. She was again sent away, for I had not changed my mind, and still thought the tumor was uterine. She was encouraged to hope that, as menstruation seemed about to cease, the tumor would quiet down. In a few weeks she was back again, urgent for operation at any risk ; her life was miserable from pain, her health had given way, and she had to work that she might live. The case was now quite a clear one for interference, and I willingly agreed to try and remove the tumor, the patient clearly understanding that this might not be accomplished. On December 12th an incision, twelve or fifteen inches was made at once. The tumor was of a dusky-brown color, covered by enor- mous veins. It was firmly attached to the right iliac fossa, right FIBROMA OF THE UTERUS. 399 lumbar region, and to tlie wall from a little below the umbilicus. This extent of adhesion quite accounted for the iixed state which the tumor liad always presented. Upward of four pints of a dirty, black, purulent-looking fluid were removed, the incision was en- larged, and with one strong pull of the arm, pushed in from behind, the adhesions were broken up and the tumor dragged out. So rap- idly was blood lost from huge, torn veins in the capsule, that she became faint. The left ovary only could be included in the wire ligature. From the previous elevation of the cervix, the stump was secured in the lower angle of the wound with less tension than in the iirst case. This part of the operation occupied only a few min- utes, but it was upward of two hours ere the wound was closed. Much trouble arose from stopping bleeding in the torn adhesions, more especially those high up on the insides of the ribs, near the posterior margin of the liver. A glass drainage-tube was left in, passing to the bottom of the pelvis. The patient was pulseless when placed in bed. This was an anxious operation on account of the unusual loss of blood. It is unnecessary to give details of the slow convalescence. The tube was removed on the fourth day, and the whole amount of red serum that came away did not exceed three ounces. This could easily have been absorbed. The pulse had fallen to below 100 by the fifth day^ and there was scarcely any disturbance of the tem- perature. There was, however, much flatulence during the second and third weeks, also much trouble with the bowels, and at one time there was a fear of obstructed intestine. It was thought — though there was no evidence of this — that there might have been some adhesion at the angles of the bowel, caused by the presence of the drainage-tube. As in the former case, the slough extended far be- yond the wire, and a large cavity was left on its separation. Six weeks later she went home. I saw her quite recently. She was in perfect health, and had been so ever since her operation, now nearly ten years ago. The application of electrolysis to the treatment of fibroids has been so thoroughly elaborated by Prof. George J. Engelmann, M. D., of St. Louis, that I have with his permission given here a few cases from his work on that subject : Uterine Fibro-myoma with Menorrhagia, Retro-uterine Hematocele, and Left Cellulitis. — The hgemorrhagic state of this case, the existing inflammation, which was active, subacute, contra-indicated electrol- ysis or negative electro-puncture. To check the haemorrhage, posi- tive electro-cauterization was resorted to, the platinum sound con- 400 DISEASES OP WOMEN. nected with the anode in the uterus, the large dispersing cathode upon the abdomen. At the first sitting a current of 60 milliamp^res was used for eight minutes, no stronger current being admissible on account of the existing inflammation. The effect was good, hem- orrhage and pain lessened. Two days later the treatment was re- peated, 100 milliaraperes used for six minutes; bleeding,, which Lad been almost constant, was stopped. After three further treatments upon alternate days, the menses appeared : previously profuse, now^ normal in quantity. This symptom being overcome, the inflamma- tory conditions were attacked by vagino-abdominal galvanism ; the negative pole, a large metallic ball covered with absorbent cotton, moistened in warm water applied per vagina, the large plate in con- nection with the positive pole upon the abdominal surface of the exudation. From 40 to 60 milliamperes were so used, serving to relieve the pain. Hsemorrhage and excessive suffering being overcome, the patient was ordered to bed at her home, and di- rected to continue the use of poultices and hot-water injections until more active measures could be taken for the destruction of the tumor. Uterine Fibro-myoma (bilobar) extending to one finger's breadth above the navel. First tentative treatment. May 2d : negative electro-puncture ; small stylet introduced to the depth of 3 centimetres; 80 milliamperes for five minutes. Second puncture, May 5th : large platinum stylet introduced to the depth of 4 centimetres ; an intensity of 100 milliamperes for five minutes ; no pain was experienced from the internal electrode, and the abdominal burning diminished greatly toward the end of the sitting. Third sitting, after an easy menstrual period. May 12th : 80 mil- liamperes, six minutes ; highest portion of the tumor 3^ centimetres below the navel. Fourth sitting, May 24th : 60 milliamperes, eight minutes ; large stylet introduced to the depth of 7 centimetres ; highest portion 5 centimetres below navel. May 31st, notwithstanding that a current of only 60 milliamperes had been applied on account of insufficiency of the battery, local pain followed, the tumor enlarged in circumference, extending above the navel, became tense, swollen, apparently fluctuating ; no rise of pulse or temperature. Treatment deferred. June 2d, fifth treatment : 50 milliamperes, six minutes ; tumor harder, less elastic, much diminished. FIBROMA OF TPIE UTERUS. 401 June Yth, sixth treatment : large stylet, 8 centimetres, 60 milH- amperes, seven minutes. June 15th, seventh treatment : 60 milliamperes, ten minutes ; tumor very hard, extending half-way to umbilicus ; pelvis, which had at first been almost full, more free ; vagina, which had been a fan-like expansion, now assuming more normal proportions. Ice-bag immediately after treatment, since it had answered well when applied during the apparently inflammatory enlargement. The patient re- turned to her home after the ninth treatment greatly improved in health, functions re-established, the tumor reduced very much in size. Each of the nine sittings had lasted from five to ten minutes. Uterine Fibro-myoxna. — General debility, scanty menstruation. Patient aged thirty-two. A fibro-myoraa, similar to the last, filling the pelvic cavity, its left half extending to the height of the navel, the right an inch and a half lower, the uterine cavity possessing a depth of 13 centimetres. This tumor, which had been first noticed in Kovember, 1885, had been rapidly growing, notwithstanding active local and constitutional treatment, mainly with ergot, at the hands of one of our ablest gynecologists, first came under my ob- servation March 9, 1886, recommended to me by her previous attend- ant, my esteemed friend Prof. Boishniere. April 28th, first tentative treatment ; the puncture made with a small stylet ; a current of 45 milliamperes was used for five minutes. Treatment was continued once a week, the puncture hereafter being made with a large platinum stylet through the cervical tissue, and the prominent vaginal projections of both right and left masses, which were punctured to a depth of from 7 to 8 centimetres. For the six treatments following the first, a current of from 100 to 110 milliamperes was used ; then a still higher intensity, from 160 to 200, was applied. The burning, occasionally intense, often decreased to a minimum toward the end of the sitting (by reason of the anaes- thetic effect of the positive pole), the punk- and chamois-covered plate being used, leaving the abdomen, after its removal, sometimes slightly reddened, but always cool. This patient, feeble, subject to fevers, at first did not improve constitutionally. The tumor, after the third puncture, was 3 centimetres below the navel on the left side, 4 on the right — the pelvis more free, a most decided shrinkage, due, I presume, in part to the powerful contraction caused by the high intensity used. In this case free bleeding followed several of the applications, from one to six hours after treatment, after the fourth puncture ; coming at one time when still on the table, checked with considerable difliculty by iron cotton tampons. By June 2Sth 27 402 DISEASES OP WOMEN. the tumor seemed again to increase ; her general condition not hav- ing improved, menstruation still being excessively scant, a mere show, I endeavored to further constitutional improvement, using no internal remedies, as she complained of her stomach, which had been ruined by constant but ineffective medication ; electrolysis was stopped, and negative electro-cauterization resorted to for the pur- pose of increasing the flow. The uterine cavity then measured 11 centimetres. July 1st, negative electro-cauterization ; 100 milliamperes, six minutes. July 12th, 100 milliamperes, eight minutes. July 16th, 150 milliamperes, ten minutes, no discomfort whatsoever being ex- perienced from the intra-uterine negative pole. August 6th, menses free, continuing five days ; more profuse and better than ever before since first established ; she has gained three and a half pounds in the last month ; looks much better ; feels well. This treatment was continued, with interruptions, during the sum- mer ; menses more free than they had been for years ; her general condition much improved. No medication whatsoever was re- sorted to. CHAPTER XXII. MALIGNANT DISEASE OF THE UTEEUS. A VERY important, and a very frequent class of diseases is that in- cluded in the above term ; and for this, if for no other reason, must we have a clear notion of the terminology so often misapphed. Malignant growths are those which tend to infiltrate and destroy adjacent tissue, to recur after removal, possibly originate remote secondary neoplastic formations, and which cause steady deteriora- tion of the general health without regard to location. They are not necessarily " cancers." Cancer is an " atypical epithehal neoplasm," distinct from growths of the pure connective-tissue type. Its forms are few and pretty well settled and agreed upon. The first is scirrhus, hard, chronic, or fibrous cancer ; the second is soft, acute, medullary, or encephaloid cancer ; the third is colloid, " gum," or alveolar cancer ; but whether epithelioma is a fourth variety or is itseK a distinct form is still a mooted question. Epithelioma is often intensely malignant ; and the term " can- croid " is a safe one as it certainly is like a cancer. Another vexed question is whether cancer of the uterus is a local exhibition of a constitutional malady, or is at first local and only later infects the system generally. The same uterus may be the seat of several varieties of carci- noma ; or, again, the neoplasm may change from one form into another as well without, as after, surgical interference. Sarcomata are malignant directly in proportion to the lo^vness of their organization. They are of the embryonal-tissue type. CANCER OF THE CERVIX. The body of the uterus is so seldom the seat of carcinosis that when the unqualified phrase " cancer of the uterus " is used, it 403 404 DISEASES OF WOMEN. means of the cervix. Malignant disease of the corpus will be con- sidered separately. Excepting epithelioma, scirrhus is the most frequent variety, says one class of gynecologists ; encephaloid, says the other. They are both right, for I believe the initial stage to be nearly always the hard carcinoma, which subsequently becomes soft and medullary ; and since it is only the later form that is apt to produce symptoms sufficiently marked for the patient to consult a physician, this may account for the supposed rarity of scirrhus, as compared with en- cephaloid cancer of the uterus. With this idea of the development of the neoplasm in view the pathology will l?e given. Pathology. — One lip of the cervix becomes hard, uneven, and h}^3ertrophied, and the nodules, which (probably) originate in the submucous tissue, subsequently ulcerate through the mucous mem- brane, which is now covered with vascular vegetations, especially near the orifice ; the opposite lip suffers an identical lesion, the cer- vical orifice enlarges and now the whole cervix is covered with veg- etations. The cellular tissue of the vaginal mucosa just beneath this fun- goid mass which projects into the vagina, becomes, in its turn, in- durated, uneven, and granulated, while, simultaneously, the muscu- lar coat of the cervix is being infiltrated with the growth. The mucous ulceration is frequently gangrenous, and a fetid fluid, containing shreds of dead connective tissue and portions of vessels wliich supplied the necrosed part, bathes the surface at the cervico- vaginal junction where the loss of continuity is best marked ; and thus a hob-nailed or fungating mass entirely takes the place of what we should normally feel upon a vaginal examination. In very rare cases the carcinomatous mass is removed in toto as a gangrenous slough, and then the ulcerated patch that remains is walled in by normal tissue. It is to all ajjpearance, a phagedenic ulcer. Microscopically, a section of scirrhus shows small cavities (alve- oli) surrounded by thick fibrous stroma, and in the alveoli are only a few polyhedral cells. An encephaloid section exhibits a delicate and scanty frame- work surrounding large alveoli which are crowded with cells (many of which are fatty) in a milk-white fluid, the " cancer-juice." The section from such a tumor is light in color and mottled. In the ves- sels are plugs made up of cancer-cells and fibrin ; the walls of these vessels are pigmented and isittj. Either variety is melanotic, when the blood pigment in the MALIGNANT DISEASE OF THE UTERUS. 405 stroma and alveoli is so ricli as to produce a deep brown or black hue. Finally, one of the rarest forms of carcinoma uteri is colloid can- cer ; the dilference between it and encephaloid (of which it is a modification) is that the cells enlarge and are filled with colloid ma- terial, the alveoli enlarge also, and as the stroma thins, one cavity communicates with another so that anfractuous spaces are formed filled with a transparent gum- like substance. The pathological effects of cancer of the womb are many and important. It may extend to, and perforate through the vesical wall ; this occurs of tener than one out of three cases, and cystitis al- ways precedes the rupture. Yesico-vaginal fistulse are by no means uncommon, and here we shall often find severe gangrenous processes attending. Rectitis may be excited and the wall of the rectum be perfo- rated. These are not half so frequent as bladder lesions. When, however, both structures are opened there is a cloacal intercommu- nication of vagina, rectum, and bladder. When stenosis of the ureters results either from external press- ure or from thickening of their walls, we will find the kidney anse- mic and full of urine (hydronephrosis). The cellular tissue of the broad ligament and iliac fossae is infil- trated, and, later, undergoes purulent infiltration, frequently induc- ing peritonitis, while the vessels and lymphatics leading to such purulent collections are the seat of carcinomatous inflammation. The peritonaeum of Douglas's cul-de-sac is jDushed upward and pseudo-membranes inclose the uterus both anteriorly and poste- riorly. The subperitoneal connective tissue of the true pelvis is thick, bard, and adherent to the bones ; it may press on, and cause fatty changes in the sciatic and pelvic nerves. The body of the uterus may be infiltrated, the organ being as large as when pregnant. Its walls may measure one and one half inch in thickness. The tubes are rarely involved ; and if carcinoma be located at first solely in the cervix the ovaries always escape. When cancer proHferates downward in the vaginal walls it forms numerous nodes, as far as the introitus vaginae, so that a physical examination will become diflicult or impossible. 406 DISEASES OF WOMEN. EPITHELIOMA OF THE CERVIX. Cancroid, formerly called rodent ulcer of the cervix, is not so malignant as scirrhus or encephaloid carcinoma. It seems to be of a more local character than the other neoplasms of this group. It appears in one of two forms — as pavement-celled epithelioma or as cylindrical-celled epithelioma. Excepting colloid cancer, this last is the rarest form of uterine neoplasm. Pathology. — Pavement-celled epithelioma begins in the epithelia of the vaginal portion of the cervix, the tumor formed being waxy, slightly vascular in spots, and dry on its surface. Tlie mass is fria- ble (" fragile cancer "), and on pressure we can squeeze out white worm-like plugs, composed of epitlielial cells. I have occasionally found this variety to begin within the cervical canal, and extend outward (not downward), so that on exploration the mass could be scooped out, leaving the cervix a mere shell, its exterior or vaginal portion showing few if any signs of new growth. The tumor is lobulated, and, when the lobules compress the ves- sels, gangrene results, and all that part of the cervix that is carcinom- atous may drop off, or a deep, crater-like ulcer is excavated whose edges are always nodular ; hence the term " ulcerating epithelioma." Squamous epithelioma extends to the body and fundus, but in general its spread is limited by the nearest chain of lymphatics. Microscopically, a tubular structure is often seen, the tubes being surrounded by a fibrous material, and probably originating from the culs-de sac of the cervical glands. The appearance of the section has given the name " cystic epi- thelioma " to it. When the tumors are crowded with lobulated nests of cells, connected together with epithelial bands, the centers are filled either with colloid matter or a hard mass resembling ordinary callous (such as that on the hand or foot). Cylinder-celled epithelioma originates as a pedunculated or ses- sile vascular wart ; and, although the dendritic tumor begins in a single spot, it tends toward the vagina in its growth, and spreads downward as the so-called " cauhflower excrescence," often as large as a hen's q^q,, and not rarely completely filling the vagina. The glands are so distended that the French pathologists call this " adeno-carcinoma." At first the cylinder cells of the cervical mucosa form a soft mass, with a milky juice ; thus it is hard to differentiate it from enceph- aloid except by the aid of the microscope. Non-maliguant papillomata also resemble these vegetating epi MALIGNANT DISEASE OF THE UTERUS. 407 theliomata, and, without a microscropical examination, whether a cauliflower excrescence is or is not malignant can not be determined. With such an examination the non-malignant is seen to lie upon healthy submucous tissue, the mahgnant upon unhealthy ; the non- malignant is a simple anastomosing framework, while the mahgnant growth has an alveolar arrangement with cell-nests. This form of cancroid invariably ulcerates ; and, though occur- ring late in the disease, this process is rapid and destructive, large vessels often being eroded. Microscopically, it consists of numerous long stems, all intercon- nected, each stem having at its center a vascular loop, the exterior covering being long cylinder cells ; thus it is Hke an intestinal villus, only longer, and the numerous vessels among the masses of cells jjer- mit serum to ooze through their walls, and this is the chief source of the watery discharge of this disease. The points of secondary invasion are many ; the bones, lungs, liver, bladder, rectum, pelvic nerves, adjacent lymphatics, and the uterus have been the loci of later malignant growth, and in the uterus it occupies the fibro-muscular structure as numerous and par- tially distinct nodules. Symptomatology. — Malignant disease of the womb runs no typi- cal course. As with cancer elsewhere, so here there is a stage where a tumor is forming, and a stage where it ulcerates. During the first of these stages the amount of pain, the leucor- rhoea, and haemorrhage are so slight that few patients will consult the physician about them. And, as I have said, it is probably for this reason that scirrhus is considered a rare form of cancer. And let me say at the very outset that the lancinating pain so often men- tioned all through our literature as strongly symptomatic of carci- noma uteri is exceptionally met with in this disease. A discharge is the earliest symptom in the majority of cases. This discharge may be bloody, watery, or leucorrheal. As a rule it assumes the character of an intense menorrhagia, the patient also bleeding between the menstrual epochs either sjDontaneously or from sudden exercise or coition. Some women will state that although their change of life occurred a year or so ago, that now they have " commenced again." The bloody discharge may or may not be fetid and grumous, but the organic matter which forms the grumous discharge, and which is continually sloughing away and passing out of the genitals, very seldom causes any septicaemia. Besides, the lymphatics are not here abundant in the immediate neighborhood of the cancerous tumor. 408 DISEASES OF WOMEN. Watery discharges consist chiefly of the clear serum of the blood ; they are usually odorless at first, but soon become mingled with ulcerative debris, and are peculiarly foul smelling. They are seldom or never free from admixture of blood, and there are very few who will not give " bloody water " as one of their chief symptoms. The watery flux is almost characteristic of the cauliflower excres- cence. In many cases the discharge is simply leacorrheal up to the time of ulceration of the cancer, after which the fetid " cancer smell " and molecular masses from the growth indicate the true cause of the discharge. A sudden bright haemorrhage indicates that a medium-sized ar- tery has been opened. The more rapidly the neoplasm forms, and the more extensively it ulcerates, the more profuse and fetid will be the discharge. Excoriations, erosions, erythema, vaginitis, vaginismus, intense pruritus, and similar conditions may result from the passage of these discharges through and over the genitals. Pain is never so prominent a symptom as the discharge, and, according to some, never a symptom so long as the cervix alone is the. seat of malignant growth. The character of the pain is described differently by different patients, as dull, boring, gnawing, shooting, and stabbing. The pain shoots in the direction of the parts supplied by branches of the nerve whose main trunk is pressed upon. The back, pelvis, and thighs are the chief regions of this kind of pain. The pain is more acute when the terminal nervous branches are involved than when the trunk alone is compressed ; and it is, again, more severe when there is a large amount of neoplastic tissue formed than when ulceration is extensive. The pain of peritonitis, which may be lighted up by the growth, has characters peculiar to itself The amount of tenderness is not always in proportion to the pain. Pain on motion and from coition (dyspareunia) is experienced almost from the onset in neoplasms of the cervix ; later on, defeca- tion and urination may produce intolerable suffering. Pain as a symptom may be absent throughout the disease, and the patient only experience weight and bearing down. As the disease progresses, the patient first loses strength, appe- tite, and all cheerfulness of disposition, emaciation following later on. The face assumes an earthy green, or, toward the end, a bronzed MALIGNANT DISEASE OF THE UTERUS. 409 hue, and the temperature may be slightly subnormal. There is som- nolence and headache, but eclampsia is infrequent. The bowels are constipated, as a rule, but irritation or actual cancer of the rectum may cause profuse and exhaustive diarrhoea ; haemorrhoids are common. Cystitis, strangury, and retention or in- continence are not infrequent bladder symptoms. When fistulas form, they give rise to their usual symptoms. In one case the first, and, indeed, the symptom on which the diagnosis was made, was a flow of urine from the region of the cervix. The breasts are frequently the seat of sympathetic pain. Toward the close of the disease there is usually a slight febrile move- ment in contrast with the tem- perature in the early stages of the disease. Physical Signs. — Scirrhus carcinoma gives a hard, hob- nailed or nodular feel to the finger during the earliest sta- ges, and the mucosa seems to be immovably fixed on the sub- jacent connective tissue, a con- dition not met with except in malignant growths. When any cancer has ul- cerated (the usual time when the physician sees it), the fin- ger meets a friable, irregular mass, which bleeds upon the slightest provocation, and which is surrounded by a tough, unyielding, irreg- ular zone of infiltrated tissue. If reached, the lips of the cervix are felt to be uneven, thick, and spreading downward like a mushroom. Palpation may further reveal in many cases fistulas, immobility of the womb, changes in the size and position, and infiltrations and indurations in the neighborhood. In scirrhus the womb is felt to be low down in the pelvis. The bowels may have been so constipated that the physician examines for stricture of the rectum before searching for anything else ; but in doing this he will directly suspect the true state of affairs, and especially so if the pelvic cellular tissue or neighboring glands be involved. A second physical sign, which is supposed by some to be diag- nostic, is that a sponge tent or uterine dilator fails to dilate a cervix Fig. 188. — Cancer of both lips (Winckel). 410 DISEASES OF WOMEN. suffering from malignant disease, whereas in all other neoplasms dila- tion will qnickly and easily follow its introduction, A third physical sign is indescribable ; it is the odor that the finger has after such an examination — an odor produced by nothing else but cancer, A fourth means of physical diagnosis is the speculum, by the use of which we see what has already been described under the head of pathology. Commencing scirrhus is accompanied by a deep pur- plish or livid hue of the entire cervix, and enlarged vessels are seen to ramify about these nodules. The extent of the growth can only be accurately appreciated by this means of examination. Epithelioma of the cervical cavity is often diagnosticated solely by the use of the speculum and curette or probe. Lastly, the microscope may be used not only to diagnosticate the presence or absence of carcinoma, but to decide which variety we have to deal with. It should be stated here that malignancy can not be decided by the microscope, since it is a clinical property. The microscopical ajDpearances of each form have already been described. Diagnosis. — Before treating of the points in which cancer and other lesions of the uterus differ, it is necessary to mention the char- acters that especially distinguish one form of carcinoma from an- other. Scirrhus gives a nodular, hard sensation on palpation, immobility of mucosa upon sub-mucosa, prevents cervical dilatation on using the sponge tent or the uterine dilator, showing less of elasticity in the tissues, and the discharge is scanty. In medullary cancer the grumous discharge containing molecu- lar debris is the prominent symptom. The course of this cancer is the most acute of all. The brittle, crumbling, ulcerated mass is pe- culiar to this form. The uterus is usually fixed and immovable. Epithelioma is accompanied by a more profuse watery discharge than any other variety ; and on palpation the finger meets, often, the characteristic cauliflower-like mass. The uterus even late in the disease suffers no fixation, and may be moved without pain. This variety seems more local than the preceding. In all instances when cancer is diagnosticated a microscopical ex- amination will determine what variety we are dealing with ; and to this end a piece of the tumor may be removed by the curette. There are numberless conditions with which cancer in general may be confounded ; the chief of these are : MALIGNANT DISEASE OP THE UTERUS. 411 Sloughing' Myomata or Fibrous Polypi. — These may, either of them, simulate cancer ; but they will be attended by fever, which is absent in cancer, and there will be in the discharges shreds of the normal uterine tissue, while in cancer discharges epithelial cells will be prominent. Frequent washings control the former, while cancer remains unmodified thereby. Syphilitic Ulceration. — This not only resembles cancer, but may even produce vesico-recto-vaginal fistulse. Here the history, the age of the patient, the effects of local and constitutional treatment, the discharge, and an examination of a small bit of the tumor will soon allow a diagnosis to be reached. Condylomata. — These will not long be mistaken for cancer. Erosions. — These are numerous ; but non-malignant erosions oc- cur in younger patients, produce no constitutional symptoms, leave no portion of the cervix intact, are attended with large, gaping fis- sures, and, on inspection by means of the speculum, large ovula N^a- bothi are seen. The discharge does not have the cancerous odor in benign erosions. The points in connection with cancer of the body and cancer of the cervix are considered hereafter. Prognosis. — It is needless to say that the invariable tendency of malignant uterine disease is toward death. The chief question in prognosis, therefore, is of the duration of life. There are no hard and fast rules for the expectation of life, nor do my own statistics or those of others afford definite statements. Three months and three years are the extreme figures given. In general, it may be stated that, a-fter the first marked symptom (some discharge), the patients live a year, except those who have epithelioma or cancroid ; these, as a rule, have eighteen months of life before them. A prognosis should never be made immediately after diagnosti- cating cancer ; the physician should wait until the disease pronounces itself a slow or rapid, an uncomplicated or a complicated, a localized or an extending process. Among the complications are hydronephrosis (see pathology), and, consequently, ursemia, cellulitis, and peritonitis, and, less fre- quently, septicaemia, phlebitis with venous thrombosis, embolism, and cancer in adjacent tissues and distant organs, the liver especially. Death may result from simple exhaustion (cancerous marasmus), or from haemorrhage when a large vessel is opened, or from rup- ture of the uterus (rare), or from any of the above-named complica- tions. 412 DISEASES OF WOMEN. Death is sometimes dela^^ed and torturing, and, in the face of its being inevitable, it often seems as though it were a mercy to hasten it. Etiology. — Until puberty the death-rate from cancer is the same in both sexes ; from this period both frequency and death-rate stead- ily increase in the female up to and a little after the menopause, at which period the difference in rate between the sexes is most marked. After the age of fifty there is a tendency for cancer to appear equally often in both sexes. There is no doubt but that there is such a condition as a predispo- sition to malignant disease ; but to what extent this can be inherited or not is not yet determined. It is well known, however, that cer- tain peculiarities of organization predispose to malignant disease. Among these is the cardio-vascular hypoplasia (Virchow), where the pulmonary arteries are undersized, and which occurs often with the phlegmatic temperament, characterized by an abundant adipose tis- sue and an appearance of health, which is an appearance and noth- ing else. Great differences are met with in authorities as to the frequency of cancer ; reliable statistics, however, tell us that the uterus was at- tacked in three thousand cases out of a total of sixty-one thousand seven hundred and fifteen cases of carcinoma (anywhere in the body) in females. The same also afford us proof that the uterus is cancerous three times as often as any other female organ. Heredity has an undoubted influence ; I have gathered the sta- tistics of many thousand cases, and find that an inherited taint can be traced in thirteen per cent of all cases on an average. Age is the most potent factor in the etiology. Before puberty, indeed before the age of twenty, cancer is unknown or phenomenal. I have seen two cases — both ending fatally — where the patients were in their twenty-seventh and twenty-eighth year respectively ; and the sister of the last named died of cancer of the uterus in her thirty-first year. The ten years following the menopause (forty to fifty) is the period of carcinoma uteri ; the decade following this is the next most eventful period, and third in order stand the ten years preced- ing the climacteric. Race seems to have little or no influence. Perhaps it is pecul- iar to my practice, yet I have seen more cases of carcinoma uteri among Germans than in any other nationality. There is more than an accidental agreement between cancer and the number of children born ; for it will be found that patients with cancer of the uterus will average one third more children than MALIGNANT DISEASE OF THE UTERUS. 413 women free from malignant disease of the womb ; indeed, every case of carcinoma uteri will average five children, a large family at the present time. Prolonged lactation, anti-hygienic surroundings, poor or improper food, exhausting diseases, grief, and anxiety are all more apt to be accompanied by cancer than an opposite condition of affairs ; never- theless, seventy-five per cent of cases will give a history of good health up to the development of this neoplasm. It is quite certain that laceration or erosion of the cervix has a causative influence upon cancroid ; hence in suspected epithelioma the previous history must always be elicited. I do not mean that laceration will cause it ; but with a latent tendency, an erosion or laceration will often determine the precise point of eruption of the disease. In recent times pathologists have favored the idea that cancer is dependent upon a certain germ. When this comes to be better un- derstood, it is possible that medical treatment may be suflicient to prevent or to cure this affection. But at the present time our knowl- edge of the disease appears to be limited to the fact that certain or- ganizations are predisposed to cancer disease ; and if it should be found in the future that the disease is due to a cancer germ, the fact will still remain that, in order that this germ may be effective in producing cancer, a certain kind of organization or a certain quality of tissue is favorable to the action of this germ. It is known that the tubercle bacilli (and the germ of cancer, if there is one), require a certain kind of tissue to live upon, hence some enjoy an immunity from these maladies, while others are predisposed to them. Some of the diseases due to specific germs attack all alike, the strong and the weak — typhoid fever, for example. It is very differ- ent with such diseases as cancer. Those germs that require special tissue to live upon act locally. The other germs that attack all or- ganizations are general in their action. There are certain things that we know now which obtain almost invariably in cases that develop cancer — such, for example, as the fact, pointed out long ago by Virchow, that the pulmonary artery is abnormally small in those who die of cancer. I have kept a record of a very large number of cases of cancer of the uterus, mammary glands, and ovaries, and I think I can say that, without exception, I have found the pulmonary circulation defective, and consequently respiration and blood aeration insufficient to a certain degree. The vast majority of subjects, also, have been stout, with a pre- ponderance of adipose and cellular tissue. In fact, they have been 414 DISEASES OP WOMEN. somewhat chlorotic as a rule, and of the lymphatic temperament. In short, while digestion and assimilation have been normal, disas- similation, disintegration, and elimination have been imperfect or sluggish. It would seem, therefore, that this condition of organiza- tion predisposes to malignant disease ; and if such is the fact, then much can be done in the way of development and general manage- ment in early life to overcome this peculiar tendency to disease. All that was said in discussing the management of chlorotic and phlegmatic girls would apply with equal force to the prevention of cancer. I need not, then, in this connection, dwell upon that part of the subject. The condition of the organization at, toward, or immediately after the menopause especially favors the appearance of cancer. The diagnosis of this condition is based upon the special tem- perament, usually phlegmatic, somewhat chlorotic, it may be, with small circulatory apparatus, at any rate so far as the pulmonary artery is concerned, and hence the imperfect respiration and blood aeration referred to, the superabundance of adipose and cellular tissue, as shown by the general appearance of the patient, with slug- gish excretion or elimination, indicated chiefly by renal and hepatic torpor. These conditions of ultimate nutrition are very often spoken of as lithaemia, and hence I might say that lithsemic patients at this period of life are predisposed to cancer. It will be seen that this condition may be largely due to in- herited temperament and general organization, and yet to a large extent it may be acquired. Some of the modifications of nutrition which have been referred to in discussing the menopause clearly eventuate in this predisposition to malignant disease. Dr. Arthur W. Johnston (in whose opinion I have profound confidence) believes that the chief cause of carcinoma is failure of the trophic nerves, the failure being brought about by some nerve strain or great sorrow. I accept without hesitation the theory re- garding the causative relation of the trophic nerves to cancer, but my clinical experience makes me doubt if nerve strain is the primary cause. I incline to the opinion that failure of the trophic nerves occurs more readily in those organizations which I have described as j)redisposed to malignant disease. But whether the nerve strain is a necessary element in the causation of cancer or not, the trophic nerves, which preside over all tissue changes, certainly play an im- portant part in the ni3tiology of cancer, and have a certain bearing on the question of treatment. Treatment. — This may be divided into the medical and surgical. MALIGNANT DISEASE OP THE UTERUS. 415 The first indications in this condition are to improve the character of the tissues, first by diet, and then by every possible means which can favor ultimate nutrition by promoting the depleting processes, or disintegration and elimination. In regard to the matter of diet, I am confident that all the articles of food and drink which retard tissue waste or elimination of worn-out tissues, such as alcohol (es}>ecially in the form of beer), tea, and cofliee, should be avoided. Certain observations that I have made lead to the conclusion that beer-drinking people, and to a less extent Mane-drinkers, are more subject to cancer. This is an additional reason for my urging the restricted use of such articles through life, and especially at the time when cancer is likely to appear. The excessive use of animal food, while it may not in itself predispose to malignant disease, 'does so when it is used in ex- cess in connection with alcohol ; and those who take sparingly of animal food, I find, can bear a larger amount of alcohol with less injurious effects. And so, in given cases, if I found that they took animal food sparingly, but alcohol in considerable quantity, I should continue the alcohol but diminish the quantity. It is, I presume, on account of this effect of animal food and alcohol in producing a tendency to cancer that milk diet has obtained a considerable repu- tation in the management of malignant disease. Kext to diet, every means should be employed to regulate the renewal of tissue ; and, first, by getting clear of waste material. Diet having been properly adjusted, and food given in quantities that can be easily and thoroughly digested, will insure the best pos- sible supply of tissue. Then if, by the means at command, free disintegration and elimination can be secured, much will be accom- plished toward preventing the appearance of cancer. The bowels should be kept regular, and yet not unnecessarily free. The kid- neys should be made to do their whole duty, and the intestinal secretions, including hepatic secretion, should be carefully looked after. The skin also requires attention ; and here I believe the Turkish bath is of value, especially to those who have not sufficient exercise to induce free, healthful perspiration. A Turkish bath once or twice a week, with thorough massage, will greatly improve the ultimate nutrition. Exercise should be carefully regulated. It is a rare thing to see cancer in an active person who does not carry a superabundance of adipose tissue, and who takes a suflicient amount of muscular exercise, and yet not too much. If diet, exer- cise, and eliminating agents be employed to excess, so that the re- newal of tissue is insufiicient, and the patient becomes debilitated 416 DISEASES OF WOMEN. and suffers from lack of nutritive supply, the tendency to malignant disease will be favored. Care must always be taken not to overdo the eliminating pro- cess. The balance between waste and repair should be maintained as nearly perfect as possible, the great object being to secure com- plete ultimate nutrition, so that the tissues may not become too old and worn out before they are broken down and thrown off. I am not sure that I will be thoroughly understood when I speak of old tissues, but I apply the term to a condition in which the process of w^aste and repair is retarded, and the tissues are not broken down and thrown off after they have served their purpose. That is what I mean, and that is the condition which I believe favors the appear- ance of cancer, and the chief thing to be overcome by treatment directed to prevent it. Dr. Johnston's views regarding causation suggest the necessity for the use of agents that may improve the condition of the nervous system. This, of course, is largely accom- plished through improvement of the general nutrition, but nerve tonics, and sedatives if needed, should be employed. This leads up to the consideration of medicinal agents which are supposed to have some influence on the ultimate nutrition, and which have been used in the past, in the hope of preventing cancer or of arresting its progress when it has manifested itself in any location. A number of remedies have been employed in the past, and we may say of most of them that they have been weighed in the bal- ance and found wanting. At one time condurango, Chian turpen- tine, and several others, were lauded for their curative power in can- cer, but they have been found, if not useless, almost so. Those that are used most at the present day, and which still claim some confidence, are prepared chalk and arsenic. In regard to the chalk, which was first used in the form of calcined oyster shells, given in powders, ten to twenty grains, three times a day, there were several theories regarding its action, but whether they were correct or not is unknown. From personal ex- perience I am unable to say that this agent is reliable. As it is a harmless article, I can see no objection to using it ; but I would rely far more upon arsenic. Arsenic has a decided influence upon ultimate nutrition, especially of the skin and mucous membranes ; and as cancer usually makes its appearance in those tissues, anything that can improve their nutrition must be of some benefit. Such is the fact, based upon the therajKnitic action of arsenic, and the same thing is observed clinically. On this account I have employed this remedy in the management of the conditions which I believe pre- MALIGNANT DISEASE OF THE UTERUS. 417 dispose to cancer and in cases wliere cancer actually had appeared, and" with benefit. On the same principle I have employed mercury and iodine, a favorite prescription being small doses of chloride of mercury with arsenic, continued for a time and then changed for iodine and arsenic. Small doses of the latter, and also of the mer- cury, should be employed, as it is a long-continued action which gives the result. These are the remedies that at the present time are most effica- cious, and I believe that if persistently continued, and if begun early in the course of the disease, but more especially if employed when there is an apparent tendency to the disease, they are poten- tial preventives — at any rate, the best there are. When cancer is present, I need hardly say that surgical treatment is indicated, and is the only treatment that promises any relief. Within the past few years much has been said with reference to the effect of pyoctanin, an aniline preparation. This, I am satisfied, is of some value in arresting the progress of the disease when ap- plied locally, but this belongs to the domain of surgery. What effect it may have when given internally is not decided. A word may be said regarding the treatment of cancer by local applications in the way of plasters and caustics, and so on. This, of course, is surgical treatment, and the most barbarous kind of sur- gery, and so nothing further need be said on that subject. It sometimes happens that, after the surgeon has done his best for the relief of malignant disease, his ejEforts fail, and the patient falls into the hands of the physician in her last days. There is only one word to say on that subject. Under these circumstances the physician's first and only duty is to give relief and add to the com- fort of the patient as far as possible. Opium is the agent which alone can do this, and I believe in the free use of it in the manage- ment of such cases — doses sufficient to relieve pain. I may add that I believe that not only does opium relieve pain in cancer, but it re- tards the progress of the disease. I have an idea that the habitual use of opium prevents cancer to a limited extent. All that has been said in this connection applies equally to can- cer of the uterus, ovaries, or mammary glands, which covers the whole field of the gyntecologist. Surgical Treatment. — Complete removal of all the diseased tis- sues is the classical treatment of cancer of the cervix uteri. In the past this was accomplished in several ways — by caustics, amputation with the knife, ablation with the curette and thermo-cautery, and in recent years with the galvano-cautery by Byrne's method. 28 418 DISEASES OF WOMEN. Since vaginal liysterectomy lias been perfected, tlie vast majority of surgeons prefer to remove the entire uterus when cancer is found in any part of the cervix or body. Having had ample opportunities for observing the safet}^ and superior results, immediate and ultimate, of Dr. Byrne's operation for cancer of the cervix uteri, I believe that it is preferable and should be adopted. Many surgeons who adopted Byrne's method complained of having trouble with the battery, owing to their not knowing how to keep it in order. There is nothing reasonable or valid in such objection, and now that the electric-light power is in most of the hospitals and houses and can be utilized for running the cautery instruments such objections can no loTiger be raised. The cautery instruments devised and used by Dr. Byrne are to be found at the instrument makers, and therefore I need not describe them here. The method I prefer giving in the doctor's own words: High Amputation of the Cervix Uteri in Cancer. — " In conditions admitting of high amputation, the following is the method usually resorted to : The uterus is to be exposed and the vaginal walls pro- tected in the manner already described. The diverging volsellnm being passed well into the cervical canal, should now be expanded to a proper degree and locked, so as to afford complete control of the uterus during the entire operation. " By alternate traction and upward pi-essure of the uterus an accurate idea may now be obtained as to the proper point to begin the circular incision, so as to avoid injuring the bladder or opening into the cul-de-sac of Douglas. As to the latter, however, should it be found that the disease has involved the retro-uterine tissues, and that its excision or destruction by the cautery can not be effected without opening into the peritoneal cavity, there need be no hesita- tion in doing so, as I have never known any harm to come from it whether done accidentally or by design. Should it be evident at tlie outset that the operation, in order to be thorough, must include a portion of the cul-de-sac^ it will be better to make the line of in- cision anterior to this, until the cervix has been removed, and leave the excision of the retrouterine parts by the cautery knife to be the final proceeding. Under these circumstances all that will be lUH'ded will l)e an antiseptic tampon ]iro])erly apjilied. " In proceeding to make the circular incision, the cautery knife slightly curved and cold, should be applied close up to the vaginal junction, and from the moment that the current is turned on should ha kept in contact with the parts being incised. Before removing the electrode for any purpose, such as change of position or alter- MALIGNANT DISEASE OP THE UTERUS. 41 9 ing the curve of the knife, the current should be stopped, and the instrument again placed in position while cool before resuming in- cision. In other words, if the knife, though heated only to a dull red, be applied to parts at all vascular, hiemorrhage more or less will certainly follow ; whereas, the cool platinum blade being already in contact with moisture as the current is being transformed into heat, vessels are shrunken or closed even before they are severed. " This is a very important point, and should never be lost sight of in all cautery operations. " The circular incision having been made to the depth say of a quarter of an inch, it will now be observed that by increased trac- tion the uterus may be drawn much farther downward, and by direct- ing the knife upward and inward the amputation may be cai'ried to any desired extent. In cases calling for amputation above the os internum, it will be better to excise and remove the cervix first, then, by dilating the upper canal sufficient to admit the diverging volsellum, once more proceed as in the first instance, taking care, however, to keep within bounds. It will be found that the cupped stump can now be drawn down and made to project as a more or less convex body. " In all cases the dome-shaped electrode should be passed over the entire cavity repeatedly, so as to render the cauterization still more complete. " It is important to add that, in carrying the knife toward the sides of the cervix, circular and other arterial branches are apt to be encountered, and hence, in this locality particularly, a high degree of heat in the platinum blade is to be carefully avoided. As an ad- ditional security against haemorrhage, the convexity of the knife should be pressed against the external surface of each particular section cut, so as to close vessels more effectually. " It is well to state that the metallic parts of the electrode for the distance of about two inches should be covered with a strip of thin flannel, so that the vagina may be protected from injury through the reflected heat." Unfortunately, however, cases occur for whom the operation just described is inapplicable, and yet for whom something may be done. For such I know no better treatment than that advised by Dr. Byrne. In describing this, he says : " It is well known to all who have had much experience with uterine cancer that in a very large percentage of the cases met with, whether in private or hospital practice, the disease is found to have already progressed so far that palliative results or a brief respite 420 DISEASES OF WOMEN. from suffering and death is all that can be hoped for from any treat- ment. In such cases, as, for example, when the entire cervix has been destroyed and the corpus uteri as well as the parametric tissues are found to be involved, my course has been as follows : First, to remove all softened and broken-down tissue by the free use of a sharp curette, and having sponged the cavity repeatedly with a mixture of one part of commercial acetic acid, three parts of glycerin, and carbolic acid sufficient to represent eight per cent of the whole, I then pack the cavity with absorbent cotton and allow it to remain for a few minutes or longer as the case may be. On removing this, if all bleeding is found to have ceased, and the cavity fairly dry, cauterization may be proceeded with. If, however, oozing of blood to any extent sliould still continue, it will be best to pass into the cavity a ]>roperly rolled tampon saturated with the above styptic and allowed to remain for forty-eight hours before the application of the cautery. " Cauterization in all such cases should be conducted in the fol- lowing manner : '• The diseased organ should be exposed to view, and the vagina protected by a Sims's speculum and an anterior and two lateral re- tractors, and it may be necessary to seize the edges of the excavation by one or more volsella. Before introducing the cautery electrode a wad of absorbent cotton is to be passed into the cavity, held for a moment, and, immediately on being withdrawn, the dome-shaped instrument, brought to a cherry-red heat, is to be rapidly and re- peatedly passed over the bottom of the cavity mainly. The latter is then to be again dried by wads of absorbent cotton held in dress- ing forceps, and cauterization resumed as in the first instance. This process is to be repeated over and over again until the deeper parts of the cavity have become dry and charred, when the sides are to be treated in precisely the same manner and roasted to the same crisp condition. The seat of operation will now present the appear- ance of a perfectly black and dry cavity. All i-agged aiid over- lapping edges are next to be trimmed off by the cautery knife ; a firmly rolled tampon of suitable size with thread attached, and satu- rated with the above styptic compound, is now to be placed in the cavity, and, finally, a supporting vaginal tampon is to be applied and the patient removed to bed. The vaginal tampon may be removed on the following day, but the other should be allowed to remain for forty-eight hours or longer. The subsequent treat- ment will consist of vaginal douches twice daily of carbolized water." MALIGNANT DISEASE OF THE UTERUS. 421 CANCER OF THE BODY OF THE UTERUS. This condition is rare as compared witli carcinoma of the cervix. Pathology. — In corporeal epithelioma the epithelium of the uterine glands undergoes hypertrophy, and there is formed a fun- gating polypoidal mass, which propagates itself over all the organ, or projects into its cavity, perhaps into the cavity of the cervix. The cancerous mass always ulcerates and leaves wide cavities in the hardened uterine wall. The uterus becomes enlarged. Scirrhus or encephaloid may, in rare cases, be found in the body of the womb, although the best authorities state that there is scarcely an unquestionable case of corporeal encephaloid, and that scirrhus has never been met with. These varieties form beneath the mucosa in the substance of the uterine tissue, and extend outward, causing peritonitis and agglutina- tion with neighboring organs and parts. When they extend inward they are certain to ulcerate. Either form of cancer, when accompanying fibroids, does not seem to modify the latter's characteristics. One case is recorded of cauliflower excrescence of the fundus ; this projected out through the cervix down into the vagina. The microscopical appearances in no wise differ from similar neoplasms in the cervix. Symptom otology. — The prominent symptoms of cancer of the cervix are also met with in cancer of the body, but not to the same degree nor appearing in the same order. In cancer of the body pain occurs early, and is severe and parox- ysmal, sometimes remaining at its pitch for two hours. Free menor- rhagia is soon accompanied by a discharge which is profuse, watery, and fetid. In some instances there will be no discharge whatever throughout the disease. The vital forces are early greatly depre- ciated, and marked constitutional disturbance is a prominent early symptom of cancer of the corpus. Physical Signs. — Inspection gives negative results. On palpa- tion (bimanual) the body is felt to be larger and harder than normal. The cervix is usually dilated, but in a few instances has been felt to be normal. Adhesions may firmly hold the uterus in a fixed posi- tion, but in most cases it is freely movable. The probe induces profuse htemorrhage in nearly all cases, and by its use we learn the degree of dilatation of the cavity of the womb. 422 DISEASES OF WOMEN. The curette is used to withdraw some of the growth for micro- scopical examination. Diagnosis. — Cancer of tlie body and cancer of the cervix may be confounded with each other. The points that enable us to dis- tinguish them are these : Cancer of the body is very rare ; that of the cervix comparatively common ; . })ain is very early and very severe in cancer of the body ; it is rare or absent in cervical cancer. Menstruation is deranged from the very onset in cancer of the body ; this is a late symptom when the cervix is attacked. Marked constitutional disturbance and peritonitis — which is often fatal — occur early and more frequently in cases where the body is the seat of malignant growth than when the cervix is involved. There is little or no tenesmus on bimanual examination in cancer of the cervix, while this is marked in cancer of the body. The probe discovers an enlarged corpus in the latter case, while in cancer of the cervix the corpus is normal in size. The adjoining structures are implicated far more frequently, and also earlier in the disease, in cancer of the body than in cancer of the cervix. Prognosis. — The same rules hold good here as in cancer of the cervix. The outlook for recovery is far less favorable, not only from the situation of the growth and the greater likelihood of adjacent tissues being involved, but also from the fact that, as total extirpation is the sole means of treatment, the probability of life after this operation is much less than after amputation, cautery, or scooping. Causation. — The body of the uterus is attacked with cancer very much more frequently in nulliparae than in multiparse, which is in striking contrast with the prevalence of cancer of the cervix. The average age of patients suffering corporeal carcinoma is ten years greater than that of women afflicted with cancer of the cervix. In every other respect the causation is the same as in cervical cancer. Treatment. — Extirpation is the sole means of effecting a cure in cancer of the body, and hysterectomy seems to be followed by far better results in these cases than when performed for cancer of the cervix. This may be accounted for on the ground that in the neigh- borhood of the cervix there is far greater liability to extension of the disease and infiltration downward and laterally. Vaginal Hysterectomy. — While the principles of this operation are the same, the details differ with different surgeons. Some — the French surgeons chiefiy — control the uterine and ovarian arteries with clamps ; others use ligatures. I shall descrii)e the operation, and note the most important dif- MALIGNANT DISEASE OP THE UTERUS. 423 ferences in the iiietliods of carrying out the various steps of the procedure. Prejxiration of the Parts for Operation. — The patient being placed in the Hthotomy position, the vulva and vagina are thor- oughly cleansed and disinfected and the rectum and bladder com- pletely emptied. If the body of the uterus is alone affected, the cervical canal must be washed out, packed loosely with cotton, and closed with a pair of forceps or with sutures. If the disease involves the cervix, so that the cancerous mass protrudes into the vagina, as much as possible should be removed with the cautery or curette, and then the canal closed in the manner described. The object of this closure of the canal is to keep the wound clean and free from infec- tion during removal of the uterus, and is very important. It is im- portant in such cases to remove all the diseased tissue about and within the cervix before proceeding further in the operation. Retractors should be introduced into the vagina, so as to thor- oughly expose the cervix and upper part of the vagina. The cervix should then be seized with a volsellum forceps and drawn outward and upward, and the posterior vaginal wall be incised, the incision being semicircular and extending half around the cervix and out- ward half an inch or less, according to the size of the cervix. The peritonseum should be opened from the base of one broad ligament to the other, and the vaginal walls and peritonaeum united with sutures. The anterior vaginal wall is to be next circumcised, and the uterus and bladder separated up to the peritonseum with the dry dissector or the finger. 1 prefer not to open into the peritoneal cavity in front until the broad ligaments are separated from the uterus up to and including the uterine arteries. The vagina may be separated from the uterus with the knife, scissors, or galvano-cautery. I prefer the cautery. Fig. 189. — Cleveland ligature forceps. The next step is to either ligate or clamp the broad ligaments and separate them from the uterus. If ligation is determined on, it is done as follows : A ligature is carried around the lower portion of the ligament with a curved needle, Cleveland's ligature forceps (Fig. 189), or an aneurism needle, securely tied, and then divided close up 424 DISEASES OF WOMEN. THE CLAMP OPEKATIOJSr IN VAGINAL HYSTEKECTOMY. (Modified from Landau.) Fig. 190. — The speculum in place, the cervix is seized and drawn down- ward, and the incision begun at the junction of the cervix (C) and the vaginal wall. Fig. 191. — The cervix having been severed from the vaginal wall all around, the blad- der stripped oif, and the vesico-uterine pouch opened, the body is caught and drawn out through this anterior opening. Fio. 192. — A forceps, guided by the fingers, is jiushcd through tiie pouch of Douglas. Fig. 103. — A forceps diaws forward into view the tube (T). F, fundus ; C, cervix. VAGINAL HYSTERECTOMY. 425 Fig. 194. — Forceps on the ovary (0) turns the broad ligament forward. The uterine artery is clamped. Fig. 195. — The tube and ovary being^ rolled forward, the ovarian ar- tery is clamped. Fig. 196. — The uterine artery can be clamped as soon as the vaginal walls are freed from the cervi.x. Fig. 197. — Placing the gauze (by the upper hand). The perinjeum is retracted and the forceps spread apart. to the uterus. The ends of the ligature should be cut off after it is tied to avoid traction, which would be almost sure to loosen it. Successive portions of the ligament are treated in this manner until the whole is separated from the uterus. The other broad ligament is treated in the same manner. The uterus, being now free from its attachments, is removed. The next step is to unite the peritonfeum to the anterior and 426 DISEASES OF WOMEN. posterior vaginal walls with fine catgut sutures. The peritoneal cuts should now be sponged clean. One end of each suture is then cut off and tlie remaining ends are tied to the opposite sutures, thus Fig. 198. — Vaginal hysterectomy by morceUement. The gray lines show the pieces to be removed in order, each being shown with a forceps fast to it. (Landau.) completely closing the wound, except in the center, where space enough is left to admit a small gauze drain. The vagina is to be loosely packed with gauze, and the operation is completed. Many surgeons prefer silk ligatures, as being more easily handled and more certain to control the vessels ; but silk is objectionable for various reasons. It is likely to cause irritation and suppuration, and a longer time is required for the ligatures to come away or be removed, so that by the use of tliis material the recovery of the patient is delayed. The French Method. — The peculiarity of the French method of performing vaginal hysterectomy consists in the use of pressure forceps instead of ligatures for the control of the blood-vessels. The circumcision of the vagina is performed in the n)anner already de- scribed, but when the peritonauim is opened the forceps are applied MALIGNANT DISEASE OF THE UTERUS. 427 to the lower part of tlie broad ligaments. The uterus is then retro- verted — although some surgeons prefer to antevert it — in order to bring the ligaments nearer to the operator, and then the upper por- tions of the ligaments are clamped with forceps. The ligaments are divided between the forceps and the uterus. To prevent unlocking of the forceps the handles are tied together. Gauze is then placed in the wound between the forceps to act as a drain, and either gauze or cotton wrapped around tlie handles of the forceps to protect the vulva. Landau's full and finely illustrated description of his clamp operation has been simplified in the series of cuts adapted from his work (Figs. 190-198). Method with ElectriG Ilcemostatic Foi'ceps. — Whatever may be claimed as advantages for the ligature, even the modern ligature, that is with much care and trouble made aseptic and can be left in the tissues, has its faults and shortcomings. The catgut ligature is very difficult to sterilize and keep surgically clean, and it is liable to slip and permit haemorrhage. In being disposed of by absorption, or being walled in or encysted, it causes more or less irritation. Dead animal tissue, though sterile, can not be taken care of in a wound without causing some disturbance. Silk, or unspun silk, called silkworm gut, properly prepared, will not decompose, and, being less likely than catgut to slip, has some advantages, but is more objectionable still because it causes irritation, and in the effort to escape or be thrown out enters the abdominal or pelvic viscera and does great damage. There are many cases recorded of serious trouble from ligatures of this kind long after recovery from operations. I^early twenty years ago I learned from Dr. Thomas Keith his method of treating the pedicle, in ovariotomy, by the clamp and cautery, and I have had ample opportunities to observe that the results are vastly superior to those obtained by any other method. Within the past three years I have discovered that the same method of closing bleeding vessels is applicable in all surgical operations. At the same time I have found that it is no easy matter to use the means which give such excellent results. Naturally, this has in- clined me to seek some simpler, easier way of accomplishing the same object — that is, to arrest bleeding in surgical operation. Hitherto the difficulty in using compression and heat to arrest hgemorrhage has occurred in the management of the heat element. The process is as follows : A portion of the end of the vessel, or mass of tissue containing bleeding vessels, is seized in a forceps or clamp and firmly compressed, and while under pressure heat is ap- 428 DISEASES OF WOMEX. plied to the instrument to desiccate or dry the parts but not to char them. In this way the walls of the arteries become united and haem- orrhage is certainly prevented. Heretofore the heat was obtained Fig. ]'■>'■>. — i^'iill-size drawing of iiiuce of fic-sh hccf-iiiusele one fourth inch thick after being seized in forccp blades two minutes with current on. The conij)resscd place is translucent as horn, not charred. The same piece is shown in section. by applying a heavy cautery iron (heated in the iire) to one side of the clamp, but this rendered the procedure difficult and unsatisfac- tory, and limited it to the treatment of the pedicle in ovariotomy. With the determination of improving the process and adapting it to the arrest of hemorrhage in all surgical operations, I have employed electricity to produce the required heat and devised instruments to meet all requirements. I have now per- fected the method so that I believe it to be worthy of the attention of the medical pro- fession. The advantages which may be fairly Fig. 2U0. — An artery from fresh beef closed solidly by author's method in one half minute. Seen in per- spective and in section. Life size. claimed for this way of controlling bleeding in surgery are, that it is certain and reliable in closing isolated ves.sels or those imbedded in ma.sses of tissue, like an ovarian tumor pedicle, for example, or the uterine and ovarian arteries in the bi-oad ligament. At the same time that bleeding is arre.stetl all lymphatics are sealed up, MALIGNANT DISEASE OP THE UTERUS. 429 whicli prevents septic absorption. Nerves that accompany the ves- sels are immediately and completely devitalized, and hence there are less pain and irritation in the stump. The heat employed sterilizes the parts involved, and therefore the operation is perfectly aseptic. Of these many advantages, the greatest, I believe, is that it leaves the stump of a pedicle or the end of an artery in a condition re- quiring the least reparatory care, so that recovery is more prompt and uneventful. My impression is that the ends of vessels and tis- sues of pedicles treated in this way become first hyd rated and then organized (during the healing process), in the same way that an inflammatory exudate upon a serous membrane becomes vitalized. I asked Dr. Keith about this. He said that he did not know exactly what became of the stump of the pedicle treated in this way, but he did know very surely that it gave no trouble or anxiety to patients or the surgeon. In this my experience fully agrees with his. I have never known trouble of any kind to occur after an operation that could be attributed to this method of controlling haemorrhage. Although fully satisfied with the results obtained by compression and heat as a liEemostatic, I have long been annoyed by the practi- cal difficulties in its employment, as already stated. While thinking of how" to overcome these difficulties, my attention was called to the use of electricity in cooking and in heating laundry smoothing irons. It then occurred to me to adapt the same heating power to surgical instruments, such as the clamp and foi'ceps. My requirements in this regard were explained to Louis M. Pignolet, an electrician who has given much attention to electricity as used in medicine and surgery. He at once took up the study of the subject with enthusiasm and soon produced the instruments and appliances required. The following is Mr. Pignolet's description, with illustrations of the instruments in question : " The construction of the hseraostatic forceps is plainly shown by the illustration, of which Fig. 201 is a side view. Fig. 202 a section of the jaw on an enlarged scale, and Fig. 203 a top view of the chamber in the jaw, also on an enlarged scale, showing the arrange- ment of the heating wire. The chamber is formed by attaching a flat case (A) of sheet metal to the inner side of one of the jaws (B) of an ordinary compression forceps, in such a manner as to form a water-tight chamber. This increases the size of the jaw but little, as the case is less than an eighth of an inch deep and has the same length and width as the jaw, so that the instrument appears like an ordinary compression forceps. 430 DISEASES OF WOMEN. " The wire {C) for heating the sheet-metal face of the jaw is of platinum or other suitable metal, and zigzags back and forth from side to side in passing through the chamber. A fireproof material, which is also an electrical insula- tor, separates and insulates the wire from the sides of the chamber. The space between the wire and the back of the chamber is several times greater than that between the wire and the front, so that the heat from the wire can pass much more easily to the front than to the back. One end of the wire is electrical- ly connected to the instrument, and the other to a copper wire (E) passing out of the chamber throncrh an insulatino; bushinof (F) in the back of the jaw. The copper wire extends back to the handle of the in- strument, and is insulated by a waterproof covering. Terminals are provided at the end of the copper wire and the handle of the forceps for making connections with the flexible wires or cables which convey the electric current to the instrument. The jmth of the current is through the copper wire, the wire in the chamber, and one blade of the forceps. The copper wire and the blade present but little resistance Fig. 202. Fig. 201. Fig. 203. to the electricity and are but slightly (if a])i)reciably) heated by the passage of the current. On the other hand, the wire in the cham- ber offers considerable resistance to the current and is heated by it MALIGNANT DISEASE OF THE UTERUS. 431 to a greater or less degree, according to the strength of the current and the resistance of the wire. " By this method of construction tlie heat is concentrated upon the inner surface of the jaw of the forceps or clamp — the mechan- ism of which remains precisely the same — and but little is expended uselessly in heating the other parts of the instrument. The elec- trical energy necessary for heating the jaw is therefore reduced to the smallest possible quantity, and varies from ten to thirty watts, according to the size of the forceps. " The required degree of heat, which varies from 170° to 19U° F., is attained very quickly, owing to the closeness of the heating wire to the face of the jaw and the thinness of the sheet metal com- posing the face. Furthermore, the instrument can be sterilized in the same manner as the ordinary forceps without damage. " On this principle, forceps of various shapes, from the largest to the smallest sizes, are heated, as the general formation of the instru- ments is not modified by the heating attachments. " The method of construction described is advantageous, for it simplifies the instrument by dispensing with the extra copper wire that would be required if one end of the heating wire were not connected to the forceps ; but if desired, the heating wire may be connected to a second insulated copper wire so that no current would flow through the blades of the forceps. " The heat developed in the forceps depends upon the strength of the electric current and the resistance of the heating wire. The current required to properly heat each forceps may be ascertained by trial and marked upon the instrument ; or all the forceps (both large and small) may be so constructed as to be heated to the re- quired degree by a current of a predetermined strength, by suitably proportioning the resistance of the heating wire. A small ampere meter included in the electric circuit measures the current re- ceived by the forceps, and enables the current to be i-egulated to suit by means of a rheostat or other controlling device. The heat of the jaw is ihus controlled with certainty, as the current required by each forceps is known, as explained above. " The length of time during which the forceps should be heated varies from thirty seconds to two minutes and a half, depending upon the thickness of the tissues compressed between the jaws of the instrument. It is advantageous to give the forceps a slight ex- cess of current for a few seconds at the commencement, as this hastens the desiccation of the tissues and shortens the time of appli- cation. If, for example, ten amperes be the current required to 432 DISEASES OP WOMEN. lieat the forceps to the proper degree, start with twelve amperes and decrease to ten amperes after the lapse of a quarter or a third of the time during which the current is to be applied. " As the forceps require less electrical energy than the average cautery electrode, the current from a small storage battery or a suitaljle primary battery, such as the excellent battery of Dr. Byrne, can be used for heating them, but the current from electric-light mains is preferable, as it is not subject to failure, and the care and attention necessary to keep a battery in working order are avoided. '' Alternating current of the pressure used for lighting buildings can be converted into a current of lower pressure adapted for the forceps, as well as cautery knives and examining lamps, by means of a small transformer capable of giving current of different strengths and pressures. The current is generated in a coil of wire called the ' secondary ' by the inductive action of the lighting cur- rent passing through an adjacent coil called the ' primary.' The two coils are carefully insulated from each other, so that there is no danger from the comparatively high-pressure lighting current, as it can not pass from the primary to the secondary. A further ad- vantage of the transformer is that it increases the quantity of cur- rent available as well as reduces the pressure, so that a current of large quantity but low pressure can be obtained without overloading the smallest electric-light wire used. " The pressure is varied to suit the forceps or other device by cutting a sufficient number of the turns of secondary wire in or out of the circuit by a switch, or by altering the strength of the inductive action upon the secondary coil by moving it to a place where the action is stronger or weaker, as a greater or less pressure is desired. " A convenient form of transformer, constructed according to the latter metliod, is illustrated by Fig. 204-. The flexible cable convey- ing the electric-light current is connected to the binding posts. A, the cautery electrode to B, and the incandescent lamp to C. The cur- rent is regulated l)y sliding the knobs (L) and E) which control the cautery and lamp coils respectively toward the center of the instru- ment to increase the pressure and quantity, and vice versa. If the electric-light current be continuous, it can be converted into an alternating current suital)le for operating a transformer by a small rotary converter. " The current from the electric mains can be used directly, with- out the intervention of a transformer, if it be controlled by a rhe- ostat ; but this is not advisable, for the high pressure of the current MALIGNANT DISEASE OP THE UTERUS. 4^3 might cause a dangerous arc or a shock under certain conditions arising from some disarrangement of the apparatus. " A portable generator of electricity which would be as reliable as the ordinai*y dynamo is an important requirement for medical and Fig. 204. — Transformer for heating hfemostatic forceps and lighting small lamps. surgical purposes where an electric-light current is not available. This necessity led to the construction of a small hand-driven dynamo for use in such cases. " The machine is represented by Fig. 205, and is a convenient and reliable means for heating the haemostatic forceps as well as cautery electrodes, and for lighting small incandescent lamps. It requires no attention, except an occasional oiling, and is less liable to derangement than an ordinary electric-light dynamo. The dynamo, which has a very high efficiency for a small machine, was specially designed for the purpose, and is driven by sprocket wheels and chains, as shown by the illustration. The armature is provided with two separate windings, each with its individual commutator and brushes for collecting the current. Each winding is capable of gen- erating a current of fifteen amperes at a pressure of from one and a 29 434 DISEASES OF WOMEN. half to three volts, according to the speed of the armature, A switch is provided for connecting the windings together in parallel, to double the quantity of the current, or in series, to double the pressure. In this way a current may be obtained of lai-ge quantity and low pressure, such as is required for cautery electrodes, as well as the current of smaller quantity and higher pressure needed for small lamps and other apparatus. The machine will furnish cur- FiG. 205. — Hand-driven dynamo for heating hsemostatic forceps and cautery electrodes. rent of any pressure from one and a half to six volts, and even slightly beyond these limits, which is sufficient for all ordinary uses. " A small voltmeter, or an inexpensive galvanometer, connected to the circuit enables one to keep the current at any desired strength." Vaginal hysterectomy offers superior opportunities for the use of the haemostatic forceps in arresting haemorrhage. I have tried every known method of doing this operation and found them all objectionable, and so I was led to do the operation as follows : The vagina is divided all round the cervix uteri with the cautery knife. The bladder is separated from the uterus and the perito- naeum opened in front and behind in the usual way. The lower portion of the broad ligament is then seized with the compression forceps as close to the uterus as possible and the heat turned on. The compression is increased while the heat is being applied. A little practice is needed in order to know the degree of heat that is PLATE 11. ()'i >e, the i< a!i »/jl Utc h the ppv electr: uade and ture ; in fact, it tak I'l.AT /' 91fi 8911 enhsia sin^C) d'jidfr ,i9J9ii .II aTAJ4 HT llTl fr YlCOTO'd: " liO • ,iif/oih >9Ja989iq9*i si .584- 9'gBq 998 .31U§& 19W0j if'ii^iqmoo ddl baa bgnoauul fl99d -gaiTBd siusiga daiS '»dT c'l^DTgi ddl .aioaaioa 9ri;t ii:ti7/ b99il Jnoma-gd beoid 9il:f lo i^texf 19770! no' ' 9rlj sdisi sdl 9vofn9i oT .qu led-o'id qBBi-n bno'ji^a £ syyl^J fit oJ bluow b[od bno'J96 aidt ^auisiu oiI) dif// gbia aidt fa oivlgq .}n9cnc§r{ bfioid B' % MALIGNANT DISEASE OF THE UTERUS. 435 Fig. 206. — Cautery incisions about the cervix. being used and the length of time that it should be continued. When one is doubtful about this, the forceps may be removed and the parts inspected, and, if need be, the forceps should be reapplied and the heat continued long enough to obtain the desired effect. The ligament is divided with knife or scissors between the forceps and the uterus as far up as the vessels have been closed. The lower portion of the ligament on the other side is treated in the same way. The uterus is drawn down, and the remaining portions of the ligaments are treated in sections until the uterus is com- pletely made free. The operation may be briefly described by say- ing that it is performed in the same way as when forceps is used to control the bleeding, with the difference that instead of leaving the forceps on long enough for the compression alone to arrest the haemorrhage, the heat completes the hsemostasis and the forceps is removed at once. Peritoneum. jjj controlling hssmorrhage from small arteries my observa- tions have been limited to such operations as amputation of the mammary gland and small ves- sels in divided adhesions in ab- dominal operations. The for- ceps employed for this purpose is in form the same as the ordi- nary artery forceps, and is used in the same way. The artery is seized and held firmly, and the electrical connection made and continued until the end of the compressed vessel is desiccated. This takes very little more time than applying a ligature ; in fact, it takes less time when the vessel is in a deep cavity and not easy to get at. In the manage- ment of small bleeding vessels in the abdomen or down in the pel- vic cavity this electrically heated forceps is very useful and con- venient, and saves much time, trouble, and anxiety. Up to the present time I have not practiced this method of con- -Snture through peri ton feu m :■•). and through KZif:- vaginal wall §:^^.- above cau- '"' '" terized edge. Fig. 20*7. — Diagram of vagina and wound after removal of uterus. The suture passes through the peritonEeum and the vaginal wall beyond the cautery cut, and is tied ; then is tied to its fellow on the opposite wall. 436 DISEASES OF WOMEN. trolling the hsemorrhage in doing abdominal hysterectomy, but I am confident that it can be employed satisfactorily in that operation. After-treatment. — The after-treatment will depend upon what method of operating has been selected. In all cases rest and, if necessary, a cathartic are to be prescribed. If pain is marked and the stomach irritable, opium and warm water may be given by the rectum. For the first few days the food should be liuid ; on the third day the bowels should be moved by a saline cathartic, and by an enema of glycerin and water. The gauze packing is left in the vagina for five or six days by most operators. If the operation has been done with ligatures, I prefer to change the gauze at the end of forty-eight hours. When forceps are used I remove the gauze at the end of thirty-six or forty-eight hours, and introduce a gauze drain, which is to be changed at the end of two or three days, and replaced if there is much suppuration. If the wound unites without much suppuration, a douche can be used, but without the least force, for five or six days, and continued daily until all the discharges have ceased. After-treatment of cases operated upon by my method : The vagina is loosely packed with gauze, which is removed at the end of forty-eight hours, and if there is any discharge it is not replaced. After the fourth or fifth day the vaginal douche of borax and water may be used, and repeated daily if there is any discharge. At the end of a week the wound is, as a rule, completely healed, and no further local treatment is necessary. SARCOMA OF THE UTERUS. Fibroplastic tumors, or " recurrent fibroids," are neoplasms of the embryonic tissue type whose seat is usually in the body of the uterus. Pathology. — The connective tissue is the origin of uterine sar- coma; and immediately beneath the epithelium this tissue forms nodules or ridges which bulge out the softened and somewhat dis- integrated mucosa into the uterine cavity. Since the projections are often polypoidal, pedunculated, soft, and medullary in consistence, rapid in their growth, and vascular, it is easy to see how they can be mistaken for carcinoma. Indeed, Klebs has found a profuse epitiielial growth upon sarcomatous nod- ules of the uterus and then the growths seem to have joined. The uterus may be greatly distended by the fungus-like growth. When the mucous membrane is wholly disintegrated, the uterus A HI aTAJ? onv. ! A ,9'f^ MALIGNANT DISEASE OF THE UTERUS. 437 may be perforated, and in rare instances the sarcoma may prolifer- ate out through the abdomen. In other cases the growth is deeper, less diffuse, and more nodu- lar. It begins anywhere in the uterine tissue between the submu- cous layer and the peritoneal investment and forms a hard, roundish mass like a fibroid. This may assume a fungoid or polypoid form and hang down in the uterine cavity ; as in cancer, so here, the soft may be a later stage of the hard sarcoma. Possibly a degenerating fibroid of the uterus may be associated with a sarcoma ; or, as it then would be called, a fibro-sarcoma. As to the effects, the vagina, peritonaeum. Fallopian tubes, and ovaries may be invaded by sarcomatous masses. The uterus is often inverted, either from an easily dilated cervix or from weakening or palsy of the uterine muscle. Symptomatology . — The classical symptoms of malignant disease — pain, haemorrhage, and discharge — are met in cases of sarcoma uteri. Pain, however, occurs late, if at all, and seems to have often been confounded with uterine tenesmus, which is a common symp- tom. At times there may be severe pain from pressure on the rec- tum and bladder. Menorrhagia is an early symptom ; or if the disease is in those who have passed the menopause, menstruation seems to have re- turned. Later, there is a discharge resembling the rice-water stools of cholera which is only faintly suggestive of the cancerous odor. But as the neoplasm ulcerates, the discharge is as fetid as that of carcinoma, and in it are pale-gray shreds, which upon microscopical examination at once reveal the true nature of the growth. A cachexia is very slowly and gradually developed, yet finally it is as marked as in cancer. Physical Signs. — Palpation reveals a soft, friable, pedunculated tumor which may be felt to spring from the body of the uterus. The OS, through which this tumor is forced, is dilated, softened, and irregular. The finger or the sponge-tent may be used to dilate the cervical canal when the mass has not yet made its way down to the OS internum. Bimanual palpation shows the uterus to be large, sometimes reaching halfway to the umbilicus, and oftentimes as irregular as when the seat of fibromata. The sound shows the extent of the enlargements ; its use causes intense monorrhagia. The curette is useful to obtain scrapings for microscopic exami- nation. 438 DISEASES OF WOMEN. Diagnosis. — Sarcoma may be mistaken for carcinoma ; but in the latter disease pain is a far more frequent, early, and severe symptom ; the discharge is fetid almost from the very onset ; the cervix is most difficult to dilate with a sponge-tent; the constitu- tional symptoms are more severe ; and the duration of the disease is rarely over a year. These symptoms are in contrast with what' occurs in sarcoma. Finally, a microscopic examination of some of the scrapings will always be necessary before determining the diagnosis. Prognosis. — Although a patient with sarcoma of the uterus lives on the average three or four years after the tumor is fairly devel- oped, yet the outlook for ultimate recovery is most grave, all cases slowly but surely tending toward a fatal issue. Sarcoma tends to reappear after most careful removal, although the time elapsing between removal and recurrence is much longer than in the case of carcinoma. The prognosis will greatly depend upon an examination of the scrapings: when these show scanty stroma with an abundance of cell elements, the course will probably be as rapid as that of enceph- aloid cancer ; but when the cells are few and the fibrous tissue is abundant, life may be prolonged for six or eight years. Among the complications are septicsemia, anaemia, peritonitis, and sarcomatous nodules in adjacent organs. Causation. — Age is the chief predisposing cause ; half of all the cases occur between the ages of forty and fifty, and before thirty or after sixty sarcoma is extremely rare. In cancer I referred to the occurrence of the disease in those who had borne many children ; but sarcoma seems to develop in sterile wombs in nearly fifty per cent of the recorded cases. It is a mooted question whether traumatism and uterine inflam- mation have any influence in the causation of sarcomata. Treatment. — When pedunculated tumors project into or out through the cervix, the sharp spoon or the galvano-cautery, or even the finger-nail, may be used to remove them. Then carbolic or nitric acid may be applied to the base of the tumor. When the growth is not sessile but apparently superficial, thor- ough curetting and the application of nitric or carbolic acid are advocated. Deep sarcomata can only be treated by extirpation of the uterus. CHAPTER XXIII. THE MENOPAUSE. The menopause marks the dividing line between middle life and the beginning of old age. The permanent suspension of the menstrual function is known by several names, such as critical time, climacteric or climacteria, turn of life, and menopause, the latter term being the most express- ive and preferable. The natural history of the final cessation of menstruation varies so much in different individuals that it is difficult to accurately give a tj^pical account of it. The time when it occurs ranges from forty to fifty years of age, the average in this country being about forty- five. The menopause coming early or late depends apparently upon the delicacy or health and vigor of individuals. There is a popular idea that those who begin early should stop early, but, according to my observations, those who reach the period of puberty betimes because of good health and strength, and who continue healthy, are likely to maintain the menstrual function later in life, providing that all the sexual functions are normally exercised throughout middle life. The question has been raised as to whether celibates do not reach the menopause earlier than fruitful women, but I have not yet ob- tained facts sufficient to answer this definitely. In women of good health, to whom the change comes without complications, I have observed that in one class the menstrual flow becomes less free and shorter in duration, then a period may be missed, to be followed by a recurrence or two, and then it finally ends. In others the inter- menstrual period is lengthened to five or six weeks, and the flow when it does come is free, often profuse, and lasts longer than usual. The time from the waning until the final cessation of men- struation varies from six months to two years or longer. The menopause being an event which is natural to woman, there is nothing in its occurrence which should cause ill health ; still it is attended by certain phenomena indicating special modifications 439 440 DISEASES OF WOMEN. of the organization which disturb the comfort and general activity of the most health}^ women, though not to a degree that can be called ill health. Many increase in flesh, become less inclined to mental and physical activity, and show signs of excrementitious plethora. There is nsually constipation, often due to deranged secre- tions, and the nervous and vascular systems are more or less dis- turbed. Very often functional heart trouble, irregular action and palpitation of the heart, with a feeling of impending danger, are the common symptoms. These are frequently associated with inter- costal neuralgia of the left side. Grave apprehensions on the part of the patient are excited by these symptoms. Similar indications appear in amenorrhoea in young subjects. This points to the fact that cessation of the menses has a peculiar influence upon the innervation of the circulatory system. The flushings of the face, " hot flashes," from vaso-motor derangement, annoy them sometimes very much. Fullness of the head and occa- sionally headache and drowsiness during the day, and disturbed sleep at night, are frequently noticed. In other cases the appetite fails slightly, and there is no gain in weight, perhaps a slight loss of flesh. The same disturbed circulation is generally present, but there is, on the other hand, increased nerve excitability. Complaint is made of restlessness, and a number of minor symptoms, such as im- paired memory from lack of interest and concentration, are observed and often dreaded. These are the usual symptoms which attend the menopause in healthy women living under favorable circum- stances. Comparing the menopause with puberty shows that they are almost exact opposites, the one being a development of structure and establishment of function, the other a decay of structure and suspension of function. One marked difference is noticeable : men- struation is complete and perfect from the beginning. Established after all the structural conditions are matured, it is maintained in full effect. The menopause comes gradually as the decline of the structures progresses. Atrophy of the sexual organs from impaired nutrition is the anatomical change that directly leads up to the menopause. The ovaries, having all along been breaking down to a certain extent, at each ovulation arrive at a condition of senile atrophy, and no longer exert their full influence in the economy. There is not now the demand for so large a blood supply, and the uterus shares in the lowered nutrition. The ovaries first arrive at the stage of atrophy through a gradual breaking down of the tissues, which causes in- THE MENOPAUSE. 441 competence. This, no doubt, is the most important factor in the causation of the menopause, but it is only one of several. There is, furthermore, an atrophy or lowered nutrition of the spinal centers and organic nerves which govern the sexual organs at this time of life, and the brain also to some extent withdraws its influence from them. Simultaneously with these changes the uterus becomes atro- phied, the degeneration progressing slowly. There is at first anae- mia of the uterus, which is apparent in the pallor of the vaginal and cervical mucous membranes. The whole organ gradually di- minishes, until finally it approximates to the infantile in form and size, although the senile uterus is a little larger than that of a child. When these anatomical changes are completed menstruation ends, but the atrophic diminution continues for some time after the menopause. Leith Napier, in his elaborate work on the Menopause, gives as the cause the general atrophic condition which comes on in senility. I have always taught that it was the result of the atrophic changes in the sexual system and in the nerve centers which preside over it. I do not believe, as Napier claims, that it is due to the general atro- phic condition of the entire organization. As already stated, the menopause occurs in consequence of a de- cline or atrophy of the sexual organs, nutritive supply, and innerva- tion ; hence there should be a harmonious falling off in all the structures concerned in the functions of the sexual organs. When that is the case the change of life is free from anything that re- quires the attention of the physician ; but when the nutritive changes which precede the suspension of the menstrual function progress faster in one portion of the economy than in another, morbid disturbances arise. It follows that certain affections which occur at the menopause are due to deranged nutrition and prema- ture deterioration of that portion of the cerebro-spinal sympathetic systems which govern the sexual organs. Others are due to prema- ture or delayed atrophic or destructive changes in the sexual organs themselves. Varying forms of derangements may arise from these causes. For example : Withdrawal of the mental influence may cause sup- pression of the menses before the sexual organs are atrophied, and an over-devotion to matters sexual may cause menstruation to con- tinue in an imperfect way after the wasting of the uterus and ova- ries takes place to some extent. On the other hand, degeneration of the ovaries and uterus may cause suppression of the menses while the cerebro-spinal structures may still be perfect and function- 442 DISEASES OF WOMEN. ally active. Certain diseases of the sexual organs may keep np a modified form of menstruation after the nutrition of the nervous system has begun to decline. When this latter condition prevails, the nervous and nutritive systems have a drain imposed upon them which they are incapable of sustaining, and consequently suffer de- rangement. On the contrary, while the nutritive and nervous systems remain healthy and active there is a necessit}'^ for men- struation, and if (owing to atrophy or malnutrition of the sexual organs) menstruation is suspended the general economy is sure to be deranged. The derangements and disorders incident to the menopause may be classified, according to the way in which they are manifested, under three heads : premature or delayed menopause, and constitu- tional derangements accompanying or following the menopause. The latter is subdivided into nutritive and nervous disorders conse- quent upon the suspension or undue continuance of this function. Premature Menopause. — The function of menstruation may be suddenly suspended, or it may gradually subside and end completely at too early an age. The abrupt ending of menstruation being the most unnatural, gives rise to the greater disturbance of the general health. The causes of premature menopause are of two classes : diseases and injuries of the sexual organs, and diseases of the nutri- tive and nervous systems. By recalling the conditions necessary to normal menstruation, given in the chapter on Menstruation, it will be seen how these causes are operative. The disorders of the sexual organs which cause a premature menopause are degenerative disease of both ovaries, double ovariotomy, and loss of the Titerns or injuries to it, which lead to its premature atrophy. Of the lat- ter, the most conspicuous are hysterectomy, the ovaries being left : puerperal metritis, which results in superinvolution ; and extensive lacerations followed by the formation of much scar tissue. Opera- tions for the relief of deep bilateral lacerations, requiring removal of large portions of uterine tissue, may lead to atrophy. This has been noticed by several observers in late years. Removal of the ovaries may be taken as the principal cause of abrupt menopause. Ovaries that are slowly destroyed by disease bring about the menopause more gradually. This is made quite apparent from the clinical facts, that those who have well-defined destructive diseases of the ovaries menstruate imperfectly for some time, and suffer very little from the menopause when it is completed by the removal of the ovaries and tubes, because the change comes more like the natural way. Premature menopause caused abruptly THE MENOPAUSE. 443- by removal of functionally competent ovaries and tuljes, removal of the uterus, or diseases and injuries of the uterus, which incapacitate that organ for performing its functions, give rise to such marked derangement of the general health as to demand special considera- tion. Fortunately, the ovaries are not sacrificed so often novs^ as in the near past, when they were removed in the vain hope of reliev- ing certain neuroses, incurable dysmenorrhoea, and uterine fibrom- ata. It is strange that Napier makes no allusion to induced meno- pause. Syonptoms. — The effect of the removal of the normal ovaries in middle life is to derange the nervous, nutritive, and circulatory systems. The clinical history appears in many cases to partake of the characteristics of neurasthenia, nervous irritability, and derange- ment of the emotions. Great muscular and nerve weakness, indi- cated by continual weariness, soon appears. In some there is decided nervous irritability (that which is known as nervousness), with a dis- position to try to do much, but who become easily fatigued. There is mental depression, indicated by sighing and lamenting over real pains and debility, and imaginary evils that are present or impending. Much of this depression and emotional disturbanced comes from a consciousness of being sexually impotent. The nervous systemic disturbance is manifested by headache, pain in the neck and back, pain in the limbs, tenderness of the skin, strange wandering pains,. and queer feelings in the head and elsewhere. These symptoms are the same in kind as those found in connection with the meno- pause at the right age for it ; but in cases of premature arrest of menstruation the disturbances, mental and physical, are greatly ex- aggerated. Dr. Savage * calls attention to some of the mental troubles com- plained of by such patients. They fancy, he says, that something has burst in the head or womb ; have a sensation as if hot blood were over the brain, and a feeling of deadness or emptiness. With the passing away of the sexual functions, querulousness, jealousy, and a fancy that their husbands no longer care for them, not infre- quently occur. All of these symptoms I have frequently observed in my own practice. There are also pelvic tenesmus and pain in the ovarian regions, presumably in the stumps left after the removal of the ovaries. The next symptoms in the history are derangement of the circu- lation, chiefly vaso-motor, due to deranged innervation ; irregular * Medical Press, November 8, 1893. 444 DISEASES OF WOMEN. heart action ; flashes of heat, and cold hands and feet ; cold per- spiration followed by hot, dry, feverish skin ; numbness of the extremities, most frequently of the left arm ; creeping, crawling feelings in the skin, and burning spots here and there. Nutrition is generally impaired, and nervous indigestion is present in all cases as a rule. Assimilation is defective, as the loss of flesh and softened state of the muscles indicate. The skin shows malnutrition in being either dry and hot or cold and clammy. These indications are all more marked at the time when the patient should menstruate. These periodical exacerbations are most distinct at the flrst. As time goes on the patients adapt themselves to the new order of things gradu- ally. If properly managed, recovery may take place in time, but if left without care they become chronic invalids or insane. Artificial menopause is more often followed by insanity than the normal climacteric. The effect upon sexual instincts of removal of the ovaries in adolescence has been discussed long and laboriously in the past years, but nothing new has been advanced. Repetition of the two opposite, old, and rather ridiculous ideas — one, that the removal of the ovaries unsexes women, and the other, that it does not affect them at all in this respect — is about all that has been heard on this subject during the last eighteen or twenty years. The fact is, that it does not unsex women, but in time impairs sexual characteristics, and they are, as a rule, finally lost. The passing away of the sexual appetence and the consciousness of being positively sterile often have a most disastrous effect upon the mind, and frequently lead to insanity. I will refer to this again in treating of insanity among women. Treatment. — The first indication is to quiet the mental disturb- ance. Much can be done to relieve the patient's depression by giving hope of recovery. Sedatives are required to give sleep, and nerve tonics, such as are suitable in melancholia, are called for ; camphor, lupulin, and in some cases small doses of opium, give relief. The opium should be given with care, and without the patient knowing what she is taking. Lately I have used codeine with better effect than opium gives. The deranged circulation is best managed with a combination of digitalis, strychnine, and bella- donna. Occasional attacks of palpitation of the heart — pain in the cardiac region with difficult respiration — are relieved with nitro- glycerin, strophanthus, and digitalis. Indigestion is generally of the nervous type, and is controlled by gastric sedatives such as bis- muth and oxalate of cerium, or subgallate of bismuth. The spinal THE MENOPAUSE. 445 symptoms are, I presume, due to a hypersemic or anabolic state, hence the irritability, nervous twitchings, and neuralgic pains. "When these are annoying, relief is obtained by dry cupping, alter- nating with hot and cold douches, or sprayings, hot and cold, applied in rapid succession to the lumbar regions. Time is the great factor in restoring the equilibrium, and the main object is to relieve and sustain the patient until the new order of things is established. Enforced Menopause from disease, injury, or removal of the uterus, while the ovaries are left, causes a general derangement which may be termed an exaggerated menstrual molimen. The nutritive preparations for menstruation go on, and when the elimi- native function is not performed there is a temporary plethora. The patient complains of fullness of the head, flushed face, very often headache, and oppression which is felt as weakness and indis- position to engage in mental or phj'sical exercise. The nervous systemic disturbance is manifested by drowsiness, low-spiritedness, and inability to think clearly and quickly. Those of a nervous temperament are irritable, fretful, and, although sleepy at times during the day, often have sleepless nights. Treatment. — The old practitioners employed bloodletting, and with decided benefit. In strong women it might be practiced with advantage at the present time, but it should not be continued at each recurring menstrual period, as the habit of requiring bleeding is easily established. Depletion by other means, like saline cathartics, for example, gives much relief, and mercurials are of great value when the liver and kidneys are inactive. Small repeated doses of mild chloride of mercury, followed by a saline, or natural cathartic waters, act well, and Turkish baths and muscular exercise aid in some cases. The headache often complained of as a painful fullness is best re- lieved by bromide of soda with antipyrine or monobromide of camphor. Piperazine is the best solvent, and gives great relief in the uric-acid saturation which is often present and causes neuralgic, rheumatic, and gouty symptoms. The diet should consist of milk, eggs, vegetables, and fruit, with very little animal food. The quan- tity of food should be limited ; underfeeding rather than full diet should be the rule. Some women have a craving for alcoholic drinks, but these should be prohibited. The indications for treatment are based upon the fact that the function of the sexual organs is suspended before the nervous and nutritive systems have been prepai-ed for the change in the economy. The nutritive activities are out of proportion to the demand, and 446 DISEASES OF WOMEN. therefore the supply should be diminished. If it is not, the nutri- tive processes become deranged. These derangements should be treated in the usual way. The disorders of the nervous system arising from enforced meno- pause from the causes now being considered are also twofold. There is in one class an exalted nerve force, which, no longer finding an outlet through the demands of the sexual system, gives rise to nerv- ous derangements which should be relieved by sedatives, and diver- sion of the nerve forces in some other direction by mental occupa- tion. Women who have given their best mental energies to the exercise of the sexual system suffer most from premature meno- pause. There is another class who suffer from nervous exhaustion or debility. They manifest nervous excitability with loss of power ; they are called nervous patients. All such require rest, tonics, and good nourishment. Whenever the nervous system is specially dis- turbed at the menopause the greatest care is required to keep its 'disorders from going from bad to worse. There is a tendency to develop diseases of the nervous system in many forms, and if there is any inherited tendency to insanity it will be brought out under these circumstances. Delayed Menopause. — The menstrual function is sometimes con- tinued to an advanced age in strong, healthy women, but so long as the function is normal there is no reason for being alarmed. It is only when the menses continue beyond the usual time for the meno- pause and there is some derangement in that function, or the gen- eral health is impaired, that attention should be given to the subject. Efforts should be made to discover the local or general conditions which cause these derangements. When the flow is profuse and irregular in recurrence, there is usually some local cause for it that can be easily discovered. It may be said, in brief, that any neoplasm, subinvolution, or old injuries of the uterus may keep up menstruation beyond its normal limit. Scar tissue in the cervix uteri, either from injuries or from the use of caustics, apparently prevents the final atrophy of the uterus by keeping up a continuous irritation. This is the only way that one can account for the relief obtained in such cases by dilat- ing the canal of the cervix. A number of cases of recovery from painful menstruation and delayed menopause have been reported cured by this form of treatment. Uterine fibroids and subinvolu- tion, as well as scar tissue of the uterus, all belong to the domain of surgery, and are only referred to here as belonging to causation. THE MENOPAUSE. 447 Delayed menopause is also caused by certain constitutional conditions, such as hepatic, cardiac, and renal disease, and also certain blood states which, if they do not favor a continuation of menstruation long after the time for change of life, certainly cause menorrhagia about the time for the menopause. Menorrhagia and delayed menopause are not infrequent in cases of mitral insuffi- ciency. The effect of this cardiac lesion upon tlie circulation is to keep up a continued hyperaBmia of the pelvic organs, and this often causes women to go on menstruating when they are old enough to have the menopause, and when they can ill afford to keep up that function. The diagnosis is easily made by the physician who makes his examination sufficiently thorough. The treatment consists in trying to improve the circulation. At the menstrual period the patient should be kept in the recumbent position as long as it can be borne with comfort. She should rest, not necessarily upon her back, but on either side that is most com- fortable. Massage and hot-water douches, which I do not hesitate to recommend if the flow is excessive, will sometimes control this condition. Digitalis and aromatic sulphuric acid in medium doses will frequently give great relief, and they are far better borne than hydrastis canadensis or ergot in those cases of cardiac disease. Hepatic disease, such as the engorgement and enlargement oc- curring in chronic malarial poisoning, not rarely causes menorrhagia in young women, and is very apt to delay the menopause. This no doubt is also due to the deranged portal circulation, which keeps up the pelvic engorgement. The treatment, of course, should be such as the physician employs in chronic malaria. It will suffice to add here that, in addition to the use of the alkaloids of cinchona bark and arsenic, I have found the most marked benefit from the use of iodine. I give five drops of the tincture in water, with enough of the iodide of soda to make a clear solution. The formula is : Tinc- ture of iodine, two drachms ; iodide of sodium, half a drachm ; simple sirup, one ounce ; water, two ounces. Dose, one drachm after meals, well diluted. To this I very often add two or three drops of Fowler's solution. Of course, attention to the bowels and general nutrition should be fully given. The premature menopause has been referred to as arising from certain constitutional affections, notably tuberculosis, and so on. Nothing need here be said about this, as suppression of menstrua- tion is a conservative matter and requires no direct attention. It may be well to add also that in case the physician can not find any disturbance of the nutritive or nervous system to account for the 448 DISEASES OP WOMEN. delayed menopause, it is evident that the cause is local, and such patients, of course, should be relegated to the domain of surgery. ILLUSTRATIVE CASES. A Case illustrating the Normal Menopause. — A lady who had a very good constitution, and, with the exception of having had some acute diseases in early life, had enjoyed uniform good health. She had borne five children, and after the birth of the last one she men- struated regularly and perfectly. Wlien she was forty-six years old the menstrual flow began to diminish in quantity and duration, varying a little in this respect from time to time. In six months from the time that the change began, the duration of the flow was reduced from five days to two. She then missed two periods, and then the flow returned and lasted three days, and was a little freer. Then she went for four months, when there was a slight show for part of a day, and that was the end. During the time when the gradual diminution of the flow was taking place she became somewhat languid, and indisposed to her usual mental and physical activity. Her appetite was not quite as good as formerly. While languid when undisturbed, she was easily roused by any excitement. Her face would become flushed, her hands and feet clammy, and she was nervous and irritable. When these feelings passed away she felt annoyed to think that she could not control herself as in times past, and would become a little de- spondent. All these symptoms were more pronounced at the men- strual periods. When suffering most she felt that if she could have a free menstrual flow it would relieve her. These feelings continued to annoy her until the flow ceased entirely, and for about nine months afterward, but they diminished in severity, and finally left her altogether. After the cessation of the flow she gained considerable flesh, and her former mental and physical activity returned, and her health has been excellent ever since. When the diminution in the flow began and her peculiar symp- toms came on, she consulted me about her condition. When told that all could be attributed to the change of life, slie pleasantly ac- cepted the situation, and made no change in her mode of life, nor (lid she take any medicine. This enabled me to ol)tain the history of the case uimiodified by treatment. Premature Menopause caused by Deranged Innervation. — The pa- tient was one having a good organization, but a very marked nervous temperament. She had three children, the youngest of whom was i THE MENOPAUSE. 449 five years of age when I fii'st saw her. She was then thirty-six years old. Three years before our first consultation she had many exciting cares thrust upon her, which affected her nervous system very injuri- ously. Though possessed of means sufficient to secure every luxury of life, her cares depressed her greatly, and exhausted her nervous system. Her nutrition was impaired to some extent, but still she had the appearance of one in fair health, although she was restless, sleepless, had headache very often, and suffered from wandering neuralgic pains. Her sufferings in this way had continued for about one year, during which time the menstrual flow was at times scanty, and less in duration than normal. Then the menses stopped altogether for six months, then returned for several months, though scantily, then ceased for two months, returned once, and then again in four months, and then stopped entirely. Five months after the last menstruation was the time that I first saw her. She consulted me because she fancied that if her menses would return her health would improve. To describe her symptoms would be tedious and unprofitable ; suffice it to say that she presented typical neurasthenia. There was no organic disease noticeable out- side of the nervous system. Being fully satisfied that if the men- strual function could ever be restored it must be accomplished by restoring the nervous system first, the treatment was directed to that object. Sleep at night was obtained by giving thirty grains of bro- mide of sodium late in the afternoon, and half an ounce of whisky at bedtime. Aconitia, one two-hundredth of a grain, relieved her at- tacks of neuralgia. Massage and general faradization were employed daily, and tonics were given, consisting first of valerianate of zinc, then pyrophosphate of iron and arsenic, and then iodide of iron. Citrate of iron and quinine was also given at times. The form of tonic was changed whenever she became used to that which she was taking, and the most appropriate diet was given. Her general health improved gradually, and in the summer she was able to rest and enjoy life in the country by the sea. Sea bathing was also tried after a time with benefit. About one year of this treatment restored her health, but the menses did not return. In fact, the restoration of that function was despaired of after three months' treatment, when, on examination, it was found that the organs of generation had undergone complete involution. The Menopause delayed by Fungosities of the Endometrium. — This patient was married, and the mother of five children. After the birth of her last child she suffered from uterine leucorrhoea, proba- 30 450 DISEASES OF WOMEN. bly caused by endometritis. She had fair health in spite of that, and menstruated regularly until she was forty-six years old, and then the menstrual ilow became more profuse. This continued intermit- tently for nearly one year, when the menses came more frequently, lasted longer, and the flow was quite profuse. Her health failed gradually ; she became ansemic, weak, low-spirited, and nervous. Tliough her flesh remained (she was rather stout), her strength was greatly reduced. Her family physician gave her the usual remedies — lead and opium, ergot, cannabis Indica, and aromatic sulphuric acid — in the hope of controlling the flow, but without effect. Finally she consented, with some reluctance, to an examination, when a large number of polypoid growths were found in the cavity of the uterus. These were removed with the curette, and the flow- ing stopped for six weeks ; it then returned for a few days, but was not very free. There was a return of the menstrual flow in two months, very scanty, and another in three months, and that was the end of it. She was then forty-eight years old. After the removal of the fungous growths with the curette, her health improved under tonic treatment, and when last seen, at forty-nine years of age, she was quite well. Excrementitious Plethora, Oppression, and Derangement of the Nervous System from the Menopause. — A strong-looking German lady gave me the following history : She was married and in quite comfortable circumstances. She had six children, the youngest being eleven years old. From the time of her last confinement her health had been good, and she menstruated normally until she was over forty-six years of age. Her menses came then at the proper time, but lasted two weeks, and the flow was too free. After a lapse of three months the menses came again in a diminished de- gree, and again in two months scantily. From the time of her free menstruation, when she was about forty-six years old, her health failed gradually. She had always been a generous liver, and continued to take her nourishment well, but she became languid, indisposed to exertion of any kind, had headaches, was drowsy and sleepy all the time, but often had restless nights. Her mind was disturbed, so that she was depressed in spirits, quite fretful, did and said " queer things " which alarmed her family, and her memory was less reliable than formerly. She had little interest in her for- mer duties and amusements, but occupied her time mostly in think- ing and talking about her feelings. There were flushings of the face at times, which she described as rushing of blood to the head, which she fancied might kill her. There were profuse but brief THE MENOPAUSE. 45 1 paroxysms of perspiration, which came at times without any phys- ical exertion. She was qnite fleshy, and, excepting an anxious ex- pression of the face, had the appearance of' good health. The tongue was coated, the bowels constipated, the urine was loaded with phosphates ; the pulse full, but slow, and at times irregular ; the appetite was not good, but she took food in abundance, and drank wine and beer in the hope of getting strength. She suffered from labored digestion and flatulence, and a sense of fullness in the region of the stomach. The sexual organs had undergone com- plete involution, although the vagina was relaxed and showed some venous congestion. The treatment was first ten grains of blue-mass, three grains of calomel, and one grain of ipecac, given at bed-time, followed in the morning with a dose of sulphate of magnesia. This was repeated twice, at intervals of five days, and after that the following mixture was given : Bromide of sodium, half an ounce ; salicylate of sodium, two drachms ; wine of colchicum seeds, two drachms ; sirup and water enough to make three ounces, and a teaspoonful to be taken before meals. She improved very much on this treatment, and the mixture was continued for about six weeks. After the effects of the mercurial cathartic had passed off she became constipated, and the following pill was given at bed-time : Sulphate of quinine, one grain ; extract of belladonna, one eighth of a grain ; and rhu- barb, two grains. When this was not sufficient to move the bowels freely, a glass of Congress water was given an hour before breakfast. Wine and beer were gradually given up, and her diet simplified and reduced in quantity. Exercise in the open air was prescribed, and light, agreeable mental occupation. The progress of the case was quite satisfactory for about two months, then there was a standstill for a time. The medicine was then changed to a mixture of hydrochloric acid, one and a half drachm ; tincture nux vomica, one and a half drachm ; tincture of cannabis Indica, two drachms ; tincture of cardamom, one ounce ; and simple sirup, two ounces ; one drachm, before meals, in water. The pill at bedtime was continued. This last prescription was given for about two months with an interval of three days after each bottle, when she took the pill only, at night. From this time onward the progress of the case was steady until she finally recovered her former good health. Such a case as this is infrequently seen in practice. The causes being conditions of life favoring derangement of nutrition and slug- gish disintegration, aggravated greatly by the rather abrupt cessation of the menses. 452 DISEASES OF WOMEN. Impaired Digestion and Assimilation arising from the Cessation of Menstruation. — This lady was married and the mother of a family, of spare habit and a nervous temperament, but her health had been good in the past. When she was forty years of age her menstrual liow diminished in quantity and duration, and simultaneously her appetite failed, and she lost flesh and strength. Always an active person, she now became restless, nervous, and irritable. Her tongue was clean, but of a deeper color than nor- mal, showing that rapid exfoliation of the epithelium was going on. The bowels were constipated ; the urine was abundant and of light color usually. Her skin was slightly bronzed and usually dry, although she had occasional outbursts of free perspiration. Her pulse was weak, and at times irregular. Her head ached quite often, and she had wandering pains about the chest and abdomen. Her greatest trouble was a feeling of distress in the stomach after eating. Eight months from the time that the menstrual flow began to de- cline it stopped altogether, and two months afterward I first saw her. As the physical condition of this patient was almost exactly the opposite of the preceding case, the treatment was necessarily very diiierent. She was directed to take nutritious food in small quan- tity, six times a day ; to rest as much as possible, and have massage at night, which gave better sleep. At first she was given five grains of oxalate of cerium half an hour before meals, and a teaspoonful after meals, in warm water, of a mixture of lactic acid, tincture of columbo, and pepsin wine, and she improved so far as to take food and digest it with less trouble, but her strength did not return as fast as I desired. She was also constipated. A tonic laxative pill was then given before meals, consisting of quinine, belladonna, and compound extract of colocynth ; and after meals she was given a teaspoonful of whisky with four drops of tincture of nux vomica and four grains of animal charcoal. This appeared to help her, and this course of tonic treat- ment was continued very faithfully for three months, when she con- sidered herself sufficiently well without further treatment. Two years afterward she was found to be in good health. Circumscribed Inflammation of the Vagina and Cervix TJteri, partly due to the Menopause. — The patient was first seen when she was forty-eight years old. The menses had stopped one year and two months l)efore. Her health was fairly good and alwaj'S had been, but for some time before the menopause, and all the time after, she had been distressed by a discharge from the vagina of sero-purulent but rather tenacious material, which caused some external irritation. THE MENOPAUSE. 453 There was heat and burning in tlie pelvis, which became more marked on walking. She had put np with her troubles so long, believing that it was due to change of life and would pass off in time. In fact, she had been told this by her physician. But, in- stead of disappearing, she found that the trouble increased, if indeed it changed at all. Her general health was below par considerably, but there was no organic disease of the organs of nutrition, and yet ultimate nutrition was a little sluggish. The sexual organs had undergone final involution ; the uterus was small, but the os externum was open, and coming from the canal was a tenacious, darkish-colored discharge, not unlike the leu- corrhcea found in young subjects, and heretofore described under the head of " Cervical Endometritis in the Imperfectly Developed Uterus." The mucous membrane about the external os was eroded in patches, and on the anterior lip of the cervix there were some granular spots that looked as if they were the products of epithelial hyperplasia. The aj)pearance of the vagina was peculiar. In place of the general congestion of a well-marked vaginitis, the mucous membrane was studded with small red points or patches, while the intervening portions of the membrane were pale. The surface of the membrane was covered with a sero-purulent discharge ; at the vulva there were several patches of congestion larger than those higher up in the vagina. Some of these were of a deep-red and slightly bluish color. The thought came to me that this might be malignant disease of the cervix just beginning, but this was put aside, because of the duration of the trouble and the fact that I have several times seen this condition after the menopause. I have also frequently seen the same conditions in young insane women who had amenorrhoea. These facts led me to suppose that the inflammatory action was due to impaired nutrition which is pres- ent at the involution of the sexual organs. This low grade of in- flammatory action is no doubt more likely to occur in those who have had some ordinary cervical endometritis and vaginitis before the menopause. The circumscribed red spots looked to me like a few live coals here and there in the ashes left after the fires of func- tional life and inflammation had subsided. The treatment consisted of general tonics and local astringents ; citrate of iron and quinine was given internally, and a teaspoonful of sulphate of zinc in a quart of water for a vaginal douche. The parts about the os externum were touched once with a fifty- 454 DISEASES OF WOMEN. per-cent solution of chloride of zinc. The sulphate-of-zinc injec- tions did very well for a time, but the progress was favored by an occasional application of glycerin and tannic acid. The local improvement did not surpass the general regaining of strength, but kept pace with it. The recovery was permanent and perfect. Pelvic pains of a neuralgic character are common about the change of life, and are often due to it. The following two cases from Tilt will illustrate this form of trouble : Ovario-Uterine Neuralgia. — Miss X. was forty-seven when she first consulted me. She is small, but well-proportioned. Has been highly nervous all her life. Menstruation was irregular, and there were muco-purulent discharge, vaginitis, and decided ulceration of the cervix, and a most irksome sensation of heat and irritation in the passages. I cured the vaginitis and ulceration by surgical measures, without relieving the vaginal heat and pruritus, so I sent the patient out of town. When she returned, after many months, the pruritus was as bad as ever, and would come on after any excitement or fatigue, or standing about, and would be relieved by resting with the feet higher than the pelvis. This vulvo- vaginal irritation would sometimes disappear on the coming on of a similar pruritus on the palms of the hands and on the soles of the feet, showing that how- ever much the chief seat of neuralgia might be in the womb or vagina, the ultimate nervous expansions in other parts of the body might similarly suffer. When this irritation affects the feet and hands there is nothing to be seen there, and she refrains from scratching them because it would prolong the irritation for hours. As might have been predicted, the symptoms were worse at night, and led to great exhaustion and despondency. I have watched this state of things for twenty years, and at times could give no relief. She was always better for plenty of food and wine, and for such small quantities of citrate of iron and quinine as she could bear. I tried all sorts of injections; tar-water did most good, but it has been repeatedly advisable to discontinue all kinds of injection, for they seemed to do more harm than good. I syringed the vagina with a solution of nitrate of silver and touched the passage M'ith the solid caustic, with questionable benefit. A rectal suppository con- taining a grain of opium and one of extract of belladonna often gave tem])orary relief, but this remedy could not be relied on. By the sacrifice of her own health many a daughter has well repaid the gift of life ; and when my patient lost her mother, who had been long a cripple, requiring anxious and fatiguing nursing, she went THE MENOPAUSE. 455 out of town and got fat, and now suffers much less, only having a slight return of the old symptoms when she gets weaker and more nervous. Ovario-Uterine Neuralgia. — A very strongly constituted lady, aged forty-seven, is said to have had some acute uterine disease twenty years ago, while residing in France, when forty leeches were ap- plied above the pubis. With the exception of not being able to re- tain the urine so well as previously to this attack, health remained so good that every year she was able to take long pedestrian excur- sions with her husband. She never conceived, and menstruation ceased suddenly at forty-four ; in the following months the nose bled very frequently, and the bowels became constipated ; for which she went to Homburg and was restored to health. On returning to town, in December, 1868, she took very cold enemata for constipa- tion, which was so great that a wineglass of Friedrichshall water, taken every hour, failed to produce watery motions, and only irri- tated the bladder, apparently causing the strange abdominal sensa- tions which have lasted ever since. The patient feels as if there were a heavy body in the pelvis bearing down upon the rectum, with a burning sensation, referred sometimes to that organ, some- times to the vagina, or to the bladder. When in bed and lying down, with the feet up, she feels comfortable ; by the time she has half done dressing the burning sensation begins, and lasts until the bowels have been moved ; soon after this the burning comes back ; it is ag- gravated by standing or sitting, by indigestion, flatulence, constipa- tion, and repletion of the bladder ; also by worry and bad news. The sensation is relieved by moderate walking, by lying down, and by regularity of the bowels. Homburg was again tried ; it did good, but on her return the lady was as bad as before, and consulted sev- eral doctors. One attributed the sufferings to stricture of the rec- tum, another to irritation of the bladder, a third to displacement of the womb. The following summer Homburg was tried for a third time, but the waters were soon left off, for they aggravated all the symptoms, and after the patient's return to town Dr. Beale sent her to me. In addition to the pelvic symptoms already described a strong-minded, sharp, matter-of-fact woman was in a state of mental confusion ; her brain felt muddled, and she would sit for hours doz- ing or doing nothing ; despondency being doubtless increased by finding herself helpless as a child, after having passed all her life in doing everybody else's business as well as her own. She forgot where she put things ; once thought she had taken out a large sum of money in her purse, and that she had lost it, whereas a month 4,56 DISEASES OF WOMEN. afterward she found it in some out-of-the-way place. On examin- ing, I found the rectum perfectly healthy, notwithstanding the pain and stricture ascribed to it. I was given to understand that marriage had never been concluded, and the vagina was so narrow that 1 could with difficulty introduce part of my index finger ; so I ordered lin- seed tea and laudanum injections, three times a day, and henbane internally. A few days afterward I was able to reach the os uteri. I found the womb exquisitely sensitive ; and on sounding the blad- der there was nothing abnormal, except great pain when the sound passed over the urethra, the pain not being caused by inflammation, for the finger in the vagina did not feel the urethra as a hard and round body painful on being pressed. Injections with acetate of lead and laudanum, as well as opium and belladonna rectal supposi- tories, enabled me, a little later, to examine the womb without giv- ing pain ; there was no ulceration and there had been little vaginal discharge. The pain was most felt at the opening of the vagina, which looked sore, red, and injected, a condition that accounted for a very unusual hardness of the recto-vaginal tissues, a hardness of which the patient was sensible, and complained of as something wrong with " the bridge." This was caused by long-continued con- gestion, although the parts were then without heat or redness. This sore state of the vaginal opening was relieved by the application, twice a day, of zinc ointment, to each ounce of which was added a drachm of diluted hydrocyanic acid. Vaginitis becoming worse, I swabbed the vagina once a week with a solution of nitrate of sil- ver, and ordered alum and zinc injections ; suppositories did harm, whether administered by the vagina or the rectum. After thus treating the patient for a few months the sensations of burning and weight had considerably diminished, but were often trouble- sotne. Digestion was much improved by nitro-muriatic acid and pepsin ; pseudo-narcotism and mental disturbance were not relieved by bromide of potassium, but were much reduced by henbane and Indian hemp ; and then the patient took, for two months, three times a day, at meals, the twenty-fourth of a grain of arseniate of iron, made into a pill with a fourth of a grain of Indian hemp — a combination suitable alike to the general nervous derangement and to the abdominal neuralgia. This leads me to the question of diag- nosis. There was no organic disease of the bladder or rectum, nor of the womb, neither displacement nor ulceration of this organ. The disease originated in vaginitis, kept up by excessive walking and drastic medicines at the (change of life ; the vaginitis causing neuralgia of both the sensory and the ganglionic pelvic nerves, the THE MENOPAUSE. 457 neuralgia causing pseudo-narcotism and the other forms of cerebral disturbance that usuall_y attend the menopause ; the neuralgic ele- ment of the case being shown by the patient's often feeling the disturbance to ascend, as it were, from the pelvis along the spinal column to the back part of the head, where there was most suffer- ing. There was a gradual recovery of health, and this patient has been able to resume her usual very active life. A long list of diseases has been given as occurring at the meno- pause. This list covers nearly all the ills that flesh is heir to. The majority of these have no relations to the menopause excepting that when there is a predisposition to any disease, the disturbances of the system due to the change would favor the outbreak at that time. ]^o notice need be taken of those affections which are common to all periods of life, the menopause only determining the time of their development. When there exists a predisposition to any of the constitutional diseases, the condition of nutrition at the meno- pause, and the disturbed or unbalanced state of the nervous system, favor the outbreak of these morbid tendencies. CHAPTER XXIV. SENILE ENDOMETRITIS. The prevailing opinion is that cancer is the only disease of the uterus to be looked for after the menopause. There is a decided immunity of the uterus from inflammatory affections in aged women. In the past and present, authorities have agreed in stating that endo- metritis ends in recovery at the change of life. These opinions are true only to a certain extent. I have seen a number of cases of en- dometritis which persisted, in a modified form, after the menopause, and a considerable number in which this affection appeared long after the climacteric. The pathology and natural history of endo- metritis in advanced life differ so from inflammatory affections of the uterus in middle life that I concluded, eighteen or twenty years ago, that senile endometritis was a special, distinct affection worthy of more attention than had been given to it. Fritsch, in Billroth's " Handbuch f iir Frauenkrankheiten," treats of this affection, and three or four others have referred to his contributions, and that is all I can find in the literature ; even at the present time there are only four or five authors who make any allusion to it. The subject was first brought to my notice most forcibly in the year 1875. A patient, the relative of a physician, aged sixty-eight, came under my care while suffering from a sero-purulent discharge from the uterus. I made a diagnosis of cancer, but found I was mistaken. She recovered, but I could see that this affection differed from endometritis as it occurs in middle life. From that time I have kept such cases carefully under observation, and I have col- lected facts sufiicient to complete the natural history of the disease. Pathology. — The inflammation may be limited to the cervix alone, but as a rule it involves the entire mucosa. "When it occurs soon after the menopause, and especially if it is a continuation of a cervical endometritis that existed before the menstrual function is finally suspended, it assumes a catarrhal form modified. As usually seen, it is suppurative, the discharge being sero-purulent. "When it 458 SENILE ENDOMETRITIS. 459 begins as a catarrh it gradually progresses to a suppurative form. In the catarrhal form, the discharge, at first a leucorrhoea, diminishes, and changes from the translucent tenacious discharge to a darker glue-like material, associated with a sero-purulent matter. The change results from the atrophy of the glands of ISTaboth, which secrete the leucorrhoeal discharge of catarrhal endometritis. The character of the discharge is modified first by the atrophy which follows the menopause, and by changes of structure which are pro- duced by the disease itself. It is not until the senile involution is complete that the pathological anatomy of the disease is fully devel- oped, and shows the characteristics which distinguish this affection from all other forms of endometritis. There is first a general atrophic thinning of the whole mucous membrane. The epithelium changes from ciliated to cylindrical, then pavement, and finally is almost entirely lost. The surface around the os externum becomes irregular, thin, and shows a bluish- red color, which presents a marked contrast to the appearance of erosion seen in endometritis of early life. Granulations of low vitality appear on the endometrium, and minute extravasations of blood occur and are seen as small pigmentation spots. The glands become obliterated entirely by the morbid process, and hence there can be no secretion, but, instead, pus formation. There is molecular death of the structures, but extensive ulceration is rare. During the development of this affection the atrophy of the muscular structure of the cervix proceeds faster than in the mucous membrane of the cervix, and there is an inversion of the membrane which gives a peculiar appearance. Around the os externum there is an elevated bluish-red ring, which stands out in marked contrast to the normal mucous membrane of the vagina. Laceration of the cervix uteri frequently accompanies senile inflammation, and when there is much scar tissue present the suffering is more marked. Stricture, partial or complete, at the os internum or externum is frequently formed. Closure of the os internum is caused in some cases by retroflexion of the uterus. In this condition the discharge is intermittent. For a number of days the flow stops, and then a free discharge of offen- sive pus takes place. Complete occlusion of the canal is caused by adhesions of the disintegrated mucous membrane — a result which follows suppurative . inflammation of the mucosa, but is rarely, if ever, present in catarrhal forms of inflammation. Pus accumulates above the stricture and distends the body of the uterus, giving rise to a condition which resembles an abscess in pathology, symptoms, and signs. If the stricture is not extensive the pressure will force 460 DISEASES OF WOMEN. it open, pus will be discharged, and there will be repetitions of the closure, accumulation, reopening, and discharge. In most cases, it is necessary to open and dilate the canal before relief can be obtained. When the disease has existed long enough to destroy the mucous membrane it may end in cicatrization, but there is a marked tend- ency to continued suppuration. The disease can hardly be called self-limiting. In nearly all the cases that I have seen in which there has been^ for a time, a stenosis of the canal, the uterus has become greatly dis- tended and prolapsed or retroverted. The cavity of the uterus measured three inches and a half in one case and four inches in an- other. The senile atrophy may be delayed by the presence of endo- metritis, and the uterus may remain larger than it should be in old age, but that does not account for nor is it like the enlargement from distention. In the enlargement of the cavity from distention with pus the walls become very thin, while in the other the normal thickness of the walls continues. Causation. — A continuation of endometritis, acquired before the menopause, accounts for a certain number of the cases, especially of those in which the disease is limited to the cervix. Some of the severer cases, in which the disease involves the body of the uterus, are caused by displacements, prolapsus, or retroversion, especially retroversion. Prolapsus in a marked degree exposes the cervix to irritation, and, if it continues for long, inflammation and ulceration will appear around the os externum, and the mucous membrane of the canal becomes involved. The atrophy of the cervix is retarded, or else infiltration takes place and keeps the cervix enlarged. These cases are easily controlled in case the displacement can be relieved. Corporeal endometritis is frequently caused by retroversion. The displacement interrupts the escape of the secretion of the mucous membrane ; its retention causes decomposition and inflammation of a purulent variety. Stricture at the os internum would cause inflam- mation in the same Nvay as retroversion, and the two are often found together, but in the majority of cases the occlusion is the result of the inflammation. Acute or latent gonorrhoea may cause this form of endometritis, but I am not sure that I have ever seen a case of acute gonorrhoea! endometritis after the menopause. Old neglected cases I have seen several times. Senile vulvitis and vaginitis, due to malnutrition and inattention to cleanliness, extend and cause endometritis in advanced life, but, as the latter very often is the cause of the former, it is difficult to SENILE ENDOMETRITIS. 461 decide in a given case whether the disease began in the uterus or vagina. Fibromata of the uterus act as a very important cause of the affection. Although uterine fibromata frequently disappear after the menopause, the endometritis which accompanies the neoplasm continues, but changes from a catarrhal to a purulent form. One patient who had a small fibroid passed the climacteric, and was free from all uterine disease until she was sixty years old. She then developed an endometritis attended with such a profuse sero-puru- lent discharge that she sought relief of her family physician. He made a diagnosis of cancer, and she was brought to me for operation, I found the remains of the fibroid in the cavity of the uterus. It was removed, and though the serous element of the discharge sub- sided at once, the endometritis persisted, and only yielded to treat- ment after several months. I have often wondered why the surgeons who find so many charges against fibromata, such as their danger to life and health, have never found senile endometritis caused by them. Perhaps they have overlooked this matter, or it may be that these are cases which they have mistaken for cancerous. Fibromata cause endometritis after the menopause by delaying senile atrophy and also by sloughing, which takes place in rare cases. Catarrhal endometritis usually accompanies fibromata and changes to the purulent variety after the menopause, as already stated. Another curious fact is that, although the fibroid that causes the metritis may slough and come away, or become pedunculated and the surgeon remove it, the metritis continues. This is the opposite to that which occurs in middle life. If a fibroid is removed in a young subject, the endometritis usually subsides when this cause is removed. I saw one lady, fifty-four years old, who had a submucous fibroid of the uterus. She had a well-marked endometritis, which was being treated without benefit. The fibroid sloughed and was completely removed. She had septicaemia, from which she recov- ered, but the purulent endometritis persisted, and only yielded to treatment after long-continued efforts. I supposed that the metritis in that case was obstinate owing to its being caused by sepsis, but I found that a like inflammation might be set up with only the pres- ence of a fibroid to account for it. A patient sixty years old had, judging from her history, a catarrh of the uterus at the menopause. It continued in a changed form, and a short time before I saw her she became worse, had more severe pelvic pains and tenesmus, with a very free sero-purulent discharge. I expected to find an endome- tritis and prolapsus, but found a small, pedunculated fibroid that had 462 DISEASES OF WOMEN. been expelled from the body of the uterus and occupied the dilated cervix. I removed it, and the patient was relieved and imprjoved, but the endometritis of the purulent form continued, and, although much less severe, was difficult to cure. Syriiptoinatology . — The symptom which first attracts attention is a discharge which varies in character according to the extent and stage of the inflammation. When a cervical endometritis is present at the menopause the characteristic leucorrhcea gradually disappears, or else changes to that of the senile form of the affection. The, te- nacious secretion of the cervical glands is replaced by a sero-puru- lent discharge which is more like a vaginal leucorrhoea. The dis- charge, sooner or later, causes a subacute or senile vaginitis and vulvitis. There is so very of ten prolapsus of the vaginal walls and uterus complicating the metritis that there is pelvic tenesmus and some disturbance of the vesical and rectal functions. These are the chief symptoms in the early stage of this affection when prolapsus is the only complication. When the utei'us is retro- verted, and owing to imperfect drainage the products of inflamma- tion accumulate and distend the uterus, there is more pain and the constitutional disturbance is much more defined. There is often a rise of temperature, and the pulse increases. The digestion is de- ranged and ultimate nutrition impaired in cases of long standing. This is due to pain, reflex disturbance, and more especially, perhaps, to a slight chronic sepsis. The malnutrition increases the appear- ance of premature old age, and the dry, bronzed appearance of the skin is suggestive of malignant disease. In cases in which true stenosis takes place at the os internum or at any point in the canal of the cervix, the symptoms are usually very pronounced. The pain is acute, and compels the patient to rest in bed. The pain differs from that of acute pelvic inflammation in being slight at first but gradually increasing, while the pain of acute disease is violent at first and gradually subsides. The constitutional disturbance is more marked in this condition or complication than in any other. There is symptomatic fever. In one of my patients the temperature reached 102° F. I have already stated that stenosis may be the cause or consequence of the metritis. The imprisoned secretion and broken-down tissue cause the inflammation, or the stenosis may be caused by the inflammation. That accounts for the fact that in some cases the distention of the uterus and the symptoms are gradu- ally developed, but in others they come on somewhat more abruptly. Physical Signs. — Inspection shows, in most all cases, patches of inflammatory redness about the vulva which are peculiar to senile SENILE ENDOMETRITIS. 453 vulvitis ; the contrast between the red portions and the anaemic ap- pearance of the membrane generally is well defined. "With the aid of the speculum the signs of the same form of vaginitis are observed. Of course the vagina and vulva are not involved in all cases, but as a rule they are. In quite a few it has been limited to the upper part of the vagina, and mostly the vaginal portion of the cervical membrane. The character of the discharge is best studied through the speculum. Its character is of much value as a sign. Indeed, upon this evidence senile endometritis is distinguished from other affections and forms of inflammation, such as cancer and gonorrhoea. The appearance of the discharge differs from uterine leucorrhoea in being less tenacious, owing to the absence in varying degrees of the secretion of the glands of the cervix. The color also indicates the composition to be sero-purulent, and in this it is more like the dis- charge in specific inflammation, and is similar in appearance to that found in the early stage of cancer. The differentiation between the discharge in senile endometritis, specific metritis, and cancer must be made by the microscope if one would make the distinction at once — i. e., without waiting for the full development of the history. In senile metritis, pus, serum, disintegrated tissue, and changed or broken-down epithelium and bacteria are found. In cancer the dis- charge is sero-sanguinolent, and later in the progress of the disease contains broken-down necrotic tissue and elements of the neoplasm. The gonorrhceal discharge can be distinguished by the specific germ of that affection. "Without the aid of the microscope it is impossible to make a positive diagnosis between the specific or non-specific origin of senile endometritis, but fortunately the indications for treatment are the same whatever the cause of the affection may be. The history may show that gonorrhoea is the probable cause, espe- cially if the disease comes on abruptly, was acute at first, and in- volved the vulva and urethra first. The differentiation between this affection and cancer of the cer- vix is made by observing that in cervical endometritis there is the characteristic discharge and degeneration and atrophy of the mucous membrane, and in cancer there is, in addition to the discharge, infil- tration of the tissues — i. e., neoplastic growth. "When the disease is fully developed in the body of the uterus the clinical history resem- bles malignant disease, but can be readily diagnosticated by the fact that pus in quantity accumulates in the cavity of the body of the uterus in metritis, while that never occurs in cancer. By aspirating the uterine cavity the material drawn off will be pus, and perhaps a little blood, while in cancer it is serum, blood, and broken-down 464 DISEASES OF WOMEN. cancer tissue. The aspiration is easily made by using a small curved pipette with a rubber bulb at the end. By compressing the bulb and introducing the pipette and removing the pressure, enough ma- terial can be withdrawn to show its character and decide the diag- nosis. Of course, if a microscopical examination can be obtained by an expert the diagnosis can be made much more certainly. The history of the progress of the disease aids in the diagnosis. Cancer progresses steadily, but metritis continues about the same, or slowly yields to such treatment as will have no effect in retarding or curing cancer. Adenoma may be mistaken for senile endometritis, but the differential diagnosis is easily made. Adenoma uteri occurs earlier in life, generally about the menopause, and is attended with monor- rhagia or metrorrhagia as the most marked symptom. This differ- ence is diagnostic, because menorrhagia does not occur in this form of metritis. There is not, as a rule, any purulent discharge in adeno- ma. By using a small curette a portion of the adenomatous growth can be removed for examination which will complete the diagnosis. Treatment. — When the disease is confined to the cervix a douche of a solution of borax, three drachms to the quart, gives much relief and prevents the discharge from keeping up vaginitis. Sulphate of zinc, one drachm to the quart of water, is very effective in case the borax fails. The hot- water douche, as used in uterine disease gener- ally, is not of much value in the senile form. If there is any pro- lapsus or other displacement it must be corrected by the use of medicated tampons until the inflammation is relieved. Sterilized absorbent cotton covered with boroglyceride, glycerin and tannin, or white vaseline answer the purpose. I have tried prepared wool for tampons, but it is more irritating and has to be changed more fre- quently. Astringent and alterative applications are useful in reliev- ing the cervical inflammation, but any caustics, even the mildest, do harm rather than good. I have most faithfully tried carbolic acid and iodine, which are so effective in ordinary metritis, but these agents are not satisfactory in the senile form of the disease. One or two applications of a combination of carbolic acid and tincture of iodine may do good, but it should not be repeated many times. All caustics rather encourage the breaking down of the atrophied tissue, and when the slough separates the surface left does not incline to heal, but to suppurate. The best results liave been obtained from the use of boroglyceride with tannin, glycerin and tannin, fluid extract of hydrastis canadensis and a mild solution of acetic acid, one drachm to two ounces. The canal should be thoroughly washed out with clean water and the application made with a pipette. SENILE ENDOMETRITIS. 4C5 I generally begin the local treatment with dilute acetic acid or tincture of iodine four parts, and carbolic one part; an application of either of the above twice in the first week. This answers the best when the discharge is very free. Following this, a mixture of twenty grains of tannic acid in an ounce of boroglyceride. This is a thickish material which is difficult to apply. I manage by warming the mixture and using a pipette wjth an opening in the end as large as the size of the glass tube will admit. Tannin and glycerin were used almost altogether some years ago ; now I prefer the boro- glyceride and tannin. The fluid extract of hydrastis canadensis is easily used and has a very good effect, and I fall back on that when the others do not do well. Iodoform is the most efficient, and when it can be freely and properly applied supersedes all other agents. Indeed, were it not for its being difficult of application to the canal of the uterus it would meet all requirements. I have only used other remedies, such as I have mentioned, because they were so much more easily applied and have not the offensive odor of iodo- form. I was first led to nse iodoform in senile endometritis by ob- serving its remarkable effects in the treatment of ulcers in general surgery. Dr. Fordyce Barker used it in cases of cancer of the uterus with great benefit. He used iodoform suppositories made in con- venient form to introduce into the uterus. The results that he ob- tained were so favorable that I am now inclined to believe that some of the cases that he believed to be cancers were really cases of senile endometritis. Many gynsecologists have made that mistake in diagnosis, and it is no disparagement to suppose that Dr. Barker may have occasionally fallen into the same error. I presumed that the effect of iodoform was due in a measure to its antiseptic quali- ties, but learned that it was not a germicide to any degree sufficient to explain its effect in checking suppurative inflammation. The " Bulletin General de Therapeutique " contains a full discussion of the subject. " Maurel, who is well known by his researches on the leucocytes, has undertaken to solve the problem why iodoform, which is so efficacious in preventing or suppressing suppuration, should appar- ently have so little action on the pyogenic staphylococci. " He first experimented with a virulent culture (on gelose) of staphylococci in the presence of leucocytes. The latter speedily absorbed the staphylococci, but succumbed in less than two hours. In the control field, however, they accomplish their evolution and live from twelve to twenty-four hours. Maurel finds that the death of the leucocytes under the influence of the pus micro-organisms is 81 4:^6 DISEASES OF WOMEN. due to a toxiue contained in tlie bodies of these microbes, not to the mechanical action of the staphylococcus or to the products which the latter yields up to its environment. Under the influence of these same staphylococci, the red corpuscles become diffluent in fifteen honrs and then disappear. " Another series of experiinents were made by subjecting the fiffured elements of the blood to the action of iodoform in the dos- age of ten to two and a half per kilogramme of blood, Neither the smaller nor the larger doses were found to be toxic to the leuco- cytes ; the vital activity of these latter was, on the contrary, aug- mented, and the action on the red globules was nil. " A third series of experiments show iodoform to be with- out marked action on cultures of the staphylococcus aureus and albus. " In a fourth series of researches Maurel subjected both the leu- cocytes of human blood and cultures of the staphylococcus to the action of iodoform in varying proportions and under varying con- ditions. His conclusions are as follows : " 1. Iodoform attenuates the virulence of the staphylococcus. While in the virulent state, this micrococcus kills our leucocytes in less than two hours ; when it is subjected along with the leucocytes to the influence of iodoform, the latter preserve their movements for eight hours at least, and even complete their evolution. " 2. The staphylococci, which have thus lost a great part of their virulence (and to such a degree that they are seemingly devoured by the leucocytes with impunity), keep all their reproductive energy un- impaired, so that virulence and the power of reproduction are inde- pendent properties. " A final conclusion is deduced that it is in both these ways — ac- cording to Maurel it is by augmenting the energy of the leucocytes and attenuating the virulence of the pus microbes — that iodoform opposes suppuration, which is, in the language of bacteriology, a massive slaughtering of the leucocytes." These teachings are in harmony with clinical experience as to the benefits of iodoform in preventing or arresting suppuration. There is considerable difliculty in applying iodoform to the cav- ity of the body of the uterus in sufficient quantity to be effective. Suppositories made with cacao butter are not retained in the cervix, and, although they remain in the cavity of the body for a time, there is not enough retained to give the full effect. I have used a solution in boiled linseed oil, and also an ether solution, but the latter causes much irritation, and the former docs not hold enough of the iodo- SENILE ENDOMETRITIS. 467 form. The best is the dry fine powder, whicli can be introduced through a small cannula. The next best (and more easily intro- duced) is the fine powder held in suspension in acacia and water by agitation and then instilled with a pipette. When the disease (limited to the cervix) is complicated with scar tissue resulting from old lacerations, I have operated with the result of relieving some of the neuralgic pain, and with benefit to the in- flammation. It is difficult to get good and prompt union. In fact, some of the operations have been failures. The treatment of the corporeal form of this affection is rendered more difficult by certain complications, such as prolapsus, stenosis of the canal, or retroflexion. Complete closure of the canal, of course, must be relieved first by dilatation, to afford room for washing out the uterus and subsequent drainage. When the stricture is at the os internum, time and patience are necessary to open the canal. This, if possible, should be accomplished by dilating the canal below the stricture and then pushing a very fine probe through the stricture. There is danger in puncturing the stricture with a knife, because it is difficult to determine the direction of the canal, and hence danger of puncturing the wall of the uterus. Gradual dilatation is best. Owing to the friable condition of the uterine tissue laceration is sure to occur if forcible dilatation is practiced. When an opening has been made large enough to pass a uterine sound, a piece of gauze should be introduced to keep the parts from contracting. Better still is a tent of elm bark, carbolized before use. This tent is bland, sterile, and swells a little, which keeps up dilatation. When the cervix is dilatable, the canal should be made large enough to admit a reflex catheter. The nterus should be washed out with a five-per- cent solution of carbolic acid and then packed with iodoform gauze. The packing should be left in forty-eight hours, if there is no severe pain and rise of temperature. Upon removing the gauze the uterus should be washed out with boiled water, and iodoform powder in- troduced in the way described in the treatment of cervical endome- tritis. Owing to the difficulty of handling iodoform I have used peroxide of hydrogen and found it very useful. When a reliable preparation can be obtained it gives most satisfactory results, pro- viding it is used twice or three times a day. Owing to the difficulty of obtaining reliable preparations of per- oxide of hydrogen, and the fact that it is easily decomposed by heat and exposure, I have lately used a preparation made by McKesson & Robbins. It is an aqueous solution of dioxide of hydrogen. It is called pyrozone. A three-per-cent solution is the one which I 468 DISEASES OP WOMEN. have used. I have not had sufficient experience so far to enable me to say that this pyrozone is all tliat it is claimed to be. In cases complicated with retroversion the malposition must be corrected in order to be able to wash out the uterus thoroughly and to keep up drainage. The treatment of retroversion is very difficult when the vagina is contracted, as it usually is after the climacteric — in fact, it is impossible to replace the thin-walled uterus that is dis- tended with the products of inflammation. Thorough dilatation and evacuation must first be made, and then by the use of a tampon or a soft ring pessary the posterior vaginal wall may be carried back- ward far enough to keep the fundus uteri from falling downward below the level of the cervix. Free drainage may be obtained al- thougli the uterus may still be retroverted in a slight degree. Pro- lapsus also requires to be corrected. Both patient and surgeon are likely to become discouraged with the treatment, which is sure to be tedious, especially if not well un- derstood. This has raised the question in my mind whether hys- terectomy would not be justifiable in the worst cases. I have seen the uterus removed, supposedly for cancer, but really in senile en- dometritis, and the results have been good. Still I would prefer to employ the treatment recommended here, and not until that had failed would I resort to hysterectomy. In cases of senile endometritis complicated with complete pro- lapsus, vaginal hysterectomy is the proper treatment in all cases ex- cepting in those whose general health presents a contra-indication. Dr. Edebohls has done hysterectomy in cases of complete prolapsus, and ahliough I have succeeded in relieving such displacement in the majority of cases without removing the uterus, I resort to hysterec- tomy without the least hesitation, and with confidence in the results, in cases of senile endometritis and complete prolapsus. CHAPTER XXY. DISEASES OF THE OVAKIES. THE ANATOMY AND PHYSIOLOGY OF THE OVARY. The ovaries are two bodies, in shape somewhat like an ahnond, situated in the pelvic cavity, one on either side of the uterus, and removed from it about one inch. They are connected with that organ by the Fallopian tubes and the ovarian ligaments. Before birth the ovaries are on a level with the iliac fossa, and it is not until the tenth year of life that they reach what may be considered their per- manent position — that is, the lateral and posterior part of the true pelvis. Hasse, of Breslau, in a female cadaver frozen in the upright position, found that the long axis of both ovaries ran outward and forward, forming with the transverse axis of the uterus an one half of the organ project- ing above the plane of the pelvic brim. Schultze, on the contrary, regards the long axis of the ovaries as being in an antero-pos- terior position, as shown in Fig. 208. It must be borne in mind, however, that the position of the ovaries is not a fixed one ; their relation to the uterus and the other pel- vic organs is such that, when any one of these is displaced, a change in the position of the ovaries will of necessity occur ; thus the full or empty bladder or rectum acting upon the uterus will tend to push the ovaries in one direction or another. The average dimensions of each ovary are : Length, one inch and a quarter ; width, three quar- ters of an inch ; and thickness, half an inch. Its weight is about eighty grains. As its position changes, so do also the measurements here given. It is probably in its most perfect condition in the vir- gin at about the age of puberty. According to Hennig's observa- tions, the ovary increases in length during pregnancy, but neither its ' 4G9 Fig. 208. — The fundus uteri and ovaries seen through The pelvic brim (His). The cross is in the center of the pelvis and on the fundus ; o, o, ovaries encircled by the Fallopian tubes in their backward sweep. 470 DISEASES OF WOMEN. breadth nor thickness exceeds that found in the virgin. When preg- nancy has ceased the ovaries become smaller, and do not at any time subsequently regain the dimensions possessed by the virgin ovary. The relation of the ovaries to the broad ligament is a matter of great importance and interest. These ligaments consist of two folds or layers of the peritonaeum, with a lining of muscular tissue, be- tween which lie the uterus and its appendages. The ovaries, however, Od' Fig. 209. — The ovary and its ligaments (Henle). Ut, uterus ; Od, fallopian tube ; /o, ovarian ligament ; ip, infundibulo-pelvic ligament ; io, infundibulo-ovarian liga- ment ; Fo, fimbria ovarica ; Po, parovarium. are not situated between these two layers, but are suspended, so to speak, from the posterior surface of the posterior layer, and are there- fore entirely behind both layers or folds of peritonaeum, which form the broad ligament, but attached to the posterior layer by their long axis, this attached portion of the ovary being termed the liilum. In the anterior face of the posterior layer of the broad ligament, on either side, is an opening or slit through which the blood-vessels, nerves, and lymjihatics of the ovary pass. The ovarian ligaments which con- nect the body of the uterus and the ovaries, leaving the former at a point between the Fallopian tubes and the round ligaments, after running for some distance between the two layers of the broad liga- ment, pass out l)y these openings in the posterior layers to the ovaries. These ovarian ligaments are about one inch in length, and are com- posed of tibrons tissue, into which some of the uterine muscular tis- sue is prolonged (Fig. 209). Fach ovary is also connected with the DISEASES OF THE OVARIES. 471 corresponding Fallopian tube by one of its fimbriae, and through this to the pelvis by means of the inf undibulo-pelvic ligament — a ligament about two thirds of an inch in length, running from the outer end of the Fallopian tube to the wall of the pelvis. Thus the ovary is main- tained in its position — subject, however, to considerable alteration — by the broad, the ovarian, and the in- fundibulo-pelvic ligaments. The supply of blood to the ovaries is by the ovarian artery, a branch of the abdominal aorta corresponding to the spermatic artery of the male. Fig. 210. — The ovarian, uterine, and vaginal arteries (Hyrtl). After this artery enters the pelvis it passes between the layers of the broad ligament in a direction toward the upper angle of the uterus ; its course is parallel to, though below, the Fallopian tube. It sends 472 DISEASES OF WOMEN. branches to the ovary, which pass out from between the layers of the broad hgament to the ovary through the opening in the posterior layer already referred to. Other branches supply the Fallopian tube and anastomose with the uterine artery. The venous blood of the ovary passes into the ovarian plexus, sometimes spoken of as the pam- piniform plexus, which is situated between the layers of the broad ligament, and is thence carried to the inferior vena cava on the right side, and to the renal vein on the left. These veins, which form a network in the ovary, have, according to Kouget, associated with them muscular trabeculse, which, in their contraction, prevent the passage of the blood from the ovary into the large venous trunks, and thus permit of what may be termed an erection of the ovary. It is probable that during the act of coition such a condition takes place in the ovary, increasing its size to a considerable extent, and causing it to become firmer and more sensitive. Rouget describes the lym- phatics of the ovary as united into six or eight trunks, which accom- pany the ovarian artery, and discharge into the middle and superior lumbar lymphatic ganglia. The lymphatic circulation becomes of spe- cial importance in explaining the method by which, under certain con- ditions, septic matter is absorbed, producing septicaemia. The ovarian and uterine plexuses communicate, as do the arteries of the same names. The nerves of the ovaries, as well as those of the nterus, arise from the cceliac plexus, which is in part distributed to the ovaries and to the spermatic ganglia. According to Frankenhauser, the superior mesenteric plexus supplies these spermatic ganglia, which Courty suggests would be better called genital ganglia. These ganglia, four in number, are supplied from the sympathetic through two large branches, and in turn supply the ovaries through a considerable number of branches. Development of the Ovary. — At a very early period in the devel- opment of the foetus two bodies are formed in the abdominal cavity, one on each side of the spinal column ; these are the Wolffian bodies, the function of which is undoubtedly similar to that of the adult kidney. According to Coste, they are fully formed at the end of the first month, and according to Longet, are hardly visible after the second month. While these organs are in a state of activity the kidneys are formed behind them, and at the same time two other organs appear in front of the Wolffian bodies, and on their inner side ; these are the internal organs of generation — the testicles in the male and the ovaries in the female. The detailed history of the development of these organs is as follows : At a very early stage of development — in the chick as early as the third day — the cells of DISEASES OF THE OVARIES. 473 the raesoblast form a longitudinal cord in the mesoblast, one on each side of the body, and just external to the protovertebrae, which are also formed from this same layer. These cords are at first solid, but a cavity gradually forms within them, and they become the Wolffian ducts. From this primitive tube diverticula are given off, forming, as it were, blind tubes, into which blood-vessels enter, and with the diverticula form the Wolffian bodies, one upon either side. Another portion of the mesoblast projecting in the form of a ridge, and cov- ered with " germ epithelium " on the inner side of the Wolffian body — that is, toward the median line — becomes the testicle or the ovary, according as the individual is to be of the male or female sex. On the outer wall of the Wolffian body an involution takes place from the pleuro-peritoneal cavity, forming at first a furrow, but later, by the union of its edges, a duct, which is known as Miiller's duct. In the female these ducts form the Fallopian tubes, the uterus, and the vagina, while in the male they have no special function, although the upper part remains as the hydatid of Morgagni, and the lower as the prostatic pouch, the uterus masculinus, or sinus pocularis. While the Wolffian ducts in the male form the body and globus minor of the epididymis, the vas deferens, and the ejaculatory duct, in the female the lower part only remains to form the duct of Gaert- ner. If the broad ligament is examined with transmitted light, a cone is seen nearly an Q/iFTM^PUCr inch in breadth, of ^ whitish, more or less convoluted tubes, in number about twenty, each of which is lined with cili- ated epithelium and contains a clear fluid (see Fig. 209). This is the parovarium of Kobelt, or the organ of Rosenmiiller, and is the remnant of the Wolffian body of fa3tal life. The pathological degeneration of these tubes produces the par- ovarian cystic tumor. The ovary itself consists of the oophoron and the paroophoron ; the latter must not be confounded with the parovarium. Fig. 211, taken from Bland Sutton, will make this distinction clear. The paroophoron is made up of fibrous Fig. 211. — Diagram representing tlie cyst-regions of the ovary (from Bland-Sutton). 474 DISEASES OF WOMEN. tissue and blood-vessels. In it are developed paroophoritic cysts, which will be described later. Minute Anatomy of the Ovary.— The fact that the ovary is situ- ated behind both layers of the broad ligament, and attached only at the hilum, has already been referred to. From this it follows that the posterior surface of the ovary is not covered by peritonaeum. The more thorough and skillful investigations of recent years have satisfactorily demonstrated that the surface of the ovary is in appear- ance and structure very different from the peritonaeum. While the epithelium which covers the broad ligament is transparent and flat- tened, that which forms the surface of the ovary is granular in ap- pearance and columnar in form. This marked difference has sug- gested to some that the covering of the ovary was a mucous rather than a serous membrane. These columnar cells are very similar to those lining the Fallopian tubes, except that the cilia which are present in the latter are wanting in the former. It is an error to regard these superficial cells of the ovary, which are arranged in a single layer, as in any sense a covering of the ovary. They are in reality an integral part of the ovary, and, as the name " germ epi- thelium " implies, their function is a most important one, being none less than the formation of the ova by a modification of their structure, as has been so well described by Waldeyer. Beneath this layer of germ epithelium is the tunica albuginea. This is made up of bundles of spindle-shaped cells, arranged, accord- ing to Ilenle, in three layers, the outer and inner ones being longi- tudinal, and the middle one circular. The albuginea contains no Graafian follicles. The third layer — that is, the one next to the albuginea — is what Schron has described as the cortical layer. This contains the smallest of the Graafian follicles arranged in groups, but separated by the stroma of the ovary, this latter being made up of bundles of spindle-shaped cells, some short and others long, each having an oval nucleus, and being probably young connective-tissue cells. The Graafian follicles of the cortical layer are spherical or slightly oval bodies, with a diameter of one one thousandth of an inch, and have as their external portion a delicate membi-anc — the mem- brana propria. Lining this is the membrana granulosa, a layer of flat, transparent epithelial cells, with oval nuclei. Within this, and occupying the entire cavity of the follicle, is a spherical cell— the ovum. The ovum is a collection of granular protoplasm containing a spherical or oval nucleus, the germinal vesicle, and this, in turn, a body known as the germinal spot. Below this cortical layer, im- bedded in the stroma, are Graafian follicles of almost every conceiv- DISEASES OP THE OVARIES. 475 able size. While the older anatomists thought the total number of follicles in an ovary did not exceed twenty, this nuuibei- being all that could be seen by the unaided eye, some of the more recent authorities have placed the number at six hundred thousand. As follicles ruptui'e and discharge each month for a long series of years, the estimate of the earlier writers is undoubtedly too low — probably EiG. 212. — Section of the ovary of a bitch (Waldeyer). a, germ epithelium ; d, ovum ; i, membrana granulosa ; /, vitelline membrane, vitellus, germinal vesicle, and spot. as much too low as that of some of the recent ones is too high. All the layers thus far described constitute the parenchyma of the ovary. Between this and the hilum is the vascular zone, which contains no follicles, but is made up of bundles of connective tissue and bundles of non-striped muscular tissue, which are directly continuous with the corresponding tissues of the broad ligament. It is in this vas- 476 DISEASES OP WOMEN. culur zone that the blood-vessels of the ovary are found, and, indeed, give to it the name which characterizes it. The Graafian follicle of medium size is, hke that of the cortical layer, made up of a membrana propria and a membrana granulosa, and contains an ovum. The ovum is, however, larger than that of the cortical follicles, and is limited by a thin membrane, the zona pellucida or vitelline membrane. This is believed to be formed by the cells of the membrana granulosa. As the follicle increases in size the ovum does not increase correspondingly, so that, while for a considerable time it completely tilled the cavity, now it does not do so, and the space between it and the membrana granulosa contains an albuminous tiuid — the liquor folliculi. It should be stated that a Graafian follicle, while it usually contains but one ovum, does some- times contain two or even three ova. At one part of the membrana granulosa the cells are more abundant than elsewhere, forming a mound which is known as the discus or cumulus proligerus ; in the center of this accumulation of cells the ovum is imbedded. Some of the Graafian follicles reach maturity, so far as can be told from their size and appearance, and undergo degeneration before the age of puberty is attained. Some of the small follicles also degenerate, never reaching maturity. The number of follicles which thus de- generate is by no means inconsiderable, and a knowledge of this fact, and that at each menstrual epoch a follicle ruptures, leads us to be- lieve that the total number of follicles in an ovary must be reckoned by thousands. Development of the Graafian Follicles and Ova. — Having described the minute anatomy of the ovary, we are now prepared to consider the manner in which the follicles and their contained ova are formed. The germ epithelium, which forms the superficial layer of the fetal ovary, undergoes rapid multiplication, as a result of which the cells grow in a direction toward the vascular stroma of the ovary ; this likewise increases, and in a direction toward the germ epithelium. The stroma, developing between these masses of cells, which are off- shoots from the germ epithelium, thus isolates them, forming islands or nests. These nests are larger below than above where they are for a considerable time still connected with the superficial germ epi- thelium. Indeed, at birth this connection exists and forms what Pfliiger has denominated the ovarial tubes. The cells composing these nests multij^ly themselves by the process of karyokinesis, thus increasing the size of the nests, and forming new ones by being con- stricted off from the old ones. Some of the cells of the germ epi- thelium undergo special development in the cell-body and nucleus. DISEASES OF THE OVAEIES. 477 and become ova, which are spoken of as primitive ova. The germi- nal vesicle is formed before the vitelliis or the zona pellucida ; but whether the formation of the germinal spot precedes that of the germinal vesicle has not been fully decided in the vertebrates. Kolhker finds this to be the order in the development of the ova of intestinal worms. As the multiplication of the cells of the germ ■epithelium goes on as already described, there is also a continually increasing differentiation of these cells forming the primitive ova. This production of ova takes place in the nests as well as in the superficial layer, and, as a result, we have each nest containing a number of ova, and ova are also found in the same manner in the ■ovarian tubes. The membrana granulosa is formed of the cells of "the nests and tubes which do not take part in the formation of the ova. If a nest or an ovarial tube contains several ova, each ovum will form a center, around which will be aggregated a layer of cells, forming a membrana granulosa, and by the ingrowth of the stroma hetween these collections the Graafian follicles are formed. External to the membrana granulosa is formed the membrana propria, and still more externally the fibrous capsule or theca f ollicuh. As already stated, two or even three ova may become enveloped in a single layer of cells, and thus a single Graafian follicle be formed contain- ing two or three ova. The ova and the membrana granulosa are consequently formed from the germ epithelium, which, as has been seen, consist of cells from the mesoblast. The membrana -propria, the theca folliculi, the stroma, and the vessels are produced from the fetal stroma, which was also originally an outgrowth of the meso- "blast. Some excellent authorities, among whom may be mentioned Pfliiger and Kolliker, believe that Graafian follicles and ova are pro- duced after birth ; others equally reliable, as Bischoff and Waldeyer, deny this. Ovulation. — The function of the ovaries is primary in the process of reproduction. Their physiological activity precedes the uterine functions, and continues, as a rule, until the menopause, and possibly after it. Hence the functions of the other sexual organs appear to be responsive to the influence of the ovaries. There are, however, differences of opinion concerning this matter. Observations have been made which show that ovulation and men- struation occur independently of each other, in exceptional cases at least, and a high degree of importance has been given to that appar- ently independent action ; but such irregularities are the exception, not the rule. There are facts in abundance to prove that, when the ovaries are absent or rudimentary from birth, the function of the 478 DISEASES OF WOMEN. uterus is never established, and the removal of the ovaries after puberty arrests menstruation in the majority of cases. All that we know regarding the influence of the ovaries upon development of the individual, and the exercise of the sexual functions throughout the reproductive period of life, points to the conclusion that these organs are the prime movers and controlling agencies, to speak flg- uratively, in the sexual system. The simple facts that ovulation and menstruation do not follow each other in consecutive order in excep- tional cases, and that the two functions are occasionally performed independently of each other, do not affect the general rule in physi- ology. Because irregularities occur in the harmonious action of the sexual organs, their independence need not be doubted. The same natural order of phenomena is observed in all processes of the human economy. The primary action of an organ that stands at the head of a system sets all the subordinate organs in functional motion. Taking food is the first step in the great process of nutrition, and digestion and assimilation follow in natural physiological order. There are occasional irregularities in the succession of the processes of nutrition, as when gastric juice is secreted in the absence of food in the stomach ; but such events are exceptions to the mle. Certain impressions made upon the brain are followed by deflnite mental phenomena, but the brain sometimes fails to respond to impres- sions ; and, again, it occasionally acts independently of extrinsic excitants. So, also, an action or function which has been be- gun by a given influence may continue after the cause which pro- duced it has been removed. If we accept the idea that the ovaries are essential to the very existence of the sexual system, and that their office is the highest and the first in the order of events which col- lectively make the complete process of production, it is easy to under- stand that their absence would arrest the action of the whole system. They are paramount, not subordinate, in reproduction, and in the maintenance of the relationship between the general and the sexual systems the ovaries are undoubtedly the most potential agents. The uterus and vagina are superadded structures, rendered necessary by a more complex and perfect system of reproduction in the higher species. The anatomical and physiological value of the ovaries as factors in the reproductive system suggests an equal distinction in their association with the general system, and in their influence upon it. This correlation has been variously estimated by authors. Dr. Henry Maudsley, in his book entitled " Body and Mind," says : " The organic system has most certainly an essential part in the constitution and the functions of the mind. In the great mental DISEASES OF THE OVAKIES. 4Y9 revolution, caused by the development of the sexual system at pu berty, we have the most striking example of the intimate and essential sympathy between the brain as a mental organ and other organs of the body. The change of character at this period is not by any means hmited to the appearance of the sexual feelings and tlieir sympathetic ideas, but, when traced to its ultimate reach, will be found to extend to the highest feelings of mankind, social, moral, and even rehgious. In its lowest sphere, as a mere animal instinct, it is clear that the sexual appetite forces the most selfish person out of the little circle of self -feeling into a wider feeling of family sympathy and a rudimentary moral feeling. The consequence is that, when an individual is sexually mutilated at an early age, he is emasculated morally as well as physically. It has been affirmed by some philosophers that there is no essential difference between the mind of a woman and that of a man ; and that, if a girl were sub- jected to the same education as a boy, she would resemble him in tastes, feelings, pursuits, and powers. To my mind, it would not be one whit more absurd to affirm that the antlers of the stag, the human beard, and the cock's comb are the effects of education, or that, by putting a girl to the same education as a boy, the female generative organs might be transformed into male organs. The physical and mental differences between the sexes intimate them- selves very early in life, and declare themselves most distinctly at puberty ; they are connected with the influence of the organs of generation." This much being claimed by so high an authority for the influ- ence of the sexual organs upon the development and function of the brain and nervous system, I may inquire how far the ovaries are re- sponsible for such results. Yirchow and others have stated that the ovaries give to woman all her characteristics of body and mind, and I accept the proposition without qualification, feehng sustained in doing so by the fact that, when the ovaries are absent or defective from birth, the characteristics of the female sex are never fully de- veloped. The tendency in the development of those in whom the ovaries are congeuitally absent is toward the masculine type of the race. I have seen two such cases, decidedly masculine in their phys- ical and mental attributes, and there are many others recorded in our literature. There are some authors, however, who appear to stand in opposition to what is here claimed. In Dr. GoodeU's paper presented to the Pennsylvania State Society, he says, that " The physical and psychological influence of the ovaries upon woman has been greatly overrated." And again he says. " In the popular mind 480 DISEASES OP WOMEN. a woman without ovaries is no woman." He then ^ives his own views wliich are that, " beyond the induction of sterility and the probable absence of menstruation, the deprivation of the ovaries after puberty does not change the character of the woman," Bat- tey, Hegar, Wells, and Peaslee, are given as confirming this doc- trine. The views held by these authors are based upon observations of mature women from whom the ovaries have been removed. This alone is not a trustworthy source of information, because the results obtained up to the present time appear to be quite variable. For example, Dr. T. G. Thomas had one patient who was passive in her sexual relations before her ovaries were removed, but became aggressive afterward. On the other hand, Dr. M. A. Fallen, in a paper read before the American Medical Association, in June last, related the history of a girl who was promptly and comjjletely cured of " hystero-epilepsy " and an incontrollable desire for self- pollution by Battey's operation. It is true, no doubt, that an individual who has been fully devel- oped under the influence of the ovaries, will continue to manifest her former attributes of body and mind after these organs are removed, but it does not therefore follow that the ovaries were negative in the process of developing and maintaining those attributes. One who has become blind in middle life will talk familiarly and understandingly of objects impressed upon the mind through the sense of sight, but one born blind can not comprehend the beauties of a landscape. This abundantly proves that mental peculiarities may continue after the physical influences which caused them have been removed. Obser- vations made from the opposite standpoint give evidence which leads to the same conclusions. We find that, if the ovaries are pres- ent in a given individual, she will manifest the physical and psy- chical peculiarities of womanhood, although all the other sexual or- gans may be absent. Women, well developed in all that is pecul- iar to the sex, have been observed in whom the uterus and vagina were defective, but I have neither seen nor heard of any such per- fection of organization occurring when the ovaries were absent. Perhaps the strongest argument on this point is the fact that other parts of the general system, when modified by the influence of the ovaries, are rendered capable of performing the major functions of the uterus, as is illustrated in a very striking manner by vicarious menstruation and abdominal gestation. In this connection, a brief reference may be made to tlie influ- ence of the nervous system in controlling the functions of reproduc- tion. The full discussion of this question involves problems in phys- DISEASES OF THE OVARIES. 481 iology which have not been solved, and are therefore beyond the scope of this work. Whether the higher nerve-centers are devel- oped to serve the demands of the nutritive and reproductive organ- izations, and whether the location of the nerve-centers which preside over sexual phenomena is in the cerebellum or the lumbo-sacral portion of the spinal cord, are questions which I am not at present able to answer. It is sufficient for the present purpose to keep in mind that the sexual organs are dependent upon the general nutri- tive system for organic support, and that they stimulate, depress, or modify nutrition through the ganglionic nerves chiefly, and that the portion of the brain which presides over the organic functions also dominates the reproductive organs. We should also recognize the fact that the emotions are in part dependent upon the sexual organs for their development, and on the other hand that the sexual organs are largely affected by the emotions. Metaphysicians agree in stat- ing that the sexual appetence, which owes its existence almost en- tirely to the ovaries, leads to more emotions than any other human tendency, and clinical observations afford good evidence to the phy- sician, that the emotions affect the functions of the sexual organs in a marked degree. Grief, fear, anger, and even great joy are capa- ble of arresting menstruation and probably ovulation also. In view of this great potentiality of the ovaries in developing certain capa- bilities of the brain and nervous system and in influencing their functions, it is evident that, in order to maintain harmonious action of the whole organization, it is necessary that the ovaries shall exist in full development and functional activity. On the other hand, these organs which are essential to the well-being of the individual must, when diseased, exercise a potent influence in deranging the brain and nervous system. From a somewhat extended consideration of this subject, I am satisfied that a great many affections of the brain and nervous sys- tem are due to disease of the ovaries. The remote effects of ovarian disease have been observed and recorded to some extent, but not so fully, I presume, as they might be. The tendency of observers has been to attribute certain mental derangements and diseases of the nervous system to the sexual organs in general or the uterus espe- cially. A little attention to some of the known defects and diseases of the ovaries and their relations to diseases of the brain and nerv- ous system will, I think, materially change that phase of the subject. Imperfect development of the ovaries not only modifies the phys- ical peculiarities of the individual, but also retards the development of the higher nerve-centers. The demands of the sexual organs (es- 82 482 DISEASES OF WOMEN. peciallj the ovaries) stimulate the brain to a higher development. A very large part of the brain and nerve power is devoted to repro- duction, and if that function is never established because of the ab- sence of the ovaries, the brain and nervous system are never fully developed. When a woman is deprived of the sexual organs the nutritive system may possibly attain a normal development, but the nervous system does not — it remains upon a lower plane. There is usually mental weakness and often derangement of mind among those in whom the ovaries are imperfectly developed. Among six- teen young single women, that came under my observation in the Insane Asylum, I found twelve who had imperfectly developed sex- ual organs. Some of them had never menstruated at all, and others had done so imperfectly. The history of these cases led to the con- clusion that the defective development of the ovaries was an impor- tant element in causing insanity. They no doubt inherited an in- sane neurosis or diathesis, but the absence of ovarian iutluence, which favors a higher and more complete development of the nerve- centers, acted as the major-cause in producing the insanity. This is not claimed to be a positively correct deduction, but there is cer- tainly strong presumptive evidence that such was the case. The mental derangement appeared in the majority of them at or about the period of puberty. There was nothing in the size or develop- ment of these patients to indicate any marked defect in the nutri- tive system. The nervous and sexual system alone were deficient. They appeared to have passed through girlhood in a normal way (although not manifesting a high order of mental capacity) until the period when the sexual organs should have begun to exercise their influence in completing the higher development of the nerve- centers. When that failed to take place, the brain became deranged,, instead of assuming new activities. Still it is possible that the im- perfectly developed sexual organs resulted from inferior general organizations which were from the beginning of a low type, and that the insanity which followed was due to transmitted lesions, and was not dependent upon the sexual organs at all. However, the facts appear to favor the opposite conclusion. One thing is certain regarding this subject : there is enough in the nature of the cases mentioned to invite further investigation in oi'der to settle, as far as possible, the relation of the ovaries to insanity and other diseases of the nervous system which occur at puberty. As the period of pul)erty approaches a considerable number of Graafian follicles (from twelve to thirty) enlarge, the largest reach- ing a diameter of half an inch. In the early stage of development. DISEASES OF THE OVARIES. 483 it will be remembered, the smallest follicles were found in the corti- cal layer, those of medium size in the middle layer, and still deeper, the larger follicles. These follicles increase in size by the produc- tion of an increased amount of liquor folliculi. This so distends the wall of the follicle as to cause it to project from the surface of the ovary, and to become thinner and thinner until finally it bursts, dis- charging the ovum with some of the cells of the membrana granu- losa, especially those forming the cumulus proligerus. The ovum passes into the Fallopian tube, and through it descends to the uterus. This ripening and discharge of ova is the process of ovulation and occurs periodically, in the human female about every four weeks. As the time approaches in each month for the rupture of a follicle there is an abundant formation of vascular loops in connection with increased growth of the membrana propria, which together with the liquor folliculi distends the wall of the follicle. This distention stimulates the ovarian nerves, and as a result there is an increased flow of blood to the ovaries and other organs of generation. The wall of the follicle, in addition to being distended, also becomes fatty at its most projecting part, and when it is no longer able to withstand the internal pressure it bursts and the ovum is discharged. When this rupture takes place there is in the human female haemorrhage from the vessels already spoken of as being found in the interior of the follicle. The amount of blood effused is sufficient to fill the cavity of the follicle. It soon coagulates, the serum is reabsorbed, the haemoglobin becomes hsematoidin, and after a time the coloring-mat- ter disappears. In short, the same changes, take place in the blood here as when a haemorrhage occurs elsewhere in a closed cavity. The wall of the follicle becomes hypertrophied and convoluted, and later on undergoes fatty degeneration, with the formation of lutein, giving to the structure a yellow color, on which account it has been called a corpus luteum. The corpus luteum spurium by which name the coi-pus luteum of menstruation is known, reaches its maxi- mum of development at the end of the third week after menstrua- tion, at which time it commences to diminish in size until at the end of the eighth week it is reduced to an insignificant yellowish cicatrix about one fourth of an inch in diameter, but it sometimes may be discovered if carefully sought at the end of eight months. If, however, the ovum which escaped from a given Graafian follicle becomes impregnated, then the process becomes modified in that fol- licle. The corpus luteum is then denominated veram instead of spurium. The differences between the two vaneties of coi-pora lutea are of degree not of kind. The changes which take place are 484 DISEASES OF WOMEN. the same in both up to the end of the third week, then, instead of diminishing, the corpus luteum verum continues to grow until the end of the fourth month when it reaches the height of its develop- ment. It retains this maximum until the beginning of the seventh month when it commences to diminish, but may sometimes still be discovered nine months after delivery. The history of the corpus luteum is admirably described by Dalton to whose work on human physiology the reader is referred for a detailed account of its forma- tion, and the subsequent changes which it undergoes. LESIONS OF FORMATION OF THE OVARIES. Both ovaries may be entirely absent, or, perhaps, it would be more correct to say, entirely rudimentary, or one may exist alone, or there may be a third one present. When a single ovary is absent the condition of uterus unicornis usually exists, although this mal- formation of the uterus is not necessarily accompanied by an absence of either ovary. The absence of an ovary may be accounted for in different ways ; it may not have been developed, it may have been properly formed, and by some dislocation of the uterus have had its circulation and nutrition so interfered with as to have caused it to shrivel and be- come absorbed, or it may have become attached to some other ab- dominal organ, and then its absence be only apparent and not real. Several cases are on record in which a third ovary has been found. The most interesting of these is one which is described and figured by Winckel in his work on " Diseases of Women." In most of the instances the supernumerary ovary was found near one or the other of the normal ovaries, and either behind or in the broad ligament. In Winckel's case it was situated in front of the uterus and connected ^vith the posterior wall of the bladder. As Winckel has so well pointed out, these cases of supernumer- ary ovaries are always to be borne in mind in making a diagnosis. A cyst forming in the third ovary as found in his case might be de- tected between the bladder and the uterus, and be mistaken for some other form of tumor. In such cases also the removal of two ovaries may not prevent conception, the third ovary being in all re- spects normal, and consequently able to discharge ova. So also even after two ovaries are removed, should a tliird exist a cystoma may form, which will require operative interference. CHAPTER XXYI. DISEASES OF THE OVARIES. (CONTINUED.) HYPERiEMIA, ACUTE AND CHRONIC OVARITIS AND PRO- LAPSUS OF THE OVARIES. Inflammatioii of the Ovaries. — There are two forms of inflamma- tion of the ovaries, the acute and the chronic. These are very dis- tinctly different so far as their clinical history is concerned. There is another affection closely allied to these which is described by some writers as hypersemia. All these are, however, but different degrees of the same affection, though each follows a different course and gives a history pecuhar to itself. This latter fact justifies the con- sideration of the acute and chronic forms, at least, of ovaritis as sepa- rate affections. The third form, hypersemia, is not so fully under- stood nor does it stand out so distinctly from the chronic form as to make its description easy. Ovarian Hyperaemia. — While many of the characteristics of ova- rian hj^jersemia are like those of ovaritis, there is very good reason based upon clinical evidence, to believe that the two are different both in pathology and clinical history. Ovarian hyperiemia, as it is generally observed, resembles many of the so-called functional diseases of the ovary, in that there is de- rangement of function, with symptoms of organic disease which usually disappear, leaving no evidence that there has ever been any change of structure or any products of inflammation. All this dem- onstrates that the pathology is, as the name implies, a derangement of circulation in which there is congestion, and the consequent de- rangement of function with the accompanying or resulting pain and suffering. The hypersemia usually affects both ovaries, and, as a rule, extends to the other pelvic organs, after a time, at least. The derangement of function also extends to the uterus giving rise to derangement of menstruation. In fact, the congestion and func- 4S5 486 DISEASES OF WOMEN. tional derangements of the uterus are secondary to the ovarian hyperaemia. There is much in regard to pathology of this affection which is inferred from the symptoms, and can not be demonstrated by post-mortem investigation. The congestion may be of long or of short duration, its continuance depending upon the persistence of the causes which give rise to it. If it is well-marked and long- continued, it tends to chronic ovaritis, and, perhaps, to degeneration of the ovaries and premature atrophy. Should the causes which pro- duce the congestion continue active and no treatment be employed, the affection may continue indefinitely. The general health be- comes undermined by the derangement of the menstrual function and the exhaustion of the nervous system ; and if the patient is not relieved by treatment or by improved hygienic conditions, she con- tinues a sufferer until the menopause. With so little that is definite regarding the pathology, one might well ask if the fact is yet established that there is a distinct affection to be known as ovarian hyperaemia. In answer to this, it can only be said that the clinical history clearly points to this derangement of the circulation as the only rational explanation of the phenomena presented in these cases. It should be stated here that there neces- sarily must be ])resent in this affection a derangement of ovarian in- nervation as well as hyperaemia. In fact, it appears that this de- rangement is the starting-point in the morbid condition. This view of the matter is favored l)y the affection depending for its origin upon perversion of the emotions in those of nervous tempera- ment. Symptomatology. — Hyperaemia of the ovaries occurs most fre- quently among those who are unmarried, or among young widows who have never had children. It does not come on abruptly like an attack of acute ovaritis, as a rule, though it occasionally does so, but is developed rather gradu- ally. Those most liable to this affection are the nervous and emo- tional wlio live in conditions of life favoring excitation without complete functional action of the sexual organs. I have never seen a case of this kind among those who lived under wholesome con- ditions of life or who were married, l)earing and nursing children, and who lived quiet, rational lives. At the beginning there are pain and heaviness in the region of the ovaries, usually accom- panied by much nervous disturbance of the nature of irritability and weakness, the patient being easily excited and as easily fatigued. Soon after the appearance of these symptoms the menstrual func- tion becomes deranged. There is usually menorrhagia, which is DISEASES OP THE OVARIES. 487 preceded by increase of the ovarian pain. Sometimes tlie pain is relieved and the patient feels much better during the menstrual flow, and for a time after it ceases. In some cases the first symp- tom developed is derangement of the menstrual function, gener- ally too frequent, and too free menstruation. In a word, menorrhagia is the most prominent symptom of ovarian hypersemia. The free flow being due originally to the ovarian excitation is conservative at first, I believe, reheving the congestion which produced it. I have frequently seen young women, who apparently suffered from ovarian congestion, recover completely after one or more free at- tacks of menorrhagia. When the excessive menstruation does not relieve the congestion, which it certainly will not do if the causes which produced it are continued, then it leads to anaemia and neu- rasthenia, and this state of health may continue indefinitely. There are other symptoms which may be mentioned, as backache and general pelvic tenesmus, increased on walking sometimes, but not always. In the less severe forms of hypersemia of not very long standing, active muscular exercise gives relief not for the time only, but is oftentimes permanently beneficial. There is often irri- tability of the bladder, which is purely nervous. Physical Signs. — There is tenderness on deep pressure made in the iliac regions, not acute, but of that dull character which is pecul- iar to the ovaries. As the disease affects both ovaries, as a rule, there is tenderness alike on both sides. Bimanual examination usually shows tenderness better than al> dominal pressm:'e, but I have found that in these cases it is very diffi- cult to grasp the ovaries between the two hands, owing to the fact that the abdominal muscles are tense ; while in the majority of cases there is tenderness if pressure is made upon the ovaries, either through the vaginal or abdominal walls, I have seen many cases in which steady but not too heavy pressure in the iliac regions gave re- lief. Perhaps these were cases of the kind that Charcot calls hys- tero-epilepsy, in which the convulsions are reheved by pressure upon the ovaries. I have seen some of Charcot's cases, and believe them to be ovarian hypersemia. The physical signs obtained are rather negative, but by excluding the evidence of other ovarian affections, and taking the history into account a presumptive diagnosis can be made, and the diagnosis will be confirmed by the subsequent history. Under treatment and im- proved moral and physical hygiene, recovery will take place much m.ore promptly and completely than in chronic inflammation. In connection with this affection of the ovaries, especially if it 488 DISEASES OF WOMEN. has existed for several montlis, there is usually congestion of the uterus and vagina which yields promptly to treatment. Prognosis. — The great majority of patients recover under appro- priate treatment. In fact, many of them recover after the causes are removed without any treatment whatever. This will be seen in the history of the cases given further on. Causation. — Overstimulation of the emotions in those of a nerv- ous temperament is one of the chief causes of ovarian congestion. This is operative among those who are not usefully employed, but are permitted or even encouraged to turn their attention to the procreative function while they are still undergoing development. Stimulating tonics which create an appetite which is not satisfied with food will cause gastric congestion, and all the consequences which arise therefrom. In like manner stimulating the sexual appetence of unoccupied emotional young girls by evil influ- ences or improper associations leads to ovarian congestion. Those who have lived in the proper exercise of the sexual function, but have been abruptly cut off from normal gratification, are prone to ovarian congestion. Indulgence beyond normal gratification is also said to have produced the same result. All these causes are, to a great extent, psychical, but ovarian congestion may be produced by purely physical causes. It may be secondary to endometritis, seden- tary habits, and constipation, which may interrupt the free circula- tion in the pelvic organs. It is rare, however, that cases of ovarian congestion can be traced to such causes. Treatment. — The removal of the cause, when that can be accom- plished, is, as I have already said, often suificient to give relief. The termination of an engagement in marriage has cured the men- orrhagia in many cases, and complete recovery has followed when pregnancy occurred. A like benefit has been brought about in younger patients by directing the attention to something other than self and the feelings and emotions. A change from books and society to the woods and fields, and outdoor occupation in the way of amusements should be employed. Bathing is useful — either sea-bathing or the shower-bath — if the patient is strong enough to bear it. Tonics to restore the general strength, nux-vomica being the most efiicient ; counter-irri- tants, ergot and bromides complete the list of therapeutic agents. The tonic and ergot should be given through the day, and the bromide at night to secure rest and sleep. Acute Ovaritis. — This is quite distinct from other ovarian affec- DISEASES OF THE OVARIES. 489 tions, because it is probably always the result of some special cause — usually a specific poison, such as gonorrhceal infection, puerperal septicaemia, or some constitutional condition like that which exists in the eruptive fevers and in acute rheumatism. It may also be traumatic, though that is rare, except when the ovaries become in- volved in a general pelvic inflammation due to an injury. There has been and still is much confusion of thought regarding the pa- thology of ovaritis. Some of the conflicting accounts arise, I presume, from confounding acute and chronic ovaritis and ovarian hypersemia. There is, no doubt, so marked a resemblance between these three affections, and they are so often associated that it is im- possible to differentiate them in many instances. Still, between the typical causes of each, met occasionally in practice, the distinction can be easily made. The acute affection runs its course rapidly, and terminates either in death or a subsidence of the acute inflammatory symptoms and a damaged state of the ovaries. There are well-detined symptomatic forms, and the changes of structure which result in connection with the clinical history are such as belong to acute inflammatory action. In chronic ovaritis there are, on the con- trary, changes which take place much more slowly, and are not marked by the same definite products of inflammation. In conges- tion of the ovaries there are no tissue changes. It appears to me that acute and chronic ovaritis are as well deflned, both in clinical history and anatomical changes, as acute and chronic nephritis. There is still much need of more observation and careful comparisons of the clinical history and post-mortem appearances in order to settle more definitely the pathology of acute ovaritis. Pathology. — When ovaritis occurs in connection with the puer- peral state, only one ovary is affected as a rule. All the tissues of the ovary take part in the congestion, which is the first morbid change produced. Following the congestion there is swelling from the transudation of serum, which is often of a reddish color. The inflammation involves all the tissues ; the vesicles, stroma, parenchy- ma, and the envelope, and not infrequently the fimbriated extremity of the Fallopian tube is involved, and the peritonseura around the ovary. Then the ovary becomes surrounded with the exudate, so that from the gross appearances it is not possible to tell whether the ovary or the peritonaeum was first attacked. The changes in the ovary are, in addition to general serous effusion, destruction of the vesicles from effusion or purulent infiltration ; sometimes one large abscess is formed in the ovary which destroys most of the tissues ; in other cases a number of small abscesses are found. In short, 490 DISEASES OF WOMEN. acute ovaritis is general as a rule, but occasionally partial ovaritis occurs. From what lias been said, it -wall appear that ovarian inflam- mation is, in its morbid anatomy, similar to adenitis generally. The congestion, serous effusion, suppuration, the formation of single or multiple abscess, and plastic exudations on the free surface of the ovary are the usual changes. These changes are manifested in dif- ferent degrees at various parts of the ovary, due in part to the course which the disease follows, but more especially to the different struct- ures or elements which compose the ovary. In addition to these pathological changes, there are others which may or may not occur. There are prolapsus of the ovary and adhesions to neighboring organs. The abscess may open into the rectum or the peritoneal cavity, or find its way into the lymphatics or veins, which are often dilated ; quite frequently the abscess does not discharge at all, but remains encysted. Sijinptomatology. — There are both local and constitutional symp- toms in acute ovaritis. There may be a chill or rigor, followed by fever, nausea, vomiting, and pain more or less acute. The acuteness of the pain appears to be greatest when the peritonaeum is affected. There is marked disturbance of the nervous system, shown by iri'i- tability and anxiety, but no delirium ; not infrequently, however, hysteria and, in a few cases, mania have been developed. The only difference which I have noticed between the symp- tomatic form of ovaritis and other acute pelvic inflammation is that in the former the nervous symptoms are more marked. In mild forms of this affection the constitutional disturbances are less severe ; still there is an elevation in the temperature, increased frequency of the pulse, and deranged primary nutrition. The appetite is poor, and there are dyspepsia, flatulence, and constipation. The symp- tomatic form subsides to some extent after the first few days, and the formation of pus reawakens the general disturbances. There may be a chill, followed by perspiration, or irregular rigors may occur, and the pain may return more acutely. The local symptom is pain, which is often circumscribed, the patient being able to point out the exact spot in the iliac fossa where the pain starts, and from which it radiates, and where the tenderness is felt on pressure. Tliere are pelvic tenesmus, and a frequent desire to urinate, and, if the left ovary is the one affected, there is often excruciating pain during defecation. Physical Signs. — There is acute tenderness on pressure, more definitely located than in pelvic peritonitis. Sometimes the ovary can be felt through the abdominal walls. This is frequently the case DISEASES OF THE OVARIES. 491 when the ovary is greatly enlarged by the products of the inflam- mation, and is fixed high up by adhesions. By the vaginal touch heat and tenderness are detected. Pressure causes pain of a char- acter peculiar to the ovary. The finger should be carried high up behind the uterus, when the ovary may be caught between it and the sacrum. By very gentle manipulation the uterus and the ovary also, perhaps, are found to be movable to a limited degree. The location of the tumor, its partial mobility, its form, and that it is not connected directly to the uterus, all go to aid in making the diagnosis. The rectal touch will enable the examiner to locate it. Differentiation. — Owing to the fact that, in the present state of science regarding this affection, the diagnosis is not at all times easy to make, it is necessary to mention the conditions which resemble it, and point out the differences which helj) to define and distinguish acute ovaritis from them. Acute ovaritis is easily distinguished from chronic ovaritis and hypersemia by the absence in the latter of symptomatic fever. Much aid is obtained by the history which nearly always presents some of the causes which give rise to acute ovaritis. It may be distinguished from pelvic peritonitis and cellulitis by the physical signs. The fixation of the uterus and the more diffuse distribution of the inflammatory products being most marked in the cellular and peritoneal inflammation. In cases of acute ovaritis that are complicated with cellulitis or peritonitis, the differential diag- nosis can not be made upon the living subject. That these affections have occurred together can be determined, but which was the pri- mary affection can only be surmised from the history. Prognosis. — When suppuration occurs, and the abscess opens Into the peritoneal cavity, a fatal termination should be expected. Death may also occur from septicseraia when the contents of the sac of the abscess find their wa}^ into the lymphatics or veins. This, I believe, is more likely to occur when there are a number of small abscesses with thin walls. If the accumulated pus is discharged through the rectum or vagina, or if the abscess becomes encysted, recovery may take place. The ovary is, of course, damaged or de- stroyed, but, if one ovary is left in a normal state, the patient may regain health and bear children. In some cases of chronic suppura- tion, in cases where the pus is discharged through the rectum or vagina, or is walled in by peritoneal adhesions from plastic exuda- tion, relief may be obtained by surgical means to be referred to when discussing the treatment. 492 DISEASES OF WOMEN. Causation, — The causes of acute ovaritis have abeady been named. Puerperal septic absorption and gouorrhoeal infection are the chief causes. Lawson Tait has called attention to the eruptive fevers and acute rheumatism as giving rise to acute ovai'itis, and my own observations agree with his in the main. While I have not seen ovaritis occurring in connection with rheu- matism, I have seen several cases caused apparently by the eruptive fevers. I have never seen ovaritis due to traumatic causes, still I can believe that such might be the case. Treatment. — In regard to the management of acute ovaritis, I may say, in brief, th^t the cases that have come under my care have been treated exactly as I have treated pelvic peritonitis or cellulitis. I have not discovered any special line of management as specific medication ; hence, to avoid useless repetition, I must refer the reader to the treatment of the aliove-named affections. 1 may remark in passing that, knowing that the causes are specific in the majority of cases, care may be taken to prevent the occurrence of ovaritis by judicious treatment of the affections which give rise to it. There is room for doubt, however, if much can be accomplished in this way. Chronic Ovaritis. — Pathology. — The study of the pathology of ovaritis derives a special interest from the fact that the ovary differs from all other organs of the body, in that its function is performed at the expense of a portion of its structure which is never restored to its original condition. The rupture of each Graafian vesicle in ovulation causes the destruction of the vesicle. Rudimentary vesi- cles mature and repeat the function of their predecessors, and are in turn destroyed. Finally, the supply ceases, and the ovary, worn out in structure, Ijecomes functionally incompetent long before the gen- eral organization has reached the end of its life and activity. In all other organs of the body function is effected tljrough cellular disin- tegration and restoration. This peculiarity in the natural history of the ovary makes it dif- ficult for the superficial observer to distinguish between the normal degeneration and the structural changes which result from chronic ovaritis. Experts also find it no easy matter to distinguish, by gross appearances, the atrophy of old age from the cirrhosis of inflamma- tion. The patholc>gy of ovaritis is characterized by changes of struct- ure brought about chiefly by areolar hyperplasia flrst, then by atro- phy of the normal tissues, and finally by a condition of cirrhosis. DISEASES OF THE OVARIES. 493 In this respect the morbid process and its products more resem- ble degeneration than inflammation such as is observed in other organs. In the natural history of its pathology chronic ovaritis is more like certain forms of chronic nephritis. Owing to these peculiar and distinguishing features, the affection has little in com- mon with acute puerperal or non-puerperal ovaritis, or with sec- ondary acute ovaritis due to peritonitis, and therefore all such conditions will be carefully excluded from the discussion of the subject in hand. The first variation from the normal toward the pathological is deranged innervation ; the ovary, owing to its important ofiice and intimate relations to the other organs, being peculiarly prone to re- flex disturbances. These, though temporary as a rule, when oft re- peated and prolonged in duration, induce changes in the circulation which impair nutrition and finally produce changes of structure. This ovarian hypersemia, the first step in the process, may subside, and complete recovery follow. Reliable evidence of this has been obtained, first by clinical observation of cases which have given all the signs and symptoms of ovarian congestion, and which, under careful management, have completely recovered. Secondly, by inspection after laparotomy. I have not infre- quently found a prolapsed, tender, and painful ovary, which upon inspection was markedly hypersemic, but presented no apparent change of structure except oedema. After fixing it in place by stitching the utero-ovarian ligament to the upper border of the broad ligament, the signs and symptoms have all subsided. The continu- ation of the hypersemia slowly produces those structural changes which are invariably effected by prolonged mal-nutrition. The first noticeable changes take place in the blood-vessels themselves. They become dilated, and a peculiar degeneration of their walls occurs. These changes have been elaborately studied by Dr. E. Xoeggerath, who advanced the idea that these vascular changes were closely re- lated to the genesis of ovarian cystomata. This may be true in cer- tain cases, but it more frequently ends in areolar hyperplasia of the stroma, which gradually goes on, and in time crowds out all the nor- mal structural elements of the ovary. Finally, a true cirrhosis is produced. With these changes in the blood-vessels the circulation is interrupted to a degree that causes oedema, which increases the size of the ovary and renders it softer. Apoplexies sometimes oc- cur, and occasionally one or more of the blood-clots may be seen near the surface. These conditions can be distinguished from a dis- eased vesicle by the staining of the tissues around the clot. This 494 DISEASES OF WOMEN. last-mentioned lesion oecnrs in the early stage of the ovaritis, and gradually disappears as the process of hyperplasia proceeds to a. complete cirrhosis. These changes explain some of the important facts in the clinical history. The ovary which is found enlarged, softened, and tender to the touch, will, in months afterward, appear subnormal in size. Likewise the same lesions may be recognized upon inspection after laparotomy, if one has become familiar with them by previous study. While hyperplasia of the stroma is going on, the follicular ele- ments undergo certain changes. The contents of the follicles be- come cloudy from degeneration of the epithelial elements. The gross appearance of the ovary at this time would lead one to sup- pose that there were a number of vesicles approaching maturity, but the uncommon number of these is evidence that they are ab- normal. The full value of a knowledge of the gross pathology of ovaritis can be fully estimated by those who have mistaken the normal for a pathological degeneration of the ovaries, and have removed them, to learn subsequently, through the microscopist, that they were not diseased. The morbid appearances which aid the surgeon in decid- ing when to remove an ovary and when not to remove it are as fol- lows : The presence of follicles which, from their size, number, and dark color, are evidently diseased : enlargement, congestion, and softening from oedema, and patches of induration, with irregular distention of the vessels and the evidence of small blood-clots, as described above. Cirrhosis, indicated by subnormal size, indura- tion, and irregular surface, when found in a young subject, can be easily passed upon. But in a subject near or after meno]>ause this appearance of the ovary does not enable the surgeon to decide with certainty whether there is cirrhosis or simply senile atrophic degeneration. Symptoinatology. — The history of chronic ovaritis includes both local and constitutional symjitoms. The constitutional derange- ments are not acute, but are usually marked by depression of the nutritive and nervous systems. The reflex derangement of the digestive organs is manifested by capricious appetite, nausea, and sometimes gastralgia. The bowels are usually consti^^ated and tympanitic. There is often nervous del)ility attended with great emotional disturbance. I believe that I have seen more marked de- rangement of the brain and nervous system caused by chronic ova- ritis than by the reflex influence of any other affection of the sexual organs. These constitutional symptoms are progressive, the patient's DISEASES OF THE OVARIES. 495 general health becoming more impaired montli after month as the disease advances. The local manifestations are pain and derange- ment of menstruation. There is often menorrhagia ; in fact, that is the rule, but in cases of long standing I have seen amenorrhoea. The ovarian pain is usually increased for several days before menstrua- tion, and is relieved to some extent when the flow has lasted a day or two. The menstrual pain is much more severe and persistent if there be a uterine disease accompanying that of the ovaries. The ovarian pain varies according to the ovarian tissue affected. When the stroma alone is the site of the disease the pain is less severe. Much more suffering is experienced when there is circumscribed peritonitis or salpingitis. All these symptoms are aggravated by standing, walking, riding, or sitting in a stooping position for any great length of time. Most comfort is obtained by the recumbent position. Sexual excitation and coitus cause so much suffering that the patient shrinks from both. There are exceptions to this rule, but not many„ Physical Signs. — The ovaries are tender to the touch, and the pain excited by pressure lasts for a long time as a rule. The char- acter of the pain excited by the touch is described as ovarian. When the ovary is enlarged or changed in form it can sometimes be made out by the bimanual touch. The ovary is usually movable, and its separation from the uterus can be distinguished. It will be observed that the symptoms and physical signs of chronic ovaritis closely resemble those mentioned as occurring in ovarian hyper- semia. The fact is that the two affections have many features in common, hypertemia being a part or the initial stage of inflamma- tion, the manifestations of the two affections are similar. Between ovaritis and ovarian neuralgia there is a close resem- blance, but the differences are also equally marked. In neuralgia there is no evidence of inflammation, it is not continuous, and very often the ovary is not tender. The diagnosis can only be made by a due consideration of the history as related to the cause, duration, physical signs, symptoms, and progress of the affection. Prognosis. — If the patient has the good fortune to be placed early under treatment, the chances of recovery are favorable. This is still more certain if only one ovary is affected. The disease may go on in one ovary to complete destruction of the organ by hyper- plasia of its cellular tissue and atrophy of its glandular elements, and after this premature atrophy all suffering may subside except occasional neuralgic pain ; and the other ovary may perform the ovarian function. In case the disease is complicated with inflamma- 496 DISEASES OF WOMEN". tion of the neighboring peritonaeum, and there is marked destruction of tissue from the inflammation, relief can only be given by remov- ing the ovaries. There is not a great mortality from this affection. I have never seen a fatal case, but I have seen several in which life was not worth living. Causation. — The causation of chronic ovaritis demands a brief notice, owing to its intimate relation to the question of treatment. According to my observations, the cause which most frequently ob- tains is imperfect menstruation. When the uterus is undersized or flexed forward or backward, and the menstrual flow is scanty and at- tended with pain, the ovaries are liable to take on chronic inflamma- tion. This is far more liable to occur in this class of subjects if the sexual function is perverted. Specific causes such as produce tlie eruptive fevers are said to affect the ovaries, but I believe that acute ovaritis is more liable to occur under these circumstances. It is probably true, also, that gonorrhoea causes acute rather than chronic ovaritis. The strumous diathesis (which I understand to be that condition of organization which invites tuberculosis) predisposes to chronic ovaritis, and inherited or acquired syphilis does likewise. Much has been written about endometritis as a cause of ovaritis, upon the theory that the structure of the endometrium and that of the ovaries have a common embryonic genesis, and the fact that the two diseases are often found together, but this is still an open ques- tion. Surgical Treatment. — The advancement of abdominal and pel- vic surgery in recent times has led to the removal of the ovaries as the most prompt and effectual treatment of chronic ovaritis. There are reasons for this upon theoretical grounds. The ovary is causing much suffering ; there is a likelihood that it will be a long and tedious trouble ; especially is this the case if general treatment has failed ; the ovaries are not necessary to existence, and can be removed with safety; it is according to the rules of surgery to remove any organ, or other portion of the body, that one can live without, in case a disease of the part tends to take life or cause unlimited suffering and invalidism; hence, from this way of look- ing at the matter, the ovaries should be removed. Tlie facts are (facts that have been proved almost sufficiently), that chronic ovaritis does not end fatally, and is self-limited though often of long duration ; the removal of the ovaries is not free from all danger, though all cases properly operated upon have recovered, and it does not in all cases give complete relief. In fact, many of DISEASES OF THE OVARIES. 49Y the cases are not much improved, if at all ; even those who are near- ing the menopause, and who bear the loss of the ovaries better than younger subjects, occasionally suffer much from those nervous dis- turbances which follow an abrupt menopause, and have to endure pelvic pain in the region of the stumps. The clinical history of cases in which the ovaries have been removed does not, in all cases, show great advantage over those in which the ovaries are left to complete the natural history of the disease. Younger subjects do not bear the loss of their ovaries well. Some become fat, indolent, inefficient, and subject to headaches; others are irritable, dyspeptic, and despondent ; while but few enjoy good general health and mental vigor. This statement is at variance with much of the published litera- ture, but is more in accordance with the actual facts. The cases cured are those operated on when near the menopause ; those who are improved are generally those who suffered from complicating affections, such as dysmenorrhcea ; while the unimproved are the younger subjects in whom the disease was uncomplicated. The objections to surgical treatment apply to the removal of both ovaries. In cases in which one ovary alone is affected, and especially where there is prolapsus of the affected ovary and retro- displacement of the uterus, ovariotomy is perfectly satisfactory. The removal of the diseased ovary gives relief, and the retro-dis- placed uterus can be restored, while the remaining ovary performs its functions, and the general health of the patient is preserved. I desire to be understood as advocating the removal of the ovary only when there are structural changes from inflammation and prolapsus at the same time. Prolapsus can be relieved by fixing the ovary to the upper border of the broad ligament, and the welfare of the patient can be thus conserved to a higher degree. When advocat- ing conservative measures in regard to abdominal and pelvic surgery it may be inferred that I am behind the age in experience, but I have had a large field for operative surgery, and have acted to the fullest extent justifiable, according to my judgment. In fact, I have in the past violated the rules I now advocate, but I have not been satisfied to have my patients simply survive the operations. I require that they be cured, and failures in this regard have led, I trust, to a ra- tional conservatism. I have no word of condemnation for those who have removed and are still removing ovaries for the relief of chronic ovaritis. Their work, while not always beneficial, has been of vast interest to science. Their doings help to perfect surgery. The rough, un- 33 498 DISEASES OF WOMEN. sightly scaffoldings employed by builders are temporary necessities, which are all cleared away when the structure is perfected and completed. In like manner the heroic, daring experiments of the surgeon are valuable stepping-stones which lead to mature science and art. General Treatment. — The indications for general treatment are to lessen the blood-supply and relieve pain by correcting the deranged innervation. This demands rest in the recumbent position in the early stages. At the same time general exercise should be enjoined, either by massage or gymnastic exercise in the reclining position. I specially desire to commend systematic calisthenics, in the recumbent position, as a most valuable aid in improving or maintaining the gen- eral healtli in many diseases of the pelvic organs which require rest as an important part of the treatment. The condition of the diges- tive organs should be carefully watched. The poor appetite, coated tongue, and constipation, or the capricious appetite, flatulence, and occasional diarrhoea, can be relieved by a number of small doses of mercury and a laxative. The saline laxatives are the best when they act without causing flatulence. The use of Saratoga waters often gives good results by improving digestion and keeping the portal circulation active. By keeping up a free elimination by the bowels and kidne}s much benefit is obtained. This applies in cases that are apparently debilitated. Many times I have stopped the use of tonics, stimulants, and forced feeding, and given saline laxa- tives, with the effect of increasing the patients' strength. To re- lieve the pain and lessen the hyperaemia, the bromide of sodium and fluid extract of hydrastis canadensis are by far the most potential agents that I have found ; they are given in combination, and in doses sutficient to produce the desired effect. Twenty to thirty grains of the bromide and ten to twenty minims of the hydrastis, three times a day, until the physiological effects of the bromide are noticed in a mild degree. If the hydrastis is given alone, in such doses, it sometimes causes pelvic pain of a dull character, but when combined with the bromide it has no such effect. These agents are most efficacious in the beginning of the attack, and hence they should be discontinued as soon as the pain is relieved in a marked degree- Should the pain and tenderness return at the succeeding menstrual periods, the bromide and hydrastis should be resumed. In some cases much larger doses of bromide are required, and in others it fails altogether to relieve pain. Then it is necessary to employ other agents, especially during menstruation. Ten-grain doses of salicylate of soda and five of anti]iyrin, given between meals and ini DISEASES OP THE OVARIES. 499 the niglit, when the stomach is empty, answer for some ; others, more especially those markedly debilitated, do better on full doses of aromatic spirits of ammonia, camphor, and chloric ether, with small doses of cannabis Indica This combination is best suited to those who get relief from gin or whisky, but it is to be preferred, as al- coholic stimulants ultimately do harm, though they may give tem- porary relief. Direct or local treatment should be adapted to the social state of the patient, and the presence or absence of complica- tions, such as endometritis. In the unmarried, local treatment is often injurious. In fact, in such cases it is better to avoid any ex- amination of the pelvic organs, if the history is sufficiently clear to enable one to make a diagnosis with reasonable certainty. Hot sitz- baths, counter-irritation, and hot vaginal douches, the latter to be employed by a competent nurse, comprise about all that I employ in the way of direct treatment The vaginal douche should not be continued unless it is decidedly sedative in its effects. Baths used according to the rules of modern hydrotherapy are of great service. In weak, nervous patients I begin with the wet-pack, used for half an hour at a time. Those who require a sedative are put into water at a temperature of 95° F. for ten or twenty minutes and then dried by brisk rubbing. When the sedative effects of the bath are no longer needed, the tonic bath should be used. This consists of the cold sponge, shower, or plunge bath. The water should be warm at first, and gradually reduced in temperature at each bath. In married women (and those who are so in all but the name) local treatment is more valuable. The treatment of any disease or displacement of the uterus that coexists should be managed in the usual way, and such local applications should be used as may aid in relieving the tender and hypersemic ovaries. I employ a small tam- pon or pledget of cotton or wool saturated with equal parts of tinct- ure of belladonna and glycerin, applied behind the cervix uteri and permitted to remain forty-eight hours, and after its removal a hot douche. These are continued during the first days of treatment. The effect is to support or steady the ovaries, while the sedative ef- fect of the belladonna and the depleting effect of the glycerin are obtained. This I have followed with applications of tincture of iodine, after the manner of Dr. Emmet. Recently I have used, with good effect, the sulphichthyolate of ammonium, five parts in nine- ty-five of glycerin, applied in the same way as the belladonna and glycerin. The general and local treatment thus briefly outlined gives re- 500 DISEASES OP WOMEN. lief from the more pronounced symptoms. The pain becomes less, and the tenderness also. The general health improves, and the pel- vic congestion subsides. This is apparent in the color of the mucous membrane, the improvement of the menstrual functions, and the diminished leucorrhcea. Then the local treatment may be employed at longer inter v^als, or suspended altogether. The constitutional treatment should now be modified. Tonics and laxatives may still be required, but alteratives are also indicated. Iodine and mercury are the chief agents. They act upon the ovaries, as they do upon all glandular organs, and modify or arrest the morbid histological changes which take place slowly. Small doses of bichloride of mercury, with chloride of iron, when iron is indicated, followed by syrup of the iodide of iron in doses as large as can be borne. These can only be used when the bromides are relinquished. When giv- ing these alteratives the patient often misses the bromides used to produce sleep. Sulphonal at such times is of great value. In fact, it is the most potent sedative that is at the same time free from ultimate or after effects that are unfavorable that we have in gynae- cological practice. When a sedative is required while iodine or mercury is being used, I find that ten grains of salicylate of sodium and five grains of antipyrin, three times a day an hour before meals, give much relief, especially in those who suffer from nervous dys- pepsia and flatulence. Important elements in the treatment are patience and careful watching. Improvement comes, and the patient or the physician gives up treatment, and there is danger of relapse. The poor in hospitals often suffer for M^ant of time for prolonged treatment, and this frequently tempts the surgeon to seek more prompt relief by removal of the ovaries. This does not api)ly with the same force to those who have time and means to secure the needed care. The description of the operation for the removal of ovaries de- stroyed by inflammation, as well as that for the removal of diseased tubes, will ])e found at page 590. Displacement of the Ovaries. — The ovaries have been found dis- located in a variety of ways. Cases are recorded in which the ova- ries descended through tlic inguinal canal after the manner of the testicles. The most interesting of these is one reported by Percival Pott, who removed both ovaries that were found in the usual posi- tion of an inguinal hernia ; and still another is mentioned by Tait, in which the ovary found its way outside of the inguinal ring and there developed a cystic tumor, which was removed by a Spanish surgeon. The ovaries have been found dislocated laterally and high up in the DISEASES OP THE OVARIES. 501 pelvis. Thej are, in sucli cases, usually fixed in tlie malposition by- adhesions. Prolapsus of the Ovaries. — Downward dislocation of the ovaries is quite a common att'ection compared with all the other displace- ments. It is tlie only affection of this class which has an interest to the gynecologist derived from the frequency of its occurrence and the great suffering to which it gives rise. On that account it de- serves more than a passing notice, such as I have given to the other forms of displacement of the ovaries. Prolapsus of the ovaries I have described as occurring in two degrees — complete and incomplete. This classification is based upon the fact that displacements of the ovaries must in practice have the natural division. In the incomplete form the ovary has simply de- scended from its normal position until it has reached the side of the sac of Douglas or the utero-sacral ligament, where it lodges. In the complete form the ovary rests in the most dependent portion of the sac of Douglas. Fig. 213 shows the position of the ovary in com- FiG. 213. — Ovary displaced and bound down in the cul de sac by adhesions, ro, right ovary ; lo, left ovary. plete and incomplete prolapsus, and the relation of the prolapsed organ in relation to the uterus and sac of Douglas. The figure also shows what is sometimes found in practice — namely, complete prolapsus of one ovary and incomplete prolapsus of the other occur- ring in the same subject. "While prolapsus of both ovaries in dif- fering degrees, or both in the same degree, may occur, I more fre- quently find one displaced, while the other is in its normal position. 502 DISEASES OF WOMEN. The left is the one most frequently displaced, or else it causes the most suffering, and on that account attracts more attention than the right, and is oftener discovered. Prolapsus necessitates a stretching of the supports of the ovary, or it may be an elongation from an increase of tissue, the result of hyperplasia or new development. Prolapsus does occur without complications or coexisting affections, which cause the displacement. Such cases are not very common, and they are probably the result of arrest of development. In many cases, perhaps the majority, there is some accompanying affection which has some part in the causation of the prolapsus. The ovary itself is often enlarged from inflammation or some degenerative changes. In other cases the sup- ports of the ovary are elongated from imperfect involution after con- finement. Retroversion of the uterus is also frequently associated with prolapsus of the ovary. A not uncommon and a very unfor- tunate complication is the formation of adhesions from peritoneal inflammation. Symptomatology. — The degree of suffering arising from disloca- tion of the ovaries is extremely varying in different cases. This is due largely to the fact that, if the ovaries are quite normal and sim- ply displaced, but little Inconvenience is experienced by the patient. It is rare to find this state of things, because the ovaries are often diseased, or else displacement soon leads to congestion, tenderness, and pain. As a rule, then, in displacement of the ovaries there is pelvic tenesmus and pain on walking or standing, relief from which is obtained by the recumbent position. In this the history differs from inflammation of the ovaries. There is usually backache and pain along the thighs, and pain and tenderness during and after sexual intercourse. There is pain after defecation, especially when the left ovary is displaced, which is most frequently the case. This pain is peculiar and, I believe, diagnostic. It conies on during or imme- diately after the action of the bowels, and continues for an hour or two. It is a dull, aching pain located in the region of the ovary, and radiates to the abdomen. It produces in many cases faintnesa and nausea, compelling the patient to lie down until it subsides. It is easily distinguished from the acute, smarting pain due to hfemor^ rhoids or fissure of the anus, on account of its location and character. There is in some cases derangement of menstruation, usually menor- rhagia. The pain in the ovary is generally aggravated at the men- strual period. The constitutional symptoms are generally produced from the confinement of the patient, made necessary by the suffer- ing caused by taking active exercise. There is often headache DISEASES OF THE OVARIES. 503 mental depression, indigestion, and ana3tnia, ending in general de- bility. It should be understood that the symptoms alone will not suflSce to make a diagnosis, because in many cases they arise more directly from the condition of the ovary rather than from its mal- position. Physical Signs. — The method of making a vaginal examination by the touch, to detect a prolapsus of the ovaries is as follows : The finger should be carried as far upward on either side of the cervix uteri as the vaginal wall will permit, and then brought downward toward the sacrum, so that if the ovary is displaced it will be caught between the examining finger and the sacrum. In that way it can be outlined by palpation, and its sensitiveness determined. Its mobility or fixation can also be determined in this way. I have frequently found while teaching my class of post-graduates that these few hints would enable them to find the displaced ovaries when they had tried in vain to make out their location. When an ovary is completely prolapsed, it is found directly behind the cervix uteri in the most dependent portion of the sac of Douglas. So ex- actly central is the position of the ovary that in most of my cases I could not tell whether it was the right or left ovary, and could only settle that question by finding the other one in its normal position. If the prolapsus is incomplete the ovary is found on one side of the cervix uteri, usually at a point a little above the junction of the body and cervix. In complete prolapsus the ovary feels not unlike the fundus uteri, and gives the impression of retroflexion of the uterus. The distinction can be made by the peculiar sensitiveness of the ovary to pressure, and by the fact that the finger can usually be insinuated between the uterus and the ovary. Should there still be a doubt, the question can be solved by passing the sound which will exclude flexion of the uterus. There is another condition which proves to be somewhat puz- zling, that is complete prolapsus of the ovary with the retro verted uterus lying directly upon and above it. In one such case which came under my care, I was able to make out the true state of affairs by passing the sound, and while it was in place raising the uterus far enough to lift it off the ovary, so that by the touch I could dis- tinguish the one from the other. Prognosis. — The prospect of permanently overcoming the dis- placement depends upon the length of time that the malposition has existed; upon the condition of the ovarj', whether nonnal or diseased, and whether there are other complications, such as adhesions, retro- version, or retroflexion of the uterus. In recent uncomplicated cases 504 DISEASES OF WOMEN. a permanent restoration may be effected if the patient Can be kept under treatment for a sufficient length of time. In complicated cases all ordinary local treatment fails. It is then that the question of advisability of removing the ovaries comes up for consideration. Should the patient be near the menopause, she may be carried along past that change, and the recovery may come. In younger subjects the ovaries should be removed if all else fails to give relief. Causation. — The following are the causes of displacement of the ovaries, named, as far as my knowledge guides me, in the order of their frequency. Subinvolution ; enlargement of the ovaries from hypertemia, ovaritis, or other affections ; displacements of the uterus ; congenital malposition from derangements of development and growth. In regard to subinvolution, it may be well to call to mind the fact that in the puerperal state, the ovaries — especially the left one — are very large, nearly twice as large as at other times, and if care is not taken to secure complete involution after confinement the heavy ovaries will naturally descend, and by making traction upon the peritonaeum and ligaments will overstretch them. I believe also that subinvolu- tion of the broad ligaments will permit the ovaries to descend into the pelvis when they are not much enlarged. At any rate, I have found the ovaries prolapsed when they were not large, but wlien the broad ligaments were long and relaxed, a condition which followed confinement. In regard to the other causes of prolapsus of the ova- ries they are sufficiently clear to warrant my saying nothing more about them. Ti'satmiient. — The first thing to do is to ascertain if the displaced ovary is movable and can be raised uj) to its normal position. If that can not be accomplished, owing to adhesions, then there is little to be hoped for from treatment. When the ovary is movable it can be placed in position by putting the patient in the knee-chest posi- tion, using a Sims's speculum, and then making upward pressure through the vaginal wall with a sponge held in a sponge-holder. In short, the same method is employed as in restoring a retro verted uterus. To keep the ovary in place the cotton tampon is the best. It should be removed every forty-eight hours, and two or three times daily the patient should take the knee-chest position if she is able to be up from bed during the day. The use of the tampon in this way takes much time, and I have taught several of my nurses to use it with very satisfactory results. Prof. Goodell recommended that the patient should separate the labia while in the knee-chest position, in order to distend the vagina DISEASES OF THE OVARIES 505 with air, and Dr. C. F. Campbell uses for the same purpose a glass tube open at both ends, which is introduced into the vagina before the patient takes the knee-chest position. I have tried both of these methods, but have given them up for two reasons : In the first place, because distention of the vagina is unnecessary. In the knee- chest position the pelvic organs will rise high enough and assume their normal position as well with the vagina closed as open ; of this, any one can satisfy one's self by making an examination before and after this position has been assumed. In the second place, I find that the less local treatment patients give themselves the better it is for them. The first medical book of any kind that I ever read was entitled " Every Man his own Physician," by one Dr. Buchan. It was a very useless production, but had the good effect of preju- dicing me against making every woman her own gynecologist. I much prefer the tampon and the knee-chest position. If there is retroversion or flexion of the uterus present at the same time, that organ should be replaced each time that the tampon is changed. When considerable has been gained by the above treatment, and the ovaries and uterus are replaced sufliciently to get a pessary under them, one should be introduced. The form of instrument and the method of using it are the same as in retroversion of the uterus and need not be detailed here. I have tried the special forms of pessa- ries recommended by Tait, Munde, and others, but have not been able to do as well with them as with the instrument which I employ in retroversion of the uterus. In a few cases I have succeeded in forc- ing the uterus, ovaries, and vaginal wall upward and backward, thus giving some relief for a time, but the traction upon the vaginal wall causes stretching, and when the pessary is removed the dis23lacement returns to a degree as great if not greater than before. AVhile this local treatment is employed every effort should be made to improve the patient's general health. Rest should be in- sisted upon, in the recumbent position at first, and as the case progresses favorably, short stages of exercise may be permitted. Throughout the whole treatment all sexual relations should be pro- scribed. When all other treatment fails, and the patient still remains a use- less invalid, the ovaries should be removed, or attached to the upper margin of the broad ligament or abdominal wall. CHAPTER XXYIL NEOPLASMS OF THE OVARIES. I HAVE made a classification of the morbid growths of the ova- ries whicli I believe will best serve the practical requirements of the gynecologist, although it may not be quite in keeping with the arrangement of the subject usually found in the text-books. In fact, it would be hardly possible to make any classification which would agree with all of the many authorities on the subject. Nor would it be possible to present an argument in favor of the classification which I have adopted without either taking more time and space than I can afford, or else omitting to mention the statements of many whose views are well worthy of consideration. I am obliged to sim- ply state in brief that which to my mind appears necessary to the student and practitioner. The first class is made up wholly of cystic tumors, with a single exception, to which I shall refer later, and of these there are two varieties — follicular cysts and adenoid cystomata. Both of these va- rieties occur in a simple and in a compound form. Thus we may have {a) simple unilocular cystoma, and (b) simple follicular cysts, or of the compound form we may have (c), multiple follicular cysts, {d) multiple cystoma, (."') multilocular cystoma, {/) papillary cys- toma, and {(j) dermoid cystoma ; and also {h) fibrous, and {i) cysto- fibroma. The second class, which many speak of as malignant growths, contains four varieties : {a) carcinoma, {1>) cysto-carcinoma, (e) sar- coma, and {(l) cysto-sarcoma. Classification. — Tliese morbid growths I have arranged in two classes : 1. Those that arc most frequently seen in practice, and that are to some extent amenable to surgical treatment. 2. Those that are rarely met with, and that resist all kinds of sur- gical treatment, and tend by their very nature to a fatal termination. 506 NEOPLASMS OF THE OVARIES. 507 Tumors of the first class are spoken of by some authorities as benign, while the term malignant is applied to those which I have placed in my second class, OVARIAN CYSTS. Pathology. — The kind of ovarian neoplasm most frequently seen is the cystic tumor, or ovarian cyst, as it is generally called. The development and growth of ovarian cysts and cystomata vary in different cases in many respects, and still there is a certain sameness in the majority. The growth of these has been divided into three stages, the division being based upon certain features of the natural history of these neoplasms rather than upon any changes in their pathology. In the first stage the tumor is small, and confined to the pelvic cavity. This stage begins with the formation of the morbid growth and ends when it is large enough to rise out of the pelvis into the abdominal cavity. The duration of this stage can not be estimated, because there is no way by which the morbid growth can be detected until it has attained considerable size. In many cases an ovarian tumor gives rise to no marked disturbance, and therefore remains unnoticed until it has reached the second stage. This stage begins when the tumor rises up into the abdomen, and ends when the patient's general health begins to deteriorate. These constitutional effects of the morbid growth mark the begin- ning of the third stage. The first stage often passes by without the presence of any abnormality being suspected. It is only when press- ure upon the pelvic organs or when some inflammatory action in the ovary or pelvic peritonaeum occurs, that there is any likelihood of the affection being discovered. There is reason to believe, from the cases which have been M-atched, that the growth is steadily pro- gressive as it is in other neoplasms. The natural history of non- malignant tumors is that they go on gradually increasing until they attain a size sufficient to destroy life. This requires from two to three years on the average, but there is a great variation in time in different cases. There are periods of cessation of growth followed by rapid increase in size. These alternations of increase and pas- siveness may occur repeatedly, or the progress may be continuous. In the third stage the general health of the patient begins to suffer. ■ There is usually loss of flesh, and the face shows evidence of ill-health. A certain facial expression has been described as the facies ovarii, but this is difficult to describe or recognize. It may be said to be an emaciated, careworn appearance, without the bronze hue of the cachectic state. This malnutrition is due at first to ex- 508 DISEASES OF WOMEN. haustion from the growth of the tumor, and finally to pressure upon the neighboring organs. The functions of the abdominal and thoracic organs become deranged from pressure, and cause exhaus- tion and death by slow degrees. Death sometimes comes suddenly from asphyxia due to pressure upon the thoracic organs. Sometimes peritonitis is the immediate cause of death. In the majority of cases that are permitted to run their course, the patient is slowly crowded out of existence by the enormous size of the tumor. Fortunately, there are few cases in this age that are permitted to be lost in this way. Toward the end of the third stage oedema of the limbs generally appears. This is more likely to occur if the patient is unable to lie down in bed. The simple cyst is the most easily comprehended, and will there- fore be first described. It is composed of the cyst proper and the pedicle. The cyst is made up of the cyst-wall and the contained fluid. The pedicle is usually composed of the ovarian ligament. Fallopian tube, and part of the broad ligament. The cyst and the pedicle have one covering in common — namely, the perito- naeum. Simple Cysts. — The simple cyst is usually globular in form, and its walls are generally of uniform thickness. The size varies in dif- Fio. 214. — Left ovary distended into one large cyst, into the interior of which smaller cysts project (Farre). ferent cases from a microscopic object to one weighing one hundred pounds or more, according to the age of the growth. By the term NEOPLASMS OF THE OVARIES. 509 simple or unilocular cyst it is not intended to imply that the tumor is absolutely composed of a single cyst, since it is believed by the best authorities that ovarian cysts are always multiple, but the term is applied to that variety of cyst v^^]lich in its gross anatomy appears to be single, and which can be managed by the surgeon as a single cyst. The one sac or cyst is large and appears to be single, but on close inspection minute cysts are generally found in varying numbers in the major cyst, or in that portion of it which joins the pedicle. Compound Cysts. — These are distinguished from the simple vari- ety by being multiple — that is, the whole tumor or mass is formed by the aggregation of several simple cysts, each being large enough to be easily recognized. The usual form of this multiple variety of cyst is that in which one of the divisions or cysts is much larger than all the others taken together. The greater con- tains the lesser ones, which are usually formed in a cluster attached to one side of the major C3^st, near the pedicle. It will be observed that the difference between the single and multiple cyst is, that in the latter there are a number of well-defined cysts, one large one and a number of others varying in size from that of a man's head to a small hazel- nut, while the former is com- posed of one cyst with a few almost imperceptible cysts. Multilocular Cysts. — These are so called because the sacs or cysts, which in the aggregate make up the w^hole tumor, are larger in size and more nearly equal. The general appearance of the mass is of one large cyst- wall containing a number of cysts which vary in size. Sometimes one or more of the cysts is much larger than the others. In other cases there are several cysts varying in size from that of a human head to that of an orange, with a large number of smaller cysts. Fig. 215. — Compound and proliferating cjst (Farre). 510 DISEASES OF WOMEN. From tlie general appearance and arrangement it would seem that the cysts included within the major cyst-wall had been de- veloped from the inner cyst-wall, and others still had been de- veloped from the second crop by a process of endogenous pro- liferation. This may or may not be the fact, but it is more Fig. 216. — Multilocular cyst (Hooper). likely that the ovary from which the morbid growth is developed contains a number of germs included in the structure of tlie ovary which forms the cyst-wall, and that they all grew from similar germs and are aggregations rather than proliferations. The gross appearance of such tumors is the chief point of interest to the surgeon, viz., that one cyst-wall contains within it a number of cysts ; usually, there are one or two large cysts, a larger number of medium size, and a very great number of small ones varying in size and united to each other. The cavi- ties of these cysts rarely communicate with each other. Occa- sionally a cyst is found the cavity of which is divided by septa, but associated with such there is always a number of independ- ent cysts. I have, on one occasion, seen two cystomata growing from an ovary, one on each side, the whole resembling somewhat a dumb- bell in shape. Complex Cystoma. — These tumors are called complex or mixed because they differ from those already described by the addition to the cyst structures of other pathological elements, or else there is a marked development of some special portion of the cyst elements — the cyst-wall, for example. These peculiar portions of the growth may consist of a hyper- NEOPLASMS OF THE OVARIES. 511 trophic increase in the tissues of an ovarian folhcle, or of hyper- trophy of the stroma of the ovary, infiltrated with serum or other morbid fluids. Proliferation of the fibrous tissue may give rise to one or more fibrous masses connected with the cyst. The cyst-wall may be greatly thickened generall}'-, or in certain portions, from hypertrophy of either its inner or middle layer. The inner surface or hning membrane of a cyst may develop new structures or pro- liferations. Again, the contents of a cyst may be of a character en- tirely different from the ordinary fluid found in simple or com- pound cystic tumors. In this way the following complex tumors are formed : Papillary Cysts. — In this form of cyst the connective tissue of the cyst-wall undergoes hyperplasia in certain places, and the growth of the tissue pushes the lining membrane of the cyst before it, and in that way a great number of papillae are found projecting into the major cyst and covering, it may be, the whole internal surface of the sac. The papillae are sometimes very vascular, and are covered with columnar epithelium. Paroophoritic Cysts. — These cysts, which, as their name implies, are developed in the paroophoron, present, according to Bland Sut- ton, the following differences from oophoritic cysts (the ordinary Fig. 217. — Papillary cystoma of ovary showing proliferation (Winckel). ovarian cysts) : They are, as a rule, unilocular ; do not affect the shape of the ovary until they have attained an important size ; always burrow between the layers of the mesosalpinx ; when large, make their way between the layers of the broad ligament by the side of the uterus, and their interior is beset with warts, which are very vascu- lar, bleed freely, and are frequently calcified. It is to be borne in 512 DISEASES OF WOMEN. mind, however, that although these paroophoritic cysts contain warts or papilloinata, still other cysts may also be papillomatous. Dermoid Cysts. — Ovarian dermoids occur much more frequently than is generally thought. According to Olshausen, they form four per cent of all ovarian tumors. In them have been found hair, sebaceous glands, sweat glands, teeth, mammse, horn, nails, bone, nnstriped muscle, a well-formed heart, a tongue, a trachea, an eye, and what has been regarded as brain tissue. They occur at almost every period of life. It is said that they have been found at birth, but Bland Sutton, who has studied the subject of dermoids most thoroughly, is unable to find the evidence of so early a case. He Fi3. 218. — Dermoid cyst of ovary, filled with hair and tallow-like masses (Winckel). refers to an authenticated one in a child of one year and eight months. They have also been found in patients above eighty years of age. Various theories have been advanced to explain their formation. The one which seems to me the most plausible is that of A. W. Johnstone, ]\I. D., of Cincinnati. He regards the process as a true parthenogenesis, in which the ovum itself is at fault. For some unexplained and probably inexplicable reason it retains one of its polar cells and goes on, under the stimulus of this male element, to form a human body in a weak and very incomplete way, giving us the great variety of tissues already mentioned as having been found as constituents of dermoids. As a consequence, while the hypertro- phic change which takes place in other ovarian follicles produces ordinary cystomata, that which occurs in a follicle in which exists an ovum that still retains a polar cell will result in the formation of a dermoid. NEOPLASMS OF THE OVARIES. 513 Cysto-Fibroma. — In tlils form of tumor tlie fibrous portions closely resem1)le, in structure, fibrous tumors of the uterus. They do not diflier in their outward appearance from the ordinary simple cyst, but the touch shows one part of the mass to be solid and the other fluid. These morbid growths are quite rare. I have met with but two in my own practice. FIBROMA OF THE OVARIES. This rare form of ovarian tumor I have classed with the cys- tomata, not because it presents any features in common with the class, but because it calls for surgical interference and does not in any way belong to the second class, having no inherent tendency to Hintert Ut&nosmzm^. Ghe^rf louch e des I'umcrs lEiZeiten Ei.erslotJ£s. Obe^fUiehe d. I.E. SchmJtflUcJte d.7tcl}t&n> Eicrstc^Cs. Fig. 219. — Fibroma affecting both ovaries (Winckel). prove fatal except by indirect effects. It is rare, and hence not of sufficient importance to demand a separate class for itself alone. In describing this form of neoplasm I may say that it is like the cysto- fibronia, minus the cyst or cysts. The composition of the growth is similar to that of the fibroid tumors of the uterus. That the fibroma of the ovary is very closely related to the cysto-fibroma. is further shown from the fact that so-called fibromata have been found with small cysts. In the one the cyst element predominates, while in the other the solid or fibrous element is the principal or onlv one found. 34 514 DISEASES OF WOMEN. Cyst-Wall. — The walls of the cysts of ovarian tumors are, as a rule, nearly all the same. For convenience of description and for the purposes of the surgeon the wall is divided into three layers. Tlie external is a serous membrane corresponding to the peritonaeum, which it is in fact. The middle coat is areolar tissue, and contains the main Ijlood-vessels of the cyst. The internal layer is like the external, so far as its fibrous elements are concerned, but it is really a mucous meml)rane. It is less uniform than the other layers in appearance, and usually contains small cysts in process of develop- ment, or follicles which have undergone degeneration. PapilUe are often found developed on this layer, as already stated. "While this in a general way describes the cyst-walls, they are subject to certain modifications, as follows : The middle layer, which is well defined at the base of the tumor, contains the large vessels, and is easily sepa- rated from the peritoneal layer. It becomes thinner the farthei- it departs from the pedicle, and when it reaches about the middle of the tumor there are only two layers easily distinguished, while at the sununit there is only one that can be made out by ordinary dis- section. While the middle layer diminishes gradually' as it gets farther and farther away from the base and finally disappears, the internal and external layers come together and are united, and increase in thickness so that the cyst-wall becomes a fibrous homogeneous mem- brane. Some authors have made more minute sul>di visions of the layers of the cyst-wall, but that I look ujion as a super- refinement in dissection which has no value in this connection. The outer and iimer coats are often modified in appearance and character. The external layei- is changed in places by circuinscril)ed peritonitis, or by great vascularity, and the internal coat is often changed l)y intlannnatory action, degeneration, or liv|)erplasia. The appearance of the outer coat has a special interest for the surgeon. To l)e able to recognize the cyst-wall when one comes to it in operating is very important. Many times, in sim])le uncomjtli- cated cases, the cyst-wall is smooth, of a whitish color, slightly tinged with a pinkish, pearly tint which resembles the ])eriton;eum, evei'v- where covering the abdominal viscera, and yet easily distinguished. Wlien there has been peritonitis, the cyst-wall becomes covered with lymph or adhesions, and so changed in a])pearance that it is ditfieult to recognize it when it is reached, owing to the ])roducts of intlam- mation. The vascularity of the outer coat of the cyst varies greatly. Sometimes the whole surface presi-nts a fine netwoi-i< (»f vessels all over the parts that ai'e seen; in other cases the vascularity is exag NEOPLASMS OF TIIP: OVARIES. 515 gerated in patclies. This great vascularity, M-lieii it occurs Avitli- out preceding evidence of intiannnation, makes a marked contrast between the cyst and the abdominal viscei-a, which enables one to promptly distinguish the one from the other. In a few tumors, all of them occurring in oldish patients, I have found large portions of the cyst- wall of a pale, grayish-white color, without any recognizaljle vascularity. This made the cyst very pecuhar in appearance and easily recognized. This rare and peculiar color is caused by com- mencing necrosis. Contents of Ovarian Cysts. — The contents of the simplest variety of cyst are a serous fluid of a lemon or amber color, hut subject to marked variation in different cases. The character of the fluid is modified by the size of the cyst, the lengtli of time it has existed, and whether the cyst has been tapped ; under these modifying influ- ences the fluid may be colorless, or chocolate-colored from the pres- ence of blood in varying quantity, or it may be of a greenish-yellow color, from the presence of pus produced by inflammation of the cyst. Shreds and flakes of whitish lymph are sometimes found with the pus when there has been inflammation. Occasionally the fluid is viscid. It generally contains albumen or paralbumen, and sometimes crystals of cholesterine are found in it. The contents of the multi- 1 ocular cysts resemble those just described, presenting the same dif- ferences in different patients. Usually the fluid is more viscid or gelatinous, sometimes quite thick, so that it escapes with difficulty. In one case I found the cyst contents exactly like jelly, but different in character in this, that jelly is friable, but this material was ex- ceedingly tenacious, so that it could not ' be pressed out of the sac, and was even pulled out with the hand with great difficulty. The fluid in the sevei'al cysts of a multilocular tumor is not always the same. It often differs in color and consistency in the dift'erent divisions of the tumor. In addition to the albumen, blood, choles- terine, pus, and lymph, which may be present in the fluid of ovarian cysts, there are other chemical and anatomical elements found which are of interest. The contents of ovarian cysts have l)een most thoroughly investi- gated as to their chemical composition by Eichwald. As has already been stated, they may be as fluid as serum, or, as is niore often the case, viscid sometimes to such a degree as to be gelatinous in con- sistency. The specific gravity may be as low as 1<)07, or as high as 1020. There are two distinct classes of elements which occur in the contents of these cysts : the one mucous in its nature, which 516 DISEASES OF WOMEN. predominates in the younger cysts; the other albnminons, whieli is characteristic of the large and older colloid cysts. The colloid sub- stance is regarded as a modified niucine formed from the substance of the colloid bodies and the parenchyma of the cells of the ovaries. Colloid degeneration is therefore but another name for mucous metamorphosis. The first or mucine class consists of four ele- ments : the sul)stance of the colloid corpuscles, mucines, colloid substance, and muco-peptone. These are distinguished l)y their solubility in water, and l)y various reactions which need not be mentioned here. The second or all)uminous class is characterized by the presence in the contents of the cysts of free albumen and the albuminate of soda. In colloid tumors the free albumen ]>ecomes albuminoid ])ep- tone, while the albuminate undergoes no change. The conversion of free albumen takes place slowly ; it first becomes paralbumen, then metall)umen. These are not fixed bodies, but pass on to the condition of ])eptone. Thus, the albuminous elements which ai'e found in this albuminous class are albuminous parall)umen, metalbu- men, and albuminoid peptone. In a chemical analysis of the con- tents of a cyst, Eichwald found the following to be its composition: Water 931.96 Organic substances 59.77 Potass, sulph .08 " chlor 59 Sod. nit 6.29 " phosi)h 16 " carb 38 Salts insoluble in water .74 Loss 03 Ktod.oo MICROSCOPIC CONTENTS OF OVARIAN CYSTS. Under tlie microscope the contents of different cysts present very different appearances. The cell elements al)ouii(l in those which are colloid in their nature, while those which are serous are very defi- cient in this res])ect. Eichwald, in one of the colloid cysts, found so large an amount of corpuscular elements that he was unable to examine it satisfactorily with the microscoj)e until he liad diluted it with water. When thus treated he found fatty elements, round and serrated cells, large colloid cells, round cells i-esem])ling those de- scribed by Lebert as jnoid Imdies, and i)y llenle as exudation cor])Us- NEOPLASMS OF THE OVARIES. 517 cles ; globular aggregations of various sizes, scales of eijitlieliuni, crystals of cliolesterine, and brown pigment were also found. As a rule, the morphological elements found in the fluid of ovarian cysts are granular cells, free granules, small oil-globules, epithelial cells, blood-corpuscles, Gluge's corpuscles, and pus cells. From time to time various cells have been described as characteristic of the ovarian cyst. Among others, Drysdale has described such a cell, which he speaks of as "• the ovarian granular cell," and which he regards as pathognomonic of ovarian disease. His claim to the discovery of this cell is thus put : " I claim, then, that a granular cell has been discovered by me in ovarian fluid, which differs in its behavior with acetic acid and ether from any other known granular cell found in the abdominal cavity, and which, by means of these reagents, can be readily recognized as the cell that has been described ; and, further, that by the use of the microscope, assisted by these tests, we may distinguish the fluid from ovarian cysts from all other abdominal dropsical fluids." This " ovarian granular cell " of Drysdale is generally round, but sometimes oval, is very delicate and transparent, and contains a number of fine granules, but no nucleus. The size of the cell varies from y.oVo' ^^ich to g.-oVo ii^ch. When acetic acid is brought in contact with this cell it becomes more transparent, and its granules appear more distinct. On the other hand, when thus treated with acetic acid it becomes larger, and from one to four nuclei appear. It is distinguished from Gluge's inflammation corpuscle by the fact that, when ether is added, the ovarian cell is unaft'ected — at most, has its granules made paler ; while Gluge's corpuscle loses its granular appearance, and sometimes entirely disappears through a solution of its contents by the ether. In reference to this subject it may be said that the views of Drysdale deserve the most careful consideration, but I am not as yet satisfied in my own mind that this corpuscle is pathognomonic of ovarian disease, nor indeed that the diagnosis can be positively made by either chemical or microscopical analysis. Complications. — Tliere are certain ])atho]ogical changes which occasionally occur during the progress of an ovarian tumor which may be considered as complications of the original affection. The presence of an ovarian tumor tends to excite circumscribed inflam- mation of the peritomieum, which gives rise to adhesions of the cyst or tumor to the pelvic or abdominal viscera. This is the most fre- cpient complication, and one which is of exceeding interest to the surgeon. The location, extent, and firmness of the adhesions differ greatly according to the duration, size, and character of the cyst or 518 DISEASES OF WOMEN. tumor. It is also possible tiiat the state of the patient's constitution and general health may have some influence in determining the development of inflammatory adhesions. In regard to the effect wliich the nature of the tumor has upon the occurrence of adhesions my observations lead me to believe that malignant growths and those that are mixed — that is, in part benign and in part malignant — are most frequently found to have adhesions. It is also a ques- tion whether the adhesions found by some of these neoplasms result in all cases from peritoneal inflammation. In some cases that I have seen it appeared to me that the ovarian tumor became attached to the viscera in contact with it by an extension of the ovarian dis- ease. It may be that in such cases the malignant disease may have begun in other organs and tissues as well as in the ovary, and that the diseased parts became united without intervening products of inflammation ; occasionally adhesions occur where the tumor is small, and then they are found in the pelvis or in relation with the lower intestines. When they take place after the tumor is large enough to distend the abdominal walls they are found higher up. Then the tumor may be adherent to the abdominal wall, omentum, stomach, loin, diaphragm, or to the lumbar region. Such extensive adhesions are rather rare, still they occur sufficiently often to be of the great- est interest to the surgeon. These adhesions sometimes displace the pelvic organs and derange their functions. When a small tumor becomes adherent to the uterus or bladder it will carry these organs up out of place when it grows larger and rises up into the abdominal cavity. Obstruction of the intestines may be caused by the traction of adhesions and also by the pressure of a very large tumor. Occasion- ally a small tumor in the pelvis may make pressure upon the rectum sufficient to obstruct the action of the bowels, but that is rather rare, unless the tumor is so firmly fixed by adhesion that it can not be dis- lodged. Rotation of the tumor upon its axis occasionally takes place. This produces twisting of the pedicle and partial or complete stran- gulation of the blood-vessels and tissues of the pedicles. The result is that the blood can not return from the tumor, and hence the ves- sels become overdistended and sometimes rupture follows. The bleeding into the cyst suddenly distends it and causes shock. Some- times the cyst ruptures under the pressure of the haemorrhage with- in it and death may fake place. Cases have been known of haemor- rhage into the cyst which have proved fatal from shock and loss of blood without the cyst bursting. Should the patient withstand the shock and haemorrhage, peritonitis and cystitis are likely to occur. NEOPLASMS OF THE OVARIES. 519 Death takes place as a rule, if the twistmg of the pedicle is suffi- cient to completely arrest the circulation. This proves fatal unless the tumor is removed. If the twisting is not sufficiently marked to arrest the nutrition of the tumor suddenly and completely atrophy may take place instead of gangrene or necrosis. Spontaneous cure has taken place in this way, the tumor shriveling up and disappear- ing. Some very curious things have happened from tv^isting of the pedicle. Atrophy has taken place so perfectly that the pedicle has been severed, the tumor becoming entirely free from all attach- ments. More strange things still have happened. The tumor has be- come adherent to some part of the abdominal viscera and subse- quently the pedicle has become separated from the tumor by a pro- cess of slow atrophy. While the separation of the pedicle is slowly disappearing the vascularity increases at the point of adhesion, and the tumor derives its nourishment from its new attachment. This has been described as transplantation, a term which clearly indicates the process which takes place. Dragging of the Pedicle gives results similar to twisting. This dragging is produced usually when pregnancy occurs during the ex- istence of an ovarian tumor. The uterus growing faster than the pedicle pushes the tumor upward and makes strong and continuous traction upon the pedicle and obstructs the vessels. Again, if the ovary is adherent in the pelvis, and the pregnant uterus ascends, traction will be made sufficient to damage the nutrition of the ovary and any cyst that may exist there. There is another way in which traction of the pedicle may occur. A cyst or tumor may be carried high up in the abdomen with the pregnant uterus, and become adherent at its higher part, and when the uterus descends after delivery the pedicle may become stretched. It is presumed that cystic tumors may become atrophied and a spontaneous recovery oc- cur. This belief is based upon the fact that in old women the ova- ries have been found to contain shrunken cysts imbedded in very hard, thickened stroma and it is believed that this condition is the result of atrophy by cystic tumors. There is no absolute proof that absorption of the fluid and shriveling of the cyst-wall occurs except by obstruction of the blood-vessels in the pedicle as already de- scribed. Rupture and Perforation of Ovarian Cysts. — Rupture may occur as the result of overdistention of the cyst-wall from rapid accumula- tion of fluid in the cyst, or from injuries such as direct blows or concussions from fallinoj or sudden exertion. The bursting of a 520 DISEASES OF WOMEN. cyst may cause death, or the opening may be closed by inflamma- tory exudation and the cyst retilh It has also been claimed that the cyst may disappear, and the patient recover. When this spontane- ous recovery occurs after the bm'sting of a cyst, there is always room for doubt about its being an ovarian cyst. For the present it must remain an open question whether ovarian cysts ever disap- pear in this way. It is, however, well known that cysts of the ovary frequently burst and empty their contents into the abdominal cavity. The results of tliis differ greatly ; sometimes there is not much trouble if the fluid is clear and non-irritating ; in other cases death is caused in a short time by shock, or peritonitis may follow and cause death or terminate in closing the opening in the cyst and forming extensive adhesions of the cyst- and abdominal-walls and viscera. In those cases which recover from the shock of rupture and the subsequent peritonitis and the cysts reflll there are always extensive adhesions found. Perforation differs from rupture in being a slow process and in the fact that the opening is frequently into the adjoining viscera of the abdomen or pelvis. There are two ways in which perforations occur ; the one by thinning of the cyst-wall from pressure, either from within the cyst or from without at a given point, and the other and most frequent by suppuration or ulceration. Perforation occur- ring in either way may open into the peritonaeum, but in case the opening is the result of suppuration it may be into some of the neighljoring organs. In some cases the perforation is very small and the opening is closed by exudations which also form adhesions to the neighboring organs. This fact has led to the behef tliat many of the adhesions found are the result of these small perfoi-a- tions which admit of a limited escape of the cyst fluid. Should the perforation bo large a free escape of the fluid may take place, and the result would be the same as in case of rupture. When the per- foration is into the intestine, the contents of the sac may be wholly emptied, but this form of perforation is rare. Another rare form of perforation has been seen in which a communication between an ovarian cyst was formed by ulceration extending from the intestine and opening into the cyst. Ovarian Cystitis. — Inflammation of the interior of the cyst occurs occasicjnally and is a serious complication. In multiple and nmlti- locular cysts the inflammation is usually limited to one or more of the cysts, the others in the tumor remaining in their original condi- tion. The inflammatiregnancy that I have seen the diag- nosis was very easy ; so much so that no one with any experience could have made the mistake of sus])ecting ovarian tumor. Uterine Fibroids and Fibro-Cysts, when large, present some of the evidences of ovarian tuniurs. The j)Osition of the tumor in the CYSTIC TUMORS OF THE OVARIP^S. 533 abdomen, and its shape and mobility, are tlie same as those of some ovarian tumors, and these are the only resemblances. In iibroids, the uterus is enlarged as shown by the touch and sound. The tumor is solid and is intimately connected with the uterus, in fact forms a part of it. In the majority of cases the cav- ity of the uterus can be probed, and will be found enlarged in case the tumor is uterine, while it will not be if the tumor is ovarian. Distended Bladder has been mistaken for a cyst of the ovary, but only at a tirst examination or by one not used to such cases. When the bladder is overdistended there is incontinence, usually the urine coming away constantly, or in spurts when the patient moves. This leads the medical attendant to suppose that the blad- der must be empty and that the tumor is an ovarian cyst, but the catheter readily settles the question, and it should always be used in cases with such histories. Fecal Impaction has always been mentioned as one of the condi- tions which might be mistaken for an ovarian tumor, but I have not considered such a thing possible. The irregular form and solid character of the fecal mass differs in every respect from ovarian tumors of all the benign variety. Encysted Dropsy of the Peritonaeum. — This is an extremely rare affection and occurs in the progress of tubercular disease as a rule, and follows an attack of peritonitis. The physical signs differ, in that the fluctuation is not so general as in ovarian cyst, and the fixa- tion is complete. The surface of the abdomen is not so prominent as in case of a cyst, but often has irregular depressions, as well as elevations, and the veins are not prominent. The general health is greatly reduced early in the progress of the disease ; nutrition is markedly impaired, and there is often sep- ticsemia in case that there is pus encysted. The vaginal examination is often quite sufficient to settle the diagnosis, by showing that the pelvic organs are normal and can be outlined and separated from the mass in the abdomen. When this can be accomplished, ovarian disease is at once excluded. Enlargement and Cysts of the Liver, Spleen, and Kidneys. — In all of these the diagnosis, so far as the exclusion of ovarian disease, can be easily made if the cases are seen early, or a correct history can be obtained. It is found that in them all the enlargement begins above and on one side, and, as a rule, is fixed there from the begin- ning, and the pelvic organs can be separated from the tumor above, and proved to have no connection with the morbid growth, and to be normal. These two diagnostic facts will suffice in most cases to 534 DISEASES OF WOMEN. settle the question, but additional evidence can be obtained from the general liistory of the growth and its effects upon the general health, also the composition of the fluid in cysts, wliich should be obtained by aspiration in doubtful cases. In regard to the differential diagnosis in cancer of the pelvic and abdominal organs, this will be discussed in connection with these affections, and hence is omitted here. Parovarian Cysts, or serous cysts of the broad ligament, as they are called, are not very easily recognized at all times. Fortunately it would be no very great mistake to remove one of these cysts suppos- ing that it was an ovarian cyst. They are very rare as comjjared with ovarian cysts, they grow slowly, and occur mostly in young per- sons. The general health does not suffer, as a rule. The physical signs differ in no way from those of the ovarian monocyst, except that the fluctuation is more distinct and the fluid differs, being clear like water and without albumen. Tapping, or rather exploratory aspira- tion, is the means to be employed to settle the diagnosis, and should be practiced when there is a doubt. Affections which resemble Ovarian Neoplasms in the Third Stage. — There are only a few affV'ctions wdiich resemble ovarian cysts in the third stage. These are ascites, uterine flbro-cysts, and very large uterine libromata. The flrst mentioned, ascites, is the most likely to be mistaken for ovarian cyst. The chief points of difference in history are, that as- cites is, as a rule, preceded by some acute disease or general ill- health, suggestive of some chronic disease of the liver, heart, or kid- neys. There is anasarca also in most cases of ascites, and the pa- tient is generally anaemic early in the progress of the disease. The enlargement of the abdomen comes on i-ather suddenly, and is not conflned to its lower part; that is, it is not circumscribed. The ex- pression of the face, while showing ana^nia in ascites, is not anxious, as it usually is in ovarian cyst. The history of ovarian cyst in growth and genei-al constitutional symjotoms is almost the reverse of ascites. The physical signs of ascites differ from ovarian cyst, chiefly in that the fluid in ascites changes its position with every change in the position of the patient. When the patient is placed upon the back, the abdomen is symmetrical and flat ; in the erect position, the lower portion bulges from the gravitation of the fluid, and the same change in the position of the fluid occurs when the patient is turned toward either side. With these changes in the position of the fluid, there is a change in the resonance on percussion. The flatness is CYSTIC TUMORS OF THE OVARIES. 535 found at the most dependent part, while the resonance is found at the upper. In large cysts there is dullness or flatness on percussion at all points except tlie flanks, where there is always resonance, except when the colon is distended with gas and flxed deep in the side, so that the fluid of ascites can not gravitate below it ; and in ovarian cyst there may be dullness on percussion in the side due to fecal im- paction of the colon. There is another exception to the rule that in ascites there is always resonance at the highest point of the abdomen whatever the position of the patient may be, and that is when the disturbance of the abdomen is extreme, and the mesentery is not long enough to permit the intestines to rise to the top of the fluid while the pa- tient is upon the back. There is also a diiference in the fluids, which gives some help in the diagnosis in case aspiration is practicable, as it may be in doubtful cases. Uterine Fibro-Cysts or Fibromata seldom attain suflficient size to resemble ovarian cysts, but occasionally they do so. The fibro-cysts of the uterus more closely simulate the ovarian cystic tumors than the fibromata. The difference in the history and the fact that the uterus is involved in the tumor in fibro-cyst and free in the other form, are the chief points of difference. This subject was discussed in treating of the diagnosis in the second stage of ovarian tumors, and need not be repeated in full in this connection. Intraligamentous Ovarian Cystomata. — I deem this variety of ovarian tumor of sutficient importance to merit a separate consid- eration. The difference between intraligamentous and the ordinary forms of ovarian cystomata is simply in the position they occupy in rela- tion to the ligaments. The location may be called an unnatural one, Ijecause it differs from that which ovarian cystomata usually occupy. The intraligamentous ovarian cystomata are comparatively quite rare. This suggests that the causes opei'ative in determining their location are exceptional. Two theories have been advanced to ex- plain the topographical anatomy of intraligamentous cystomata. The one assumes that, owing to some error of development, the ovary, during embryonic life, finds its way into the folds of the broad ligament and there remains. In that case, if a cystoma of the abnor- mally located ovary occurs it is certain to split up the ligament and convert it into a capsule for itself. The second theory is, that during the growth of the cystoma it burrows, so to speak, into tlie folds of the ligament, and once having 536 DISEASES OF WOMEN. insinuated itself there pushes the folds apart, and these folds grow with the cystoma and form a ligamentous capsule for it. In order that this may come about, the ovary must be closely attached to tlie ligament, in place of being held by a special fold of ])eritona^um, which leaves it to some extent free from the ligament proper. Or the ovary may be bound down to the ligament by an inHammatory adhesion. Where a cyst develops deep in the ovary and meets re- sistance on the free peritoneal surface, it pushes its way in between the folds of the ligament. There is good evidence in favor of this theory in the fact that these cystomata come from the paroophoron, which is the portion of the ovary that is nearest to the uterine ligament. Furtherniore, I have in one of my own cases found the ovary from which the cystomata came imbedded in the postei'ior fold of the ligament. It would be more correct, perhaps, to say that the ovary was stretched out uj^on the posterior fold of the ligament. It was so changed in form that I should have overlooked it had it not been that there were several small cysts in it surrounded by what appeared to be ovarian stroma. In another case I found, while enucleating the cyst, that it was very firmly adherent at a point in the posterior fold of the liga- ment where the ovary should be found. The vessels Avere lai-ger at that point than anywhere else, which led me to think that the ovary was there; l)ut the tissues were so changed l)y inliannnatory products that I could not positively detect any ovarian tissue. This, I think. is sufficient to settle this point in the })athology and causation of some of these cystomata, and presumably the larger portion, if not all. of them. Still, it may be admitted that malposition of the ovary, be- cause of a lesion of development, may obtain in some cases. PafhoJfxj!/. — These cystomata may be single or multiple. I think, however, they are more often single. All of my own cases, eight in number, have been nionocysts. Another interesting feature is that they are generally papillary or proliferous cysts. This, ac- cording to some anthorities, notal)ly Bland Sutton, of London, is due to the fact that they are developed from the deeper structures of the ovary, the paro(')|)li(iron, as already noted. The position of these cystomata and their relations to the pelvic organs have a very imj)oi-tant bearing upon the question of treat- ment, as will be seen fiii-thcr on. In my own practice. I have found them occupying widely difier- ing positions in relation to the ligaments and pelvic organs. In some, the tumor was situated in one ligament, displacing the uterus to the opposite side of the j)elvis, and, in a lesser degree, the bladder CYSTIC TUMORS OF THE OVARIES. 537 also. In others, the tumor occupied a position in both, ligaments and between the uterus and bladder. When thus located the tumor, uterus, bladder, and ligaments have been found high up out of the pelvis, so that the most dependent portion of the tumor could not be easily reached through the vagina. Again, I have found the tumor behind both the uterus and bladder, and yet between the folds of both ligaments. In all these the pelvic organs were carried up into the abdominal cavity, while the tumor descended deeply into the pelvis. It appears that there is a rule which deter- mines the location of those tumors which occupy both ligaments, in regard to their relations to the pelvic and abdominal cavities. This rule may be formulated as follows : When the tumor is between the uterus and bladder, all three structures rise up into the abdomen; whereas, if both of these organs are in front of the tumor, it dips well down into the pelvis. The reason is, that in the one case the vagina arrests thfe process of burrowing downward, while in the other there is no resistance to the descent of the cystoma. In all cases the broad ligaments become greatly enlarged and thickened, usually covering the whole cyst, although they are thinned out at the upper portion. When the cyst does not descend into the pelvis and has attained considerable size, the upper portion of the cyst may present a wall of medium thickness ; in fact, the liga raents diminish in thickness and vascularity until there is little left but the peritonaeum ; and the upper part of the cyst then appears more like an ordinary intraperitoneal ovarian cystoma. These facts are of the utmost importance in regard to treatment, and hence the reason for this brief account of the various positions in which these intraligamentous cystomata may occur. Symptomatology . — These tumors cause more pain and functional derangement of the pelvic organs than the ordinary ovarian cysto- mata, but in other respects the history is the same. Physical Signs. — The diagnosis of such cases is of interest chiefly because of the difficulties encountered in operating and the urgent necessity of clearly comprehending the exact conditions present, in order to manage them to the best advantage. I have found it im- possible to make a complete and comprehensive diagnosis in all cases. It is generally possible to make out that there was a cystoma in the broad ligament, but with no definite certainty as to its posi- tion and topographical anatomy. Judging from the literature of the subject, it appears that others have suffered from a like uncer- tainty in some cases. When a cystic tumor exists in the abdomen and is firmly fixed below, with no history of infiannnation during the 538 DISEASES OF WOMEN. earlier stages of the growth of the tumor, and the uterus is drawn u]) out of the pelvis and lies behind or in front of the cystoma, I suspect tliat it is intraligamentous. If the uterus is displaced later- ally in a marked degree by the cj'stoma that is present, or if the cyst descends deep down into the pelvis while the nterus is high up and in front of the cyst, the facts point to the same conclusion. When a portion of the tumor found in the pelvis is cystic, this is a great aid ; but. as a rule, these tumors, as already stated, are prolifer- ous, and there is so much solid material in the most dependent part that fluctuation is not found, and the tumor appears to be soHd to the touch and may l.)e mistaken for a libroma or fibrocyst of the uterus. One case was seen by two well-known ovariotomists, and both sus- pected fibroma of the uterus as well as ovarian cystoma. My first impressions were the same, but ujion opening the abdomen I found the uterus normal, but displaced upward by an intraligamentous ovarian cystoma. * Cases may be divided into two classes — those in which a com- plete diagnosis can be made, and those in which the diagnosis is incomplete. In the one, the nature and composition of the tumor, its relations to the abdominal and pelvic organs, and the extent and location of its attachments, can be clearly determined; in the other, which is incom])lete, there may l)e suthcient evidence to Avarrant either operative treatment or a full assurance that the case is not amenal)le to surgical treatment. The lirst or complete diagnosis can 1)6 made from the usual physical signs and the history. The incom- plete diagnosis may be made complete by surgical means, such as aspirating or by laparatomy. It is of tlie utmost importance to dif- ferentiate between these two classes of cases. When only a partial diagnosis can be made, leaving doubts as to a possible malignant ele- ment existing in the case, the cpiestion of the pro])riety of ovariotomy may be determined by an examination of the intraperitoneal Huid, which is often present. If this ]u-oves negative, the operation is advisable; while, if the cells characteristic of malignant disease are found, the case should be left alone. Keeping still to the (piestion of diagnosis, I may say that in cases of intraligamentous cystomata one can usually make sure that an operation is called for and is jus- tifiable, but the diagn(»sis must often remain incom])lete until the abdomen is o])en('(l. At the same time it is not an easy task to com- plete the diagnosis aftci- lapai-otomy. A few words on this subject may be admissibU\ in view of the inqiortance of the matter. We hear much of making an exploratory operation for diagnostic pur- poses, but I am satisfied that skill and exiH'rience are very necessary CYSTIC TUMORS OF THE OVARIES. 539 to do this. To recoii:;nize just what is present, and to determine what to do in these cases wlien the tumor is exposed, is no easy task ; and still, upon a rapid inspection and palpation, and prompt decision regarding the exact conditions and how to manage them, depends the success of the surgeon in complicated cases. I may not have seen or carefully thought of all the conditions which simulate, and hence may he mistaken for, intraligamentous cystomata, l)ut such «)l)servations as I have made cover the most important part of the ground. When the tumor is exposed hy laj)arotomy its intraligamentous character can he determined by incising the peritomTeum, which will retract and expose the cyst-wall. In all other tuniors the perito- Uieum is so closely adherent that no retraction occurs. The appear- ance resembles most closely a uterine fibroma, and owing to the thickness of its walls it feels to the touch like a fibroma, especially if the cyst has very tense walls, as usually is the case ; but by rest- ing one finger on the tumor and ])ercussing the abdominal wall at a distant point, fluctuation can be unmistakably made out. This excludes fibroma at once, but still leaves the possibility of the tumor l)eing a uterine fibrocyst, and, although this is not important as bear- ing upon the main question of removal of the tumor, it affects the method of procedure and should be correctly decided at once. This can be done by tapping, which shows the character of the fluid, which is all-sufiicient, with few exceptions. If pus is found, it may Ije impossible to say whether the cyst is uterine or ovarian. The tapping, however, gives more room for the introduction of the hand, which enables the operator to make out the attachments and the relation of the tumor to the pelvic organs, and thereby complete the differentiation. The pregnant uterus also looks, in color and vascularity, like this form of tumor, and may lead to doubt. At least I think that when this mistake has been made, an intraligamentous tumor must have Ijeen suspected, because it is the only ovarian cystoma that appears at all like the uterus. This can be made clear by observing con- tractions of the uterus, which can be easily excited, and by passing the hand into the abdomen the ovaries can be found, and the condi- tion of the cervix uteri and normal ligaments will show that there is pregnancy. Treatment. — These tumors require special treatment, owing to the fact that they are not pedunculated like the ordinary cystomata, but are encapsulated, and differ in their relations to the pelvic out of its grasp. OVARIOTOMY. 549 The next, and perhaps the most important, essential of success is cleanliness, or, to put it technically, the antiseptic method of operat- ing. Surgeons were beginning to feel a certain sense of security in performing ovariotomy when they carried out all the details of the Listerian method ; but more recently they have found that carbolic acid in place of saving patients, sometimes sacrifices them. "When the danger of carbolic-acid spray in ovariotomy was first announced many surgeons thought that Thomas Keith had given up antiseptic surgery ; but that great surgeon is still as earnest and enthusiastic in his war against dirt as he ever was. Although he has given up the use of the spray, because he found that the good that it did was counterbalanced by its injurious effects, he still retains all the other known elements of antiseptic surgery. These elements I under- stand to be, first, to keep wounds free from extrinsic germs, which are in themselves injurious to living tissues, or which favor morbid action in the tissues ; and, on the other hand, to provide for the es- cape of morbid material which may be developed in wounds. To prevent the entrance of septic germs perfect cleanliness of every- thing which pertains to the operation is necessary. The carbolic- acid spray can at most only disinfect the air in the operating-room, and consequently it is only one fraction of the antiseptic method of operating. Clean operators and assistants, clean instruments, sponges and everything which may directly or indirectly come in contact with the patient before, during, and after the operation, are all of the highest importance. Still more, it is absolutely necessary to keep all things clean during the operation. A clean, fair start may be made ; but during the operation the operator's hands and the instru- ments may become contaminated by contact with the contents of the cyst, and the patient be exposed to septicaemia. This has often occurred when the spray has been thoroughly and faithfully used. Indeed, if too much dependence is placed upon the spray, there is great danger of contamination from want of care in other respects. Some of the fluid contents of the cyst may enter the abdominal cav- ity, or the hands of the operator or his assistants may become soiled from the same source, and mischief may be wrought in that way. In short, it is exceedingly difficult to guard against all sources of un- cleanliness in this complicated operation. I think, then, that if all the other essential elements of antiseptic surgery are carefully ob- served, the spray may be left out and still the highest success can be attained. But spray or no spray, too much can not be said in favor of antisepsis in relation to ovariotomy. There is still another fact which stands out prominently, and 550 DISEASES OF WOMEN. upon which success depends, and that is the management of the dead material which maj be unavoidably left in the abdominal cavity, or that may accumulate there after the operation. Blood or bloody serum or the contents of the cyst that may be left or may accumu- late in the peritoneal cavity is dangerous, and should be removed by drainage. It is tme that within the last year or two there has been some difference of opinion regarding the value of drainage. Some of the great men in London have laid it aside as a rule, while Keith still employs it and insists that he saves many of his patients by it. I believe that I can see that those who employ drainage have the best of it. I incline to this view because Keith, who practices drain- age when necessary, has had the highest number of successes ; and because the reasoning against drainage by those who have given it up does not appear to fully harmonize with the facts in the case. It is claimed that if ovariotomy is performed with all the attendant means of antisej^tic surgery, including the spray, any fluid which may be left or that may accumulate in the peritoneal cavity is harm- less. Spencer "Wells states that fluids do not accumulate after the use of antiseptics, or if they do collect they do not putrefy, but are absorbed without injury. Now it is difficult to understand how antiseptics used in the operation could prevent the accumulation of serum in cases where there were many and extensive adliesions, and, on the other hand, it is equally incomprehensible that carbolic acid in sufficient quantity should remain in the abdominal cavity to disinfect the fluids which transude from broken surfaces. Without daring to decide the matter or to express any positive opinions, I may state that the truth appears to me to be this : Antiseptic operating will lessen the danger to a very great degree, but there will always be cases which call for drainage. The value of drainage depends largely upon the mode of using it. The method which I have usually seen practiced in this country is to pass a tube through the lower angle of the wound down into the sac of Douglas, and then to close its outer end with a cork. This cork is removed several times a day, and the fluid pumped out. This gives a kind of intermittent drainage which is very imperfect. The method which I obtained from Dr. Keith is much better. In place of closing the end of the tube he passes it through the center of a piece of rubber cloth, and then places a carboUzed sponge upon the end of the tube. The rubber cloth is folded over the sponge, and tied securely with a string. The tube and the sponge are thus OVARIOTOMY. 551 excluded from the air, and any fluid which accumulates wells up through the tube, and is taken up by the sponge. The sponge is changed several times a day, and any residual fluid which may re- main is pumped out at each dressing. In this way continuous drain- age is kept up, and still a perfectly antiseptic dressing is maintained. This may appear to be a simple matter, but it constitutes the differ- ence between perfect and imperfect drainage. In a case operated upon last summer, I obtained twelve ounces of fluid in thirty-six hours by this method of drainage, and the temperature of the pa- tient never rose above normal, excepting one day when it reached one hundred, and remained there for a few hours. This case alone would be sufficient to demonstrate both the safety and value of drainage. In addition to the requisite skill in diagnosticating ovarian tu- mors, it is highly essential to success to make a correct estimate of the patient's general condition before operating. Preparatory Treatment for Laparotomy. — One meets not infre- quently with urgent cases which must be taken as they are and operated upon at once. The majority of cases, however, can be kept under observation long enough to obtain a clear idea of their characteristics. When the diagnosis of the local condition is made, the general state of the patient should be carefully examined into. The advantage accruing from acting on this principle was recently impressed upon my mind in a case of a large fibro-cystoma of the uterus which required removal While under preparatory treat- ment the patient's temperature rose to 103-|^° F., and there was much pain in the abdomen. Septic peritonitis was suspected, but the temperature came down and again went up, showing that the trouble was a zymotic one, and it yielded promptly to the use of quinine. Had I operated without knowing that the patient was disposed to this form of fever, I doubt if she would have recovered as promptly as she did. The Nervous System. — The state or condition of the nervous system should be investigated, and, if found defective, should be cor- rected as far as possible. Many patients leave home to be under the care of the special surgeon, and this, together with the dread of the treatment, often deranges the nervous system. All this can be over- come, usually, while other preparatory treatment is instituted. Time should be given for the patient to become accustomed to her sur- roundings and to gain confidence in the nurse and surgeon. Dur- ing this time the true state of her nervous system can be ascertained. If she is sleepless and depressed, relief should be given by nerve 552 DISEASES OF WOMEN. sedatives and tonics. Quite often the damaged state of the nervous system is due to impaired nutrition, and will be relieved by improv- ing the digestion. Occasionally the nervous trouble is primary, and requires direct attention. Opium in small doses is most reliable in producing sleep and relieving depression, but it deranges digestion and nutrition in some cases, and on that account other remedies should be employed. Sulphonal does remarkably well as a sleep- producer, and is much preferable to bromide, chloral, or any com- bination of these remedies. It produces the desired result in the great majoi'ity of cases that are not kept from sleep by severe pain. This remedy is worthy of note as rather new, and is certainly one that will cause sleep with no other j^erceptible effect, good or bad. To restless, anxious patients, who find the days very long even when they sleep at night, and on whom opium does not act well, I have given large doses of lupulin and small doses of cannabis Indica. If these do not answer, opium should be tried. One of the greatest advantages of this preparatory treatment is that the effect of opium on the case in hand can be observed, so that, if it becomes necessary to use it in the after-treatment, the surgeon knows how far to depend upon it and what effects may be expected. The Nutritive System. — This requires attention in all patients. In the majority, nutrition is impaired because of derangement of the digestive organs. In others the general nutrition is good, while the digestive organs alone are at fault. The time during which the trouble calling for surgical treat- ment has existed makes the difference in the general condition of the patients. There are two classes of patients usually met in practice who re- quire attention in regard to digestion and general nutrition : First, those who have not been long under the influence of the affection, and need very little treatment, except, perhaps, to relieve consti- pation and subacute indigestion Such cases are often left with- out any preparatory treatment save a cathartic the day before the operation. This may be safe enough, but in the majority of cases the tongue is coated, the bowels sluggish, the appetite variable, and the kidneys act imperfectly. These conditions can all be relieved by a few small doses of the mild chloride of mercury, followed by a saline laxative. If this does not clear the tongue, improve the state of tlic stomach, and increase the action of the kidneys, the treatment should be repeated in a few days. Second, the more advanced cases, in which there is general mal-nutrition as well as impaired digestion. These require more care and for a longer time. It sounds well to OVARIOTOMY. 553 say of sucli patients tliat the cause being tlie neoplasm, if tliis is re- moved the mal-nutrition will be cnred ; bnt the chance of the patient being able to stand the operation may be improved by overcoming the constitutional derangements as far as that is possible. Gas- tric sedatives, such as bismuth or cerium, may relieve the irritation and improve the appetite, and tonic laxatives, such as nux vomica, belladonna, and rhubarb, will relieve constipation far better than salines. Management of the Bowels. — The objects in view in the man- agement of the bowels are threefold : First, to clear out the canal ; second, to establish as far as possible normal secretion ; and, third, to remove the causes of flatulence, whatever they may be. A cathartic should be given two days before the operation. In the choice of a laxative or cathartic, one should be sought which will meet all these indications. In cases showing deranged secretion, in- dicated by the state of the tongue and appetite, an alterative dose of mercury should precede the cathartic, as already suggested. The mercury, being a reliable disinfectant, will also meet another indica- tion, the relief of flatulence. The selection of a cathartic to be given just before the operation is important. Castor oil is the best in case there is constipation or a suspicion of faecal impaction. The only difficulty is that many patients strongly object to it. When it can be taken, it should be given two nights before the operation. This gives time for the oil to act, and also gives the bowels a chance to be- come quiet. The rectum should be washed out the night before the operation or early in the morning. In feeble patients who require a cathartic and yet are not strong enough to stand its operation, I give half an ounce of castor oil and two drachms of oil of turpen- tine. This is a most valuable preparation, if the stomach will retain it. In fact, this is the only cathartic that will act thoroughly in weak, debilitated patients without causing depression. The dose of turpentine is large, but if less is given it will affect the kidneys and fail as a cathartic to some extent. This may be called a tonic or stimulant and cathartic. A similar effect may be obtained by giving six grains of rhubarb, one grain of compound extract of colocynth, one grain of camphor, and a tenth of a grain of extract of bella- donna, in pills. There is a little depression following the action of this, but it is not so certain in its action as oil and turpentine. To those who can not take either oil or pills without having their stomachs upset, I give one or two teaspoonfuls of calcined magnesia and half a teaspoonful of charcoal, followed in a few minutes M'ith a glass of warm lemonade. This empties the bowels and relieves flatu- 554 DISEASES OF WOMEN. lence very tlioroughly. This is given in the morning of the day before the operation, the object being to have the bowels quiet and empty at the time of operating. The condition of the heart and kidneys should be carefully no- ticed, especially that of the kidneys. The urine should be thorough- ly examined before giving an anaesthetic. I am satisfied that disease of the kidneys is the most important of the contra-indications to the use of anaesthetics. If any renal disease is found, it should be care- fully treated and watched, and, if it proves to be acute or subacute, sufficient relief can in time be obtained to warrant the operation ; but chloroform might be chosen in place of ether as the angesthetic, and extra efforts should be made to shorten the time of operating. I have for a long time made it a rule to examine the urine always before giving an aneesthetic, and believe that it sliould be the invari- able practice to do so. I refer to that matter here because I have found many who do not think it necessary. In regard to the state of the heart, I find that it is often de- ranged in its function from pressure or indigestion, and it nearly always improves under treatment. When there is time, I order muscular exercise as well as remedies to improve nutrition, and find that much improvement in the heart action follows. Organic heart disease, other than extreme hypertrophy, moderate dilatation, or aortic stenosis or insufficiency, does not deter me from giving an anaesthetic and operating. Many cases having disease of the mitral valve take ether very well. The day and evening before the operating day call for certain attentions. The bath so generally given the night preceding the operation is not always advisable. If the patient is used to daily or frequent bathing it may be safe to give it, but otherwise it is dan- gerous. The patient may get cold or become exhausted. The loath- ing should be done, in such cases, several days before, and then with great care. When there is marked debility, with weak lieart, digi- talis and nux vomica should l)e given the preceding day ; especially is this necessary when the operation promises to be a bad one. I formerly gave quinine, believing that it was a good tonic and helped to prevent shock, but I am satisfied that digitalis and nux vomica are better. The number of doses should depend upon the effect. As soon as the heart action is noticeably improved the drugs should be withheld. The food should be of the most nourishing kind, and at the same time easily digested, or else it should be artificially digested. Sterilized or peptonized milk, clear soups, tender beef, mutton, eggs, OVARIOTOMY. 555 and raw oysters, either or all of these, according to the preference of the patient, may be used. The time to operate is, as a general rule, midway between the menstrual periods. An exception should be made in cases of menor- rhagia and dysmenorrhoea, in which there is an improvement in the strength toward the period of menstruation. Advantage should be taken of that temporary improvement by operating immediately be- fore the menses. The morning is by far the best time to operate. The patient is then at her best, and the stomach is empty — a condition very neces- sary to the taking of an anEesthetic. This would not be referred to here were it not for the fact that a great many surgeons in this coun- try operate late in the day. There are many disadvantages in doing so. The patient suffers from anxious anticipation, and becomes fa- tigued if food is not given ; and if it is given, it is not, as a rule, either digested or absorbed, and the stomach acts badly during and after the ansesthssia under such circumstances. I am led to dwell a moment on the general therapeutics of ab- dominal section, for the reason that my attention and that of my as- sistants has been so fully engrossed with the details of antisepsis and the technique of the operation, that many important items in the general therapeutics have been at times overlooked. It is likely that a similar experience may fall to the lot of others. There are certain points in the management of the patient dur- ing the operation which may be briefly mentioned. The patient should be kept warm, but the room should be cool, not over Y0° F. A very warm room has been advised, and there are many surgeons who still prefer it, believing that there is dan- ger of chilling the patient by exposing the abdominal organs to cool air. This can be obviated in other ways, by keeping the patient's head and feet warm by hot water if need be, and protecting the trunk with rubber cloth. Chilling the peritonaeum is avoided by the use of warm sponges. One large sponge should be placed in the wound as soon as the tumor is removed. This prevents the es- cape of the intestines, and protects the peritonaeum from the air. The sponges are maintained at the proper temperature by being kept in a pail which is placed in a larger one filled with hot water. The sponges are thus kept dry, while the water in the chamber around the inner pail keeps up the warmth. In case the operation is a long one, the water surrounding the sponge-pail can be renewed. Warm ether is also of value in avoiding shock and chilling the patient. This is obtained by using my ether-inhaler, in which the 556 DISEASES OF WOMEN. ether is vaporized in a reservoir and conveyed to the patient throngh a rubber tube. This warms the ether sufficiently to make it agree- able and safe. I have on former occasions spoken of the advantages of this ether-inhaler, by which the anaesthetic can be given pure, or diluted with pure air to any degree, and without the reinspiration of the expired air. I may add here that experience only tends to confirm my confidence in that method of using an anaesthetic such as sulphuric ether. List of Instruments and Appliances 'usually required in the Operation. — Scalpel with fixed handle ; dissecting-forceps ; artery- FiG. 223. — Keith's short compression-forceps. forceps ; six Keith's compression-forceps (Figs. 223 and 224) ; one vulcellum forceps; one fenestrated forceps; small, straight, blnut- pointed scissors ; large, straight scissors ; trocar and rubber tube. Fig. 224. — Keith's long compression-forceps These are placed together in an enameled pan filled half -full with a one-to-forty carbolic-acid solution. Twelve to twenty sponges, the exact number to he carefully noted., prepared and placed in a double tin pail with hot water in the outer compartment; six towels soaked in a one- to-twenty carbolic solution, and put in the sponge pail ; No. 1, 3, and 11 prepared silk for liga- tures. These should be cut the proper length for ligating thick adhe- sions and the pedicle, and wrapped in gauze and put into the car- bolic solution. No. 4 silk for the abdominal sutures should be prepared in the same way ; No. 2 catgut ligatures ; Keith's needles, two for each ab- OVARIOTOMY. 557 dominal suture (Fig. 225) ; Peaslee's needles ; Keith's fine forceps for carrying the Hgatures (Fig. 226) through the pedicle ; sutures to — — - -TIT iirrrr-n-.-r - - iiB » Fig. 225. — Keith's needle. be used with Peaslee's needle if required ; a sheet of rubber cloth, three by four feet, with an oval hole in the center, the border of which is coated with sticking-plaster an inch wide all around ; long 226. — Keith's ligature forceps. straps of saddle-girth to fasten the patient's limbs to the table ; a yard of gauze or cheese-cloth soaked in a solution of one part of carbolic acid to eight of glycerin for a dressing ; sheet of absorbent cotton large enough to cover the abdomen ; flannel bandage ; safety-pins, Instrumeoits and Appliances that may he needed. — Cautery clamps ; cautery irons ; Keith's clamp (Fig. 227) ; curved scissoi's ; concave mirror ; counter-pressure instrument for tying ligatures in abdominal cavity ; several drainage-tubes of different sizes ; piece of -s^rEvSfNS^xtJ.— ^" Fig. 227. — Keith's modification of Spencer Well's clamp. sheet-rubber, ten by ten inches, to cover the end of tlie drainage- tubes ; twelve or more extra sponges; twelve to twenty extra com- pression-forceps ; aspirator ; elastic ligature. These should be clean and placed within reach of the operator, but not mixed with the other instruments named. The instruments to be used should be placed on a stand beside the operator, and also a basin with carbolic solution, or such disin- fectant as the surgeon chooses to use for keeping the hands clean. 558 DISEASES OF WOMEN. The sponges, ligatures, towels, and dressings maj be placed beside tbe first assistant Assistants. — Three assistants are certainly needed, and one more may be required. One gives the ether, one stands on the left side of the patient, facing the operator, the third on the left of the op- erator, and the fourth one attends to the washing of the sponges. The chief assistant on the opposite side of the table sponges tlie wound during the incision of the abdominal walls, holds the vessels or adhesions when the operator is ligating them, supports the cyst when brought out, helps to apply the sutures to the wound, and ful- fills all orders of the operator. The second assistant supports the abdomen and cyst or tumor while the abdominal walls are being opened, and, when the cyst is being removed, he helps to expel it by pressure, and at the same time prevents the escape of the ab- dominal viscera. The assistants carry the patient from the bed to the table. A blanket is wrapped around her limbs, and a rubber bag of hot water JF^^B^ ,BTAND, WITH INSTRUMENTS AND BASINS/) It^^i Fig. 228. — Position of operator, assistants ami accessories in the operation. Both arms should lie close to the patient's side. placed at her feet. The strap is passed over the thighs and around the table. The abdomen is made l)are by opening the dressing-gown and raising the undergarment. The rubber cloth is spread over the OVARIOTOMY. 559 patient, and the edges of the opening in the center stuck fast to the skin around the lower and central portions of the abdomen. One of the carbolized towels is laid over the thighs of the patient, upon which are placed the instruments which are first to be used. This diagram will show at a glance the position of all concerned. The several steps of the operation are as follows : 1. Making the incision in the abdominal wall. 2. Exploring for adhesions. 3. Tapping the cyst or cjsts. 4. Treating adhesions and removing tumor. 5. Treating the pedicle. 6. Examination and treatment of the other ovary. 7. Cleansing the abdominal cavity. 8. Closing the incision. 9. Dressing the abdominal wound and placing the patient in bed. The details of the several steps in the operation in uncomplicated cases are as follows : The incision is made in the linea alba — traces of which can usu- ally be seen — down to the muscular layer. The length of the incis- ion should be about three inches, extending from one inch above the pubes upwards. The assistant should follow the knife with the sponge, and any bleeding vessels should be caught up in plain for- ceps. The tissues at the bottom of the wound should be picked up with a dissectiug-forceps, and an opening made in the median hne with the knife, the edge of which should be directed away from the tumor. When making this opening care should be taken to find the median line between the muscles. This is often done at the first trial, but, if the muscle is exposed, its sheath should be followed in either direction until the median line is found, and then another opening made there. The knife is then put aside, and one blade of the blunt-pointed scissors is introduced into the opening, and the incision completed by cutting in both directions. This usually ex- tends through the muscular layer ; the fascia and the peritonaeum still remain. These should be opened in the same manner. A sound, finger, or the whole hand may be introduced to de- termine the presence and character of adhesions, if such exist. The trocar and cannula are then plunged into the cyst at the highest end of the incision, the trocar drawn back and handed to the assistant, who takes care that fluid does not enter the abdominal cavity. The cyst- wall should be seized with a lock-forceps between the cannula and left side of the incision. This is also handed to the assistant, who holds it and the trocar in his left hand, and makes the necessary 560 DISEASES OF WOMEN. traction to withdraw the cyst, which he grasps with his right hand when it comes out, and holds it without making traction upon the pedicle. The operator pushes a sponge into the wound behind the tumor. The pedicle is then examined to ascertain its size and character, and whetiier it be twisted. The cautery clamp (if that method of treat- ing the pedicle is to be practiced) is then applied, and the pedicle di- vided within half an inch of the clamp. The operator then sponges the abdominal cavity, taking special care not to leave any fluid be- tween the bladder and the uterus. The assistant meantime takes care of the clamp. The operator examines the other ovary, and decides whether it requires to be also removed or not. One or more sponges are left in the abdomen while the pedicle is being treated with the cautery. Two carbolized towels are placed under the clamp, and the remains of the pedicle are removed with the cautery. The clamp is then loosened a very little by unscrewing, and the cautery applied until the clamp is heated throughout to a degree that will admit of the tinger being firmly placed upon it. Before finishing the cauterizing, the clamp should be screwed up tight. While the cauterizing is being done, the assistant should remove all fluid and dehrls with a sponge and forceps, and, if the towels beneath the clamp become heated, they should be changed. The clamp should be cooled with a moist sponge without touching the cauterized edge. The pedicle is then seized with two forceps below the clam];), which is gradually and with great care loosened. The stump of the pedi- cle should be watched for a few seconds to see if the blood inclines to pass up any of the vessels in the part that has been cauterized. If there is no sign of such taking place, then the stump is dropped back and covered with intestines, and the omentum over all. Should the operator decide to ligate in place of using the cautery, the pedi- cle is secured by two compression-forceps, and a doul)le ligature is passed through the center of the pedicle with a Keith's ligature- forceps, and ligated in two halves. Care should be taken to cross the ligatures, so that when the two are tied they will draw the tis- sues together in one mass. When the pedicle is small and long, it can be tied before cutting away the cyst, and without using a clamp at all. The sponges should be recounted at this stage of the operation, to make sure that none is loft in the abdominal cavity — ail accident which has occasionally happened. A flat sponge is placed over the omentum and beneath the edges of the wound, and left there while the sutures are being introduced. All bleeding vessels in the abdominal wall should be ligated. Two OVARIOTOMY. 561 Keith's needles are used for each suture, one at each end. The needles are introduced from the inside of the abdominal wall, and include the peritonjEum. This method of introducing the sutures is the quickest and the best when the incision is long or medium in length, but when the ihfcision is short I prefer to use Peaslee's needle of smaller size than that which is usually found in the shops. The needle is passed from without inward, and the suture is carried through the double of the thread in the needle, and, as the needle is withdrawn, the suture is brought into place. Having introduced all the sutures, the ends on each side are gathered together and held while the flat sponge is removed. The air should be pressed out of the abdominal cavity, and the sutures tied. Slip-knots are prefera- ble. The sutures should be close together, about four to the inch. Here and there a superficial suture may be needed to make the co- aptation as complete as it should be. The dressing of gauze, soaked in the one-to-eight solution of glycerin and carbolic acid, is applied, and over that absorbent cotton and a flannel bandage. The patient is put into a warm bed, and hot water-bags or bottles put around her, and one sixth or one quarter of a grain of morphine given hypo- dermically. Comjjlications. — The several steps in the operation are liable to be complicated by a variety of conditions. The chief of these may be mentioned in the order in which they come. When there is much fat beneath the skin it is diificult to make a straight incision. In that condition the wall may be grasped in the left hand, raised up and transfixed with the bistoury and divided from within outward. This leads down at once to the muscular layer, and then the incision is finished in the usual way. Great vascularity of the abdominal wall, while easily managed, takes time. One or two bleeding vessels may be caught in plain forceps and con- trolled, but when there are many it is better to tie them because a number of compression-forceps are in the way during the operation. Firm adhesions of the tumor to the abdominal wall in the line of incision are often a troublesome complication, which leads the opera- tor either to open into the sac before knowing it, or else to sepa- rate the peritonaeum from the abdominal walls. When the tumor can once be reached at any one point, it is very easy to separate the adhesions, but it is often diflicult to get that one point. Enlarging the incision is a help, and it should be carried in the direction up or down according to the possibility of reaching a point where the cyst is free. Sometimes the exudation which forms the adhesion can be recognized when it is reached; it is then easy to follow it up until 37 562 DISEASES OF WOMEN". the detachment is complete. "When the cyst is exposed all the par- ietal adhesions should be loosened. This should be done by the hand. When the tumor has been of slow growth and is tense and tlie walls opparently thick and strong, a very great amount of force can be used in separating adhesions. If the tumor is flaccid it is well to steady it with a pair of for- ceps while separating the adhesions and before introducing the trocar. Parietal adhesions are treated before tapping the cyst, at least as far as they can be easily reached by the hand. EMPTYING THE TUMOR IN COMPLICATED CASES. In multiple cyst and multilocular cases in which the contents of the sac can be removed by tapping, the trocar and cannula are thrust into the nearest cyst and it is emptied in the usual way ; the trocar is then pushed into another sac, which in turn is emptied, and so on, until all are emptied. To do this safely the tumor should be steadied w^ith the left hand, while the trocar is used with the right, and this helps to make sure that the trocar goes into the sac and not into the viscera or abdominal walls. When the contents of the tumor are semi-solid and will not flow through the cannula, the trocar and cannula should be removed, and the opening in the sac enlarged in the axis of the body ; i. e., the opening should correspond to the opening in the abdominal wall. A pair of forceps should be fastened near each end of the opening on the left side, and perhaps a small one at the lower end on the right' side. These forceps are held by the assistant, and as the tumor becomes smaller he draws the sac out and down until the opening in the sac is below the level of the opening in the abdomen. The operator introduces his hand through this large opening into the cyst that is emptied, and breaks down the other cyst-walls and sweeps them out ; while the finger of the right hand is boring through the cyst- walls the tumor is steadied with the left hand on the abdominal wall. In this way the contents of large tu- mors may be broken down and removed. While this is being dene the edges of the rubber cloth should be raised so as to direct the fluid into the tub or basin at the side. When the tumor is very vascular and great bleeding is likely to occur in emptying the contents, the pedicle should be found if pos- sible and compressed with catch-forceps. Adhesion of the omentum and the abdominal and pelvic viscera OVARIOTOMY. 5(53 is treated after the tumor is emptied of its fluid contents. The omental adhesions are most easily tied while attaclied to the tumor, and that should be the rule, but if it is necessary to get the omen- tum out of the way before the operator has time to tie it properly, compression-forceps may be put on, and the whole wrapped up in a carbolized towel, and left on the abdomen at the upper angle of the wound until tlie cyst is removed, when attention can be given it. It should then be tied in sections of about the width of two fin- gers. Dr. Keith treats adhesions to the bowels and mesentery by mak- ing traction upon the cyst and pressing against the adhesions with a sponge. In this way the adherent tissues can be pushed apart with less injury than in any other way. Pulling upon adhesions should always be avoided, if possible. Sometimes when there are many ad- hesions high up strong traction must be made, there being no other way of separating the firm adhesions, but it is a dangerous practice and only to be resorted to when it can not be avoided. Long bands of adhesions should be tied before being detached, and the following points should be observed ; to have no tension upon these parts ; to ligate as far from the free end as possible, and make sure that all bleeding is stopped before letting go the parts. The bleeding which comes from the broad adherent surfaces which have been separated, should be controlled by placing sponges in the abdomen and making pressure, and as soon as possible bleeding points should be looked for and the vessels ligated. When the sponges are removed the position of the bleeding vessels can be seen. When there are many adhesions high up in the abdomen, it is an advantage to find the pedicle, clamp it with two spring catch-forceps, and divide it, and then remove the tumor from the pelvis first. When the adhesions are all treated and the tumor removed, the sponges which have been introduced should be removed, and the bleeding vessels caught up and tied. During this search for bleeding vessels in the pelvis the assistant holds the side of the abdominal wound with his left hand, and with a concave mirror in his right throws light into the pelvis. In using the mirror the assistant directs it so that he himself can see, knowing that if he can see the operator will see also. The artificial light is to be used as little as possible, because if once begun it is difiicult afterward to do without it. Drainage should be employed when from the number of adhe- sions there is seen to be a free transudation of serum ; when all the bleeding has not been or can not be stopped, and when either of the above conditions are present even in a very limited degree and the 564 DISEASES OF WOMEN. patient is feeble. The tnl)e sliould be left in until tlie discharge becomes clear. When adhesions to the intestines or pelvic organs are so iinn and extensive that they can not be separated with safety, Dr. T. F. Miner, of Buffalo, enucleates the tumor or cyst from its peritoneal covering. This can be done, but it is often exceedingly difficult, and there is left a large surface from which a free transudation takes place, and requires long-continued drainage. This method is not practiced much now, except in cases of intraligamentous cyst. When adhesions are very extensive and firm there usually has been inflammation of the cyst, and then its layers can not be sepa- rated ; this renders enucleation impossible. Treatment by Drainage answers in such cases if the cyst is small or of medium size. If the cyst is adherent to the abdominal wall it is laid open without being separated and its cavity thoroughly cleaned out, and a drainage-tube introduced, and kept in place. The sac is washed out frequently, and when it has contracted down it may be induced to close by the use of tincture of iodine and car- bolic acid. When not adherent to the abdominal wall, but so gen- erally adherent to the viscera that exploration is deemed impossible, the free portion of the sac should be trimmed off and its edges care- fully united to the incision in the abdominal wall, and then the drainage practiced. 1 am aware that an experienced and dexterous operator can man- age very bad adhesions, but there are cases where it is safer to use drainage. Five cases have been treated in this way in my own prac- tice, and four of them recovered. In the fifth, a bad case of rupt- ured cyst in which there had been very general peritonitis, the cyst was adherent everywhere. I could not find a single free spot, and the patient was very feeble. The sac was filled with inflamma- tory products, winch were carefully cleared out, and large drainage- tubes used. She improved for a time and took food better than she had done before, but died at the end of a week, apparently from uraamia ; the kidnevs were found to be diseased. In case of very intimate adhesions to the liver, spleen, uterns, bladder, or intestines, Dr. W. L. Atlee did not detach them at all, but separated the peritoneal from the middle coat of the cyst at the point of attachment, and left it there. This also is not often neces- sary, but it may be the easiest and safest thing to do, and if drain- age is employed good results may be expected. In this I have had no experience. Arrest of Haemorrhage. — All adhesions in the form of bands ex- OVARIOTOMY. 565 tending from the cyst to other parts should be tied before dividing them. This applies especially to adhesions of the omentum. Large bands sliould be tied with prepared silk ligatures. The liner bands may be tied with catgut. In my own practice I use silk alto- gether. Intimate adhesions which have to be separated by trac- tion leave bleeding surfaces, and if any large vessels are found they should be tied if possible. General oozing can usually be stopped by pressure with a sponge. Hemorrhage deep down in the pelvis from vessels large enough to be ligated can be reached by throwing in the light from the mirror and using a long artery-forceps. The ligature can be easily tied by using the counter-pressure instrument employed in tying the sutures in the operation for restoration of the cervix uteri. To check oozing from surfaces like the uterus, liver, or spleen, pressure with sponges is to be performed as stated already. An application of persulphate of iron is made by some operators, and the thermo-cautery has also been commended. Both are objection- able, and should be avoided if possible. After-Treatment. — The bed in which the patient is placed should be warmed to about the normal surface temperature. The patient's head sliould be covered with a soft woolen shawl or soft blanket. The hands should be kept under the bed-covers and not disturbed. The pulse should be watched at the temporal artery. A hot-water bag may be placed near the feet, but not in contact with them. I have repeatedly seen the feet burned by placing a hot-water bag close to the skin. This will not occur when the bag is wrapped in flannel. The air in the room should be kept at about Y0° F., and ventilation secured without having the patient in a draught. For a number of hours ether is thrown off with the expired air, and it is difficult to keep the air in the room agreeable. It is fortunate if the patient sleeps after the operation, and no effort should be made to awaken her, as is frequently done, to find out how she feels. During the first twenty-four hours or more, the greater the amount of rest that can be obtained the better. Absolutely noth- ing should be given in the way of food or medicine unless there is some urgent demand for either. ISTausea and vomiting, which occa- sionally occur, should be counteracted with sips of hot water if the patient is anxious to have something to di'ink — not otherwise. Keith usually gives a hypodermic dose of morphine immediately after the operation, to control the restlessness which supervenes when the patients come out of the anaesthetic. This is not always necessary. I wait and see if there is much restlessness or pain, and 566 DISEASES OF WOMEN. if there is, the hypodermic is given. Nervous restlessness alone can often be controlled by the efforts of a judicious, experienced nurse. If the patient can be controlled until night, it is better to withhold the morphine until then. This expectant treatment should be continued until the stomach has become reliable and gas has passed from the bowels. In many cases nothing else is required during the first forty-eight hours. I am sure that great harm is done by giving nourishment and medi- cines when there is no demand for either. I certainly have seen more harm come from doing too much at first than from doing too little. There are exceptions to this rule of doing nothing. In case the vomiting continues, and is not relieved by hot water, I use the following : Magnesise carb., 3 ij ; magnesise sulph., 3 iij ; aquse menth. I^ip., § iij. Of this, a teaspoonful may be given every one, two, or three hours in a dessertspoonful of water. This prescription is used in the Samaritan Hospital in London. A mustard plaster to the pit of the stomach is also usefid. When these remedies fail, and the patient complains of burning in the stomach, dessertspoonful doses of iced water may be used. When the patient is depressed, ten drops of whisky in a teaspoonful of water every few minutes will be of service. In desperate cases I have given a large quantity, as much as the patient could drink, of lukewarm water and a little taljlc salt. This is thrown oif prom])tly, and sometimes gives relief. It should not be repeated. If relief is obtained and the nausea returns, the stomach should be washed out in the usual way. When the vomiting is attended with abdominal pain, morphine hypodennically will give relief in many cases. Peritonitis and Septicaemia after Laparotomy. — From recent re- ports in the literature of medicine it appears that a new departure has been taken in the after-treatment of cases of ovariotomy and similar opei'ations. In place of giving opium and keeping the bowels at rest for several days, the bowels are moved early, and opium is withheld. Cases which show signs of septicaemia or peri- tonitis are given saline cathartics. It is claimed that free action of the bowels effects a kind of drainage which arrests the tendency to inflammation of the peritontienm. and also favors the elimination of septic material. One should gladly accept whatever theories or facts may be advanced in favor of this plan of treatment, or any other which might prove better than the old ways of managing such cases. But I have failed to see that this new treatment has many advantages. So far as I can learn, the results, on the whole, do not compare OVARIOTOMY. 56Y well with those of other surgeons who give opium and let rhe Ixjwels and the stoniacli rest, until the first dangers are past. Furthermore, I have found in my own practice that as soon as the indications for cathartics appear, it is impossible to have the patient retain tliem, in the great majority of cases. Perhaps the advocates of this treatment may be able to anticipate the coming storm, and, by giving salines, ward it oif ; but I have not been able to do so. "While there are a number of reasons why opium should be used, I have not yet heard of any good reason why it should not be, in certain cases. That there are patients who do not need opium, and others with whom, it does not agree, must be admitted ; but the majority require it to relieve pain, produce sleep, and, above all, rest and quiet, which are so very necessary to recovery after major operations. These effects of opium, it may be claimed, simply contribute to the comfort of the patient^ but do not secure safety or aid in recovery. Grant- ing that such may be the case, the humane surgeon will find in this good reason for the use of opium ; but I am confident that opium has a therapeutic value in addition to that of relieving suffering. The danger from shock which arises from major operations is, I am sure, controlled by opium better than by any other drug. So also is the depression from anaemia resulting from haemorrhage. All careful observers have noticed that the rapid and feeble pulse becomes fuller, slower, and steadier under the influence of opium. The anxious, pinched face also changes to a better expression. This has led me to look upon opium as the most reliable of all heart ton- ics in the depression which follows these operations. When the organic nervous system is tottering under the oppression of severe injuries to the abdominal and pelvic viscera, opium is the greatest sustaining agent. Alcohol, no doubt, will bridge over a moment of extreme and immediate danger, but its effects must almost always be supplemented with opium in order to obtain a continuous sus- taining effect. Perhaps more important still is the question, Does opium have the power of preventing peritonitis and septicaemia, or of controlling their fatal tendencies ? To judge fairly of the therapeutic effects of opium in surgery, it is necessary to keep in mind the fact that after an operation there are injured tissues left that must be repaired. These tissues may or may not be affected with septic material, but in either case the safety of the patient depends upon these wounded tissues being speedily closed in by reparative material, which re- 568 . DISEASES OF WOMEN. stores continuity of tissne and at the same time protects the normal surrounding tissue from inflammation and the jmtient from general septicaemia. Now this process, by which the general system is pro- tected from the dangerous effects of local injuries, requires time ; and it is the most important time, because upon completion of this protection depends the safety of the patient to a great extent. Wounds may do badly, but, if an exudation has been thrown around them which protects from septicaemia, recovery may be expected Of course, the modern surgeon protects his cases from sepsis l)y his cleanly operating ; but in spite of his best efforts there may be trouble occasionally, and then the great point is to gain time for this natural protective process, which comes, or should come, first in the order of restoration. The princii)al condition necessary to secure the protective factor in the general process of repair is re- pose or quietude of the nervous and circulatory sj^stems, and ojjium is the most potential agent in effecting this condition. The process of repair is arrested when the nervous system is in turmoil and the circulation is running wild, and opium should be used to give the necessary rest. It is a fatal mistake to wait until there is evidence of inflammation or septicaemia. It should be given to control the nervous excitation which generally precedes these complications. The time to give it, then, is an important question. Some of the most successful surgeons give it immediately after the ojieration, and that is best when the case is bad and there is shock. In easy cases I prefer to wait until the ether effects pass off to some extent ; and if there is distress or pain present, then is the time to give opium, and the effect should be kept up until there is no danger of complications, so far as the condition of the i:)atient indicates. The way of giving it is of some importance, no doubt. I prefer to give it at first hypodermically, and keep up the effect in that way, or by rectal instillations of opium and warm water. The question which follows is, When shall the opium be with- drawn, and cathartics resorted to ? Opium should be gradually given up as the constitutional and local evidences of disease sub- side, and then cathartics or laxatives should be given. To state this in another way: opium should only l)e given when there are indications for its use, and it should be given up as soon as the indi- cations disappear. The bowels should rest until the time for peri- tonitis is past, or, if there has been inflammation or sepsis, when the acute symptoms and signs of these have subsided. CHAPTER XXX. ILLUSTEATIVE CASES OF OVAEIAN NEOPLASMS. In giving the Mstories of ovarian neoplasms it has been deemed best to omit simple and typical cases, because they would add noth- ing to the description already given. The following complicated ones, on the other hand, will tend to convey clearer ideas of the peculiar cases which are frequently met in practice, and the aj^proved methods of management adopted at the present time. Monocyst of the Right Ovary ; Firm Adhesions to the Abdominal Wall ; Necrosis of the Posterior Wall of the Cyst ; Ovariotomy ; Re- covery. — The patient was fifty four years old, and the mother of four children. After the birth of her last child, the attending physician told her that she had a small tumor on the right side of the uterus. There was considerable intermittent pain in the region of the neo- plasm from the time that it was fiist discovered up to the time that she came under the care of my associate, Dr. Palmer, fom* years afterward. The growth of the tumor was slow, scarcely noticeable for the first three years, but very noticeable during the last year. When she first came under the care of Dr. Palmer the tumor ex- tended above the umbilicus, and fluctuation was well marked. There was evidence of circumscribed peritonitis, and, although the tumor was movable, adhesions were being formed. The peritonitis was quite pronounced at this time, and the constitutional symptoms were well defined. She was treated for this, and in about two weeks the acute symptoms subsided, but she still remained weak. The doctor sent her home in the hope that she would gain strength, and the tumor being still small there was no urgent necessity for its re- moval. In a month she returned to the hospital not improved. She was losing flesh, the parts were still tender, the appetite poor, the pulse weak, and the temperature kept above 100° F. Another effort vr as made to get her into better general condition, but without success. She lost strength gradually, and i^ was de- 569 570 DISEASES OF WOMEN. cided that tlie only chance for her was by retooving the tumor. At this time the adhesions were firm and involved all parts of the ab- dominal wall which were in contact with the tumor. Just before the operation the j)ulse was 120 and the temperature 101°. When the abdominal incision was made, the adhesions were very firm and vascular, except in a small space just above the sym- phisis pnbis. The cyst was emptied by tapping, and the lower por- tion, which was not adherent, was drawn out, and the pedicle grasped with strong fixation forceps, and divided. The adhesions were now easily reached and separated. The pedicle was then ligated, and the bleeding stopped by pressure with sponges. By managing the pedi- cle in this way, the tendency to bleeding from the site of adhesions was lessened very decidedly. When all bleeding had stopped the wound was closed and dressed in the usual way. An examination of the cyst showed a portion of its posterior wall (al)out the size of one's hand) perfectly bloodless, of a dirty gray color and friable, indicating that it was necrosed. No doubt the death of this portion of the sac had taken place many days be- fore the operation, and I presume was the cause of the constitutional disturbance. Fro:n the facts in this case and from those observed in other cases of necrosis of the cyst-wall, I believe that the dead tissue causes a form of septicaemia, certainly in this case there was nothing else found to cause the high temperature and pulse, and the subsequent history confirms this view. The operation was performed between eleven and twelve o'clock. She soon recovered from the ether, and showed no depression. At seven in the evening her condition was better than before the oper- ation. The pulse was 112, temperature 99"5° F. and respiration 20. During the night she had slight pain in the abdomen and was given a hypodermic injection of morphine. She slept well, and had no vomiting. On the second day there was some slight distention of the abdomen from gas ; this was relieved by six grains of sul- phate of quinia in solution, given by the rectum. From this time onward her progress was very satisfactory. The temperature never rose above 99° F. Five days after the opei-a- tion the bowels were moved by enema. On the twelfth day she left her bed, and four days later was able to walk about the ward. About four weeks after the operation the left leg became swollen, and remained so for about a week. The cause of this was not certain. She was discharged from the hospital at the end of the fifth ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 5^1 week feeling perfectly well and having gained flesli and strength 8ur()risinglj. Intraligamentous Ovarian Cystoma; Multiple Cyst of the other Ovary; Ovariotomy and Hysterectomy; Recovery. — This patient was under the care of mj friend Dr. F, H. Stuart, and most of the facts in the history of the case — before and after the operation — are given here as I obtained them from him. The lady was iifty-six years of age, and had passed the meno- pause about six years. At the age of thirty-nine years she had a pelvic abscess which opened into the bladder, and she was then sick for a long time. About three years before the time when this history was taken she noticed a tumor in the right iliac region. She was first seen by Dr. Stuart, April 30, 1886. He found the uterus high up behind the symphysis, attached to an elastic tumor, which was immovable, and by external examination appeared to be larger than a fetal head and extending up into the right iliac fossa. There were two other tumors of smaller size, one above and one to the left of the larger one. These appeared to be adher- ent to the first one, and were also rather immovable. 1 saw the patient the next day with the doctor, and confirmed the diagnosis of ovarian cysts. On account of the adhesions, and as the patient was not suffering any great inconvenience, we thought it best to await further developments. She passed a very comfortable summer, but increased steadily in size, with a corresponding increasing discomfort in locomotion. About the 1st of December, 1886, she began to have frequent and painful urination, and some fever. After a few days of quiet and some quinine (as there was a decided intermittence in the irritability of the bladder), she became again quite comfortable. Immediately before the operation the physical signs were as fol- lows : The general outlines of the enlarged abdomen were irregular, three cysts could be mapped out, and fluctuation was distinct in each. The most dependent cyst was about the size of the uterus at the seventh month of utero-gestation, and occupied the center and lower region of the abdomen. It was not movable to any extent, and appeared to be separated from the other cysts except at the up- per and right side, where it seemed to be adherent but not firmly so. The two other cysts occupied the upper and left lower regions of the abdomen, raising the diaphragm and causing the lower ribs to project slightly. These two cysts could be moved together in the abdomen, but were closely united forming one tumor. The flnetua- 572 DISEASES OF WOMEN. tion was very clear in each of them, but was not distinctly felt through the mass formed by the two. All around the circumference of the abdomen there was dull- ness on percussion, and distinct fluctuation, though broken at points where the divisions between the cysts were. These signs simply in- dicated the presence of a multiple cystic tumor. The umbilicus was high up, showing that the lower portion of the abdominal mus- cles was distended most, and in a space about five inches in diame- ter in the umbilical region there was tympanitic resonance and gurgling on pressure, showing the presence of intestines at that point. Taken altogether the abdomen appeared to be occupied by a large cystic tumor with a mass of intestines in a cup-shaped space in its center. By vaginal touch the uterus was found displaced upw^ard and forward, and the cervix could be reached without difliculty, owing to its being crowded toward the pubes. Behind the uterus and ex- tending down into the upper and posterior portion of the pelvis a segment of cyst was found. The uterus was displaced by moving the cyst in front, and pushed forward by raising the cyst behir.d it. The examination indicated very certainly tliat there was a cystic ova- rian tumor of the multiple variety, but there was evidently more than that. The fact that the uterus was involved raised the ques- tion of uterine iibro-cyst, as well as ovai-ian tumor, but there was some doubt about the nature of the whole mass. It was possible that the uterus was simply adherent to the cystic tumor, and that the adhesions had been formed while the tumor was still in the pel- vis, and the uterus had been carried upward as the tumor grew. It also was presumed that there might be two cystic tumors, and that the uterus was attached to one of these. While the exact pathological conditions were not decided upon, two facts Mere (piite evident ; first, that there was at least an ovarian tumor, and tliat the patient must obtain relief, if at all, by ovariot- omy. Operation. — After making the abdominal incision, the flrst cyst \vas exposed, and adhesions of the omentum were found on the right side. The omentum was vascular and its adhesions covered the upper part of the tumor. After emptying the cyst by tapping, the omental adliesions were ligated and separated, and it was tlien found that this cyst had no connection with the cysts above, but was situated between the folds of the broad ligaments, and extended from one side of the pelvis to the other, between the uterus and the bladder. The uterus, being behind the cyst-wall and firmly attached to it, had ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 6Y3 been stretelied laterally so that its long diameter was transverse. The empty cyst was held outside of the abdominal womid at this stage of tlie operation by forceps, and the incision extended uj^ward so that I could reach the other tumor, which I found to be a multi- ple cyst of the left ovary. The four lar,e mothers was lost. It is gross unfairness to attribute the deaths in this table to electricity. The fatal result in the patients of Braxton-Hicks, Duncan, and Boulton was due to the other measures employed. In the first case it was due to the puncture of the cyst through the vagina five weeks later, which started an internal haemorrhage. With Janvrin's patient internal haemorrhage had begun, and the case was not a proper one for electricity. Tait lost two out of thirty-five patients treated by laparotomy, and Veit three in twenty. In the hands of less expert men abdominal section is still more dangerous. Electrical foeticide comes nearest to the spontaneous method of relief. If carefully and skillfully employed, it is safe ; should it fail, or if any unfavorable results follow, such as suppuration in the tube, or rupture, the case can still be treated by abdominal section. The objections have little weight. The first is, that we have no moral right to sacrifice the life of a foetus under any circumstances. If this objection came from a certain class of theologians, it should be accepted as a guide in dealing with those who desire to accept tliat doctrine. Strange to say, it comes from those who urge and advocate abdominal section and removal of the ovum. The argu- ment appears to be that it is wrong to arrest ectopic gestation with electricity, but right to do so by abdominal section. It has been said that the embryo may be destroyed by electricity, but the pla- centa will continue to live and grow and prove dangerous. The one or two reported instances are very doubtful. Brothers's collec- tion contains no such case. At the time when electrical treatinent is indicated the placenta is only partiall}^ developed, and it loses its vitality when the death of the fa3tus occurs. That is the rule in normal gestation, and there is no proof that the natural law is re- ECTOPIC GESTATION. 655 versed in tubal gestation. There is said to be danger of the dead ovum causing suppuration and septicaemia. That is true, but it seldom does so ; and, as stated already, if a case goes wrong, abdomi- Tial section can be employed with as good results, or better than after rupture takes place. Finally, the most unfair argument of all is, that those cases claimed to be cured by electricity are cases of mistaken diagnosis. This is not worthy of serious consideration. Treatment after Primary Rupture of the Sac. — Abdominal section is the method of management which is called for in case rupture has taken place. When symptoms of rupture appear, the operation should be at once resorted to. If it is possible to determine that the rupture is into the broad ligament, operation is not called for ; but in case there is doubt, the abdomen should be opened, and if there is no haemorrhage into the peritoneal cavity the abdomen should be closed. "When the peritonaeum is reached, the presence of blood within it is shown by the dark color of the translucent membrane and by its bulging, and, if further evidence is required, by nicking the peritonaeum and passing in a pipette toward the cul- de-sac. The operation is the same as in removal of the diseased tubes. Search for the tube should be made, and, when found, it should be withdrawn and its attachments ligated and the whole removed. This controls the bleeding, and then the peritoneal cavity can be cleansed of blood. The wound is closed in the usual way. This operation is indicated and is highly successful when the ovum has died and decomposition has followed. Years ago I saw a patient who was not treated in any way until acute inflammatory symptoms had developed. She was then treated for peritonitis, and died of septicseraia. Post mortem, the gestation sac was easily separated from the peritoneal adhesion and removed. This experience enabled me to save the life of a similar patient by abdominal section. I am more and more disposed to operate as soon as a presump- tive diagnosis is made, unless the patient objects on ethical grounds. When rupture takes place into the peritoneal cavity — that is, in intraperitoneal cases — operation should be resorted to immediately if the symptoms are urgent. When the rupture extends downward the question of treatment is changed in all its important features. Those whose opinions are most rational advise delay in subperitoneal cases until the ovum either dies or continues to grow. Operation is indicated if after the death of the embryo there are inflammation and suppuration ^56 DISEASES OF WOMEN. with evidence of coming septicaemia. The treatment, then, is to evacuate and drain the sac through the vagina, making the incision with the cautery, according to the method practiced by Dr. T. G. Thomas long ago. There are some who advocate operating through the vagina while the ovum is still living and growing, but I am sure that this is very dangerous. There is always a strong possibility that the pla- centa may be at the most dependent part of the sac and in the line of incision, and hence haemorrhage is caused that can not be con- trolled even when the cautery is used in making the incision. In the subperitoneal cases that have progressed to or near the fourth month I prefer the treatment devised and carried out suc- cessfully by Dr. D. Berry Hart, He opens the abdominal wall on the side down to the peritonaeum, and, raising up the peritonaeum, opens the broad ligament and removes the contents of the sac ex- cepting the placenta, which he leaves ; he then packs the cavity and drains until the placenta dies and can be removed or washed out ; afterward the sac is permitted to close. Dr. Hart has had iive successful cases of this kind, and that gives great confidence in the treatment of this subj^eritoneal variety of ectopic gestation. The operation can be done when the embryo is still living, and with far greater safety than by either abdominal section in the median line or vaginal section. Operation after Rupture of the Sac. — When secondary rupture occurs, with dangerous haemorrhage, laparotomy is indicated, just as it is in primary rupture. In this condition the time to operate and the method of proce- dure are determined for the surgeon, to a great extent at least. The secondary rupture is indicated by the local and constitutional symp- toms, which in some cases are comparatively mild, while in others they are marked and call for interference. On opening the abdomen, the foetus, which has escaped into the abdominal cavity, is removed, and the cavity cleared of blood. The rent in the sac is sought for and all haemorrhage arrested. If the rent is in front, the walls of the sac are fastened to the parietal wound with sutures and the sac drained. "Wlien it happens that the rupture is so situated that it can not be brought to the wound in the abdominal wall, it should be closed, and another opening, large enough to admit a drainage-tube and the cord, made in front. The further treatment should be as if the original rupture had occurred in front. Drainage of the abdominal cavity should also be em- ployed. ECTOPIC GESTATION. 657 Operation when the Foetus is Dead. — In this condition it should be understood that while the foetus has died the sac is not rup- tured, and that the decomposition of the foetus causes danger from septic infection, and the danger therefrom demands operative inter- ference. The complications which may occur in this state are very vari- able. The length of time that is permitted to elapse, and the extent of inflammatory products or changes that may take place, give char- acteristics that render no two cases alike. Some cases are as simple to operate on as an ordinary abdominal abscess ; in others, intestinal and other adhesions are found that make the operation the most difficult. The method of procedure must depend upon the nature of the case, and the judgment and dexterity of the surgeon must be the only guides. The whole gestation sac may be removed as easily and in the same way that an ovarian cyst is removed, the conditions being favorable. When the adhesions are such that it can not be safely removed, as determined by a careful exploration, then the sac should be aspirated and its walls fixed to the abdominal wall and drained. Drainage of the abdominal cavity as well as of the sac may be neces- sary. As a rule, the placenta should be removed. Operation at or before Full Term when the Child is Alive. — It is no easy matter to decide whether to operate at once and save the child — primary laparotomy — or to wait until spurious labor has come on, the child has died, and sepsis threatens — secondary laparotomy. If we wait until the child has been dead two or three months, the placental vessels atrophy, and the danger of haemorrhage from the placental site after the operation is -vastly diminished. Harris gives thirty per cent as the death-rate in secondary laparotomy. Hereto- fore the maternal mortality has been so great after primary lapa- rotomy (ninety-six per cent previous to 1880) that it was not justi- fiable, but since the death-rate dropped to sixty per cent between 1880 and 1888 (Harris), and as it has dwindled to twenty-eight per cent since 1888 (Pozzi), the operation demands consideration. The sac is stitched to the abdominal wound and then incised. The child is removed and the cord tied. Then the placental site may be con- trolled by a haemostatic suture, and the placenta, together with a large part of the sac, may be removed. If this procedure is not feasible, the placenta may be left to come away later, and the cavity carefully drained. The after-treatment consists in pumping out the fluid that ac- cumulates in the sac and does not escape through the tube. If the 43 658 DISEASES OF WOMEN. drainage is not perfect in this wise, the cavity should be washed out through the tube. This is generally necessary in order to remove the debris of the placenta as disintegration goes on. Portions of the placenta are liable to slough, and it is then necessary to enlarge the wound to permit such masses to escape. There are certain complications which may occur. Several of the most common I here refer to and discuss their management. If there is much fluid in the sac, it should be removed by tapping. In- testinal adhesions in front should be separated in the usual way, if that is possible. If not, the portion of the sac which is adherent should be divided around the point of contact, and allowed to remain attached to the intestine, using the opening thus made to extract the child. AYhen the attachment of the placenta is in front and in the line of incision, its presence there is indicated by the extraordinary vas- cularity and dark color of the sac-wall. This may possibly enable the surgeon to avoid making the opening at that point of the sac. If the placenta can not be avoided, the incision should be quickly made and the bleeding arrested with forceps, until sutures can be introduced through placenta and sac-wall to control the bleeding. Every effort should be made to avoid the placenta, as it complicates the operation greatly. In the subperitoneal variety the sac consists of the peritonaeum and broad-ligament tissue, and differs in vascularity, thickness, and character from the intraperitoneal variety. The sac looks like an intraligamentous ovarian cystoma or uterine myoma. In this con- dition of things there is much haemorrhage where the sac is opened, and the same manipulations are called for that were described in speaking of opening the sac at the point of placental attachment. We may broadly summarize as follows : The intraperitoneal form (of ectopic gestation) should be operated on when rupture takes place. The subperitoneal variety should be let alone after rupture unless suppuration occurs, and should then be operated on through the vagina. DISEASES OF THE UEIISTAEY OEGAl^S. CHAPTER XXXYI. ANATOMY AND DEVELOPMENT OF THE BLADDER AND UEETHKA. This portion of the present work is undertaken with the full assurance that the medical profession is in need of a systematic and practical treatise on the diseases which affect the urinary organs of the female sex, and that such a treatise should be included in every work on gynecology which lays claim to being complete. Those engaged in active practice often encounter cases of cystic disease among their female patients, many of which are exceedingly trouble- some if not altogether impossible to manage. There is, moreover, but little in English literature, at least, to aid them when thus per- plexed with the difficulties of diagnosis and treatment. In considering this important subject after the plan which I have adopted, much will be purposely omitted, which, though interesting, is not absolutely necessary to a clear understanding of its essential principles. The conflicting views of various authors regarding un- settled questions will, when possible, be entirely disregarded in order to make room for the more practical points which the physician is expected to carry with him in his daily practice. In short, it will be my purpose to supply, so far as I may be able, the deficiency in this branch of medical literature, the existence of which a busy life in private practice and in teaching medical students and post-gradu- ates has demonstrated. To proceed systematically, I will first take up the form and struct- ure of the bladder and urethra, and the relations which they bear to other organs and tissues in the female, and then pass on to the con- sideration of their development. Anatomy of the Bladder. — The bladder is a musculo-membranous sac, situated in the anterior part of the true pelvis. Its form varies with the age of the individual and the degree to which it is dis- 659 660 DISEASES OF WOMEN, tended. In childhood, the vertical diameter is the longest ; in mid- dle life, the transverse ; in old age, from the sagging of the infe- rior fundus and gradual atrophy of the pelvic organs, the vertical . again becomes the longest diameter. When empty, its walls are closely coaptated, and it lies behind the pubes. Between the pubes and the bladder is a space containing loose fat. When moderately filled, it rises slightly above the pubes, and assumes a somewhat ovoid shape, which is much more marked during distention. In the fe- male the bladder has a shorter antero-posterior and a greater lateral diameter than in the male. The bladder in the female is, for accuracy and convenience of description, divided into corpus (body), fun- dus (base), and cervix (neck) (see Fig. 238). The corpus is all that portion of the organ lying above an imaginary plane, passing through the vesical openings of the ureters and the center of the symphysis pubis. That part lying below this plane is the fundus or base, and is variously divided. The portion which lies between the vesical openings of the ureters behind, and the vesical oritice of the urethra in front (Fig. 239), is known as the trigone, or vesical triangle. That portion Fig. 238.— Diacram of the of the base lyiug just behind the ureteric an'd Jundus'^'*'' ''''''"' openings is known as the bas fond. This is usually but a slight depression in early and middle life, but in disease and advanced age it often becomes a deep pouch or sac. This is more often the case in the male than in the female. The cervix or neck of the bladder is that funnel- shaped space at the apex of the trigone, where the bladder and ure- thra merge into each other. The bladder has three coats — two complete and one partial or incomplete. From without inward these are the serous (incomplete), the muscular, and the mucous. The serous investment of the blad- der, like that of all the abdominal and pelvic organs, consists of peritonsBum, of which I will sjieak more fully when I come to con- sider the ligaments and topographical relations of this organ. The middle or muscular coat has a peculiarly efficient fiber ar- rangement. Its layers have been divided into two — external and internal — but so frequent and so intimate are their interlacements that, though when minutely considered they are two, practically they act and appear as one. The main direction of the outer fibers is ANATOMY OF THE BLADDER. 661 longitudinal ; of the inner, circular. There is also a thin stratum of muscular fiber lying just under the mucous membrane, and con- tinuous with the longitudinal fibers of the urethra. The main fibers are of the unstriped or involuntary kind, and take their origin chiefly from the neck of the bladder. According to some authors, the sphincter vesicae is formed by a strong band of muscular fibers, varying from one eighth to half an inch in thickness. By others, and these are perhaps the best au- thorities, it is claimed that there is no true anatomical sphincter of the bladder. Tlie function of the sphincter vesicae is said to be per- formed by the closing together of the longitudinal folds of the tis- sues at the junction of the bladder and urethra, or by the transverse semicircular folds that close over each other. At the base of the bladder two little muscular slips arise from the portion usually designated as the sphincter vesicae, and find in- sertion about the vesical openings of the ureters. These muscular fasciculi are but imperfectly developed in the female, and probably have little if any specific action. The lining or mucous coat of the bladder is like that of the ure- ters and urethra. It consists of a basement membrane, supporting two or more layers of epithelium, in some parts squamous, in others cylindrical, the whole lying upon an elastic, cellulo-vascular bed that is fitted into the meshes of the reticulated muscular coat beneath. This mucous membrane is nowhere attached closely to the sub- jacent muscular layer, save at the trigone, the neck, and about the orifices of the ureters. Owing to the general looseness of attach- ment when the bladder is partially or wholly contracted, the mucous membrane is thrown into rough, uneven folds everywhere, save at the points of close attachment already mentioned. In the trigonal sj^ace the membrane is thinnei-, more closely ad- herent, and the surface epithelium is usually of the medium-sized, squamous variety. The nerve-supply to this small space is very rich, and, in consequence, it is the most sensitive part of the blad- der. Although Savage denies the presence of glands or papillae in the mucous membrane of the bladder, Holden and many others main- tain (and correctly, I think) that the membrane is studded with numerous little glands and follicles, whose function is to supply mucus to the internal surface of the organ. They are most numer- ous at and about the vesical neck. The trigone in the female is a smaller space, and has less dis- tinctly marked boundaries than in the male. That little elevation 662 DISEASES OF WOMEN. of mucous membrane lying at the very apex of the trigonal space, and known as the uvula, is also but little developed in the fe- male. Running between the vesical orifices of the ureters, Jurie claims to have found what he calls the inter-ureteric ligament, in the ends of which he asserts that the ureteric orifices are imbedded. To its action he attributes the jsower that the bladder has of preventing regurgitation into the ureters. I will speak more fully on this point presently. Normally, the bladder has three openings, one for each ureter, and the urethral orifice. The openings of the ureters lie on each side of the median line at the base of the bladder, about one inch and a half behind the vesical opening of the urethra, and about two inches apart. The ureters pierce the bladder-Avall obliquely, and their openings are so minute as to be hardly visible to the naked eye. Their points of entrance are marked by a slight puckering in the mucous membrane. ^f / y The third opening is the ostium urethrae internum, which is a diagonal slit at tlie juncture of the vesi- cal neck and urethra. According to Ru- tenberg, the color of the vesical mucous membi'ane in the liv- ing subject before dilatation is a dull, grayish red ; but, as dilatation proceeds, and the irregular folds are straightened out, it becomes grad- ually a brighter red, and, when complete distention is accom- plished, the minute arteries can be seen Fig. '/<39. — Base and neck of the bladder (Savage), a, sym- physis putjis. 1, 1, Ureters. 1', Ureteric openings. 2, 3, Uterine artery and veins. 4, Outline of cervix uteri. 5, Vesical neck. 6, Arciis tendinous and vesico- pubic muscles. 7, 7, Pubo-coccygeus muscles. forming a beautiful interlacing network on tlie bands of the muscu- lar reticute. AVhenever it has been my good fortune to see this membrane in the living subject, it has appeared to me as being of a ANATOMY OF THE BLADDER. 663 gra^ash-pink color, not unlike that of the mucous membrane of the cervix uteri when anaemic. The vascular supply of the bladder is very free, being derived from the superior, middle, and inferior vesical arteries, and branches from the uterine artery. They all arise from the anterior trunks of the internal iliac arteries. The anastomoses of the arterial twigs are numerous and free. The veins are also numerous and large, form- ing by interlacement and connection thick, tortuous plexuses about the base, sides, and neck of the bladder, and finally terminate in the internal iliac veins. This plexus about the neck of the bladder com- municates freely with that of the labia minora, uterus, and rectum. These venous plexuses are the chief elements in the so-called " haem- orrhoids of the bladder." In their tortuous course these veins are accompanied by lym- phatics that seem to have their origin in the submucous cellular tissue of the bladder. They enter the glands situated about the internal iliac artery, and from there go to the lumbar glands. The nerves of the bladder are of two kinds — spinal and sympa- thetic. The spinal nerves are branches, usually from the fomth, sometimes from the third, and rarely from the second sacral nerve. They terminate chiefly in and about the neck and base of the blad- der. The sympathetic nerves have their origin from the hypogastric plexus, which lies in front of and on the last lumbar and first sacral vertebrae. It is formed by a mazy interlacement of numerous gan- glionic fibers, and branches from the spinal nerves, especially the second sacral. Ganglia are common, more particularly at the point of junction of the spinal and sympathetic nerves. This plexus sends branches to all parts of the bladder, and to the vagina, uterus, and rectum. This common nerve-supply to the various j)elvic organs must be borne distinctly in mind in order that the functional de- rangements and neuroses of the bladder, hereafter to be described, may be thoroughly understood. Anatomy of the Urethra. — The female urethra is a musculo-mem- branous canal, from one to two inches in length, the average being about one inch and three eighths. Its diameter is greater than that of the male, being about one fourth of an inch. It lies in the median line, just under the pubic arch, and is held in position by the median pubo-vesical Hgament. In the erect posi- tion it has a direction upward and backward, and at all times, when normal, its axis closely coi-responds to that of the pelvic outlet. It terminates anteriorly at the base of the vestibule by an opening 664: DISEASES OF WOMEN. i' J ■Ji^^i.^1 known as the meatus urinarius, and posteriorly at the neck of the bladder. It has a cellular, a double muscular, and a mucous coat. Accord- ing to Robin and Cadiat, its mucous membrane is richer in elastic tissue than any other in the body. The epithelial covering of the anterior or lowest portion is of the pavement variety, and closely resembles that of the vagina, except that it is not so large. Figs. 242 and 243 show the difference between the If -^' -V two. Posteriorly and superiorly it is like that of the bladder — columnar and squamous. Scattered throughout are little papilke, con- taining blood-vessels, and near the meatus there are numerous lacunae surrounded by villous tufts. There are also a number of small mucous glands, that in old people often contain black particles, like the prostatic con- cretions of the male. Upon each side, near the floor of the fe- male urethra, there are two tubules large enough to admit a No. 1 probe of the French scale. They extend from the meatus urinari- FiG. 240. — Urethra laid US Upward, from three eighths to three quar- ters of an inch. Fig. 240 is a drawing from a section of the urethra, laid open by division of its posterior or vaginal wall. The tubules, having been distended by probes passed into them, are plainly seen. Fig. 241 shows the same thing from the opposite side, the ure- thra having been laid open by section of its an- terior wall. The space between the tubules is the floor of the urethra. From these it will be observed that the tubules run parallel with the long axis of the ♦urethra. They are located l)eneath the mucous mem- brane in the muscular walls of the urethra. This is represented by Fig. 242, which is a draw- ing taken from a transverse section of the ure- thra, about a quarter of an inch from the meatus. The mouths of these tubules are found upon the free surface of the mucous membrane of the urethra, within the labia of the meatus urinarius. The location of the openings is subject to slight variation, according to the condition and form 240. — Urethra laid open with probes dis- tending the glands (pos- terior wall divided). Fig. 241.— Urethra laid open with probes in Skene's glands (an- terior wall divided). ANATOMY OF THE URETHRA. 665 of the meatus. In some subjects, especially the young and very aged, and in those in whom the meatus is small, and does not pro- ject above the plane of the ves- tibule, the orifices are found about an eighth of an inch with- in the outer border of the mea- tus. When the mucous mem- brane of the urethra is thickened and relaxed, so as to become slightly prolapsed, or when the meatus is everted, conditions not imcommon in those who have borne children, the openings are exposed to view upon each side of the entrance to the urethra. What is here described is rep- resented in Fig. 244. The labia of the meatus have been slight- ly everted to bring the orifices into view. The upper ends of the tu- bules terminate in a number of divisions, which branch off into the muscular walls of the ure- thra. By injecting one of the tubules with mercury, and then dividing it, the openings of the branches can be easily seen. This description of the anatomy of these glands is taken from dissections and microscopical examinations made by Drs. B. F. West- brook and J. M. Van Cott, Jr. I have called them glands because they differ in size and structure from the simple follicles found in abundance in the mucous membrane. When I first discovered these glands I presumed that they were mucous follicles that were accidentally of unusual size in the subject examined, but, having investigated more than one hundred of them in as many different subjects, and finding them constantly present, and so uniform in size and location, I became satisfied that they were worthy of a separate place in descriptive anatomy. The dissections made by Dr. Westbrook, and the pathological lesions to which these structures are subject, confirm this belief. So far as I know, the anatomy of these glands has not been de- scribed, nor have the diseases to which they are subject been referred Fig. 242. — Transverse section of urethra with gland on either side. 666 DISEASES OF WOMEN, to by pathologists. At least this much may be said, that the stand- ard text-books on anatomy and gynecology in English, Gennan, and French contain no reference to them. It is easy to understand why these insignificant glands should Fig. 243. — Longitudinal section of urethral glands. have been overlooked by anatomists, or, if noticed at all, classed with other mucous follicles. It is only when their pathology is under- stood that their real importance becomes apparent. I know nothing about their physiology. They serve some pur- pose in the economy, no doubt, but what is their function is a ques- tion to be answered in the future. This will doubtless be attended to at an early date, as the subject is worthy of investigation. The pathology of these glands, so far as has been investigated up to this time, is of great practical interest, and there remains, no doubt, much still to be studied. Clinical observation has already shown that they are subject to inflammation of various degrees of intensity and duration. The meatus urinarius in the female differs from that of the male in being a puckered and somewhat prominent, rather than a slit-like ANATOMY OF THE URETHRA. 607 and depressed opening. The mucous membrane of the urethra is tlirown into longitudinal folds throughout, save when opened and unwrinkled during micturition or by arti- ficial dilatation. When at rest it is a closed canal. Beneath the raucous membrane there is a thick Hbro-elastic network into which the mucous glands dip. These are lined with cylindrical epithelium and surrounded by a network of veins. This submucous areolar tissue has direct vascular connec- tion with the muscular layer that sur- rounds it by means of cavernous venous si- nuses, partly in the muscle and partly in the elastic connective tissue. Thus there is an arrangement almost exactly like that of the corpus cavernosum penis in the -t ''■^' ^ male. The venous plexus of the urethra -..^=^==4= - is situated chiefly at the sides, in what is ^i^- 244.— The meatus everted, ^ showing the mouths of the known as the urethrO-publC space. glands. (From a prepara- The muscular layer is double, the outer tio^i preserved in alcohol.) portion being composed of both circular and spiral fibers mixed, and the inner of longitudinal fibers only, and these two layers are so closely bound together by the cavernous venous sinuses as to be in reality but one. Dr. Ufileman claims to have found an additional external layer, the fibers of which are voluntary. He divides this layer into two — an external and an internal — the former longitud- inal, the latter transverse. These make what he calls the outer or voluntary sphincter of the bladder. From the vesical neck to a point about half-way down it w^holly invests the urethra, forming only a partial investment from that point to the meatus. Luschka claims to have found a sphincter of the urethra and vagina. He describes it as being smooth and circular, from one sixth to one third of an inch broad, lying directly behind the vesti- bule, and girdling both the vagina and urethra. Its function, he says, is to close the urethra by pressing it against the urethro-vagi- nal septum. Being closely adjacent to the cavernous venous tissue of the urethra, it locks its fibers posteriorly with those of the mus- culus transversus profundus. In the female as in the male, the urethra pierces the triangular subpubic ligament, two layers of which extend around it ; one back- ward and the other foi'w^ard. 668 DISEASES OF WOMEN. There is great diversity of opinion as to the nature of the vest cal opening of the nrethra in the female. Aeeording to Winckel and Simon it is a diagonal slit, the mucous membrane of which is longitudinally and superficially corrugated. According to Savage, it is a triangular opening ; and according to Holden and others, a. funnel-shaped opening. It of course varies somewhat with age, size of urethra, vesical contraction, or quiescence, and in the living and dead subject ; and hence the diverse opinions of the various ob- servers. Anatomical Relations of the Bladder and Urethra. — Having dis- cussed the anatomy of the bladder and urethra, it remains to exam- ine the topographical relations of these organs. This is very neces- sary to a proper understanding of the influence of other organs in causing diseases and displacements of the bladder and urethra. The bladder of the female lies lower in the pelvis than that of the male, between the pubes anteriorly, the uterus posteriorly, the vagina and uterine cervix inferiorly, and the small intestines superi- orly. The organ when empty lies behind the symphysis pubis, its highest point slightly overtopping it. In this position it occupies but little space. When partially or wholly tilled it rises above the pubes to a varying extent. In doing this it alters but slightly the position of the other pelvic viscera, although relatively its position is somewhat changed. Anteriorly the bladder is separated from the posterior face of the pubic symphysis by intervening cellular tissue. Inferiorly it forms a close attachment to the anterior vaginal wall by means of a dense celhilar cushion which increases in thickness from before back- ward. The bladder rests upon this vesico- vaginal septum as far up as the point where the body and neck of the uterus join each other. Posteriorly and somewhat superiorly to the bladder lies the uterus^ and superiorly and postero-laterally are the ovaries and broad liga- ments. The close attachment of the vesical neck to the arch of the pubes, by the pubic ligament anteriorly and the vagina inferiorly, makes a kind of wedge that gives but little surface for bagging downward if the vagina holds its proper position. Though imperfectly, still to a certain extent, this arrangement resembles the perin?eum in the male. Superiorly, tlie organ is held in position by a number of ligaments ; five false and five true. The false ligaments (one supe- rior, two lateral, and two posterior), are formed of peritonaeum. This membrane is reflected from the inner face of the anterior ab- dominal wall to the bladder investing it superiorly, laterally, and, to RELATIONS OF THE BLADDER AND URETHRA. 669 a certain extent, posteriorly. It joins the organ in front, dipping down just above the pubic summit to the superior vesical surface, and passes as far backward as the point of contact between the vesi- cal base and uterus, which is at the junction of the uterine body and cervix. Although this peritoneal covering of the bladder is hrmly adherent, it never leaves its uterine or other attachments, however much the bladder may be distended and rise above the brim of the pelvis. That portion of the bladder lying behind the pubes, that resting on the vagina and uterine neck, and a small posterior and lateral portion have no serous investment. The true ligaments are also five in number — two anterior or vesico-pubic, two lateral, and the superior or urachus cord. Laterally, the round ligaments of the uterus pass over the blad- der-wall, and just below and posteriorly the ureters enter that organ. These ducts, the excretory ducts of the kidneys, are usually de- scribed as passing downward, forward, and inward, after entering the cavity of the pelvis, to the base of the bladder, and after passing for an inch between the muscular coats of that organ opening into it by constricted orifices. In their course they pass along the sides of the cervix uteri and upper part of the vagina, and at their points of entrance into the bladder are from one half to three quarters of an inch in front of the cervix uteri. It is very important that the re- lation of the ureters to the bladder should be borne in mind, espe- cially in the operation of gastro-elytrotomy. Garrigues, who has in- vestigated this point, says : " The ureter does not lie in the broad liga- ments, it does not keep the same direction on reaching the wall of the bladder, and it does not lie close up to the wall of the cervix, as taught by anatomical authorities. After having crossed the iliac vessels the ureters diverge, running downw'ard, backward, and a lit- tle outward on the wall of the pelvis, behind the broad ligaments to a point near the spina ischii. Then they lead downward, forward, and considerably inward so as to converge toward the bladder. They pass beneath the base of the broad ligament, lying in the abundant cellular tissue found in this locality. They cross the cervix at some distance from behind, at an acute angle, so as to come in front of and below it. They lie outside and above the anterior part of the side wall of the vagina on a spot as large as the tip of the finger. On reaching the wall of the bladder they turn rather sharply inward and go downward until they open with a small slit into the inte- rior of the bladder at the outer angle of the trigonum vesica. But 670 KELATIONS OF THE BLADDER AND URETHRA. on dissecting the bladder from the utenis and vagina their substance is seen to continue as a solid ridge between the two apertures, and forming the base of the trigone (Jurie's inter-ureteric ligament.) " The illustration of Gar- rigues makes this descrip- tion very clear (Fig. 24-5.) Just in front of the small lateral space lacking serous investment the ob- literated umbihcal arteries pass upward and forward to the summit of the blad- der reflecting the perito- nteum, and thus forming a double pouch on eitlier side. The relations of the urethra are as follows : it lies just under the pubic symphysis, and, piercing the deep perineal fascia, extends from the vesical neck, at the ostium ure- thrte internum, to the meatus urinarius or ostium urethrse externum, situate at the base of the triangular space known as the vestibule. Its anterior three fourths are imbedded in the vaginal wall. The meatus urinarius lies about four fifths of an inch below the clitoris, in the vaginal margin of the vestibule. The vesical end of the urethra is about the same distance below the lower surface of the pubic symphysis. Its course is upward and backward forming a very sliglit curve. Development of the Bladder and Urethra. — With this brief sketch of the structure of the bladder and urethra their development may be next considered. It would be very interesting, from a scientific point of view, to examine the process by which the bladder and urethra are formed in the embryo ; but it would, I think, be rather tedious to take up the subject in all its minutiae. A few of the more important points in the process of development must be un- derstood, however, in order to comprehend the malformations Avhich are occasionally met with. Most, or at least many, of the malfor- mations of the urinary apparatus, like those of other organs are due to arrest of development at various stages of that process. A clear Fig. 245. — The relations of the ureters (Garrigues). u, uterus ; b, bladder ; ur, ureter ; u, urethra ; V, vagina ; f, Fallopian tube ; o, ovary ; b, broad ligament ; r, round ligament. DEVELOPMENT OF THE BLADDER AND URETHRA. G71 conception of the normal, therefore, will aid in better understanding the abnormal. The urinary organs are develojjed in separate portions or sec- tions having distinct points of origin, and by the union and fusion of these parts the entire apparatus is completed. The bladder is formed from a portion of the allantois. When the abdominal plates of the embryo close around that portion of the allantois that forms the umbilical cord, they also shut in a j)ortion which fonns the urinary bladder. There remains, for a time, a di- rect communication between that portion of the allantois from which the bladder is formed and that which makes the cord, which takes the name of the urachus. The canal or duct in the urachus is usu- ally obliterated before or soon after birth, so that all that remains of it is an impervious cord known as the superior vesical ligament. It will thus be seen that the bladder is developed from the allantois, which may be called one center of development for the urinary ap- paratus. The centers of development for the ureters are the same as those for the kidneys. Indeed, the ureters are processes that are developed from the kidneys, and extend downward until they unite with the bladder, and finally open into it. While the bladder and ureters are being thus formed, the lower portion of the alimentary canal — that which forms the rectum — be- comes separated from the section of the allantois that forms the bladder. Into this space, between the rectum and bladder, Miiller's ducts descend, and, uniting, form the vagina (see Figs. 53-57). Posterior to Miiller's ducts and anterior to the rectum, a mass of tissue is developed which helps to form the recto- vaginal wall above and the periugeum below. Anteriorly Miiller's ducts unite with the lower portion of the bladder, and aid in the formation of the urethra, or, at least, the up- per portion of its posterior wall. The lower or external portions of the genito-urinary organs are formed from an ovoid eminence which appears in the median line of the lower anterior part of the trunk of the embryo. At the lower part of this eminence there appears a fissure, which, incurvating and uniting with tlie lower portion of Miiller's ducts (vagina) forms the terminal portion of the urethra and the introitus vaginae. From this same center of development the labia majora, the labia minora, and the vestibule are formed. CHAPTER XXXYII. MALFORMATIONS OF THE BLADDER AND URETHRA. Malformations of the Urethra. — Malformatioiis, as has already been said, are usually the result of arrested develoi3ment. Yarious fail- ures in the processes necessary to form the complete urethra result in a number of malformations. The most important of these may be classified as follows : 1. Defectus urethras totalis. 2. Defectus urethrse externus. 3. Defectus urethra3 internus. 4. Atresia urethrfe. In the first form (defectus urethrse tofalis) there is, as the term implies, entire absence of the urethra. It is said to be due chiefly to an arrest in the development of the vagina at a point where it should form the main portion of the posterior wall of the urethra. It is very probable that there is also an arrest of development of the clitoral process. Coexisting with this malformation other developmental defects are generally but not invariably found, for it has been known to exist with an otherwise perfect genito-urinary apparatus. Petit tells of the case of a child, four years old, who had neither urethra, clitoris, nor nymphfe, but had a comparatively wide vagina. Langenbeck men- tions the case of a girl, nineteen years of age, in whom the bladder and vagina formed a common canal. She was incontinent up to the age mentioned, and is reported to have gained control of the bladder afterward. The second deformity (defectus urethrae externus) is due to the absence of the lower and anterior portion of the urethra. It has been called " hypospadias in the female." One of the most marked cases has been recorded by Von Mosengeil. The subject was a girl eight years old. The opening in the urethra was situated below a large clitoris, having a very full prepuce. It was much higher than 672 MALFORMATIONS OF THE BLADDER AND URETHRA. 673 the normal situation of the meatus urinarius. There was a groove running from the lower border of the vestibule up to the opening of the urethra, and it appeared to be formed from the anterior wall of the urethra. The upper portion of the urethra held its normal rela- tions to the bladder and vagina, but was only half an inch in length. The bladder, in comparison with the other organs, was larger, and had a number of sacculae. It will be observed that in this case the upper portion of the urethra was complete, and that there were present in the lower portion of the canal an anterior and two rudi- mentary lateral walls, the posterior wall alone being absent. There is another form of defectus urethrse extemus or hypos- padias, in which the lower part of the canal is entirely wanting. In such cases there is but one opening between the clitoris and peri- nseum, and but one canal, this dividing into vagina and urethra at some distance from the outer opening. An interesting example of this was observed by Willigk, in a woman, who died at the age of forty-six. The uro-genital canal, at its opening, was about the size of a catheter, and ran in a curved direction under the pubes. About an inch and a half from its outer opening it divided into two pass- ages, one anteriorly, V long — the urethra, and one posteriorly, 2" to 10'' long — the vagina. The third defonnity (defectus urethrse internus) is that in which the internal or upper portion of the urethra is wanting, and is a comparatively rare affection. The only cases, so far as I know, are given by Oberteufer and Duparcque. In Oberteufer's case, as I understand it, the lady was forty-two years of age, and all her life had passed water from the umbilicus. Her vagina was normal, and so were the external genital organs. The upper or internal portion of the urethra alone was wanting. Duparcque's case was one in which the urethra was pervious as far as the bladder, but was there closed. This case, however, appears to me more properly to come under the head of atresia urethrse. The fourth class (atresia urethrse) is a comparatively common affection. There are two forms of congenital atresia mentioned by authors. The first is produced by imperfect development of the vaginal process, or of both the clitoral and vaginal segments. Du- parcque's case was of this kind, the urethra being open up to the bladder and there closed. It was a form of defectus urethriB in- ternus with atresia at the upper end of the canal. In this case the bladder and ureters were greatly distended. The other form of atresia is found when the clitoral and vagi- nal processes are both defective. In such cases there is no trace of 44 674 DISEASES OF WOMEN. a urethra, except an imperfect vaginal wall which extends obliquely downward and closes the bladder. E. Rose relates a case of this kind in which the bladder, kidneys, and abdomen were filled with water. The urethral malformation was not the only one in this case, the vagina and uterus suffered from an arrest of development and were both double or rudimentary. Before leaving this interesting subject I will mention another rare malformation. It is an obstructive anomaly, and consists in a double condition of the urethra. The only case, so far as I know, which has been described with any accuracy, is that of Furst. He observed in a preparation taken from the body of a young virgin the following peculiarities : In looking at the anterior bladder- wall at the first glance only one urethral orifice was to be seen, but one tenth of an inch forward toward the meatus the single urethra was seen to bifurcate ; a fine septum, nearly straight, divided it from right to left into an anterior and posterior half ; these continued with an ever enlarging and diverging septum until they opened into the vagina about one tenth of an inch apart. In this way they twisted, so that the anterior or superior one opened toward the right, while the posterior (the one in the region of the bladder) opened into the vagina on the left. The left urethra opened with a caliber of one fifth of an inch into the median line of the vagina. The right opened on the right of the median line, having a caliber of only one tenth of an inch. The length of the w^hole urethra was one inch. It is of very rare occurrence that the double condition of the allantois persists in this manner, and, considering all the changes that the sinus uro-genitalis has to undergo, it seems strange that blending did not take place. It is also interesting from the fact that the allantoic openings into the cloaca can only take place by a very rapid and early interruption of development. The uterus and vagina, in this case, were perfectly normal. Symptomatology of Malformation of the Urethra. — The symptoms that arise from malformation of the urethra are incontinence in the one class of cases, and retention of urine in the other. When the urethra is deficient in part and the bladder perforate, urine con- stantly escapes ; and from the wetting, the excoriation, and the odor, the unfortunate subject is kept in continual misery. In cases where there is an abnormal contraction of the vagina the urine can be retained, partially at least. This is supposed to be effected by the small size of the genito-urinary sinus, and, possibly, a voluntary contraction of the sphincter vagina muscle which may act as a sort of sphincter and aid in the retention of urine. MALFORMATIONS OF THE BLADDER AND URETHRA. 675 Atresia of the urethra and the consequent retention of tlie urine cause hydrops of the bladder, ureters, and kidneys, and also ascites, as has already been mentioned. Distention of these organs occurs in utero, and such malformed children are usually born dead, or die soon after birth. So great is this distention of the bladder and ab- domen in some cases that delivery is difficult or impossible until the fluid is evacuated by puncture. I remember seeing one such case. The head was delivered, but there was great difficulty in de- livering the body. The abdomen was enormously enlarged by the overdistention of the urinary organs. The child was very feeble, and after moaning for a few hours, died. ISTo efEort to relieve the bladder was made because a diagnosis was not reached until the lit- tle one was dead. This malformation usually leads to fatal results, and our knowl- edge avails us little save in accounting correctly for the cause of death. The only natural way that the evil effects of this malforma- tion can be obviated is by the occurrence of another developmental anomaly, viz., fistula of the urachus, the urine then escaping from the umbilicus. Atresia is an undoubted factor in the production of urachal fistula. I shall speak more fully of this when I come to consider vesical malformations. When defectus urethrse externus occurs in patients whose uro- genitals are otherwise normal, the function of the bladder and re- productive organs may all be performed easily and uninterruptedly. Coitus has been possible, and conception has been known to occur in such cases. Diagnosis. — In making a diagnosis of these deformities reliance can not be placed on the symptoms alone. A physical examination of the parts is necessary. The general relative apjDcarance of the external organs must be observed, and if the vagina is large enough, to admit the speculum it should be used, and if there is any malfor- mation internally it can easily be discovered and its exact location and nature ascertained. There is usually very little trouble with such cases, but where the entrance to the vagina is so narrow that it will not admit a sound or speculum, tbe diagnostic skill of the physician will be severely taxed. Such cases resemble imperforate hymen, or acquired atresia of the vulva, and one case, at least, has been mistaken for an hermaphrodite. Under such circumstances an attempt should be made to pass the sound into the bladder, and by introducing the finger or another sound into the rectum the pres- ence or absence of a vagina may possibly be made out. If the patient is an adult, and the case one of imperforate h}Tnen, men- 676 DISEASES OF WOMEN. Gtrual fluid will probably be found in the vagina. Should there still remain any doubt, the only resource would be to try dilatation of the introitus vaginae, and see what lies beyond it. Treatment. — The treatment may be either radical or palliative. Where there is an entire absence of the urethra, with the existence of vesical fissure, or in persistence of the sinus uro-genitalis with partially developed urethra, the production of an artificial canal has been suggested. This may be done by dissecting from the vaginal wall a flap from under the symphysis. It should be about one third of an inch in breadth, and after being turned with its epithelial sur- face inward, should be united with the freshened edges of the vesi- cal fissure. It is objected by some authors that even if the opera- tion is successful, the patient will be but little benefited, the new urethra being devoid of muscular tissue, and consequently lacking the power of contraction. The passing of urine into the vagina, however, will be done away with, and the general condition of the patient will be greatly improved by the use of an artificial urinal. This of itself is a great point in favor of the operation. Heppner beheves that the method of producing an artificial ure- thra by trocar puncture of the soft tissues and sewing up the vesical fissure is dangerous, because vessels of considerable size are liable to be injured ; a further disadvantage being that the canal tends to close. The cases of Carbol and Middleton bearing on this point he puts aside as unreliable. He moreover maintains that reduction of the vesical fissure to the size of the urethra is a disadvantage, since the anterior wall of the fissure will be without any muscular tissue. The experience of those who have treated fistula has been, so far as he knows, that linear clefts, even of greater caliber, hold back the urine better than round openings of smaller size, the former allow- ing more complete coaptation of the edges. In Ileppner's case, there being only nocturnal incontinence, he contented himself with applying a bandage in the manner suggested by Sawostitzki. A girdle was put around the lower part of tlte ab- domen, and to it was fastened a little olive-shaped compress, by means of a steel spring, something after the manner of a truss. When put into the vagina this compress pushed the posterior vesi- cal wall toward the pubic symphysis, thus closing the opening and relieving the incontinence. The patient soon became used to the instrument, and obtained great relief from it. Atresia of the urethra can only be cured by operation. Carbol operated in 1550 on a servant-girl in Beaucaire, who had suffered from this difficulty from her youth up. The urine flowed from a MALFORMATIONS OF THE BLADDER AND URETHRA. 6Y7 coxcorab-like growth, some four fingers in length, at the umbilicus. The stench that arose from her body was intolerable. Carbol per- forated in the region of the urethra, and successfully removed the growth at the umbilicus by ligation. In the case of a child, seven days old, who had never passed urine, and whose bladder was enormously distended, Middleton pushed a trocar through in the direction of the absent urethra, emptied the bladder, and kept the opening pervious. Oberteufer's patient, who had atresia urethrse and urachal fistula, relieved herself somewhat by wearing a large sponge over the um- bilicus secured in position by a bandage. In such cases as this the apparatus usually employed in urinary fistula should be made use of. MALFORMATIONS OF THE BLADDER. These malformations follow the general rule of being in most in- stances due to some defect in the normal process of development. Those which are of sufficient importance and especially demand atten- tion are : 1. Fissure. — The most frequent and prominent anomaly of devel- opment in the bladder is that of fissure. It consists in partial or complete absence of the anterior vesical wall, and is usually accom- panied by malformations of other organs. The anus and umbilicus in these cases, as a rule, lie nearer than normal to the pubic symphy- sis. There are various grades of this affection. There may be sim- ple fissure of the lower part of the bladder, with the opening about three quarters of an inch in breadth, as has been seen by Desault, Palletta, Gosselin, Coates, and others. In the cases reported by them the symphysis pubis was but loosely united. There may also be fissure of the clitoris. A higher grade of this malformation is that in which the fissure is near the umbilicus, the lower part of the pelvic cavity and the pubic symphysis being closed, and the lower part of the bladder, urethra, and external genitals normal. This condition is next in order to patency of the urachus — fistula-vesico-umbilicalis. In the latter case, the urachus may remain pervious its entire length, and open into the ring of the umbilicus. The highest grade is that in which the whole anterior wall of the bladder seems to be absent. In these cases the inferior abdominal region is generally much shorter, and the umbilicus nearer the base of the pelvis. The abdominal walls are divided, and the resultant 678 DISEASES OF WOMEN. fissure "is filled up by tlie bladder-wall, the mucous membrane of wbicli is putted out and red, and gradually merges into the skin of the abdomen. It is often wrinkled, thickened, moist, shiny, and the edges dry and covered with thickened epidermis. On each side of the lower portion of the evei-ted bladder are situ- ated the orifices of the ureters. They usually appear as little ex- crescences, but are sometimes hidden in the folds of the membrane. The pubic bones are imperfectly developed, and the pubic symphy- sis never closed, save by a ligamentous band, the bones lying from half an inch to three inches apart. These separations of the pubic bones, as has been shown by Dubois, Dupuytren, Mery, and Littre, are congenital. As a rule, in such cases, the urethra is absent. The clitoris is either divided with a portion on each side of the upper part of the imperfectly formed labia, or there may remain but a trace of it, or, again, it may be entirely absent. The hymen can be seen beneath the fissure. The vagina may be absent, as in cases observed by Herder and Eschenbach, and the uterus may be divided by a septum. Atresia vaginae and imperfect ovaries have also been found in such cases. This grade is known as eversio or exstropia vesicae. If there is simply a fissure of the bladder the organ may be pro- lapsed through the fissure (inversio vesicae cum prolapsu per fis- suram). This must be distinguished from inversio vesicae cum pro- lapsu per urethram and exstropia per urachura. That this may be clearly understood, it must be remembered that inversion of the bladder occurs in three ways : First, by a protrusion of the organ through an opening or fissure in its own Avails (the form now under discussion) ; second, by an inversion through the urethra ; and third, by an inversion through a pervious urachus. The ureters, as a rule, are considerably widened. Isenflamm found them dilated from three quarters of an inch to more than an inch ; Petit as much as two inches ; Flagani and Bailie found them to be four inches ; Desault three inches ; and Littre two and one half inches, and containing small calculi. Their course, as a rule, is changed, sinking dee])er into the pelvis, and thence rising up into the bladder. There are, however, exceptions to their enlargement. Bonn, in one case, observed as long ago as in 1818, found their length and breadth normal. Winckel also speaks of a case where both kid- neys and ureters were normal. The anomalies known as epi- and ana-spadias belong under the head of vesical fissures. 2. Double Bladder. — Cases of double bladder, says Voss, are be- MALFORMATIONS OF THE BLADUER AND URETHRA. 679 coming quite rare as patliological knowledge advances, for many of these were probably cases of pathological division of the vaginal wall. Mollinetti mentions, in his '' Anatomico-Pathological Disserta- tions," the case of a woman with five bladders, live kidneys, and six ureters. Blasius describes a case of perfect division of the bladder into two separate halves, which at the vesical neck ended in one common m-ethra. Each bladder had one ureter. The subject was a male adult. Isaac Cattier has found this anomaly in little children. One case was that of a child fifteen days old. The bladders were separated by the rectum to such a degree that a finger could be laid between them. Sommering found this condition in a child two months old. In one that was born miserably nourished, and lived but twelve hours, Schatz found perfect division of the whole geni- tal apparatus, double bladder, and double congenital vesico-vaginal fistula. In double bladder, the double allantois, instead of forming one passage, forms two, with a ureter opening into each. Testa gives a case of perfect separation by the vaginal wall. Scanzoni found, in making a post-mortem examination on the body of a tuberculous woman, a division of the bladder into two lateral halves. He does not say, however, whether the division was com- plete or whether the septum was pervious. Sometimes horizontal septa are formed that are due probably to a crumpling up of a part of the bladder while growing, or a com- mencing closure of the urachus lower down than usual. Roser, of Marburg, had a case of urachal cyst, which, when enormously distended, reached as far as the umbilicus. By means of a small connection with the bladder it was filled when that organ contracted, and, finally, it and the bladder were emptied by contrac- tion of the abdominal muscles. Yesical cysts and diverticula may be confounded with the anomalies resulting from arrest of devel- opment. The slightest grade of anomaly is that in which, as Chonsky has observed, there is no full septum, but simply a band or seam, appar- ent externally. Etiology. — The original urinary sac of the embryo, it will be remembered, is the allantois, which takes its origin as a cul-de-sac from the rectum, and is, consequently, an offshoot of the intestine. It is foi'med by the ba2:2;in2:: of the cloaca, which baffS'ino; is due to the collection there of urine from the primitive kidneys. This allan- tois, especially in the human species, is double, and remains only a short time. After the fourth week of embryonic life, the layei*s 680 DISEASES OF WOMEN. coalesce, and the division ceases. Yet the original double form may remain for some time beyond the normal period, if there are anv hindrances to union. Roose and Creve maintain that the cause of this malformation is the failure of the pubic bones to unite. Meckel takes exception to tliis, and says that the bladder in its primitive condition shows itself as a simple, plain sm-face, which only becomes a cavity by the grow- ing toward each other and union of its edges. Dimcan and, at a later date, A. Bonn, and, still later, B. S. Schultze- and Thiersch, held that vesical fissure had, as its primary cause, an atresia of the urethra, with great dilatation of the bladder, the distended organ pushing aside, iirst, the recti muscles, later, the cartilaginous pubic bones, and, iinally, bursting. E. Rose, on the contrary, maintains that these cases of bladder-lissure are cases of perpetuated urachus, and are due to developmental failure in the bladder itself, remain- ing open as far as the urethra. He says positively that the edges of recent preparations of the bladder show a fresh, smooth surface, and that there is no trace whatever of any cicatrix or callosity. He mentions one case of tearing and rupture where the evidences were plainly to be seen. Moergelin, who was unable to find proof of rupture as a cause of this anomaly, says that, if there was a quan- tity of urine in the bladder, greatly distending it, there would be a reopening of the urachus or a bursting into the abdominal cavity, rather than a rupture through the abdominal walls. He looks favor- ably on the idea of a bursting of the allantois before the abdominal walls have closed in front of it. Against this, however, is the fact that Hecker extracted a foetus with atresia, having an enormously dilated, unruptured bladder. He found in the abdominal walls a cicatrized slit covered by perito- naeum. This makes manifest the possibility of a rupture of the ab- dominal walls, and also of the bladder, occurring at a comparatively late date. In the case related by Rose no information is given as to whether there was a normal umbilical cord or not, whether there was any urachal fistula, whether the abdominal ring was closed entirely, or whether the fissure was confined to the inferior part of the anterior vesical wall, as described by Gosselin, Bertet, and others. In their cases it was not possible for the fissure to have originated by the re- opening of the urachus. In any event, most of the late authors are agreed that hindrance to the outflow of urine has most to do with the production of this anomaly, and it may, as Rose has shown, and as has been said before, arise from atresia or absolute absence of the urethra. MALFORMATIONS OF THE BLADDER AND URETHRA. 681 Another possible mode of causation of this malformation is bv the falling of some of the larger abdominal organs into the pelvic cavity, compressing the m-ethra, and hindering its formation. E. Rose once found the right kidney in the pelvis, and Winckel has recorded a case described by one of his students, Dr. Kriiger, where the left lobe of a considerably enlarged liver and a quantity of small intestines were so tightly wedged into the pelvis as to cause marked bulging of the perinoeum. Such a condition, coming at a time when the urachus and urethral end of the bladder are hrmly closed, must tend to form a vesical fissure. Perfect eversion of the bladder may, however, be found at a very early date, even before the two halves of the allantois are joined, as in cases related by Friedlander, E. Rose, and Winckel. Lying be- tween, and in front of the single- or double-everted bladder or blad- ders, there are sometimes found, as in Rose's and Winckel's cases, bands of perforated skin-folds, behind which a sound may be passed. Their presence may be explained in this way : That the underlying serous connective tissue (Rathke's membrana reuniens inferior), which closes the abdominal cavity before the development of the skin and muscular system, is the covering of all urachal fistul^e, open bladders, and persistent allantois. Then, where the urine pressure is the greatest, the bladders move upon each other, so that no further development can take place between them ; but the abdominal plates develop themselves around and between them. This intermediate development, owing to the imperfection of the lower connective tissue, becomes a band or rim where the two conically formed bladders push together, so that they can not become a symmetrical whole, but have an intermediate arch. In these cases the cause probably lies in the patency of the urachus and the eversion of the bladder ; also the open condition of the abdominal walls, inter- ference with the development of the lower parts of the musculi recti, and, later, the imperfect development of the pelvis. There can, however, be a fissure of the abdominal walls without a fissure of the bladder, the closed organ protruding from the ab- dominal fissure (ectopia vesicae). Lately Ahlfeld has brought forward the hypothesis that eversion of the bladder is complicated with and dependent on a pulling down- ward of the ductus omphalo-meseraicus, making an obtuse angle in- feriorly, whereby, the rectum being pushed forward, it pushes the inferior wall of the allantois before it. Communication between the rectum and the allantois ceases, and the allantois, becoming enor- mously distended, bursts. Ruge and Fleischer contend that in this 682 DISEASES OF WOMEN. affection the duct of the iimbihcal vesicle is implicated, and hold that the tense cord (duct) in question is a continuation of the uraehus. Winckel is of the opinion that bursting of the bladder at an early stage from urine-pressure is the weightiest cause in the produc- tion of bladder fissure. Against the idea of Rose, which is that eversio vesicae does not take place from rupture, Winckel says that the jjresence of scars is not absolutely necessary to prove the point, for the abdominal walls are not yet joined, and therefore can not be ruptured ; and, moreover, he has often seen children immediately after birth in whom the umbilical cord was normal, and yet an ever- sion of the bladder existed. He raises the query as to why we can not have rupture of the bladder at an early period, since we know that it occurs later in Hfe, as in w^omen with retroflexion of the gravid uterus. Another fact that he advances in favor of the view that rupture of the bladder is due to urethral obstruction is that it occurs oftener in males than in females, the former having a canal much more favor- able to such obstruction, for, of sixteen cases of vesico-umbilical fist- ula, given by Stadtfeldt, fourteen were males and two females. Dr. AVunder, of Altenberg, in 1831 observed the cases of two boys, aged respectively eight and eleven, with congenital eversion of the blad- der. It is interesting to note that their mothers were sisters. The various causes that give rise to vesical fissure produce also imperfectly developed pelvic bones, dislocation of the head of the femur, and other malformations from pressure. The excessive dilata- tion of the bladder drives the horizontal rami of the pubes asunder, and the changed direction and imperfect growth of the pelvic bones cause a lessened acetabular circumference and consequent slipping out of the head of the femur. Thus does Voss explain the disloca- tion occurring in one of his cases. It will be found on touching the red mucous membrane of an exposed bladder that it is exceedingly sensitive. In such a case the urine may be seen oozing from the ureters and diibbling over the surface. The mucous membi-ane is often protruded and wi-inkled up by the movements of the bowels, and can, in case the bladder- opening is great, be inverted through the fissure (inversio vesicas per fissuram) or through the uraehus (inversio vesicae per urachum). If the fissure is small it may remain for years without any inversion. If the prolapsed mucous membrane is replaced and indirect pressure is made on the dilated ureters, the urine will spurt from the ureteric orifices. Sometimes these patients have partial control over their urine : MALFORMATIONS OF THE BLADDER AND URETHRA. 683 as in cases where an umbilical hernia exists with umbilical fissure, the posterior wall of the bladder being forced into the opening plugs it up. Such a case is described by Paget. The hernial sac, which was about the size of a goose-egg, completely plugged the umbilical foramen by pressing firmly against the posterior bladder- wall. If the patient desired to urinate, the contraction of the blad- der caused a gradual disappearance of the hernial tumor ; and when it had entirely disappeared he passed urine from the umbilicus and then through the urethra. After the urethral flow began the stream from the umbilicus ceased, and no urine passed at that point unless strong pressure was made upon the abdomen. Another way in which partial retention may be accomplished in imperfect eversion is by the greatly thickened muscular walls acting as a sort of sphincter. Such a case given by Yoss is that of a female child, twenty months old. When lying down and quiet, the urine did not flow away so freely. The bladder-wall was nearly one inch in thickness, and the ureters, though three inches broad, were greatly narrowed at their point of entrance into the bladder. In fissures situated low down there may be coincident inguinal hernia, as is illustrated by a case related by Bertet. This comphca- tion may act so as to aid in the retention of urine. From the con- stant flow of urine, the inferior end of the fissure and neighboring parts become moist, red, eroded, and sometimes incrusted and ulcer- ated. There are various painful sensations, as itching and burning, and the patient becomes a nuisance to herself and to those about her from the offensive urinous odor that is constantly given off. The edges of the mucous membrane in time become changed, and resemble skin in appearance. At other points, oftentimes, the membrane is much changed, having upon its surface loose, villous growths, that bleed readily when touched, and give the impression of a malignant new-formation. By reason of a separation of the pelvic bones there is an irregu- lar, uncertain gait. The pelvic diametric proportions, as observed by Moergelin, are in these cases much changed, the transverse being much greater than the antero-posterior, the dissimilarity increasing as age advances, the proportion being sometimes trebled. Women with these troubles, however, have borne children. A close inspection of the ureteric openings being possible in these cases, the interesting observation may be made that in action the kidneys seem quite independent, the one of the other, the right discharging urine and the left none, or the reverse, or both may dis- charge together. 684 DISEASES OF WOMEN". Diagnosis. — the diagnosis of urachal fistula is comparatively easy, for the affection is at once recognized by finding the ureteric orifices with the mine flowing from them. As to frequency, the following statistics are of importance : In 12,689 new-bora children, Sickles found this malformation to occur twice in twenty-seven cases of developmental anomalies. In thirty-five hundred births occurring in the Dresden Institute, from 1872 to 1875, Winckel saw one case, Velpeau, in the year 1833, mentions seeing and finding on record more than one hundred cases of this kind. Percy says that he has seen it twenty times in his own practice. Winckel saw five cases, three of which were girls, and two boys. Phillips saw twenty-one cases, all girls ; but in Wood's twenty cases, only two were girls. Prognosis. — The prognosis is usually unfavorable. The children are weak and puny, and, as a rule, die early. They are, however, seldom destroyed by the fissure itself. Many of them are born liv- ing, and can be kept alive, and some attain a fair age. Lebert saw in Salpetriere Hospital, Paris, an old woman with this affection. Operative procedures and the various apparatus to prevent trick- ling of urine are of little avail. This, however, is only the case in total eversion. Urachal fistulae, simple tistulse, above the pubic symphysis, and even those situated inferiorly, where the pubic bones are united, may be readily cm-ed by the ordinary operation for fistula. Treatment. — Stadtfeldt operated in eight cases of urachal fistula, in seven of which he obtained perfect healing. In deep fistula he recommends freshening of the edges of the skin and mucons mem- brane, and attempting union by the first intention. In cases where the edges extrude themselves yhyj much, he puts on either a clamp or ligature. Winckel favors operative procedure since, in that way, the ab- normal protiiision can be removed. Sometimes, as recommended by Paget, it will be sufficient to freshen the edges, put in insect-pins, ligature, and union may be expected in from two to four weeks. In fissura vesicae, superior or inferior, an attempt might be made to draw the edges together, and even to loosen the skin in front by incision, so as to remove traction from the edges. In that case it will be necessary to freshen the edges and put in sutures. The re- sult, unfortimately, is not uniformly successful. In earlier times, in cases of true eversion of the bladder, no one dared to operate, and the only alleviation granted to the patient was such as could be obtained by a properly-adapted urinal. Ku- MALFORMATIONS OF THE BLADDER AND URETHRA. 685 meroiis appliances have been invented for tins purpose, some of them very useful. Gerdy was the first to operate for eversion by closure. Failing to bring an inverted bladder back into place, he tried to form a suf- ficient sac by partial excision of the ureters. The patient, a man, was attacked with peritonitis and nephritis, and died. Jules Koux, in 1853, proposed cutting out the ureters, and unit- ing them with the rectum. Simon tried this once, and succeeded ; but the patient died six months after from peritonitis and exhaus- tion. At a later date, he again attempted to treat this malforma- tion by operative procedures. He made one inferior and two lateral flaps, but these became gangrenous. Ten years later, these attempts were more successfully made by John Wood and Holmes, and their results recorded by Podruzski. The first one, however, who obtained a perfect result was Dr. Daniel Ayres, of Brooklyn. He cut a long flap from the under and lower side of the abdominal walls, turned the skin-side in, and united it with both edges of the bladder. A full account of this case will be found at the close of this chapter. Since then I have seen three cases, but as they were not patients of mine I had no opportunity to interfere surgically in their treatment. Subsequently, Wood operated on a girl one year and a half old, whose bladder-fissure was continuous with the uro-genital sinus, so that the os and cervix uteri were always wet. He raised one flaj) from the neighborhood of the umbilicus, and another from the soft parts, and turning the skin-side in, covered them with a larger flap from the other side. The mucous membrane, however, pushed through inferiorly, and broke the fresh adhesions. Ashhurst's case was more successful. He cut a piece from under the umbilicus, and joined it with two flaps from the sides (they being somewhat turned) so that their upper edges met each other in the median line. They were joined by sutures, and through each side of the upper flaps two pieces of malleable iron-wire were carried, then drawn through the lateral flaps, and twisted over little rolls of plaster. Traction was thus relieved. The flaps healed by the first intention. The sutures were removed on the eighth day. The rest of the wound healed by granulation. When in the up- right position, incontinence of urine still continued ; but when lying upon her back, the patient was able to retain urine for about two hours, her general condition being thus greatly improved. Ashhurst gives a resxLine of twenty cases of eversio vesicae, oper- ated on up to his time. Fourteen of these were successful — Ayres, 686 DISEASES OF WOMEN. Holmes, Wood, Morey, and Barker, each being credited with one, Three were unsuccessful, by Holmes and Wood ; and three resulted fatally, by Richard, Pancoast, and Wood. In the last two death resulted from causes other than the operation. In all cases when the skin is turned in, the growth of hair al- ready present or to come will ])e apt to give rise to incrustations. Thiersch, in his six cases, allowed the flaps to granulate on their raw surface before applying them. When the flap-union is perfect, he advises closing completely the upper part of the bladder. The diagnosis of double bladder may be made by urethral dilata- tion and exploration by the finger and catheter. Destruction of the bladder-septa is not to be thought of. In case of the existence of urachal cyst causing difficult urination, one might try extirpation of the cyst by cutting into the abdominal \xa\\s, and after freshening their edges unite them with those of the bladder. ILLUSTRATIVE CASES. Extroversion of the Urinary Bladder. (By Daniel Ay res, M. D., LL. D.) — The patient was admitted to the Long Island College Hos- pital, November 1, 1858, and a history of the case recorded by the house surgeon, Dr. Ostrander. She is twenty-eight years of age, born of healthy parents, both of whom were free from deformity ; her height is below the aver- age of females, and she is unmarried. She declares her health to have been always good, appetite and digestion excellent, bowels regular, and the catamenia in all respects normal. She states that, on the 5th of July preceding, she was delivered of a well-developed child, having carried it to maturity without extraordinary difficulty. Labor commenced with free hfiemorrhage (footling presentation), and lasted two hours, at the end of which time the child was bom, having died in process of delivery. Peri- naeum uninjured. She reports having made a tolerable recovery, though for a long time weak, and her present appearance is some- what anaemic. Shortly after she began walking about symptoms of prolapsus uteri came on, becoming gradually worse, until the organ projected external to the vulva, attended with dorsal, dragging pain, difficulty of locomotion, and gastric disturbance. In quest of relief, she entered the Brooklyn Cit}' Hospital on the Ist of September following her confinement, and remained there one month. Here she states that a variety of jiessaries were tried, none of which could be retained, and finally a surgical operation MALFORMATIONS OF THE BLADDER AND URETHRA. 687 was performed, tlie nature and character of which is not very appar- ent. A short article, descriptive of this ease, appeared in the "Vir- ginia Medical Journal" for January, 1859, written by the house surgeon of that institution. Tlie writer states that an attempt was made to retain the prolapsed uterus " by removing an inch of mu- cous membrane from the bottom and sides of the vulva, and unit- ing them by two ligure-of-eight sutures, which were removed on the sixth day, when no adhesion was found to have taken place." The writer continues : " The patient was allowed to get up on the fourteenth day, when the prolapsus was found to exist nearly as much as before," etc. It is obvious that no effort was made to relieve the congenital deformity, and that she was discharged in much the same condition as when she entered. Finally, a species of stem-pessary was contrived which was in- tended to support the uterus, while kept in position by strings passed around the thighs. This, however, proved very inefficient — the uterus slipping by the instrument upon the slightest extra exer- tion. Moreover, the parts had now assumed an irritable condition, partly due to increased friction of the apparatus, and undue attention to cleanliness, added to the causes already noted ; altogether, her de- plorable condition was scarcely susceptible of being made worse. I may here remark that the figures, both before and after the operation, have been photographed from accurate plaster- casts, taken directly from the patient — a very difficult and delicate procedure, for which I am much indebted to the skill and kindness of my colleague Dr. Bauer, and our valuable assistant, Mr. J. F. Esslinger. Fig. 246 is an exact representation of the parts at the time of presentation to the clinical class of the Long Island College Hospi- tal, for the purpose of critical examination. The prolapsus, having been carefully and completely reduced, was found to retain its place so long as the patient maintained the recumbent position. The distance between pubic abutments was estimated at about three inches. The bladder {a) formed an oval, elliptical tumor, mammillated upon the surface, which in the recumbent position measured two inches in its long, and one inch and a quarter in its short diame- ter. This was soft, elastic, or bright verniihon color, and covered with a thick tenacious mucus ; bleeding readily when rudely han- dled, and so exquisitely sensitive, that while under the full influence of chloroform, and insensible to the knife, a sponge passed over the exposed bladder excited reflex motions. 688 DISEASES OF WOMEN. The integument immediately surrounding the bladder was found red and puckered, but very soft, delicate, and free from hair be- tween the bladder and point of sternum. The labia majora (o, oint to a tendency to neu- rotic difficulties, liable to be localized. Proyno-ns. — As a rule, the prognosis is favorable. This, how- ever, is not always the case. The longer the affection has lasted, the more difficult it is to cure. Most cases may be cured in a few wrecks' time, and even the most obstinate in a few months. The danger to the patient lies in the fact that continuance of the disorder is liable FUNCTIONAL DISEASES OF THE BLADDER. ^09 to bring on an organic lesion, and, whether this results or not, the reaction on the general system tends, in the worst cases, to produce hypochondriasis or even melancholia. Causation. — These nervous affections of the bladder occur most frequently in those of the nervous temperament. A highly devel- oped nervous system predisposes one to nervous affections of all kinds. Especially is this the case if the subject is not well sustained by a vigorous nutritive system. Those in whom the emotional ele- ments predominate in the mental composition are more liable to nervous affections of the bladder than those of the more intellectual type- The exciting causes include all influences which depress or ex- haust the nervous system. Mental taxation or excitement which tends to increase the excitability of the nervous system may derange the function of the bladder. Constitutional diseases which lower the tone of the w^hole organization also tend to produce the affections now under discussion. It is not possible to give any satisfactory explanation of the reason why the innervation of the bladder becomes deranged in some per- sons from causes which are in others inoperative. It may be that those who are most susceptible to this cause are so because of some inherited sensitiveness of the pelvic organs which responds to the disturbing influences. This appears to be the case with those who suffer from irritation of the bladder caused by ovarian disease. This is apparent from the fact that one affected with disease of the ovaries will suffer from derangement of the function of the stomach, while another having a similar ovarian affection will suffer most from fre- quent urination. Regarding the causative relations of malaria to irritation of the bladder, all that can be said at the present time is that this materies niorhi appears to act upon that viscus through the nervous system. Treatment. — This may be classed as general and local. In pure neuroses, attention should be first directed to improving the general condition of the patient. Cheerful company should be provided at meals and at other times, and there should be exercise suited to the strength of the patient, daily ablution, and proper regulation of diet. This latter should be simple and nourishing, and of a kind calculated to produce as little urea and urinary solids as possible. In cases where the urine is limpid, the opposite course is to be pursued. Pastry, irritatmg condiments, and stimulants, except in rare cases, should be prohibited. The exception to this is where a condition of the system calling for stimulation exists. In such cases the irrita- 710 DISEASES OF WOMEN. tion of the bladder produced by their use may be more than counter- balanced by the good they do the general system. Tea is better than coffee, but neither is to be used in any great quantity. The condition of the urinary secretion must be carefully watched, and any abnormality quickly and judiciously corrected. Where there is any tendency to excessive acidity, the effervescing waters, rich in carbonic-acid gas, will be found of use. The bowels should be kept moderately well open, but should never be irritated with active cathartic agents. Tonics and medicinal stimulants are often of great value when judiciously exhibited. Strychnia in very small doses does not, as might be supposed, aggravate the irritable condition of these organs. The nerve-tone being below par, strychnia, by gradually increasing it, is of great service. In large doses it is undoubtedly hurtful, and should never be long continued. Quinine, iron, and the various sim- ple and compound vegetable bitters act well in the cases where their exhibition is indicated. If the irritation is extreme, various soothing emulsions and de- coctions may be given by the mouth. Of these, preparations of marshmallow, triticum repens, acacia, pareira brava, and buchu act well. Emulsio-amygdalse is much used and highly recommended by the German authors. Some objections have been raised to the use of these drugs on the score that they increase the flow of urine, thus aggravating the local irritability. The fact is, however, that the presence of fairly normal urine in the bladder in moderate quantity seems to relieve rather than increase its irritable condition. The local treatment may be as follows : A cupful of M-arm ho])- tea, containing from twenty to forty drops of laudanum, may be injected into the rectum. Suppositories containing opium may often be used with benefit. With the opium or morphine in the supposi- tories may be combined belladonna, atroijine, or hyoscyamus. Mor- phine in the form of Magendie's solution may be injected directly into the bladder. There seems to be no especial advantage in this mode of administering anodynes, hypodermic injections of the drug acting as well, if not better. Emulsions, decoctions, and infusions of cannabis Indica, hyoscyamus, belladonna, and other like drugs may be used by the mouth, as the case may require. Good effects have followed the use of rectal injections containing chloral hydrate (grains 15 to water ^i or 3 ij). It may also be given by the mouth, but does not usually act so quickly or have such a direct local effect. FUNCTIONAL DISEASES OF THE BLADDER. 711 The injection into the bladder of a sohition containing morphine, followed by cauterization of the mucous membrane, is highly spoken of by Braxton Hicks. He claims in this way to deaden the reflex irritability of the membrane. I must insist on this — that opium shall be used in such cases with great care, and never continued long. If this rule is neglected, it will lead many nervous patients to contract the opium-habit, which disease is worse than irritable bladder. Debout recommends the use of bromide of potassium by the mouth, and also in suppository, combining with it in the latter tinct- ure of opium and belladonna. I prefer hydrobromic acid to the bromide of potassium. When the trouble is due to masturbation, moral and mental in- fluences must be brought to bear, as well as medication and regula- tion of diet and habits. In these cases the bromides will be of serv- ice. If all otlier treatment fails to accomplish the desired result, resort should be had to mechanical means, viz., the rapid and forcible dila- tation of the urethra. Some authors, indeed, think so highly of this method that they boldly assert that time spent in medication is time lost. Astonishing and very gratifying results have certainly followed its use in a number of cases. Hewetson reports in the "Lancet" (page 4, vol. xii, 1875) that in this manner he cured a case of cysto- spasm of fifteen years' duration. This procedure is spoken of in the highest terms by Teale (" Lancet," page 27, vol. xi, 1875), as also by Spiegleberg, Tillaux, and others. In the cases where this treatment gives relief, I believe that there is some inflammatory condition present, or at least something more than a neurosis. When due to malaria, the treatment is usually simple and satis- factory. Quinine in full doses, as recommended by Bricheleau (" Arch. gen. de med."), for one day, and then in small doses before meals for a week, will usually cut the trouble short, and j^revent its return. The digestive organs require attention when they are out of order, as they usually are. If due to hysteria, the original disease should be treated, not, however, neglecting the local trouble. When accompanpug acute or chronic systemic diseases, it is only relieved when the original disease is cured, although in the mean time the annoyance may be greatly alleviated by the treatment already recommended. 712 DISEASES OF WOMEN. nXUSTEATIVE CASES OF FUlSrCTIONAL DISEASES OF THE BLADDEK, EST WHICH THERE IS NO RECOGNIZABLE ORGANIC LESION. Neuralgia of the TJretlira and Neck of the Bladder. — A married ladj, who had never been pregnant, was tirst seen when she was twenty-six years of age ; she had then been three years married. She was well developed, and, although of a marked nervous tempera- ment, had always enjoyed good health. From puberty onward she had suffered pain at her menstrual periods, but not of severe charac- ter. When she was twenty-four years old she was chilled while rid- ing a long distance on a cold day, which was followed by frequent and painful urination. This was somewhat relieved by rest and diuretics. From that time she was subject to violent attacks of spas- modic pain in the urethra and bladder. The pain was of a sharp, lancinating character, generally coming on before and after her men- strual period ; it was, however, brought on at any time by nervous excitement or great fatigue. During the pain there was some diffi- culty in urinating, but the pain was neither relieved nor increased by the act. The duration of the pain varied, but usually did not last more than twenty-four hours. At times she became almost frantic, so great was the suffering. Large doses of opium would relieve her, but, as it caused very distressing after-effects, she avoided taking it, except when the attacks were exceptionally severe and prolonged. When she first came under my care she had a flexion of the uterus, with slight general tenderness of the pelvic organs, which accounted for her mild dysmenorrhoea, and I j)resumed that that might be the cause of the neuralgic pains in the bladder and urethra. She was treated for the uterine affection, and obtained complete relief from the painful menstruation and tenderness of the pelvic organs gener- ally, but no relief was obtained from the periodic attacks of pain in the urethra and bladder. She acknowledged that it was not quite so severe at her menstrual periods, but was " bad enough in all con- science," as she expressed it. Careful and repeated examinations of the urine were made M'hen she had pain, and when she was free from it, but no trace of any renal, vesical, or urethral disease was obtained. The urethra and neck of the bladder were examined with the endoscope several times, but were found to be normal. Suspecting that the neuralgic pain — for such it apparently was — might be due to malaria, she was given fifteen grains of quinine within a period of eight hours, followed by Fowler's solution of arsenic in doses of three minims after each meal. The arsenic treatment was continued for several weeks, and FUNCTIONAL DISEASES OF THE BLADDER. 713 gave lier some relief, the attacks being less violent, but still she suffered greatly. Moderate dilatation of the urethra was then practiced. This ag- gravated the trouble. Several different remedial agents, including opium, hot water, aconite, infusion of hops and belladonna, were in- jected into the bladder, but none of them gave any relief. The citrate of iron and quinia in five-grain-doses was then prescribed to be taken before meals, and Parrish's comjDOund sirup of the phos- phates in drachm doses to be taken after meals. When the pain came on she w^as directed to take every three hours a drachm of camphor- water containing eight grains of muriate of ammonia, and to use a vaginal douche of hot water. This treatment usually re- sulted in mitigating the pain, but did not completely abolish it. Thirty minims of the compound spirits of ether and five minims of the tincture of cannabis Indica every four bours were substituted for the camphor-water and muriate of ammonia and with good effect. Under this treatment her attacks were far less frequent, and the re- hef from pain was prompt. She was so much pleased with her im- provement that she took a trip through the West and returned quite well, and has remained so for the past eight years. More re- cently I have had a case which resembled this one in many respects, particularly as regards the character of the pain and its causation, in which a four-per-cent solution of muriate of cocaine instilled into the urethra and bladder gave relief. A Peculiar Form of Neuralgia not yet described, excited by a Desire to Pass Water and by Micturition. (By Dr. Putegnat, of Luneville. (Gaz. Hebdom de med. et chirurg., April 15, 1864.) — The following two cases, out of six published by the author, will give an idea of this peculiar neuralgia, which consists on the one hand, in a special sensation in the bladder, and on the other, in symptoms of a neurosis of the ulnar nerve. M. X., aged fifty, wdth chestnut hair, of a nervous and san- guine temperament, very abstemious, in affluent circumstances, lead- ing a very active hfe, occupying very healthy apartments, free from all diathesis, except a slight rheumatic affection, liable to coryza in cold, damp weather, has never had any other nervous complaint be- yond headache and occasional gastralgia after eating dressed salads or raw fruit. From time to time, at varying intervals of weeks, months, and even years, without any apparent physical or moral cause, in all electric, barometric, and thermometric conditions of the atmosphere, as soon as his bladder is full, and he has a strong desire to pass 714 DISEASES OF WOMEN. water, he feels along the urinary passages, especially in the perinaeum a peculiar sensation of numbness, not very painful, but acute, burn- ing, lancinating, and unpleasant from the accompanying sense of prostration. This strange sensation next affects the shoulders, comes down both arms, along the course of the ulnar nerve only, and gives rise in the forearm, the little and the ring fingers, to the same sensation as when the ulnar nerve is strongly compressed at the elbow. The pain is more acute on the left than on the right side, lasts about twenty or thirty seconds, and after diminishing gradually, disappears without leaving any trace behind it. M. X., of Luneville ; living in healthy rooms ; very active, easily moved and excited ; subject to headaches and to rheumatic pains ; free from any diathesis ; very abstemious ; complains, for several successive days, but at irregular intervals, and without any known cause, of a strange sensation along the outer border of the left forearm, on the inner side of the thumb, and the outer surface of the index-finger especially. This sensation he compares to the one produced in the last two fingei's of the hand by compression of the ulnar nerve at the elbow. The painful sensation only comes on whenever he has a strong desire to j^ass water, persists during micturition, and ceases com- pletely immediately afterward. On analyzing the six cases of the author, we find four of them to have occurred in females. The mean age of the patients is forty- six; the oldest being fifty-two, and the youngest thirty-six years old. They are all in easy circumstances ; five occupy healthy apart- ments, the sixth only living in damp rooms on the ground fioor. Three patients have had gastralgia ; the fourth sciatica, and great troul)les have shaken his nervous system ; the fifth is subject to vio- lent headaches ; and the sixth, a female, seems to have epileptiform seizures, and has a double neuralgia. From the above, then, it may be concluded that neuralgia and great nervous excitability are pre- disposing causes of this strange neuralgic affection. In one of the four female patients the catamenia had ceased ; in three they had not, and in two of those thef neuralgia showed itself before and during the menstrual periods. Uterine congestion seems then to be a predisposing cause also. Four of the six patients had had rheumatic pains ; but the other two having never suffered from such pains, this can not be consid- ered as the exciting cause of the neuralgic affection. The desire to pass water, and especially the act of micturition, brings on the sensation, which only appears at those stated times, FUNCTIONAL DISEASES OF THE BLADDER. 715 and it reaches its maximum intensity at the beginning of the mic- turition. It has all the characters of neuralgia, and can even aggra- vate, as in one case, an already pre-existing neuralgia — that of the median nerve. As to the precise seat of the sensations, we find them affecting the four extremities of one patient, but the upper limbs only of the re- maining five. In three cases they simulate to perfection neuralgia of the ulnar ; and in two they are felt in the tips of all the fingers. In one case they coincide with and intensify pains in the course of the median ; and lastly, as in the first case we have given above they are felt in the distribution of the left radial nerve. The first patient complains of pain in both shoulders, especially the left ; the fourth, of pain in both arms and hands, but chiefiy in both breasts, and in the left breast more than the right ; the sixth, again, of pain in both forearms and hands, but more marked on the left side. Hence, the left side of the body would seem to be either the only one affected, or the one most affected. The patients always distinguished clearly the special painful sen- sations felt in the urinary passages from the normal sensations due to a distention of the bladder and the subsequent desire to pass water. Retention of Urine Due to Hysteria. — A single lady, thirty -one years of age, of delicate organization and pronounced nervous tem- perament, yet very quiet and self possessed in manner, suffered for some time with difficulty of urination. At times she could m'inate very well, at others she was obliged to try repeatedly before she succeeded. She was a lady of high culture and liberal education, but was not interestedly occupied, and hence she had much time for introspection. She called her physician who prescribed remedies, but finding that they did not give her relief, made an examination of the pelvic organs but could find no cause for her inability to urinate with facil- ity. Soon after she was taken with complete retention which was re- lieved by the catheter. This continued for weeks, requiring the doctor to visit her three times a day, and occasionally at night, to pass the catheter. For some reason which was not very evident and could hardly be due to weakness or suffering, she remained in bed most of the period during which the catheter was used. Be- coming weary of such close attention, the doctor tried letting her wait, to see if a full distention of the bladder would have any good effect. This caused her so much pain that the doctor felt somewhat 716 DISEASES OP WOMEN. mortified at liis want of feeling in permitting her to suffer. Dur- ing this time he had tried a number of remedies, but without eiieet. At this stage of the history I was called in consultation ; I could find no evidence of any organic disease, local or general. The urine was found upon examination to be normal. I suggested to the attending physician that the trouble was hysteria, but he as- sured me that she was sin^ilarly free from all evidences of that affection. Indeed, he had found her a remarkably calm and sensible lady, and very free from nervousness of every kind. The impression that I received was that there was a very decided hysterical element in the case, and I advised full doses of bromide of potassium and a sitz-bath when she desired to urinate. I also recommended that she should go to Saratoga, and drink Hathorn water. She did this, and the water gave her diarrhoea, and her retention was immedi- ately relieved. Frequent Urination Due to Hysteria. — A lady twenty-three years of age, in very good general health, and living in very easy circum- stances, had some disappointment which caused her much distress. She had faintings of a mild character which alarmed her mother and called forth much sympathy. About this time she began to suffer from frequent urination. This did not yield to the treatment employed by the family physician, and she was brought to my office for advice. Her health was at times excellent, but she was greatly annoyed by this frequent urination. The urine was normal except at times when it was of a very light color. She could sleep all night without being disturbed by a desire to urinate. If by chance she did not go to sleep immediately on retiring she was obliged to urin- ate every few minutes, and if she was awakened in the night she had to urinate many times before she could sleep again. Any little mental excitement, such as going to church or to the theatre, would bi-ing on the trouble, so that she had to give up all public duties and pleasures. Systematic exercise and occupation, cold baths, bromide of sodium, and a full assurance on my part that she would soon recover, helped her greatly. She was commanded in a very decided way to resist the inclination to such frequent urin- ation, and she obeyed orders. Soon after this her attention was attracted in another and more interesting direction, and she roeovcred completely. Frequent Urination from Perverted Sexual Function, — A girl nineteen years of age who had a good general organization and en- joyed good health up to puberty at fourteen, sought advice regard- ing impatience of her bladder. She was obliged to return home FUNCTIONAL DISEASES OF THE BLADDER. 717 from boarding-school because slie had to urinate so often that she could not attend to her studies and recitations. Her general nutri- tion was good, she menstruated regularly, freely, and without acute pain. Her nervous system was depressed. She was sometimes lan- guid, low spirited and fretful, at other times she was bright and dis- posed to be cheerful. Her manner was rather timid and excited. Her hands were clammy, and her eyes dull, and had dark streaks under them. Her chief symptom was the frequent urination which persisted but was much worse at times than at others. Occa- sionally she would pass the night without getting up more than once or twice, but during the day she was often obliged to urinate every half-hour. There was very little pain except occasionally a little smarting at the meatus. She complained of heat and burning about the vulva and occasional aching in the region of the ovaries. She was easily fatigued and had backache, especially on standing and walking — leucorrhoea troubled her only at times. I suspected at first that she had either cystic and urethral con- gestion, or else hysteria giving rise to excessive renal secretion of limpid urine, but an examination of the quantity and composition of the urine proved the contrary. She was put in charge of a very competent nurse who was directed to find out the habits of the patient. The report of the attendant was that she had begun to indulge in masturbation soon after puberty, and that the habit had gradually grown upon her. Her nurse surprised her by telHng her the cause of her suffering, and readily gained her consent to make all due efiPorts to recover her self-control. By care, occupation, and exercise out-of-doors, and the moral control of her nurse, she began to im- prove. Bromide of sodium was given when she was very restless and irritable, but no other medication, except the free use of bathing. In about two months the frequent urination had disappeared, al- though she would occasionally have a day or a night when she suf- fered in that way a little. She now has two children, and enjoys life very well, being free from her former symptoms and no doubt cured of her former habit. Frequent and DifB-cult Urination from Sexual Continence. — The patient, a strong and active lady in good circumstances, was married at twenty-one years of age, and had her first baby before she was twenty-two. She nursed the child for eighteen months. Her menses came on when the child was one year old. About three years after her marriage, her husband, a strong, vigorous man, died Y18 DISEASES OF WOMEN. of pneumonia. Several months after the loss of her husband she began to suffer at times from frequent urination, and also had some difficulty in voiding the urine, requiring voluntary efforts. These attacks would pass off, and she would be comfortable for days, when the same irritation of the bladder would return. She was always made worse by excitement, often being kept awake nearly all night after spending the evening in company. Her symptoms became so troublesome that she sought advice of a physician, who treated her for cystitis by giving medicines of va- rious kinds. When she first came under my observation I found her in perfect health in every way. The urine was normal, and caused no pain when she passed it. I was easily able to exclude all diseases except deranged innervation from a possible malarial influ- ence. The periodical character of the attacks favored this view of the case, but the use of the anti-malarial remedies gave no relief. I then ordered her to take more active exercise and a limited quantity of plain food, to bathe frequently, and to avoid excitement as far as possible. Bromide of sodium was also given when her suffering was most severe. She improved on this treatment for a time, in fact she became so much better that I lost sight of her for nearly a year. She returned to say that her former symptoms had returned, and were about as troublesome as before. The same treat- ment was employed but did not help her very much. She was now rather nervous and restless, and disposed to be emotional. Three months afterward she was married, and left the city on an extended wedding-tour. Upon her return she reported herself as perfectly w^ell. A Case of Malarial Irritation of the Bladder in the Female. (By Henry K. Leake, M. D., Dallas, Texas. Abstract of a paper read before the Texas State Medical Association.) I desire to record an observation, which I have recently made, exemplifying the effect that tlie malarial poison may exert upon the female blad- der ; an observation which may appear commonplace since, as is well known, it has not escaped mention by Prof. Skene in his excel- lent work on tlie " Diseases of the Bladder and Urethra in the Female" as well as by other authors of equal or less prominence, who have attended to the same subject. Nevertheless, considering the mere allusions by these writers to irritation of the bladder in women, which may be caused by the presence of malaria in the system, on account, doubtless, of the rare occurrence of this affection, it may be (juestioned whether the latter has been sufficiently individualized as a distinct and independent FUNCTIONAL DISEASES OP THE BLADDER. YlQ malady, deserving especial prominence in the nosology of diseases of the bladder, which seriously disturb the functions of this sensitive viscus. There is the additional reason, also, for reporting the ex- perience which I have had of this peculiar and interesting disorder, in the fact that much obscurity yet surrounds the entire subject of disturbance of the functions of this organ in the female, the integrity of which is so vital to the comfort, happiness, and safety of the in- dividual. Moreover, such conditions often tax the diagnostic acumen of the physician to the utmost, and even when by the exclusive method, rigorously employed, many causes of UTitation of the bladder may be eliminated from the problem in hand, there will yet remain in particular cases, other causes which may elude discovery, thus ob- scuring the pathogeny and defeating every measure of treatment which is attempted. About March 1st, of the present year, a lady, whose health has been uninterruptedly good, thirty-seven years of age, the mother of six children, the last of which being an infant of four months, ap- plied to me for treatment for what she considered the ailment to be, incontinence of urine. She stated that the condition had come on gradually, at the first amounting to a mere frequency of urina- tion during the day, vfithout any attendant pain or other symptom which attracted her attention. This frequency had increased, how- ever, to such an extent as to seriously embarrass her in the perform- ance of domestic duties, and prevent her from visiting friends, or doing necessary shopping. Moreover, she soon became troubled at night, often rising six or, perhaps, a dozen times, in obedience to the urgent calls for micturition. The amount of urine passed at each discharge was not large, but exceeded in quantity that ordi- narily retained in cases of acute cystitis, which the affection in many respects closely resembled. There were no deposits in the urine worth noting. It appeared to be somewhat higher colored than normal. There was also a superabundance of mucus, in the form of large floccuH, but no pus or blood. As the case progressed, the desire to evacute the bladder was preceded by a sharp twinge of pain, which the patient aveiTed was " low down at the very neck of the bladder," but which was imme- diately relieved on emptying the viscus. There was no tenderness at any point except a slight pain experienced when the neck of the bladder was firmly pressed toward the pelvis. The frequency of micturition increased to almost constant drib- 720 DISEASES OF WOMEN. bling from the bladder, botli daily and nocturnally the cloud of mucus in the urine was much augmented, and while the color a]>- peared to remain unchanged, there was evidently a large excretion of solid matter composed probably of phosphates. The uneasiness elicited at the neck of the bladder by pressure on this part soon changed to actual soreness. At the end of the second week the case had passed into one of apparently serious import, and was operating with telling effect on the vitality and mental equipoise of the patient. The tripod of treatment, namely, rest, opium, and alkalies, upon which Yan Buren and Keyes cogently jirotest the successful manage- ment of cystitis rest, was relied on to relieve what I now feared was a case of this distressing disease, the cause of which I could not then determine. The constitutional effect of belladonna was evoked also to mitigate the symj^toms, and finally hot-water vaginal injections were employed for their well-known analgesic and anti- phlogistic effects upon the pelvic viscera. Such measures gave only temporary relief, the features of the case resuming their original character whenever the effect of medi- cation—which was occasionally suspended to ascertain the status quo of the disease — had passed off. At the beginning of the third week from the first appearance of the symptoms, the patient complained of slight chilliness toward evening, and it was obsei-ved that this was followed by fever, the thermometer in tlie mouth registering 101.° These symptoms were interpreted to indicate the constitutional expression of the local in- fiammation existing in the bladder. Hence, no special attention was directed toward them. The chilliness was repeated, however, on the third evening, and on the fourth day at the same hour reap]5eared as the prodrome of a marked rigor, followed by an abrupt rise of temperature of 103° succeeded by sweating and a return to the normal temperature m about four hours, thus clearly demonstrating a well-defined periodicity of the febrile movement. Suspicion being now aroused as to the essential nature of the case, the patient was promptly placed on ten-grain doses of the sul- phate of quinine, to be taken every four hours with mercurial and saline purgatives, the latter being indicated by the appearance of the tongue and the confined state of the bowels, which was due not alto- gether to the opium administered, since this physical n;odifier had been exhibited both freely and sinmltaneously. The substitution of the quinine for the treatment previously pursued, like the fabled wand of the magician, broke tiie spell ol FUNCTIONAL DISEASES OP THE BLADDER. ^91 enchantment, which, by its subtle and potent influence had held the patient with relentless grasp for three weeks and had trans- formed a hopeful and contented disposition into one of melancholy and apprehension. At the end of four days from the administration of the first dose of quinine the patient was virtually convalescent. During this period no opiate was employed nor any other medicine but quinine taken, save an occasional dose of neutral mixture, chiefly for its su- dorific effect. Nevertheless the irritation of the bladder did not re- turn, and the close of the week found the patient, although debili- tated by the trying ordeal through which she had passed, enabled to resume her accustomed duties. Periodical Attacks of Frequent and Painful Urination and Vesical Tenesmus caused by Malaria. — About two years ago a patient came to my college clinic complaining as follows : In the afternoon of each day she experienced a sense of heat and burning in the bladder and urethra, with a frequent and irresistible desire to urinate. Evacua- tion of the bladder, attended with a great deal of smarting and pain in the urethra, did not give complete relief but left some vesical tenesmus which increased in severity as the bladder became dis- tended. These symptoms persisted during the night and kept her awake, but toward morning her suiferings entirely left her, and she became quite comfortable until the next afternoon. This condition had existed for nearly two months, and accordingly her digestion be- came impaired and her strength diminished. This was attributed by her to the want of sleep, and no doubt in part was due to this cause. The urine was examined, and found to be normal except that it contained a slight excess of phosphates. She was carefully exam- ined, and no evidence of organic disease was found. While she al- ways enjoyed full health and had been a vigorous woman, she had had an attack of malarial fever about six months before I saw her, and about the time this bladder trouble came on she said she had symp- toms of her former ague. From the facts in her history I ventured to state to my class that this was a functional derangement of the bladder and urethra caused by malaria, which would promptly yield to judicious doses of quinine. I accordingly prescribed twenty grains of quinine to be taken between early morning and noon, to be followed by two-grain doses before meals with four drops of Fowler's solution of arsenic after meals. She was ordered to report at the clinic the following week. She did so, and declared that she had been perfectly well since the first day she took the medicine. The quinine and arsenic in small doses were continued for three 47 722 DISEASES OF WOMEN. weeks, at the end of which time she reported herseK as having been well and free from all irritation of the urinary organs. No change in the character of the nrine could have occurred to produce such marked periodicity in tlie functional derangement of the bladder and urethra ; moreover, the urine was found to be nor- mal, and she completely recovered on the use of quinine. Vesical Tenesmus and Frequent Urination due to Prolapsus and In- flammation of the Ovaries.— In prolapsus of the ovaries and inflamma- tory alfections of these organs irritation of the bladder often occurs. This is illustrated by the following case : A young girl of twenty-one was brought to me suffering from great distress in the pelvis, which was much aggravated by standing or walking. Her suffering was constant, but was tolerable when she remained in the recumbent position. She began to complain about six months before I saw her, and about the same time she found that she was obliged to urinate too often, and that there was an un- easy feeling in the bladder most of the time, a feeling as if the bladder had not been fully evacuated. She was nmch worse at her menstrual periods. Upon a thor- ough examination I found both ovaries prolapsed, slightly enlarged, and exceeding tender. In every other respect she was perfectly well. In consultation with her physician, a course of treatment for the ovarian disease was decided upon. This was fully and faithfully tried for over one year, but at the end of that time she was worse. She was then quite impatient, being very nervous and irritable from her confinement and suffering. Her parents and friends were quite weary of seeing her suffer. Her bladder ii-ritation was no better ; in fact it was a great source of suffering. She could not urinate without getting up, and the erect position increased her ovarian pain. The ovaries were still prola2)sed and just as tender, in fact, more so than they had been. The complete failure of treatment so far indicated that removal of the ovaries was the only thing that promised to give her relief. Accordingly the ovaries were removed, and she made a rapid recov- ery from the operation and was completely relieved not only from her ovarian pain but also from the frequent urination and vesical tenesmus. It should be stated that at no time was there any evidence cf cystitis found upon frequent and careful examinations. CHAPTER XL. FUNCTIONAL DISEASES OF THE BLADDEK (cONTINTJED). Having considered the vesical derangements in which there is no recognizable organic lesion, and which may be local neuroses, or may be due to hysteria, disorder of the sexual function, malarial or ovarian affections, I will now invite attention to the second class of these disorders. I. Derangements of function due to diseases of the nutritive and nervous systems, or to abnormal conditions of the urine which re- sult therefrom. This class naturally subdivides itself into : 1. Derangements occurring in both acute and chronic diseases. 2. Derangements due to consequent abnormal conditions of the urine. 1. Of the derangements which occur in the course of acute dis- eases, such as retention and incontinence of urine and frequent urin- ation, nothing more than the mere mention is necessary. Tliey rarely require any treatment, except possibly in the case of reten- tion, when catheterization is to be employed, and they cease as soon as the acute stage is passed. Those, however, which are due to chronic affections of the nutritive and nervous systems are more permanent, and often tax the resources of the physician to the utmost. The two most important are : (a) Paralysis of the bladder, and, {h) Incontinence of urine. (a) Paralysis of the Bladder. — This affection has also been de- scribed under the names of weakness or palsy of the bladder, and vesical atony. It occurs in two forms : First, from causes residing in the organ itself ; second, from those due to outside influences. As affections in the first form ^vill be fully described in another place I shall here simply mention them. They are : Fatty degenera- tion and atrophy of the muscular walls of the bladder, a common 723 724 DISEASES OF WOMEN. cause of paralysis of this \ascus in old women ; overstrain of tlie muscular structure from prolonged retention, voluntary or involun- tary ; displacements and inflammations of neighboring organs aifect- ing its position or nutrition ; and abdominal and pelvic tumors. In fevers of a serious type the power of nerve conduction may be either lost or impaired, and a partial or total vesical paralysis re- sult, with overdistention and dribbhng of urine. The second form is due to influences acting from without the bladder, and includes acute and cln-on'ic meningitis ; apoplexies of the brain or spinal cord ; sopor ; delirium ; myelitis of the lower part of the spinal cord ; inflammation of any kind primarily affect- ing or involving in its results either the lumbar nerves or ganglia ; endarteritis deformans of the pelvic arteries ; lumbar or renal ab- scesses ; blows or fall upon the loins, supra-pubic region, or head ; shock or disease of the vesical or lumbar nerves from the prolonged use of opium or poisoning by it, and also shock due to overdisten- tion of the organ itself. Syrrqytomatology. — Except in cases of injury of the brain and apoplexies, the invasion of the disease is usually very gradual. This is especially the case in the aged, and sometimes, though rarely, in young peoj^le. The patient first observes that the urine is expelled from the bladder with less force than usual ; that the act of empty- ing the bladder is more slowly accomplished, and that after a time the organ is unable to expel its contents without considerable strain- ing and aid from the abdominal muscles. At a later date, if the disease goes on unchecked, the stream is less and less forcibly ejected, intermits, and the bladder, after much straining, is but pai-tially emptied. Finally, partial or complete retention follows. The female bladder seems to be capable of more distention than that of the male. Lieven, in a case of supposed ovarian tumor, re- moved by catheterization about nine pints of urine. The patient was a woman thirty-three years of age. The fundus of the bladder reached as high as the ensiform cartilage. I once saw a case exactly like this, except that the bladder only reached to about two inches above the umbilicus. More than a gallon has been drawn off by Hof meier and others. A peculiarly interesting experiment bearing upon the dilatability of the bladder was made by Budge. He found that section of the lower part of the spinal cord, when the bladder was considerably distended, allowed increased reflex action of the sphincter, and enormous distention then took place — even more than could be pro- duced by force, after death. This is especially interesting in rela- FUNCTIONAL DISEASES OF THE BLADDER. Y25 tion to vesical paralysis and retention due to injury or disease of the lumbar portion of the spinal cord. In some cases of overdistention the resistance of the sphincter is overcome somewhat, and a constant dribbling of urine takes place. It has been called by some authors incontinentia parodoxa. These cases are hable to be mistaken for those of pure incontinence. In rare cases rupture of the bladder may take place ; more com- monly dilatation of the ureters and hydronephrosis. If the condi- tion of vesical distention be not soon relieved, vesical catarrh, true inflammation, ulceration, and death take place. In cases due to in- jm*y or disease of the spinal cord, low down, there seems to be a paralysis or peculiar condition of the nerves presiding over the nu- trition of the vesical mucous membrane, and destructive changes are not uncommon. Diagnosis. — The diagnosis though easy, is sometimes not made, owing to careless observation or ignorance. When called to a case where there is supposed distention of the bladder, the abdomen should first be examined to see if there are signs of a tumor, and then a catheter should be passed if that be possible, to determine whether an abnormal amount of urine is present. K this is the case, and the tumor gradually subsides as the urine flows, the diag- nosis is at once made. "When, however, a catheter can not be passed into the viscus, fluctuation should be sought both through the vagina and on the surface of the tumor. If the diagnosis be still obscure, the aspirator-needle should be passed into the tumor, and its fluid contents carefully tested. The age of the patient, the duration of the disease, and its time and method of invasion will aid in settling the question. The trouble may, however, occur at almost any age, and the fact that a little urine has been passed at short intervals will tend to deceive. In the early stages of the disease an idea can be gained as to its progress by carefully noting the amount of urine passed at each micturition, the amount passed in twenty-fom* hours, the length of intervals between urination, the force of the stream, whether the bladder is fully or but partially emptied, and whether the stream intermits. The urine should be examined often, else cystitis may get a firm foothold before its existence is recognized. In drawing off the urine for testing or other purposes, the catheter should be absolutely clean. Incontinentia paradoxa must be differentiated from incontinence due to mechanical causes, such as abnormal urine, or the pressure of neighboring organs upon the bladder. 726 DISEASES OF WOMEN. Prognosis. — If the disease be uncomplicated the prognosis is good. Paralysis of the organ accompanying the fevers, dysentery, peritonitis, and the like, usually disappears mth the cure of the original disease. If the paralysis be accompanied by disease of the bladder-walls, or if it occurs in weak, debilitated constitutions, or has been of long duration, or occurs in old age, the prognosis is not good. A cure, if effected at all, will be only after long and tedious treatment. When due to centric causes or to serious spinal disease or injury, or when it occurs in old people, or with meningitis, or with sys- temic trouble, the prognosis is very grave indeed. Causation. — Deranged innervation due to the central lesion already mentioned, either cerebral or spinal, may be regarded as the principal cause of this affection. If the paralysis has been of long duration nutritive changes may occur in the bladder, but as these will be discussed under the appropriate head I need say noth- ing of them here. Treatment. — In all cases where there is fear of vesical distention, the bladder should be emptied at stated intervals. By way of helping the patient to pass water herself, hot hip-baths may be tried and fomentations over the bladder. The sound of water falling from one vessel into another often accomplishes the same result. If these means do not succeed the catheter must be used. And here attention may be called to a very important practical point in connection with the use of the catheter. When the blad- der has become very much distended it can not be thoroughly emp- tied unless pressure is made upon the abdominal walls ; if this press- ure is made while the catheter is in the bladder, and then discontin- ued, air will be drawn through the catheter into the bladder and decomposition of the urine will thus be favored. Marked distention can usually be relieved by the catheter. In some cases, however, the bladder rises up into the abdomen and puts the urethra upon the stretch, thus changing the direction of its axis from the normal to one from below directly upward, the canal being nearly parallel to the posterior surface of the pubic symphy- sis. In these cases passing the catheter will tax the skill somewhat. Great care must be used to avoid injuring the urethra. In emptying a greatly distended bladder a binder should be ap- plied to the abdomen and tightened gradually as the urine flows. It is not safe to draw off all the urine at once. It is better to take away about half, and then after a time to draw off more, until the organ is empty. Syncope and even death, which is said to have FUNCTIONAL DISEASES OF THE BLADDER. 727 occurred in these cases after rapid emptying of the organ, are prol> ably due to the sudden removal of the pressure on the abdominal organs, which so deranges the circulation as to cause these serious results. The sudden removal of pressure from the vesical walls, which that pressure rendered anaemic, now allows intense conges- tion, and the vesical walls being paralyzed catarrh and cystitis result. Therefore, for many reasons, a distended bladder should be emptied slowly. When, for any reason, a catheter can not be introduced into the bladder, hot hip-baths should be again tried, and opium given in suf- iicient amount to relieve pain and any spasmodic action that may exist. If, after this, there is failure to enter the bladder (and it is only in very rare cases that this occurs), recourse should be had to the aspirator, and after having punctured the bladder, the urine should be drawn slowly and carefully, in the manner already de- scribed. In commencing vesical paralysis, and when incontinentia para- doxa exists or has existed, the patient should be taught to use the catheter herself several times daily until the vesical power returns. It is of the utmost importance that the catheter be absolutely clean. After each time that it is used it should be thoroughly rinsed in a chlorine solution, and put away in carbolized oil or vaseline. A great deal of vesical catarrh is undoubtedly lighted up by foul cath- eters. This is especially the case in hospitals, where the same in- strument is often used on a number of patients. In cases of commencing or established paralysis the effect of the induced electric current may be tried. One pole thoroughly insu- lated up to the point to be used should be placed in the bladder, and the other over the pubic symphysis and loins, letting the cm'- rent flow in various directions, through, over, and into, the affected organ. The German authors, especially Winckel, by whom this method is highly recommended in this and like affections, say that the sitting should last but about five minutes. Forcibly distending the urethra and washing out the bladder with a solution containing salicylic acid has been tried and recom- mended. I can not see the expediency of this unless vesical catarrh exists ; and even then washing must be done gently and carefully, and without previous dilatation of the urethra. Attention should be paid to the general health. The food should be good and nourishing, and the alimentary canal kept in a proper condition to receive and digest it. Wines (especially champagne), beer, and ale may be of use. I can at least say if stimulants are 728 DISEASES OF WOMEN, ever given in diseases of the bladder it should be in cases like these now under consideration. These patients are usually more com- fortable in the standing or sitting, than in the prone posture, be- cause then the weight of the abdominal viscera replaces to a cer- tain extent the natural tonicity of the organ. As they are usually worse in winter than in summer it is advisable, if the case is chronic and the patient able to bear transportation and rich enough to meet the expense, to send her to a moderately warm climate during the winter months. This will apply in most of the diseases of the bladder. If the trouble be purely atonic, camphor or musk may be used internally. Tincture of cantharides, in from five to twenty drop doses, three times a day, has been recommended as a vesical excit- ant. I can not indorse its use without the caution that besides the tendency to irritate the kidneys and produce congestion and nephritis, it may light up a severe cystitis. In these cases it may produce serious trouble without causing much pain to give warning of the danger, as the paralysis lessens the sensitiveness of the blad- der, so that destruction of tissue may occur without producing the usual pain and suffering. Strychnia has been extensively used in this complaint, and with good results in some cases. Its failure to do good in many in- stances is undoubtedly due to the fact that it was not given in suffi- ciently large doses. It may be safely pushed as high as the one- twentieth of a grain three times a day, stopping for a few days if any of its characteristic symptoms appear. It has also been used hypodermically in the neighborhood of the bladder. Ergot has been found useful in cases where the paralysis was due to exposure to cold, or prolonged retention from any cause. The fresh powder has been recommended, and may be given in doses of from eight to sixteen grains, four or five times daily. It is more pleasant and probably more effective to give its equivalent of the fluid extract, Alliers has used it with decided success in cases of vesical paralysis due to centric troubles, such as apoplexy. He has used as nmch as forty-five grains in the twenty-four hours. It is highly s})oken of also by Roth, Jacksch, and others. Rutenberg (" Wienner Med. Wochenschrif t," 1875, No. 37) has recommended, in cases where there is destruction of muscular tissue or incurable paralysis from any cause, to make an opening into the bladder just above the pubic symphysis, keeping the fistula open, and closing the urethra by operative procedures. The urine can thus be retained, unless the patient bends forward and downward FUNCTIONAL' DISEASES OP THE BLADDER. 729 or lies upon lier abdomen. A urinal would, of course, be necessary to protect the patient. I think I should prefer to produce a vesico-vaginal fistula, and adapt an apparatus to receive the urine. {b) Incontinence of Urine. — Enuresis nocturna is usually an affec- tion of childhood, but has been known to persist up to the age of thirty years. In some children it is hereditary, the mother having suffered in early years, and all the children bom to her being affected in the same way. Of all cases, these are the most difficult to manage. They often persist until puberty, when they recover of themselves. The subjects of this affection are usually of the weak, nervous type, although apparently healthy children have been known to suffer from it, but usually only at intervals. These cases of incontinence may be divided into two distinct varieties: First, the anaesthetic variety. An excellent example of this class is seen in infants who, up to a certain age, wet the bed and their diapers. In the infant this is not disease ; it is simply a good normal example of this condition ; the incontinence in severe fevers illustrates the abnormal phase of the same thing. Second, the hyper- aesthetic variety, which is really nothing more than irritable bladder. Each variety may exist alone, or both be combined in the one case. In the first variety the retaining power is defective, the resisting power of the sphincter being insufficient to retain the urine or wake the child. When it is put to bed, it sleeps soundly through the night, and the nerve susceptibihty to urine-pressure on the neck of the bladder, being lowered beyond the normal degree, fails to wake the little subject and impress it with the necessity of calKng the sphincter muscle into action sufficiently to resist the expulsive power of the bladder-walls. In short, in sound sleep the balance between the resisting power of the sphincter and the contractility of the waUs of the bladder is disturbed, and the urine flows away without the child's even dreaming of its unfortunate behavior. In other forms of this affection the brain takes cognizance of the desire to urinate, but too late to control the act. This is seen in children who awake crying when urination is but just begun or half finished. In this case the fault probably lies in the vesical neiTes. In the second variety there is an irritable condition of the blad- der (vesical hyperaesthesia), which renders the expelling power greater than that of resistance or retention, and, while the will and cerebration generally are lost in sleep, the contents of the bladder are unconsciously passed before the subject wakes to resist the act. Closely allied to this is the peculiar affection known as vesical chorea, 730 DISEASES OF WOMEN. in which the child while awake, it may be in school, in church, oi at plaj, suddenly experiences the sensation that it is about to make water, but, before it is possible to resist, the urine is forcibly spurted out. There are usually choreic movements of other muscles or groups of muscles. This affection is the most annoying when the little ones are nervous, cross, and fidgety. It may be accompanied by nocturnal enuresis. It is apparently more common in the male than in the female child. An irritable condition of the bladder may coexist with an an- SBsthetic condition of the sphincter vesicae — i. e., the two causes of incontinence may be combined. Irritable bladder, it should be remembered, may be due to some systemic condition — that is, a simple neurosis or to abnormal urine, or reflex irritation from anal fissure, ascarides in the rectum, fistula in ano, haemorrhoids, or vulvitis. Enuresis noctuma is not only a filthy habit, and a source of great annoyance to parents, but, moreover, by keeping the genitals wet and irritable, strongly predisposes to masturbation. Then, too, other serious results may happen. The constant wettings are dangerous, in that they may produce many serious complaints from causing the child to " take cold." Prognosis. — In some cases the cure is easily and speedily ef- fected ; in others, the disease cures itself at or just after puberty ; but in a few — a very small percentage — no medical or other means seem to aid the sufferer at all. Treatment. — That the treatment is not unifonnly satisfactory is seen by the number of remedies that have been tried. The proper way — and I can not call attention to this too often — here, as else- where, is to find the cause producing the disease, if it be discovera- ble, and it generally is. The treatment will, of course, differ in the two classes, and be greatly modified by diathesis and idiosyncrasy. In anaesthesia, local or general, stimulation is indicated. In hyper- aesthesia, irritability should be allayed. Winckel, Barclay, and Brugleman speak very highly of the use of tlie syrupus ferri iodidi, the last-named gentleman having by its use cured a girl perfectly of incontinence in the short space of four- teen days. This result was probably due more to the effect of the medicine on the blood and general system than to any specific action on the bladder. The sirup of tiie iodide may be given in from ten to thirty minim doses three or four times daily, according to the age of the patient. Althongh belladonna has been lauded by many as a specific in FUNCTIONAL DISEASES OP THE BLADDER. ^31 this disorder, its success is by no means general. Tlie drug is usually given by the mouth in from iive to twenty drop doses of the officinal tincture. It would be better to begin with small doses in young children, and gradually increase them ; for, although no serious re- sults may come from its exhibition in the routine dose — ten drops — the parents may be greatly alarmed by the peculiar redness of the skin produced in some cases. It is maintained by some medical men that the good effects are not obtained unless the administration be pushed to the appearance of the scarlet rash. There is, I think, no proof of the correctness of this statement. A combination of belladonna and chloral hydrate has been used and well spoken of. Winckel, however, though using them in cer- tain cases for a long time, and daily increasing the amount of chloral, has had but poor results, and even in those cases where the patients improved the benefit was seldom permanent. These drugs may be given singly or together, in suppository or by the mouth. If given together, they should not be combined until the time when they are administered, lest the chloral lose its power. JSTarcotics with tinctura ferri chloridi have been recommended by Campbell Black. Winckel speaks well of five to ten drop doses of tinctura thebaica, to a child from ten to fourteen years of age, just before retiring. According to Sauvage, cold baths and cold douches to the spine at night are of great service. Dr. Xelp (" Le Mouvement Med.") reports that he has, on sev- eral occasions, drawn attention to the value of subcutaneous injec- tions of the nitrate of strychnia in the treatment of obstinate cases of nocturnal incontinence. He practices the injections in the neigh- borhood of the sacrum. A single injection of a very small quantity of the drug suffices to arrest the affection for a certain time, and w^hen it reappears the operation can be repeated. His latest paper cites the case of a young woman, eighteen years of age, who had suffered from enuresis every night for several months ; it came on after an attack of scarlatina, and persisted in spite of all precautions. The first injection produced a respite of several nights, and the second produced a permanent cure. The patient was a strong, healthy girl, and had never suffered from enuresis previous to the attack of scarlatina. Such a plan of treatment I regard as useful only when there is deranged innervation, characterized by weakness. It would be diffi- cult to get a child to submit to these injections, and I should in any case, whether child or adult, expect the incontinence to return as soon as the strychnia was discontinued. 732 DISEASES OF WOMEN. In cases where the vesical irritability is due to abnormality of the urine, such as lithiasis, oxaluria, and acidity, these conditions should be corrected in the manner I have already pointed out. If to ascarides, anal fissure, and that class of rectal trouble, when the cause is removed the result will usually disappear also. In irrita- bility the usual soothing and demulcent drinks, such as have been already recommended, should be used. Oil of sandal-wood has acted remarkably well in some of these cases. Bromide of sodium and tincture of nux vomica have been effectual in some cases. In the anaesthetic variety, where the anaesthesia is more or less marked, special or local and general stimulants should be employed. Narcotics are as hurtful here as they are useful in the hyperaesthetic class. Strychnia by the mouth, in suppository, or hypodermically, often produces good results, as also quinine, whether the presence of malaria is suspected or not. Tonic and astringent injections into the bladder are sometimes of service. In cases of abnormally small bladder, forcibly washing it out, distending the organ a little more each time, is well spoken of. In one such case, where there was irritability, Winckel produced a cure by first injecting a solution of nitrate of silver, and following it with sulphate of morphia. This treatment, however, applies more to the irritable than to the anaes- thetic type. The little patients are very hard to operate upon, and, unless great care is exercised, much mischief may be caused by local treatment. Winckel claims good results from the use of the electric current, applied in the manner I have spoken of under the head of paresis vesicae. When the bed-wetting is due to pure carelessness, laziness, fear, or dread of the cold air in rising, in idiots and half-witted children,^ much may be gained by proper education. There is a general plan of prophylaxis recommended by common sense, viz., the heartiest meal should be in the middle of the day; but little water should be taken toward evening ; the food should be plain and unseasoned ; the bowels should be kept regular ; no coffee or tea should be allowed ; the little patients should be put to bed early, after it is assured that the bladder is first thoroughly emptied ; they should lie upon a hard bed, with not too much covering ; the air in the room should be maintained fresh and pure ; the genitals should be kept clean and dry ; no places of amusement should be visited after dark ; and they should be awakened occasionally to urinate, especially at about the time the parents are going to bed. When it is discovered that they have wet the bed, they should be FUNCTIONAL DISEASES OF THE BLADDER. 733 awakened, aud talked to and reasoned with, if they are able to com- prehend what is said and meant. Children should not go to school too early, or stay too long. If the enuresis be due to masturbation, the parents must be cautioned to watch closely, and to use every means in their power to stop it. A child should never be whipped for the offense or misfortune of wetting the bed, unless the inconti- nence be due to pure laziness. Owing to the fact that incontinence is an affection of childhood, and occurs but seldom in women, cases will not be given to illustrate what is said in the text on that subject. This omission is made for the additional reason that partial incontinence due to displacements of the bladder aud urethra and from other causes will be discussed further on, ILLUSTRATIVE CASES, Paralysis of the Bladder followed by Incontinence in Case of In- sanity. — This was a single lady, twenty-eight years of age, who had been insane for eight months. I was told that at first she was vio- lent, but had become quiet and rather demented toward the time that I saw her. Her physician had observed for some time that her bowels were obstinately constipated, and the nurse noticed that she had great difficulty in evacuating the bladder. She also appeared to have some discomfort in that region ; finally, she went for over twenty-four hours without urinating, and then I was called to see her. I found the bladder greatly distended, and yet I could not see that she had pain or tenderness on that account. The catheter was used, and three and a half pints of urine were removed. After this the catheter had to be used twice in twenty-four hours for five weeks. During this time the usual means were tried to restore the function of the bladder, but without effect. The urine then began to flow constantly. When I heard of this, I presumed that the bladder had become overdistended, and that the nurse who used the catheter had not emptied the bladder. This I found was not the case ; the blad- der was empty. The incontinence continued until the patient died of general paralysis. Paralysis of the Bladder from Cerebro-spinal Meningitis. — A girl twelve years old was taken with cerebro-spinal meningitis, and pre- sented the usual clinical history of that affection until the seventh day of the disease, at which time the pain had subsided to a great extent, but her mind, which up to this time had been clear, began to wander. Retention of the urine was noticed by her nm'se, who called my attention to the fact. I found the bladder distended, but 734 DISEASES OF WOMEN. not greatly so. She was asked if she did not desire to urinate, but she answered in the negative, so far as I could understand her. The catheter was used, and, although the distention was not great, the bladder did not contract well, so that abdominal pressure was neces- sary to make the urine flow through the catheter. The use of the catheter was necessary for some time, during which she improved in her general condition, the mind becoming quite clear. She then began to express at times a desire to urinate, but could not relieve herself. Four days later she succeeded in urinating, but did not completely empty the bladder. She gradually improved, but the catheter was passed once every twenty-four hours for a week longer. The desire to empty the bladder became more and more urgent, and she had pain in the urethra in urinating. An examination of the urine at this time showed that she had cystitis, due, I believe, to the use of the catheter. The cystitis was treated according to my usual methods, and she made a good recovery. Paralysis of the Sladder from Progressive Locomotor Ataxia. — A lady who had been affected with locomotor ataxia for more than a year, came under my care for retention of urine. I found that there was some decomposition of the urine, but nothing else to distinguish the case from paralysis of the bladder, occurring in other cases of disease and injury of the spinal cord. The attendant was advised to use the catheter regularly, and to wash out the bladder with a solution of borax — one drachm of borax to a quart of warm water. I learned subsequently that this patient had incontinence of urine before she died„ II. Derangements due to Abnormal Conditions of the Urine. — The bladder being made to contain urine, almost constantly uniform in its composition, it at once feels and responds to any abnormality. If the aberration is only occasional, the effects are slight and of short duration ; but, if the abnormality be constant, or almost so, or if the altered urine has a hypersesthetic surface to deal with, the results are more annoying. Urine which is too acid or too alkaline, too limpid or too greatly concentrated, acts somewhat like a foreign body — it irritates, and the bladder inclines to expel it. Deposits of any of the urinary solids in the viscus may produce an irritaljle condition, and, if unchecked, lead to organic disease of the bladder. Uric acid, in large or small crystals, in little masses, forming gravel and minute calculi, the amorphous urates, the triple and amorphous phosphates (tliese, as a rule, however, occurring only in decomposition of the urinej, and oxalate of lime may give rise tc FUNCTIONAL DISEASES OP THE BLADDER. 735 considerable trouble. There are some other deposits, such as cystine,^ that are of such rare occurrence that they need not be mentioned in this list. In any of these cases^ but especially when there is a de- posit of uric acid, there may be one of two things resulting; and, in order to treat tho case properly, they must be borne in mind : First, a real excess of the salt in the urine ; and second, a condition of the secretion, where, whether the amount of salt present be nor- mal, or less or more than normal, it will be precipitated in the blad- den As an example of the first may be mentioned some cases of dys- pepsia, when, owing to a defect in either primary or secondary as- similation, the salt or salts are eliminated by the kidneys greatly in excess of the normal. Here a normal or even an abnormal amount of water in the secretion could not hold them in solution, and they are consequently precipitated. As an example of the second may be taken some cases of hepatic disease, in which, although the uric acid is eliminated in abnormally small amount, it is precipitated on account of the deficiency of water, excessive acidity, and possibly too rapid absorption of the watery element of the urine while in the bladder. In some cases with an excess of salts, there may be excessive acidity and lack of water. Some forms of dyspepsia are notable examples of this, and as low nerve condition frequently accompanies these disorders, the abnormal urine meets in the bladder with an irritable mucous membrane. In these cases the acidity is quite as hurtful as the deposit. Deposits of oxalate of lime in the bladder are not so common (except in lime-water regions) as those of uric acid. In cases of the persistent deposit of oxalate of lime in the urine, known as oxaluria, there is usually marked irritability of the bladder. This has been ascribed by some to the presence of minute octahedra of this salt irritating the mucous membrane. It is more than likely, however, that the derangement of the general nervous system, always existing in these cases, stands as a propter rather than a post hoc, and that the bladder difiiculty is but a local manifestation of the general dis- ease, and consequently a pure neurosis. That the urine of oxaluria does possess irritant properties there is but little doubt, but it is hardly likely that the symptoms here occurring would be produced unless there was already an abnormal condition of the vesical mucous membrane. Many authors hold that the high specific gravity of a single speci- men of urine must not be taken as an evidence of concentration, oj 736 DISEASES OF WOMEN. the low gravity of excessive limpidity of the twenty-four hours' urine. This is very true in regard to the total amount passed in a day ; but as the bladder has to do each time only with the urine in it at that time, it will be well in these cases to examine several spec- imens in a day, rather than to depend for information on the reac- tion of the total amount of urine passed. Urine may irritate the same patient at one time from being too limpid, and at another time from being too highly concentrated. These variations must be carefully watched and treated. A bladder that is irritable at all times and witli urine of. varying reactions, may be set down as one affected with a pure neurosis, if no organic cause be found, for the urine could not work the mischief continu- ally, if normal at certain periods. Symjptomatology. — Patients suffering from this affection usually complain of frequent urination and vesical tenesmus. In some cases there is smarting pain in the urethra during the passing of water and for some time after, and there is a sense of heat in the bladder and a desire to urinate which are not fully relieved when the bladder is empty. This last-named symptom belongs more especially to those cases in which the urine salts are in excess. When the urine is defective in the salts, that is, when the urine is limpid, the only symptom present is frequent urination. It will be observed that these symptoms are the same as those presented in a variety of affections, and hence can not be depended ujion in making a diagnosis. Diagnosis. — The diagnosis must be made by excluding all other conditions which give rise to this derangement of function, and by re- peated examinations of the urine, which will show its abnormal state. Prognosis. — The relief of this class of cases will depend upon the possibility of correcting the constitutional affections which pro- duce the pathological state of the urine. In case the abnormalities of the urine persist for a long time cystitis and urethritis may be produced. I am sure that I have seen cystitis which could be traced to long continued abnormal states of the urine. Causation. — In discussing tlie pathology of this class of func- tional derangements the causes which produce them liave been fully brought out, so that they need not be repeated here. Treatment. — In cases of concentration of the urine due to acute febrile action, the patient should be liberally supplied with cooling drinks ; and as in these affections the urine is generally too acid, the slightly alkaline, effervescing waters will be found useful. FUNCTIONAL DISEASES OF THE BLADDER. 737 In digestive troubles, with excessive acidity or saline deposit, at- tention slioiild be paid to diet, bathing, and regularity of the bow- els, as well as the taking of a proj)er amount of exercise, Wliere deposits of uric acid take place there is usually some defect in either primary or secondary assimilation. This should be sought out and remedied. In excessive acidity with deposits of uric acid, the alka- line carbonates act in a double way ; first by neutralizing the acid- ity of the urine, and second by acting on the liver to lessen the amount of uric acid produced. The following is a very pleasant and efficient prescription in these cases. 1^. Potassii bicarbonatis, Potassii citratis aa 3 ss. Syrupi simplicis 3 i^. M. Sig. Take 3i in half a tumbler of water, adding 3ij of lemon- juice. Drink while effervescing. The late Prof, Armor gave some very excellent advice regarding the management of such cases, which I will reproduce in his own words : " When the urine is acid in any of the forms of cystic irritation, great relief is experienced from the use of alkalies, especially when administered in an infusion of buchu, I regard buchu as a remedy of undoubted efficacy in all cases of vesical irritability. It seems to possess similar properties over the urinary tract that bismuth does over the intestinal, and is an admirable vehicle in which to adminis- ter the various alkalies. The citrate of potash with buchu is an excel- lent combination where we desire the joint action of these remedies. The liquor of potash, the bicarbonate and the iodide of potash also possess a high degree of utility in the class of cases refei-red to, and their therapeutic action is certainly never disturbed by administer- ing them in an infusion of buchu, " In irritable conditions of the bladder associated with a gouty and lithic-acid diathesis, the carbonate of lithium is a remedy of un- doubted efficacy. It perhaps excels the preparations of potash in rendering uric acid and the urates soluble," The following is the formula of a prescription which answers well : 5,. Lithise carbonatis 3 ij- Acidi benzoic • 3 iij- Sodii boratis 3 j- Aqu?e dest 3 i^"- M, Sig. One teaspoonf ul in a large glass of water. 48 738 DISEASES OF WOMEN. Limpid urine is usually due to some general nervous trouble or cerebral disease. In such cases treatment should be directed to the original disease. Deposits of amorphous or triple phosphates are rare, unless there is some organic disease of the bladder. Where the deposits are not due to decomposition, some decided nerve trouble is usually pres- ent, and here, as in limpidity, the attention must be turned to treat- ment of the general trouble. In oxaluria attention nmst be paid to the moral, mental, and physical condition, and time must not be wasted in treating mere symptoms. In the way of medication, the following prescription is looked upon by many as almost specific in these cases : 9.. Acidi nitro-muriatici diluti 3 v-vj. Tincturge nucis vomicae 3 iij- Olei gaultherise TTLxij. Aquse ad 5 iv. M. Sig. — 3 i in water before each meal. In some cases the pure non-diluted acid, freshly made up, acts better than the dilute. It should be given in smaller doses than the dilute, and in plenty of water at the time of taking it. In all cases of urinary deposits, water should be freely taken, and the greatest attention paid to general hygiene and to mental and moral surroundings. Many of the slightly alkaline mineral-spring waters will be found of use, acting gently on the liver, flushing the kidneys and urinary organs, and slightly relaxing the bowels. A considerable quantity should be taken in the course of the day when the stomach is empty. ILLUSTRATIVE CASES. Irritation of the Bladder from Abnormal Urine. — A patient forty three years old, large and stout, had menstruated scantily for sev- eral months and, as the flow diminished in quantity and duration, she gained in flesh but not in strength. She had a very good appe- tite and lived very well, but she did not feel in her usual health. She noticed a gradual disinclination to mental and physical activity. Backache, headache, and wandering pains here and there, occasionally annoyed her. After these symptoms had continued for a time urin- ation became more frequent and at times slightly painful. She noticed also that there was a sediment in the urine. These symp- toms caused her to seek advice from the fear that she had Bright's disease. She was found to possess a very good organization ; and there was no organic disease of any kind present. All the evi- FUNCTIONAL DISEASES OF THE BLADDER. 739 dences of excrementitious plethora were well expressed in the abun- dant adipose tissue, coated tongue, constipation, muddy appear- ance of the eyes, full slow pulse, shortness of breath on exertion, depression of spirits, disposition to sleep, and at times sleepless- ness. The urine was examined, and found to be slightly alkaline. The specific gravity was 1030. There was neither albumen nor casts. The salts of the urine were in excess, but as a quantitative analysis was not made the exact composition of the urine was not obtained. The diagnosis of general excrementitious plethora from imperfect elimination was made, and the frequent urination was at- tributed to the abnormal condition of the urine. Ten grains of pil. hydrarg. and one grain of ipecac were given at bed-time and a Seid- litz powder an hour before breakfast the next morning. This was repeated in five days. The quantity of food was diminished — she had been taking ex- tra diet to make her stronger — milk was the chief article permitted, with a very little animal food once a day. A Turkish bath twice a week and gradually increased out-of-door exercise. The bowels were kept rather free by giving a dose of Congress water an hour before breakfast every morning. Under this treatment she im- proved in every way. The irritation of the bladder subsided, and has not returned. The urine is now normal. Frequent Urination from Abnormal Urine. — An unmarried lady, thirty years old, of good constitution, very ambitious and energetic, overtaxed herself during the winter, and toward the end of the season, began to suffer from frequent urination and a sense of burn- ing heat in the bladder and urethra after urinating. After a time these symptoms became very annoying, and as she was a nervous, sensitive person, she suffered quite severely. She was found to be quite out of health. Her appetite was poor and her digestion im- paired ; she was constipated, and suffered from rheumatic pains in her joints, and in the back of her neck. In short, she gave a fairly good history of dyspepsia and neurfesthenia plus the irritation of the bladder which was her chief source of discomfort. The urine was diminished in quantity, dark in color, very acid, aid of high specific gravity ; no albumen or casts were found. She had been quite free from any affections of the pelvic organs, the present dis- turbance of the bladder being the only suffering she had ever had in that regard. My first impression was that she had cystitis, but there were no products of inflammation found in the urine, and therefore the diag- nosis was made as stated above. 740 DISEASES OF WOMEN. Peptonized milk was ordered witli raw eggs, and, in addition, barley gruel, clear soups, and bread. Two drops of liquor ammonite in a wine-glass of water were given every two hours until the urine became normal. Her bowels were kept regular by small doses of Rochelle salts and cream-of-tartar taken in the morning. Rest was insisted upon, and massage every third day. As soon as the urine became less acid and dense, she obtained some relief, but was not restored to her usual condition. It was not until her general health had been improved that the urine became normal and the irritation of the bladder finally left. An interesting point in the treatment was observed. For a time she was partially relieved by the alkaline remedies, but, when she ceased taking them, the irrita- tion of the bladder returned. When her general health was restored by rest and tonics the urine became normal, and the irritation of the bladder disappeared entirely. At the present time I have a lady under treatment for specific disease of the uterus ; during the last four weeks she has had irrita- tion, causing frequent urination. She obtains relief by drinking very freely of lithia water. Case of Baruria (by Dr. Samuel West). — The patient, aged thirty- nine, complained, after catching cold, of pains and aching in her limbs, which became severe enough after a week to keep her in bed. When admitted, these pains continued, but there was swelling of joints. The temperature was 100°, and she perspired freely, but the sweat did not smell sour. The urine had a specific gravity of 1040, and yielded copious crystals of nitrate of urea, with nitric acid. Her appetite had been for some days almost absent, and in the hospital she took but a little milk or beef-tea. For two days the condition of the urine was the same, and the percentage of urea 5"1. This per- centage gradually fell to normal, and, as it did so, all the patient's symptoms disappeared. The case was regarded as one of baniria. The account of the case given by Prout was summarized and com- pared with the present case, and reference was made to other authors, by some of whom the existence of the affection was questioned, while by others it was not referred to. A somewhat similar case, the result of overfeeding and constipation, has been described, in which like symptoms were associated with a high percentage of urea, and disappeared when the amount became normal. III. Derangements of Function due to Affections of the Pelvic Organs other than the Bladder. — Functional diseases of the bladder, caused by disorders of the neighboring pelvic organs, are frequentl? FUNCTIONAL DISEASES OF THE BLADDER. ^41 met with in practice. In this class the vesical trouble is secondary to some primary and more important affection, but the derangement of its function is often the most prominent and troublesome symp- tom ; hence it is important to understand its relation to the primary disease, in order to make a correct diagnosis, and to treat such cases properly. This class of functional disorders frequently resembles in history some of the organic diseases of the bladder, so that care is necessary to distinguish the one from the other. What I may say upon the subject will have reference to diagnosis only. When we know that the bladder trouble is due to disease of some other organ, attention is at once turned to the primary affection. These facts must be borne in mind, and the symptoms not mistaken for the disease. Diseases of the rectum affect the bladder sympathetically. Irri- tation and pain in the rectum from any cause affect the bladder more or lesSo Chronic hsemorrhoids will cause frequent urination, and so will rectal fissure, especially after defecation. Abscesses in the neighborhood of the rectum will frequently cause retention of urine. One very interesting case of this kind occurred in the practice of my friend Dr. Gushing. The patient had an abscess in the neigh- borhood of the rectum which caused retention of the urine, and this in turn caused acute renal disease. After the bladder had been emptied and kept from overdistention for some time, the urine was examined and found to contain albumen and casts. She made a rapid recovery, and all evidence of kidney-disease soon disappeared. Yery troublesome vesical irritation may come from ascarides. The itching of the anus and rectum, caused by these troublesome little worms, keeps up an almost constant desire to urinate. Chil- dren are most troubled with these parasites, but women often suffer in the same way. Marion Sims points out the interesting fact that almost all cases of vaginismus are accompanied by an irritable condition of the blad- der, and that, as the terminal fibers of the hymen often extend from the meatus to the vesical neck, cystospasm may in these cases be due to reflex nerve irritatioUo An attempt to catheterize these patients is as liable to cause spasm of the bladder as an analogous attempt to examine the uterus would be to produce vaginismus. In these cases the hymen should be excised, and the vaginismus treated after the usual methods. Acute pelvic peritonitis and cellulitis cause great distress in many cases by their effect on the bladder. A constant desire to urinate, without the ability to make sufficient straining effort to accomplish Y42 DISEASES OF WOMEN. the object, is very often observed in all these acute pelvic inflamma- tions. Thedisturbance of the bladder is, of course, only a symptom of the primary and more important trouble, and simply requires to be mentioned here. The after-effects of pelvic peritonitis are what I especially desire to call attention to at present. The adhesions formed by the products of the inflammation of the pelvic peritonaeum are in some cases sufficient to prevent the normal filling of the bladder, and frequent urination then becomes a necessity. This derangement of function generally exists alone. The urine is retained without trouble up to a certain amount ; it is passed without pain, and no vesical tenesmus follows evacuation. Unless the contraction of the bladder is great, and the frequent necessity to urinate very troublesome, patients rarely consult a J)hy- sician for it. Paralysis of the bladder with retention may be caused by a pecul- iar condition of oedema, by which the detrusors are rendered power- less to act. It is usually caused by disease of the cervix uteri, para- metritis, or peritonitis. CHAPTER XLI. METHODS OF EXPLORATION OF THE BLADDER AND URETHRA. Preparatory to the study of organic diseases of the bladder and urethra, I desire to call attention to the methods and means of ex- ploring the bladder and urethra, and to some of the physical signs of disease obtained thereby. In all cystic affections the urine should be carefully examined, both chemically and microscopically. It is not necessary for me to describe the methods to be employed in this examination ; they will be found in the various books published on that subject. I may, however, in passing, state that the condition of the kidneys is better determined by ascertaining the quantity of urea eliminated than by examining for albumin or casts. This will be referred to again in discussing the diagnosis of cystitis. If an examination of the urine does not make the diagnosis clear, attention should be directed to a physical exploration of the bladder and urethra. For this purpose either a digital or an endoscopic ex- amination may be made. Digital examination per vaginam is one of the most valuable means of investigating the bladder and urethra. By this and by the bimanual touch the physical signs of many of the affections of these organs can be readily obtained. The method of making these examinations is exactly the same as practiced in examining the uterus. The vaginal touch reveals the position of the bladder and urethra, the degree of their sensitiveness, the location of tenderness, if any is present, the increase or diminu- tion of elasticity, and the state of their walls, as regards thickening or irregularity. Distortions of the urethra from neoplasms or the products of inflammation can also be detected in this way. The bimanual touch will show whether the bladder is full, empty, or partially distended, and any foreign body of considerable size can be felt in the bladder in case the abdominal walls are not too rigid. As a means of detecting stone in the bladder of women, the biman- ual touch is the easiest, safest, and surest of all methods of explora- tion. The presence of neoplasms can be discovered in this way, 743 7U DISEASES OF WOMEN. although their composition can not be clearly made out. In some cases it is necessarj'^ to give an angesthetic to relax the parts before a satisfactory bimanual examination can be made. There are many advantages gained in anaesthetizing the patient while making a^ bimanual examination, but some of the most important signs may be lost by the unconsciousness of the patient, such, for instance, as the location of tenderness. On that account I prefer in critical cases to make an examination both without and with anaesthesia. It is also well, when the object is to search for foreign bodies, like stone or tumors of any kind, to have a few ounces of urine in the bladder, unless that much gives the patient pain. The longer I practice the more I depend upon this method of examination. Another method of examination is by means of the endoscope. For this purpose I devised and have employed for years an endo- scope which has Fig. 250. proved of great service. This in- strument is com- posed of three parts. A glass tube (a, Fig. 251) is shaped like the ordinary test tube used by chemists, except that the mouth is a little more flaring. The second part (J, Fig. 251) is composed of two pieces — a mirror and its holder. A piece of very thin silver plate is made to fit nearly the whole length of the inside of the glass tube, and about one third of its circumference. To the end of this arrangement the mirror is attached at an angle of aljout 100°. At the other end a delicate handle projects at an obtuse angle. This part of the instrument looks like a section of a tube that has been divided into three equal parts by longitudinal section, with a mirror attached at one end and a handle at the other. This piece is made perfectly black on the inside, and answers two purposes — it holds the mirror, and, when placed in position for use, darkens one side of the glass tube. It will be seen that the mirror can be moved forward or back- ward, and turned around ; so that when the tube is introduced into the urethra or l)ladder the exposed internal surfaces can be brought into view by moving the mirror while the tube remains stationary. Figs. 250-252. — Skene's endoscope. METHODS OF EXPLORATION. Y45 Fig. 250 shows the glass tube placed inside of a fenestrated hard- rubber speculum, and Fig. 252 shows the glass tube inside of a speculum that is open and beveled at the end. These specula are used in making applications to the urethra and bladder, as will be described hereafter. The method of using this instrument is as follows : The tube, with the mirror inside, is introduced into the urethra, and bladder Fig. 253. — Urethroscope with electric light. also, if an examination of the lower portion of the latter be desired. Formerly I used a concave mirror to throw in the gas or electric light, but now I use the following improved urethroscope with elec- tric light : The instrument consists of a chamber of convenient size, which has a second chamber or housing built upon its center. The upper or vertical chamber contains an electric lamp. The rays of light are thrown upon a mirror, which is placed in an oblique posi- tion immediately below the lamp. The light is reflected upon the mirror to the front of the instrument, and through any urethral tube which may be attached. The mirror has a perforation in its center, through which the operator sees the parts to be examined. The eyepiece has the proper magnifying lenses, and is adjustable, so that the focus can be changed to suit tubes of various lengths (see Fig. 253). The complete instrument, as illustrated, has three sizes of straight urethral tubes and a Skene's endoscopic tube, with a mirror on the distal end of an adjustable stem. This enables one to exam- ine the entire length of the female urethra through the glass tube, which is held in position while the mirror is inserted or withdrawn. 746 DISEASES OF WOMEN. The color of the mucous membrane lining the urethra and blad- der has already been described ; but it must be borne in mind that tlie endoscope modifies the color to some extent. This is especially so when examining the urethra. If a large-sized tube is used, the parts are put upon the stretch, and the pressure of the glass on the mucous membrane interrupts the capillary circulation to some ex- tent, and renders the color as seen in the mirror a pale pinkish white. This, when understood, does not interfere with the exami- nation, as it only tends to make the contrast between the normal and the diseased tissues more marked. The only condition where the endoscope might lead to error is in acute general congestion of the urethra. The pressure of the instrument causes the congestion to disappear in part, and gives the idea that there is less hyperemia than there really is. In such cases I use the speculum or the ordi- nary endoscope (Fig. 252), and thereby remove all possibility of error. By a little practice in managing the light, sufficient dexterity to examine the urethra and neck of the bladder thoroughly and satis- factorily can soon be acquired. Cystoscopy. — The cystoscope of Nitze and Leiter is the instrument usually employed for thoroughly investigating the bladder. Bruck, of Breslau, first discovered the principles of the instrument, and Nitze and Leiter perfected it. The cystoscope (Fig. 254) consists of a silver tube of the shape of a catheter, in the short beak of which a platinum wire is fastened. - Wall of the bladder. Platinum. Prism. Telescope. Fio. 254. — Cystoscope. V Water-pipes The latter is made incandescent by means of an electric current which passes through it, and then darts its rays upon the wall of the blad- der through an oval window in the concavity of the beak, covered with transparent quartz. To convey the current of electricity to the platinum, an insulated wire runs through the whole length of the METHODS OF EXPLORATION. 747 shank ; the metal of the tube forms the connection with the oppo- site pole. No cold-water current is needed. According to Nitze's design, a telescope is introduced into the shank of the cystoscopy It enlarges and magnifies the spot coming into sight. Without this telescope we should not see much more at the time than a spot about the size of a pea ; with it we are enabled to inspect a portion as large as a silver dollar, and even more. At the junction of beak and shank, corresponding to the con- cave side, a rectangular prism is cemented in, the hypotenuse-plane of which acts as a mirror on account of the total reflection of the rays. Thus a diminished, inverted real picture arises in the shank of that wall of the bladder which is situated at a right angle to the longitudinal axis of the instrument, and opposite the prism. It is again inverted by means of the lenses of the telescope, and thrown to the outer end of it, where the examining person looks at the now upright picture through the magnifying ocular of the telescope. If the fundus of the bladder is to be inspected with this instru- ment it must be turned 180°, and its handle deeply depressed be- tween the thighs of the patient, the latter being in the recumbent (lithotomy) position — the best for examination with the cystoscope. This manipulation may sometimes be very painful. To avoid this, a second instrument (Fig. 255j is made with the window for Telescope. Water-pipes. Wall of the bladder. Fig. 255. the incandescent platinum on the convex side of the beak. There is another window at the end of the straight tube through which the observer looks with the telescope. Of course there is no prism. Leiter's cystoscope shows the old pattern with the improvements mentioned. A key near the handle can be made to make or break the current by turning to the right or left upon or from an ivory plate. The shank of the instrument is somewhat short ; its tele- scope diminishes the part in view a trifle. Before using the cystoscope the beak should be put in water, and the light tested to see that it is in working order. Glycerin should 748 DISEASES OF WOMEN. be used to lubricate the instrument. The bladder must be washed,, provided the urine is bloody or cloudy with mucus, and then be partially distended with from five to six ounces of clear water. If the urine is quite clear no preliminary washing is necessary. A few years ago Howard A. Kelly gave to the profession his method or system of investigating the diseases of the urinary organs of women, which I consider a most valuable contribution to this Fig. 256. — Leiter cystoscope. branch of surgery, especially in the management of the class of cases now to be considered. The original element in Kelly's method is placing the patient in the Trendelenburg or knee-chest position while using the endoscope for the purpose of making a diagnosis, and in catheterizing the ureters, and for direct treatment of the urethra and bladder. His modification of the endoscope and his way of using it are no doubt improvements of great value, but are not likely to supplant other ways of exploration for diagnostic purposes. For inspecting the bladder and urethra the older ways are pref- erable, and in catheterizing the ureters the newer method of doing so, with the aid of the cystoscope, is easier for some of us. The objections to the general employment of Kelly's method of exami- nation are that rapid and extensive dilatation of the urethra are neces- sary, and that it requires the patient to be anaesthetized. Taken altogether, it makes the examination really a formidable operation. Dilatation of the normal urethra is an outrage that often does dam- age that is not easily relieved. Since the discovery of the germ causation of surgical diseases practitioners have felt safe in being surgically clean in their work, and have become unmindful of the fact that injuries such as abrasions, contusions, or lacerations of tlie mucous membrane of the urinary tract often cause serious troul)le. There is no reliable tendency to repair injuries of tissues that are continually bathed with urine, and when the urine is abnormal very serious results may follow the slightest traumatism. In view of METHODS OP EXPLORATION. 749 these facts, and recalling the results of the practice of a few years agfo, when dilatation of the urethra was in fashion for diacrnostic purposes and for the relief of certain affections, one shrinks from the risk of adding to the list of cases of incontinence and chronic urethritis. In my hands some slight disturbance has often followed the use of the cystoscope of Xitze and Leiter, which raised the same objection to its use as to Kelly's instrument. Owing to the sharp flexion at the point of the instrument it could not be passed through the ordinary-sized urethra without causing pain and doing some little damage. These difiiculties were all overcome by having a cystoscope made straight. This improvement has been a great help to me. With this instrument the female bladder can be explored without pain or injury, excepting when its walls are thickened and contracted so that it will not hold the required amount of water. In such cases Kelly's method meets the requii-ements most admi- rably. At one time I was unable to use the cystoscope when there was hgemorrhage from vascular neoplasms or ulceration. Then I looked to Kelly's method for aid, but I found it was not satisfactory, because the blood obscured the field of vision and one could not see what it came from. This obstacle can be overcome by prolonged washing of the bladder with a solution of acetic acid, which controls the bleeding, so that there has been no trouble in this respect since adopting this plan. In cystitis and urethritis together the use of the endoscope and cystoscope is painful, but the application of cocaine overcomes that difficulty. Instilling into the urethra a two-per-cent solution of that local anaesthetic renders the parts tolerant to the use of the instru- ments in most cases. To obtain the desired ansesthesia, a mild solu- tion should be repeated as many times as is necessary. That is safer and more efficient than one application of a strong solution. I can safely say that with the straight cystoscope the bladder can be examined with as much facility as one can make a speculum ex- amination of the uterus and vagina, and with no moi"e distress to the patient. And I am sure that it is not claiming too much to say that all structural changes, gross and minute, can be seen and studied far more clearly than by any other method of inspection yet discovered. For examination of the urethra I still use my old endoscope, per- haps because I am used to it, but I must acknowledge that the older endoscope, improved in mechanism by Kelly, is more easily em- ployed and satisfactory^ to the majority of surgeons. W. Donald Napier has invented a probe that is of use in detect- ing foreign bodies in the bladder. No dilatation of the urethra is 750 DISEASES OF WOMEN. needed for its use. It consists of a beaked sound, the vesical end of which is covered with pure metallic lead. This, having been care- fully polished with soft leather, is dipped into a one-per-cent solu- tion of nitrate of silver, which gives it a beautiful black coating. Fig. 257. — Skene's nioilifiuation of the cystoscope ; half actual size. Before use it should be carefully examined with a lens to see that its surface is perfect. When introduced into the bladder, if any hard body be present, such as a calculus, against which it strikes, an obvious impression is made upon the polished surface. Exploration of the bladder by dilatation of the urethra is a most valuable means of diagnosis. It may be employed in various de- grees. The urethra may be enlarged only sufficiently to admit a fair-sized endoscopic tube, or it may be dilated sufficiently to admit the finger. I will first give the methods that are commonly in use, Fig. 258 i?m sufficiently large to quiet the desire to urinate, and alkaline diluents to render the urine non-irritant, when it was found to be excessively acid. If tho bleeding-point or points can be discovered with the endo- scope, applications of acetic acid, persulphate of iron, or nitrate of silver may be made. Great care must be taken in using these reme- dies, lest inflammation and ulceration of the bladder result. Nitrate of silver and strong acetic acid are more to be feared than the others. When the liiiemorrhage is so free as to excite fears of prostration, ice may be employed. Small smooth pieces should be introduced into the vagina at regular intervals as long as the patient can com- fortably bear it. Ice may also be applied to the hypogastrium. When the blood coagulates and forms a large clot in the bladder, it should be allowed to remain until it breaks down and comes away of itself. The experience of surgeons is that there is much more danger in attempting to remove the clot than in letting it alone There are two dangers in removing coagula from the bladder. Ono is, that doing so will almost certainly start the bleeding again ; and the other is liability to injure the bladder, and cause inflammation. Let the clots take care of themselves, keeping the patient quiet and comfortable (with opium, if necessary) until the coagula are disposed of. Lime-water has been recommended as a solvent of blood-clots by Dr. J. H. Ledlin, of Pittsfield, Illinois, and, in the case reported by him, and which is narrated with the cases of haemorrhage in this chapter, seems to have acted well. In one case of traumatic vesical ha3morrhage that came under my care, a large clot formed in the bladder, and urination was com- pletely arrested. I was unable to determine wdiether the inability ORGANIC DISEASES OF THE BLADDER. 759 to urinate was due to the presence of the clot or to loss of contractile power of the vesical walls from the injury. The patient suffered so much, however, from the pain caused by retention that I was obliged to use the catheter. I employed the flexible instrument of Jaques, and, by carefully worming it in past the clot, I succeeded from time to time in drawing off enough of the urine and broken-down clot to relieve the lady until she was able to reHeve herself. I was careful not to disturb the clot. Allusion has been made to varicose veins of the bladder, called by some haemorrhoids of the bladder. This condition is chiefly found in pregnant women, especially those who have borne several childi'eu. The cause is interruption of the venous circulation Ijy pressure of the gravid uterus. The veins of the anterior vaginal wall, introitus vulvae, and labia, will often be found in the same condition. Occasionally prolapsus of the bladder ^\dll also be found. This affection gives rise to those symptoms of pelvic distress and frequent urination that are so troublesome in some pregnant women. It must be kept in mind, however, that the same symptoms may come from pressure which does not produce varicose veins. If it is found that the patient feels relieved to some extent in the recumbent position, and the urine is normal, this trouble may be suspected, and, if the symptoms are sufficiently urgent, a local examination should be made, which wdll reveal a varicose condition of the vessels of the urethra and vaginal walls, and from this it may be inferred that the same condition exists in the bladder. If the diagnosis is still doubtful, the endoscope will aid in settling the question. This affection is relieved or passes off altogether after confine- ment, and the best that can be done usually is to give rest and try to make the patient comfortable until the end of her " term." Should the trouble continue after delivery, especially if there is cystocele or prolapsus of the bladder, much good may be done by restoring and keeping the organ in place. This can best be accom- plished by using the cotton pessary or a roll of marine lint packed loosely into the vagina, like a tampon. The patient can be instructed to use this herself. Attention should be given to the general health, and particularly to the condition of the bowels and portal circulation. Rest in bed, and the use of cool water as a vaginal injection, may also be of use. Should haemorrhage occur from this condition of the veins, it may be treated as described in the discussion of that subject. 760 DISEASES OF WOMEN. ILLUSTRATIVE CASES. Case of Haemorrhage of the Bladder ; Blood-clots dissolved by Lime- water. — J. II. Ledlin, M. D., Pittsfield, Illiuois, in a letter to the " Medical Record," November 8, 1879, says : I have a patient, a man who for years has suffered greatly from hgematuria. The blood comes from the kidneys. At times the hsemorrhage is very profuse, and clots the bladder. Heretofore I have always succeeded in wash- ing it out with a double current catheter. Last Saturday I was called to see him. He had lost a great quantity of blood, and was suffering very much from vesical tenesmus ; I passed my catheter, and injected a stream of water. All at once the stream, returning, would stop. By withdrawing the instrument I could start it again, but he insisted there was a foreign body in there. I must say that the previous day he had experienced excruciating pain along the course of the ureter; 1 suspected stone, and sounded him, but could not discover one ; still, my instrument touched something ; I repeated the washing out of the bladder until the water returned colorless. I then made up my mind that there was a clot, with the coloring matter washed out, and, recollecting your account of dissolving the false membrane with lime-water, I threw in one half j)int of lime-water, allowing it to remain half an hour. When it passed off it resembled what you describe as the appearance of the false meml^rane after lying in lime- v/ater. He also passed a large piece of tibrin, which had evidently been acted on by lime-water, although not sufficiently to dissolve it entirely. Had it not passed away, I am convinced another injection would have dissolved it entirely. He is now quite comfortable, all sense of a foreign l)ody in the bladder having passed away. Haemorrhage from the Bladder due to Malarial Influence. — This patient was a lady of twenty-one, married two years, never pregnant, and of a slightly strumous constitution. For several days she had to urinate more frequently that usual. She then began to be I'estless at night. These symptoms developed into well-marked fever in the afternoon and first part of the night. With this came frequent urin- ation, with pain and hfemorrhage from the bladder. The blood came from the neck of the bladder evidently, from the fact that it was mixed with the urine, but was dark in color, as it would have been if from the kidneys. There was no blood passed after the l)ladder was empty, as would have been the case if it came from the urethra. The temperature was 103° F. in the evening ; normal in the morning. This continued for two weeks, at which time I gave qui- ORGANIC DISEASES OF THE BLADDER. 701 nine, gr. x, in the morning. After the qninia, tlie fever and bleed- ing stopped, and did not return. She was for over a year well, then her trouble returned — that is, she had painful urination without haam- orrhage. I found the cause to be a polyj^oid growth, which looked like a wart, in the anterior wall of the urethra near the meatus. I removed it by snare, with the result of relieving her completely. CYSTITIS. This is a disease that is much more common among women than is generally supposed. It is necessary, therefore, to inquire carefully into the etiology, pathology, and therapeutics of this affection, which causes great suffering on the part of the patient, and taxes the high- est skill of the ablest surgeons. To the several forms, grades, or degrees of this disease various names have been given, such as acute, subacute, and chronic cystitis, cystitis mucosa (catarrh of the bladder), interstitial cystitis, peri- and epi-cystitis, croupous, diphtheritic, and gonorrhoeal cystitis. This medley of names should not be allowed to lead to confusion, but this fact should be firmly fixed in tlie mind, that, with the exception of the last three (the etiology and pathology of whi'jh are somewhat different), they are all simply steps or stages in one general process. Thus a patient may have received an injury of the bladder by the use of a catheter, causing an acute cystitis. This may end in con- valescence, or merge slowly into the more chronic form, having very likely as an intermediate step catarrhal cystitis. This, too, may go on to recovery ; but, if the process extends, and its severity increases, ulceration takes place, and the submucous and intermuscular tissues become involved, producing interstitial cystitis. If the inflammation extends still further, and involves the serous coat of the bladder, either by extension or ulceration, with or without perforation, we shall have peri- or epi-cystitis. In this example I hope I have made clear the fact that names are only given to denote the degree of in- tensity of the inflammatory process, and the character and extent of the tissue involved. Inflammation of the mucous membrane alone is by far the most common form, and hence, in using the term cystitis, reference is usually made to inflammation of that membrane only. When other tissues are involved, or the character of the disease is peculiar, some qualifying word is added to distinguish it. Acute inflammation of the bladder, other than that due to local causes, is emphatically denied an existence by many authors. The 762 DISEASES OF WOMEN. statements made are usually too broad and sweeping to be sustained by the facts observed in actual practice. I am inclined to believe that cases of acute cystitis from exposure to cold and wet do occur. It must, however, be admitted that such cases are very rare, and some that have been considered as acute idiopathic cystitis may have been but a development of acute inflammatory disease upon a pre- existing abnormal condition. It is also possible that those who deny the existence of acute idio- pathic cystitis may base their belief upon the fact that in what is called acute inflammation of the bladder all the phenomena of well- defined inflammation are not present, while others consider hyper- semia of the mucous membrane and derangement of bladder function all that is necessary to constitute cystitis. Thus the apparently dif- ferent opinions that exist among authors upon this subject may arise from conflicting views as to what really constitutes inflammation. I prefer to class this condition (of congestion, hypersecretion of mucus, abnormal exfoliation of epitlielium, and irritability) among the inflammatory affections, and call it acute cystitis. Such an affec- tion as this is met with in every-day practice, and I know of no bet- ter name for it. With this understanding, then, I will pass to a discussion of acute cystitis. Pathology. — As acute cystitis soon terminates in resolution, or merges gradually into chronic cystitis, I think it best to give the pathology of both diseases at once, they being, as I have already said, simply different in degree of intensity and duration. The morbid anatomy of cystitis is the same as that of inflamma- tion of mucous membranes in other parts of the body. In the more acute forms the membrane is swollen and relaxed, and of a bright or deep red color, from hypertemia. The surface is partially or en- tirely covered with a thick, tenacious mucus. There is exfoliation of the epithelium, as shown by the partially denuded condition of the membrane, especially at the top of the rug?B, and pus and loose cells are found in the sulci between the folds. In some instances, especially in cases of acute cystitis caused by extreme overdistention due to mechanical or other retention, tliere may occur a throwing off of the whole or only a part of the mucous membrane of the bladder. This is more apt to occur wlien the re- tention and overdistention are caused by various accidents of the puerperal state or during delivery. That the separation of the nmcous membrane is not due to direct injury caused by the child's head or instruments carelessly used, but to the effect of overdisten- ORGANIC DISEASES OF THE BLADDER, Y63 tion, is shown by tlie fact tliat the vesical neck, which is subject to the most direct injury, seldom shows separation of its mucous mem- brane. That injury to the organ may predispose to separation, or even determine it when abeady predisposed to it by some other cause, there can be no doubt. Most of these cases of separation of the mucous membrane have occurred in women, and almost all fol- lowed delivery. The bladder which has participated in the general congestion of the pelvic organs incident to the puerperal state is in an excellent condition to allow such separation to take place. The manner of its production is probably as follows : A woman at full term is delivered after a long and tedious labor, with or with- out the use of instruments, of a healthy child. The child's head or the forceps may have done violence to the urethral mucous mem- brane by crowding the urethra against the unyielding puljic bones. Swelling of the mucous membrane results, and retention of urine (if the patient be not relieved by the catheter) follows and persists for a varying length of time. The doctor, the nurse, and the pa- tient herself are often led to believe, from the constant or inter- mittent dribbling of urine, that there is an irritable condition of that organ, with frequent urination. The truth is, that this drib- bling (stillicidium) is almost a certain sign of an overfilled bladder, and if the patient be not relieved the distention will gradually in- crease. The organ having reached its limit of distention, or being stretched to its utmost, tlie pressure within is so great as to cut off the supply of blood to the submucous tissue, and thus to the mu- cous membrane itself. This is more readily accom]3lished, as the muscular fibers are pulled apart and the mucous membrane thereby allowed a certain amount of bulging, by which its blood-supply is seriously interfered with. If the distention be relieved early enough; nothing worse than an acute cystitis results ; but if not re- lieved, partial or total death of the membrane occurs, and it is sooner or later thrown off. Although death of the membrane may not take place in every case, or in one half of the cases of overdis- tention, it is no argument against this method of its production. Nor yet is it an argument in favor of the idea that it is caused by instrumental violence to the body as well as the neck of the viscus ; for that the latter can not be the only cause may be seen from the fact that it has occurred in the male (Liston per Barnes). It is probable that there are several causes, and that these may work to- gether to produce the result. From the uniform exfoliation it would look, however, as if the most important cause was a uniform pressure cutting off the blood-supply, and thus causing death of the 764 DISEASES OF WOMEN. part. It is even to be conceived that where marked injury has been done the membrane by overdistention (though not sufficient in it- self to cause death), too rapid rehef of retention causing congestion, irritation by catheter, peculiar systemic conditions, and the intense inflammation which follows may finish the work. viz. : fully carry out tlie impression already made by the overdistention. This affection is not a common one, and though cases may sel- dom be met 1 desire to lay stress upon the great importance of pay- ing strict and individual attention to the condition of the urinary organs in pregnant and parturient women. The catheter can tell more of the condition of the patient's bladder in such cases than any nurse, and can do no harm whatever when a soft instrument is used with care. Experiments on dogs have proved that the detachment of the membrane begins at that part of the bladder just opposite the vesi- cal neck. At this point the membrane bulges out with a collection of blood and serum beneath it, and this bulging gradually extends to other parts. Meantime, in the bladder, the mucus poured out to shield the membrane causes the urine to decompose, and incrusta- tions of amorphous and triple phosphates are found on the surface of the exfoliated membrane. The color of the mucous membrane is usually either a deep red, greenish red, or black, and it may come away either in pieces or as a whole. In some cases (Mr. Wells's second case, Barnes) part of the muscular as well as the mucous tissue sloughed off and came away. In Mr. Liston's case the entire nnicous membrane came away through a supra-pubic opening made by that gentleman to relieve retention. This occurred in the case of a male adult. Some of these patients have recovered, and it is believed by Schatz that the reproduction of the membrane commences at that portion of it always left at the vesical neck. That the completion of the sloughing does not takes place until sometime after the injury is done, and that the membrane itself may block the urethra and cause further retention, is illustrated by the following case, taken from Barnes's able lecture in the " Lancet," January 2, 1875. The case was under the care of Dr. Wardell, at the Infirmary, Tunbridge Wells. " A woman was admitted with retention of urine. Fetid urine was drawn off. A fietus of three or four months was ex])elled followed by its placenta. Then incontinence ensued. The urine was still offensive, and loaded with mucus. Twelve days later she was seized with great pain over the pubic region. Next morning the house surgeon was ORGANIC DISEASES OF THE BLADDER. Y65 called to see lier on account of excessive pain. He felt a substance being expelled, and saw a mass protruding throngb the meatus uri- narius. This was expelled in half an hour. At the moment of ex- pulsion the urine gushed out in great force and in large quantity. Instant relief followed, and she perfectly recovered. The substance looked as if it were the whole mucous coat of the bladder. Its inner surface was coated with gritty deposits. Its minute structure is not described." Barnes has no doubt but that the retention was in this case caused by retroversion of the gravid uterus. One of Mr, Spencer Wells's cases, also cited by Barnes {loc. cit), is very instructive : " A woman, aged 22, had a natural labor with her first child. The bladder was not emptied for sixty-two hours. Five pints of turbid, bloody urine were then drawn off. Cystitis fol- lowed, then incontinence of urine, and a train of distressing cerebral symptoms, ending in death two months after delivery. The bladder after death was found to contain a detached cast, lying loose, cov- ered with gritty deposits of urates and phosphates. The walls of the bladder were thick and contracted, the muscular fibers being distinctly visible. The cast resembled degenerated epithelium. On boiling a piece of it in dilute acetic acid, much of the saline matter became dissolved, and some of the tissue became clear, look- ing like smooth muscular tissue which had begun to degenerate, as shown by the deposit of fatty or albuminous particles in its sub- stance." Further pathological results may follow the prolonged retention of urine. The bladder having reached a certain point where no more urine can enter it, and even before this time, the ureters are filled from the urine above, and as the renal pelves fill, both they and the ureters are put greatly on the stretch. The kidneys con- tinue to secrete urine until the pressure in the urinary tubules equals that of the blood in the glomerulus. At that point all secretion ceases, and pressure on the emulgent veins becomes so great that de- generative changes are apt to take place. In some cases after the pressure is relieved, acute nephritis results. The urine following such a condition of distention is loaded with hyaline, granular, and epithelial casts, and epithelial elements from the kidneys. The following ease, which occurred in the practice of Dr. Geo. W. Gushing, of this city (the doctor having kindly furnished me with a report of it), may serve as an illustration of what I have been saying : " Mrs. S., of New York, aged twenty-six ; married eight years ; one child ; catamenia regular ; appetite fair ; bowels sluggish ; no 766 DISEASES OP WOMEN. dysuria previous to present attack. Has been under treatment for the past two months for cervical endometritis. Local applications of mild astringents and glycerin, with injections of borax. Tonics and laxatives internally. There being some tendency to tubercu- losis, she was given cod-liver oil. "I was called to see this patient May 29, 187Y. She told me she was suffering from internal haemorrhoids, and that the lectal tenesmus was very distressing. She had had similar attacks before, and seemed to have no doubt as to what the trouble was. As she was menstruating I made no examination, but advised rest and a laxative powder, to be followed by morphia suppositories. " May 30. — Bowels moved since last visit with considerable pain. Complained of some vesical irritation, but had passed urine. Not much relief. "J/«y 31st. — No better. An examination showed no haemor- rhoids. Menses ceased. Vaginal examination revealed a very sensi- tive spot, with hardening on the right side, between the rectum and vagina. Pulse and temperature slightly elevated. Vesical and rec- tal tenesmus, but no trouble in passing water. Made diagnosis of probable pehac abscess. Advised poultices to the perinseum, warm applications over the abdomen, and gave anodynes. Patient much relieved by the treatment, but still having severe pelvic distress. '' June 2d. — Condition the same. ^'June 3d. — Found the vesical distress increased. Her husband said that she had passed urine during the night. Was called to her in the afternoon, and found her in great suifering. Said that her husband had misinformed me, and that she had passed no urine for about thirty hours. I examined the abdomen, and found dullness well up to the umbilicus. Introducing a catheter, I drew off a large quantity of very offensive, high-colored urine, with much relief to the patient. For the next two days I was obliged to use the cath- eter. An exaiuination of the urine drawn off was made, and showed the presence of renal epithelium, granular, hyaline, and epithelial casts, and considerable albumen, as also epithelium from the bladder and ureters. " June 5th. — T found a tendency of the inflammatory products in the pelvis to point about the center of the perina^um, and, tliough not quite sure of pus, I punctured and evacuated quite a large amount of it. " Since then the treatment has been the use of alkalies and sooth- ing drinks — tr. ferri chloridi — and washing out the bladder with lukewarm water containing salt and a little carbolic acid. The ab- ORGANIC DISEASES OP THE BLADDER. 767 scess remaining open and very sluggish for some time, I put the patient under ether, and performed the operation for fistula in ano. At the present writing, October 30th, Mrs. S. is in excellent condi- tion, having gained in flesh and strength, and being no longer trou- bled with the vesical disorder." This case is not only interesting as showing the serious changes that may occur in the kidneys from vesical distention, but as illus- trating the occurrence of retention of urine from reflex nervous in- fluence. Abscesses about the rectum are especially prone to cause retention. Although in this case the mischief done to the kidneys was soon corrected, it does not follow that it will be so readily accomplished in all cases, especially if the retention continues un- relieved for any length of time. CHRONIC CYSTITIS. Pathology. — In chronic cystitis the redness of acute inflamma- tion gradually gives way to a muddy gray color, the membrane being smeared in places with a dark yellow muco-purulent secretion. As the disease advances, there is excessive cell growth on the free mu- cous surface. Patches of ulceration appear here and there, attended with the formation of pus and occasional, though usually slight, haemorrhages. Sometimes, at the portions destroyed by ulceration, the process of hyperplasia is established, and a polypoid material is developed. This has the appearance of exuberant granulations, as seen on a healing sore. At other times, and even in portions of the same organ in which hyperplasia occurs, the process of ulceration advances. The submucous intermuscular tissue partakes of the inflammatory trouble, and thickening of the vesical walls results. The decomposed urine, mixed with pus, mucus, blood, and shreds of membrane, forming the chocolate-colored fluid found in the advanced stages of this disease, acts as an irritant on the unhealthy membrane, and produces deeper or fresh ulceration. In advanced cases, with deep ulceration, the muscular fibers (which resist the destructive processes longest) are occasionally seen, stretching from one side of an ulcer to the other, forming a sort of bridge. When the end of one of these fibers becomes detached, it floats like a filament in the contents of the bladder. In some cases the salts of the urine are deposited, and form incrustations on the ragged mucous membrane. I remember that one of my patients frequently passed lumps of material that on examination proved to consist of all these products Y68 DISEASES OF WOMEN. of destructive mflammation, among whicli were mixed deposits of the urinary salts in the form of hard, gritty particles. In cases of long standing, the vesical ends of the ureters are obstructed by swelling and hypertrophy of the bladder- walls. This produces obstruction to the free flow of urine, and leads to dilatation of the ureters and renal pelves, and in some cases organic disease of the kidneys follows in the train of pathological sequences. J wnll refer to this subject again. When the disease has destroyed the nuicous membrane partially or wholly, and extends to the muscular parietes, we have what is known as interstitial cystitis, and, if the serous coat becomes in- volved, there is also pericystitis. This latter is simply an inflam- mation of that portion of the pelvic peritonaeum which covers the bladder. In interstitial cystitis, after destruction of portions of the mucous membrane by ulceration, the areolar tissue beneath it and in the muscular walls gives way, the muscular liber generally becomes thickened and burrowed by ulcerated cavities, irregular in form, and surrounded by cicatricial tissue. The extreme hypertrophy of the muscular coat found in the bladder of the male under these circum- stances does not so commonly exist in that of the female. In epi- or peri-cystitis the peritoneal coat is found to be hyper- semic and thickened by exudation, and the adhesions which follow bind together the bladder and the neighboring organs. Perforation of the pentonaeum sometimes occurs, allowing inflltration of the urine. Tliis usually develops general peritonitis or septicaemia, or both, and death almost inevitably follows. I have already stated that the walls of the bladder, including the serous coat, may become involved by the extension of a primary inflammation of the mucous membrane. This is undoubtedly the usual mode of occurrence, but, in some cases, I think that all of the bladder coats may become inflamed at the same time, making an inflammation in toto. At least, it is a fact that in some cases the mucous, muscular, and serous layers of the organ in question become involved in such rapid succession as to prevent us from detecting its progress from one tissue to another. The inflammatory process, having traversed the mucous and mus- cular coats, and involved the serous, especially where ulceration of the mucous membrane accompanies it, is likely to extend to the other portions of the pelvic peritonaeum and cellular tissue if the patient lives sufficiently long. It will be observ^ed that in this condition there is about the same pathological anatomy as in pelvic peritonitis and cellulitis where in- ORGANIC DISEASES OP THE BLADDER. YG9 ilammation of tlie bladder-walls is caused by, and consequently sec- ondary to, the pelvic intiamniation. In such condition the kidneys and ureters are usually found diseased. In some cases the cellular tissue about the bladder becomes greatly increased, and occasionally abscesses form, as in ordinary pelvic cellulitis. I am satisfied tliat the disease described in some of the text-books as idiopathic pericystitis is, in almost all cases, when it occurs in women, a pelvic peritonitis originally, the bladder becoming aflfected secondarily. One of the most serious results of intense vesical inflammation is gangrene. The bladder becomes distended from paralysis of its muscular walls, and its contents are found to be a brownish colored fluid, consisting of decomposed urine, shreds of broken-down mucous membrane, altered blood, pus, epithelial elements, and urinary salts. The mucous membrane is found to be soft, pultaceous, and altered in color, the latter varying from a deep, charred black to a dark greenish or greenish yellow. The submucous connective-tissue layer and the muscular coat are softened, discolored, and infiltrated with malodorous pus. The peri- tonaeum is also injected, and in places discolored, sometimes per- forated, and having undergone fatty degeneration. This complica- tion usually occurs in the course of chronic cystitis with considerable ulceration, and in which an acute inflammation is lighted up, there not being sufiicient vitality left to prevent rapid and deep gangrene. These extreme forms of cystitis are rare, and occur generally in connection with abnormal cases of labor, A pregnant woman having a cystitis of a mild form is liable to develop acute general cystitis at her confinement. Again, inflammation and gangrene of the blad- der sometimes follow instrumental or manual delivery in which severe contusions of the bladder have occurred, I desire now to call attention to some of the effects of cystitis on the ureters and kidneys. That form of vesical inflammation known as chronic cystitis may travel up the ureters to the kidneys, produc- ing ureteritis, pyelitis, pyonephrosis, or renal abscess. This affec- tion seems more commonly to attack the left ureter and kidney. I say seems, that being simply my opinion, derived from the cases that I have seen or of which I have read. I know of no statistics upon the subject. This complication is not so common in females as in males, which is owing, perhaps, to the fact that their short ure- thra, being, as a rule, free from stricture, and seldom obstructed otherwise for any length of time, the inflammation of the bladder 50 YYO DISEASES OF WOMEN. has less tendency to extend, is less severe, and, as a rule, is earlier and more easily treated locally than in the male. It can not be denied that the damming back of urine into the ureters and renal pelves is a factor in the production of disease in these parts. Suppose that an inflamed ureter becomes blocked up from any cause (a mucous, purulent, or blood plug ; by the impaction of a small calculus from the kidney ; thickening of its mucous mem- brane ; or hypertrophy of the bladder-walls), the urine behind the point of obstruction greatly distends the ureter and renal pelvis, de- composes, and produces acute pyelitis, which often leads to destruc- tion of the kidney on that side. In post-mortem examinations of such cases it will be found that the mucous meml)rane of the dilated ureter and pelvis of the kid- ney is swollen, pulpy, and of a dirty-drab, grayish, or greenish color, and possibly with incrustations of saline matter upon its surface. The renal pelvis may be sacculated, and the pouches may contain shreds of membrane, thickened, dirty pus, and saline matter. The kidney, when free from organic lesion, is always sympathetically affected, being enlarged and congested. Abscesses of the kidney itself have been found in these cases. The inflamed and dilated pelvis of the kidney, gradually enlarg- ing, flattens out, and implicates the papilliie, and later the pyramids in the inflammatory process, until, finally, the whole organ is con- verted into a sacculated abscess. When there is destructive inflammation of the kidney (the ureter not being obstructed, and the pus having a free exit), the organ shrinks until it is converted into a little shriveled body, weighing from a few drachms to an ounce or two. If the purulent matter has not free exit, it fills the kidney, and becomes thick and putty-like, cutting like fresh cheese. This may be the case where the punilent matter can not or does not escape from the kidney, the ureter being perfectly free throughout. The septa between the sacculi are occa- sionally calcified. The pyramids alone may suffer, their tissue being converted into purulent matter, the whole having the appearance of soft putty, in some cases studded with calcareous masses. When the purulent matter is washed out, the hole left looks as though the pyramid had been punched out, so smooth and clean cut are its edges. Again, the kidneys may be studded wi;;h miimte abscesses. Where one kidney is wholly or partially destroyed, the other, if healthy, is, as a rule, largely hypertrophied. In some cases of long standing the affected kidney does not break ORGANIC DISEASES OP THE BLADDER. 771 down into purulent matter, but by a slower process, probably that of chronic congestion, becomes granular and contracted. The study of the renal complications of cystitis is a very interest- ing and instructive one, but it is too extensive to permit of anything like a full discussion here. For a more elaborate consideration of the subject, I must refer to the special books on renal diseases. Symptomatology. — The various forms of cystitis being simply stages of the same disease, I shall speak of their symptoms all under one head. They may, for convenience sake, be divided as follows : 1. Symptoms referable to the organ or its contents. 2. Symptoms referable to neighboring organs, that suffer either from sympathy or through direct extension. 3. Symptoms referable to various conditions of the general sys- tem, as : («) The vascular system, (h) The digestive tract, (c) The cutaneous surface, {d) The nervous system — cephalic and sub- cephalic. 1. The symptoms referable to the organ itself are chiefly de- rangement of function — viz., pain, tenesmus, and frequent urination. The symptoms vary in severity according to the extent and intensity of the cystitis. In the mildest form of the trouble there is frequent desii-e to pass water, which often comes with unusual force. Mic- turition is followed by a desire to strain, called vesical tenesmus, as if the organ had not been fully emptied. In the more acute cases this gives rise to the most intense agony, the patient remaining on the vessel for hours at a time. The sensation of a few drops of urine remaining in the bladder may pass off in a few moments, but, as a rule, returns after each micturition. As the disease advances, and ulcerative changes take place, this vesical tenesmus returns in full force, and the powerful squeezing together of the bladder-walls during and after urination produces intense pain. Sometimes pains shoot up into the breast or the re- gion of the umbilicus. There is often a dull, heavy aching in the perinseum. In nearly all cases there is continuous backache, or, more correctly, sacral pain. These pains seem to be most severe in cases of long standing, where, upon an already ulcerated surface, an acute inflammation is set up by errors in diet, medicines, violence in cath- eterization, rapid changes in temperature, and the weather. The condition of the urine in acute or chronic cystitis is of im- portance, but if reliance is placed upon it alone for a diagnosis there w\\\ be many disappointments. The specific gravity is usually low in the more chronic types, varying from 1*005 to 1*018, being usu- 7Y2 DISEASES OP WOMEN. ttally about I'OIO. In the primary acute form the gravity is little if anything below the normal, and, if there is marked fever, may rise as high as 1*030. In acute attacks engrafted on a chronic state, the gravity is usually low. When the specific gravity is low in acute cystitis, if not dependent on the diluent drinks and diuretics given, it is probably due to a slight sympathetic hyperaemia of the kidneys. The low gravity in chronic cystitis is possibly due to the same cause, and a urine not only proportionally but really deficient in the urin- ary salts is excreted. To this may be attributed many of the urseniic (ammonsemic) symptoms accompanying the disease, which are sup- posed by many to be due to absorption of decomposed urine. That such absorption might take place after ulcerative processes had be- gun, or even slight epithelial erosion had taken place, there can be no doubt; but it is a question whether we are to look to the absorp- tion from the eroded bladder as the only method of their production. I shall speak of this more fully very soon. The reaction of the urine in acute cases, when the affection is not due to, or accompanied by, retention, is at first usually acid. If there be retention, the reaction is usually alkaline, due partly to the fixed alkali of the mucus which is present in excess, but chiefly to the ammonia disengaged in the breaking down of the urea. In chronic cystitis the reaction is almost invariably alkaline, being in- tensely ammoniacal. In the primary acute form, the color is but slightly altered. The presence of a little blood may give to the urine a smoky tint, and if decomposed it will look hazy and perhaps contain sparkling crystals of the triple phosphate. In the chronic form the urine is of a pale, dirty yellow hue, and may be of a deep red from the presence of considerable blood. The odor is ammoniacal in the acute type, if the urine be de- composed, otherwise it is normal In tlie chronic form it has not only an ammoniacal but a peculiar pungent odor of flesh. This is usually known as organic, from the fact that it is due to the amount of organic material present. The sediment in acute cystitis is usually mucus, sometimes pus (white and clinging to the bottom, or somewhat flocculent). It may be tinged with ])lood, or rendered denser and whiter from the pres- ence of the amorphous and triple ])hosphates. In chronic cystitis the sediment is commonly heavy, and of a dirty brown or brownish yellow color. Flakes of pus, shreds of tissue, as well as blood and epithelial elements, cause it to vary greatly in different cases. When the intense alkalinity of the urine has rendered the pus gelat- ORGANIC DISEASES OF THE BLADDER. YY3 inouSj the sediment is seen as a ropy mass that clings tenaciously to the bottom of the vessel when inverted, or slides about in a jelly- like mass. •Microscopically, this sediment presents a varied and interesting appearance. In the acute form numerous fibrillse of mucus, a few pus-corpuscles, and possibly blood-globules are to be seen, and if de- composition has taken place, the amorphous and triple phosphates. In chronic cystitis pus-corpuscles are usually present in large amount. There is also a varying amount of mucus, triple and amor- phous phosphates, spheres of the urate of ammonia, organic debris, and in some cases epithelial elements. In the advanced stages of chronic cystitis epithelial elements of any kind are very rarely found. It is only in the earher stages that normal and transitional forms of vesical epithelium are present. Even then dependence must not be placed upon that alone in making a differential diagnosis, lest a pye- litis may be mistaken for a cystitis, or vice versa ; the transitional forms of epithelium from the bladder closely resembling the nor- mal epithehum from certain other parts of the urinary tract. The return to a healthy condition is marked by the disappearance of pus ; the reappearance of epithelium in the urine, first transitional, then perfect ; while the products of inflammation decrease in amount and finally disappear altogether. When there is sympathetic congestion of the kidneys, small light granular and hyaline casts may be found. If organic renal disease is present, large, small, and medium-sized hyaline, light and dark granular, and pus casts will be found, as also epithelial and blood casts. In some cases, where extensive de- structive change has taken place in the kidneys, no evidences are found in the urine, either during its progress or after its completion. Upon testing the urine chemically, albumen wiU be found in proportion to the amount of pus or blood present. If renal disease co- exist, the amount of albumen will be greatly increased. In chronic cystitis without renal disease the amount of albumen in a number of cases studied varied from one sixteenth to one fifth of the bulk of urine. There is usually a real excess of both fixed and volatile alkaline salts, as also of the earthy and alkaline phosphates and the chloride of sodium. In the advanced stages, where there is a depraved condition of the blood, urohaematin is present in a marked degree, and ui"ea is either somewhat or decidedly diminished. In other cases, and at first, the urea may be present in normal amount. 2o Symptoms Referable to Neighboring Organs. — These are not especially marked. In some cases, with the intense vesical tenes- 774 DISEASES OP WOMEN. mus, there may exist an irritable condition of the rectum, with some tenesmus and pain at stool. The uterus is often congested, which causes a free leucorrhoea ; subinvolution often occurs after the coniinement of those who have had cystitis during pregnancy. Extension of the inflammation in extreme cases may cause metritis and pelvic cellulitis and perito- nitis. The symptoms thus arising will be characteristic of the dis- ease of the organs or tissues involved. Menstruation may be variously disturbed ; menorrhagia, metror- rhagia, or amenorrhoia resulting either from congestion, infllamma- tory extension, or reflex nervous influence. Neuralgia of the uterus or ovaries may also be produced in this way. I have just said that subinvolution of the uterus is almost sure to follow a pregnancy occurring during the existence of a chronic vesical inflammation, and I am inclined to believe that the same result is produced in some cases by an acute cystitis following delivery. Renal disturbances upon which I have already touched will be spoken of more at length hereafter. 3o Symptoms Referable to Disturbances of the General System. — These symptoms may be due to reflex nervous influence, or to di- rect blood-poisoning. For convenience sake I will first consider : («) The Vascular Sydem. — Although there has been much dis- pute among authors as to how and by what the general poisoning is caused, there seems to be no question as to whether such a poison- ing really does take place. As general systemic effects may be pro- duced by two separate blood conditions, I will discuss the subject under two heads, prefacing their consideration, however, with the remark that, as a rule, the two conditions exist together. They are : first, abnormal ingredients existing in the blood; and, second, a poor condition of the blood itself (anaemia). The poisoning of the general s^'stem that usually complicates cystitis of long standing may be produced in three ways, viz : 1. Organic renal disease, or renal hyperaemia (sympathetic), leading to imperfect elimination of urinary salts. 2. Direct absorption of one or more of the ingredients of the decomposed urine (ammonsemia, urineemia). 3. Absorption of purulent or septic matter, produced by decom- position of sloughing tissue and organic debris. 1. Probably in almost all cases of chronic cystitis the kidneys are kept in a more or less active or passive hyperaemic state ; and while eliminating a normal amount of fluid, fail to rid the blood of OEGANIC DISEASES OF THE BLADDER. Y75 the accumulating salts ; and thereby a slow, steady blood and tissue poisoning is brought about. So slow is it, that the system seems to establish a certain amount of tolerance tor the poison. A French experimenter has found that a small amount of urea is daily eliminated by the mucous membrane of the bowels in health, and we know that in renal diseases, with partial or total sup- pression of urine, the bowels are largely concerned in the elimina- tion of the poison from the system. In this manner may be ex- plained the occasional attacks of vomiting and almost uncontrollable diarrhoea in bad cases of cystitis. Of course, when destructive renal disease complicates the cystitis, the general poisoning is more marked and more readily explained. 2. In the chapter on the function of the bladder I pointed out that experimenters had pretty well established the fact that a nor- mal vesical mucous membrane was unable to absorb anything except possibly a little water, but that where erosion of the epithelial surface or ulceration existed, absorption was possible. This being the case, it will at once be seen how easy it is for a patient suffering with chronic cystitis to become poisoned by the absorption of decomposed, ammoniacal urine in the bladder. Whether the materies morhi be the urea, the ammonia, or all or part of the urine, is not as yet deiinitely settled. This form of poisoning by absorption has been denied on the ground that the urine remains but a short time in the bladder owing to the intense vesical tenesmus, and that the eroded surface is fairly well shielded from contact with the urine by mucus or gelatinous pus, and that therefore there is neither time nor opportunity for absorption. As against these arguments, let me say that of all kinds of urine, the highly limpid seems the most easily absorbed ; that poisoning is not supposed to be due to the fresh urine that comes directly from the kidneys, but to its decomposing sediment, caught in the meshes of the mucus and muco-pus. Fur- ther, the intense vesical tenesmus, while keeping the bladder com- paratively empty, thoroughly mixes the decomposing urine with the mucus, thus at each micturition applying freshly charged de- composing matter to the eroded and ulcerated surface. It will also be observed that in some cases where, by the use of opiates or in the course of the disease itself, the tenesmus wholly or in part abates and the urine remains in the bladder for a longer period than usual, the patient, while feeling greatly relieved by not having the inces- sant calls to urinate, still begins to experience a peculiar sensation of sleepiness and the other manifestations of systemic poisoning. That this is not due to the opiates or other remedies used, is evident 776 DISEASES OF WOMEN. from the fact that as large or larger doses of the same remedies do not j^roduce these peculiar results when given at times when the vesical tenesmus is marked. It is midoul)tedly explained by the fact that the bladder has more time to absorb a part of its contents, which, when absorbed, produce these results. 3. Blood contamination due to the absorption of purulent or sep- tic matter. — This material may l)e the liquor jpui'is^ the disinte- grated corpuscles of jdus, or possibly the whole corpuscles, as also the decomposed shreds of sloughed membrane and organic debris. I think there is little doubt but that feuch material is at times ab- sorbed, and gives rise to the peculiar septicsemic or pysemic symp- toms. The chill, fever, and sweating, with peculiar head symptoms (all to be spoken of more fully hereafter), the sudden diarrhoea, with copious black, oifensive liquid stools, are probably caused in this way. Whether the general symptoms are produced at the time of each absoi"ption, or whether by slow degrees the poisonous material col- lects, and, tolerance being finally exhausted, nervous disorder, with a powerful effort at excretion by the bowels, results, we do not know. ■i. Depraved blood condition — (anaemia). — In cystitis of long standing, owing to frequent ha3morrliages, poor digestion, excessive diaphoresis and diuresis, and reflex nervous influences, the blood be- comes poor in red corpuscles and fibrin. Injuries on persons thus affected do not heal readily, and poor tissue renovation is a general accompaniment of this affection. Cerebral aufemia is an accompanying complication, due to the same cause, and various ab- normal nervous phenomena result from poor nourishment of nerve- tissue. All the fluids and solids of the body are but pcorly con- structed, and imperfect performance of function necessarily results. This poor blood condition, as I have already said, is manifested by the presence of urohseraatin in the urine. (Jj) The Digestive TraH — Anorexia, especially at the morning meal, is a common accompaniment of chronic cystitis. In some cases this is the only meal where the appetite does not invite the patient to partake. A longing for peculiar foods is also very common, the patient often having lost the desire before the article in question reaches her. The common symptoms of disordered digestion are usually present, and the affection may be either of the nervous type, or of the chronic catarrhal form ; it is usually a mixture of both. If, as is believed, the poisonous material aT)sorbed from the bladder and the non-eliminated urinary salts find vent through the aliment- ary canal, we have no trouble in discovering a cause for the catar< OEGANIC DISEASES OP THE BLADDER. YY7 rlial disorder. The nervous disorders are readily explained by the effects of the abnormal condition of the blood, and the broken and sleepless nights which interrupt and retard the nutrition of the nervous system. The bowels are usually irregular and constipated, and require daily enemata to open them. This costiveness is occasionally in- terrupted by a profuse watery diarrhoea, which would seem to be an effort of nature to relieve the blood of its abnormal contents, as I have already said. It may last for days or for only a iew hours, and the discharges are usually rich in the carbonate of ammonia. The septicteniic diarrhoea differs usually in tlie great prostration ac- companying it, the character of the stools (black or greenish black, and very offensive, the organic odor quite or partly hiding the ammoniacal odor), and the fact that it is usually preceded or accom- panied by chills, fever, and sweating. If checked too abruptly, head symptoms, mild muttering delirium, etc., are hkely to follow. The results of imperfect digestion are seen in the poor, un- healthy condition of the patient's flesh and skin, and all the signs of malnutrition present. (c) The Cutaneous Surface. — The skin of patients with chronic cystitis is usually sallow, loose, and has a lifeless feel. Indeed, one might ahnost make a diagnosis from the complexion alone. Sweat- ing of the palms of the hands and soles of the feet is common. In low states of the system the patients are especially liable to iiight- sweats. The perspiration sometimes has a urinous odor. I have al- ready spoken of the septicaemie diaphoresis. (d) The Wervous System. — I will first consider the symptoms appertaining to the brain and its function, and then to the sub- cephalic nervous system. There is a peculiar brain condition, supposed by some to be caused by cerebral anaemia ; others attribute it to a peculiar poison circulating in the blood. By anaemia of the brain in this connec- tion is meant not only lack of blood in that organ, but an exceed- ingly impoverished condition of the blood there circulating. Those remedies that tend to lessen the amount of blood in the brain, as bromide of potassium and ergot, produce most unpleasant symp- toms in these cases, such as dizziness and fainting. Medicines which act in a manner to congest the brain, if given in small doses, improve this condition, as also do the ferruginous tonics, especially iron by hydrogen. From this it would appear that this peculiar con- dition is due more to the amount and imperfect constitution of the blood circulating in the brain, than to the absorbed or non-eliminated 778 DISEASES OF WOMEN. urinary matter. Against this theory, however, is the fact that when the vesical tenesmus is least and the urine remains in the bladder longest, and hence the blood-poisoning is presumably the greatest, the weak and somnolent feeling is the worst. Both causes probably act to produce this condition. By some, however, this cerebral anpemia is attributed partly to the poor blood condition, but chiefly to imperfect circulation due to want of exercise. This view is supported by the fact that digitalis and exercise in the open air greatly improve these patients. When septic complications arise and the patient becomes very low, or when the septic diarrhoea is checked too suddenly, low, mut- tering delirium with hallucinations commonly results. This has been alluded to before. The mind is usually markedly affected, the patients feeling " blue," morose, lacking hope, confidence, and spirit. At times, indeed, they become so despondent as to seriously contemplate suicide. The little rest that they get at night is often broken by horrible dreams and nightmare. I am now speaking of the most severe cases. The Bubcephalic nervous system is seldom affected beyond oc- casional irregular action of the heart, chills, fever and sweating, and occasional neuralgia. Pains in the nipple, abdomen, arms, legs, hands, and feet, are by no means rare. The vesical pain has already been referred to. Of course all these symptoms that I have spoken of as accompanying cystitis, do not occur in each case, nor are the greater part of them peculiar to cystitis alone. I now pass to diag- nosis. Diagnosis. — The diagnosis of cystitis is generally easy in marked cases, but in mild attacks care is necessary to distinguish it from other conditions that cause similar symptoms. Frequent urination occurs in many other troubles, such as pro- lapsus uteri, adhesions from pelvic peritonitis, with abdominal tu- mors, and in various neuroses. Pregnancy, also, sometimes gives rise to annoying frecpiency of micturition. Frequent urination from prolapsus is worse when the patient is standing or walking, and is relieved wholly, or to a great extent, by the recumbent position ; while in cystitis, position makes no marked difference. I have seen one very interesting exception to this general rule. The patient had a complete prolapsus for many years, and when in the erect position she could retain the urine for an ordinary length of time, but when she was reclining the most urgent desire to urinate came on, and she could only retain a very small quantity of urine. The cause of this I found to be inflammation of the neck of the ORGANIC DISEASES OF THE BLADDER. Y79 bladder. When in the upright position the urine settled down in the dependent portion, but while recumbent the pressure came on the tender part. In adhesions from pelvic peritonitis, abdominal tumors, and pregnancy, the desire to urinate only comes on when the bladder is partly filled, and is about the same day and night. Frequency of urination is not usually accompanied by tenesmus, except when due to cystitis. In the various forms of vesical neuroses frequent urina- tion is very irregular, the patient at times being almost entirely free from it, and at other times very much troubled. The frequent and painful urination of cystitis may be simulated by urethritis and other painful, irritable conditions of the urethra. The distinction can be made usually, from the fact that in urethral disease there is no vesical tenesmus, or if any, it is much less than in cystitis. There are acute pain in the act of urination, and a burn- ing sensation in the m-ethra, which sometimes cause sympathetic vesical tenesmus ; but when this latter passes off the bladder will tolerate distention to the fullest extent. The urine should be carefully examined and the results as care- fully considered. Implicit dependence, however, must not be placed on the condition of the urine. Acute or chronic congestion may produce considerable mucus that is sometimes mistaken for pus that has become gelatinous by the action of strong alkali. Pus may be present in the urine from suppuration of the upper urinary pas- sages (pyonephrosis, renal abscess, and pyelitis) ; from abscesses of neighboring organs or tissues opening into the bladder, as in colitis and pelvic cellulitis. When there is doubt on this point, Sir Henry Thompson's method of procedure as recommended by Van Buren and Keyes for detecting the source of blood should be tried. A differential diagnosis between cystitis and pyelitis, by means of the urine alone, is almost an impossibility, especially in the later stages of the former. Thompson's method, the endoscope, and the presence or absence of a tumor in the loins, with the gen- eral symptoms, must be the guides. No dependence can be placed on the epithelium, as transitional forms from the bladder, as already explained, are very likely to be mistaken for the normal epithelium of tiie renal pelves, and lead to error. One of the difficulties that long perplexed the diagnostician M'as to ascertain the condition of the kidneys in cases of cystitis. The products of the cystitis made the analysis of the urine almost use- less in the investigation of nephritic diseases. The first step toward clearer light on this subject was taken in washing the bladder clean 780 DISEASES OP WOMEN. of all pus and mucus, and then collecting for examination the urine first secreted after the washing. This was a great help, but was not fully satisfactory because only small quantities could be obtained at a time. I succeeded much better in estimating the condition of the kid- neys by determining the quantity of urea eliminated, and not by the presence or absence of albumin or casts. It is only necessary to remove the products of the cystitis by filtration from the specimen of urine and lind out in the usual way the quantity of urea. This method of investigation gives a far more accurate idea of the state of the renal function than the finding of albumin and casts. Again, by estimating in this way the degree of impairment of function one obtains an idea of the extent of organic changes that liave taken place in the kidneys. This is especially reliable if the impairment of function is persistent. There is an exceptional condition in which a diagnosis can not be made in this way, and that is when one kid- ney only is diseased. Then the diagnosis can not be made without the use of tlie ureteral catheter. In fact it is only in such cases that I need to catheterize the ureters for diagnostic purposes. In all other conditions of the kidneys a diagnosis can be made without resorting to physical exploration with the cystoscope, endoscope, or ureteral catheter. To make a positive and reliable diagnosis, resort must be had to physical exjiloration of the organ. The methods of exploration are palpation, percussion, and auscultation of the abdomen ; examination of all the pelvic organs by the touch and speculum ; and, lastly, ex- ploration of the bladder by the catheter, or sound. By palpation and percussion of the abdomen tenderness and dis- tention of the bladder may be detected, if either exists. By the same means it may be ascertained whether the bladder is contracted and its walls thickened, rigid, or relaxed. Auscultation will possibly reveal friction sounds in cases where inflammation has extended to the serous coat, and caused roughen- ing by exudation on the peritoneal surfaces. These may seem to be rather delicate points in examination, but in obscure cases we must avail ourselves of all the means that can ffive the slightest evidence. Examination of the pelvic organs by touch will detect an}' dis- ease of these organs that may either cause or complicate the cystitis. Disj^lacements and inflammatory affections of the uterus, vagina, or rectum, pelvic peritonitis, or the products of a former attack of that disease, ovarian diseases and tumors, should be carefully sought for, ORGANIC DISEASES OP THE BLADDER. Y81 and, if present, tlieir relations to tlie vesical trouble carefully studied. Cystitis produced by or producing pelvic cellulitis and perito- nitis has the same symptoms as ordinary purulent vesical inflam- mation, plus those of well-defined pelvic inflammation. There are usually pain and tenderness of the pelvic organs, and the sympto- matic fever of local inflammation. In those cases where, from gluing together of the pelvic organs, the bladder walls are separated and kept upon the stretch, inconti- nence often results, sometimes overdistention with dribbling. In such cases the cystitis may be entirely secondary to the pelvic ad- hesions, and consequent vesical distention. The urethra should be examined with care, for some of its diseases present a natural his- tory closely resembling that of some vesical affections. By a careful use of the catheter or sound introduced into the bladder, the degree of tenderness of that organ can be determined, and the presence of foreign bodies, such as a stone in the bladder, can be excluded. The sound being in the bladder, the finger may be introduced into the vagina, and the posterior and inferior walls be examined as to their thickness and tenderness. In supposed cystitis the neck of the bladder ought always to be examined with a view of detecting ulceration and fissures at that point. These fissures give rise to symptoms very closely simulating cystitis, and the differential diagnosis can only be made by the en- doscope. The endoscope affords the only means of ascertaining the exact appearance of the interior of the bladder. The extent of conges- tion, the degree and extent of ulceration, and other lesions can be observed in this way, and this instrument should be used in all cases where the diagnosis is doubtful, or when the case does not yield to supposed proper treatment. The chief value of the endoscope is in examining the urethra and neck of the bladder. When, by the use of this instrument, urethral disease can be excluded, the diagnosis of cystitis may be made by exclusion. If this is not satisfactory, then the bladder should be emptied, washed, and thoroughly cleaned of all inflammatory products. The catheter should be left to drain off the urine as fast as it flows into the bladder. This urine, coming almost directly from the kidneys, will show if any renal disease exists. Sometimes the bladder is too irritated to permit the presence of the catheter ; then the patient should urinate as soon as there are a few drachms secreted, and, if there should be any evidence of renal dis- ease, the diagnosis would be complete. Y82 DISEASES OF WOMEN. AVhen from an examination of the urine or the symptoms it is impossible to tell whether disease of the kidneys complicates the vesical trouble, recourse may be had to the ophthalmoscope, by means of which renal disease, retinitis albuminurica, may often be diagnosticated. Causation. — The cause of acute cystitis may for convenience be classed under five heads, each of which will be studied separately : 1. Direct injuries, such as blows in the vesical region, falls, frac- tures of the pelvic bones, violent copulation, sudden urine displace- ments and pressure therefrom, contusions and injuries during labor, foreign bodies, rough catheterization, and overdistention from reten- tion of urine. 2. Abnormal urine. 3. Inflammation of adjacent organs. 4. Constitutional diseases. 5. Drugs, improper food, and the virus of gonorrhoea. These causes also pertain to chronic cystitis, whether it begins as an acute or subacute affection. 1. Direct Injuries. — Blows over the vesical region, falls, and espe- cially fracture of the pelvic bones, caused by some great force, usu- ally produce acute inflammation of the bladder, with or without rupture of that organ. The bladder, when full, is, of course, more readily ruptured than when empty, rupture in the latter condition being almost an impossibility. This item of knowledge can be turned to practical use in traveling, either by rail or water, by remembering to frequently empty the bladder. In cystitis from severe and direct injury, even without any perceptible traumatic lesion of the mucous membrane, there is apt to be marked haemorrhage, much greater, indeed, than in cystitis from other causes. Sudden displacement of other pelvic organs, as the uterus, may act in two ways : First, by pressure on the bladder, or by dragging it out of place ; second, by blocking the urethra by pressure. These dis- placements may be due to falls or blows, and it is not an uncommon occurrence for the gravid uterus to topple over by its own weight. Supposing a retroversion of the gravid uterus, the cervix would compress the urethra against the pubes, while the utero-vesical liga- ment would drag the upper part of the bladder downward and back- ward. Even after the uterus has been replaced, and the pressure on the urethra removed, with relief of the vesical overdistention, the retention is likely to persist, and overdistention recur, for by the pressure the urethra becomes much tnmefled, and the nniscular and elastic tissue of the vesical walls overstretched and partly paralyzeil. ORGANIC DISEASES OF THE BLADDER. ^83 If the distention has been great and prolonged, tliere may be par- tial or total sloughing of the vesical mucous membrane. In retention of urine, and consequent overdistention of the blad- der during or after labor, from either injury or carelessness, acute cystitis is very apt to occur. Here injury of a serious nature may be done to the urethra by pressure against the pubic bones by the child's head, with or without the intervening soft cushion of the anterior uterine lip. This is especially the case in slow, tedious labors, where the pressure is almost continuous. The extent to which the bladder may be distended without rup- turing is quite wonderful. My friend Dr. Bodkin invited me to see a lady with him in consultation, who went without urination for four days and nights after her confinement. The bladder reached above the umbilicus, and contained about three ordinary pots-de- chambre full of decomposed urine, which was drawn off by the catheter. The bladder remained paralyzed for three months after- ward, but finally regained its expelling power. At the time I saw her she was suffering from cystitis, brought on by the maltreatment. In justice to the medical profession I ought to say that this lady was attended in her confinement and for a time after by a member of the so-called new school of medicine. The ignorant or careless use of instruments during delivery is also a cause of serious vesical inflammation. In all these cases the catheter should be used several times daily, and with great care, until the organ has regained its power, and the contused urethra fully recovered itself. I may digress here long enough to say that the soft-rubber catheter is the only one that I have used for years. The old female silver catheter is the most dangerous instrument I have ever seen. It should be discarded forever. In cases where the bladder has been perfectly healthy, and the catheter passed a num- ber of times by way of experiment, the points of membrane with which the instrument had come in contact were abraded and con- gested, thus showing the danger attending the unskillful use of this instrument. If the frequent introduction of the instrument into a healthy bladder produces these results, how easily must the bladder of a pregnant woman be inflamed under such treatment, for the organ has been for a time more or less congested, and during labor perhaps severely bruised ! The question has been raised as to whether the irritation and in- flammation following catheterization in some cases is not due to the introduction (during manipulation) of air, either pure or containing germs that will cause decomposition of the urine. The experiments Y84 DISEASES OF WOMEN". of P. Dubelt, in which the air was injected into the bladder, show that it is perfectly harmless. Moreover, the same experimenter found that the injection of decomposing urine into the bladder did little or no harm unless the mucous surface was abraded. What- ever may be the effect of such things on a health}' bladder, I do not doubt but that the introduction of germs by means of air or a dirty catheter, decomposing urine, or the rough or too frequent use of a catheter, would produce an acute exacerbation in an organ already diseased. The influence of decomposed or decomposing urine in producing inflammation of the bladder will be more fully spoken of again. Forcible and excessive copulation is a decided exciting, as well as predisposing, cause of acute or subacute cystitis, and, if persisted in, a chronic inflammation of the bladder is usually the result. Foreign bodies in the bladder, such as pieces of wood, pins, needles, hair-pins, bodkins, and the like, that are sometimes slipped in by hysterical girls and those who masturbate, excite acute inflam- mation if not speedily removed. 2. Abnormal Urine. — No known abnormality of the urine will, I think, excite acute inflammation in a perfectly healthy bladder. In a bladder, however, that is suffering from chronic congestion ; in one whose walls bear deposits of tubercle ; in cases where some slight degree of inflammation already exists, then abnormal urine may and does give rise to marked inflammatory trouble. As a rule, however, inflammatory vesical disease precedes urine decomposition. In cystitis following overdistention, the retained urine, being mixed with mucus thrown out by the irritated and tense mucous mem- brane to shield ioelf, rapidly decomposes, and still further aggra- vates the abnormal condition of the membrane. "Women, sometimes from abnormal modesty, more often from the lack of opportunity, retain their urine until the bladder is dis- tressingly overdistended, and the urine partially decomposed. Of course this is wrong and can generally be avoided, but is neverthe- less a frequent cause of disease of this organ. Where there is considerable suppuration of the upper urinary passages (renal abscess, pyelitis, or pyonephrosis), the acid urine, loaded with pus, has, or seems to have, an irritating effect on the vesical mucous membrane, and in some instances probably lights up a cystitis, and certainly aggravates one when already existing. Deposits of the amorphous phosphate of lime, or of the ammonio- magnesian phosphate, often greatly aggravate and render serious a previously mild cystitis, but seldom if ever produce acute inflamma- ORGANIC DISEASES OP THE BLADDER. 7S5 tion in a healthy bladder. This raay be said also of uric-acid gravel and other crystalline urinary sediments, they being at most only able to produce some hyperaemia of the membrane with a little excess of the mucous secretion. Urine which is already decomposed, or decomposing, as I have already said, can produce acute cystitis only in an already diseased bladder, or in one where abrasions of the epithelial surface exist. To show how some of these causes may combine to produce cys- titis, let me take, for example, the bladder of a pregnant woman which has for some time shared congestion with the other pelvic organs. Retention and some distention of the bladder occur from some cause ; a clumsy physician attempts to pass a metallic catheter, and does it roughly and rapidly, and relieves the viscus of its con- tents. A slight catarrh of the mucous membrane, the surface of which is somewhat abraded, ensues. By the catalytic action of the mucus present in it, the urine is rapidly decomposed. The decom- position is often aided by germs introduced with the catheter. Car- bonate of ammonia, being set free from the broken-down urea, as- sists in alkalizing the fluid, precipitating the amorphous phosphates thereby, and forming, with the phosphate of magnesia already pres- ent, the ammonio-magnesian, or triple phosphate. The urine is further alkalized by the alkali of the mucus. The bladder-walls not having fully regained their tone, a little decomposed urine remains after each micturition, and aids in decomposing that which is next secreted, and would otherwise be normal. The mucus increases in amount, the ammonia is more rapidly set free, and the mucous membrane more and more irritated, until a true acute cystitis is set up. Such cases are of almost daily occurrence. The decomposed urine alone, however, produced without the overdistention or without the abrasion would not have occasioned a true acute cystitis, but might possibly by slow gradations have worked up a subacute cystitis. The rule, if it may be called such, is the one that I have already given — viz., that some abnormality of the urinary organs (as catarrh) almost invariably precedes urinary decomposition. 3. Inflammation of Adjacent Organs. — Acute cystitis may arise from the extension of inflammation from neighboring organs, as in vaginitis, metritis, uterine and vaginal cancer, extra-uterine preg- nancy, abscesses of the colon or other organs opening into the blad- ber, pelvic peritonitis, cellulitis, etc. Gonorrhoeal inflammation of the urethra may extend to the bladder. As gonorrluiea of the female urethra is comparatively rare, such an extension is seldom seen. 51 786 DISEASES OF WOMEN. When it does invade the urethra it is very apt also to extend to the bladder, and is very severe. Intlanimation of the renal pelves and ureters may extend to this organ and cause cystitis, the usual course, however, being from the bladder to the ureters and the kidneys. 4. Certain diseases of the general system affect the bladder, such as the eruptive fevers. In scarlet fever, and measles especially, I have noticed that the mucous membrane of the bladder suffers, to some extent, like the mucous and tegumentary tissues elsewhere. Diseases of the heart and liver act more as predisposing causes, by producing chronic vesical congestion, than as exciting causes, and when they do produce cystitis it is usually of a low chronic type. Old age, when the has fond is greatly deepened, acts more as a pre- disposing cause, by allowing the collection and decomposition of urine. Paraplegia and other affections of like nature, by allowing overdistention and decomposition, as a rule, produce cystitis, but of a low form. 5. Drugs, Improper Foods, and the Virus of Gonorrhoea. — Of all drugs, cantharides is undoubtedly the most active in producing true acute cystitis. In many cases it produces simple irritation and hy- peraemia, stopping short of actual inflammation. Arsenic and tur- pentine also produce irritation and active hyper^emia, but seldom if ever go further. Alcoholic beverages persisted in for a length of time act more as predisposing than as exciting causes. They may, however, produce a low grade of cystitis, or, like the medicines given above, light up an acute process in an already diseased vesical membrane. Dr. A. Jacobi has seen aggravated cases of cystitis caused by the free and long-continued use of large doses of the chlorate of potassa. The various foods can not produce acute cystitis in a healthy bladder, but may aggravate an already diseased condition. The pro- hibition, therefore, of stimulating condiments, alcohol, asparagus, and onions in these diseases will at once suggest itself. I have al- ready spoken of gonorrhoea as a cause of cystitis, and need not dwell on it here. M. Eugene Monod (^' Annales de Gynecol.," May, 1S80), in discussiug the question of cystitis, presents the following con- clusions : 1. The urinary symptoms incident to pregnancy proceed from two different canines, to each of which there corresponds a distinct clinical group of symptoms. The first group receives its explana- tion from the pressure produced by the gravid uterus, which leads to retention of urine. The second is caused by vesical congestion ORGANIC DISEASES OP THE BLADDER. 787 which results from the predisposition of the bladder to inflamma- tion, owing to its close vascular connection with the uterus. 2. During the first weeks of utero-gestation there may occur a variety of acute cystitis which is unquestionably caused by the de- velopment of pregnancy. 3. Immediately after, or during the first weeks following normal delivery, there may arise a variety of cystitis which, owing to the time of its appearance, deserves to be called post-puerperal cystitis, ■J:. The anatomical relations between uterus and bladder, as well as their vascular interconnections, account for the frequency of ves- ical disorders accompanying many uterine maladies. Certain physio- logical changes of the bladder during menstruation, and at the time of the menopause, also influence the establishment of bladder troubles. Thus there is seen to exist a whole class of vesical inflammations be- longing only to women, and, contrary to the generally accepted opin- ion, cystitis is by no means rare in women. CHAPTER XLIII. OKGAJS'IC DISEASES OF THE BLADDER (CONTINUED). TREATMENT OF CYSTITIS — CROUPOUS AND DIPHTHERITIC CYSTITIS— CYSTITIS WITH EPIDERMOID CONCRETIONS. Cystitis requires both local and constitutional treatment, and withal it is a troublesome disease to manage, especially in its chronic form. The constitutional treatment consists, first of all, in so regu- lating the character of the urine that it shall be unirritating to the diseased organ. Pain and vesical tenesmus should be relieved if possible. The skin should be kept in a healthy and active condi- tion and the bowels regular and free, in order to prevent all strain- ing at stool and secure free action of the portal circulation. Free elimination by the skin and bowels will give the kidneys and blad- der less to do. To overcome existing constipation, saline laxatives should be used. A glass of purgative mineral water, given an hour before breakfast, answers very well in most cases. Cold-water ene- mata are advised by good authorities. Winckel recommends the use of saline laxatives, pushed to a point where intestinal hypersemia is produced and maintained for a time. He believes that the blood may, in this manner, be to a cer- tain extent diverted from the bladder ; and I am of the belief that the practice is a sound one. A case of my own is of interest as showing the benefit effected (supposably) in this way. A lady had cataiTli of the bladder of some months' standing, which I had been treating in the usual way, with only slight benefit. She was one day attacked with cholera morbus with serous purging and vomiting, the former almost as severe as that of Asiatic cholera. The effect, for a time was to almost suspend the action of the kidneys. AV^hen she recovered, she was delighted to find that her cystitis had left her. Among the conditions which produce irritating urine, and hence tend to produce cystitis or to aggravate it if it already exists, are malnutrition from any cause and the strumous, gouty, and rheu- matic diatheses. When either of these is present it should be ORGANIC DISEASES OF THE BLADDER. 789 treated for the general good of the patient and the indirect effect upon the bladder. The diet of patients suffering from this disease must be care- fully regulated. Milk will be found to agree excellently in most cases. In the hands of Dr. George Johnson, of England, an exclu- sive milk diet has cured several cases, some of great severity and long standing. He says : " The milk may be taken cold or tepid and not more than a pint at a time, lest a large mass of curd, dilBcult of digestion, form and collect in the stomach. Some adults will take as much as a gallon in the twenty-four hours. With some persons the milk is found to agree better after it has been boiled, and then taken either cold or tepid. If the milk be rich in cream, and if the cream disa- gree, causing heartburn, headache, diarrhoea, or the symptoms of dyspepsia, the cream may be partially removed by skimming. Constipation, which is one of the most frequent and troublesome re- sults of ail exclusively milk diet, is to some extent obviated by the cream in the unskimmed milk. When the vesical irritation and ca- tarrh have passed away, solid food may be combined with the milk, and a gradual return made to the ordinary diet." I have tried this method of treatment in several instances with decided benefit. I may briefly state that the bill of fare usually given consists largely of fluid foods, as milk, yolk of egg, soups, and beef essence. Lean meat in small amount, and other solid or semi-solid foods that are easily digested and nutritious, may also be allowed. The cause, whatever it may be, should be removed, if possible ; and the reme- dies must be adapted to the stage and condition of the inflammation. In the acute stage aggravated by exposure to cold, diaphoretics should be freely used, and the patient made to rest as quietly as pos- sible. Diuretics should be given if the urine is loaded with solid material, and the alkahne salts are to be preferred. Yichy water or flaxseed tea with citrate or nitrate of potash, wiU answer very well at the beginning of the treatment. In using such salines, it serves admirably to give them in an infusion of buchu in case the patient's stomach does not rebel at the taste of it. This of itself is a most valuable remedy in almost all bladder affections. Care must be taken, however, not to push diuretics too far. Sufficient to bring the urine to its normal proportions, and make it slightly alkaline if naturally acid, is all that is required. In the early stages of acute cystitis, as well as in irritable blad- der, Sidney Kinger and other authorities strongly commend the use 790 DISEASES OF WOMEN, of minim doses of tincture of cantbarides repeated every hour, and even often er, but I have not seen very good eifects from its use in cystitis. One or two leeches to the anterior vaginal wall may be tried, and hot applications to the epigastrium in acute cases. To relieve pain, opium is indicated. Dover's powder is very valuable, and may be given with ordinary doses of camphor. If there is any ob- jection to anodynes given in this way, or if there is sympathetic rectal tenesmus, suppositories of morphia and belladonna should be used. While I have said that opium may be used at the onset of acute cases, and to relieve the suffering in old cases that can not be cured, I must impress upon the mind the great harm that may come from the injudicious use of this drug in cystitis. It deranges the digestive organs and the secretions generally, especially that of the kidneys ; and, by changing the quantitative composition of the urine, renders it irritating to the bladder. In some cases, where frequent urination and tenesmus are very severe, owing to excessive nervous irritability, twenty-grain doses of the bromide of potassium, every four hours until relieved, act very nicely ; indeed, this succeeds in cases where opiates fail entirely. Recently I have used hydrobromic acid and lind that it acts even better than the bromide of potassium in some cases. The comparatively new drug, eucalyptus globulus, is worthy of a trial in obstinate cases. From its well-marked beneficial action in albuminuria and other affections of the urinary tract, Dr. W. Ander- son was led to try it in cystitis, and he reports it as decidedly useful. Dr. J. J. Mulheron, of Detroit, gives it in doses of twenty minims in subacute cystitis with good results. As this remedy has tonic, antiperiodic, and antiseptic properties, it might be especially suit- able in malarious districts. An infusion for injection in cases where the urine was decomposed, would most probably give good results. Benzoic acid is perhaps the dnig that would be found most use- ful in the largest number of cases. It often seems to act like a spe- cific, giving speedy and permanent relief. It may be given in about ten-grain doses, in infusion of buchu, three or four times a day. As the acid is sparingly soluble in cold water, an equal proportion of borax may be added to the mixture. To insure a perfect solution, one may prescribe the l)enzoate of ammonia, which in the same dose acts admirably, and is more palatable. In the more advanced stages of the disease remedies are used for tiieir direct effect upon the mucous membrane, and much good is ORGANIC DISEASES OF THE BLADDER. 791 obtained in this way. The drugs which have the best reputation in urethritis are employed in cystitis. Balsam of Peru and of copaiba, oil of turpentine, and tar-water are the most important of this class, and should be given in capsules in the same way as for gonorrhoea. Oil of sandal-wood is also valuable in chronic cases. When the pain is not severe, and the urine is loaded with mucus and pus, astringents should be given. Tannin continued for a con- siderable time is of very great value. Decoction of uva ursi, in half-ounce doses, may also be used for this purpose. In place of tliese, I have employed, with occasional good effect, a mixture com- posed of two ounces fluid extract of buchu, one ounce tincture of conium, and one grain and a half sulphate of morphia, giving tea- spoonful doses every three or four hours. When pain is not severe, the morphine should be omitted. Dr. B. A. Segur, of this city, has used salicylate of soda in puru- lent cystitis, and found that the quantity of pus in the urine rapidly decreased under the use of this remedy. Dr. Sansom, of London, found that the administration of carbolic acid and the sulpho-carbolates to animals prevented the decomposi- tion of urine, although he could not detect any of the salt in the secretion. He gave the sulj)ho-carbolates, and afterward collected and preserved the urine, whicb after six months had not decomposed. This fact should be kept in mind, and turned to account in cases where there is a tendency to decomposition from retention or other causes. An English physician reports, in the " Canadian Practitioner," that he has met with no case of offensive urine (intestinal -vesical fistula excepted) that ten or twenty grains of boracic acid given every three hours would not cure. All these remedies may be tried in cases that are seen early ; but, when they fail, or when the acute stage of the trouble is long past before advice is sought, then local treatment must be employed. The bladder should be washed out, and medicated injections used. This every surgeon will feel com- petent to do, no doubt, but I must give some general directions as to the methods of manipulating, as I feel assured that much of the good which ought to come from this kind of treatment is lost, and harm done instead, by not clearly knowing bow to perform this op- eration, which I consider both difiicult and very important. There are certain rules which ought to be carefully observed in washing out the bladder. The catheter should be sufficiently soft and flexible to be incapable of injuring the bladder or urethra ; it should be surgically clean ; the bladder should be emptied slowly, 792 DISEASES OF WOMEN. especially when withdrawing the last of its contents, otherwise the bladder will contract abruptly upon the catheter, and be injured thereby ; instillations should be made very slowly (the bladder can not be rapidly distended without injury), and the quantity used should not be more than the patient can tolerate without pain. An ounce is sufficient, and much less will suffice if more gives pain. When the quantity which can be borne is determined, the instillation and withdrawal of that quantity can be repeated until the desired effect is obtained. By carefully following these rules, the possible benefit of local treatment can be obtained. Neglect of these will certainly bring disfavor upon the method. Some years ago I employed a rather complicated arrangement for washing out the bladder, consisting of a reflux catheter with a fountain attachment. It was the best that I could find at that time, but I have long ago discarded it for a sim- pler and much better instrument. I use now a soft-rubber catheter, having attached to it a piece of rubber tubing, these being joined by a piece of glass tubing, the whole being about two feet in length. A small glass funnel is introduced into the end of the rubber tube, and this completes the instru- ment (Fig. 260). This is used as a cathe- ter to empty the bladder of urine, and then, leav- ing it still in place, the wasliing out is accom- plished by pouring the so- lution to be used into the funnel, and raising it high enough to make it flow into the bladder. The funnel is then lowered to permit the fluid to escape, and the process is repeated as often as may be necessary. Any desired quantity of fluid can be instilled into the bladder at any degree of pressure that may be necessary for the comfort of the patient, and the fluid can be drawn off slowly or rap- idly by elevating or depressing the funnel. It is very important not to let air ^nter the bladder, and this can l)e accomplished by letting the patient retain a few drachms of urine before beginning the treatment. When the catheter is introduced, and the urine in the bladder drawn off", enough of the urine will remain in the catheter to till it, and, by filling the funnel before elevating, the fluid used will Fig. 260. — Fountain-syringe for washing bladder. OEGANIO DISEASES OF THE BLADDER. 793 meet the urine in the catheter and exclude the air. In case the blad- der is empty, the catheter should be filled before introducing it into the urethra, and the air will be excluded in that way. When once the process of washing is begun, the exclusion of air is easily man- aged by regulating the elevations and depressions of the funnel, so that the catheter and tube will be kept full all the time. This instrument fulfills all the indications perfectly, and very little practice is necessary to enable one to use it with facility. When the bladder has been thoroughly cleansed in this way of all inflam- matory products, medicated applications may be made in the same manner. The quantity of fluid instilled, the length of time it is left in the bladder, and the time occupied in making the instillation and withdrawing it can all be regulated according to the will of the sur- geon and the toleration of the patient. Much care should be taken in lubricating the catheter so that it can be introduced readily. Oil has been used for this purpose, and I believe that some surgeons use it still. Castile soap and water or vaseline answers much better. The oil decomposes, and renders the catheter unclean unless great care is taken to wash and disinfect the instrument very thoroughly. In fact, it is hardly possible to keep a catheter clean for any length of time if oil is used as a lubri- cant. Vaseline is best, and, if that is not at hand, then soap will an- swer. Cleansing the catheter after use requires more than a passing notice. I have found that if a soft-rubber catheter is simply washed after use in the ordinary way — i. e., by washing it off with warm water, and then rinsing it in a mild solution of carbolic acid — say five per cent — it becomes very foul. A catheter used in that way for a few days will be found swarming with bacteria on the inside. Such an instrument is dangerous, and should never be used. In my private hospital each patient has a catheter for herself alone, and, when she is through with it, it is destroyed. After each time that a catheter is used it is well washed in hot water, and then kept in a ten-per-cent solution of carbolic acid, and once in every twenty-four hours it is kept for fifteen or twenty minutes in boiling water. With all this care the catheter can be kept clean and safe for use. Simply washing out the bladder is often beneficial, and ought to be repeated frequently. It should always be done before using any medicated application. Warm water alone is usually employed, but the addition of chlorate of potash or common salt makes it less h-ri- tating to the bladder. I prefer borax or common table-salt, using about sixty grains to the pint of water. It is generally conceded that salt and water are more acceptable to serous and mucous mem- 794 DISEASES OF WOMEN. branes than any other fluid, because more like the normal secretion of these parts ; but I have not found it any better, if as good, as borax. AVhen there is ulceration or suppuration, carbolic acid and water make a most valuable wash. A drop to tlie drachm or there- about is the proper proportion. Having prepared the bladder for local applications by carefully washing it out, the material to be used may be selected from a long list of remedies. I shall mention only a few — those which I believe to be the most valuable. I need hardly say that anodynes have been tried most faithfully. The painful cliaracter of the disease suggests their use, but they are neither reliable nor very eifectual. The mucous membrane of the bladder is not intended to absorb, and, therefore, very little of the anodyne effect of opium, or any of its preparations, is obtained when injected, even when the dose is very large. Should there be ulceration, then the local and constitutional effects of morphia will be produced by absorption. Braxton Hicks uses one or two grains of morphia to the ounce of water as an in- jection, allowing the patient to retain it as long as possible, and claims good results from its use. Remedies which produce local anaesthesia do relieve the pain to some extent, but not altogether, by any anodyne action, such as we get from opium given by the mouth or rectum. Cocaine relieves the pain for a short time, but not long. Its chief value is to benumb the parts so that curative applications may be more easily made. In some cases it acts as an irritant. Chloral hydrate is recommended to relieve the ])ain. I have used it in solution, ten to fifteen grains to an ounce of water, and found benefit from it. The astringent and alterative injections most beneficial and most commonly used are nitrate of silver, sulphate of zinc, tannic acid, and acetate of lead. My rule is to use one or two grains of either to the ounce of warm water, and to increase the quantity if no good effect comes from the small doses, but to carefully avoid injections strong enough to cause much pain. Chlorate of potash is valuable, and perchloride of iron is said to be useful. Infusion of hydrastis Canadensis has been used, and great virtue is claimed for it. I have tried it, and believe that it acts well in some cases, but still it fails, like the rest, in others. When the urine is alkaline and offensive from long retention, which is occasionally the case in prolapsus of the bladder, then nitro-hydrochloric acid, of the strength of two minims to the ounce of water, should be used. Whenever pain is caused by any of these astringent injections, morphia should be used afterward, as directed by Braxton Hicks. ORGANIC DISEASES OF THE BLADDER. ^1^95 In obstinate cases a strong solution of nitrate of silver is one of the most reliable remedies. Twenty grains to the ounce of water has been used with great benefit, and it does not cause as much pain as might be supposed. Very small quantities only can be used at a time — not more than live or ten drops. The only trouble which r have experienced is in being sure of injecting that small quantity and no more. My favorite method of making such applications to the interior of the bladder is by instillation, as it is called. I take a glass tube of the size and shape of a JN'o. 8 or 9 male sound, with a small rubber bulb attached to the straight end. The curved point is introduced into the solution to be used, the bulb is compressed by the thumb and finger, and then relaxed, which draws up the desired amount. The tube is then carried into the bladder, and, by Fig. 261. — Skene's instillation tube. again compressing the bulb, the fluid is easily deposited in the organ (Fig. 261). If a larger quantity is to be used, it can be introduced through the instrument used for washing out the bladder. In fact, T seldom use the pipette now except for medicating the urethra. There is one rule that should be followed in using nitrate of sil- ver in the treatment of cystitis, which is this : If a strong solution is used, only a few drops should be employed, and, if a large injec- tion is made, the solution should be mild. I am indebted to Frof. John W. S. Gouley for this valuable guide in the use of this remedy. Normal urine has been highly recommended as an injection in cystitis. The urine from a healthy person is obtained and used in the same way as the other injections described. I have always looked upon this treatment with a little suspicion. It may be of value in cases where from some derangement of the general system the urine secreted is abnormal, and therefore irritating to the bladder, and where constitutional treatment can not remove that condition. When the urine secreted can be kept in a normal state, it must, it seems to me, be as acceptable to the bladder as the same kind of urine from another person. Theoretically, one would expect that healthy urine poured into the bladder from the kidneys would be more likely to cure cystitis than if it were injected through the urethra. However, this method may be of value ; but one thing is certain — it fails like all other injections in certain cases. Iodoform has been used locally in cystitis, and with good effect ; but I regret to say that I have not used it enough to test its merits fully. 796 DISEASES OF WOMEN. One great obstacle often met with in using instillations is a ten- der or inflamed urethra. This difhculty I have recently been able to overcome by using cocaine. It is applied as follows : I take a pipette like the one described above but larger, till it with cocaine solution, and introducing the tapering part of it into the meatus, force the solution along the urethra and into the bladder. This often makes the rest of the treatment easy. Another direct method of treating the bladder has been employed by Dr. Robert Newman, of New York, who has made some useful contributions to the therapeutics of vesical disease. He employs the endoscope of Desormeaux to make the diagnosis, and makes direct applications to the diseased parts through that instrument. In ulceration, he has been very successful in his practice. He applies a solution of the nitrate of silver (twenty grains to the drachm of water) to the ulcerated surface, and by carefully regulating the amount, finds that the pain is less than wlien a weaker solution is used in the ordinary way. I have done the same thing ^vith greater facility by using the endoscope which I have described. The in- strument is introduced, and the ulcerated part found ; the glass tube is drawn out, and the application made directly to the diseased part, through the rubber speculum. Forcible and extreme dilatation of the urethra has been advocated in the treatment of cystitis by many surgeons otherwise well informed. Within the past few years the medical journals have contained the histories of many cases of cys- titis said to have been cured by this operation. This is all quite er- roneous. Cystitis can no more be cured by dilating the urethra tlian could a gastritis be cured by dilating the sphincter ani. It is a fact that if the urethra be destroyed by overdistention, inconti- nence will follow, and the perfect drainage of the bladder may cure the inflammation ; but verily the cure is worse tlian the disease. I am sure that the mistake in regard to the value of this operation in cystitis comes from its having been practiced in cases of acute cystitis which would have ended in recovery without any sur- gical treatment, and again in cases of inflammation of the upper third of the urethra which have been mistaken for cystitis. On the one hand the operation gets the credit of curing a disease which cured itself, and on the other of curing a disease which did not ex- ist. It will be observed that in the cases which I give at the close of this section, the urethra was dilated with no benefit, and to these I could add many others which were treated in the same way with a like result. All the means of treatment yet described will fail in some of the ORGANIC DISEASES OF THE BLADDER. 797 worst cases of clironic cystitis. Indeed, this has led to the last re- sort, as I look upon it, namely, cystotomy for the establishment of vesico-vaginal tistula to drain the bladder and set it at rest. The perfect rest obtained by the urine flowing out through the fistula as soon as it enters from tlie ureters places the inflamed surfaces in a condition to recover, and the patient is relieved from the constant pain and the torments of urinating every few minutes night and day. This is certainly a great triumph, and is especially applicable in cases that are incurable by all other means. Indeed, it is adapted to eases which are incurable by this operation, because it gives relief from pain, and makes the last days of an incurable sufferer tolerable. Dr. Willard Parker, I believe, was the first to do cystotomy for the cure of cystitis in the male, and Dr. T. A. Emmet adopted the operation, and has practiced it extensively among his female patients. In fact, he has become a zealous advocate of this method of treating cystitis. In his book on gynecology, in speaking of cystitis in women, he says that our management of this afliection is limited to one procedure, and that is vaginal cystotomy. Such a dogmatical statement is quite in opposition to facts well known to many in the profession. Drainage by vesico-vaginal fist- ula is neither the surest, safest, nor simplest method of treating cys- titis in women, but only one method to be employed in those rare cases which do not yield readily to other means. While writing on this subject some years ago, I obtained from one of the resident surgeons of the Woman's Hospital the statement that cystotomy was performed for the relief of cystitis on seventeen cases in that institution, and that four were cured and thirteen im- proved. This shows about twenty-four per cent of recoveries, and this I stated in my book on " Diseases of the Bladder." Dr. Em- met in his book on gynecology objects to this statement of mine as not being in accordance with a published report of the Woman's Hospital. The report referred to was not published at the time that I prepared my manuscript, nor did I see it until after my book was published. I presumed that the interne of the hospital gave me a correct report, but be that as it may, Dr. Emmet's own statistics (as given in his book, page 788) of the hospital practice are less favor- able to cystotomy for the cure of cystitis than those quoted by me. They show but about twenty per cent of recoveries, whereas my statement obtained from the interne was twenty-four per cent. This shows that if I made a mistake it was in favor of the operation ; or else if I was correctly informed of the results of that operation at 798 DISEASES OF WOMEN. that time, then the subsequent hospital experience of Dr. Emmet has been more unsatisfactory. Dr. Emmet's method of making the fistulous opening is by dividing the vesi co-vaginal septum with the scissors, and then introducing a glass tube to keep the opening from closing. This is the most difficult way of operating and the most painful to the patient afterward. The wearing of this tube has been a torture to those that I have seen using it. There are two other methods of operating. One is to make the opening, and then stitch the mucous membrane of the bladder to the mucous membrane of the vagina, thus preventing the closing of the oi)ening, and at the same time enabling the edges of the wound to heal in a short time, a great gain in itself. The other method is to make the opening with the galvano- or thermo-cau- tery. Dr. M. A. Fallen was the first to operate with the thermo- cautery. This is what he says about it : " The main difficulty hitherto has been to keep the incision open after the use of the scissors or knife. Artificial means must be resorted to, such as an India-rubber tube passed from the urethra through the opening, which is annoying and painful ; or a glass button introduced, which is difficult to retain, and when retained is apt to beget vesical tenesmus. I believe that the use of the actual cautery at a red heat will be found to answer all purposes. If the platinum tip is at a white heat it cuts through too rapidly, and we are apt to have as much h^Buiorrhage as with the knife or scissors. Haemorrhage is sometimes quite serious after incision of the vesico-vaginal septum, particularly if the scissors or knife strike the tortuous, enlarged veins, often ramifying upon or under the mucous membrane of the bladder. If the platinum tip of the cautery be heated to a white heat, it cuts through as rapidly as the knife, and therefore the haemorrhage is to be expected ; besides, the thin pellicle of slough following the white-heat tip soon peels oli, and union might ensue. To avoid both bleeding and contraction, the red-heat tip should be slowly passed along the site of the proposed opening, dividing first the mucous membrane of the vagina, and then resting for a moment or so to allow the adjacent vessels to contract and become throm- botic. The submucous connective tissue is then burned, and after- ward the bladder-wall itself. Extreme delicacy of manipulation is required upon the part of the surgeon, lest he bum directly into the cavity of the bladder, which should be avoided if he wants to make sure of a result that will prevent haemorrhage, contraction, and subsequent union. '• The care after an operation of this kind consists in daily cleans- ORGANIC DISEASES OF THE BLADDER. 799 ing the bladder thoroiigldy with demulcent warm fluids, such as starch or flaxseed water. The pain in the bladder following the burning is comparatively slight, and usnally subsides within thirty-six or forty-eight hours." Dr. John Byrne, of Brooklyn, operates in a very easy and satis- factory manner. He has a forceps, one blade of which is intro- duced into the bladder and the other into the vagina to grasp the vesico-vaginal septum. The blade in the vagina is fenestrated and the blade in the bladder is grooved. The theruio-cautery knife is introduced through the fenestrum of the forceps and the septum is divided, the knife being guided by the forceps. This method makes the operation simple and easy, and the after treatment is also greatly simplified. One serious drawback to cystotomy is the incontinence which keeps the patient in such an uncomfortable state by the constant trickling of urine from the fistula. I tried to obviate this trouble to some extent by using a hollow-globe pessary, made of hard rub- ber, with a tube attached to it. The globe is perforated with nu- merous small holes all around, except for about half an inch from where the tube begms. The globe is introduced into the vagina, and the tube projects through the introitus. The urine collects in the globe, and escapes through the tube ; and by attaching a piece of flexible tubing to it the urine can be conveyed into a vessel. When the introitus vulvae is small and the sphincter vaginae perfect, this answers very well, especially during the night, when the patient is in the horizontal position. When worn during the day, it is ne- cessary to have a rubber bag attached to the leg of the patient to act as a receptacle. Encouraged by my success with the globe-pessary, I had another made, shown in Fig, 262. It is the ordinary Smith's pessary, with an oblong cup on the upper anterior portion of it, which fits over the fistula, and collects the urine and guides it out to a urinal. In artificial fistula, made in the center of the va- gina, this pessary answers a most valuable purpose. I was led to devise this way of relieving patients with vesico-vaginal fistulae by hav- ing one under my care who was in no condition to be operated on Fig. 262. — Skene's urinal cup-pessary. «, rep- resents the posterior portion which sur- rounds the cervix uteri ; b, the cup ; and c, the tube which conveys the urine from the cup to the urinal. 800 DISEASES OF WOMEN. for the cure of fistula, owing to general ill-health. She also had severe vulvitis, and the urine constantly passing over the inflamed surface drove her almost insane. Her suffering was terrible ; so to relieve her until I could operate I had made the perforated stem globe-pessary, or whatever one may see fit to call it. I come now to what I believe to be another important part of the treatment of these obstinate cases. I allude to drainage by means of the self-retaining catheter. Years ago I had a very trou- blesome case of cystitis, which I faithfully tried to relieve by all the means at my command, but without success. My patient was obliged to urinate every fifteen or twenty minutes, day and night, and the pain and want of rest were fast wearing her out. In the hope of securing rest at night I introduced a Sims's self-retaining catheter with a rubber tube attached, to convey the water to the urinal. The result was very gratifying. She could sleep well, and gained in health and strength rapidly, and the cystitis gradually improved. Since that time I have resorted to drainage by catheter in cases which resisted the ordinary treatment. A description of this plan of treatment will be found in the " Proceedings of the New York Obstetrical Society," recorded in the " American Journal of Obstetrics," for Febraary, 1874. This method has been successfully practiced by Hunter McGuire, a com- plete history of his case being published in the " Richmond and Louisville Medical Journal" for June, 1874. Dr. McGuire took a piece of tubing about twelve inches long, and made holes in about four inches of the end of it with a shoemaker's punch. He passed a silver tube into the bladder, and then pushed the gum tube through it until the perforated four inches were coiled in the bladder. This was retained in place by tapes fixed to the tube and to a bandage passed around the patient's body. The tube became obstructed by mucus, but was easily cleared by injecting warm water through it. But this long piece of tubing being frequently expelled by the blad- der, the doctor tried a shorter piece, and found it was more readily retained. The patient after a time went about and attended to her household duties while wearing the tube, and in about four months made a perfect recovery. This method of drainage is an improvement on Sims's catheter, but still is not all that w^e require. Since my first case I have found that a good self-retaining catheter for this purpose is Holt's, made of perfectly flexible rubber, and, in place of an eye in the point, is cut into strips near the end, and made to spread out like an umbrella (Fig. 203). OEGANIC DISEASES OF THE BLADDER. 801 Another instrument for drainage is a catheter devised by Prof. Goodman, and described in the " Richmond and Louisville Medical Journal," for February, 1S69, as being used in the treatment of vesico- vaginal fistula, and I have recently learned that he has used it for years in treating cystitis. The following is Dr. Good- man's description of his cath- eter : " It is about two inches in length, and bent to cor- respond to the curvature of the urethra ; at the lower or ^i«- 263.— Holt's catheter, with its modification. external end there is a button ten sixteenths of an inch in diameter, and at the other, or external, end a shouldered, cup-shaped expan- sion, varying from five sixteenths to seven sixteenths of an inch in diameter, and beveled on the convex aspect of the instrument, in order to make it easier of introduction, and perforated with a num- ber of small holes. The stem, intervening between these two por- tions, is one and one half inch in length, a quarter of an inch in diameter, with as large a bore as is compatible with the requisite strength. This catheter is self -retaining in all positions of the pa- tient ; first, by reason of the bulb at its upper extremity, which passes beyond the urethra into the bladder ; second, on account of its curved shape ; and third, in consequence of the button being overlapped and grasped, as it were, by the vulva. At the lower end there is a slight projection, or knob, over which an India-rubber tube may be slipped, this being inserted into a bottle at night, or into a urinal when the patient is up ; her person may thus be kept per- fectly clean." I like this instrument for the purpose of draining the bladder, when the patient can tolerate it; but I believe that the sharp point of the conical end which rests in the bladder is objec- tionable, and I can see no good reason for having it so. I had the point made larger and rounder (Fig. 248), and found that it answered certainly as well, and was easier to introduce. In drainage by any method it must be remembered that the instrument should be frequently removed and cleaned, and the bladder occasionally be washed out at the same time. 52 Fig. 264. — Skene's modification of Goodman's self-retaininp; catheter. 802 DISEASES OF WOMEN". Fortunate it is that we have this method of treatment now at our command. By this means we can restore to health and comfort many of those cases which have hitherto been considered hopeless. I believe that a normal condition of the urethra is a prerequisite to drainage. When there is tenderness of the urethra, the patient can not tolerate the catheter ; this form of treatment would be more popular if this point had not been overlooked. Where there is hsemoiThage into the bladder, the rules already given are to be followed. In cases of exfoliation of the whole or a part of the mucous mem- brane of the bladder, and the organ is evidently trying to expel its contents, the urethra should be sufficiently dilated to allow the mass to pass, or it may be removed by the forceps, if this can be done without force. After its extraction antiseptic and disinfectant meas- ures should be resorted to. Injections of lime-water, weak solutions of carbolic acid or salicylic acid should be used, and the organ washed out once or twice daily with warm water. Above all, urine should not be permitted to remain in the tender organ for any length of time. In passing the catheter, especially in cases where the bladder is bound to neighboring organs, care should be taken to let no air enter, for Winckel has seen vesical catarrh follow its introduction, and makes it a point, even after using Rutenberg's apparatus, to wash out the organ with some antiseptic. Prognosis. — In acute cystitis occurring in a healthy subject the outlook is good, recovery being usually attained in from one to three weeks. When occurring in the course of pregnancy, or after de- livery, the prognosis is not so good, there being a tendency for the disease to become chronic, and, even if cured, it leaves a weak state of the organ afterward. The prognosis in diphtheritic and croupous cystitis depends mainly on the systemic disorder, and is, therefore, grave. When due to displacements of the gravid uterus, the prognosis will, of course, depend on the ability to replace the womb. In can- cer of the womb, vagina, anterior vaginal wall, or of the bladder it- self, the prognosis is the same as in malignant disease generally. In chronic cystitis, with ulceration, the prognosis is very serious ; for, with the tendency to haemorrhage, extension to the peritonaeum, perforation, blood-poisoning, with low systemic condition, extension to the renal pelves, and destruction of one or both kidneys, a fatal termination comes sooner or later, and may come when we least expect it. ORGANIC DISEASES OF THE BLADDER. 803 About one half of tlie cases of exfoliation of the vesical mucous membrane have recovered. Gangrenous inflammation, involving, as it usually does, all the coats of the bladder, is the most speedily and certainly fatal of all the forms of cystitis. Hygiene. — There are certain points to be considered in the man- agement of all cases where, from certain circumstances, vesical dis- ease is to be expected, and also M^here it already exists. In pregnant women, where the pelvic organs are constantly tend- ing to congestion, attention should be given to the patient's circula- tion ; friction to the legs, feet, and arms ; daily warm baths ; mod- erate exercise, alternated with periods of rest in the recumbent position, and astringent or saline vaginal injections should be em- ployed. Upon the least suspicion of malposition of the uterus, that organ should be examined, and, if malposed, replaced. The diet should be bland and unirritating, yet nourishing, and any indigestion corrected as speedily as possible. An occasional saline laxative will prove of use when there is constipation. Tonics will be found serv- iceable in some instances. In women not pregnant, where there is a tendency to vesical dis- ease, the same plan should be followed, with the addition of injec- tions of water, as hot as can be borne, into the vagina every night, as recommended by Dr. Emmet. ]^ot less than a gallon should be used. Where from any cause retention exists, or there is a tendency thereto, the urine should be drawn carefully with a soft catheter, well soaped, being sure that the catheter imperfectly clean, and that no air is permitted to enter the viscus for the reasons already given. Winckel believes that in every institution for lying-in women each patient should either have a new catheter assigned to her, or one rendered absolutely clean b}^ some efficient chemical process. To the enforcement of this rule Winckel attributes the great exemption from vesical inflammation enjoyed by the patients in the Dresden House for Child-bearing Women. I must fully indorse the teaching of this great authority. I have seen so much bladder trouble brought on by the careless use of foul catheters that I have come to look upon clumsy operators and un- clean instruments as the most common causes of cystitis. In weakness of the detrusor vesicge (which is not an uncommon affection in pregnant women), Winckel has achieved great success with injections of simple warm or medicated water into the bladder. In irritable bladder, -with a tendency to congestion, a solution of borax may be injected with good results. Every woman, even at the risk of disturbing company or neglect- 804 DISEASES OF WOMEN. ing important duties, should evacuate the bladder regularly, and never long resist the desire to urinate. ILLUSTRATIVE CASES. Chronic Cystitis with Intermittent Drainage ; Death from Perfora- tion of the Bladder. — The patient was under mj care from November 9, 1869, to February 10, 1870, while suffering from a cystitis, which began after one of her confinements several years before. At that time she had a well-marked cystitis of the pui-ulent variety. She was treated by injections — the method in vogue at that time — with some benefit. I also employed drainage part of the time by intro- ducing a catheter in the evening, and letting it remain all night. This gave her great relief, and permitted her to sleep — a blessing which she had not enjoyed for several years. She was improving in her general health, although her local disease remained about the same, or at least only a little improved. She expected to return for further treatment, but, her husband becoming paralyzed, she was obliged to give up the care of herself to look after her family. From that time up to July, 1882, she continued to suffer tortures during the day, while she was obliged to be up and around attending to her liousehold duties. At night she obtained relief by wearing the cath- eter, which she had continued to use ever since she was taught to do so, twelve years Ijefore. Her sufferings were almost beyond descrip- tion, but, having an iron constitution and extraordinary will-power, she managed to Hve until the summer of 1882. During June and July of that year she failed more rapidly. Having heard of dilata- tion of the urethra as a cure for cystitis, she urged her physician to try that operation. He did so, and repeated the operation one week later. The only effect of this treatment (as stated in the notes of her history, which I obtained; was to reduce the number of evacua- tions from one hundred and sixty to one hundred in twenty-four hours. Her physician then injected her bladder in the hope of re- lieving the inflammation and also overcoming the contraction, which was very marked. Immediately after the first and only injection she was seized with violent abdominal pains, and rapidly developed a peritonitis, which proved fatal on the second day. On post-mortem it was found that the bladder was adherent to all the viscera around it, the result, no doubt, of a former pericys- titis. Upon the posterior wall of the bladder, and directly opposite the urethra, there was a nipple-like projection outward, with an opening at its apex large enough to admit a lead-pencil. This pro- tuberance had been produced by the long use of the hard catheter. ORGANIC DISEASES OF THE BLADDER. S05 The instniment had worn through the inner walls of the bladder until the pai-ts had become less resistant ; it then pushed the remain- ing muscular tissue and peritonaeum outward, and formed the nipple- like projection. At the time of the fatal attack, the catheter had made its way through all the coats of the bladder except the thick- ened peritonaeum. The rupture of the peritonaeum was caused bv the injection. That was the belief of the physician in attendance, and the history points detinitely to the same conclusion. The blad- der was firmly contracted and in distensible ; its retaining capacity did not exceed half an ounce. The muscular wall was oyer haK an inch thick ; the mucous membrane was entirely destroyed by the inflamtuation. Pumlent Cystitis; Recovery after Two Years' Treatment. — This patient was a lady possessing a remarkably good organization. She was married, and had one child. Her age was thirty when her illness began. TVliile riding horseback she was thrown off, and sustained some apparently slight injuries. Her health up to this time had been yery good, but from the time of her accident — September, ISTS — she had symptoms of cystitis. She was residing in the far ^est at the time of the accident, and, as 1 did not see her for seyeral years after, and haye not been able to correspond with the surgeon who then at- tended her, I do not know the relation which the injury sustained at that time bears to the deyelopment of the cystitis. I only know that the one followed the other immediately. The cystitis persisted, and the constitutional symptoms increased from time to time. She then returned from the West to Xew England to be under the care of her father, who is a physician of known ability and large experience. He gaye her eyery attention, and placed her in the care of a neigh- boring physician, who has a high reputation as a gynecologist. "With- out o-iyino; full details of her treatment at that time. I may fairly state, upon information receiyed from her father and her physician, that all the recognized means of treatment were tried, including complete dilatation of the urethra on two occasions. The cystitis was not at allrelieyed by the treatment, and the constitutional symp- toms increased continuously, until she became confined to bed. Hay- ing a highly sensitive neryous system, she suffered greatly from wane of sleep and the constant pain of cystic tenesmus. I first saw her in consultation about a year fi'ora the time when she was first taken ill. It was then that this much of her history was obtained. She continued under treatment for six months longer, and, at the end of that time, she consulted one of the best known and most worthy authorities in ^S^ew York. He adyised cystotomy and drainage for 806 DISEASES OF WOMEN. six months or longer, stating at the same time that, in view of the failure of her former treatment to give relief, there was nothing else left to be done. She decUned to submit to the operation at that time. Her father sent her to me about two and a half years later. At that time she was obliged to urinate about every hour, night and day. She suffered from constant tenesmus, and her nervous system was greatly debilitated. Dr. McCorkle examined the urine for me, and found that it contained a large quantity of pus, and that there was a remarkable absence of epithelial cells. The doctor's report was that the specimen was pus, containing a small quantity of urine, and evidently came from a bladder which had entirely lost the upper layer of its mucous membrane. The diagnosis then made was chronic purulent cystitis. It appeared to me that the case was one which called for cystotomy ; but, knowing the objection of the patient to that operation, treatment was undertaken, and the results soon gave some slight encouragement. The constitutional treatment was at first chiefly tonic in character, and subsequently she took saline waters, lithia waters, bromide of lithia, and, Anally, buchu, benzoin, tar, turpentine, and the like. These last preparations, however, did not help her, and were not long continued. The local treatment was at first instillations of a warm solution of borax. Half an ounce was instilled at a time, and repeated until from eight to twelve ounces were used at each treatment. The instillations were always made wdth very low pressure. As the sensitiveness of the parts diminished, the quantity used was increased up to one ounce, but never beyond that. Three months of this treatment showed im- provement. There was less pain, and the patient's general health had improved considerably. About this time nitrate of silver was used, and, later, sulphate of zinc in solution of various degrees of strength, but this always caused pain. Indeed, the suffering caused by this kind of treatment was great, and the benefit which followed being very little, it was given up. I then began to use instillations of an infusion of hydrastis Canadensis, containing a small quantity of salicylate of soda, which was used to prevent decomposition of the infusion. I am now satisfied that the salicylate was of value in its effect ujion the suppurating mucous membrane. The hydrastis wasvery faithfully used, first by myself, and subsequently by the patient, who made the instillations with unusual intelligence and care. The result was a gradual diminution of the pain and lessening of the frequency of urination. The pus diminished in quantity, and simultaneously young epithelial cells appeared in the urine, and in- creased in number as the pus diminished. At the end of one year ORGANIC DISEASES OF THE BLADDER. 807 of treatment the local and constitutional symptoms liad all disap- peared. The urine was normal, and the patient had fully recovered, excepting that she was obliged to urinate about every four hours. This was owing to contraction of the bladder. To overcome this, gradual distention was practiced. The patient was directed to re- tain her urine until discomfort, not pain, was felt. Injections were used, each time distending the bladder a trifle more, always stopping short of causing pain. About two years from the time she first came under my care she was perfectly cured of the cystitis, and had regained her normal retaining power. Four more years have passed, and there is not the slightest evidence of any return of the former affection. Cystitis treated by Cystotomy without Benefit. — This lady, thirty- four years of age, is married, and had four children. She is said to have had retroversion of the uterus, which was held in its abnormal position by adhesions. She was treated for this displacement in the Woman's Hospital of New York, so she said, and, while under treat- ment, a cystitis was developed, which continued until I saw her. After leaving the hospital, she became pregnant, and her sufferings increased. Two years ago, when her last child was four weeks old, she consulted a physician here in Brooklyn, who advised cystotomy, and soon after he performed the operation, using the cautery. She experienced some relief from the operation, but she still suffered very acutely. Being led to hope that in time the operation would cure her, she bore her afflictions for nearly a year, when she con- sulted me on the 5th of September, 1881. I then found her to have the tubercular diathesis, rather well marked, but there was no appar- ent disease of the lungs at that time. The vesico- vaginal fistula made by the operation was large enough to admit the little finger, and the drainage of the bladder was quite complete. Yet, strange to say, she had constant pain in the bladder, and a desire to urinate. These symptoms I found to be due to inflammation and ulceration of the urethra and bladder below the fistula. The disease at this location caused pain and irritation, which provoked reflex action, such as that which arises from the presence of urine in the bladder, but in a much greater degree. General tonic treatment was advised, and local treatment employed to relieve the inflammation of the urethra and neck of the bladder. Locally^ she improved slowly. The pain and vesical tenesmus subsided almost wholly, but she has not yet recovered completely. My object was to cure the local dis- ease, and then close the fistula. This I shall never be able to do. While the local disease is improving, she is developing phthisis pul- 808 DISEASES OF WOMEN. monalis, which prechides all thought of operating to close the fistula. The facts in this history, which I trust will be borne in mind, are, that this patient was of a tubercular organization ; that cystotomy did not cure her cystitis and urethritis, nor relieve her suffering to any marked extent. Cystotomy for the Cure of Cystitis without Benefit; Death from Phthisis following Pneumonia contracted while under Treatment. — Six years ago I had a case of cystitis under observation, which illustrates the same facts in pathology and therapeutics as in the case just re- lated. I shall give a very brief outline of the history simply to show the result obtained by another method of doing the same operation. This patient was a married woman, who had several children. She was of a highly nerv^ous temperament, and came from a tubercular family. She consulted me for cystitis, the cause of which is not recorded in her history. I treated her with injections for several months without benefit. I also dilated her urethra, with the same result. In fact, I believe she rather grew worse, in place of better, while under my care. Her general health failed noticeably at any rate, and she gave signs of a tubercular deposit going on in her lungs. Her friends urged her to enter the Woman's Hospital in New York. She did so, and was under the care of Dr. Emmet, who performed cystotomy, which he did by incision and keeping the fistula open, first by his glass tube, and afterward by dilatation with the finger. After the operation, she had an attack of ])neu- monia — at least, she told me this when she returned from hospital. Upon her return home, I found that she had been much relieved of her most urgent symptoms by the operation. Still, there was cys- titis remaining, and she had vesical pain and tenesmus. The tuber- cular disease of the lungs had progressed rapidly, and that portion of her lung which was involved in the pneumonia never cleared up. Her strength rapidly failed, and she died before the cystitis subsided. CROUPOUS AND DIPHTHERITIC CYSTITIS. Croupous and diphtheritic diseases of the bladder are very rare, and therefore require but a brief notice here. From the difficulties that have existed in the detection of the exact pathological conditions in diseases of the bladder, we may presume that mild attacks of these affections have been overlooked or not correctly diagnosticated. But, even granting this, we are compelled, from the few recorded cases, to believe that croup and diphtheria of the bladder seldom occur. ORGANIC DISEASES OF THE BLADDER. 809 What little exact knowledge we possess on this subject has been obtained to a great extent from post-mortem examinations, and from this statement it will be inferred and correctly too, that these diseases, especially diphtheria, tend to end fatally. From the names employed one would naturally suppose that these affections were exactly the same as the diseases of the mucous membrane of the air-passages, known as croup and diphtheria. Be that as it may, it will suffice for my present purpose to have it un- derstood that in these diseases of the bladder there is developed an exudation or membrane like of that of croup or diphtheria. The pathology of the local lesion in these two diseases differs only in the depth of tissue involved and in the character of the membranous formation. Thus in croupous cystitis, the false mem- brane, while moderately adherent, is usually on the surface, covers the whole or most of the mucous membrane of the bladder, and sometimes portions of the outer genitals, and is fibro-epithelial in structure. The diphtheritic membrane, on the contrary, dips deeply into the mucous membrane of the bladder, exists usually in scattered patches, and is denser and more fibrous in character, its interstices being filled with little rounded cells and some fatty and granular matter. Exfoliation of the affected portions of the vesical mucous mem- brane usually results from this diphtheritic inflammation, as in the analogous affection in the throat. When the membrane comes away, ulcers of varying size and depth are left to mark its former site. The destructive processes are not alone confined to the mu- cous and submucous tissues, but in some cases involve the muscular coat of the organ. The whole vesical surface, not covered with the membranous exudate, is of a deep-red color, and in some places ecchymotic, especially about the exudation. The inflammation is truly acute, and passes rapidly from the stage of mucous exudation to that of epithelial exfoliation and pus formation. Symjytomatology. — The symptoms in no way differ from those of acute cystitis, save that as a rule they are more intense and the con- stitutional symptoms are more severe. The nervous system is usu- ally profoundly affected. There is pain before, during, and after micturition — pain that may be purely local, felt in the outer genitals, or radiate in all directions. When the shreds of broken-down membrane separate, they may block up the urethra, and cause retention and decomposition of urine, Eetention, however, may be produced at any time by in- 810 DISEASES OF WOMEN. tense inflammatory tumefaction of tlie urethra, which is often in- volved. This exfoUation of false membrane must not be confounded with the slouffhinor of the mucous membrane of the bladder caused by pressure from overdistention or very severe inflammation. As the symptomatology of these diseases is very much the same as those of acute and chronic cystitis, it may be best not to enlarge upon them here, as that would involve much useless repetition. Diagnosis. — Microscopical examination of the urine, but more especially of the tissue shreds, will afford much reliable information. Wheu a membrane is found consisting of flbrillge interspersed with numerous small nucleated cells, having undergone fatty degenera- tion, and involving the superficial mucous or muscular layer, the case may be set down as one of diphtheritic cystitis. The urine rarely affords any positive information ; and really it is useless to attempt to make a differential diagnosis between these diseases and ordinary cystitis in which there is much destruction of tissue. Thus far I have had no opportunity of examining croupous or diphtheritic disease of the bladder with the endoscope, and can not say how much information could be obtained in this way. \ pre- sume that much could be gained by this instrument, and I base this opinion upon the examination of several cases of catarrhal and croupous inflammation of the rectum. In these cases the distinction between catarrh and croup could be easily and positively made by the endoscopic appearances, and I believe that what has been done in determining rectal disease could be accomplished in diseases of the bladder. In these cases the vesical walls are very fragile, and this should be borne in mind in using either catheter or endoscope. This con- dition would preclude the distention of the bladder with air and examination with Ttutenberg's apparatus. Prognosis. — This is very grave indeed. Treatment. — This, in brief, is to keep the patient perfectly quiet, to let the diet be the most sustaining, the drinks free and bland, and to keep the bladder pretty well emptied, to allay the pain and spasm by the judicious exhibition of narcotics, preferably by the vagina, in suppository. The bladder should be washed out daily with warm water, containing a little of Labarraque's solution or a little carbolic acid. jV[uch relief of both pain and spasm will thus be afforded, even when the inflammation is at its highest. Tissue shreds should be removed as soon as their presence is as- certained. ORGANIC DISEASES OF THE BLADDER. 811 CYSTITIS WITH EPIDERMOID CONCRETIONS. This is a very rare affection of the bladder, and I only mention it as a pathological curiosity. Rokitansky supposes it to be due to, or a sequence of, chronic cystitis. It consists in an unusually rapid formation of epithelium by the vesical mucous membrane, resulting in the shedding of quite large white, shining plates or bodies of this caked scale. The following case, related by Lowenson (1862), is thus given by Winckel. The patient spoken of by him, suffered from mitral stenosis, and came into hospital in a moribund condition. After death her bladder was found to be enormously dilated. From it were taken a great number of small, rounded yellow masses, lying between a number of plates of dullish color, the general appearance being that of yellow pea-soup, with some of the hulls left in. The whole of the internal surface of the bladder was covered with flakes, many of them having these little balls interposed and superimposed. Their diameter varied from one twenty-fifth to one half inch. These attached flakes were tolerably firm and bright, something like mother- of-pearl. From the mucous membrane itself, after removal of these flakes, pieces of membrane could be stripped off. Except in these places the mucous membrane seemed normal. The urethra and ureters were normal, but the kidneys were in a condition of granu- lar atrophy. On microscopic examination it was found that the young, often- times fatty degenerated epithelial cells (in the commencement), as they approached the surface, took on gradually all the changes of the very large epidermic cell, becoming non-nucleated and granular. The little balls consisted of grains of fat, calciform concretions, lit- tle nuclei, and epidermic cells. There was considerable stearine but no cholesterine. Reich claims lately, however, to have found the latter in the vesical mucous membrane of a man flfty-six years old, who suffered from catarrh of the bladder. Treatment. — Of course I have no experience, never having seen a case, but on general principles I would suggest that the treatment would be to relieve any inflammation or irritation that may be pres- ent, the exhibition of alkalies and arsenic (in small doses) by the mouth, daily washing out of the bladder, removing all scales or plates that form, and the application of a strong alkaline solution to the diseased surface. I am unable to give the symptoms of this disease. The same may be said of the diagnosis. I presume, however, that an examination of the urine would enable one to determine the nature of the trouble. CHAPTER XLIV. NON-INFLAMltfATORY DISEASES OF THE BLADDEK. DISLOCATION OF THE BLADDER. II, Non-mflammatory diseases of the bladder. These are : 1. Dislocations. 2. Foreign bodies. 3. Rupture. 1. Dislocations. — These may be of six kinds : {a) upward ; (h) backward ; (c) forward ; {d) lateral ; {e) downward ; in addition to these, we may have {f) inversion of the bladder. Some of these are, even in their worst form, not tme disloca- tions, but represent some hindrance to the proper distention of the organ or its position when distended. Of all dislocations, the most important are the upward, backward, and downward. All of them, however, interfere more or less with the vesical function. Marked dislocation of a healthy bladder often gives rise to less disturbance than slight dislocation of an already irritable organ. Dislocations of the bladder have various causes, the most com- mon and troublesome being abnormalities of structure and position of the uterus and vagina. As a matter of fact, these dislocations are usually secondary to some aifection of the other pelvic organs. This necessitates a de- scription of their causes as well as the conditions under which they occur, thus deviating from the general order followed in this work. {a) Dislocation Upward. — The upward dislocation of the bladder may be caused by the dragging up of the organ by the gradual rising from the pelvis of the gravid uterus. This, however, is a rare aifec- tion, and only occurs, I think, in cases where there has ])een previous inflammatory action in the pelvis, gluing the parts together. In most pregnancies the bladder retains what is, under the circum- stances, its normal position. Bands of adhesion passing from the 812 NON-INFLAMMATORY DISEASES OF THE BLADDER. 813 bladder to tlie various abdominal and pelvic viscera may, when short- ening takes place, produce this dislocation. It may also be produced by ovarian tumors, and, in some cases of uterine retroflexion and retroversion. The dislocation accompanying the last two affections is, however, usually more backward than upward. The other most probable causes are tamors about the neck or base of the organ, tumors of the cervix uteri, pelvic deformities, and pelvic exostoses. The symptoms are usually those of irritable bladder. In some cases of pelvic tumor the pressure on the neck of the bladder, forc- ing it against the pubes, produces retention. This is purely me- chanical. In other cases, where there is no obstruction to the out- flow, but pressure on the bladder, there may be incontinence ; and, again, from traction on the muscular walls, patients are unable to contract and expel the vesical contents, and retention results. I saw a case, in consultation with Dr. A. W. Ford, of Brooklyn, in which the patient had retention of urine, so that she could not urinate while standing, but was compelled to lie down before the bladder could be emptied. The retention lasted one week, and was brought on by the efforts to urinate, which wedged the uterus in the pelvis, and compressed the neck of the bladder. She was relieved by urinating while on the hands and knees. (5) Dislocation Backward. — This dislocation stands next in order of importance and unfavorable results to downward dislocation. It may be caused by tumors of the abdomen or by pelvic adhesions, but the most frequent cause is backward dislocation of the uterus, such as retroflexion and retroversion. Retroversion affects the bladder in the same manner as prolapsus, except when the uterus is very much enlarged, and is thrown backward and impacted in the pelvis, so that the cervix presses flrmly on the urethra. In such cases urina- tion is impossible. Examples of this are seen in retroversion, occur- ring in the early months of pregnancy or after delivery. Schatz gives a case due to retroflexion of the uterus during pregnancy, produc- ing the same trouble in the bladder as retroversion. Winckel saw a case in the body of a non-puerperal woman, in which the uterus was lying almost horizontally in the pelvis, with its fundus adherent to the rectum. That part of the bladder that was drawn most backward had a diverticulum, containing a calcu- lus. The neck of the bladder was fastened down posteriorly by tight bands of adhesion that passed from it over the uterus to the rectum. In retro-displacements of the bladder, with no pressure on the 814 DISEASES OF WOMEN^. vesical neck, the symptoms are usually those of irritation, causing frequent urination and tenesmus. I give here the following cases, as they are of interest, and may serve to fix more clear- ly in the mind the general points. ILLUSTRATIVE CASES. The first is a case of chronic retroversion of the uterus, causing marked vesi- cal trouble in a nervous wom- an. The cause of the blad- der trouble is here double : ■P ^ oaK T> * • e ^v, -A ^ first, vesical neurosis, and i!iG. 265. — Ketroversion of the gravid uterus ' , ' (after Schatz). The bladder pulled upward SeCOnd, a displaced UteruS. and backward, and the urethra, u, put great- lur rr ^ |T^- x • ly upon the stretch. ^^^'^^- "-> ^S^^ imrt}-SlX. Married five years, and a vridow three years, of a marked nervous temperament. Has never been pregnant. Menstruation always normal, and general health fair in early life. Her general system has been much reduced by nursing her husband, who died of phthisis. Nervous system also much im- paired. When first seen, all the functions except those of the blad- der were performed well. She suilered night and day from frequent urination, but there was no pain either during or after the act, unless she tried to hold her water for a few hours, when there was great pain after the completion of evacuation. Nervous excitement, pleasant or unpleasant, made the trouble much worse. Her urine was normal. On examination, complete retroversion of the uterus was found, with shortening of the anterior vaginal wall ; the bladder was much contracted, but otherwise normal. The uterus was restored to its place, and held there by a pessary. Hydrobromic acid in thirty-min- im doses was given four times a day. She made a rapid recovery. The next is a case of vesical tenesmus and partial retention from a sudden retroversion of the uterus. Mrs. G., aged forty-three, the mother of four children. "Widow for several years. She was a strong, healthy lady, and had been on her feet all day attending to her household duties, and in the even- ing, while hanging some pictures, slipped from a chair, and fell heavily to the floor, striking on her feet. She was at once seized with a desire to urinate, and soon after pelvic tenesmus came on. The desire to urinate was constant, and, after strong expulsive NON-INFLAMMATORY DISEASES OF THE BLADDER. 815 efforts, she was able to pass a little urine from time to time, but without relief. The bowels became distended and tympanitic. On the following day she was ordered anodynes, but they gave very little relief. On the next day she was examined, and the uterus was found to be completely retroverted, and the bladder full, but not overdis- tended. Replacing the uterus gave her great relief at once, and she has remained well and free from all bladder trouble since the acci- dent occurred, some two years ago. This was a case of acute retro- version of the uterus, producing an intensely painful affection in a normal bladder. (c) Dislocation Forward. — Forward dislocation of the bladder, unless it be through the open abdominal walls, is very rare. Some change in its shape from pressure of organs or tumors from behind may occur, but this is really not a true displacement, except in some rare and marked cases. The most frequent cause is pressure from the anteverted and enlarged utei-us in either the virgin or puerperal state. Anteversion of the uterus usually causes frequent urination, perhaps as much so as prolapsus ; but whether this frequency is due to the fundus uteri resting on the bladder, or to the supersensitive- ness of the whole pelvic organs, which usually accompanies this dis- location, I have not always been able to determine. I have been in- clined to the belief that the latter was the case. In this displace- ment (anteversion) the uterus is generally enlarged and elevated, so that the body and fundus rest upon the bladder, and impede its dis- tention. True dislocation of the bladder forward is the rarest of all dis- locations, only three cases being on record. It has been variously called ectopia of the unfissured bladder, ectopia vesicae totalis, and prolapsus vesicae completus per iissuram tegumentorum abdominis. The first name is too vague, the last best of all, but rather lengthy for every-day use. The three cases on record are by O. Yrolik, Stoll, and Lichten- heim. In aU these the bladder was protruded through a small slit in the abdominal wall, and appeared as a bright-red, rounded tumor at the lower and anterior part of the abdomen. In Lichtenheim's case only was the tumor reducible. The pubic bones were separated about two inches. The urine could be retained perfectly, and the patient was able to micturate in a small stream. Microscopical ex- amination of the outer covering of the bladder-walls proved it to be mucous membrane, Uke that lining the interior of the organ. In G. Yrolik's case, according to Winckel, there is doubt as to 816 DISEASES OF WOMEN. whether it was a true vesical ectopia. He believes it to have been a gaping of the fissured abdominal walls over a dilated urachus, the latter communicating with the bladder by a small oi3ening. In Lichtenheim's patient no operative measures were thought of, for, beyond a little excessive secretion of the external surface, no trouble was experienced. If, however, from the protrusion of the tumor or other cause, difficulty in passing or retaining urine be pres- ent, an attempt should be made to close the abdominal fissure. If it be large, two or more flaps may be needed to accomplish the de- sired result. The operation is very like that for fissure, already de- scribed, only more simple. If an operation is not desired or consented to, the patient should wear a concave compress, and, by attention to bandaging, keep the surface of the organ in as nearly a normal condition as possible. id) Lateral Displacements. — Lateral displacement of the bladder is not very often met with. It is generally due to inguinal or fem- oral hernia, tumors at the side and base of the organ, arid contract- ing pelvic adhesions. There is generally more or less distortion of the urethra that may hinder the outflow of urine or prevent the easy introduction of a catheter. Irritability may result, but it is not so common as in the other varieties, the organ being generally but slightly displaced, and, soon getting used to the disturbing cause arising from the malposition, produces but little disturbance. One case of this kind I have seen which was of interest. The patient was a young lady, who had had a pelvic peritonitis, which left her with pelvic tenesmus, ovarian pain, and some vesical tenes- mus and difficulty in emptying the bladder. One of my assistants, while examining her, found a fluctuating tumor on the left side, which he supposed to be an ovarian cyst, but which proved to be a left lateral displacement of the bladder fixed in its malposition by adhesions. Causation. — Its causes are of two kinds — predisposing and excit- ing. Of the predisposing, the most common are a loose, flabby con- dition of the vesico-vaginal septum, excessive venositj^ of same (these may be due to pregnancy or to a general systemic condition), ab- normally capacious vagina, unusually large introitus vagina?, total or partial loss of perineal body, and the tendency of the bladder to pouch inferiorly as age advances. As exciting causes, we have violent expulsive efforts, as in def- ecation, lifting heavy weights, and especially child-bearing. The latter is probably one of its most common causes, for not only do we have expulsive efforts of the most violent kind, but a lax, spongy NON-INFLAMMATORY DISEASES OF THE BLADDER. 817 condition of the vesico- vaginal septum — i. e., the anterior vaginal and posterior vesical walls, which are pushed downward before the advancing head. Another common cause is prolapsus uteri, though in many cases the cystocele precedes the prolapse of the womb. Whichever is the cause, the one aggravates the other. In slight prolapse of the uterus, the vesical symptoms are only those of irritation ; and it is a strange fact that the irritation is often as great in the first degree of prolapse as in the third. Other less frequent causes of cystocele may be tumors in the posterior vesical or anterior vaginal wall, stone in the bladder, vesi- cal diverticuli, violent efforts at urination, and marked pressure fi'om above. The bladder begins to sag inferiorly as age advances, and conse- quently the tendency to prolapsus advances, as does the age. The number of pregnancies may, ho-wever, have more to do with the fre- quency than the tendency to pouching in old age. {e) Dislocation Downward. — I have reserved this malposition to the last, because it is the most important. There are various grades of the dislocation, the most marked of which is known as cystocele vaginalis. Pathology. — This affection may be conveniently divided into three grades. In the first, there is but a slight bagging of the or- gan. In the second, about one half the bladder lies below the nor- mal level of the anterior vaginal wall, giving the organ an hour- glass shape, the urethra entering the upper segment just above the point of partial constriction. In the third or highest grade, the whole bladder lies below the level of the normal anterior vaginal wall. The urethra in these cases has a direction from above back- ward and downward. The ureters in the last two grades are so bent and obstructed by pressure, that dilatation and hydronephrosis may result. Such instances are given by Phillips, Froreiss, Yirchow, Braun, and Winckel. The vesico-uterine pouch is, in cases of marked vesical and uterine jDrolapse, greatly increased in size, and may contain a loop of intestine. In some rare cases it may become constricted superiorly, and exist as a closed sac. In chronic cases the vesical mucous membrane becomes hyper- trophied, and, in the lower segment especially, congested and cedem- atous. To this may be superadded cystitis and ulceration, which often follow in cases of long standing. Symptomatology. — In the first grade of downward dislocation 53 818 DISEASES OF WOMEN. the symptoms are those of irritable bladder, such as frequent and sometimes painful urination. When the displacement has existed for a considerable time, the bladder seems to accommodate itself to the new relations, and the calls to urinate become less frequent. In cases in which the prolapsus of the bladder is slight and there is dila- tation or prolapsus of the upper third of the urethra, partial inconti- nence occurs, a very annoying symptom. Every time the patient coughs, lifts a heavy weight, steps suddenly down from the curb- stone into the street, or even indulges in a hearty laugh, there is a sudden escape of urine. In complete prolapsus of the utei-us and bladder, we find instead of frequent urination, difficult urination, and in the worst cases, re- tention. Partial retention always occurs in the marked cases, and the urine remaining in the bladder decomposes, and in time causes cystitis, which greatly aggravates the patient's sufferings. Such cases are very like those occurring in old men, and due to retained urine by reason of an enlarged prostate gland. There is usually a dragging pain experienced in the region of the umbilicus, which is due to traction on the urachal cord, and also a constant sense of pain and uneasiness, due partly to the vesical and partly to the uterine malposition. To fully empty the bladder in the worst cases, it is necessary to relax the parts by lying down, and then force out the urine by press- ure on the vaginal tumor. Cystitis is a common secondary affection, and is due to decompo- sition of the retained urine, and to chronic congestion with oedema and hypertrophy of the mucous membrane. Winckel's experience has, however, differed from that of most observers, he having failed to find a single instance of cystitis in sixty-eight cases of cys- tocele. From pressure on the ureters there may result dilatation and hydronephrosis, and if marked or long-continued, uraemia. There may also be set up that condition known as pericystitis, and the lower vesical segment be rendered irreducible owing to the formation of adhesions. If cystocele occurs in a patient already suffering from cystitis, the original trouble is of course greatly aggravated. Cystocele may interfere with delivery during childbirth. In one such case, McKee, being unable to push a catheter into the bladder, punctured the tumor with a lancet, and dehvery was rap- idly accomplished. In another case, a certain physician mistook the vesical tumor for the bag of waters, and punctured it. NON-INFLAMMATORY DISEASES OF THE BLADDER. 819 Diagnosis. — This is readily made. The patient should be laid upon her back, with the thighs flexed on the body. If the tumor is already down it should be examined carefully, and also the position and condition of the neighboring organs. If possible, a catheter should be passed into the bladder, to ascertain if it enters the tumor and the direction it takes in so doing should be ol)served. The tumor should be slightly compressed, and notice taken whether the urine flows from it through the catheter. An attempt should also be made to try to reduce it. The urine should be carefully ex- amined for pus, mucus, albumen, epithelial elements, and the amount of urea should be determined. Prognosis. — The prognosis is generally good ; but in giving an opinion the degree of dislocation, the size of the tumor, the condi- tion of its mucous membrane, whether it is reducible or not, the age of the patient, and the gravity of the producing cause, must all be taken into consideration. In young patients, Sims, Simon, Hegar, Verf, and others claim to have obtained radical cures. Some of these cures were not, how- ever, lasting. Scanzoni claimed that he had never seen an opera- tion for this displacement that resulted in a permanent success, and that his own operations were by no means satisfactory. My own experience entirely accords with that of Scanzoni. Treatment. — The treatment consists in reposition and retention. The former is easy, the latter hard to accomplish, as prolapsus uteri and cystocele generally go hand in hand ; one can not be treated without the other. Having pushed the uterus up into position, emptied the bladder and replaced it, some mechanical ^^^^^^ means should be sought to retain /^^^^^^ one or both organs in place, im^ W^^^^ For the purpose of support- >^^^ ^^ fW ^t ^H^^ ing the prolapsed bladder I de- wm^ -^^^^yy^^ '"^■"8 ^^ vised the pessary shown in Fig. ^t^ " ^-<(^^^^^^^^^*^^ 266, and it has been found to ^^^^^S^^ accomplish the obiect fairly well ^i^- J^^--^^f ^^'y, for prolapsus of the ^ 1 • 1 • • bladder (Skene). 1 he main portion, a, when the pelvic floor is not m- surrounds the cervix uteri, and b sup- inred ports the bladder and upper portion of J ' , the urethra. The other part, c c, joins This pessary is adapted and the main portion in front of the uterus, introduced in the same way as a and rests on the posterior walls of the •^ vagina. retroversion pessary, an account of which will be found under the head of the treatment of retro- version. 820 DISEASES OF WOMEN. The facility of introduction and removal is one of the minor, but by no means unimportant, qualities of this pessary. Several sizes are made, wliich answer in most of the forms of displacement of the bladder ; but a case will occasionally occur in which it is necessary to hrst take measurements, and have the in- FiG. 267. — Pessary holding up the bladder. strument made exactly to suit. This can be easily done. The pa- tient is placed on her left side, and after introducing the speculum, the uterus and bladder are restored to their proper positions ; then a thin strip of sheet lead is bent to the size and shape of the ante- rior walls of the vagina and cervix uteri. This form will enable the instrument-maker to produce the required size and shape of the pessary. I have also devised another form which suits some cases. It is like the retroversion pessary which I use, but the sides anteriorly are made more curved and very much thicker than, the ordinary one, Fig. 208. Should a pessary fail to accom- plish the desired result and the case grow gradually worse and the de- ^'»- 2fi8.-Modification of the retrover- J 7 T /'• 1 *^'"" pessary, used in prolapsus oi mand lor reliei become more urgent, the bladder. NON-INFLAMMATORY DISEASES OF THE BLADDER. 821 the operation may be performed whicli is described on page 925 and illustrated in Fig. 281, Plate IV. HERNIA OF THE BLADDER. This injury was first recognized by Dr. Taul F. Munde, and described by him in the " American Journal of Obstetrics," June, 1890, page 614. That it may have been observed by others is pos- sible, but it was evidently not understood until thoroughly investi- gated by Munde. Guided by the light which he has thrown upon tlie subject, I have been able to comprehend a number of cases which were previously obscure, and which, not knowing better, I had classified as cases of prolapsus of the bladder. The pathology is the same as in all hernial protrusions. There is first a giving way of the anterior muscular wall of the vagina in the median hne, and then the bladder, covered only with the vagi- nal mucous membrane, protrudes into the vagina. Ccmsation. — There are three causes which I have observed in the cases which have come under my observation : The first, which occurs less commonly now than formerly, is removal of a part of the vaginal wall, colporrhaphy. In time the scar-tissue stretches at the site of the operation, and the bladder protrudes at the point at which muscular tissue is deficient. The second cause is, apparently, a laceration of the muscular tissue in the median line during labor. When the hernia is caused in this way the urethra and lateral walls are in proper position, but at the point of hernia the muscular tissue and fascia are absent. The remaining cause is atrophy of the muscular tissue. This I believe to occur, because it has been found in women past the meno- pause who have not had children, and who have not been subjected to any injury which could have produced muscular laceration. Syinptotnatology. — The symptoms, so far as I have observed them, are the same as in prolapsus of the bladder. Physical Signs. — The physical signs are, when understood, quite diagnostic. When the perinaeum is retracted, the hernia appears as a smooth, hemispherical body, around the base of which the vaginal walls are in normal position. With a sound in the bladder, the thin vaginal wall, which is reduced to mucous membrane only, is appar- ent to the touch. If any doubt exist about the diagnosis, the results of treatment will determine whether the condition is that of hernia or of prolapse. If it be a prolapsus, which has been treated by the use of a tampon or pessary, witli rest in a recumbent position, there will be a noticeable contraction of the vaginal wall and a temporary 822 DISEASES OF WOMEN. relief ; but no such change occurs as a result of this treatment in case of hernia. Treatment. — Having failed to relieve hernia by any of the oper- ations recommended for prolapse, I was driven to try an operation which gave me good results, and that, too, before I understood the true pathology of the aifection. The operation consists in making a small opening in the vaginal wall at the junction of the urethra and bladder, and at the lower margin of the hernia. Through this opening a probe is passed and pushed up to the upper margin of the hernia, between the vaginal wall and the bladder. A delicate forceps is then introduced into the tunnel made by the probe, and its blades are spread forcibly apart. The vaginal wall and bladder are then completely separated to the extent of the hernial opening in the muscular layer of tlie vagina. The probe or forceps is held in place and upward j^ressure is made with it. This keeps the bladder in place while traction is made upon the vaginal mucous membrane at its upper part. This brings the lateral edges of the muscular layer of the vagina together and develops a ridge of mucous membrane. Sutures are now intro- duced to hold the parts in position. The mechanism of this proceeding is the same as in making a tuck. The ridge or tuck of mucous membrane projects into the vagina like the segment of a circle, but soon flattens out and over- hang's the line of sutures. Care should be taken not to make the sutures tight enough to strangle the tissues, but only sufficiently so to hold them together until they unite. I have operated in a number of cases, and the immediate results are all that could be desired. I have had an opportunity to observe but four cases long enough to determine whether the cui-e is permanent or not. In one of these, done five years ago, the hernia shows no disposition to return. The same is true of all the cases that I have operated upon. The first operation was done five years ago, and the last, one year. Dr. Munde, in his paper on this subject, commends the opera- tion of Stolz, which consists in the removal of the circular portion of the mucous membrane which covers the hernia, and the bring- ing of the parts together at one central point Math a purse-string suture. I have tried this operation in three cases, and have found that, while it appeared to answer the purpose, the scar gave way in time and the hernia returned. In fact, the worst case of hernia of the bladder that I ever saw followed a similar operation, which was done for prola^jsus. NON-INFLAMMATORY DISEASES OF THE BLADDER. §23 ILLUSTRATIVE CASES. A patient who had had a number of children suffered from a prolapse of the bladder and laceration of the perinaBum. I performed Noeggerath's operation for the relief of cystocele, and obtained a good result so far as relieving her for a time. She returned four years afterward, suffering as much as ever. I found that the scar left after removing the section of the an- terior vaginal wall had become stretched and thinned out, so that the bladder protruded. I vivified the vaginal wall all around the outer edge of the scar, and brought the surfaces together and obtained good union. Two years after this I found the her- nia had again returned. This led me to devise the operation which I have described above, and which has given me far more satis- faction. Hernia following Stolz's Operation. — A patient fifty-nine years old had a prolapsus of the bladder and a laceration of the peri- nseum of sixteen years' standing. I performed Stolz's operation and restored the perinseum. She was apparently cured, but two years afterward I saw her again, when I found what I believed to be a return of the prolapsus, but I now know that she had a vesical hernia. Frequent TJrination due to Prolapsus of the Bladder. — The patient was thirty-two years old, and had given birth to five children. She had always been well and strong, and at the time that I saw her she was in very good general health. After her last confinement, one year previous, she began to suffer from frequent urination. At first she obtained relief from emptying the bladder, but subse- quently the desire to urinate, though not very urgent, was constant when she was upon her feet. On lying down she obtained relief and retained the urine all night, but upon rising and going about the tenesmus returned. By digital examination I detected a prolapsus of the bladder, but only in a slight degree. There was considerable relaxation of the pelvic floor and of the vaginal walls, but no laceration of either. In all other respects she was quite well. The urine was normal. She was ordered to rest for a few days, most of the time reclining, and to use vaginal injections night and morning of sulphate of zinc, sixty grains to the quart of warm water. Afterward a pessary was used shaped like Graily Hewett's anteversion pessary, but having the anterior bars thickened. 824 DISEASES OF WOMEN. Immediate relief was given by the pessary, and she was able to walk and stand as she used to in former times. The zinc-douche was kept up once a day, and she was cautioned against walking or standing too long. At the end of six weeks the pessary was re- moved to see if she could do without it. In a few days the old symptoms began to return, and the pessary was replaced to her en- tire relief. From this time onward the pessary was changed once a month for a smaller one. Seven months afterward the instrument was removed, and the injections of the zinc solution continued for one month longer. She had no fui-ther trouble. Prolapsus of the Bladder caused by Laceration of the Perinaeum. — This lady was forty-one years old, of large form, and had an excel- lent constitution ; she had two daughters, the youngest seven years of age. For nearly six years she had suffered from vesical tenesmus and frequent urination. These symptoms were greatly aggravated by the erect position. In fact, for a long time she was quite comfort- able while sitting or lying down, especially the latter. Her symp- toms gradually increased, and within the past two years she has had partial incontinence. Any sudden motion such as is caused by cry- ing or sneezing would cause a spurt of urine which was most dis- tressing to her. She became quite helpless although in perfect health. Bemg unable to stand or walk for any length of time and having partial incontinence she remained in the house all the time. She had been treated with all kinds of drugs, but, as might have been expected, without any relief. I found that she had a laceration of the perinaeum, and also a bilateral laceration of the cervix uteri. The bladder was prolapsed and the upper third of the urethra pre- sented the usual signs of the ordinary cystocele. She was admitted to my private hospital, and after having been submitted to prepara- tory treatment the cervix was restored. While she was recovering from that operation the bladder was kept in place by the tampon, and astringent vaginal injections were used. One month later the pelvic floor was restored, and as much tissue brought together as pos- sible. After the operation the pelvic floor was kept well sup- ported with a compress and T-bandage. The astringent injections were continued. Six weeks from the last operation she was per- mitted to take exercise, but the pelvic floor was supported for two months longer. After restoring the pelvic floor it was necessary to use the catheter to draw the urine ; that excited some irritation of the bladder, but this was relieved by injections of borax and water. She made a perfect recovery, and has remained quite well for more than four years. NON-INFLAMMATORY DISEASES OF THE BLADDER. 825 Cases of Displacement of the Bladder due to Displacement of the Uterus and Causing Retention of TJrine. — (D. Berry Hart, M. D., " Ob- stet. Jour.," Great Britain and Ireland, August 3, 1880) : Case I. — A. B., aged eighteen, was seen in Prof. Simpson's out- patient clinic, on account of white discharge and pain on making water. Ocular examination of the external parts showed a recent laceration of the hymen and glairy discharge from the ostium ^aginse. On vaginal examination the cervix was found normal in all respects, except that the os looked downward and forward ; bimanually, a fluc- tuating tumor, reaching up a little above the level of the pelvic brim, was felt in front of the partially retroverted unimpregnated uterus. The catheter introduced drew off twenty-seven ounces of urine. Case II, — Mrs. C. was admitted to Prof. Simpson's ward on ac- count of retention of urine, necessitating catheterism ; bimanual ex- amination showed a large tumor in the hollow of the sacrum, marked elevation of the os uteri above the symphysis, and a fluctuating tumor in the hypogastric region, reaching almost as high as the umbilicus. This physical examination and the history of four months amenor- rhoea made the diagnosis of retroversion of the gravid uterus per- fectly plain. What concerns us here, however, is that the bladder contained only about twenty-three ounces of urine, a less amount than in the previous instance. Case III. — Along vdth Prof. Simpson I saw at the Maternity Hospital a patient with rigidity of os uteri, supposed to necessitate early application of the long forceps ; supra-j^ubic inspection and palpation revealed a fluctuating tumor bluntly triangular in shape, with the apex down. Exact measurements showed that vertically it extended four inches, and transversely for about the same distance. The catheter passed deeply up, and drew off only two ounces and a half of clear urine, and some time afterward the same apparent dis- tention occurred, when three ounces and a half were removed. Af- ter the bladder was thus emptied, the furrow between cervix and uterus could be felt two fingers' breadth above the symphysis pubis. These three cases are typical instances, and evidently call for expla- nation. In the first case narrated the bladder was simply distended. It had pushed the intestines up, tilted the uterus back, but its posterior wall was still in its nonnal position. The peritonaeum was still on the summit of the bladder, but, of course, was stripped to a certain extent from the lower part of the posterior aspect of the anterior abdominal wall. Thus the bladder, though its summit was only at the level of the brim, was considerably distended. Now, in the 826 DISEASES OF WOMEN. retroversion of the gravid uterus, the bladder was certainly distended, supra-pubic palpation, however, misled as to the amount of disten- tion, and for the following reason : The cervix uteri was tilted high up behind the symphysis pubis, and consequently the blad- der, to whose posterior angle the cervix is attached, was swung up, as it were, into the abdominal cavity, a movement permitted by the anatomical relations behind the pubis. The peritoneal relations were the same as in Case I. In the third case, the bladder was, of course, drawn up, as I have already shown,* and its relations were as follows : In front it touched the anterior abdominal wall ; behind, the child's head, the cervix, of course, intervening. In this way the anterior and posterior vesical walls were in contact, and thus a film of urine, as it were, gave the appearance of distention. As I have before pointed out, the peritonaeum is stripped off the bladder more or less.f The conclusions advanced are : 1. The retro-pubic anatomical attachments of the bladder admit of its distention and passage up- ward. 2. Supra-pubic palpation gives no sure indication of the amount of urinary distention. 3. When the summit of the blad- der is above the pubis, it may be (a), a pure distention (Case I) ; (h), distention plus a tilting up (Case II) ; (c), drawing up of the blad- der, with almost no distention (Case III). The reason why gynecologists use a long gum-elastic catheter is very evident. I have already described the empty bladder in the non- parturient female as forming a Y-shaped figure on vertical section. During parturition, however, the urethra is elongated, and forms with the bladder, on vertical section, a continuous tube. :{; Only that part of the bladder above the pubis is available for the recep- tion of urine, so that in this way the path for the catheter to travel is increased. In Braune's section of a woman in labor, the distance for the catheter to travel is about four and a half inches, more than twice what it is normally. In the last place, the distended female adult bladder is quite comparable in its anatomical relations to the distended fetal one. This may point to the explanation that the ultimate changes which convert the urinary bladder from an abdominal organ into a pelvic one is chiefly in the l)ony pelvis itself. Retrocession and Forward Transposition of the Uterus. — The vari- ous forms of displacement of the l)ladder described thus far, ai'e usu- * "Edinburgh Medical Journal," April, 1879. f "Edinburgh Medical Journal," September, 1879, "Edinburgh Obstetrical Transac- tions " (Part II, p. 142). | See " Die Lage des Foetus," Brauue, Tab. C. NON-INFLAMMATORY DISEASES OF THE BLADDER. 827 ally associated with uterine dislocations, and are familiar to those who have given attention to gynecology. There remains to be no- ticed two forms of displacement of the uterus not generally described by authors, but which markedly disturb the functions of the blad- der, viz., 7'etrocession 2iTi^ forward transjposition. In the first form, the uterus, without any change in the relation of its axis to the plane of the sujDerior pelvic strait, is found to rest far back in the pelvis, and is fixed there. In the second form, the reverse of this exists, the uterus resting just behind the pubes. Figs. 271 and 272, wiU show these conditions. The best example of retrocession I have ever seen was in a pa- tient who had had a severe pelvic peritonitis sometime before she came to me. The uterus was firmly fixed in the posterior portion of the pelvis, and the bladder was drawn backward, and was exceedingly irritable. This condition caused her great trouble, as she could never Fig. 269. — Forward transposition of the uterus. The bladder will be seen somewhat flat- tened against the pubes, and the urethra pushed out of its axis. completely empty the organ, except when the catheter was usedo Owing to the fixation of these organs in their malposition, it was impossible to relieve her from the frequent and diflicult urination, and she remained a great sufferer, until she died of phthisis pul- monalis. 828 DISEASES OF WOMEN. To illustrate the forward transposition, I may mention a case that came under xnj notice several years after she had had an intra- peritoneal pelvic hsematocele. Her physician told me that she had Fig. 270. — Retrocession of the uterus. The vagina is here found lengthened, and the bladder and urethra pulled upward and backward, a, adhesions, b, bladder. severe inflammation following the internal haemorrhage, and nearly lost her life therefrom. She was confined to her bed for many months, and after recovery she suffered from frequent urination. Night and day she was obliged to pass water every two hours, and if she went longer than that, she had pain which was not relieved till some time after emptying the bladder. The uterus was situated at its proper elevation, and was just behind the pubes. The bladder was compressed from before backward, and (as the uterus was firmly fixed in its forward position) of course it could never be fully distended. There was no disease of the bladder, so far as could be ascertained from an examination of the urine, or of the organ itself. No treatment that was employed gave anything more than temporary relief. (/) Inversion of the Bladder. — This affection stands next in rarity of occurrence to complete prolapsus of the bladder through a fissure in the abdominal walls. It is sometimes denominated as extrover- sion of the bladder through the urethra. NON-INFLAMMATOKY DISEASES OF THE BLADDER. 829 By some authors it is supposed to be a simple protrusion of the mucous coat of the bladder through the urethra, but by others to be a prolapse of the whole organ. In support of the latter belief is the fact that after death Joubert, Rurly and Leoret found a sinking in or partial inversion of the whole organ. Moreover, Meckel claims to have found under the labia minora, and protruding from the meatus a mass of tissue that on careful examination proved to consist of all the elements of the several coats of the bladder. Burns thinks it much easier for a prolapse of the whole organ to take place than a separation and prolapse of the mucous membrane alone. Streubel, after a careful review of the literature of the sub- ject, was able to find but one case in which the mucous membrane was alone prolapsed. As the posterior vesical wall in the empty organ lies over the vesical opening of the urethra, it is easy to com- prehend how this dislocation might occur from sudden straining efforts, pressure of the overloaded colon, or pressure of a heavy uterus. Vesical tumors with long pedicles coming out through the urethra, by weight or from traction, might produce this result. The process of extroversion is generally slow. De Haen, quoted by Streubel, gives a case, however, where from force, the bladder, rec- tum, and vagina were all prolapsed together. It will be understood that in order to have the bladder turned inside out, the urethra must be abnormally dilated. It may occur at any age. Weinlecher saw it in a child but nine months old ; Oliver, in one of sixteen months ; Crobs, in one from two to three years ; Streubel, in a girl fourteen years old ; and Thom- son and Percy, in women aged respectively forty and fifty -two. Symptomatology. — The patients, even before the tumor appears, feel strong pressure in the organ on urination, and may have stop- pages in the stream and retention. After a time these symptoms become aggravated, a small red tumor appears at the meatus, and with each urination enlarges. With the appearance of the tumor comes pain. In some cases, when the desire to urinate is felt, severe contraction of the bladder takes place, but no urine flows. Then suddenly the little tumor disappears inside, and the urine flows freely. With each appearance of the tumor there is considerable constitu- tional disturbance, and after a time the appetite is lost, and the suf- ferers emaciate rapidly. From continual traction on the ureters, they may become inflamed, and also the kidneys, and ursemia super- vene. Blood is sometimes passed with the urine. Cystitis may occur, which increases the suffering and danger. The mucous mem- brane may become hypertrophied, congested, and even oedematous. 830 DISEASES OF WOMEN. The constitutional symptoms bear no relation to the amount of tissue extruded or the area of mucous surface exposed. Diagnosis. — Fortunately, this affection is a rare one, for the diag- nosis is by no means easy. The surface of the tumor should be ex- amined, and the nature of its epithelium carefully noted. Reduc- tion should be tried, and, if successful, examination should be made by the sound in the bladder, and the linger in vagina or rectum (the latter in infants), to ascertain, if possible, whether there be any thick- ening of the membrane or a tumor in the viscus. If on the surface of the protrusion the orilices of the ureters can be found, the diag- nosis is at once settled. Polypoid projections of the mucous mem- brane must be differentiated from protrusion of the viscus itself. Such cases are described by Baillie and Patron. From prolapsus of the urethral mucous membrane, which I shall hereafter describe, this condition is to be difl'erentiated by the absence in the latter of the ureteric openings and the position of the meatus urinarius. In urethral prolapse the orifice is situated either centrally or superiorly, while in vesical protrusion the meatus surrounds the pedicle. In the latter there is a large strong pedicle ; in the fonner none. Treatment. — The treatment naturally divides itself into prophy- lactic and curative. To prevent partial extroversion from becoming complete, narcotics and demulcents should be given by the mouth and rectum, or injected into the bladder. Opium, hyoscyamus, and belladonna may all be tried. Local cauterization and washing out with tonic injections might prove serviceable. These preventive means are usually sufficient, provided the urine is normal and the mucous membrane healthy. If either of these abnormalities exist, they should be corrected. If the tumor is down, its reposition should be attempted. Gentle manipulation with the finger should be tried, and, if the mass can not be put back in this way, a well-oiled blunt catheter should be used, making pressure with it in the direction of the axis of the urethra. If this is very painful, and there are spasmodic contrac- tions of the abdominal muscles, which prevent replacement, the patient should be etherized, and success may then follow. She should be on her back, or in the Sims's position. To prevent prolapse after reduction, the catheter may remain in situ for a time, or the colpeurynter or tampon may be used. Schatz's pessary for urinary incontinence may be employed advantageously, as its use tends to contract the vesical neck. Astringent injections may be used. No operative procedure is required. CHAPTER XLY. NON-INFLAMMATORT DISEASES OF THE BLADDER (cONTINUEd), FOREIGN BODIES IN THE BLADDER. Foeeign bodies found in the female bladder are divided into three classes by Winckel, as follows : {a) Those that come from the body, entering the bladder by per- foration. (Ij) Those which have their origin in the bladder. {c) Those that are introduced from without through the urethra. I will adopt this classification, believing it to be the most natural and convenient. (a) First then, as to those that come from the body, entering the bladder by perforation. That cysts ever originate in the bladder is doubted by some and denied by others. In most cases where they are found in this organ they can be traced to dermoid cysts of the ovary which have found their way into it, thus accounting for the presence of hair, teeth, and other tissues in this viscus. These things are never found there unless such a cyst has opened into the bladder. The contents of these dermoid cysts may become nuclei for calculi, and lead to seri- ous trouble. I think there can be no doubt but that some of the cysts found in the bladder have their origin there. Mucous follicles certainly do exist in the bladder, and are liable to have their orifices blocked or occluded, and by secretion behind the point of obstruction grad ually form cysts. Interesting cases, where the cysts evidently had their origin in the bladder itself, are related by Paget, Liston, and Campa. It is, however, undoubtedly the fact that most cysts of the bladder have their origin outside that organ. Cysts of the ureters and uraclius may open into the bladder. Hydatid cysts have been found, but are less frequently seen in this 831 832 DISEASES OF WOMEN. country than in almost any other. Iceland is especially cursed with them, about one sixth of the population suffering from them in some part of the body. They may appear in the urine, white and pearly in appearance, or be of a dirty yellowish color, from prolonged soak- ing in foul urine. Treatment. — These cysts, or their contents, if giving rise to any trouble, should be treated in the same manner as the neoplasms, of which I shall speak later. In the treatment of hydatid cysts, iodide of potassium has been especially recommended. Having never had occasion to use it for this purpose, I can say very little for or against it. Other Foreign Bodies. — Various parts of the foetus have found their way into the bladder by ulceration during extra-uterine preg- nancy, and pieces of ulcerated intestine, masses of feces, fecal con- cretions, and biliary concretions, are some of the curious things that have been found in this viscus. In gun-shot and other injuries to the pelvic bones, osseous splinters have found their way into the viscus, and been evacuated through the urethra, or have passed into the vagina or rectum by ulceration, or have remained, forming nuclei for calculi. Yarious parasites may penetrate the walls from the immediate tissue or neighboring organs, or come down from the kidneys, such as the echinococci, already spoken of, the distoma haematobium or the iilaria sanguinis hominis. Joints of tape-worm, the ascaris lum- bricoides, and the thread- or seat-worms have also been found here, entering either through a fistulous opening, existing between the bladder and intestine, or through the urethra. In acute destructive change in the kidneys (pyonephrosis and abscess), pus and pieces of renal tissue are not unfrequently carried down into the bladder, and may, by frequent incrustation with the urinary salts, result in the formation of calculi. Of themselves, they give rise to very little, if any, irritation, and are consequently of no importance save in relation to the destructive changes going on in the kidney, of which they tell the story. If such discharges from the kidneys continue for a long time, they cause cystitis. Kenal calculi may become dislodged, and be swept down into the bladder, there to enlarge by further incrustations, or pass out through the urethra. I^yinptoinatology. — The symptoms of the various foreign bodies in the bladder differ only in degree. They are at first those of irri- tation ; later those of acute or subacute inflammation. Bodies round, smooth, and soft, are, of course, less irritant than those that are rough NON-INFLAMMATORY DISEASES OF THE BLADDER, 833 or sharp. Cysts, therefore, bits of flesh, aud tlieir like, as a rule, give ris6 to no very severe symptoms, while splinters of bone and calculi occasion much more severe manifestations. Pain and tenes- mus will vary with the character of the offending body. If the mucous surface be abraded or torn, hsematuria will result ; and, if the foreign body remains in the organ, and continues to irritate it, cystitis will follow, and the patient suffer increased agony. The extension of the inflanmiation upward, and involvement of one or both kidneys, will give rise to pain in the back, hectic fever, partial or total suppression of urine, and consequent uraemic symp- toms, ending fatally. The urine shows the various appearances of cystitis, of which suflicient has already been said, and also the signs of renal involve- ment, if such be present. Treatment. — Any foreign body, when known to be present in the bladder, should be removed at as early a date as possible. In the adult female this may be readily accomplished by dilatation of the urethra, or, if the body be too large, by Simon's vesico-vaginal section. In cases of fistulous communication between the bladder and in- testine or other organ, an attempt should be made, in the manner already spoken of, to close the opening. Echinococci and other parasites should be treated with the vari- ous remedies recommended for their destruction elsewhere, always, however, removing the offending body from the bladder first, and trying to prevent further invasion by proper medication. If cystitis be present, this will be attended to in the prescribed way. Hydatids in the Bladder. — Dr. J. A. McKennion, of Selma, Ala- bama, reported a case in the " American Medical AVeekly," Louisville, Kentucky, in 1874 or 18Y5. The purport of this report, according to my recollection, is that it was a case which, when first seen, had every indication of cystitis, with great thickening of the walls of the bladder. Frequent micturition caused the patient to exclude her- self from society for two years before a correct diagnosis of the case was formed. She was becoming pi'ostrated from constant dysuria, and, in order to give her quietude, Dr. McKennion says, I attemjDted to introduce a Sims's catheter, to be retained during the night ; but, meeting with an obstruction in the bladder, and, by manipulation with catheter, finding that she was insensible as to the point of the instrument, I concluded that a hydatid formation was present, and designed at once to have it expelled if possible. 54 83i DISEASES OF WOMEK I would say here one of the strongest arguments in my own mind at the time of hydatid formation was, when force was used to pusli up the instrument farther, a small amount of fluid escaped, and no blood. I injected into the bladder two drachms of liq. sodse chlor. (French preparation). In about an hour violent spasms of the blad- der occurred, the urethra dilated, and there was expelled into the vessel about a pint of hydatid. The shape and attachment of these resembled the cactus ; the sacs were transparent and well defined. There was but slight haemorrhage. This I attributed to the forcible distention of the urethra. It is now over five years since their ex- pulsion, and up to this day my patient has had no more inconven- ience with her bladder. Fortunately, my case was a female, and she is well ; this might not have been if it had been one of our own sex. — Ne 1.1:1 Yo7'k Medical Record^ Nfrvemher 20, 1880, p. 588. (b) Bodies having their Origin in the Bladder Itself. — Under this head come calculi, which may be of various kinds, as uric acid, triple and amorphous phosphates, oxalate of lime, and cystine. The latter are quite rare. Again, the calculi may consist of more than one of these ingredients. Time will not allow me to enter into the extensive field embrac- ing the etiology and treatment of stone. For a comprehensive study of this matter, I must refer the reader to any one of the many excel- lent works on that subject. Calculus. — I shall only speak of one or two points in connection with calculus that are of especial interest in the study of disease of the female bladder. Stone in the bladder is not so common among women as among men. This, I presume, is owing to the large and easily dilatable urethra of the female, which permits small renal cal- culi to pass out ; calculi of the same size in the male being retained in the bladder, and serving as nuclei for larger ones. Si/mpto9nat(do(/f/. — The symptoms are simply those of a foreign body in the bladder, varying with the size, shape, and number of the stones, and also their roughness of surface. Frequent urina- tions, tenesmus, pain before, during, and after urination, some- times incontinence, and always more or less cystitis. Hjematuria is not at all infrequent, and the urine presents all the characters of bladder inflammation, as shown by the presence of pus, epithelium, and, sooner, or later, numerous crystals of the triple and amorphous phosphates. The constitution suffers from the constant pain and frequent urination, and the patient gives all the symptoms of a severe cystitis. Diagnosis. — This is comparatively easy in the female bladder. NON-INFLAMMATORY DISEASES OF THE BLADDER. 835 for between the judicious use of the sound, conjoined manipulation, and the bladder speculum, a stone can hardly escape detection un- less it be very small or completely encysted. Prognosis. — The prognosis in vesical calculus in women is good, provided the kidneys be not seriously disordered. The cystitis usu- ally disappears soon after removal of the foreign body, under proper treatment ; and even if renal disease exist, it may also sub- side. Causation. — The causes of stone in the bladder are about the same in both sexes, and so I need not dwell long on this part of the subject. I may call attention to one cause of the formation of stone in the bladder of the female. In cystocele, a mass of mucus or shreds of membrane and triple and amorphous phosphates gradu- ally collect in this abnormal pouch, and form a nucleus for stone. It is a curious fact, too, that women are particularly liable to have stone after the operation for closure of vesico-vaginal fistula. There has been considerable discussion as to whether calculi, discovered soon after this operation, existed undiscovered in the bladder before the operation, or were formed rapidly after it. Henry F. Camp- bell, M. D., of Virginia, relates one case in favor of the former view, and Dr. T. A. Emmet several in favor of the latter. The belief has been advanced that irritation in the bladder mod- ifies the urinary secretion sufficiently to cause deposit of the urin- ary salts, and thus account for the formation of stone after the operation for fistula. It is claimed that reflex nerve action is ex- cited by the operation, the inflammatory action about the edges of the wound, or by cystitis already existing. This idea that the reflex nerve influence modifies the urinary se- cretion sufiiciently to result in the formation of stone in these cases, is, I think, hardly tenable ; for in hundreds of cases of cystitis, where the reflex action does undoubtedly^ exist, no stone is formed. Then, too, the secretion is as a rule rendered more watery, instead of concentrated, a condition in which precipitation of the urinary- salts would be very unlikely to take place. A middle position on this question seems to me to be the most rational, and stones found after operations for closing fistula might be due to any one of three causes : {a) Calculus already existing in the bladder, escaping detection by being pocketed, or so small as to lie beneath a mucous fold, and rapidly increasing in size after operation, due to the retention of the salts of the urine (deposited by decomposition), that formerly es- caped by means of the fistula. 836 DISEASES OF WOMEN. (5) Calculi, small or large, existing in the kidneys or renal pelves, and washed down after the operation by the increased flow of limpid urine : these, too, increasing in size by incrustation. {c) Calculi, the formation of which commences directly after closure of the wound, due partly to retained products of decomposi- tion, possibly to modified secretion, or to small nuclei swept down from the kidney, or, what is much more likely, to nuclei consisting of pieces of mucous shreds, blood-clots, or possibly incrustations on one or more of the sutures which may be exposed in the bladder. I am quite sure that the formation of calculi after closing a ves- ico-vaginal fistula is favored by the presence of the catheter in the bladder during the healing process. The drainage is imperfect and if the bladder is not frequently washed there is every facility for the deposit of urinary salts and the formation of stone. I am the more persuaded that this explanation is correct from the fact that, since I have permitted my patients to empty the bladder in the natural way after the operation, I have not had a case of stone following this operation. Treatment. — The female bladder presents an inviting field for experiments on the treatment of stone by solvents ; but as the opera- tion here is so easy and its results so good, it seems hardly justifiable to recommend any other method of treatment. In patients, how- ever, who object to the operation, it may be tried. For a full and interesting account of experiments and statistics on the solvent method, I refer to Mr. Roberts's most excellent work on " Urinary and Renal Diseases." The stone being found and its size determined, it may either be removed by cystotomy or crushed. If the stone be small and soft, it may be advisable to crush it, washing out the fragments through the open speculum in the moderately dilated urethra, thus saving the urethral mucous membrane from laceration by the sharp fi'ag- ments ; or better still the dehris may be removed by Bigelow's method. If much cystitis be present, however, or if the stone be large, it is advisable to perform vaginal cystotomy. In this way a stone of large size may be removed from any part of the bladder, and an opening for drainage is left to act beneficially on the inflamed organ by giving vent to the urine and its sediment. The bladder should be carefully washed out daily with a warm solution of salicylic acid (1 to 600 or 1 to 400j. If drainage is desired, care must be taken to keep the incision open, for it closes veiy readily. I have spoken several times already as to the method of per- NOX-INFLAMMATORY DISEASES OF THE BLADDER. 837 foraimg vaginal cystotomy, Emmet dwells especially and justly on the necessity of Mxing the vesico-vaginal wall Hrmly with a tenacu- him before commencing the incision, which may be made with either a knife or scissors. A calculus in the bladder, if interfering with labor, or if liable to be caught between the child's head and the pubes, should, if possible, be pushed up out of the way. This is seldom successful, and as much damage may be done the bladder by the crushing of its walls, it is best to puncture and remove the stone at once in ease there is time during the labor and the attendant is prepared to operate. Should it be impossible to operate before labor is completed, it should be done as soon afterward as practi- cable. It should be borne in mind that the vascularity is greater in the puerperal state and hence every preparation should be made to arrest hajmorrhage. ILLUSTKATR''E CASES. Foreign Bodies in the Bladder. — ^By L. H. Dunning, M. D. ; read before the " Indiana State Medical Society " : Case I. — Mrs. A., aged thirty-eight, married, a lady of culture and reiinement, was delivered, four years previously, of a hydro- cephaloid child. The delivery was instrumental. Whether from long pressure of an abnormally la,rge head, or from maladroit use of instruments, I know not, a vesico-uterine or vaginal fistula re- sulted. The precise location of the original opening of the vaginal or uterine extremity of the fistula I am unable to state, as two operations had been done for its closure, both of which were un- successful. The last operation was done in June, 1883, and in the folloAving December I was consulted in consequence of intense pain and burning in the region of the bladder, and pain at the close of the act of urinating. The patient stated she had, a few weeks previously, passed a small stone by the urethra, and now thought there was another and larger one present. An examination, with the sound confirmed her diagnosis. I proceeded to remove the stone, assisted by Dr, S, L, Kilmer. The urethra was dilated with a three-bladed dilator, the stone crushed with a Thompson's lithotrite, and removed with Bigelow's evacuating apparatus. We were both confident all the stone was removed. The patient made a good recovery, but was not entirely relieved of the bladder symp- toms. In March, 18S4, I was again called to remove a stone, which the patient stated she had felt with the large end of a shawl-pin in- troduced into the bladder through the urethra. This time, assisted by Dr, M, L. Morse, a large quantity of stone was removed in the same manner as at the first operation. The lithotrite was introduced 838 DISEASES OF WOMEN". three times, and, the last time it was withdrawn, we found within the grasp of its closed blades a silver-wire suture, with the loop cut, but the twist intact. The whole was coated with a phosphate-of-lime deposit. We now felt confident we had secured the foreign body around which the calculus had collected. The patient stated to us that she had been aware ever since the last operation for fistula that there was a wire left behind, and that she had once visited the sur- geon to have it removed, but it could not be found. There are many other points of exceeding interest connected with this case, but they are not pertinent to this subject, hence will be omitted. There was a band of dense cicatricial tissue extending transversely across the fundus of the bladder. Posterior to this band was a pocket, in the bottom of which was the vesical extremity of the fist- ula. In this pocket lodged the stone, and was evidently made sta- tionary by the suture, which remained partly imbedded in the tissues. That the wire rendered the stone stationary finds support in the fact that, July 18th, four months after the wire was removed, a fourth large calculus had formed in the bladder, and was quite movable. This last calculus was readily crushed, and voluntarily expelled from the bladder along with water freely injected into the organ. Since this fourth stone was removed, there have been no signs or symp- toms of a calculus in the bladder. Case IT. — Mr. B., a laborer, aged fifty-seven years, was brought to me, by Dr. Kettring, September 19th, of last year, for the re- moval of a foreign body from the bladder. The patient stated that, about the middle of August, he passed a cigarette-holder into the orifice of the urethra ; that it slipped away from him, and passed down into the urethra, and, in his efforts to remove it, pushed it into the bladder. Being a mechanic, he had invented an instrument with which he attempted to remove the body, without success. I sounded the bladder, and found the holder lying obliquely across the organ. I judged it to be about two and one half inches long, and as thick as a small lead-pencil. A No. 1 8^ sound dropped readily into the bladder, and, since the urethra was of so large a caliber, and the patient had frequently passed his instrument along its track, I concluded to attempt its remov^al without further dilatation. A Thompson's lithotrite was introduced, and the body seized ; but I was made conscious that the instrument did not grasp it at the end, so I withdrew the lithotrite and introduced a sound, and endeavored to bring the long diameter of the holder in line with the urethra. Now, with but little difiiculty, the end was grasped by the blades of the lithotrite, and I proceeded to withdraw the whole. It soon NON-INFLAMMATORY DISEASES OF THE BLADDER. 839 became evident that we had not rightly estimated the size of the holder, for, although it, together with the instrument, entered the prostatic portion of the urethra, we had consideraljle dithculty in making it advance through the membranous portion. However, avoiding much force, but keeping steadily at work, with the aid of Dr. Kettring, I succeeded in withdrawing it to within one inch and a half of the orifice of the urethra. Further than this we could not advance ; so the urethra was incised posteriorly down to the end of the holder, and, by applying pressure from behind, made to enter the incision, and was finally entirely withdrawn. We were surprised to see the size of the holder and its breadth when in the grasp of the lithotrite, thirty-five millimetres. There was a moderate amount of haemorrhage from the urethra or bladder ; probably from the mem- hranous portion of the urethra, since that is the most constricted por- tion of the canal. The bladder was washed out with tepid water, and the patient taken to his home in a closed carriage, the operation having been done at my ofiice on account of the patient's refusing to have it done at home for fear of exposure. Soon after reaching home, the patient had a chill, followed by fever. In the next twenty-four hours he had three chills, each time followed by in- creased fever, the temperature ranging from 102° to 104° F. The urine passed was freely mixed with a considerable quantity of mucus and a little blood. 20th, 1.30 p. M. — Patient seen by Dr. Kettring and myself. Had a temperature of 106°. He voided urine in our presence ; it was quite bloody, and, upon close examination, was found to contain a wedge-shaped piece of mucous membrane twelve millimetres long, four millimetres broad, and about two millimetres thick. This was not examined with the glass, but was supposed to be from the mem- branous portion of the urethra, since at that point there was the most resistance. There were also voided at this time several small grains of gravel, some as large as wheat-grains Patient complained of con- siderable pain. Bladder was washed out with warm carbolized water. Twenty grains of quinia sul. were given ; one grain opium and ten grains of acetate of potash every four to six hours, and a milk-diet ordered. Further than this, I will not attempt to minutely detail the history of the case, but will simply outline it. In the next twenty- four hours the patient had four chills. The temperature ranged from 101° to 104:°, and the pulse from 108 to 120 per minute. Patient perspired profusely, and was at times delirious ; great nervousness ; prognosis was regarded unfavorable. Whisky, in 3 jss doses, every hour, when the temperature mounted high, was added to the treat- 840 DISEASES OF WOMEN. ment. Dr. Kettring washed out the bladder twice every day, using for this purpose a soft-rubber catheter and a rubber bag. We de- bated the advisability of this procedure, but found that, by this means, we removed a considerable quantity of turbid urine, small clots of blood, and occasionally small grains of gravel ; and further, the cleansing of the bladder seemed to afford the patient relief ; so we decided to persist in it as long as its use was indicated. 22d. — Patient slightly delirious ; pulse, 112 ; temperature, 101° ; slept moderately well last night : has had no chill since 9 p. m. yes- terday. Dr. Kettring found morphine, gr. one sixth, ar. spts. ammo., 3 jss, very efficient in relieving or aborting the cbills. At noon to-day patient seemed much better ; at 9 p. m. temperature had fallen to 100°, and pulse to 90 ; but the urine had accumulated in the blad- der, and had to be removed by catheterization. 23d, 7.30 A. M. — Patient rational ; has slept well during the night, and voided urine frequently ; pulse is 70, and temperature normal ; the nervous symptoms have nearly disappeared ; had symp- toms of a chill last night, which quickly disappeared under the effects of the morphine and ar. spts. of ammo., with the addition of ten drops of chloroform. From this time forward the recovery was uninterrupted. In one week the patient was able to sit up. A few days later he was walk- ing about the streets, and in two weeks after the operation resumed work. Thus happily terminated a case that at one time was exceedingly alarming, in consequence of the intense urethral fever that devel- oped. It would undoubtedly have proved fatal had it not been for the skill and unremitting attention bestowed upon the case by Dr. Kettring. Stone in the Bladder ; Lithotrity by a Single Operation. (N. A. Powell, M. D., Edgar, Ontario.) — S. F., aged now live years, first presented symptoms of trouble referable to the urinary organs in October, 1876. Pain, partial incontinence, and the passage of blood and mucus continued from this time, and in January, 1878, a bit of " gravel " the size of a split pea came away. During the following spring the desire for urination became almost constant, and vesical tenesmus was marked. On June 12th, ray friend, Dr. I>lackstock, of Hillsdale, was called to see her, and on the 13th, under an anresthetic, he examined, and found a calculus at the neck of the bladder. An operation for its removal was advised, and pending this, anodynes were freely given. On July 9th, the writer, in consulta- NON-INFLAMMATORY DISEASES OF THE BLADDER. 841 tion, saw the case for the lirst and only time. The child was said to be faihng very fast ; she was much emaciated ; was suffering severely, and seemed to gain a respite from her pain only when violently rocked while in the knee-chest position in a cradle. Pulse 140, temperature 102^° F. Chloroform, replaced later by ether, was given, and a stone found jammed into the upper part of the urethra. This was displaced upward, caught in the blades of a smaller Weiss and Thompson lithotrite, and crushed. The scale showed five eighths of an inch separation of the blades. Further comminution of the fragments was effected by means of long polypus forceps. Evacua- tion was accomplished by the same, aided by the frequent injection and aspiration of warm water through a large-sized Eustachian catheter, to which a strong rubber bulb had been attached. This last was the best substitute at hand for Bigelow's or Clover's appa- ratus. The vagina was too small to admit a finger without undue stretching, but water could be retained in the bladder by pressure upon the urethra. The first calculus being removed, suprapubic pressure brought two other and smaller ones within reach, and these were treated as the first had been. The distance between the outer surfaces of the blades of the forceps used when grasping the largest fragment re- moved was three tenths of an inch; this, then, was the limit of urethral dilatation. The lithotrite was used for crushing five times, the forceps twenty or thirty times. The time occupied was one hour and a quarter. The bladder being washed and aspirated till, as nearly as possible, freed of its solid contents, the child was put to bed with hot applications over the pubes and to the extremities, and a full anodyne was given. The detritus collected at the time of operation weighed 241 grains; subsequently seven grains more were obtained from the strained urine. For the history of the case after this, I am indebted to notes kindly sent me by Dr. Blackstock or his assistant Mr. Gould, who, with my students Messrs. Shepherd and Bremmer, gave assistance during the operation. " Partial control of the urine returned on the day following the lithotrity, and complete control, except during the night, after three days. The desire to void urine occurred about every hour for several days, and at the end of a week, about every third hour. Slight hEematuria was noticed for two days." Under date August 27th, I hear that "the child's general health is good. She is gaining in flesh, and has no symptoms of her former trouble." The above case would a year ago, hardly have merited transcrip- 842 DISEASES OF WOMEN. tion from the case-book of a country physician to the pages of a medical journal. But since the appearance of Dr. Bigelow's paper on litholapaxy * the whole subject of the tolerance of the urinary bladder for prolonged instrumentation has come up for reconsid- eration, and this is offered in evidence. From Civiale down, all lithotritists, so far as the writer's knowl- edge extends, have held that the visits of a lithotrite to the interior of a bladder must be strictly limited in point of time. Though ex- perts may, at times, have given themselves more latitude, they have always taught others not to exceed five minutes for any one crush- ing. Of late years, also, the tendency has been to confine the opera- tion within narrow and yet more narrow limits, treating by it only such moderate sized stones as could be got rid of in from two to four sittings. It remained for the Harvard professor to demonstrate that the calculus-containing bladder of an etherized man might be manipulated for one, two, or more hours, and yet not resent it by cystitis or subsequent atony ; ^wovided that no sharp fragments were left in it to do outrage to its lining membrane. Although the case just given occurred in a female child instead of in an adult male, it seems to support Dr. Bigelow's conclusions as to vesical tolerance. Surely the delicate tissue of a child's bladder is ill adapted for pro- longed contact with instruments, while the proportion of the organ covered by periton[eum in the child being greater than in the adult, there would seem to be a greater danger of serous inflammation. Yet, here all irritation j)romptly subsided when the irritant was re- moved, although its removal took one hour and a quarter. May we not expect like results when even large stones are crushed in the male bladder, and evacuated by the new method % Statistics so far — seventeen cases, sixteen successful — seem to point that way. It may be asked why the urethra was not more widely dilated in this case % My answer is that too large a proportion of those thus treated have been made dribblers for life by it. The ease with which stretching may be accom])lished, and the free access which it gives to the bladder, will strongly tempt a surgeon who does not look beyond the operation he has to do at the future life of his patient. Prof. Simon, of Heidelberg, made f many accurate meas- urements to determine the extent to which the adult female Urethra may be dilated without the risk of incontinence. His limit is in width, eight tenths of an inch ; in circumference, 6'3 cen., (=2-4 inches). This would allow a finger to pass, but not a finger plus a * " American Journal of Medical Sciences," January, 1878. f Translation in " New York Mcilical Journal," October, 1875. NON-INFLAMMATORY biSEASES OF THE BLADDER. 843 pair of forceps. Mr. J. R. Lane thinks no stone larger than an acorn should be removed entire through the urethra of an adult female, and none larger than a beau through that of a child. Dr. Hunter McGuire, of Richmond, Va., states that many cases of so- called successful operations by dilatation and extraction have, to his personal knowledge, been followed by incontinence. Rapid dilata- tion, however, seems to be less dangerous than slow. In proof of this, I may, in conclusion, mention that I have knowledge of the •case of a girl, aged twelve years, into whose bladder a pair of sequestrum forceps was pushed, a calculus seized and extracted "vi et armis^ dilating and lacerating the urethra as it came. The stone was as large as a pigeon's Q^g. Absolute incontinence existed for twelve days, but was followed by recovery. Stone sacculated in the Bladder of a Female. (By Charles Will- iams, F. R. C. S., Ed., Surgeon to the JSTorfolk and JSTorwich Hos- pital). — Cases in which a vesical calculus is impacted in a cyst situated in the walls of the bladder are so extremely rare that I consider it a duty to record this very interesting example : A ■ fine, healthy girl, aged three years, living in ISTorwich, came Tinder the care of the late Mr. George Hutchison in the year 1873, having for several months previously suffered from very decided symptoms of stone in the bladder. It had been noticed by her mother that from the time of her birth she had experienced diffi- culty, as well as occasionally severe pain in passing urine, and that sometimes she voided blood mixed with it, and was in the habit of straining so violently as to produce prolapsus of the rectum. On sounding the bladder, which was an unusually capacious one, it was with some difficulty that a calculus could be detected. At the wish of the parents Mr. Hutchison resolved to remove the stone by dilatation. Mr. W. H. Day assisted at the operation, and I was requested to administer chloroform. The urethra was freely and quickly dilated with Weiss's trivalve dilator. There was considera- ble trouble to lind the stone, and when found a still greater trouble to seize it "with the forceps, (and it was particularly noticed that, although the patient was thoroughly under the influence of the anaesthetic, the getting hold of the stone with the forceps occasioned severe straining) ; the blades could not be made to grip the calcu- lus ; they continually slipped oil, bringing away pieces of the stone. At last it became absolutely necessary to ascertain what occasioned the difficulty. For this purpose the urethra was still further dilated, and the neck of the bladder was also divided with a probe-pointed bistoury. The stone could now be felt with the point of the finger 844 DISEASES OF WOMEN. immovably fixed in the floor of the bladder on the patient's left. It appeared to be of the size of a pigeon's egg, and was inclosed in a sac, through the neck of which a small portion protruded into the vesical cavity, and it was off this nodule that the forceps so continu- ously slipped. Many efforts were made to dislodge it — first with a scoop, then with the finger, which could barely reach it, and next with the forceps ; they all proved unsuccessful. Several portions were broken off the uncovered portion, but the main piece was left in situ, as it was considered undesirable to make any further at- tempt to remove it, the patient having been a long time under the influence of chloroform, and ap^jarently in a very exhausted con- dition. The next day the child had voided very little urine. A catheter was introduced, and a small quantity of sanguineous urine flowed out. She was very drowsy, and had been so since the operation. When aroused she took milk and brandy very freely, but immedi- ately afterward became drowsy again. She did not ajjpear to have recovered from the influence of the chloroform. The next day she died. No post-mortem examination was permitted. I am induced to believe that this child died of chronic chloroform- poisoning, and not from the effects of the operation, which was by no means roughly performed, and that there was very little blood lost. She never thoroughly revived, but became comatose, and died in that condition. It is difticult to imagine what could have griven rise to the formation of the sac. There never was an obstruction to the escape of the urine, such as stricture or prostatic enlargement might engender, for neither existed. We are taught that a cyst is usually formed by the straining necessary to expel the urine ; the mucous membrane is forced between the bands of muscular fibers, hypertrophied in consequence of the strain to which they are sub- jected. Nothing of the sort can apply in this case, and it is not easy to believe that the stone was the cause of the cyst, which it might have been, had it been situated close to the neck of the bladder. When impacted in this situation, the very pressure to which a stone is subjected by the constant and long-continued action of the bladder to expel it, causes the mucous membrane to ulcerate through, and the stone is in due time forced into a cavity, which enlarges as the stone grows, and in this way it may form a tumor in the vagina. An effort is then made by nature to contract the opening, which in this child was nearly accomplished ; but the calculus was far from the neck of the bladder, and could barely be touched with the point of the finger, so that a different explanation of the formation of the NON-INFLAMMATORY DISEASES OF TUE BLADDER. 845 cyst is required ; and as no examination was allowed to Ije made, it seems to me to be almost impossible to suggest in what way tbe sac was formed. Sabulous matter, or a few urinary crystals, may prob- ably have been deposited originally in a mucous follicle, lacuna, or fossa, and gradually augmented in quantity, and in this way tbe sac inclosing tbe calculus may bave been produced. Tbe mother of tbe girl at four years of age suffered from stone, wbicb was removed by tbe late Dr. Edward Lubbock ; it was tbe size and shape of a wal- nut. She has suffered from incontinence since that time. I believe tbat it would bave been very mucb better to bave re- moved tliis stone by cystotomy. Had the patient lived sbe would bave suffered from injured urethra. {c) Foreign Bodies introduced into the Bladder through the Urethra. — Of these it may be truly said tbat "tbeir name is legion," for in tbe literature of tbe subject we find recorded a most numerous and diverse bst of objects found in tbe bladder of tbe female. Some of these objects were forced into tbe bladder by accidents, such as falls or blows ; others were intentionally introduced into tbe urethra for tbe purpose of masturbation, and then pushed or drawn into the bladder. Tbe same may occur in auto-catbeterization, the instru- ment being sometimes broken off in tbe bladder, and at others, drawn bodily into tbe viscus. Hysterical and foolish women, with or without tbe intention of masturbating, bave passed all manner of things into tbe bladder, as pins, needles, matches, sand, charcoal, bits of glass, bodkins, and tooth-brush handles. Masturbators have also forced in various articles, such as twigs, small wax candles, penholders, nails, pencils, and tbe like. Cathe- ters and clay-pipe stems, tbat bave been used for purposes of cathe- terization, have been broken off and left in tbe bladder. Pessaries, which have been badly fitted, or worn too long, have passed by ulceration from the vagina into the bladder. Sym])toinatology. — Tbe symptoms need not be given in detail, as they are tbe same as those caused by any foreign body, usually aggra- vated, however, if the body be sharp and bave jagged edges. Bleed- ing is not uncommon, and pain varies in amount and severity with the kind, size, and shape of tbe foreign body. Hysterical women have been known to conceal tbe pain and tenesmus for a long time. If the bodies be small and blunt, they may give rise to but little pain or tenesmus, and, remaining in tbe bladder undisturbed, form nuclei for calculi. I doubt if a modification of tbe urinary secretion by reflex nerve influence (excited by these bodies) is necessary to 846 DISEASES OF WOMEI^. cause incrustation, or form calculi. The hypersecretion of mucus and decomposition of urine is all that is required. Treatment. — The treatment of a foreign body in the bladder is summed up in two words — remove it. This must first be tried through the urethra. A pair of forceps (those kno\vn as the alli- gator forceps being the best) are guided to the object, which is to be seized and removed. If this is difficult, the operation may be done through the speculum. If the bodies be small, they may possibly be washed out. If they are so situated that their removal by the urethra is impossible, vaginal cystotomy may be performed, and the foreign bodies thus removed, using such after treatment as will re- lieve any cystitis, which may have been produced. CHAPTER XLYL NON-ESTFLAJVUyiATORT DISEASES OF THE BLADDER (cONTDTUED), BTTPTURE OF THE BLADDER. Rupture of the bladder may be classified according to its loca- tion and extent, as follows : I. Complete and incomplete. II. (a) Occurring at a point where the bladder is cohered with peritonaeum. (h) Where the bladder is not covered with peritoneenm. I. In the complete rapture all the coats of the organ are divided, while in the incomplete variety one coat at least remains undivided. Pathology. — The complete form of rupture is the most common, and the location at which it most frequently occurs is the posterior and upper part ; that is, the part where the walls of the bladder are the thinnest, and probably where there is the greatest exposure to the causes of the injury. There is another reason given why rupture is more frequent where the bladder is covered with peritonaeum, and that is because the peritoneal covering is not so elastic as the other coats. When the laceration occurs within the limits of the peritoneal coat, and is complete, the urine escapes into the peritoneal cavity, and produces shock and peritonitis, which usually prove fatal. In rupture at any point not covered with peritonaeum, infiltra- tion of urine takes place in the tissues beneath, not within, the peri- tonseum. This infiltration is sometimes very great, extending from the cellular tissue of the pelvis to the labia and thighs. The clinical history of these two varieties differs in its char- acteristics because of the fact just mentioned — that in the one va- riety the urine escapes through the rupture into the peritoneal cavity, while in the other the urine infiltrates the tissues in and about the pelvis, 847 848 DISEASES OF WOMEN. In the one, peritonitis is speedily developed, as a rule, and gen- erally proves fatal ; in the other, the progress is slower, and the chief danger is from septictiemia. There is another class of cases having a pathological history which holds an iDtermediate position between the two already described. In this class the history points to the fact that the rupture has been at a point destitute of peritonaeum, or else the rupture has been incomplete, not involving the peritonaeum. This gives rise to symptoms of severe internal injury, but less severe than in complete rupture, which is followed by a sudden giv- ing way and escape of urine into the peritoneal cavity, and subse- quent peritonitis. This opening into the peritoneal cavity at a pe- riod remote from the injury, is due to pressure or ulceration or sloughing, which completes the rupture. Symjptoinatology. — Y^Q symptoms of rupture of the bladder are ordinarily developed as follows : There is usually shock in a mai'ked degree, and if the pelvic bones are broken — a frequent comj)lication of this injury — the patient is unable to move after having rallied from the shock. Severe pain is felt in the hypogastric region, and a continual desire to urinate, without the power to void the smallest quantity of urine, or possibly but a few drops mixed with blood. The constitutional symptoms indicate great prostration, which rapidly ensues. The patient has an anxious look, the countenance is pale, the pulse feeble and fluttering, respiration sighing, skin clannny ; the abdomen in a short time becomes tympanitic. There is also a rise in temperature after a time, but during the shock the temperature may be sub-normal ; delirium, convulsions, and coma may occm*, and death may take place in a few hours in severe cases, or it may be delayed a few days. A fatal result occurs sooner in complete than in incomplete rupture. If the patient survives the shock or collapse, life may be en- dangered by the development of peritonitis or septic<\?mia. The physical signs of rupture are few and by no means reliable. I must therefore give more attention to the clinical history and symptoms, '.ncidentally bringing out the only physical signs obtainable, such as the empty state of the bladder found when that viscus has not been emptied in several hours, and the withdrawal of a small quantity of bloody urine by means of the catheter. The surgeon is not able to make a certain diagnosis in all cases, as the symptoms are not always pathognomonic. The statement of the patient that she received a blow ov^er the hypogastrium, or that while in the act of straining she felt something give way, are valu- NON-INFLAMMATORY DISEASES OF THE BLADDER. 849 able as evidence when acute pain and other symptoms of rupture follow. The evidence obtained from tlie use of the catheter is of value, especially when it is known that the patient had not urinated for several hours prior to the accident. Under these circumstances when the bladder may contain a small quantity of bloody urine or when the bladder is empty, there is strong evidence of the bladder being lacerated. But the evidence pointing to rupture is by no means always certain. And again very often signs and symptoms which the diagnostician depends upon most are absent, and those that are present are Hable to mislead. This is very unfortunate, but true. The diagnosis is especially ob- scure when there has been a long interval between the receipt of the injury and the development of characteristic symptoms. It is there- fore necessary to watch a patient in whom there is suspicion that rupture of the bladder may have occurred. The symptoms may be for a time concealed and then develop rapidly. The first symptoms may be delayed or be obscure and not attract attention, because the vesical rupture may be involved with other injuries whose symp- toms for the time hide the more dangerous lesions. As a rule, it is rare to find any external signs or mark of injury on examination of the abdomen. When much depends on the history given by the patient regarding the nature of the accident and the condition of the bladder at the time, it frequently happens that she is not able to answer questions correctly, because of the shock and the fact that this accident often occurs while the patient is intoxicated. Strange as it may appear, in exceptional cases the patient may have uo difiiculty in urinating, and indeed may pass a large quan- tity of water. Cases have been recorded where the patient regained the power of voluntary urination after the catheter was passed for the first time. * Although it is important to make a diagnosis early in all cases, yet it is of equal importance to know whether the rupture is com- plete or incomplete. This can be done by noting the fact that in the one case there will be infiltration of the urine into the cellular tissue of the pelvis, and in the other such infiltration is absent. It is often necessary to pass the catheter both for diagnosis and treatment, and great care should be taken in its introduction, for sometimes by using too much force it is accidently pushed through the viscus into the abdominal cavity. Prognosis. — The chances of recovery are not favorable, espe- cially when the urine passes into the peritoneal cavity through a 55 850 DISEASES OF WOMEN. rupture higli up. When the rupture is incomplete or does not in- volve the peritoneal coat and treatment is early employed, the pros- pects of saving the life of the patient are encouraging. Causation. — The predisposing causes of rupture are certain con- ditions of the walls of the bladder, such as atrophy, fatty degenera- tion, ulceration, and sacculation ; overdistention from stricture or other causes, and alcoholic intoxication which favors overdisten- tion, and exposure to the exciting causes of the accident. The empty bladder may be lacerated in connection with injuries of the other pelvic organs, but it is a fact that in the majority of cases the bladder has been less or more distended at the time of the accident. It should be borne in mind, however, that rupture has occurred a great many times when the bladder was normal and not overdis- tended, there being no predisposing conditions present that could be recognized. The most common determining causes are blows over the region of the bladder. These may be sustained in a variety of ways, such as direct blows or knocks, falling from a height upon something which violently strikes upon the hypogas- trium. Kupture often occurs in connection with severe injuries which fracture the pelvic veins. In such cases it is not possible to say whether the rupture occurring under such circumstances is due to the direct blow or to laceration by pieces of the broken bones. Rupture has occurred sufficiently often in the puerperal state to warrant placing this condition in the list of predisposing causes. One can see how a distended bladder might be ruptured during the violent labor -pains or the contortions of instrumental and manual delivery, and this accident has occurred in that way. In a number of cases, however, the rupture has not taken place un- til after delivery, showing that the labor gave rise to retention, and that to rupture. So far, then, as the puerperal state is related to rupture of the bladder it may be said that a full bladder may be ruptured by the direct violence done during delivery, but quite as often retention occurs in the puerperal state, and the rupture is caused by overdistention. In a similar way rupture has occurred in displacement of the uterus which caused retention of the urine. The bladder has frequently been wounded during ovariotomy and hysterectomy when there were adhesions, but this accident does not come under the head of rupture now under consideration. Treatment. — The first indications are to relieve pain and shock if either is present. These objects can be attained usually by opium and stimulants. If there is infiltration of urine into the pelvic cellular tissue the urine should be removed by puncturing or incis- NON-INFLAMMATORY DISEASES OF THE BLADDER. 851 ing the parts affected. Next, and most important of all, the bladder should be continuously kept empty by retaining the catheter in the bladder. The catheter should be a flexible one of soft rubber with a perfect eye very near the end. It should be made to enter the bladder only far enough to secure perfect drainage and not far enough to disturb the wound in the bladder. Yaginal cystotomy has been recommended as a means of drainage, but I feel sure that the catheter is a simpler, and certainly as reliable a means of accom- phshing the object. The management of the graver cases, in which the rupture opens into the peritoneal cavity, must be of the most heroic character in order to be effectual. The great object is to cleanse the peritoneal cavity of urine and blood. This has been done when the case was seen early, by pass- ing the catheter into the peritoneal cavity through the rent in the bladder. When this can be done easily it may answer that purpose, and the patient may be treated by rest and opium ; but, unless the catheter passes without much effort and the one catheterization is sufficient, this method should not be persisted in. Laparotomy appears to offer the best chances in these very for- midable cases. If the patient is seen early, and before extensive peritonitis has been established, I believe the best that can be done is to open the abdominal cavity, and thoroughly remove all blood and urine that have accumulated. When this has been accom- plished the wound in the bladder should be accurately closed with sutures. In case the edges of the wound are very irregular, and will not fit together accurately, they should be trimmed suffi- ciently to give a clean and complete coaptation. The after-treat- ment should then consist in draining the bladder, as already mentioned, and managing the patient as in laparotomy for any purpose. ILLUSTRATIVE CASES. Case of Rupture of Female Bladder associated with Abortion (by T. Lawrie Gentles, L. F. P. S. G., Derby).— On October 13th I was requested, at 3 a. m., to visit a woman in a neighboring street, who was said by the messenger (her husband) "to have had a mishap." On reaching the house I found a well-made woman of thirty-six lying on her left side in bed, vomiting large quantities of a dark- brown, pungent-smelling liquid. The pillows were drenched with the fluid, so also was the carpet in front of the bed, and on the walls opposite to the patient were stains of a similar nature. There was also half a pint of vomit in the chamber-vessel. The woman was in 852 DISEASES OF WOMEN. a state of collapse ; a cold, clammy perspiration stood on her face, her hands and feet were like ice, and her pulse was impercei^tible. There was no one in the house except her husband and two little children, the latter occupying the same bed as the patient ; while, to add still more to the ghastliuess of the scene, the younger of the children (a babe of nine months) was vainly endeavoring to reach its dying mother's breast in order to obtain its usual nourishment. I made a rapid examination by the vagina, but found a closed OS uteri, and no marked traces of haemorrhage. I observed, however, that the abdomen was greatly distended. I tried to administer some ammonia, but the patient was unable to swallow ; she gave me one agonizing look of dread, moved her lips as if to sjDeak:, and then died, tlie death taking place within a quarter of an hour after my arrival at the house. My first impression was that the woman had died of internal haemorrhage ; the only things which seemed to militate against tliis being the redness of the lips and the copious vomiting. This idea of hsemorrhage seemed also confirmed by what the husband said at the bedside — viz., that " his wife had had a good many clots come from her, and that her linen was very much stained." I refused, of course, to give any certificate, and communicated with the coroner. In collecting evidence for the inquest, the follow- ing facts were clearly brought out ; first, that the woman was a drinker ; secondly, that she had had a drinking-bout for some days ; and thirdly, that she had had occasional difliculty in passing urine. In regard to the first two points, the husband's evidence was most conclusive, and showed clearly that when the poor woman had one of her drinking-fits on, she would not only consume large quantities of beer (her favorite drink), but also all the spirituous liquors she could lay her hands on. In regard to the third point, the hus- band also made clear the fact that his wife had often suffered from retention of urine, but, "so far, had always got over it." At the inquest, further details of evidence brought to light the fact that the woman had complained of pain in her belly for two or three days previous to death. She had, however, been "up and down stairs" until 1 p. M. of the day preceding her death ; but when her husband came home at 6 p. m., he found her in great pain, and was told by his wife that "she had been losing blood." A good many clots were in the chamber-vessel, and these he threw away into the ash- pit. The pain getting no better, and finding that his wife was " altering for the worse," he came for a medical man as already stated. NON-INFLAMMATORY DISEASES OF THE BLADDER. 853 At tlie autopsy there were no external signs of violence found, except a slight abrasion on the forehead, and another on the lower lip, and a small bruise on the inner side of the right thigh, none of which were of recent date. On cutting through the abdominal walls, the great depth of fat and its extreme " watenness " arrested our at- tention, the knife going through the tissue with a distinct " swish." Suspecting an accumulation of fluid in the abdominal cavity, a small incision was made at first. No sooner was this done than a reddish- brown liquid began to well up. Some of this was drawn off, and the opening enlarged, when nearly six pints of fluid were removed. The stomach and. intestines, having been carefully examined, were then taken out, in order to facilitate further search for the lesion. The flrst thing which we noticed was a pint of blood lying in the pelvic basin ; and, on making more minute search, a rent was discovered in the posterior wall of the bladder — a rent large enough to admit four fingers. Here, then, was the cause of death. There were some fresh adhesions on each side of the bladder and the pelvic walls; there were also similar adhesions between the bladder and uterus. All these adhesions, however, were extremely soft, and broke with the slightest pressure. The walls of the bladder itself also seemed much thinner than usual. No flakes of lymph could be discovered in the fluid removed from the abdominal cavity, and neither did the peritonseum exhibit any great degree of vascularity. It may be, however, I think, safely affirmed that a large portion of the fluid found was effused from an irritated peritonaeum, the other portion of the fluid being, of course, urine from the ruptured bladder. On opening the uterus, signs of recent delivery presented them- selves ; on observing which I asked my son to tell the husband to rake up " the clots " from the ash-pit. The husband did so, and one of the "clots" was found to be a foetus, three inches in length. Now comes the question : When did the rupture of the bladder occur, and had uterine action anything to do with it ? Supposing that the " pains in the belly," of which the woman complained for two or three days before death were the commencement of the abortion, it is reasonable to infer that, when true expulsive efforts on the part of the uterus began, these efforts would be aided by the action of the abdominal muscles ; and, supposing still further, that the bladder was at that time distended to its fullest capacity, it is perfectly possible that the pressure of the abdominal muscles would be the "last straw" necessary to produce the fatal lesion. I am, therefore, inclined to think that the rupture took place in the after- noon of the 12th. I ought to have stated that, although, when the 854 DISEASES OF WOMEN. husband came home at 6 p. m. on that day he found his wife in bed, she, nevertheless, " kept getting out of bed, trying to pass urine, but could not." There can be little doubt that the alcoholic condition of the patient would rob her of her sense of attending to the calls of nature ; and it is melancholy to think that, if she had only been seen earlier, a simple catheterism might have saved her. As a piece of concurrent evidence of the habits of the patient, it may be stated that the liver was a genuine " nutmeg " ; that the kidneys were thoroughly disorganized (the cortical substance being rarely distinguishable); and that the spleen was exceedingly soft. The heart was small and fatty. The lungs were fairly healthy, but there were extensive adhesions in the right pleural cavity. The head was not examined. — British Medical Journal, January 6, 1883. Cases of Rupture treated by Laparotomy. — (A. G. Walter) — Ten hours after a severe injury, no urine was found by the catheter. The abdomen was opened in the linea alba by an incision beginning one incli below the umbilicus and terminating one inch above the pubes, to the extent of six inches. The intestines were found inflated, their peritoneal coat, as well as that hning the interior of the ab- dominal walls, already showing evident marks of congestion. A soft sponge was then cautiously introduced into the abdomen, with which the extravasated fluid, consisting of urine and blood, was carefully removed from the pelvis and between the convolutions of the bowels, amounting to nearly a pint. A rent was found at the fundus of the bladder, two inches in extent. The cavity of the ab- domen being cleansed of the noxious agent, the wound of the blad- der was left to itself, as no urine was seen to escape from it. The abdominal wound was closed by strong Carlsbad needles, secured by silver wire (only skin and fascia being stitched, while the peritonaeum was left untouched) ; a flannel bandage encircled the whole abdomen. The patient, awakenirg from the anaesthetic sleep, felt relieved of pain and the desire to urinate, so distressing before the operation ; vomiting did not return ; opium in one-grain doses was ordered ; abstinence of drink and perfect quietude of body, with retention of the catheter, were sti-ictly insisted upon. lie soon began to doze, had a comfortable night, was free from pain the next morning, com- plaining only of soreness in the abdomen, without tympanites, sick- ness, or calls to urinate ; thirst less urgent. The treatment being vigorously continued, for drinks iced barley-water, water only in very small quantities, with pieces of ice, being allowed. No un- pleasant symptom followed ; urine in small quantities, but free of NON-INFLAMMATORY DISEASES OF THE BLADDER. 855 the admixture of blood, passing by the catheter. On the third day the intervals between the doses of opium were lengthened to two hours; on the fifth, to three, and thus gradually decreased as all signs of iniiammation had passed. At the end of a week the abdominal wound a2:)peared to be closed by first intention ; the stitches, however, were not removed till a week later. The gum-elastic catheter was replaced by a new one every two days, and was not withdrawn for two weeks after the injury had been received, and then only for a short time. At the expiration of two weeks, with the absence of all pain and tenderness, opium was omitted. The intestines were re- lieved by warm-water injections on the tenth day, when mild nour- ishment was ordered. Between the second and third week the catheter was permanently withdrawn, and only introduced every four hours for the evacuation of urine. After the third week, the patient left his bed. He has remained well, working at his trade, and feeling no impediment in his urinary organs. (Alfred Willett). — An incision some five to six inches in length, from the umbilicus to the pubes, was made in the mesial line and carried through the parietes. All bleeding points having been se- cured, the peritonaeum was opened, and at once several ounces of dull, brownish fluid, with strong urinous odor, escaped. The intes- tines were greatly distended, and instantly bulged out through the wound. The peritonaeum generally was highly injected, and adja- cent surfaces were glued together. Passing my hand into the pelvis I detected a laceration of the bladder. The coils of gut were only slightly more adherent here than in the abdomen proper ; I satis- fied myself that there was no protrusion of bowel into the lacerated bladder. The omentum was raised from off the intestines, and so much of the latter as lay in the pelvis was drawn up, laid upon the upper part of the patient's abdomen, and protected from harm and chill by flannels wrung out of moderately hot water. There was about half a pint of bloody, urinous fluid in the pelvis, and when this had been sponged away, a rent of the bladder some three and one half inches in extent was exposed. It extended diagonally across the fundus, having a direction from before backward and from right to left. The appearance was that of a nearly straight tear through all the coats of the bladder, except at its most dependent parts, where it was jagged and uneven. The bladder was flaccid, but, of com'se, quite empty, and at the site of rapture its walls were fully haK an inch in thickness. I brought the torn edges easily in apposition, and united them by eight interrupted sutures of fine Chinese silk. The sutures were placed at intervals of rather less than half an inch, and seemed 850 DISEASES OF WOMEN. to close the rent completely. Before returning the intestines I cleaned out the abdomen as thoroughly as I was able ; but the mes- entery of the gut lying outside the abdomen acted as a transverse diaphragm, and I was disappointed to find on replacing these coils that some of the fluid had been pent up above it. Owing to gaseous distention, very considerable difficulty was experienced in replacing all the intestines mthin the abdomen, and I was quite unable to in- troduce my hand and cleanse the upper part of the peritoneal cavity as satisfactorily as I could have wished ; but tlie patient's shoulders were raised in order to make the pelvis more dependent, and all fluid that found its way there was removed. The intestines that had been lying out of the abdomen during the operation were sponged over with warm water and carefully cleansed before returning them. So extreme was their distention that to enable me to introduce sutures, and close the external wound, Mr. Langton, who assisted me, was obliged to spread out his hand and restrain the bowels from forcing their way through the wound, withdrawing his hand gradually as the successive sutures, also of Chinese silk, were tightened. Through the lower angle of the abdominal wound I passed a carbolized drain- age-tube into the pelvis, securing it to the edge of the external wound, which was then dressed precisely as after ovariotomy. A Thompson's catheter was introduced and retained in the bladder. On being replaced in bed, hot bottles were placed beside the patient, and he was well covered uj). The wound in the abdominal parietes was found on the autopsy to be adherent almost 'along its whole line ; not much swelling of abdomen. The intestines immediately behind the wound were adherent to it. All the coils of intestine in the lower half of the abdomen were adherent to each other and to the abdominal walls by recent lymph. The intestines in contact with the bladder were adherent to it. There were about two ounces of bloody fluid at the back of the peritoneal cavity ; about an ounce of this lay just above the bladder. The opening in the bladder was everywhere well closed, excejit between the posterior two stitches, where there was an orifice through which water injected per urethram escaped very freely. Even here there appeared to be an attempt at repair. Elsewhere the edges of the wound were adherent. There was very little sign of inflammation in the interior of the viscus. (Christopher Heath). — Man, aged forty-seven. Pubes being shaved and washed with carbolic lotion, an incision was made in the middle line just above the pubes for two inches, and the tissues di^^ded down to the peritona'um, which appeared blue, the recti mus- cles, which were firmly contracted, being held aside by retractors NON-INFLAMMATORY DISEASES OF THE BLADDER. 857 with difficulty. Tlie peritonsTeum was then picked up and a cut made into it, when a gush of fluid, like that di-awn off by the catheter, came out. A large quantity of clots was then taken out from the peritoneal cavity. The linger introduced into the peritoneal cavity found a long rent in the posterior wall of the bladder high up. This was sewed up by a continuous catgut suture hrmly tied at both ends. The clots were removed as far as possible from the peritonaeum, and the cavity sponged out after injection with warm water, and a long large-sized drainage-tube was inserted at the lower angle of the wound, the upper part of the wound being brought together by deep and superficial sutures. A catheter was passed into the bladder, to which was afterward attached some India-rubber tubing leading into a vessel under the bed. Hot poultices were applied to the abdomen, and one grain of opium was administered every four hours. The fur- ther history shows great relief and improvement, but on the fourth day after the operation the patient became rapidly worse and died. Autopsy. — Small intestines considerably distended. For two inches around the abdominal wound the intestines were adherent by recent lymph to each other, and to the abdominal parietes. Above and on each side of these adhesions there was no trace of peritonitis. On tearing away these adhesions some coils of intestines were seen lying over the pelvis glued together, and to adjacent parts by recent blood- stained lymph. On lifting these coils upward, the recto-vesical pouch of peritonseam was exposed, containing about six ounces of clotted blood, black in color, and moderately offensive odor. There was a rent in the mid line of the posterior wall of the bladder two inches in length, extending upward as high as the apex. The lower third of the rent was gaping ; the edges of the rest were aj)proxi- mated by the catgut suture, the lower end of which was free and loose. CHAPTEK XLVII. NON-INFLAMMATOKY DISEASES OF THE BLADDER (CONTINUED). NEOPLASMS, HYPERPLASIA, ATROPHY. Owing to the very imperfect facilities for observing the internal surface of the bladder during life, the study of vesical neoplasms up to within a few years was chiefly post-mortem, and of course their therapeutics was almost nil. At the present time, however, by means of the endoscope, the microscope, and the operation of cystotomy, more accurate methods of diagnosis and of rational and successful treatment have been developed. The neoplasms of the bladder may be classified as follows : Benign. — Myxoma, fibroma, myoma, myo-fibroma, tubercle. Malignant. — Epithelioma, encephaloid, scirrhus, sarcoma. Tumors of the bladder and deposits in its walls are by no means common, and those of a benign nature are less common than those that are malignant. There has been some dispute as to whether some of these neoj^lasms are malignant. This is especially tlie case in regard to the villous growth, the German and some English authorities ranking them as essentially malignant, while some American authors, as Van Buren and Keyes, deny in toto that they have any such property. More will be said of this when I come to the class in which I have placed them ; not that I am satis- tied that they are malignant, but for lack of positive evidence of the new idea, temporarily at least, I adhere to the old one. Benign Growths. — Myxomata, Mucous Polyju, and Polypoid Hy- pertrophies, while having nearly the same anatomical characters, are really different affections as regards etiology, sjonptomatology, prog- nosis, and treatment. Mucous polypi are isolated hypertrophies of the mucous mem- brane, varying in size, and giving rise to trouble only in proportion to their size. They may exist at birth, or be developed at any time during life, being more common, however, in youth and middle 858 NON-INFLAMMATORY DISEASES OF THE BLADDER. 859 age. The mucous membrane covering them is thickened and pulpy, and that about their base and in their immediate ueighl:)orhood is somewhat thickened, and more vascular than normal. If the polypi are situated at or near the neck, or in other portions of the bladder, where their long, narrow pedicles admit of a blocking of the m-ethra, the entire mucous membrane of the organ suffers, as in all cases of retention and decomposition of urine. If the obstruction is great, and the organ requires spasmodic and irregular muscular effort to empty it, there will be, sooner or later, not only cystitis, but mus- cular as well as mucous hypertrophy. These growths may be as small as the head of a pin, or as large as a goose-egg ; they consist of hypertrophied and hyperplastic connective tissue, covered by soft, pulpy, hyioerplastic mucous membrane, that bleeds easily on touch. They may coexist with uterine fibroids. Their favorite seat is the j)osterior wall of the bladder. General polypoid hypertrophy of the mucous membrane con- sists in an irregular thickening of the mucous membrane through- out, accompanied as a rule by hypertroj)hy of the muscular and serous coats. There is an increased blood-suj)ply, the membrane be-' ing bright red in color, the capillaries dilated, and the whole mass bleeding easily on the touch. It has somewhat the appearance of fresh granulations. Upon the free surface of the mucous membrane, there is, as we should expect, an excessive cell proliferation, these cells being in a transitional condition, i. e., occupying the position between imperfect and perfect, and not all of the same degree of perfection or imperfection of development. There may be either serous or gelatinous infiltration, giving it a heavy, sodden look. Upon the surface are often found incrustations of the urinary salts. It appears to me that there has been an undue complexity of classification of this subject, especially among the German patho- logists, some of whose differences are too minute to be of any prac- tical value from either a pathological, diagnostic, or remedial point of view. Tumors which they call villous or papilloma vesicae are, in many, if not all respects, identical with the so-called polypoid hyper- trophy of the vesical mucous membrane. For all practical purposes they are essentially the same. They have been described as enlarged papillae, the vessels of which are dilated, and their walls thinned. They only differ from the polypoid hypertrophy in increase of vascularity, and the fact that they are usually limited to the trigone. Underlying and about them is a thin, wavy stroma of connective tissue, that becomes in- creased as the disease advances. 860 DISEASES OF WOMEN. The surface of these growths varies very much in different cases ; in some looking hke large granulations, in others having more body, being more compact, and looking somewhat like a I'aspberry or mul- berry. Occasionally, they are slightly pedunculated. Their surface has an epithelium resembling the superficial layer of the bladder, unless proliferation is very rapid, when the cells lose their identity, and take a multiplicity of forms, to which may be attributed, perhaps, their having sometimes been mistaken for cancer cells when found in the urine. Fatty degeneration of the most superticial cells is by no means uncommon. As the villi increase in size and number, the connective-tissue stroma, while increasing about their base, dimin- ishes in the prolongations themselves, leaving little besides a mass of tortuous, thin-walled, dilated vessels hanging free in the bladder. The rest of the mucous membrane is usually soft and hyperplastic, and, if there be any stoppage to the free outflow of urine, inflamma- tion may coexist, with incrustations, and possibly dilatation of the ureters. The muscular coat is also usually slightly hypertrophied. Fibroid tumors and myo-fibromata are very rarely found in the bladder. When they do exist they have all the characters of the flbroma or myo-fibroma found elsewhere, and give rise to the same changes in the vesical walls and ureters that other tumors do, viz., retention with hypertrophy, or dilatation, cystitis, and inflammation of the ureter. They may have their seat in any part of the bladder- wall, and occur at any period of life. Symptomatology. — The symptoms of vesical neoplasms are di- visible into local and constitutional ; the former being by far the more important. The local symptoms, if the tumors be of any size, are those produced by a foreign body in the organ, viz., irritation, and sooner or later inflammation. Obstruction to urination sometimes occurs when the tumors are in a position to block the urethra, and by the sloughing off or de- tachment of small fragments, which may or may not be incrusted. These are forced into the urethra, and obstruct the outflow of urine. Pain in one form or another is almost always present. It may consist of a simi:)le uneasiness in the hypogastric region, or amount to actual pain. It may have its seat in the hypogastric region in the perinseum, or more rarely at the end of the urethra. It may also be felt in the loins, or along the thigh and knee. It is usually more intense, as all the symptoms are, during the menstrual flow. This is not so in all cases. Frequent urination and vesical tenesmus are as a rule present. NON-INFLAMMATORY DISEASES OF THE BLADDER. 801 but are not proportionate to the size of the tumor, a very small neo- plasm often giving rise to most intense spasm. Haemorrhage is by no means infrequent, and in some cases is very severe and not readily checked ; in others it is slight, sim])ly tinging the urine or imparting to it a smoky appearance, that is characteristic of the presence of a small amount of blood or blood- coloring matter in acid urine. When the hsemorrhage is extensive, and the bladder is distended by the fluid or clotted blood, retention of urine is apt to occur, and sometimes obstructive suppression, that may lead to most serious results. Hsematuria is as liable to occur with the benign as with the ma- lignant growths, and consequently is of little value in differential diagnosis. The effects of prolonged or repeated hf^emorrhage upon the constitution are often most serious, and the patients are apt to be ansemic and also cachectic in appearance. I have had one case in which hgemorrhage was the only symptom present. The presence of the foreign body in the organ soon gives rise to inflammation, which is seriously aggravated if retention accompany it. The urine is then found loaded with mucus, muco-purulent or purulent matter, epithelial scales, tissue shreds, bits of tumor, and the triple and amorphous phosphates. Intense and repeated vesical tenesmus aggravates the inflamed condition of the membrane, and after a time leads to muscular hyper- trophy and increased hemorrhage. In these cases, as in cj^stitis from any other cause, dilatation of the ureters, with a traveling upward of the inflammation and destruc- tion of the kidney, may result. This dilatation and the evil after- results are more apt to occur if the neoplasm be of sufficient size to obstruct the free outflow of urine, as at every spasmodic and forcible contraction of the hypertrophied organ some urine is dammed back in the ureters, dilating them gradually. When the ureteric openings are dilated, so that urine regurgitates at each vesical contraction, serious lesions result, as ureteritis, pyonephrosis, renal abscess, or, if the process be slow, gradual renal atrophy, uraemia, and finally death. The general system may or may not suffer severely for a long time. In most cases it does. The usual train of symptoms, such as loss of sleep, disorder of digestion, sweating, and blood contamina- tion are developed in regular sequence. The patients become thin, and have a worn, anxious expression, and, as I have already said, are apt to be both anaemic and cachectic. If renal troubles complicate this affection, casts, renal cells, and 862 DISEASES OF WOMEN". albumen may appear in the urine. In renal abscess-atropliy, or pyo- nephrosis, however, the urine may be examined for weeks without showing any renal tissue, casts, or epithelium, there being simply an abundance of pus. Diagnosis. — The diagnosis of vesical neoplasms is made chiefly by physical signs. The methods employed in their investigation may be arranged under two heads. Direct. — Bimanual touch, speculum, endoscope, curette, catheter, palpation. Indirect. — Urine. Direct. — An intelligent employment of the methods classed under the first head is all that is necessary to make a clear diagnosis in some cases. The bimanual touch will reveal the presence of the tumor, if it is of any great size, and also its size and fixation in one place. This fixed position is of much importance as distinguishing a neoplasm from other foreign bodies, stone, for example, which is movable, and can be pushed from one side of the bladder to the other. The use of the endoscope will show at once the appearance of the tumor, if it is favorably located, and by scraping away a little with the curette (through the speculum), its nature may be discov- ered by a microscopical examination. The use of the catheter or finger in the bladder, or one in the bladder and the other in the vagina, may be resorted to in cases where the diagnosis is difficult. But these are extremely painful manipulations, are not free from danger, and, consequently, should not be resorted to unless there is failure by other means. Indirect. — An examination of the urine in these cases will lead to the suspicion of the presence of some neoplasm in the bladder, from the occurrence of tissue shreds and bits of the tumor in this fluid. A piece of tumor will sometimes become detached and be expelled with the urine, and by careful searching it may be found. This can be placed under the microscope, and thus the examiner may be able to tell exactly what kind of a growth exists. Prognosis. — With our present means for exploring and operat- ing upon the inside of the female bladder, the prognosis of benign neoplasms is very good, if the operation for removal be performed early enough in the disease. Operation, however, at any time gives promise of good result. There is danger of relapse, as we learn from the cases of Simon, Hutchinson, and others. If the operation be carefully done, even incontinence of urine may be avoided, and com])lete, and permanent recovery follow. Without operation patients have lived as long as NON-INFLAMMATORY DISEASES OF THE BLADDER. 863 nineteen years, in some cases suffering but little ; and it may be well to say that not all of these cases are accompanied by cystitis, a little pus and blood in the urine at intervals, with occasional frag- ments of tumor, being all that is found. Causation. — The causes of these neoplasms are very obscure ; in- deed, no definite facts can be adduced in favor of any of the causes given by the various authors. Some speak of them as due to the irritation of calculi, calculous fragments, and incrustations. These, however, may be readily secondary to and produced by the neoplasm, being the effect rather than the cause. Moreover, it is known that while persons carrying foreign bodies of various kinds in the blad- der for a length of time are very apt to have cystitis, neoplasms are seldom found, and are very rare under any circumstances. Some authors look — with a show of reason, I think — to the irri- tation from blood transudations into the bladder-walls as a cause. This is borne out by two well-authenticated cases occurring one in the practice of Hutchinson, of England, the other in that of Winckel, of Germany. The etiology of these neoplasms needs further care- ful study before any cause or causes can be pronounced upon with certainty. The free and intelligent use of the modern means of physical exploration in all affections of the female bladder will in a few years throw much light upon this subject. Treatment. — There is really but one form of treatment for these benign neoplasms, viz., removal. The treatment of ulcerations and small neoplasms of the urethra and bladder has been completely revolutionized within the past five or six years. The changes that have been made are, in my opinion, all for the better. I now use the galvano-cautery, instead of strong caustics that were employed in days gone by. Strong caustic injections for ulceration of the bladder and nrethra, and similar applications to new growths, were always unsatisfactory. They caused no end of suffering and often failed to relieve or cure, and, when successful in arresting disease, scar tissue followed that was troublesome — many times extremely so. The great objection to the use of caustics for the purpose of de- stroying diseased tissue is that the effect can not be controlled. If one destroys all of the diseased tissue some of the normal tissue is sure to be scorched, and if one guards against the latter he fails in the former. The advantages of the cautery in treating ulcers and neoplasms are that its action can be thoroughly controlled. Morbid growths and diseased or ulcerating tissue can be completely destroyed, while the normal tissues are left uninjured. The line of demarkation be- 8g4 DISEASES OF WOMEN. tween the charred and normal tissue can be sharply defined by the operator, and the healing process goes on rapidly and without pain. By the time the eschar separates the parts beneath have become suf- ficiently repaired to withstand the contact of urine, and so the re- currence of inflammation or ulceration is guarded against. When the cautery can be properly used the results are very gratifying. There was much trouble in getting at new growths, ulcers, and fis- sures at the neck of the bladder, especially until Kelly introduced his method ; but after that I found the cautery could be used at any point that could be brought into the field of the endoscope. In treat- ing neoplasms a fine cautery point is used, touching repeatedly the parts until all new or diseased tissue is destroyed. For ulcers a flat point is used, passing it over the diseased surface in about the same way that one would apply a solution with a pencil. Of coui-se, small neoplasms and ulcers only can be treated in this way. Since adopt- ing this plan of treatment I have been able to cure cases of cystitis with ulceration and vascular proliferations that formerly baflfled me completely. Such cases conld only be relieved by drainage through a vesico-vaginal fistula, which Emmet taught us to establish in bad cases. A full description of the apparatus I employ is given by Mr. Pignolet on page 429. The treatment of large tumors of the bladder has hitherto con- sisted in doing suprapubic cystotomy and removing the neoplasms with the scissors or curette, controlling the Imemorrhage by pressure or styptics, and then draining. Tlie results have been very unsatis- factory. Some patients did not recover, and those who did required a long time to do so. There certainly was room for improvement in this, and I have tried to do better by adopting a new way, which I desire to submit for your judgment, and that is compression and desiccation with electric heat. The process consists in seizing the tissues to be treated — the base of a vascular tumor of the bladder, for example — in a clamp or forceps, and then heating the inner side of the blade of the forceps with electricity to a degree sufficient to desiccate the tissues under pressure, thus arresting all haemorrhage and reducing the stump to the smallest ])ossible size. The after-treatment consists in washing out the organ thoroughly yet carefully with warm water to which may be added salicylic acid (1 part to 00). The pain may he controlled by opium, either by the mouth or rectum. The urine should be kept slightly alkaline, and under no circumstances allowed to remain in the bladder long enough to decompose and irritate or overdistend it. NON-INFLAMMATORY DISEASES OF THE BLADDER. 865 If the tumor is too large to admit of removal jper urethrann Si- mon's operation should be resorted to. Also in cases where the tumor is so situated as to be beyond the operator's reach through the ure- thra. I have already fully described this operation. A T-incision is made into the anterior vaginal wall, the bladder opened, inverted through the opening, and the tumor is thus brought into easy posi- tion for any operative procedure. When removed, its base may be cauterized, and the bladder replaced. When the surface has entirely healed, the wound in the vesico-vaginal septum may be closed. Union soon takes place in most of these cases, if not interfered with. The after treatment should be the same as when the tumor is removed through the urethra. I need hardly say that when the general system is below 2Dar, it should be attended to. Polypus of the Bladder. — Dr. Godson showed a polypus which he had recently removed from a woman aged sixty, who was under his care in St. Bartholomew's Hospital. He first saw her a year ago, when she complained of bleeding from the vagina. The uterus and vagina were found healthy, there had been no recurrence of the hsemorrhage until a week since when the patient again presented herself. On examination a tumor the size of a walnut was found at the orifice of the vagina. It had at first sight the aspect of a firm fibrinous clot ; it was discovered, however, to protrude from the urethra, and to be connected by a narrow pedicle with the fun- dus of the bladder, which organ it partially inverted. Dr. Godson applied a catgut ligature, and separated it with scissors. A micro- scopical examination showed it to consist of fibro-cellular tissue, with a few muscular fibers covered over with mucous membrane. Such polypi are of extreme rarity, and it was fortunate that the subject of it was a woman. — {Obstetrical Journal^ AjjpU 1879, p. 28). Excision of Papilloma of Bladder. — M. C, aged thirty-four, was admitted to the St. Mary's Hospital, under the care of Mr. Norton, suffering from the effect of long-continned haemorrhage of the bladder. On examination 2)er urethram, a tumor one inch square, coated with phosphatic calcuhis, but not much raised above the mucous membrane, was discovered occupying the trigone about half an inch from the sphincter. It was evident that the tumor must be removed, and the patient submitted to the risks attendant upon a severe operation, or she must be left to endure the tortures brought about by the contractions of the bladder upon the growth after micturition, and with the certainty of an early death from hsemor- 866 DISEASES OF WOMEN. rhage or from blood-poisoning. It was impossible to remove the growth through the urethra, and it was decided to cut the mass away by opening the vagina. It was considered that the growth could not be cleared without cutting through the urethra, and the opera- tion was performed as follows : The spring-scissors were inserted, one blade into the bladder nearly up to the tumor and the other into the vagina, and closed ; the front wall of the vagina was then incised centrally to within half an inch of the uterus, and the vaginal wall, which was found not to be incorporated with the growth was dissected from the bladder ; the growth was then seized with the vulsellum forceps, and drawn forward, and was then excised by the scissors and removed. Bleeding was averted by the actual cautery, and the lateral flaps of the vagina approximated by sutures. To prevent further haemorrhage a catheter was inserted, and the bladder compressed by plugging the vagina ; no haemorrhage of importance took place. The temperature remained below normal, and the pulse rose to 120. Severe vomiting persisted until the tenth day after the operation, when she was considered out of danger. On the twelfth day, when apparently in health, she vomited, and shortly afterward fell asleep, in which sleep she died from syncope. At the autopsy the wound was green, and sloughing upon the surface, but healthy immediately beneath. No peritonitis or cellulitis was present, or any thrombosis of vesical, pelvic, or iliac veins. A microscopical examination showed the tumor to be a papilloma. Since writing this case Mr. Norton had operated upon a second case of tumor of the bladder, which had completely recovered from the effects of the operation. — The Medical Press and Circular, May i^, 1870 ; and Medical Record, Jidy 26, 1879, pp 82 and 83. Tubercle of the Bladder. — Tubercle of the female bladder is a comparatively rare affection. Winckel, of Germany, in 2,505 autopsies, found it but four times. Though not often existing as an accompaniment of pulmonary tuberculosis, it does not occur alone, but is usually accompanied by similar deposits in the intestines, kidneys, liver, and elsewhere. It is usually found in early life, though cases have been recorded where it occurred as late as the sixty-fifth year. The favorite site for its first appearance is at the vesical neck, or about the meatus urinarius, these places being rich in minute glands and follicles. The deposits appear as minute white or yellowish white points on a red, indurated base. After a time, owing to their coalescing and breaking down, large spots of ulceration result. With these deposits in the bladder there are very apt to be simi- NON-INFLAMMATORY DISEASES OP THE BLADDER. 867 lar deposits in the kidneys and ureters, giving rise to destrnction of the former and tuberciTlar pyehtis in the latter. Symptomatology. — The symptoms are at iirst those of irrita- tion, and later of true cystitis, with ulceration, induration, and hypertrophy. Diagnosis. — The diagnosis may be made by means of the endo- scope, if there is opportunity to make early and repeated examina- tions. If by chance the deposits are located at the neck of the bladder, where they can be seen and watched going on to ulcera- tion, the diagnosis is not impossible. The history of the case and the presence of the tubercular diathesis will also aid in the final conclusions. The urine examined by the microscope is found to contain a granular matter mixed with the pus of cystitis which is sooner or later produced. In case the microscopist is fortunate iu finding the bacillus tuberculosis the diagnosis is sure. Prognosis. — The prognosis is bad, as there usually exists serious trouble of the same nature elsewhere, and as local treatment accom- plishes very little, the end comes much sooner if the kidneys and ureters are involved in the disease. Treatment. — Local treatment is out of the question, except such as may allay the irritation or inflammation to a certain extent, and prevent undue pain and spasm. This is not readily done. Daily cleansing of the viscus with warm water; opium, and belladonna suppositories, or enemata of atropine, are the best methods of treat- ment. Warmth, attention to diet, general tonics, cod-liver oil, and the various remedies used in phthisis pulmonalis should be advised. Malignant Growths. — These are not common, although occurring more often than the benign growths. They are usually secondary, and may be of different varieties, as sarcoma, scirrhus, encephaloid, epithelial, villous, and even colloid cancer. Sarcoma, scirrhus, colloid, and epithelial are very rare ; encephaloid and villous are more common. Symptomatology. — The symptoms are the same as those of the benign tumors, differing only in the greater extent and severity of the pain, and, as a rule, less haemorrhage. The condition of the gen- eral system is usually low, the patient soon becoming feeble and cachectic. Cancerous deposits in the kidney and extension of the inflammation up the ureters, may produce renal destruction and consequent uraemia. Diagnosis. — The only means of making an absolute diagnosis is. by using the endoscope, and removing a bit of the tumor with 8fi8 DISEASES OF WOMEN. the curette, and submitting it to a microscopical examination. Sarcoma and scirrhus may exist either as distinct tumors or as diffused indurations. The encephaloid variety usually grows rap- idly, and is very soft, and easily broken down. I have already said that cancer of neighboring organs may open into the bladder and produce most serious results, sooner or later involving the bladder- tissue in the destructive process. In any case, adhesion to the neighboring organs takes place, and the disease is liable to extend. Thrombosis of the veins of the vesical neck is apt to occur and lead to embolus elsewhere. Peritonitis is a frequent accomjDaniment. The favorite seat of cancer, especially of the villous form, is at the trigone. Some authors deny the existence of villous cancer, saying that it is simply a luxuriant growth of vesical papilloma, and base their opinion upon the nature of its structure and certain facts in its clinical history. " They never lead to secondary can- cerous deposits elsewhere. They do not spontaneously ulcerate. The lymphatic glands are not implicated. There is no characteristic cachexia. When they kill, death seems due purely to loss of blood and exhaustion from pain." — Va7i Bnren and Keyes^ ]}• ^^'^• Most German authors claim that this growth is malignant, and think that in drawing deductions, such as I have given above, the observers saw only cases of simple non-malignant papilloma. Causation. — Nothing is knowm about the causes of malignant disease of the bladder, except that which is known about malignant disease elsewhere, consequently, that subject need not be discussed here. Treatment. — If the disease is not too far advanced, extirpation or breaking down of the tumor may be advisable, but except in the case of epithelioma, and the so-called villous cancer, but little good is to be hoped for. When removal is not advisable, we must look to narcotics and tonics to prolong the patient's life and relieve the intense pain and tenesmus. If the tumor is generally distributed throughout the bladder, or has its origin in a neighboring organ, extirpation is out of the question. Sarcomatous Tumor of the Bladder. — Dr. L. A. Stimson, at a society meeting, exhibited a tumor of the bladder removed from a gentleman sixty-three years of age. When admitted to the Presbyterian Hos- pital in the eai'ly part of October, the patient complained of frequent and painful passage of bloody urine. His lirst attack occured in the eariy part of July, and two or three weeks after a fall from a buggy. NON-INFLAMMATORY DISEASES OF THE BLADDER. 8^)9 For the previous four years he gave a history of attacks of so-called bilious colic, which in connection with his bladder trouble gave rise to the suspicion, in the mind of Dr. Stimson, of renal colic, and the possible existence of vesical calculus. After unavailing efforts to reduce the irritability of the bladder the patient was sounded for stone with negative results. A subsequent examination was also of a negative character. The use of the searcher was followed each time by blood in the urine for two or three days consecutively. 'Exa.miusbtion per rectum revealed enlargement of the prostate, and fulness and doughiness about the bladder, which condition was sup- posed to be due to cystitis. The existence of a tumor was suspected, but the suspicion could not be confirmed, inasmuch as the condition of the patient forbade bimanual exploration. Ruling out the prob- ability of the existence of a tumor of the bladder, pyelitis was thought of as a cause for his trouble. The patient died rather suddenly without a positive diagnosis having been made. At the autopsy, and before the body was opened, bimanual palpation was performed, and the existence of a tumor was made out. On open- ing the bladder the morbid growth, which proved to be a sarcoma, three inches in diameter, was attached by a pedicle as thick as the finger to the posterior surface of the bladder, about four inches above the neck of the organ. HYPERPLASIA. Hyperplasia of the bladder may be partial or total ; may be con- fined to the muscular, mucous, or connective tissue. In using the term hyperplasia reference is usually made to an increased thickness of the muscular walls alone. There usually coexists with this con- dition (which is partly hypertrophy, partly hyperplasia) increase in thickness of the various other structui'es of the organ. This may or may not be the case, and when existing it is more hyperplasia than hypertrophy. The terms partial and total have been used to convey the idea of hypertrophy of a part or parts of the muscular tissue, and do not usually refer to the number of coats involved. The truth is, however, that one part of the muscular tissue of the organ seldom becomes hypertrophied to any extent without involving the other parts ; the increase in one part simply being greater than in another. This affection is much less frequent in the female than in the male, owing to her exemption from the more common causes of it. Any obstruction to the outflow of urine, as tumors of the urethra or bladder, partly or wholly blocking the passage; cystocele, by 8Y0 DISEASES OF WOMEN. preventing complete evacuation ; inflammatory or nervous troubles, causing unusually active muscular contraction, continuing for some time ; all these may produce muscular hyperplasia. Inflammation of the mucous membrane is almost always present ; sooner or later, that membrane becomes to a certain extent thickened, and may go as far as the production of tufty, polypoid hyperplasia. Van Buren and Keyes state that Civiale mentions hypertrophy, chiefly of the anterior vesical wall, due to chronic inflammation or tubercular in- filtration — evidently not simple hypertropliy. As the production of hypertrophy is almost always due to some obstruction to the outflow of the urine, dilatation after a time oc- curs, producing eccentric hyperplasia. When dilatation does not occur, but Inperplasia alone, the condition is produced which is known as concentric hy|)erplasia. In these cases of muscular hyper- trophy in which great force is required to expel the urine, pouches are sometimes formed, usually at the inferior fundus, caused by the pushing of the mucous membrane between the enlarged muscular fibers. These diverticula are comparatively rare in the female. A sagging or dislocation of the entire posterior inferior bladder-wall need not be discussed here, as it has been already disposed of. Symptomatology. — In concentric hyperplasia there is usually vesi- cal spasm, some pain, and forcible ejection of urine. A certain amount of cystitis almost always accompanies this affection, and surely aggravates the original disorder, by which it is itself further aggravated. In the eccentric form the symptoms are almost the same, there being sometimes superadded those of overdistention. Diagiiosis. — This is readily made by introducing the finger into the vagina and the sound into the bladder, by which means the ca- pacity of the organ can l)e measured and the thickness of its walls ascertained. It is not unusual in the concentric form for the sound to be forcibly expelled from the bladder by a sudden contraction of that organ. The capacity of the viscus can be further measured by noting the amount of urine passed at each micturition, or by inject- ing into it some bland solution, such as salt and lukewarm water. Treatment. — The treatment must be directed to the removal of the cause when that is possible. If due to stricture of the urethra or the presence of tumors, their removal is to be considered; if to cystocele, replacement, and retention in place by a proper pessary, and other measures of which I have spoken fully in a previous chapter, must be adopted. When existing in the eccentric form an abdominal belt, cold baths, cold douches to the hips, astringent injections into the blad- NON-INFLAMMATORY DISEASES OF THE BLADDER, 871 der, and electricity, should be tried, having first, where possible, removed the cause, and palHated or cured the aggravating compHca- tions. Daily catheterization, in cases of obstruction to the outflow of urine, or where, without obstruction there is liability to over- distention, is of great importance, and should be practiced. ATROPHY. So far as I know this is not a common disease. Its recognition during life being by no means easy, and but little attention being paid to the bladder in autopsies, very little knowledge of its fre- quency is had. I am inclined to believe, however, that it exists oftener than is commonly supposed. Its causes may be ranged under two heads, viz., constitutional and local. Constitutional. — In most women from fifty years of age upward a degenerative change takes place in the bladder, as in the other pelvic organs, and this is a perfectly natural process. In this con- dition the several coats are found proportionally changed, the three sometimes forming a wall not much thicker than fine writing-paper. This, however, is extreme and uncommon. The process causing atrophy is one of fatty and granular degeneration, and often at this age the epithelial cells of the bladder found in the urine are fatty and granular, as is also the case in both the vesical and vaginal epi- thelium of some women just after parturition. Walls thus thinned by the degenerative changes of age are of course much more Hable to be still further altered by various causes, such as paralysis or overdistention. Winckel attributes the cysto- cele of aged women to atrophy of the bladder walls, and the result- ing retention of urine. In soft, flabby and debilitated women, and also in men, an atro- phied condition of the bladder- walls often exists, and in ay lead to rupture. " Bonnet, Hauf, and Hunter (quoted by Pitha), give ex- amples of sudden rupture of the bladder in young persons from this cause (atrophy). Civiale gives the caution of avoiding pressure on the bladder- walls during catheterization, for fear of perforation." — Van Btiren and Keyes. Local Causes. — Extreme distention of the bladder, leading to temporary or permanent paralysis, or paralysis with resulting over- distention, may lead to fatty degeneration and atrophy, as well as inflammatory trouble. Interrupted nutrition, due to shutting off the circulation, is the usual method of causation. Nutritive changes may also be due to lack of, or to perverted, innervation caused by 872 DISEASES OF WOMEN. disease or injuries of the spinal cord. "When atrophy occurs in women under fifty years of age, who are in otherwise good heahh, and of good constitution, I beheve that it is due to habitual over- distention of the bladder from retention of urine. Treatment — Daily use of the catheter, strychnia in pretty full doses, electricity, building up of the general system, and gentle washing out of the organ with warm medicated solutions, may be tried. But little can be clone when the defeneration is due to age. Atrophy of the Bladder from the Habit of retaining the Urine for a Long Time. — The lady was thirty-three years of age, large, and well developed, except that her heart and arteries were rather small. Her uterus was also undersized. She began to menstruate at lifteen years of age, and her menses were irregular in recurrence and dura- tion, and always attended with pain. Early in life she became a school-teacher, and had followed that profession up to the time that I saw her. She fell into the habit of retaining her urine for long periods, and for several years urinated only twice in each twenty- four hours. For some time she had noticed a growing difficulty in emptying her bladder, and five months before consulting me she found that she had lost the power of urinating altogether. Her physician used the catheter regularly for a time, and then taught her to use it herself. Under this treatment, with tonics and seda- tives, she gradually regained a partial control of her bladder; but with it came an irritable condition of that organ and the urethi-a, which caused an almost constant desire to urinate. When I examined her I found slight prolapsus of the base of the bladder, and, by passing a sound into it, and a finger in the vagina, I found the posterior bladder-wall quite thin. There were also in- dications of a slight catarrh of the organ, doubtless brought on by the continued overdistention and prolonged use of the catheter. She told me that she had to make strong efforts to pass urine, and that it came away in interrupted jets. My impression of this case is, that her constant neglect of the bladder function caused overdistention, which led to atrophy and further distention. The use of the catheter permitted the organ to partially regain its muscular power, and also excited some catarrii. Passing the urine in spurts or jets was due, I presume, to the volun- tary muscular efforts. CHAPTER XLYIII. PATENCY OF GARTNER's DUCT. DISEASES OF THE URETHRA AND URETHRAL GLANDS. It is now generally conceded that Gartner's duct may remain patent after birth. This condition must be very rare, but its rarity makes it very difficult of recognition when it does occur. The fol- lowing case is illustrative of this anomaly, and is given in detail with the liope that it may be of service to some practitioner in arriv- ine at a diagnosis. "With this in mind, other cases that have been regarded as suffering from incurable " incontinence of urine " may be permanently cured. ILLUSTRATIVE CASE OF PATENCY OF GARTNEr's DUCT. The patient was nearly fifteen years of age, very large, well de- veloped, and in perfect health of body and mind, but all her life had been greatly annoyed by a constant watery discharge from the urethra. The exact amount of the discharge could not be estimated. That it was considerable may be inferred from the fact that it kept her underclothing wet all day, and saturated a protecting napkin at night. She retained her urine the normal length of time ; urinated freely and without pain or discomfort. The discharge from the urethra was not modified in quantity by the erect or recumbent position, nor by the empty or distended condition of the bladder. The most careful examination of all the pelvic organs revealed noth- ing abnormal, excepting a slight ridge or fold of mucous membrane in the vagina on the right side anteriorly. This elevation or ridge ran from the upper third of the urethra upward to the junction of the vagina and cervix uteri. Its presence attracted my attention, but did not impress me as anything of importance. The urethra was rather short, but normal 873 874 DISEASES OF WOMEN. in every way, and the urethral ducts also ; and I presumed that the muscular tissue might be defective at the neck of the blad- der, and hence there might be a slight incontinence. This, how- ever, was not sustained by the clinical history. The patient was admitted to my sanatorium, where I was able to investigate the case thoroughly. Under the observations of a skilled nurse it was determined that the discharge came from the urethra and that there was no leaking from the bladder. I then suspected that there might be an irregular implantation of one ureter. A cystoscopic examination was made, and both ureters were found in their normal position and were per- forming their function all right. Double bladder was thought of, with a communication between the one into which the ureters en- tered and the other. This idea was abandoned, because no known derangement of development could eventuate in such a malforma- tion. Being unal)le to find any cause for this discharge in any lesion of the bladder, I examined the fluid and found that it contained a very few epithelial cells and a trace of albumin, but none of the con- stituents of urine. It was not urine at all, as had been supposed. A number of endoscopic examinations of the urethra were made at different times in the hope of finding the opening into the urethra, with most discouraging results. Finally, on one occasion, after making a prolonged exploration (M'ith a fine probe used through the endoscope) of the upper part, I withdrew the instrument a very little way and observed a jet, as fine as a hair, of clear fluid. The discharge had been stopped by the pressure of the endoscope, and on the removal of the pressure the discharge came with force enough to make it visible. 1 then tried to introduce a probe into the opening, but that was impossible, owing to its small size. The opening, I observed, was at the place where the small ridge in the vagina joined or disappeared in the wall of the urethra. I at once concluded that this ridge contained a patent Gartner's duct that was the source of the discharge. Several other careful and prolonged efforts were made to probe the duct in order to confirm the diagno- sis, but without success. Though much gratified with having discovered with reasonable certainty the nature of the trouble, 1 was perplexed about the treat- ment, but finally determined to close the entrance of tlie duct into the urethra. This was accomplished by passing a ligature round that portion of the vaginal wall (close to the urethra) which was presumed to contain the duct. The ligature was tied quite tight, and, to my great satisfaction, the discharge w^as promptly and com- PATENCY OP GARTNER'S DUCT. 875 pletelj stopped. The following day the ridge in the vagina was enlarged considerably, most at the upper portion. This coniirmed the diagnosis of a patent Gartner's duct. I then divided the ridge or fold of the vagina just above the ligature, and about c drachm or two of clear fluid escaped. I then cut away the whole of the ridge of the vagina. In the portion thus removed I found the duct, which was very small at the lower part, but large enough at the upper part to admit a pocket-case probe. There was some bleeding, which was arrested with a tampon. The vaginal wound healed readily, leaving the end of the duct open through which the probe could be passed up to the parovarium. A clear discharge, in diminished quantity, continued. Tincture of iodine with five per cent of carbolic acid was injected into the duct. After this there was pain and some rise of temperature, which sub- sided in about thirty-six hours. Several days after this there was a slightly colored discharge, very small in quantity, which subsided completely, and there was an end to the trouble. Apparently the portion of the duct left became obliterated. All examinations were made and the treatment employed without ansesthesia, which shows that my patient possessed remarkable self-control and was quite heroic. This is the first case of patency of Gartner's duct opening into the urethra that I have ever seen ; neither have I found any such case recorded in the literature on the subject. It must be of special interest to the profession on account of its being unique, the difficul- ties of diagnosis, and the special treatment required, which proved successful. The subject is of personal interest because it confirms the opinion that I have always held, that Gartner's ducts are quite distinct from the ducts of the urethral glands, which I described years ago. This whole subject has been treated in an original and masterly way by Amand Eouth, M. D., B. S., M. E. C. P., in vol. xxxvi of the " Transactions of the Obstetrical Society of London." In this valuable contribution, entitled " On Cases of Associated Parovarian and Vaginal Cysts formed from a Distended Gartner's Duct," he gives the history of cases occurring in his own practice and that of others. He also relates two cases in which the persistent Gartner's duct opened into the vagina. One is by Mr. Milton, of Cairo, Egypt, and the other by Lawson Tait. The following gives Dr. Routh's views on this question : " Details of three cases of the above are given, and also of two analogous cases of patency of the whole length of the duct, with an 876 DISEASES OF WOMEN. anterior opening allowing free discharge, and thus preventing dis- tention of the duct along its course. " Comparison is drawn between such cases and those of distended but imperforate Miiller's ducts. " Evidence adduced from these cases is thought to establish, or at least to render plausible, the following propositions : " 1. That Giirtner's duct can be traced in some cases in the adult female from the parovarium to the vestibulum vulvae, ending just beneath and slightly to one side of the urethral orifice. " 2. Homology tends to show that Max Schiiller's glands are diverticula of Gartner's ducts, just as the vesiculee seminales are diverticula of the vasa deferentia. Some evidence is given that Skene's ducts are not necessarily identical with the anterior termi- nation of Gartner's ducts (as most of those who have traced Gart- ner's duct to the vestibule have thought), but that Skene's ducts lead directly and solely from Max Schiiller's urethral glands, Gartner's ducts being continued to the vestibule, behind but parallel to Skene's ducts. " 3. That Gartner's duct, if patent, may become distended at any part of its course, constituting a variety of parovarian cyst if the distention be in the broad-ligament portion, and a vagi- nal cyst if the distention be in the vaginal portion. The cases described are instances of the association of both of these cysts, owing to simultaneous patency and distention of both portions of the duct. " 4. Attention is drawn to these cases as affording explanations of some obscure cases of profuse watery discharge from the vagina, not coming from the uterus or bladder. " 5. The question of treatment is also approached, and the opin- ion is expressed that where the whole duct is distended the vaginal part of the cyst may be laid open as far as the base of the broad ligament, and the broad-ligament portion encouraged to contract and close up. " A very valuable work on ' The Duct of Giirtner,' by Bland Sut- ton, was published in 1886, giving his results of examinations of seventy cows ; and Mr. Alban Doran, in his review of this work, points out that as Gartner's ducts are generally admitted to be the homologues of the vasa deferentia, and as the vesiculge seminales are diverticula of the vasa, close to their termination on the floor of the prostatic urethra, it follows that the ]\Iax Schiiller's glands of the female urethra are the homologues of the vesiculge seminales, and he believes with Bland Sutton in thinking that in woman, as in Bos, DISEASES OF THE URETHRA AND URETHRAL GLANDS. 877 Skene's tubes represent the anterior termination of Gartner's ducts. This latter conchision is not, I think, correct. "When this view was expressed in 1886, no cases liad been pub- Hshed of a persistent Gartner's duct opening at tlie base of the ves- tibule ; but the cases now given, and other cases of cysts formed out of the vaginal portion of Gartner's ducts, show that the opening of Skene's ducts and the opening of Gartner's ducts are not neces- sarily identical in situation." I am glad to add this case in further evidence of the ground taken in my first studies in this department. DISEASES OF THE URETHRA AND URETHRAL GLANDS, The diseases which affect the urethra and its glands may be divided into two classes : I. Functional diseases. II. Organic diseases. I. FUNCTIONAL DISEASES OF THE URETHRA. I know of but one form of affection which properly comes under this head, and that is commonly denominated neuralgia. A case will be occasionally met in which there are pain and tenderness of the urethra, with frequent desire to urinate, and pain in doing so. In short, there is a history of subacute urethritis ; but, upon the most careful examination that can be made, with all the means at one's command, there will be failure to find any lesions to account for the symptoms present. To this condition the name neuralgia has been applied, rather improperly, no doubt. From my own observation of this affection, in which there are well-marked symptoms, with no apparent anatomical lesions, I have been led to the conclusion that it is a disease of the nerves of the part — one of the neuroses, as they are called. It is quite possible, however, that progress in the diag- nosis of urethral diseases may yet enable diagnosticians to find lesions other than of the nerves to account for the sym]5toms presented by the disease in question. But for the present it must be classed among the neuroses. So far as I know, it is an affection peculiar to young women. I have only seen it among young married women of marked nervous temperament, and who have not borne children. In some of the cases observed, it was associated with an irritable condition of the introitus vulvse. 878 DISEASES OF WOMEN. The symptoms are such as occur in a great variety of pathologi- cal conditions, and are, therefore, of little value in guiding to a cor- rect idea of the real trouble ; and, as there are no diagnostic physical signs present, the diagnosis must be made by exclusion. The most thorough examination of the urine should be made, and the urethra and neighboring organs should be carefully investigated. Perhaps the greatest liability to error lies in mistaking this condition for reflex irritation of the urethra and bladder, arising from ovarian, uterine, or rectal disease. Careful inquiry into the condition of those organs should therefore be made before concluding that the disease is of the urethra itself. The affection is fortunately rare as well as obscure. I will, there- fore, relate the history of some cases, which will give the facts as they were obseiwed chnically. ILLUSTRATIVE CASES. One case was that of a lady of a highly nervous temperament, whose parents died of tuberculosis. She was twenty-six years of age, and had been married three years. From the time of her marriage she began to suffer from painful menstruation and uterine Jeucor- rhoea. She attributed her trouble to getting cold while driving in an open carriage behind a fast horse. She had an anteflexion of the uterus and cervical endometritis. The right ovary was large, tender, and prolapsed. Before, during, and after her menses she had smart- ing and burning pain in the urethra, with a feeling of spasmodic contraction, which sometimes rendered urination difficult and pain- ful. In the interval between the menstrual periods she had tender- ness of the urethra and discomfort in passing urine. The urethra was repeatedly examined throughout its whole extent with the endoscope, but no disease could be found, only tenderness and spasmodic action. She derived relief from suppositories of morphine and bella- donna, but, when last seen, she still had attacks of the same trouble. It was supposed, at first, that the urethral trouble was due to the disease of the uterus, but the former persisted after the latter was relieved. Another case was that of a lady, aged twenty-nine, who had been married for seven years, but had never been pregnant. She was of a highly nervous temperament, but her general health had always been good. She began to menstruate at fourteen years of age, and con- tinued to do so regularly, but scantily. For several years she had suffered from backache and slight uterine leucorrhoea, and coitus had ORGANIC DISEASES OF THE URETHRA. 8Y9 always been painful. Slie had frequent and painful urination. The ntenis was small — in fact, all the reproductive organs were under- sized. There was marked tenderness of the introitus vulvae. The remains of the hymen were very tender, and at the meatus urinarius and on the vestibule there were a number of quite small papillomata (of the same color as the mucous membrane) that were also exceed- ingly tender. These were destroyed by an application of equal parts of carbolic acid and tincture of iodine, and the leucorrhcea was ar- rested by the usual treatment. This relieved her of aii the symptoms except those of the urinary organs. Her urine was examined repeat- edly, and was found to be normal. The urethra was also investi- gated, but nothing wrong was found there except that the papillae appeared to be unusually prominent. I learned that if she retained the urine for an hour or two the desire to urinate passed off, and did not return until the bladder was fully distended. When she did urinate, the desire to empty the bladder continued — i. e., she had vesical tenesmus — but, if she indulged this feeling by passing the urine repeatedly, this tenesmus continued ; while, if she resisted the desire, it gradually subsided. This proved conclusively that the cause of the frequent urination was the condition of the urethra. Quite a variety of agents, which I need not give in detail here, were tried in this case. Suffice it to say that she only derived bene- fit from coating the entire mucous membrane of the urethra with dry subnitrate of bismuth once a day for a week, and then applving equal parts of tincture of aconite and aqueous extract of opium twice a week for a time. The bismuth was made into an emulsion with water and a little acacia, and applied with the pipette. A steel sound was also passed once a week, and allowed to remain in place for about five minutes. This gave pain at the time, but relief fol- lowed. During the local treatment she took nourishing food, iron, and arsenic. She may be said to have recovered ; but overtaxation, mental or physical, would bring back the trouble in a slight degree for a short time. II. ORGANIC DISEASES OF THE URETHRA. This class may be subdivided into ten groups. 1. Inflammation or urethritis. 2. Granular erosion. 3. Vesico-urethral fissure. 4. Neoplasms. 5. Dilatation. 880 DISEASES OF WOMEN. 6. Dislocation. T. Prolapsus. 8. Stricture. 9. Foreign bodies. 10. Fistula. 1. Inflammation of the Urethra, or Urethritis. — This is of three varieties [a) acute, (J) chronic, and {c) gonorrhoeal. Acute urethritis, though not a very frequent disease among women, is a very distressing one, and often difficult to relieve. In many cases it will be found to depend upon a speciiic cause, that is, gonorrhoea ; and I would treat this subject as gonorrhoea in women, were it not that it is often difficult to tell a specific or venereal ure- thritis from simple inflammation of that portion of mucous mem- brane. There is a difference in tlie history when correct testimony is obtained from the patient. Simple urethritis usually comes on gradually, and is often preceded by symptoms of uterine or vesical disease ; while the gonorrhceal variety comes on rather abruptly, and is preceded or attended by acute vaginitis and vulvitis. The chief symptom in both varieties is painful urination. Sharp scalding is l^roduced by the urine passing over the tender surface. There is often a frequent desire to urinate, but not so urgent as in cystitis. In some cases the urine is retained for a long time, evidently from a dread of the pain caused in passing it. In quite a number of cases I have noticed haemorrhage. That the blood comes from the urethra is known by the fact that it is not intimately mixed with the urine ; and after micturition it will ooze from the meatus uri nanus. An examination of the parts will show signs of inflammation about the meatus, with or without the same condition of the vulva. Occasionally, there is a discharge seen coming from the urethra, but if the ])arts have been recently bathed this may not be apjiarent. Introducing the finger into the vagina, and pressing upon the urethra from above downward, the discharge can be started, unless the pa- tient has passed water immediately before. The appearance of the discharge corresponds to that of gonorrhoea in its various stages. An examination of the discharge with the microscope may reveal the presence of the gonococcus, and, if so, that will determine the nature of the urethritis. The absence of that germ is not positive proof that the inflammation is not gonorrhoeal, unless frequent and skilled examinations fail to find it. Cystitis, wliich is liable to be confounded with urethritis, may be excluded by using the catheter, and after letting urine flow for a ORGANIC DISEASES OF THE URETHRA. 881 time, collecting the remainder for examination. The raucous mem- brane, as seen through the endoscope, is of a deep red, with pus or mucus lodged in its folds. The instrument can not be used in all cases, owing to the acute tenderness of the parts. Bleeding is very likely to occur at the examination, simply from the contact of the endoscope. The treatment of acute urethritis, whether specific or not, may be conducted on the same principles as that of gonorrhoea in the male, using the same constitutional remedies, local baths, etc. This will suffice in most cases of acute disease ; but when it assumes the sub- acute form from the beginning, then the use of injections becomes necessary. Dr. Avery Segur, of Brooklyn, finds that the discharge of gonor- rhoea is markedly lessened, and sometimes cured, by ten-grain doses of salicylic acid, given in solution several times a day. I have seen much benefit derived from douching the urethra with water as hot as the patient could bear it. For this purpose I use a catheter made like the fluted roller of a crimping-machine, the appearance of which is doubtless familiar, Fig. 271. Inside the cath- Fig. 271. — Skene's reflux catheter. eter there is a small supply-tube, which conveys the water to the rounded point of the instrument. Behind the point of the catheter, where the grooves terminate, there is a perforation in each groove through which the water returns. By this arrangement the water as it flows back through the grooves is brought in contact with every portion of the mucous membrane. The instrument is passed up to the neck of the bladder, and a fountain -syringe attached to it, and the water as it flows away is caught in a cup. The injection of solutions of nitrate of silver, sulphate of zinc, and the like, will often prove useful. It must be home in mind that the female urethra will not hold more than ten or fifteen drops, and if more is used it will enter the bladder, even where but very slight force is employed while injecting. I use a large pipette, placing the nozzle over (not in) the meatus, and inject slowly and without force a small quantity. When the case is of long standing, and the neck of the bladder appears to be involved also, I use a mild injec- tion of one or two grains of nitrate of silver to the ounce, and inject 57 882 DISEASES OF WOMEN. it through the uretlira with force enough to enter the bladder, and let it remain there, to be passed off when the patient urinates. In acute urethritis the most efficient treatment that I have found is to wash out the uretlira with the reflux catheter two or three times a day, and then introduce a suppository of iodoform in cocoa-butter, or bismuth and cocoa-butter. In old cases, which began by a severe acute attack, and where the walls of the urethra are very much thickened and the canal contracted, dilatation with bougies does much good. While the bougie is passed once or twice a week, I apply to the vaginal portion of the uretlira oleate of mercury or the unguentum hydrargyri. This will often suffice to stop the gleety dis- charge, as well as remove the thickening of the urethral walls. The case reported by Dr. Howard, which will be found at the close of the consideration of the diseases affecting the urethral glands, would seem to indicate that a gonorrhoeal urethritis in which these glands are involved may continue indefinitely unless appropriate treatment is directed to them. Treatment of Chronic Urethritis and Spasm of the Bladder. — Dur- ing the past ten years Weiser has adopted a new method of treat- ment in chronic gonorrhoea, and out of twenty-five cases he has suc- ceeded in curing all but one. The latter was afterward advised to consult Dr. Greenfeld, who, by means of the endoscope, discovered granulations in the uretbra, which being cauterized, the man got well after several weeks' treatment. Weiser first passes an elastic or metallic catheter into the bladder, and, after thoroughly evacuating the viscus, injects into it by means of a clysopompe, or, preferably, an irrigator, a solution of sulphate of zinc, 2 to 3, and tannin, 0*5 in 500 of water, at a temperature of 26° E. The catheter is then withdrawn, and the patient directed to empty his bladder, thus bring- ing the medicated solution in thorough contact with the whole of the urethra. This method is effectual in all cases when no granulations exist. The latter require the application of caustics. The author has, however, omitted to state how long the treat- ment must be continued. In cases with associated cystitis three to f(jur drops of nitrite of amyl should be added to the above solution, the former being a very active disinfectant — one or two drops added to a bottle of urine serving to prevent the development of anmionia in the latter for a couple of years. When strictures are present they should be treated with metallic sounds. For the relief of cysto- spasms, the above-mentioned solution may also be employed ; one or two injections a day, continued for an average period of three months, usually suffice to entirely cure this condition. Frictions ORGANIC DISEASES OF THE URETHRA. 883 with cold water and lukewarm (2C° R.) sitz-baths may be employed as adjuvants. — " Mittheilungen des Wiener Med., Doatoren-CoUeyi- ums, June 23, 1881 ; New York Medical Reoord, October 1, 1881, p. 375. A Case of Chronic Urethritis treated by Emmet's Button-Hole Operation. (By Yirgil O. Hardon, M. D., Atlanta, Ga.) — E. J., white, widow, aged sixty-one, was married at thirteen, and has borne nine- teen children. All her labors were normal, as far as she knows, and her health had always been good until twelve years ago. . She then began to suffer from frequent desire for micturition, and the act was always accompanied by burning pains. These symptoms gradually increased in severity, until at the present time she is obliged to uri- nate at intervals of from iifteen to thirty minutes throughout the day and night. The passage of urine produces an intense pain in the urethra, especially at the meatus, radiating upward into the abdomen and downward into the thighs. This pain persists for some time after micturition, so that she is hardly ever free from it. In other respects her health is good, but her naturally robust constitution is breaking down under the constant pain and annoyance to which she is subjected. She is entirely unfitted for social or domestic duties, and nearly her whole time and attention are given to keeping her bladder empty. Examination shows the meatus contracted so as to scarcely admit a No. 6 sound, and surrounded by cicatricial tissue, forming bands by which it is much distorted. Extreme tenderness exists along the urethra and in the neck of the bladder. The passage of a sound gives exquisite pain. The urethro-vaginal septum is of abnormal thickness and density. Otherwise the pelvic organs are found to be normal. The urine, of which about an ounce is passed at a time, is straw- colored and slightly turbid. Upon standing there is formed a de- posit of about one fourth its bulk ; specific gravity, 1028. Chem- ical and microscopical examination shows it to be free from albu- men, sugar, pus, and mucus. The deposit is made up of amorphous urates. The patient has been treated by internal medication by compe- tent practitioners, but without receiving any apparent benefit. January 23, 1886, with the assistance of Drs. Bizzell and Wile, she was etherized, and Emmet's button-hole opei-ation was per- formed. An incision was made through the urethro-vaginal sep- tum, commencing a quarter of an inch behind the meatus and ex- tending so a quarter of an inch from the neck of the bladder. 884 DISEASES OF WOMEN. Through this opening the cut edge of the urethral mucous mem- brane was drawn, and stitched on all sides to the cut edge of the vaginal mucous membrane with carbolized silk sutures. Thus no surface was left uncovered to heal by granulation. The urethral mucous membrane was found to be so intensely congested as to pre- sent a deep purple color, and capillary oozing of blood from it was very free. The parts were smeared with vaseline, and the patient was afterward instructed to make the same application before each micturition. The wound healed satisfactorily, and the sutures were removed on the eighth day, leaving a permanent urethro-vaginal fistula. In the twenty-four hours following the operation the patient urinated five times, with only slight pain. After the second day she was entirely free from pain, and has continued so ever since. She urinates sometimes twice, usually only once, and occasionally not at all during the night, and from four to six times during the day. She frequently holds her urine for six hours without any dis- comfort. The urine passes entirely through the artificial opening. The pain at the meatus and the tenderness along the uretlu-a have ceased, and the congestion of the urethral mucous membrane is now very slight. — Atlanta Medical and Surgical Journal. 2. Granular Erosion. — This very troublesome affection of the urethra may result from urethritis, or may appear without any pre- vious disease. The mucous membrane is covered with young, im- perfectly developed epithelium ; the papillae are hypertrophied and extremely sensitive. This gives rise to the most excruciating pain during micturition, and generally keeps up a distressing tenesmus. This disease is, fortunately, not very common. Old people are most liable to suffer from it. The diagnosis is made from the history and appearance of the urethra. The treatment which is most reliable is cauterization of the whole surface. The milder washes and injec- tions do not accomplish much. Pure carbolic acid may be tried first, brushing it over the surface, and repeating it in eight or ten days. This is the least painful application, and answers in some cases. "When it fails, a solution of nitrate of silver (one drachm to the ounce) should be used. In some cases it is desirable before using strong caustics to dilate the urethra, and then touch it with carbolic acid in a mild solution, say two per cent. Among the inflammatory affections of the female urethra are mild forms of congestion and irritation, that fall short of well- marked urethritis. Indeed, some of these attacks amount to little more than congestion or slight catarrh. In others, I h ve found ORGANIC DISEASES OF THE URETHRA. 885 circumscribed patches of the urethra inflamed, and tlie rest of the canal normal. There is little, if anything, in medical works on the subject of these mild yet troublesome affections, and I hope that a clear idea of the subject will be gained from the narration of some cases which have come under my observation. ILLUSTEATIVE CASES. A young, married lady had been under my care for dysmenor- rhoea caused by anteflexion. She had recovered sufiiciently to be- lieve that she was well enough to go to a party and dance to excess, which she did, and caught cold on the way home. On the second day after I was called to see her, and found her with the usual symptoms of an ordinary cold, that caused her little anxiety. But she was suffering severely from frequent and painful micturition. I found slight general congestion of the uterus and vagina, and sus- pected cystitis, but the urine was normal. I then examined the urethra, and found it congested throughout, and with streaks of mucus lodged in the folds of the membrane. There was neither erosion nor ulceration. I directed her to rest quietly in bed, and drink freely of flaxseed- tea and spiritus setheris nitrosi. A suppository containing one quarter of a grain of extract of belladonna and a sixth of a grain of sulphate of morphia was directed to be introduced into the vagina at bed-time. Under this simple treatment she rapidly improved. Twelve days after the date of my visit she called to see me, and I then found that she could retain her urine for hours, but still had slight pain and burning during micturition. The urethra was again examined with the endoscope, and a few red patches found scat- tered here and there along the canal. This was all that remained of the trouble. Liquor bismuthi, sufficient in amount to fill the urethra, was injected every second day for a week, when she de- clared herself quite well. A second case was that of a young lady, healthy and active, who was head saleswoman in a department of a large dry -goods estab- lishment. During the holidays, from Christmas to New Year's, she was on her feet from eight in the morning until ten or eleven at night. On the last day of the year she was seized with pain and burning in the urethra, and soon after she began to suffer from fre- quent and painful micturition. Three or four days after the attack I examined the urethra, and found several small ecchymoses at various parts of the mucous mem- 886 DISEASES OF WOMEN. brane, the highest one being near the neck of the bladder. These spots were due to haemorrhages that bad taken place into the mucous membrane, beneath the epithelial layer. The spots were dark, al- most black in the center, and surrounded by an inflamed border, which was bright red at the inner margin, but gradually shaded ofl: into the natural color of the surrounding mueous membrane. My idea of the pathology of this case is that the congestion aris- ing from the maintenance of the erect position for so long a time caused some of the small vessels to rupture, and the haemorrhage into the membrane produced little circumscribed spots of inflam- mation. She was directed to rest in the recumbent position, and drink freely of Yichy water. This she did, and made a good recovery ; but it was six or eight days before the pain in urinating left her entirely. It will be observed that these cases were both acute, and recov- ered very promptly ; and I could give several more histories which might lead to the supposition that such trivial ailments of the ure- thra are not of much importance after all. It might also be pre- sumed that this form of urethral disease would disappear in most cases without being treated. This is no doubt true, but they do not all recover spontaneously. Some of these mild cases tend to continue. They become chronic, and if neglected will continue for years, to the great annoyance of the subject. Of the chronic or continuous fonn of urethritis the following are good examples : A single woman, thirty years of age, had for ten years been occupied as dressmaker, and was in the habit of operating a sewing-machine occasionally. Her general health had always been excellent, but she consulted me for what she supposed to be an affection of the kid- neys. She said that for five years she had been annoyed with pain- ful and frequent micturition. She was obliged to urinate every two or three hours during the day, and several times in the night. Standing, walking, or exposure to cold invariably made her worse. An examination of her pelvic organs revealed slight catarrh of the cervix uteri, and a mild vaginitis, limited to the upper and pos- terior portion of the vagina, most marked behind the cervix. Her urine was examined carefully and found to be normal. The urethra was then examined by the endoscope, which brought to view a highly inflamed spot on the anterior wall of the urethra, and an in- flamed ulcer on the posterior wall. Tlie disease was limited to the middle third of the urethra, and, while extending all around, was most marked anteriorly and posteriorly. The ulcer, which lay in ORGANIC DISEASES OF THE URETHRA. 887 the posterior wall or floor of the urethra, was superficial and appeared through the endoscope as a gray spot surrounded by a bright red areola. It bled on contact with or stretching by the instrument. The color of the nj^por and lower third of the urethra was somewhat darker than usual, but otherwise normal. The recovery in this case was somewhat tedious, because it was one of my first cases, and my treatment was experimental and not always beneficial. First, I touched the inflamed parts with a solu- tion of nitrate of silver (one drachm to the ounce), using just enough to whiren the surface. This gave her rather sharp pain, which passed off, however, in a few hours. After this she had much pain in passing water, but the frequency was about the same as before the application. About ten days after using the solution the parts, though still inflamed, were much improved. This advantage gained suggested a repetition of the application, which I made. It was followed by very severe pain, that lasted two days and nights before it subsided. There was no improvement. After this I injected into the urethra, twice a week, a solution con- sisting of ^ Zinci sulphatis gr. iv. Fl. ext. hydrastis Canadensis § j. AquEe § iij. M. About half a drachm of this was used at a time. This was con- tinued for about a month with marked benefit. At the end of that time she could rest all night without urinating, and had to micturate only about every four hours during the day, and had very little pain. Injection of liquor bismuthi (half a drachm) was then begun, and continued twice a week for three weeks, when she was free from all trouble, but was obliged to urinate every four or six hours, from habit, I suppose. One other case may be given to show the disposition of this form of urethral trouble to continue. This patient was thirty-nine years of age, and had been a widow for sixteen years. Her only child was a growu-up woman. Four years before I saw her she had a catarrh of the bladder, for which she was treated by a skilled physician. She recovered from that after a time, the urine becoming normal, and the abiUty to retain it excellent. She continued, however, to have pain in passing urine, but as there was no discomfort at any other time she was satisfied to tolerate that. Being troubled ^vith constipation while traveling, she was taken with agonizing pain after defecation, continuing to suffer ^^'ith it for several months. She then applied to me for relief. She stated that 888 DISEASES OF WOMEN. the pain during micturition had been much worse since the develop- ment of the rectal pain. The rectum was examined with the endo- scope (the same instrument used in exploring the bladder and urethra, but of larger size), and a well-delined tissure detected. This explained the rectal symptoms, and it is fair to suppose that the urethral trouble was aggravated by it sj-mpathetically. The lower third of the urethra was found to be inflamed, and in places eroded. The anal fissure was relieved by the usual operation, and the urethra was treated with applications of nitrate of silver (one grain to the ounce). Recovery was speedy and satisfactory. 3. Vesico-Urethral Fissure. — This affection holds an intermediate position between cystitis and urethritis, and in its symptomatology bears a marked resemblance to both, and I have therefore deferred its consideration until both these diseases have been treated, 1 am fully satisfied that it is often mistaken for infiammation of the blad- der or urethra. It is only within the last few years that this trouble has been brought to the notice of the profession, and hence there is very little in medical literature on the subject. This affection has heretofore been called fissure of the neck of the bladder. Were I to name it according to its location, I should say vesico-urethral fissure, for its usual site is at the point of junction of the two. The lesion, as the name indicates, is a crack or fissure of the mucous membrane, produced by ulceration. It runs lengthwise of the urethra, and is situated in one of the sulci or folds of the mem- brane formed by the corrugations which always exist when the urethra is not distended. It is usually spoken of as situated in the vesical neck, but as a rule two thirds of it is situated in the urethra, the upper end of it only extending into the bladder. It may occur at any part of the circumference of the urethra. In the majority of the cases that I have examined it has been situ- ated on the right side anteriorly. Those who are familiar with fis- sure of the rectum will understand that fissure of the vesical, neck is exactly the same in appearance, save that it is much smaller. It is from a quarter to three eighths of an inch in length, and from one twelfth to one sixth of an inch in width at the center, but tapering off at each end. The deepest part has a yellowish gray color, like that of an in- dolent ulcer, while the edges are red and actually inflamed, like those of an irritable ulcer. When seen through a large endoscope that puts the parts upon the stretch, it may appear freshly torn and bleeding. The edges are usually abrupt, elevated, and indurated, ORGANIC DISEASES OP THE URETHRA. 889 and of a dark or bright red color. This shades off gradually into the normal membrane of the urethra. The importance of this lesion depends upon its site. An ulcer or fissure of the same size, if situated in any other portion of the urethra, would cause little suffering beyond a smarting sensation during micturition. But occurring at the union of the bladder and urethra it is submitted to constant though slight pressure, which causes severe and continuous pain. I believe tliat the very great suffering caused by this disease is due largely to the fact that these parts of the bladder and urethra are by far the most sensitive, and that the upper portion of the fissure, which extends into the bladder, is exposed to the irritation of the urine, which excites the constant desire to urinate. The pain which is thus produced causes exces- sive contraction of the urethra and bladder, and this contraction again causes pain, " the vicious circle," as it is termed, being thus established. In other words, the cause produces an effect, which in turn, acts as a cause and aggravates the original disorder. Syiwptoinatology . — The symptoms of fissure are a constant desire to urinate, and a feeling of burning pain at the neck of the bladder. There is acute pain both during and immediately after the act of micturition, and severe tenesmus, which causes the patient to make voluntary straining efforts at evacuation after the bladder is empty. Immediately after urination the p)ain and burning are often intense. After a time it partially subsides, but again commences when a lit- tle urine collects in the bladder. When the patients resist the desire to urinate (as they often do at night when unwilling to get up) the distress is much aggravated. It will be seen that all the symptoms mentioned are much the same as those presented in cystitis, and on that account are not reliable guides in diagnosis. Urethritis also gives rise to many of the symp- toms named above, and might be mistaken for urethro-vesical fissure. There are, however, some points of difference between the symptoms of these three affections that are deserving of notice. In fissure the pain is, as a rule, more circumscribed than in either cystitis or ure- thritis, and in many cases more acute. Urination in fissure is always followed by the maximum of pain, while in cystitis there is a slight sense of relief. In urethritis the greatest pain is experi- enced during the act of urination ; it then subsides gradually, and is usually absent before the next evacuation of the bladder. Diagnosis. — The question of diagnosis will usually rest between fissure, urethritis, and cystitis. The latter can be easily and posi- tively excluded by an examination of the urine. Passing a catheter 890 DISEASES OF WOMEN. into the bladder and allowing a little urine to flow through it will wash away any pus or mucus that may have been caught up in its introduction. The remaining urine should be saved for examina- tion, when if Assure alone exist, it will be found free from all the products of cystitis. The exclusion of urethritis and the detection of fissure are ac- complished by the endoscope, and by the use of this instrument a correct diagnosis can easily be made. I have already described the method of using my endoscope, but there are a few points in the examination for fissure to which I have yet to call attention. In the first place, the neck of the bladder must be found exactly, and to accomplish this the instrument must be used when there is at least a small quantity of urine in the organ. Then the tube is to be introduced far enough to be sure that it enters the bladder. Next the mirror is to be passed in, and, when it enters that part of the tube surrounded by urine, it will be seen that it becomes black, i. e., the wall of the urethra (which was reflected as the mirror was passed in) disappears, and nothing can be seen. By slowly withdrawing the mirror the upper end of the urethra will come into view, and by moving it backward and forward and turning it round, the whole circumference of the vesico-urethral juncture can be clearly seen, and the fissure distinctly observed. The service rendered me by this instrument in studying this affection has been very great. Indeed, I was never able to detect a vesico-urethral fissure until I used this endoscope to look for it. I have tried repeatedly to find a fissure with the ordinary open-tube endoscope, and have invariably failed, and for these reasons : Fissure lies in a longitudinal sulcus of the mucous membrane, and is hidden from view at the upper or open end of the tube. It can only be brought to light by distending the urethra at the point to be ob- served, and that can not be done with the instrument in question. Again, when the open tube is carried up to the neck of the bladder, where the fissure is situated, the urine flows into the tube and puts a stop to observations. The description of the appearance of fissure already given was taken from my own observation with the endoscope, and, therefore, need not be repeated here. Cmisation. — The cause or causes of fissure here are not well understood. At least, I have not been able to find anything in the books that is clear and definite on the subject. From a careful study of the cases which have come under my own observation, I am satisfied that fissure (or irritable ulcer) ia ORGANIC DISEASES OF THE URETHRA. ciQl developed from urethritis, I will suppose that a woman gets urethritis, from any cause, and that it extends to the neck of the bladder, and dips down into the folds of the mucous membrane. It is easy to understand that the pressing together of the two inflamed surfaces of the membrane in these folds will increase the irritation and keep up the disease. Urine, mucus, pus, and exfoliated epithe- lium are liable to lodge in this location, and add very much to the irritation. All this leads to ulceration, and when this is established it remains, with no tendency to recover. Even if the parts were inclined to heal, the irritation of the urine and inflammatory prod- ucts, as well as the contraction of the inflamed stu^faces upon each other, would prevent, or at least hinder, recovery. It can be seen that an urethritis might end promptly in recovery (either by the natural tendency of mucous inflammation to return to health, or under the influence of treatment), except at the point of fissure, where the conditions named tend to produce ulceration, and when once developed, to keep it up. Injuries during confinement, displacements of the bladder, indeed, injuries of any kind that are sufiicient to cause inflammation at the vesico-urethral juncture, doubtless tend to the establishment of fissure. Bungling or careless use of the catheter, or injections into the bladder or urethra, might have the same evil effects. I suspect, but am not quite sure, that very small calculi passing along the urethra may be a cause of this trouble. This supposition is based on a case which occurred in my practice. Its history is this. The lady had a vesico-vaginal fistula, and after it was closed she had catarrh of the bladder. During the course of that disease she was taken with hgemorrhage, which lasted some days. She then had violent pain in urinating, and passed several lumps which were composed of mucus and some of the salts of the urine. These pieces were rough, gritty masses, which no doubt scratched the urethra as they passed out. Soon after this she was found to have a fissure that tormented her to an extent beyond description. Dilatation of the urethra and topical apphcations relieved her. Treatment. — The subject of the management of vesico-urethral fissure is one of interest and importance, as much so as anything in surgery. On the one hand there is the terrible suffering of the patient, and on the other there are many difficulties to be encoun- tered in the efforts to relieve her. The demand for treatment is urgent, and skill in the highest degree is necessary to accomplish a cure. 892 DISEASES OF WOMEN. I must first say wliat ouglit not to be done in tliese cases, and thereby guard against making them worse instead of better, as it has been my misfortune to do on more than one occasion. As a rule, all injections and instillations such as I have recommended in cys- titis, and shall advise in urethritis, do harm in fissure. I have used injections of mild solutions of nitrate of silver, and the application of stronger solutions to the diseased part, with the invariable result of increasing the spasmodic contraction of the bladder and aggrava- ting the suffering of my patients. While such applications are useful in inflammation of the bladder and urethra they do harm in fissure. This I have repeatedly proved to my own satisfaction, and the facts accord with our experience in other departments of practice. Nitrate of silver and nitric acid have been applied to ulcerations of the rectum with marked benefit, and without being followed by pain of any account ; but the same appli- cation made to fissure within the grasp of the sphincter ani does little if any good, and usually increases the suffering of the patient. The same is true of the fissure under discussion. When a diagnosis of vesico-urethral fissure has been made, the usual local treatment is not to be employed, at least active measures in the way of powerful applications are to be avoided. Soothing applications, alterative in their action, are worthy of trial. Exposing the fissure with the fenestrated speculum, and dusting it over with calomel or finely pulverized iodoform, some- times give relief. Subnitrate of bismuth may be used in the same way in the hope of doing good. There is one great point to be remembered in using these remedies, and that is, that if they fail to accomplish the desired end, they do no harm. I have used with benefit the "mitigated" stick of nitrate of silver. It consists of one part of nitrate of silver to two or three parts of the nitrate of potash. Drawing a fine point of this through the fissure causes sharp ]3ain at the time, which is often followed by burning, and tenesmus, which, however, soon subside. In some cases the trouble is relieved by this treatment. Incising the fissure, in the manner that surgeons treat the same disease of the anus, has been followed by ^^'^^^'^^Z^::=,======^^^^^ great relief, but I do not believe that I ever p^^ 272.-Skcne's fissure probe and knife, cured a case in this way. For this operation I use a small knife, which is represented in P'ig. 272. ORGANIC DISEASES OF THE URETHRA. 893 In the employment of this local treatment great difficulty will be found in getting at the diseased spot. The fissure can easily Ije seen through the glass tube of the endoscope, but to expose it and make applications to it are exceedingly difficult tasks. I have tried in a variety of ways to do this, but have found that the only satisfactory way is by means of the endoscope, consisting of a glass tube, hard- rubber external tube, and mirror, which I have fully described. This combination of speculum and mirror answers very well in applying such remedies as bismuth, calomel, and the like ; but it will be found that skill and patience are required to touch the fissure with the nitrate-of -silver stick, or to incise the part as already advised. The method which I employ is this : A small silver probe is bent into the shape shown in the figure (Fig. 272), and its point is coated with the material to be used. It is then introduced tlirough the speculum and drawn slowly through the fissure so as to produce superficial cauterization of the ulcerated part. The point of the probe is coated by melting the " mitigated " stick of nitrate of silver in a platinum cup, into which the probe is dipped and the coating allowed to cool. The dipping may be repeated as often as is neces- sary to get the required amount of caustic or coating on the probe. Before applying the caustic, any mucus or serum that may be in or about the fissure must be sponged away. This may be done by wrapping a piece of absorbent cotton on the end of a probe, and using it as a sponge. It will be observed that I condemned caustics in the treatment of fissure, and still advise cauterizing the diseased part with nitrate of silver. The point is simply this, that caustics applied by injec- tion to the neck of the bladder in which there is fissure do harm, but caustic appHed to the fissure only, does good. I have observed that pain follows the application of caustics, but if the diseased portion and nothing more is thoroughly touched, re- lief follows. The old trouble and pain are, however, liable to return in time. The same may be said of incision, viz., that relief is but temporary. I think that the bleeding which is caused relieves irri- tation and congestion for a time, but I can not say that I have ever seen a permanent cure follow this treatment, except in a few cases, where the treatment was begun early in the course of the disease. I come now to dilatation of the urethra as a means of relieving fissure. Although I have left this measure until the last, it is really the first in importance in the treatment of this affection. Indeed, I am inclined to think that it is of much more value in the treat- ment of fissure than in that of either cystitis or urethritis. 894 DISEASES OF WOMEN. I have already sounded a note of warning against the two great dangers of dilating the urethra — viz., rupture and incontinence, and incontinence without rupture. Both accidents are liable to occur in dilating the uretlira, but they only occur when the dilatation is carried to a great extent, sufficient at least, to admit the ordinary sized index-finger. This extreme dilatation is not necessary in the treatment of fissure. I generally ascertain what sized sound can be passed with ease, and then dilate sufficiently to admit one three or four sizes larger. Tliis is usually all that is necessary. Before dilating it must be seen that the urine is normal in char- acter, or as nearly so as can be made by general treatment. Then the urethra is to be dilated, the patient being kept at rest, and the urine made as bland as possible with diluent drinks. In case that incontinence should follow (though I presume that will not occur), its treatment should at once be commenced by sup- porting the urethra in the way that I have advised, viz., with the pessary for that purpose. I believe that, if taken in hand within three or four days after it occurs, the incontinence can be relieved. Should the treatment that I have thus far recommended fail, then a vesico-vaginal fistula should be made, the bladder and urethra washed out regularly, and if need be medicated. The fistula may be allowed to close of its own accord, as it usually will do. By the time the fistula closes, the fissure will have healed. In making a vesico-vaginal fistula to cure fissure, the knife or scissors should be used, and not the cautery ; because it is not necessary to maintain the opening in the bladder for a very long time : and if it closes of its own accord, a very important operation is avoided. 4. Neoplasms of the Urethra. — A knowledge of urethral neo- plasms is by no means confined to recent times, but up to a late date they have not been studied as closely as they deserve to be, nor classified in a comprehensive and scientific manner. The various tumors have frequently been confounded with one another by authors and observers, and much confusion and obscure statement have resulted in regard to their symptomatology, pathology, and treatment. These grow'ths have been variously known as carunculse, cellulo- vascular tumors, fleshy and vascular growths, fungoid excrescences, strasvberry and raspberry tumors, each name sometimes having been used to cover the whole class. "VVinckel's division and classification are most excellent, and to some extent I shall follow them in the consideration of the subject. I will classify these tumors as follows : ORGANIC DISEASES OP THE URETHRA. 895 Papillary. — Condyloma. Glandular. — Cysts, myxo-adenoma, mucous polypi. Vascular. — Angioma, varices, phlebectases. Areolar Connective Tissue. — Fibroma, sarcoma. Epitlielial. — Epithelioma, carcinoma. Compound. — Papillary polypoid angioma, erectile tumors. Neoplasms of the urethra are more common in the female than in the male, and, of course, easier of diagnosis and treatment. Papillary Neoplasms. — Under the first head, or that of papillary neoplasms, will be seen condyloma, a growth of a low grade, and of a warty appearance. The surface may be bright red, or partially white, from epithelial aggregation. These growths are painless, and do not bleed on touch or manipulation. They may or may not be pedunculated. They may occur singly or in clusters, and be wholly within the urethra or projecting from the meatus. They consist of somewhat dilated capillaries set in a tough homo- geneous network of connective tissue, the whole having a thin epi- thelial covering, that may at times be increased by an unusually rapid epithelial proliferation. This only occurs when the tumors are much irritated. Glandular Neoplasms. — Cysts of the female urethra are not com- mon, and are not confined to any period of life, having been found in a foetus of from six to seven months and in all subsequent periods of life. They are in early age situated in the anterior or meatal portion of the urethra, but later in life nearer the vesical neck. They may or may not project from the urethra ; however, they cause a greater or less obstruction to the free outfiow of urine. They are usually formed by the occlusion of the orifice of the small urethral ducts or glands, and, in some cases, a black speck upon the surface of the cyst indicates the seat of the former orifice. By bagging of the mucous membrane and absorption of the con- tents, these small cysts may be transformed into polypi. Winckel says that the internal wall of the cyst usually shows numerous small papillge, and is lined with pavement epithelial scales. Myxo-adenoma are quite rare. They are small (the largest being seldom larger than a small hazel-nut), of a bright scarlet color, and quite vascular. They consist of a number of vessels set in partly destroyed gland tissue, and small meshes containing myxomatous matter. The whole is contained in the meshes of a soft, loose con- nective tissue. Polypi coming under this head are those formed by occlusion of 896 DISEASES OF WOMEN. the orifices of one or more of the ducts or follicles of the urethra. The other forms of polypi will be considered under their proper head. Vascular Neoplasms. — Angioma, varices, and phlebectases are really different names for about the same condition — viz., an increase in the caliber of the veins and venous radicles, allowing an overdis- tention, at first intermittent, and later chronic. They appear as bunches or bundles of worm-like, irregularly distended dark blue or bluish red vessels. There is more or less thickening of the mucous membrane and connective tissue about them ; they are, in fact, in all respects analogous to rectal haemorrhoids. They may occupy any part of the urethra, but usually select the floor of the canal. The trouble they cause depends on their size. If large, they obstruct the urethra. Sometimes the vessels rupture, and the blood is poured out beneath the mucous membrane. Tumors resulting from rupture of such varices under a normal mucous membrane have been known to some authors under the name of hsematoma polyposum urethrse, which describes very well the condition resulting. Some of these vascular tumors have been found to be erectile, the anatomical peculiarities of which structure are already familiar. Virchow believes these tumors to be a combination of urethral haemorrhoids and remnants of embryonal duplicity of the vagina. Areolar Neoplasms. — Tliese new growths are either fibromata or sarcomata. The fibromata may lie within the canal of the urethra or be im- bedded in its walls. When in the urethra or protruding from the meatus, they are pedunculated, and have been known as urethral polypi. They vary in size from that of a pea to that of a goose-egg. They consist of numerous densely packed fibers, that give the same appearances as fibromata elsewhere. They have been found in several cases at birth, but are of rare occurrence at any age. When congenital, they have been known as congenital polypoid excrescences. The tumors are usually covered with several layers of pavement epithelium. Sarcoma of the urethra is an extremely rare affection, but one or two cases being on record. One case observed by Beigel is described by Winckel. It was trilobed, about the size of a walnut, and was situated about the edge of the external meatus. It was in part hard, in part soft, the harder portion consisting of a fine fibrous network, the interstices of which were filled with small cells. In some places the cells were absent and the stroma more dense, and in the pe- ripheral jjarts the network, while coarser, was firm, and presented ORGANIC DISEASES OF TUB URETHRA. S97 3avities filled with a colloid material. Tlie tumor was extirpated, but uotliiug is said about its return. Epithelial Neoplasms. — The existence of cancerous disease of the female urethra as a primary affection is greatly doubted Ijy many authors, but it probably does occasionally occur. Indeed, as a sec- ondary disease, it is quite rare, for, when extending from the uterus or neighboring organs to the bladder, death, as a rule, results before the urethra is involved. In cases where hfe is unusually prolonged, the disease seldom attacks more than the vesical portion of the canal. Extension from the outer genitals, which are very rarely affected with cancerous disease, is still more uncommon, and possibly has never occurred. One case is recorded, however, in a woman who had long suffered from uterine prolapse, where a tumor, which de- pended from the fraeniculum clitoridis, had invaded the meatus urinarius. Under the microscope it proved to be a flat-celled epi- thelio-cancroid. We have the record of cases of periurethral cancer that ap- peared at the introitus vulvae near the meatus, and in the connective tissue about the urethra, as small, hard, painless tubercles, the ure- thra or its membrane not being involved. Symptomatology. — Pain is the exception rather than the rule in this affection ; but in some instances acute, lancinating pains are pres- ent. At first the tubercles are small, hard, and usually painless, but after a time they soften, ulcerate, and bleed freely. The vesti- bule and urethral mucous membrane are usually involved in the mischief. The affection has been divided into three grades, in the first of which, according to Winckel, " but half the length and depth of the urethra is invaded by the cancerous tubercles ; in the second the vesical neck and pelvic fascia; and in the third the pubic sym- physis, descending pubic rami, and the closely blended connective tissue are involved." Compound Neoplasms. — The most common, and consequently the most interesting form of urethral neoplasm, is the papillary polypoid angioma. These tumors vary in size from a pin-head to a hickory-nut, and may be either multiple or single, but are usually single. They vary in color from a pale to a bright red, and may or may not be pedun- culated. Their favorite seat is on the posterior wall of the lower half of the urethra, very near to or at the meatus. This neoplasm is generally known as urethral caruncle, or vascular tumor of the urethra, and is described very fully in most of the books on diseases 68 898 DISEASES OF WOMEN. of women. Indeed, it is the only abnormal growth of the female urethra that I ever read or heard of in my student days. There is really not much difference between this form of neoplasm and the vascular tumor of the urethra already described, and what is far more important both of these neoplasms have been confounded with hyper- plasia of the tissues around the mouths of the ducts of the urethral glands. This condition will be discussed under the head of diseases of the urethral glands. There are very good reasons why this affection should have claimed early attention from gynecologists. It occurs frequently, and nearly always causes great suffering, and is easily detected, because it grows at the meatus urinarius, where it can be seen. It consists of bunches of dilated capillaries set in a moderately dense stroma of connective tissue, and covered with mucous mem- brane, which has the usual pavement ej)ithelium. One case, however^ is recorded where the pavement was replaced by columnar epithe- lium. The vessels are greatly dilated, and in some cases very tor- tuous ; in others much less so. In some cases these tumors partake of the erectile character, being markedly increased in size at the menstrual period, and at other times. Occasionally small tumors .of this kind are found singly in the vestibule. As a rule they bleed very easily on touch, and are ex- quisitely sensitive. Observers differ as to whether the nerve supply to the tumor is marked, some claiming to find a large nerve distri- bution, others to find none. As they are exceedingly tender, the inference may be drawn that they are well supplied with nerves. Symptomatology. — Unless the tumors be of large size the patient may go on for a long period without experiencing anything more than a slightly irritable condition of the urethra. When, however, the tumors become large, or are of the polypoid angioma variety, the pain is markedly increased, and the obstruction to the outflow of urine becomes very apparent. These tumors, by constant moisture and friction, become eroded on their surface, and these ulcerations, being constantly aggravated, give rise usually to slight hemorrhage and increased pain. Retention of urine may result from their clos- ing the urethra. Of all the urethral neoplasms, however, the papillary polypoid angiomata are the most intensely painful, and patients retain their water for a long time to avoid the agony that is produced by passing it. The pain is, in some cases, present at all times, and is greatly aggravated by sitting or lying down. The clothes coming in con- ORGANIC DISEASES OF THE URETHRA. 899 tact witli the exquisitely sensitive surface often produce vaginal and anal spasm. Coition is sometimes impossible. A case is related of an old woman thus affected, who, though married some thirty years, was still a virgin. Indeed, this affection is sometimes mistaken for vaginismus, and treated accordingly. The directions which I shall give under the head of diagnosis will, I think, be sufficiently plain to prevent such mistakes. Even when these tumors are too small to obstruct the urethra, obstruction may occur from severe spasm due to the pain caused in the act of micturition. Bleeding from these tumors is not uncommon, but it seldom amounts to much, and is easily controlled. The pain in any of these new growths is not always confined to the urethra, but may be felt in the back, hips, suj)rapubic region, thighs, knees, and feet. In carcinoma lancinating pains may be present, but this is by no means the rule. As the tumors increase in size, the urethra becomes gradually dilated, and the mucous membrane eroded, h3rper8emic, and catarrhal. Its structure may become loose, flabby, and vascular, and a pouch form behind the tumor. If far enough back to interfere with per- fect closure of the vesical neck, incontinence may occur, and incon- venience and distress the patient greatly. Sometimes the bleeding is severe, and the patient suffers from anaemia caused thereby. This is more usually the case if, in the de- structive process attending carcinoma, an artery of any considerable size is opened into. This accident, however, rarely occurs. In the extremely painful neoplasms, the face gives evidence of constant pain, distress, and anxiety ; and in the most aggravated forms patients are pale, emaciated, and extremely low-spirited, often wishing earnestly for death to relieve their sufferings. If the tumor be of sufficient size to be a serious bar to free mic- turition, cystitis, pyelitis, and more serious results, as renal destruc- tion, are to be feared. The presence of small, and even large tumors, in the urethra and about the meatus often gives rise to increased sexual desire, that is gratified in the young girl by masturbation. The urine is normal, save that it contains the products of urethral disease, viz., epithelium, pus, mucus, and sometimes blood. Small pieces of the tumor, small cysts or polypi, the pedicles of which have died or been torn through, are sometimes found in the urine. In cancerous neoplasms, as the disease invades the tissues to the second and third degrees mentioned in connection with malignant 900 DISEASES OF WOMEN. tubercle, the patients gradually sink and die from exhaustion from severe bleedings, loss of rest, and general cachexia. Soine cases, however, do not succumb until long after the third degree has been reached, with extensive destruction of tissue. Diagnosis. — The diagnosis of urethral neoplasm is really quite easy, provided the investigation is thoroughly and intelligently con- ducted. When a woman comes to the physician complaining of pain on micturition, pain in sitting, obstructions to or interruptions in the flow of urine he should at once proceed to a thorough investi- gation of the parts, first by the eye and touch, and second by the aid of the speculum, endoscope, and an examination of the urine. If the tumor presents at the meatus, it will, of course, be readily seen, and can be easily diagnosticated. If in the urethra, the finger passed along the course of the ure- thra in the vagina, with some dilatation of the meatus, will discover it. If of small size, the endoscope, with a strong light, will give an excellent view of it. If the tumor be exquisitely sensitive, as some are, the patient should be wholly or partially anaesthetized, and then the examination can be fully and freely made. Vaginismus may be excluded by passing the finger into the vagina, away from the urethra, when no spasm will take place ; but if the urethra is touched, the spasm is at once produced. To determine whether the inflammatory mischief, when it exists, resides in the urethra alone, the patient should be directed to pass one half of her urine into one vessel, and the other into another. If the trouble is seated in the urethra only, the last urine passed will be totally or almost wholly free from the inflammatory products. The same may be accomplished also by drawing off the urine with a clean catheter. In some cases the varicose condition of the vessels of the nmcous membrane, with considerable swelling, may simulate prolapse of the mucous membrane. If, however, the blue discoloration is borne in mind together with the elastic feel, and the reduction in size under compression of the urethral haemorrhoids, there will seldom be any error in the diagnosis. Of course, prolapse of the mucous membrane and a varicose condition of the urethral veins sometimes coexist, and this must not be forgotten. Tumors, usually those of large size and pedunculated, often cause gome degree of pi'olapse of the mucous membrane by constant drag- ging. A prolapsus of the mucous membrane may also simulate a tumor. The position of the meatal orifice, and the fact that it can be reduced, will distinguish the prolapse. ORGANIC DISEASES OF THE URETHRA. QQl To distinguish one kind of tumor from another is not always easy, but with a little care it can be accomplisiied. The condyloma will ])e recognized by its painlessness, its warty, cracked, pinkish white or white surface, and the fact that similar growths are at the same time usually found on the vestibule. The polypoid angioma will be known by its bright-red surface, its tendency to bleed easily, and the exquisite pain produced when touched. The sar- coma will be readily confounded with the angioma, but it is very rarely found here ; and if there is any doubt, a little piece may be scraped off with the curette, and examined microscopically. Should doubt still remain, the history and progress of the disease will soon determine the nature of the trouble. The malignant tumor will grow much faster than the other. The varices can be told by their bluish color and their shrinking under pressure, and the cysts and fibromata by their smooth, painless surface, normal mucous cov- ering, and their consistence. Carcinoma appears, as I have already said, as hard tubercles (usually periurethral), which after a time break down. When this occurs, the endoscope, the lancinating pains (if present), the rapid invasion of neighboring tissue, and the composition of the diseased mass, under the microscope, will tell the story. Prognosis. — The simple forms of urethral tumor are easily removed, and do not return. As a rule, therefore, the prognosis is good. Of this class are cysts, condylomata, mucous polypi, and fibromata. The angiomas are of a more serious nature, as by the pain and suffering which they cause the constitutional condition is usually low ; and, though they may be extirpated, they are likely to return and rapidly increase in size, even in from one to three months' time. Although the bleeding from these tumors is rarely very great, still there may be numerous small hsemorrhages, and at times severe ones, either from the urethra externally or into the bladder. Under proper treatment, however, there is always a possibility, and in some cases, a certainty of cure. In carcinoma there is no hope of effecting a cure, although the patient's condition may be much improved in some cases. Death usually ensues before the third degree is reached. Almost the same may be said of epithelioma, unless it is treated in its early stages. Causation. — The causes of the various neoplasms are not yet clearly made out, and will not be, I think, until more extended ob- servations are made on the subject. Even then it is more than probable that some of them will remain obscure. 902 DISEASES OF WOMEN. The predisposing causes are a laxity of the urethral tissues, with a tendency to a varicose condition of the parts, usually found in old age ; a general tendency to venous stagnation, catarrh of the mucous membrane, and dislocation of the urethra, partial or complete. As a proof that no single special cause produces these condi- tions, it may be said that these growths have been found congeni- tally, and at every period during life, as late indeed as the ninety-sec- ond year. The exciting causes, as given by different authors, vary. The following are some of those usually mentioned : 1. Temporary or chronic congestion of the urethra during preg- nancy, uterine and ovarian tumors, and obstructed portal circulation. 2. Injuries to the parts during labor, external violence, the irri- tation of chronic and acute urethritis (specific or simple), syphilitic poison, and masturbation. Of course, the carcinomata, cysts, and simple mucous polypi, are not here included, although some of the above causes might aggra- vate if not produce them, for I have already spoken of their method of causation as far as it is known. Cancer occurs by extension of the disease from other parts ; cysts and mucous polypi, from occluded duct orifices. This narrows the list to the nervous class and the compound, viz., the polypoid angiomas. And of these I may vent- ure to say that any cause, such as constant irritation, sudden injury, or slow congestion, may produce these conditions, especially in those who are somewhat predisposed ; but that any one cause, such as the gonorrhoeal poison, is sufficient to produce them, in all cases, is more than doubtful. Most of these tumors occur in married women, both in those who have borne children and in those who have not. It might be supposed from all that has been said upon this sub- ject that urethral neoplasms are very common. On the contrary, they are very rare, with the exception of polypoid angiomas. Treatment. — The treatment of these cases is, in most instances, entirely surgical, but when the general system is deranged in any way it should receive careful attention. If there is a congested condition of the urethra, the portal circulation should be kept in a normal state by securing a healthy action of the liver and bowels. The condition of the circulation in the part involved may possibly be influenced by constitutional medication. For this purpose, ergot, digitalis, and nux vomica, in small doses regularly repeated, may be of service. These remedies will at least aid in securing a good general circulation, and may influence favorably the local affec- ORGANIC DISEASES OF THE URETHRA. 903 Fig. 273. — Skene's urethral speculum. tion. If there is local congestion due to pressure on the pelvic ves- sels, the cause, interfering with the return circulation, should be removed, or remedied, if possible. The local treatment recommended by the various authors differs widely, but has tlie same end in view, viz., destruction or removal of the abnormal growth. The various methods of extirpation em- ployed are ligation, torsion, excision by the knife, scissors, curette, ecraseur, galvano-cautery, caustics, and electrolysis. Any one of these methods may be made to answer in all cases, but a judicious selection, according to the location and nature of the neoplasm, is advisable. A combination of means is best at times, as, for in- stance, excision by the scissors and cauterization afterward. Whatever method may be chosen the patient should first be placed in the lithotomy or in Sims's position, on the left side, which I prefer, and the part to be removed exposed by a speculum. There are two instruments which I use for this purpose. The first is here shown. Fig. 273. It is made on the principle of Sims's specu- lum, the ends being of dif- ferent sizes. An elevator is attached at the central portion between the blades, and so arranged that when it is closed on one blade it is thrown out from the other. This is seen in the figure. The elevator is pressed down on the blade, and the instrument introduced, and then by pressing on the other end of the elevator the urethra is distended to its full natural capacity. When it is necessary to expose one side of the urethra completely, the elevator should be removed, and the instrument used in the same way that Sims's speculum is em- ployed in the examination of the vagina. The other instrument is a modification of Folsom's nasal speculum, made of wire. Fig. 274. By turning the nut-screw the blades are closed, and the instrument is introduced ; and by unscrewing it the elasticity of the handle throws the blades apart. This instrument an- swers well when the tumor to be removed is small, and we are obliged to operate without as- sistance. It is self-retaining. The other spec- ulum is preferable in most cases, but, in operat- ing through it, it is requisite that some one should hold it. When the tumor is at or near the meatus, and has a laree base. Fig. 274.— Skene's modi- fication of Folsom's nasal speculum. 904 DISEASES OF WOMEN. or if it is vascular and troublesome haemorrhage is feared, removal by ligature is preferable. Having exposed the part with the specu- lum the base of the tumor is to be transfixed by passing a needle from without inward, parallel to the axis of the urethra ; a ligature is then to be passed around under the needle, then the tumor is grasped with a forceps, and traction made so as to bring the sides of the base within the grasp of the ligature, which should then be tied slowly and as tightly as possible without cutting the tissues. By taking all these precautions the ligature will be certain to include all the abnormal tissue, a very impoi-tant result indeed. If the base of the growth is too large to be included easily in one ligature, transfixion may be made with a needle armed with a double thread, and its two halves tied. In choosing the material for a ligature, I would advise the use of tine plaited silk, boiled in a mixture of beeswax, carbolic and salicylic acids. A ligature prepared in this way ties easily, does not stick like the ordinary ligature, and, more than that, it does not slip. If the tumor is within easy reach and is pedunculated, the pedi- cle can be seized with a small forceps, and the tumor grasped in a polypus-forceps, and removed by torsion. Or it can be cut off with the knife or scissors, and, if the pedicle inclines to bleed, touched with caustic. Allen's polypus-forceps for the ear will be found one of tlie most conven- ient instruments for taking hold of these little tumors, Fig. 275. In cases where there are several small growths high up in the urethra, they can be removed with the curette, and, when the haemor- rhage has subsided, the base of each should be cauterized. But little difficul- ty will be experienced in operating in the various ways described when the neoplasms are low down in the urethra, where they can be easily seen and handled. When they are high up in the canal, then great skill and care are required to remove them. In such cases Fig. 2*75. — Allen's polypus forceps. ORGANIC DISEASES OP THE URETHRA. 905 success will be best obtained with the ecraseur, or the instrument known as Blake's polypus-snare, used for removing polypi from the ear, Fig. 27G. It is simply a very delicate ecraseur, the chain or wire of which is C> o ■ ' ■-■■ ' ' i^ ^ tightened by the G.TIEMAKN ^CO. T^^^ n . , p linger m place ot a screw\ It will be found that, in- stead of the wire T. ^H. T,, , , 1 commonly used. Fig. 276. — Blake's polypus snare. , . the steel - wire Btring of the zither is better ; it is stronger, more elastic and pliable, yet stiff enough to be manageable. Dr. John W. S. Gouley, of New York, was the first to use this instrument for removing tumors of the urethra, and I can testify to its great value in such operations. In operating with the snare, the tumor is exposed with the urethral speculum ; and, if the growth is pedunculated, the loop of wire is passed over it, and removal effected by constriction. When there is a broad base, the whole mass is seized with the polypus-for- ceps, and the snare is then passed over it and tightened until it comes away. There is one accident that very often occurs in this operation, and that is breaking of the wire. This takes place, usually, just when the tumor is almost cut off, and it annoys and hinders the operator, but does not spoil the operation, as a new piece of wire can be used, and the operation completed. This accident can often be avoided by taking time. The base or pedicle of most of these growths will give way under long-continued pressure, but the wire will break if there is too much hurry. In order to operate high up in the urethra, it is sometimes necessary to dilate its lower portion. A convenient way to do this is the following : Take a piece of fine rubber tubing and draw it over the blades of the Folsom speculum, and then introduce the in- strument into the urethra. Open the blades, and let it distend the urethra as far as it can. To produce the extra dilatation, take a series of graduated sounds or dilators — wood or hard rubber will answer — and force one of these in between the blades of the specu- lum ; remove that one, and use a size larger, and so on until the requisite amount of dilatation is obtained. The blades of the specu- lum and the rubber tubing protect the mucous membrane of the urethra from injury while passing in the dilator. The danger of in- continence of urine, which is Hable to follow from forcible dilata- 906 DISEASES OF WOMEN. tion, can be avoided by distending the lower portion of tlie urethra only. To obtain sufficient light for operating high up in the urethra, it is necessary to have clear sunlight ; or, if that is not obtainable, gaslight should be used ; and, in either case, the concave head-mir- ror should be employed. Of late years the galvano-cautery has been very extensively used in surgery generally, and has been recommended for the re- moval of urethral tumors. As a means of removing large and vas- cular growths from the meatus, it has high claims, but for general use it will be found objectionable. In removing tumors from the in- terior of the urethra with this cautery, it is imjDossible to avoid cau- terizing portions of the normal membrane unless extraordinary skill is employed. This unfortunate liability, and the difficulty in keep- ing the instrument in good working order, stand in the way of this means of operating ever becoming popular in this department of surgery. Caustics have been more extensively used than any other means of removing urethral neoplasms, and I know of no better way of destroying small growths. Of all the agents used, I prefer pm-e nitric acid, which I use as follows : Exposing the tumor with the speculum, represented by Fig. 276, I wrap a little cotton around a probe, and dip it into the acid, and apply it to the j^art to be de- stroyed, taking care not to touch any of the normal tissues. The speculum recommended has the advantage of protecting one side of the canal, and, by exercising care in handling the acid, accidents may be avoided. I come now to the last method of removing these tumors which I shall mention, viz., electrolysis. This means of treating abnormal growths has been employed so much lately that I need not dwell upon the method of its use, but simply state that those tumors that recur, and those that are suspected to be malignant, and those also that are so high up in the urethra as to be difficult to remove, should be treated by electrolysis. Two long, slender needles should be in- sulated by coating them with collodion, except at the points. These are attached to the electrodes of a galvanic battery, and their points introduced into the base of the tumor, and the current passed through until the whole of the abnormal tissue is decomposed. I prefer to use a current sufficiently strong to char the tumor, and thereby com- pletely destroy it. There is one rule which should be kept in mind in treating tumors of the urethra, and that is, to be sure to remove all the ab- ORGANIC DISEASES OF THE URETHRA. 907 normal tissue. "Whatever method is employed, no portion of that which ought to be removed should be left. I am coniident that much of the trouble experienced by the repeated return of these growths might be avoided by a careful observance of this rule. Urethral catarrh or inHammation, which frequently accompanies abnormal growths, usually subsides after their removal. In some cases it persists, and then it should be treated according to the methods already given. CHAPTEE XLIX. OEGANIC DISEASES OF THE URETHRA (CONTINUED). DILATATION, DISLOCATION, AND PROLAPSUS. 5. Dilatation of the TJrethra. — Changes in the caliber of the female urethra occur in two forms, dilatation and contraction ; but neither of these is very often met with in practice. Of the two, dilatation is the more common. The increase in the size of the urethra may involve the whole canal, or be limited to a portion of it. I will first speak of dilatation of the whole urethra, and then, dividing the canal into thirds, consider the affection of each portion. Dilatation of the Whole Urethra. — It will be understood that dila- tation to such an extent as to have the canal open and its walls sepa- rated is an unknown condition. The true state of things would be more correctly expressed by calling it an abnormal dilatability. The tissues of the walls of the urethra are in such a relaxed condition as to admit of extraordinary distention without injury. Dilatation of the whole urethra is not so common as dilatation of a portion. Even when the whole canal is larger than it should be, it will generally be found that it is not uniformly so. Some portions of it are more distended than others. The extent to which this dilatation may occur is very great. A number of cases are recorded, especially in the German literature of the subject, where copulation took place for years in the urethra instead of the vagina. In these cases the dilatation was extreme. In this affection the urethral walls and the urethro-vaginal sep- tum are usually relaxed and flabby. After a considerable time they may become indurated by infiltration, or by hyperplasia of the con- nective tissue. The mucous membrane is usually soft and loosely adherent to the subjacent tissues. Beneath the membrane will some- times be found masses of enlarged veins, which give a dark-bluish ap3)earance to the parts. If the meatus be distended like the rest of 908 ORGANIC DISEASES OP THE URETHRA. 009 tlie urethra, the mucous membrane, witli the large veins beneath it, may protrude and form tumors, wliich will have quite the appear- ance of rectal haemorrhoids. This is especially so when the veins are large and numerous, and the mucous membrane thin, so that the color of the veins can be seen through it. On the other hand, if the meatus remains normal in size nothing will be seen by the examiner until the catheter or sound is passed into the urethra, when the distended or distensible condition of the canal will be de- tected. The dilatation can easily be made out, even when the meatus is normal in size, by observing that the sound can be moved about in the urethra, conveying the same impression to the hand as w^hen it passes into the bladder. By making a digital examination of the vagina the enlarged urethra can be felt, and is usually elastic and compressible. Through Sims's speculum the abnormal fullness or bulging of the anterior vaginal wall can be plainly seen and dis- tinguished from displacement of the urethra. The points of differ- ence between dilatation and displacement will be brought out more in detail further on. When the dilatation has existed for any length of time, the mucous membrane is usually hypergemic and sometimes catarrhal, secreting a muco-purulent material, which may be seen escaping from the meatus, or lodged in the folds of the membrane, where it can be observed through the endoscope. When the mucous membrane is prolapsed and forms a tumor outside of the meatus, it soon becomes lissured and ulcerated, and consequently very tender and painful. This condition is produced by the retarded circulation, chafing, and the irritation from exposure to the air, and the urine passing over it. Dilatation of the Anterior or Lower Third. — This is the rarest of all the forms of urethral dilatation, and occurs usually as a conse- quence of some enlargement or swelling of the mucous membrane, neoplasm of the urethra, or mechanical dilatation. The dilatation may include the meatus or it may not. In rare cases it does not at first, but later in the course of the trouble the enlarged mucous membrane slowly, sometimes rapidly, dilates the orifice. The gen- eral appearances of the parts are the same as those of which 1 have spoken under the head of dilatation of the whole urethra. When the dilatation is due to any abnormal growth in the urethra, the conditions presented will be the same as those already described under the head of urethral neoplasms. I have seen but one case where the lower end of the urethra was dilated without any recognizable cause for it. This was a sin- gle lady, thirty-five years of age, a school-teacher. She had dis- 010 DISEASES OF WOMEN. placement of the uterus and catarrh of the cervical canal, for which she consulted me. She had no trouble with her urinary organs. While examining the uterus I noticed that the meatus urinarius was peculiarly formed. In place of the concentric corrugations of the mucous membrane which form the closed meatus, the orifice was funnel-shaped, and lay open when the labia minora were separated. About half an inch of the lower end of the urethra admitted a Xo. 21 (English) sound. The remainder of the urethra was normal, and there were no signs of disease about the mucous membrane of the dilated portion. I could obtain no history which pointed to the origin of the dilatation, and it caused no discomfort to the patient. Dilatation of the Posterior or Upper Third. — This form of dilata- tion usually occui-s in connection with other pathological conditions, such as prolapsus of the bladder and urethra. On this account I will defer what is to be said on this subject until I come to disloca- tions of the urethra. Dilatation of the Middle Third of the Urethra. — Dilatation of this part of the urethra is more common than either of those I have described. I do not desire to be understood as saying, that it is con- fined to exactly the middle third of the urethra, or that the other dilatations are confined to thirds only. It is about a third, and I use the division to fix the idea clearly in the mind and for conven- ience of description. In this form of dilatation the anterior wall of the urethra main- tains its normal position, but the central portion of the canal being distended settles down, so that in time the urethra, in place of be- ing a straight or slightly curved canal, becomes triangular, the upper wall being the base, and the central portion of the posterior wall (that is midway between the neck of the bladder and the meatus) the apex. A cavity is thus formed in the central portion of the urethra. Fig. 277 will convey the idea of the anatomical appearances of this affection. Tliis form of dilatation has been called sacculated urethra and urethrocele. A valuable article on this subject will be found in the "American Journal of Obstetrics" for Fel)ruary, 1871, by Nathan Bozeman, M. D. Some of the cases related there by him are, in my opinion, not simply urethral dilatation alone, but dilatation and dislocation combined. However, his description of this form of trouble is the best that I have ever seen, and I prefer to give it in his own words. It is as follows : " In the study of urethrocele, the anatomical points to be consid- ered are the triangular ligament and its relations with the urethra. ORGANIC DISEASES OP THE URETHRA. 911 the muscular structure of the urethra, and the different relations of the urethra to the vagina in tlie upper and lower parts of its course. Fig. 277. — Dilatation of middle third of the urethra (urethrocele). " These anatomical peculiarities exert a marked influence on the etiology of the lesions in question, and supply the first links in the long chain of morbid results indicated by the histories of the cases above cited, and others known sometimes to follow. '^ In the male, stricture, although not the first morbid alteration, denotes the first serious interruption of the stream of urine, and superinduces morbid changes in the urethra above the prostate gland, in the bladder, the ureters, and the kidneys. " In the female, rare as it is to meet with organic stricture of the same kind as in the male, the caliber of the canal is quite as often, if not oftener, compromised, and with due allowance for the ana- tomical differences of sex, the pathologic sequences observe the same order. " The starting-point of urethral and vesical lesions in the female is to be sought in the lower half of the urethra, closely related in front with the triangular ligament, and blending behind with the spongy erectile tissue of the vagina. " The caliber of the urethra may be transiently narrowed by 912 DISEASES OF WOMEN. congestion of its mucous lining, or permanently narrowed by infil- tration of coagiilable lymph into the underlying cellulo-elastic tis- sue, which constitutes properly the so-called organic stricture, as in the male, and which, however seldom met with, is liable to the same sequences. " Infiltration into the spongy erectile tissue outside the urethra, by plastic lymph, is, I believe, by far the most common beginning of the morbid process, whatever be the cause that produces it. This interrupts the stream of urine, either by encroaching on the caliber of the urethra, or by deflecting it beneath the triangular ligament, both cases being attended with more or less dilatation above. " The next step in sequence is increased functional activity of the urethral muscular coat in overcoming the obstruction to the flow of urine. The result upon its structure is hypertrophy, and this will be of the eccentric type, thickening the urethral walls while enlarg- ing the caliber. Hence the ease with which large catheters of a proper curve pass at all stages of the disease. False and true hyper- trophy here coexist. The true hypertrophy increases j^aW j9«S5w with the muscular contraction, and is followed by still greater distor- tion of the canal, at an angle more and more acute, as it turns the triangular ligament, and with corresponding coarctation of its walls at that point. This mechanical impediment below coincides with the increased weight and volume of the stream of urine above, to put the walls of the urethra on the stretch in the upper part of its course. " Thus is gradually formed the urinous tumor, which drags down in front the adjacent vaginal wall, appearing as a prolapsus between the nymphse, and filling up the ostium vaginae. " The looser attachment of the urethra to the vagina in the upper part of its course facilitates this result. Such is the condition of the parts to which I apply the term urethrocele. Often confounded with cystocele, it is really distinct. " The arrest and retention of but a few drops of urine at first goes on until this may amount to a teaspoonful or more. It is then decomposed in this pocket, becomes alkaline, and by its irritation provokes congestion of the urethral mucous membrane." In the earlier stages of this affection the urethra in front and behind the pouch is really or apparently contracted ; but as the disease progresses the upper part of the canal and the neck of the bladder become dislocated downward, and finally the upper portion of the urethra becomes also dilated to some extent. There is in this, as in the other forms of urethral dilatation, fre- ORGANIC DISEASES OF THE URETHRA. 913 qnent nrination, usually more marked ; Vjut unlike the others, there is difficulty in passing water. This frequency of urination, and the straining efforts necessary, affect the bladder, producing irri- tation, and, in time, hypertrophy of its walls. Cystitis also follows in the order of morbid developments ; but whether that comes from the frequent and difficult mination, or from extension of the inflammation from the urethra to the bladder, is a question. One thing we know, and that is, that if this form of uretlu-al dilatation goes on without treatment, cystitis will sooner or later appear. Symptomatology . — The symptoms vary according to the extent of the dilatation, the portion of the urethra involyed, and the condition of the mucous membrane. When the whole urethra is dilated, the only symptom present may be frequent urination. When there is inflammation or prolapsus of the mucous membrane, then pain will be caused by micturition, and the desire to micturate will be more urgent and frequent. The patient may also be annoyed by a slight loss of control of the bladder, under the pressure of lifting heavy weights or coughing. Dilatatation of the lower third of the urethra does not cause any derangement of function, unless accompanied with inflammation or idceration ; then there will be frequent urination possibly, painful urination certainly. The symptoms in this form of dilatation are less marked than in the other varieties. When the trouble is located in the upper third of the urethra, the symptoms are sometimes very distressing. In addition to the frequent — it may be constant — desire to pass water, the patient is tormented with partial incontinence. Coughing, laughing, sneezing, stooping to lift anything, a jar on stepping from the curbstone in crossing the street, causes an escape of urine. This distresses the patient very greatly. She is not troubled so long as she keeps quiet, or at least she suffers only from frequent urination ; but as soon as she undertakes the usual duties of exercise or enjoyment, then this partial incontinence makes her miserable. From the constant wetting of the external parts they become inflamed, unless very great care is taken to keep them dry and clean. In some of these cases the morti- fication is sometimes more distressing than the physical suffering. The symptoms occurring in dilatation of the middle portion of the urethra (urethrocele) are the same as those already given, with the addition of a slight mechanical obstruction, which causes difficult urination. That is, more voluntary effort is necessary on the part of the patient to empty the bladder. The forcing, straining efforts made by some of these patients wliile urinating are even greater 69 914 DISEASES OF WOMEN. than tlie mechanical obstruction appears to account for. This maj be due to the accumulation of urine in the urethra, which excites extra retlex action in the bladder and urethra out of proportion to the obstruction. This is the only way that I can account for the difficult urination and muscular hypertrophy found in these cases in which there is no obstruction from stricture. The constitutional symptoms arising from these urethral troubles are the sauie as those produced by uretliritis, and are not peculiar to this class of affections. In fact it will be observed that the symptoms here given may all be produced by other pathological conditions, and consequently can not alone guide to correct diagnoses. The clinical history in such cases leads us to suspect the nature of the disease, but the true character of the trouble can only be discovered by physical exploration. Diagnosis. — In dilatation of the whole urethra, a digital exam- ination will detect the increased space occupied by the urethra. The canal encroaches upon the anterior vaginal wall, and feels like a ridge extending from the meatus to the neck of the bladder. This elevation or thickening of the urethra is elastic and compressible in recent cases ; in those of long standing where there is hypertrophy, the tissues are firm to the touch, but still the canal is compressible. The extent of the dilatation can be measured by the size of the sound that can be easily passed. If even the ordinary female catheter is at hand an idea of the size of the canal may be obtained. By introducing that instrument and pressing it first against the anterior wall and then upon the posterior, the distance between the two can be approximately made out. While the catheter or sound is in the urethra the finger should be introduced into the vagina and the thickness of the urethral wall ascertained. This will give a good idea of the increase of tissue from inflammatory products or hyper- trophy. When the meatus is dilated and the mucous membrane and en- larged vessels are prolapsed, care must be exercised to distinguish that condition from urethral neoplasm. This can be done by ob- serving that in prolapsus the opening is situated either at the upper side or in the center of the protruding mass, whereas in abnormal growths of the urethra the meatus surrounds the tumor or its pedicle. More than that, by making pressure on the distended vessels the size of the prolapsed membrane can be reduced, and the membrane can be pushed up into the canal. This can not usually be done with tumors. Dilatation of the lower third of the urethra is easily diagnosti- ORGANIC DISEASES OF TEE URETHRA. 915 cated. A large sound will pass in as far as the dilatation extends, and will be arrested when it comes to that portion of the canal which has a normal caliber. Great difficulty will be encountered in the diagnosis of dilatation of the upper third of the urethra, bat by attention to the following points success will usually follow. By using the sound it will be observed that while the lower portion of the canal hugs the instru- ment firmly, the point of it can be moved freely in the upper part of the passage. The same impression is conveyed through the in- strument as that which is experienced when the sound enters the bladder ; only in dilatation of the upper portion of the urethra, the motion of the point of the so and is, of course, more limited. Again, by introdacing a curved sound, and with it holding the anterior wall of the urethra well up under the arch of the pubes, and then carrying the finger of the other hand along the anterior vaginal wall, the posterior wall of the urethra will be found to hug the sound until the dilated portion is reached ; this wiU be felt to lie away from the instrument. By pushing up the vaginal and urethral walls at the point of dilatation until they touch the sound, and then by remov- ing the pressure and allowing the parts to recede from the sound, the relaxation can be easily detected. In some well-marked cases of dilatation complicated with pro- lapsus of the upper portion of the urethra, the diagnosis can be clearly made, by slowly introducing the catheter until the urine be- gins to flow, and then marking the catheter at the meatus urinarius and withdrawing it. The distance from the mark made to the upper edge of the eye of the catheter indicates the length of the normal portion of the urethra. If that is subtracted from the normal length of the urethra, the remainder will indicate the length of the dilated portion. Dilatation of the middle third of the urethra-^urethrocele — is most likely to be confounded with thickening of the urethro-vaginal septum. The diagnosis is made by observing that the enlai'gement due to dilatation corresponds to the central portion of the urethra, and that it yields to pressure more or less. Also, by passing a curved sound with the point upward, the anterior wall of the urethra will be found to occupy its normal position. Withdrawing the sound and again introducing it with the point downward it will pass in- ward and then down into the pocket found at the point of dilatation, where it can be felt through the vaginal wall. In all cases, except one, that have come under my observation, the diagnosis has been easily made by this method of examination. 916 DISEASES OF WOMEN. The exception referred to was a case of periurethral inflammation, in which an abscess formed in the urethro- vaginal septum and dis- charged into the urethra. A fistulous opening from the floor of the urethra into the sac of the abscess remained. The urethra occupied its normal position, and admitted the sound easily ; and by intro- ducing it with the point downward it passed into the sac of the abscess, thus giving the physical signs of urethrocele ; but the small size of the opening in the floor of the urethra, the marked infiltra- tion and induration of the tissues, and the history of the case, led to a diagnosis of its true character. Prognosis. — There is no natural tendency to recovery in these affections. If left alone they generally get worse ; recovery under treatment is modified by the location of the dilatation and the dura- tion of the trouble. The conditions upon which an unfavorable prognosis is to be based are bladder complications, inflannnation or ulceration near the neck of the bladder, great varicosity of the veins, and fatty degeneration of the muscular tissue. In the absence of all these complications a complete cure can be obtained. In all cases great relief can be secured by treatment, and the patient guarded from getting worse. Causation. — The hypersemia of the urethra which occurs in pregnancy, and which tends to produce overdistention of the veins, favors dilatation of the whole urethra. It is not uncommon to find an apparent increase of tissue in the walls of the urethra during utero-gestation, and the dilatability of the canal is often increased also. This condition of the parts disappears during the involution which takes place after delivery ; but when from any cause the process of involution is interrupted, the enlarged vessels and relaxed condition of the urethral walls remain and sometimes increase. When to this state of the parts a catarrh of the mucous membrane is added, the enlargement of the membrane by swelling still further increases the caliber of the canal. The dilatation caused by passing calculi may remain permanently, and the same may be said of the use of large sounds. Neoplasms obstructing the meatus, or stricture at that point, may so obstruct the escape of the urine as to cause dilatation at all points above. This is no doubt one of the most important and frequent causes of dilata- tion. Indeed, the recognition of this fact has led to the suggestion of treating stricture of the upper portions of the urethra by com- pressing the meatus, and then forcing the urine into the urethra and retaining it there. I have already stated that dilatation of the lower third of the ure- ORaANIC DISEASES OF THE URETHRA. 917 thra is rare, and is usually due to inflammation of the mucous mem- brane at that point or to abnormal growths, the distention remaining after the causes that produced it have been removed. This and mechanical dilatation from any cause cover the etiology of this form of the dilatation. Baker Brown says that the meatus is always dilated when there is stone in the bladder. Regarding dilatation of the upper third of the urethra, I am in- clined to believe that it occurs in consequence of a partial prolapsus of the bladder and the upper end of the urethra. The displacement of these parts implies a relaxation of the tissues, caused originally, it may be, by injuries during confinement, and the prolapsus permits an unusual pressure of the urine upon the upper end of the urethra, and dilatation is the result. On the other hand, the prolapsus and the accompanying relaxation of the urethral walls may be sufficient to cause the dilatation, and the whole trouble can invariably be traced to child-bearing or anteversion of the uterus. The fact that the upper part of the urethra is torn from its attachment to the subpubic ligament, and thereby deprived of its normal supports, would incline it to dilate, and I presume that this is oftentimes the cause of the dilatation. One cause of dilatation of the middle third of the urethra (ure- throcele) has been sufficiently dwelt upon in Bozeman's description of the pathology of that affection — that is, narrowing of the lower end of the urethra. This does not explain the etiology of all cases, however, for I have seen this form of dilatation where there was no stricture or hypertrophy of the lower end of the urethra. In such cases I have traced the cause to childbirth, during which the pos- terior wall of the urethra had been pushed downward and contused, while the upper remained in its normal position. The relaxation caused by this overstretching of the urethral wall formed a small pocket in the central portion, which gradually dilated more and more by the pressure of the urine until the urethrocele w^as fully devel- oped. This explanation of the cause may be rather hypothetical, but, so far as my observations go, it agrees with the facts found in those cases which can not be accounted for by Bozeman's views on the pathology of this affection. Treatment. — In the management of all forms of urethral dila- tation, any inflammation of the mucous membrane that may exist should be relieved by employing the usual methods of treatment of urethritis. When there is a relaxed and prolapsed condition of the mucous membrane, astringents should- be used to overcome it. Tan- nic acid will answer well. When these fail, the redundant mem- 918 DISEASES OP WOMEN. brane should be retrenched, either by touching it with the thermo- cautery or excising a portion with the scissors. In employing the cautery for this purpose, the long-pointed tip of the instrument which is used for cauterizing haemorrhoids by puncture should be chosen, and, having protected one side of the uretlira with the specu- lum, a narrow strip of the membrane parallel to the axis of the canal shall be cauterized. Two or more of these cauterizations may be made at points equidistant on the circumference of the urethra. Operating in this way leaves pieces of normal membrane between the portions cauterized, which prevents stricture from occurring after healing — a misfortune which is sure to follow if the mucous membrane is destroyed by cauterization all round. In excising the prolapsed portion, I prefer to remove one or more Y-shaped portions on opposite sides, and bring the edges together by sutures. This is preferable to clipping off the whole of the pro- truding mass, because the cicatrices left are less likely to give after- trouble by contraction. When the dilatation is caused by varicose veins, it may be well to follow the example of Gustavo Simon. He exposed the vessels by cutting through the vaginal wall, ligated the largest, and arrested the haemorrhage from the smaller ones by applying liquor ferri per- chloridi. He repeated this operation several times on the same pa- tient, who experienced little or no inconvenience from the proceed- ings, and made a good recovery. Dilatation of the lower third of the urethra is usually secondary to some other trouble, as I have already stated, and all that the physi- cian will usually be called upon to do for such cases is to remove the cause and treat any inflammation that may exist. The dilatation will then disappear, and, if it does not, but little, if any, trouble will I'esult. The treatment of dilatation of the upper third consists simply in supporting the parts. This can be effectually done by using the pessary already recommended for the relief of prolapsus of the blad- der. It will be necessary to have the instrument so formed as to bring the pressure where it is required. This can easily be done by placing the pessary in position, and observing what change of form, if any, is necessary, and then directing the instrument-maker to make the alteration. If the parts are well supported in this way, recovery will follow, unless atrophy of the muscular wall has previously taken place. Even then the patient can be kept comfortable by wearing the pessary. If there is urethritis present, it may be necessary to relieve that before using the pessary ; otherwise, the pressure of the instrument maj- cause pain, and aggravate the inflammation. ORGANIC DISEASES OF THE URETHRA. 919 This brings me to the only remaining form of this affection to be mentioned — dilatation of the middle third, or urethrocele. Dr. Boze- man has proposed making an opening into the most dependent part of the urethra through the vaginal wall, and maintaining it until all inliammation has been relieved, and then closing the opening by the usual plastic operation. By this means the urethra is perfectly drained of urine and the products of inflammation which accumu- lated thei-e before. This, with appropriate cleansing and topical applications, soon restores the mucous membrane to its normal con- dition, and the removal of the redundant tissue during the operation of closing the opening effectually cures the whole trouble. This treatment is admirably adapted to marked cases of long standing, and should be employed. By using the thermo-cautery to make the opening, the operation is easily performed. In recent cases of less ■severity, I have obtained satisfactory results by dilating the lower part of the urethra, and supporting the dilated portion either with a pessary or a tampon of marine lint. This permits the urethra to keep itself empty, and then, by frequently washing it out and apply- ing such remedies as will cure the urethritis, recovery will sometimes follow. This treatment can be tried, and, if it fails, Bozeman's method can be resorted to. Dr. T. A. Emmet has extended the usefulness of this operation. He calls it button-holing the urethra, and employs the operation for diagnostic purposes as well as for the ■cure of various affections of the urethra and bladder. I have tried this operation as faithfully as I could, and find that it is easily per- formed by using a scissors modified, but like the button -hole scissors used by tailors (Fig. 2Y8). Fig. 278. — Button-hole scissors (Skene). The probe-jpointed blade is introduced into the urethra, and the short blade into the vagina as far as the point at which the opening is to be made. One clip usually is sufficient, but if a larger opening be desired, it can be made by carrying the scissors up or down, and dividing as much more of the septum as may be desired. This operation is most thoroughly efficient for the purpose desig- nated for it by Dr. Bozeman, and it is also a convenient way of re- moving neoplasms situated in the middle and upper thirds of the 920 DISEASES OF WOMEN. urethra, when they can not be easily reached through the meatus urinarius. In regard to this operation, as a means of diagnosis, I have not been able to discover that it has any advantages, either to the patient or surgeon, over the methods I have already described. On the contrary, so far as simplicity, safety, facility, and efficiency are concerned, it is very inferior. 6. Dislocations of the Urethra. — This is one of the affections that will frequently be met with in practice, although very little is said about it in text-books. I have found very few cases recorded in medical literatm-e. This neglect of the subject by authors is perhaps due to the fact that in many cases of displacement of the urethra, the bladder is also dislocated, and the whole trouble is described under the head of vesicocele or cystocele. Now it is true that dis- placement of the two occurs together, but it will also be found that either may take place alone. It is not by any means uncommon to find prolapsus of the bladder while the urethra is in its normal posi- tion, and occasionally a case will occur in which the urethra is pro- lapsed, while thebladder remains in its proper place. The urethra is subject to displacement upward and downward. In pelvic tumors the bladder is sometimes pushed up out of the pel- vic cavity, and the urethra dragged along with it. Usually no harm comes from this displacement, except that it may cause some difficulty in using the catheter, should this be necessary ; hence I need not dwell on this part of the subject. Dislocations downward are the most important because they occur more frequently, and almost invariably cause suffering to those so affected. The extent of dis- placement varies ex- ceedingly, but I shall describe only the par- tial and the complete. A clear comprehension of these two degrees will cover all interme- diate forms. In partial displacement downward, the upper two thirds of the urethra are pro- lapsed, so that the direction of that portion of the canal is backward, Fig. 279. — Dislocation of the upper third of the urethra. s, symphysis pubis ; r, rectum. ORGANIC DISEASES OF THE URETHRA. 921 instead of curving upward, as in the normal condition. Fig. 279 will convey the idea of this degree of dislocation. In complete prolapsus the urethra runs from the meatus (which is in its normal position) backward, and rests upon the perinneum ; or in extreme cases, accompanied with prolapsus of the bhidder and uterus, its direction is backward and downward ; the position of the vesical end of the urethra being below the level of the meatus. In this degree of displacement the urethra and bladder can be seen pre- senting at the vulva, or lying between the labia minora or thighs. Fig. 280. — Complete dislocation of the urethra with dilatation, c, urethra. The urethra is usually shortened considerably when the prolapsus is. marked. Fig. 280 illustrates complete dislocation. Symptomatology . — The symptoms arising from displacement of the urethra are much the same as those found in dilatation and other urethral diseases. I need not, therefore, repeat them in detail. Suffice it to say, that in dislocation of the upper portion of the canal, there is, in addition to frequent urination, a partial loss of control of the bladder. Under the extra pressure of coughing, for example, the urine will escape. This loss of control does not exist, as a rule, in complete displacement. On the contrary, there is usually diffi- cult urination, which requires increased voluntary efforts to empty the bladder. In some cases the bladder can not be emptied until 922 DISEASES OP WOMEN. it is pushed up into position. In all degrees of displacement, the symptoms are increased in the erect position, and are markedly re- lieved when the patient lies down. Diagnosis. — An examination of the vagina, either by the touch or speculum, will reveal the downward projection of part or all of the urethra, which will demonstrate that there is either dilatation or prolapsus. The two conditions can then be differentiated by the use of the sound. The change in the direction of the canal will be shown as the sound passes in, and dilatation can be excluded by ob- serving that the urethra grasps the instrument firmly at all points. In dislocation of the upper two thirds of the urethra, it will be found that the sound passes in the normal direction, but is arrested at half or three quarters of an inch from the meatus ; but, by pushing up the vaginal wall and the urethra, the sound will then pass into the bladder. When the prolapsus is complete, the instrument passes in easily, but takes a downward and backward direction. Prognosis. — Uncomplicated displacement of the urethra can be remedied in the great majority of cases, if the trouble has not been of long standing. By placing the parts in proper position, and hold- ing them there, the relaxed tissues will usually contract sufficiently to support themselves. Should they fail to do so, the patient can be at least made comfortable by wearing some supporter. In many cases the pelvic floor is imperfect, and by restoring it and bringing the parts together high up the urethra will be kept in place by the natural supports. Causation. — Utero-gestation and delivery are the most important causes of this affection. In the advanced months of pregnancy I have observed that, while the bladder rose above the pubes, the urethra was pushed slightly downward by the settling of the en- larged uterus into the pelvis. In such cases, when labor occurs, the head of the child dislocates the urethra still more, by pushing it still farther down. This process 1 have often w\atched in forceps delivery. When the child's head is large, and there is a partial pro- lapsus of the urethra existing before the forceps are applied, one can see during traction that the urethra and anterior vaginal wall are forced down before the advancing head, and that, too, while counter- pressure to prevent it is being made. The displacement produced in this way is often corrected during convalescence, if proper care be taken to push the parts back into place, and the patient kept at rest until the tissues regain their tonicity. But in many cases the trouble is overlooked, and, by permitting the patient to get up and be on her feet while there is still prolapsus, it will slowly increase, until ORGANIC DISEASES OF THE URETHRA. 923 the dislocation is complete. This will surely be the case if there is any loss of perinseum. Indeed, rupture of the perinseuni is an acci- dent which permits the urethra to descend from its place. I believe that the pei'inseum supports the vaginal walls, which in turn support the urethra ; and if the pennseum is lost, even in part, the vaginal walls become relaxed, or perhaps never regain their tonicity after delivery, and, settling down more and more, carry the urethra with them. I need hardly repeat what has ah'eady been said, that dis- placements of the uterus often cause malposition of the bladder and urethra. Treatmnent. — When the displacement of the urethra is caused by any other affection, such as defective perinseum or prolapsus uteri, then these things should first be attended to. Should there be urethritis, that also should receive approj^riate treatment. But the chief indication is to retain the urethra in place, and this may be accomplished by using the pessary which has been recommended for supporting the prolapsed bladder. Prolapsus of the upper part of the urethra can be remedied in this way quite satisfactorily. When the whole urethra is displaced this instrument, while it supj^orts the upper part, will still permit the middle portion of the urethra to settle down. This may be remedied by making the anterior portion of the pessary long enough to engage in the introitus vulvae, and in that way keep the whole canal where it should be. Should this cause the patient much discomfort the vagina may be tamponed with marine lint, and the parts kept in position until the trouble is partially overcome, and then the pessary will complete the treatment, ILLUSTRATIVE CASE. By way of illustrating what has been said on this subject, I will give the history of a case which may be accepted as a fair repre- sentative of such as will oftentimes be met in practice. A lady, fifty-seven years of age, who had borne seven childi'en, and possessed excellent general health, was very much troubled by a partial loss of control over the bladder. While at rest she had no difiiculty, but on coughing, laughing, stooping, or lifting any heavy weight, the urine would escape in spite of her efforts to control it. I found the upper two thirds of the urethra displaced downward. Upon separating the labia, the urethra and vaginal wall presented just within the introitus, like the tumor seen in prolapsus of the anterior vaginal wall or cystocele. Introducing the catheter, I ob- served that it passed in the usual direction for about three eighths or half an inch, and then turned downward and backward, in the 924 DISEASES OF WOMEN. direction of the hollow of the sacrum. I also satisfied myself that the urethra was not dilated, by observing that it grasped the catheter firmly throughout its whole extent. It was shortened to about an inch. This I ascertained by slowly passing the catheter until the urine began to flow, and then withdrawing the instrument and measuring from its eye to the point marked at the meatus urinarius. A pessary was fitted to keep the parts in place, and very marked relief was at once secured. From the nature of the dislocation, and the very prompt relief following the treatment, I am inclined to think that the incontinence in cases such as this is due to the settling down of the upper por- tion of the urethra, by which the pressure of the bladder and its con- tents falls directly on the sphincter vesicae, and overcomes its resist- ing power. Whether this is the correct explanation or not, one thing is certain, and that is, that cases like the foregoing are often met in practice, and the treatment of restoring the dislocated urethra gives prompt relief. It must not be supposed from what has been said about this case, that the partial loss of retentive power in the bladder so frequently met with in women who have borne children, is always due to dis- location of the urethra. The following case will illustrate sufliciently well a class whose symptoms might lead to the suspicion of disloca- tion of the urethra when it did not exist : A lady, fifty-five years of age, the mother of six children, con- sulted me on the subject of her urinary troubles. She said that she was obliged to urinate oftener than she used to, and that she could not stand or walk for any length of time without being annoyed by the dribbling of urine. She was rather out of health. Her digestion was labored, and she was antemic and easily fatigued. Dislocation of the urethra was suspected, but upon examination the pelvic organs were all in proper position and free from disease, except that there was a want of muscular tonicity of the perinoeum and vagina. The ure- thra was congested throughout its entire extent, and supersensitive, especially at its upper portion. There was also some slight dilata- tion, or aVjnormal dilatability, of the upper two thirds of the canal. She was treated with vaginal injections of cold water, applica- tions of tannin in solution to the urethra, and tonics, including small doses of nux vomica. As her general health improved, the urinary troubles gradually left her. This case properly belongs to the class of dilatations, but is given here to show its resemblance to that of dib- locations. ^ FIG.282 PAGE946. R L.D. DtL. tin PLATE IV. Figure 382. Page 946. Inflammation of the Urethkal Glands. The hyperplasia of the mucous membrane about the mouth of the ducts is usually called caruncle. The red points about the vulva show inflammation caused by the discharge from the glands. '•■ Figure 381. Page 935. .Operation for Prolapsi's of the Bladder and Urethra. .. Incision on the lower side, and buried suture partly intro- , duced. The line on the upper side shows the location of the < incision. V ,. canal, "i ! r > U . . . . :s partially et; The longei i ♦I'^'comes, and thi >.n>iA boaiiBO aoii&amiBhai nrocUj -■^■tnioq bs-r orlT 'orirrK ! sdi ')nil 9£n ORGAXIC DISEASES OF THE URETHRA. 925 The failure (in certain cases) of all methods of treatment led me to devise the following operation for the relief of prolapsus of the urethra. An incision is made on each side of the m-ethra down through the vaginal wall, and extending from half an inch within the vulva upward and outward an inch or more. The edges of the wounds are retracted, and with a buried catgut suture the tissues below the vaginal wall are drawn together and at the same time united to the fascia which forms the subpubic ligament. Another row of sutures unites the deeper portion of the vaginal wall, and the third closes the surface portion of the wound. No tissue at all is removed. The object of the operation is to gather together the tissues on each side of the urethra, and unite them to the fascia above. See Fig. 281, Plate IV. I am unable to speak from sufficient experience regarding the results of this operation, but it promises to be of great value. Prolapsus or Inversion of the Urethral Mucous Membrane, — This subject has been already spoken of in connection with ui-ethral dilatations, and little more need be said about it, except to mention that it occasionally occurs as a distinct affection. In fact the mem- brane can not become inverted unless there is a change in its stract- ure and its relations to the tissues beneath it. Hence it must in all cases be a secondary affection. The membrane must be increased in extent of surface, either from relaxation of its fibers or hyperplasia, and its basic attachments be loosened, before it can be prolajDsed. These changes are doubtless the result of malnutrition in the fonn of degeneration. The prolapse may be limited to one side, or extend all around the canal. The size and extent of the protrusion varies considerably. If the meatus is of full size, the prolapsed portion will usually pre- serve its natural color for a time ; but after a while, from chafing when wet with urine, and especially if not kept clean, it will become red and oedematous. When the meatus is small, these changes occur sooner and in a more marked degree, because the prolapsed portion is partially strangulated. The longer the membrane remains exposed, the more sensitive it becomes, and the frequency of urination and pain attending it in- creases. It also becomes very tender and painful to the touch. In marked cases the ordinary movements of the body irritate the parts, and in that way render walking painful. These are symptoms that closely resemble those of irritable growths at the meatus urinarius ; and, so far as history is concerned, it will not be possible to make a differential diagnosis. To do this it 926 DISEASES OF WOMEN. is necessary to make a local examination. The physical signs, and the points in the diagnosis between this affection and other diseases, have been given briefly but sufficiently, under the head of dilatations of the uretlira, and need not be repeated here. Pi'ognosis. — This disease does not yield promptly to mild treat- ment, unless it is seen early in its progress; and if it does yield to mild, soothing, and astringent applications, it is liable to return. But in case there is no other disease present that tends to keep it up, it can usually be cured by surgical means. Causation. — The causes of prolapsus of the urethral mucous membrane are numerous, but those that are best known are long continued congestion, urethral and cystic irritation, causing frequent urination, and vesical tenesmus. Chlorotic and greatly debilitated women are said to be predisposed to it, as also old prostitutes. The few cases that I have seen were in women over hfty years of age, and all of them were weak, nervous patients, who had suffered from some organic disease or functional derangement of the urinary organs. When a case is first seen it is well to remove any inflammation or other complicating conditions. The prolapsed membrane should be replaced, and the patient kej)t quiet in bed, to favor the retention of the parts in situ. Astringents, such as tannic acid, alum, or persul- phate of iron, in a mild solution, should also be used. Should these fail, resort must then be had to the operation for removal of the pro- lapsed portion of the membrane. The methods of doing this (by excision and the thermo-cautery) have already been described. It only remains for me to say that Winckel operates by clipping off the prolapsed |)ortion of the membrane, and then stitching the internal edge of the membrane to the edge of the meatus with silver wire, allowing the sutures to remain in place for from five to seven days. If the operation is performed in this way the patient must be kept under observation, to see if contraction of the meatus takes place ; and if it does, it should be treated by dilatation. CHAPTEE L. OEGANIC DISEASES OF THE TJKETHEA (cONTmUED). STRICTURE, FOREIGN BODIES, AND INCOMPLETE FISTULA, 8. Stricture of the Tlrethra. — Obstruction of tlie urethra, by nar- rowing of its caliber, is a mucli less common affection in the female than in the male ; still it occurs sufficiently often to demand atten- tion. There are some facts in the pathology of urethral stricture, peculiar to women, which I will first notice. Passing over congeni- tal narrowing of the urethra, by simply saying that such a malfor- mation has been seen, we find that stricture is developed in the female, as in the male, by the deposit of inflammatory products beneath the mucous membrane, which by gradual contraction con- strict the canal. Ulceration of the membrane in a marked degree produces the same results. The inflammation and ulceration which end in the formation of stricture are usually specific in character ; but the same may follow from the too free use of caustics, and in- juries during childbirth. Stricture may also be produced by bands of scar tissue formed in the anterior vaginal wall and stretching across the urethra. Contraction of the whole canal occasionally occurs in cases of vesico-vaginal fistula of long standing. There the narrowing is simply the result of disuse. The form of stricture that will most frequently come under observation will be a contraction of the meatus urinarius, produced in many cases by the too liberal use of caustics in the treatment of abnormal growths at the lower end of the urethra, or from vulvitis. This form of stricture is the least troublesome, and is easily relieved. When due to the results of former urethritis or peri-urethritis, the walls of the urethra are thickened and indurated at the point of the stricture, and there is usually subacute urethritis, sometimes ulceration. In those cases where the cahber of the canal is diminished by cicatrices of the vaginal walls, and in general contraction of the urethra in vesico- 927 928 DISEASES OF WOMEN. vaginal fistula of long standing, the mucous membrane may be per- fectly normal. Syinptomatology . — Frequent and difficult urination are the chief troubles caused by stricture of the urethra. The stream becomes smaller, and may be twisted or flat, but this is rarely observed. Patients, as a rule, only notice that they require to urinate more fre- quently and that they have to make more voluntary efforts to empty the bladder than were necessary before. It will also be found in almost all cases of stricture, that the subject has at some previous time suffered an injury at childbirth, urethritis, or something to which the origin of the stricture can be traced. Great care should be taken to obtain the previous history of cases in which stricture is suspected. This will aid in settling the diagnosis and causation. Diagnosis. — A digital examination by the vagina, will reveal thickening and induration, if the stricture is due to that cause. Cicatrices of the vaginal wall compressing the urethra can be de- tected in the same way. The use of the sound will aid in deter- mining the location of the stricture and the extent to which the canal is contracted. When the stricture is at the meatus it can be found with facility, and the size of the opening can be measured with equal ease ; but when it is located higher up, the largest sound that can be introduced without force should be passed up to the point of stricture. This will localize it ; then, by using a sound that will pass through it, the extent of the constriction will be ascer- tained. The affections which are liable to be mistaken for stricture are retention of urine or difficult urination from pressure on the urethra by the displaced gravid uterus, pelvic tumors, and dislocations of the urethra. The former can be excluded by a vaginal examination, and the latter can be detected by the sound, used as I directed while discussing the diagnosis of the dilatations. Prognosis. — Stricture of the urethra usually yields very promptly to treatment so that the prognosis is good. The only exceptions are where the stricture has existed in a marked degree long enough to cause dilatation of the ureters and disease of the kidneys. Chronic cystitis or urethritis occurring as a result of the stricture, or coinci- dent with it, may so complicate matters as to make recovery slow or even impossible. In cases where the whole urethra is contracted because of the existence of a vesico-vaginal fistula of long standing, there may be found extreme difficulty in restoring the tissues of the urethral walls to their normal state. Treatment. — The treatment of stricture will depend upon its ORGANIC DISEASES OF THE URETHRA. 929 location and cause. If it is situated at the meatus, it can be divided by the urethrotome, or forcibly stretcbed with the dilator. When due to bands of scar tissue in the vagina, they should be divided at several points, and the urethra dilated by passing the sound. When it is owing to deposition of the products of inflammation in the submucous tissue, forcible and rapid dilatation, as practiced on the male subject, will answer well if the proper cases for this form of treatment are selected. While operating in this way the dilatation should be made carefully, with a view to breaking up the constiict- ing tissue without lacerating the mucous membrane. To do this it is not necessary to dilate the urethra to any great extent. As soon as it is recognized that the stricture has given way, the dilatation should be suspended. Incising the stricture from within outward, according to the method commended by Otis and others, for the cure of stricture in the male, will no doubt answer a good purpose. In fact, I am in- clined to believe that this plan of treating the ajffection is the best ; but my own experience with this operation on the female urethra is not sufficient to warrant my speaking positively. In contraction of the w^iole urethra, arising from disuse in cases of vesico-vaginal fistula, gradual dilatation with graduated sounds answers very well. This should be attended to before closing the opening in the bladder. In all cases, attention should be given to any inflammation that may accompany the stricture or follow the treatment. It is well also to keep such patients under observation and pass the sound from time to time to see if there is any ten- dency for the stricture to return. Stricture at the Junction of the Urethra and Bladder. — I desire to direct special attention to this form of stricture because it is, so far as I know, peculiar to women, and its influence on the function of the bladder has not been pointed out. In fact, no distinction has been made between the pathology or clinical history of stricture at the upper end of the urethra and elsewhere in the canal. At least, I am not aware that writers on this subject have mentioned this form of stricture. My own observations on this subject have been limited, but sufficient, I think, to warrant me in saying that strict- ure does occur at the junction of the bladder and urethra, and that it behaves differently from ordinary stricture at other parts of the canal. From the study of the cases which have come under my notice, I have been led to the conclusion, that stricture at this point may be produced by the causes which give rise to the same affection else- 60 930 DISEASES OF WOMEN. where. The upper portion of the urethra is liable to the same trau- matic affections and inflammatory troubles as the rest of the urinary organs ; and the same products or results of disease which cause stricture of the other portions of the urethra act just the same at the point in question. I need not, therefore, dwell on the anatomi- cal lesions found in this affection. The point of most importance to which I desire to call particular attention is the fact that stricture at this part of the urethi'a will cause dijfficuit urination, which is out of proportion to the extent of the narrowing of the canal. In other words, thickening of the tissues at the union of the urethra and bladder, with contraction of the canal in a slight degree, will cause great difficulty in urination, and frequently retention. This is contrai-y to the history of strictm-e of the urethra at other points. In such cases there is no retention of urine until the stricture closes the canal, or very nearly so ; but I have seen retention in cases of stricture at the neck of the bladder while a medium-sized catheter could be passed with ease ; thus showing that the narrowing of the canal was not the only cause of the deranged function. It would appear that the change in structure of the tissues prevented the nor- mal action of that portion of the canal which performs the function of a sphincter vesicae. In discussing the anatomy and function of the bladder and urethra, I stated that the process of closing and opening the neck of the bladder was not fully understood, and I must acknowledge a like difficulty in explaining the disturbance of function which is caused by partial stricture at this point. Spas- modic stricture suggests itself as the explanation of the symptoms presented in such cases ; but it is excluded by demonstrating the presence of organic narrowing of the canal. Symptomatology. — The symptoms presented in this form of stricture are difficult mination, and in some cases complete retention. I have also noticed in one case that there was a frequent desire to urinate ; but that was accounted for by a slight catarrh of the blad- der. These symptoms are such as occur in other conditions, such as atrophy and paralysis of the bladder; obstruction of the urethra from tumors ; calculi ; or the pressure of the displaced uterus and prolapsus of the bladder. The affection can not, therefore, be de- tected from the phenomena presented. Diagnosis. — In this form of stricture there is thickening and induration of the neck of the bladder, which may be detected by digital examination of the vagina. The sound will also reveal a narrowing of the canal at the vesical neck, but the contraction may ORGANIC DISEASES OF THE URETHRA. 931 not be marked. Main reliance must be placed upon the exclusion of all other conditions which can produce the same symptoms. Pressure upon the urethra and prolapsus of the bladder can be ex- cluded by an examination of the pelvic organs ; and the use of the sound will show anything like a complete obstruction of the canal. Having cleared away the possible existence of either of these conditions, I come to the two affections which are most likely to be confounded with this form of stricture, viz., atrophy and paralysis of the bladder. To distinguish these from the stricture, the cathe- ter should be passed when the bladder is well distended, and the character of the flow of urine watched, when it will be observed that in stricture the urine comes away with the usual force. The bladder contracts normally, and with its natural vigor, and expels the urine in a well- sustained stream through the catheter if there is stricture. On the other hand, in paralysis and atrophy, the stream is slow and without force, so much so that voluntary effort, or the pressure of the hand on the abdomen, is sometimes necessary to empty the bladder. This is especially so when the catheter is used while the patient is in the recumbent position. Finally, the diag- nosis is confirmed by testing the dilatability of the urethra. This can be done by passing a dilator along the urethra, and gently test- ing the resistance of the walls of the canal. In this way a slight yielding can be observed at all points until the stricture is reached, and then decided resistance will be encountered. By careful atten- tion to these points in the investigation, I believe it will be possible to make a diagnosis with reasonable certainty. ILLUSTRATIVE CASES. A lady, aged thirty-two ; married fourteen years, and has had three children ; the eldest twelve years and the youngest four, years of age. Thirteen years ago she had typhoid fever, and during the fever had retention of urine, which necessitated the us6 of the catheter for about two weeks. After recovering, she was able to empty the bladder without difficulty, but she suffered from frequent and pain- ful urination. After the birth of her second child, eight years ago, her bladder trouble became much worse, and she has been obliged to use the catheter almost daily ever since. When comparatively free from pelvic pain and tenderness (a relief that she seldom enjoys ex- cept for a few days at a time) she can empty the bladder by making strong voluntary efforts ; but the rule is that she is obliged to use the catheter about every four or Ave hours. The bladder and ure- thra were, upon examination, found to be in their normal positions, 932 DISEASES OF WOMEN. but there were thickening and induration of the tissues at the union of the urethra and bladdei*. A No. 10 (Eng.) sound passed easily up to the neck of the bladder, where it was arrested. A No. 8 (Eng.) sound was then used, and it entered the bladder after encoun- tering a little resistance at the point named. The catheter was then introduced, and the urine flowed freely and rapidly, the bladder con- tracting promptly and with its normal vigor. While the instrument was still in place, a vaginal examination by the linger was made, and the enlargement and induration of the urethral wall were distinctly felt. Dilatation of the urethra was then tried, and the canal yielded readily at all parts except at its extreme upper end, where it was found wanting in elasticity. There was slight catarrh of the blad- der, as shown by an excess of mucus in the urine. The urethra was also congested. The patient was very weak, nervous, and dyspeptic. She was put upon a course of tonic treatment, and the canal slowly dilated by passing twice a week graduated conical sounds, each one being allowed to remain in place for five or ten minutes at a time. She improved, but when last seen she still had difficulty in passing urine. Other cases might be given from my own records, but I prefer to present one, the history of which was given to me by Dr. Paul F. Munde. I do not wish it to be understood that the only difficulty in the following case was stricture ; I only desire to call attention to the fact that the patient had retention of urine and also stricture at the neck of the bladder. Still I am aware that the retention may have been due to some other cause — perhaps paralysis of the blad- der. There are some points in the history of the case which do not pertain to the question now under discussion, but I will give the full record in the doctor's own words : " Lizzie C, twenty-two years of age, single ; admitted to the Woman's Hospital, December 27, 1876. Menstruated first at twelve. The menses since have been irregular, amount small, and always with pain in back and hypogastrium, through whole flow of two days. General health always good until she had a 'bilious attack' six years ago. Four years ago the flow became more and more scanty, and finally ceased entirely three years ago, since which time she has not menstruated at all. Four years ago, after a ' bihous attack,' she had retention of urine for three days, at which time the catheter was used. She had several attacks of retention thereafter, at intervals, then micturated naturally for one year, but for the past three years has not been able to empty her bladder without the aid of a catheter, which she introduces herself habitually three times in the ORGANIC DISEASES OP THE UB^THRA. 933 twenty-four hours. She has no desire to micturate, and can hold her urine twenty-four hours without discomfort, save a sliglit sense of distention. She lias leucorrhoea. Has slight menstrual molimina every four weeks, backache, hypogastric pain and soreness in breasts, constant pelvic weight and dragging. Bowels constipated. General health good. There is now frequent nausea. " Physical Examination. — -There is anteflexion ; depth of the uterus, two and a half inches ; both ovaries prolapsed and tender ; right enlarged. " Treatment. — Hot vaginal douche, strychnia, benzoic acid ; later, daily washing out of the bladder with acidulated warm water (ac. muriat. dil., gtt. ij. to Oj). Urine contains a large quantity of mucus and triple phosphates. Washing out of bladder gives no relief. Phosphoric-acid mixture with ergot and iron was given for months with no benefit. Cups to lumbar region ; galvanic current through pelvis twice a week. "February 3, 1877. — Bladder washings omitted, as they caused pain. Large doses of ergot were given for two months (the strychnia being omitted after four months' trial), but without benefit. Faradic and galvanic current also used alternately every day for months without benefit. Discharged unimproved in any way, May 30, 1877. "Readmitted, October, 1877. Condition the same. "October 31. — Urethra dilated under ether; finger introduced into bladder, which was found flaccid, and did not contract on the finger, which, however, was so closely constricted at the sphincter vesicae as to leave a circular ring on the finger, the distal portion of which appeared blue and almost numb on being withdrawn, after about five minutes. During the introduction of the finger the greatest amount of opposition felt was at the sphincter ; therefore, tlie supposition was expressed that the retention might be due to spasmodic contraction of the sphincter (hysterical probably, con- nected with and dependent on the amenorrhoea, or deficient pelvic innervation), accompanied by atony of the detrusor from the same causes. " On examining the pelvic cavity with the finger in the bladder, the left ovary was found normal in position, but smaller than it should be, being about the size of a shelled almond ; the right, how- ever, was distinctly felt as a globular body of the size of an English walnut. While practicing bimanual palpation on this ovary, it suddenly collapsed under the fingers and entirely disappeared, and could not be found on careful palpation. The explanation, doubt- 934 DISEASES OF WOMEN. less, is that a cyst had been ruptured, and a partial cause at least for the amenorrhoea was thus discovered. Peritonitic symptoms were feared, and ice and opium given ; but, save some suprapubic sore- ness, no inflammatory reaction followed. Retention persisted, and urine had to be drawn the afternoon of the dilatation. '" November 9. — Goodman's self-retaining catheter, with rubber tubing attached, was introduced for the purpose of allowing the urine to dribble off into a urinal, and thus give the bladder a chance to recover its tone. But the catheter caused so much pain that it had to be removed after several days. " November 19. — Soft-rubber catheter was introduced, with tub- ing, etc., for like purpose, and is now retained and on trial. This also caused pain, and was removed. Subsequently vaginal cystotomy was performed by Dr. Emmet, but without avail ; and the patient, after months of ineffectual treatment, was finally discharged un- cured." Treatment. — Regarding the management of stricture at the junction of the urethra and bladder, I am obliged to say that my experience has not yet been sufficient to enable me to speak definitely. It will be seen by the history of Dr. Munde's case that rapid and free dilatation is not sufficient to effect a cure ; at least, it did not relieve his patient. Division of the stricture by incision suggests itself, but I am confident that that operation would be unsatisfactory, because of the great irritation which always occurs when there is a solution of continuity at that point. My practice, therefore, has been to produce slow and gradual dilatation by the use of graduated sounds, and the application of oleate of mercury or iodine to the anterior vaginal wall at the site of the stricture. More extended observation may develop other and better methods of treatment, but for the present this is all that I have to offer on this subject. 9. Foreign Bodies in the Urethra. — Having treated at some length the subject of foreign bodies in the bladder, I shall confine myself here chiefly to the practical points relating to foreign bodies in the urethra. The character of the bodies and their classification are the same as those given while discussing foreign bodies in the bladder. Sijmptomatology. — The chief symptom, if the body be of any size, is retention of urine. In some cases the obstruction is complete, in others the urine comes away in drops. In all cases there is pain and spasmodic action of both the bladder and urethra. If the body be rough or pointed, it will injure the urethral wall, and there will usually be haemorrhage, and later, inflammation, possibly peri-urethral abscess. If not pointed, but hard and rough, it may ulcerate through ORGANIC DISEASES OF THE URETHRA. 935 the urethral wall, causing considerable hsemorrhage. "When the obstruction is kept up for any length of time, the greatly distended bladder becomes very painful, and may be felt as a hard tumor above the pubes. If obstruction occurring from this cause be neglected, such in- juries of the bladder and kidneys as have already been described will ensue. Diagnosis. — The pain and retention will lead to the examination of the urethra, first by catheter or sound, and then by the finger in the vagina. In this way the foreign body is readily detected, un- less it be very soft, in which case it seldom produces retention, being usually washed out by the urine. Treatment. — The foreign body being detected, its extraction should be attempted first by seizing it with a pair of long-bladed forceps, keeping it firmly in place by a finger pressed on the urethra through the vagina behind it. If this is not successful, an attempt may be made to hook it out with a wire loop. I have seen calculi lodged in the urethra in two cases. The first one was detected by using the catheter to relieve the retention of urine, and the other was felt through the vaginal wall, while ex- ploring with the finger to determine the cause of the pain in the urethra and the inability to pass water. The first one, which was lodged near the meatus, was removed as follows : The forefinger of the left hand was introduced into the yagina and pressed above the calculus to steady it. A wire curette was then passed beyond the stone above, and by making traction with the curette and pressing with the finger from above downward, the body was extracted. The other was lodged higher up in the urethra and was removed by the same method, except that I used the alligator forceps instead of the curette. If it can not otherwise be reached the urethra may be dilated up to the point where the body is lodged, and then extracted. If ex- traction is impossible, there is a choice of cutting into the urethra and removing it, or of pushing it back into the bladder and then performing lithotripsy. To me the former seems preferable. 10. Incomplete Internal XTrethral Fistula. — This is one of the rather rare affections, but it deserves a brief notice here, because little if anything, is said about it in the books, and it will be very likely met with at some time in the practice of every physician. The pathology is pretty clearly indicated by the name. It is simply an opening in the urethra which leads into the walls of the 936 DISEASES OF WOMEN. urethro-vaginal septum, but does not open into the vagina. It is the result of some pre-existing trouble. The causes which produced this affection in the cases which I have seen (I recall only two that have come under my notice) were, in the iirst, a jDeri-urethral inflanunation which suppurated and dis- charged into the urethra, and in the second, a cyst which formed in the urethro-vaginal septum, which also opened into the urethra. In the first case, I suspect that the patient had gonorrhoea during preg- nancy, and that after confinement an abscess formed in the anterior vaginal wall, and opened into the urethra as I have already stated. The walls of the abscess contracted, but instead of healing com- pletely, there remained a sinus which communicated with the urethra. Tliis much was inferred from the history obtained regard- ing its origin. When she was first seen, the fistulous opening was found in the floor of the urethra, and it led into the thickened and indurated septum between the urethra and vagina. The other case was developed under my own observation in the following way. The lady was pregnant, and during pregnancy observed that there was some enlargement just within the introitus vaginse. On examination, a cyst was found in the anterior vaginal wall at the middle of the urethra. She was at the eighth month of utero-gestation when this diagnosis was made, and I decided to let the matter rest until her confinement. Immediately after the birth of her child, inflammation was set up in the cyst, and suppuration followed. An opening was made into the cyst from the vagina, and pus was freely discharged. At the same time pus began to flow from the urethra. The discharge continued from both openings for some time, and then the vaginal opening closed, but pus con- tinued to flow from the urethra for many weeks. A probe could be passed from the fistulous opening in the urethra into the sac, which slowly contracted, and finally, at the end of six months, closed en- tirely, and the patient completely recovered. Symptomatology. — There is pain during urination, and heat and aching disti'ess in the urethra ; and if the opening is near to the neck of the bladder, frequent urination and vesical tenesmus. Pus is discharged from the urethra during urination, and is found in the urine. It also oozes away at all times. In some cases, the urine enters the fistula and causes smarting, burning pain during and for some time after urination, by distending the sac or burrowing in the tissues. Diagnosis. — Examining the vagina by the finger will detect the thickening and induration of the walls of the urethra and vagina at ORGANIC DISEASES OF THE URETHRA. 937 the seat of tlie fistula ; and by making pressure with the finger from above do^v^lward, pus and urine can be pressed out, and may be seen as they escape from the meatus urinarius. A small probe with a bulbous point should be bent, so as to make a short curve at the end, and then passed into the urethra with the curve directed toward the floor of the canal ; and by njoving it to and fro the fistula can usually be found. The point of the probe will catch in the open- ing, and when carried downward it can be felt through the wall of the vagina. The only condition which is liable to be confounded with fistula is urethrocele, but by keeping in mind the physical signs of that af- fection the distinction will be recognized. Should there be any doubt, the endoscope should be used to examine the urethra. The fistula will then be found, and by using the speculum the opening can be probed through it. A flexible gum catheter may be used if the silver probe does not succeed. Ti'eatment. — The cases that have come under my care were treated by washing out the urethra with warm water and borax sev- eral times a day, and keeping the sac emptied as completely as pos- sible by making pressure on the urethra, through the vagina, with the finger. Both cases were very tedious, and required much care and long treatment. This experience has satisfied me that the man- agement of such cases ought to be altogether different from that which I employed. I am con ti dent that better and more prompt results would be obtained by converting the incomplete into a co'm- plete fistula. This could be easily accomplished by passing a probe into the opening as far as possible, and then cutting down upon it through the wall of the vagina. By this operation a urethro-vaginal fistula is made, which by proper treatment will close of its own ac- cord. During the after treatment the patient should wear a self- retaining catheter, or, what is still better, have the bladder emptied regularly by the catheter. This will keep the urine from getting into the fistula, which prevents healing. Care should be taken to keep the opening in the vagina from uniting before the urethral opening is healed. This can be accomplished by passing the probe into it from time to time. The whole fistula should be kept clean by injecting water into the urethra and letting it flow through the fistula into the vagina. In case the tissues are so indurated and changed in character as to refuse to heal under this treatment, the fistula must be closed by the usual operation. The method of oper- ating is the same as in vesico- vaginal fistula, a description of which will be hereafter given. CHAPTEK LI. DISEASES OF THE GLANDS OF THE FEMALE URETHRA. The diseases of these glands to which I invite attention are ; 1. Subacute inflammation or catarrh. 2. Gonorrhoea! inflammation and its results or productSo 3. Inflammation following vulvitis such as occurs in strumous children. 4. Tuberculosis. 1. Catarrhal Inflammation. — The first affection named in the classi- fication is a mild form of inflammation which occurs in connection with subacute vaginitis, such as we find accompanying ordinary uter- ine disease, or following parturition. This condition gives the patient very little, if any, inconvenience, and readily passes unnoticed by the gynecologist unless specially looked for. The mouths of the ducts are slightly enlarged, and sometimes surrounded by a very narrow areola of a bright red color. By pressure upon the urethra from be- hind forward they discharge a white serous fluid. The cases which have come under my observation were detected while examining for other diseases, and none of them was attended with any marked symptoms. In some of them the inflammation disappeared without treatment. In others it continued without showing any tendency to increase in severity or lead to important changes of structure. It is quite possible that a non-specific vaginitis might induce a high grade of inflammation in these glands, with all the pathological changes to be described hereafter, but up to the present time I liave not observed any evidence tliat such is the case. 2. Gonorrhceal Inflammation. — This is of the chronic purulent variety, and in time extends from the mucous membrane of the ducts to the surrounding tissues. It does not usually attract atten- tion until the vaginitis and uretliritis have subsided. The lesions presented differ according to the length of time which the disease has existed. AVhen examined early there is a slight 938 DISEASES OF THE GLANDS OF THE FEMALE URETHRA. 939 swelling of the lower portion of the urethra. The mouths of the ducts are larger than normal, and the tissues around them are con- gested. There is tenderness to the toucli, and pressure upon the urethra from above downward causes a free purulent discharge. Sometimes it is necessary to separate the labia of the meatus in order to see the orifices of the ducts. In cases of longer standing the mouths of the ducts are brought into view by a slight prolapsus and eversion of the mucous membrane caused bv swelling. The mucous membrane in the neighborhood of the ducts becomes thickened by proliferation of the areolar tissue and epithelium, presenting an ir- regular papillomatous appearance of a deep-red color, upon the inner sides of which the orifices of the ducts appear like minute ulcers, of a yellowish gray color. The lower third of the urethra is gener- ally thickened and indurated. The general appearance of the j)arts is quite like caruncle or papilloma of the meatus. In fact, inflamma- tion of these glands has been mistaken for caruncle, at least it has been my misfortune in the past to confound the two affections, and 1 can not see how others could have made a differential diagnosis, if guided by the current literature upon the subject. In a large propor- tion of the cases of this disease I have observed that upon the inner sides of the labia minora, which rest upon the meatus, there are patches of inflammation which are caused and kept up by the purulent dis- charge from the glands. These circumscribed patches of inflamma- tion sometimes extend downward on each side of the introitus, and occasionally involve the carunculse myrtiformes. This gives rise to much tenderness, which simulates vaginismus. The chief symptoms are extreme tenderness to the touch, great discomfort in sitting and walking, occasional sharp stinging pain, and a continual sense of heat in the parts. There is painful urination in some cases, and in others there is not. In some of the most marked cases that I have seen, this symptom was entirely absent, while in less severe forms it has been present. That peculiar difference in the history of cases I have attributed to the fact that, in the well-developed forms of the disease there is a considerable eversion of the lower portion of the urethra, which throws the diseased and tender portion outward, and thereby prevents the urine from coming in contact with the irritable surfaces. Occasionally there is frequent urination, due probably to sympathetic irritation of the bladder. The symptom which is always present, in varying degrees of severity, is tenderness. The diagnosis and treatment may be left unnoticed until the other two affections of these glands have been described. 3. Purulent Vulvitis. — This occurs in children, especially those of a 940 DISEASES OF WOMEN. scrofulous diathesis, and occasionally extends to the urethral glands. When such an extension of the disease occurs, it adds to its well-known rebeUiousness to treatment. The original inflammation of the vulva may be relieved, but if the glands are involved, the purulent dis- charge from them will soon light up the disease of the external parts. From my own observations I believe that these glands rarely become involved ; but when they do, there is little possibility of curing the affection of the vulva until the glands are first successful- ly treated. There is really nothing peculiar in the cHnical history of this form of disease, except its etiology, and therefore I need not dwell longer upon it further than to say that I have seen a case of this kind, which had resisted treatment for a long time, but prompt- ly recovered after the inflammation of the glands was detected and treated, 4, Tuberculosis, or Tubercular Inflammatioii of the Urethral Glands. — This is an affection to be distinguished from the other forms of the disease already considered. It occurs only in those who are of thfr tubercular diathesis, and may appear as a primary affection, or be developed during the progress of tubercular disease of other organs of the body. When the disease is first established, it presents th& same pathological appearance as has been described under the head of gonorrhoeal inflammation. There is, apparently, the same purulent discharge, with redness and proliferation around the mouths of the ducts, giving the peculiar caruncular or papillomatous appearance. The only peculiar characteristics of this affection that have been ob- served up to the present time, are the accumulation of caseous ma- terial in the tubules and ulceration, which occur in more advanced stages of the disease. The ulceration takes place in the newly-formed tissue in the walls and around the mouths of the tubules. These caseous con- cretions and ulcerations are not found in all cases. Indeed, they are rare. There is generally urethral inflammation accompanying this con- dition of the glands. It sometimes begins simultaneously with the disease of the glands, and when it does not it follows soon after. In time the bladder becomes affected, and also the kidneys. At what- ever point the disease commences it increases in severity, and ex- tends until the whole of the urinary organs are involved, unless the patient succumbs before it has completed its progress. In some cases there are polypi and papillary growths of small size found along the urethra. These, I believe, originate in inflammation of mucous follicles and papillsB of the mucous membrane. DISEASES OF THE GLANDS OF THE FEMALE URETHRA. 941 The symptoms presented in this form of disease are the same as those found in the other forms ah-eady described. From this it will be observed that the physical appearance and the symptoms are in- sufficient to establish a diagnosis. When there are ulcerations and caseous deposits the disease may be strongly suspected of being tu- bercular. Still, there is room for doubt until we find tuberculosis of other organs. This either precedes or soon follows the appearance of the disease of the glands. In all the cases which have come under my observation, the lungs were either tubercular when the patients were first seen or became so soon after. This affection is a source of great annoyance and suffering, and no doubt hastens the progress of the pulmonary disease, with which it is generally accompanied. It has also another very important significance in the fact that it indicates the commencement of gen- eral tuberculosis of the urinary organs. The diagnosis of tubercular cystitis and urethritis has always been exceedingly difficult in the early stages of the disease. Indeed, it has been deemed imiDossible by most authors to distinguish ordinary cystitis from the tubercular form until the disease became developed in other organs of the body. Now the tuberculosis of these glands is understood, a valu- able aid to diagnosis has been gained. Whenever an inflammation of these glands is found that can not be traced to a former gon- orrhoea or vulvitis, it is almost sure to be tubercular, and the diagnosis is placed beyond doubt if the patient has the tubercular diathesis. I am greatly indebted to Dr. Terrillon, of Paris, for some very valuable information upon the relations of disease of these glands to tuberculosis. In the " Progres Medicale " he published a very elaborate article entitled "Polypoid Excrescences of the Female Urethra, Symptomatic of Tuberculosis of the Urinary Organs," which is full of original observations of inestimable value. In comparing his observations with my own, I am fully satisfied that he has mis- taken tubercular inflammation, and the products of these glands, for excrescences, in some of his cases at least. Without being aware of the presence of these glands, it is perfectly natural that he should class those vascular developments found at the meatus urinarius among the ordinary neoplasms of the urethra, just as all others have done in the past. There is every reason for believing that the ex- crescences which Dr. Terrillon refers to differ in their essential pa- thology from the ordinary polypoid growths, usually called carun- culae, which, are found in the urethra and are not associated with 942 DISEASES OF WOMEN. tuberculosis. And as the history of his cases coincides with the his- tory of the cases of tuberculosis of these glands which I have seen, I am compelled to believe that he has not fully comprehended the true pathology of this aJfection. He has, however, clearly shown its relation to tuberculosis of the urinary organs, and that alone is worthy of the highest honor. Dr. Terrillon's article is too long to be given in full, but a few condensed extracts will show his views upon the subject. His description of the symptoms and the general appearance of the parts affected is so complete that I will give it in his own words : " The fungoid growths show themselves usually at the surface of the urethral orifice. They are projecting and pedunculate. Sel- dom isolated, they form most frequently a wreath more or less regu- lar, around the orifice of the meatus. In yery aggravated cases they are united into a mass, and then form a real projecting tumor with a fringed aspect, of a lively red. In the center of the tumor is easily to be found the orifice of the urethra masked by those papillary growths. The clinical history of fungoid excrescences of the urethra accompanying tuberculosis of that organ and the bladder includes the observation of two distinct parts : First, the study of the growths themselves and the character of them ; second, all the phenomena to be found in cystitis and tubercular urethritis. Sometimes the symp- toms of the two lesions are found together ; sometimes on the con- trary, they exist singly up to a certain period of the disease. One of the special symptoms of this affection is the exquisite tenderness of which these fungoids are possessed. The least touch, the least rubbing, the passage of urine, sufiices to cause the most extensive pain, which renders life insupportable. This hypersesthesia, which may extend to the neighboring parts, causes, at the sides of the ori- fice of the vulva, symptoms of the most acute vaginitis. These are the ordinary symptoms of fungoid growths when existing exter- nally." The author at this point refers to excrescences found within the urethra as being of the same nature as those found at the meatus. He makes no distinction between the two forms of disease. There is, however, a difference w^orthy of notice. Excrescences found within the urethra are usually cystic polypi or enlarged pa- pillae of the mucous membrane, conditions which may exist inde- pendently of tuberculosis. I infer from some other statements made in his writings that the granular urethritis — as we are in the habit of calUng it — is generally secondary to the disease of the urethral glands. The views of this author in regard to the order of develop- DISEASES OP THE GLANDS OF THE FEMALE URETHRA, 943 ment of iiretliritis, cystitis, and finally tuberculosis of the lungs, are set forth in the following: " Sometimes at the time of their appearance these fungoids ap- pear to be altogether isolated from all other serious lesions. Yet they seem to precede tuberculization, or soon take a rapid course in developing granulations in the urethra. In other cases these growths may appear some time after the symptoms of tuberculization have been established," The cases recorded by Dr, Terrillon, and also those which have come under my o^vn observation, show that, as a rule, this disease of the urethra precedes the appearance of tuber- culosis in other organs of the body, such as the lungs. It also is one of the first lesions observed in tuberculosis of the urinary organs. The following is from Dr, Terrillon's paper on this part of the sub- ject : "IS^ow comes up the important question whether these polypi of the mucous membrane should be considered as a jDrimary or an idio- pathic lesion, and I think that it can be solved in the following man- ner : These polypi are most assuredly the result of chronic inflamma- tion and an irritation of the mucous membrane. Now, development of tubercular granulations within the mucous membrane is at first the cause of irritation, before any changes in the urine ; ulceration does not occur until after a sufficient length of time. With one of our patients the first irritation induced the fonnation of polypi, and the common painful symptoms followed. Their extirpation gave relief, but that lasted only up to the time when urethro- vesical ulcera- tion occurred. It will be observed that in this case the affection began in the urethra and extended to the bladder, and also second- arily involved the left kidney (ascending tuberculosis), causing, finally, change in the urine, with the free formation of pus. I there- fore do not hesitate to maintain that the fungoid polypi are the result of tubercular irritation of the mucous membrane of the urethra, which gives rise to the very serious symptoms which occur in the early stages of the disease. Without them, urinary tuberculosis would not give rise to those striking symptoms until after a sufficient length of time, when the ulcerations appear in other organs. An analogous phenomenon which is observed in the larynx should be mentioned here. We know, as a matter of fact, that the tuberculiza- tion of the larynx does not only occasion ulceration, but also poly poid growths. There is produced at the expense of the ulcerated mucous membrane an hypertroj)hy and proliferation, in the form of cauliflower excrescences or cockscomb growths, a species of polypi, smaller or larger, by which the glottis might be more or less 944 DISEASES OF WOMEN. obliterated. It will, therefore, be admitted that there is a resem- blance between laryngeal excrescences and those found in the ure- thra of women. The polypoid excrescences of the female urethra are shown, from an etiological point of view, to be of two distinct va- rieties. The iirst variety is idiopathic, and may be recognized by a slight irritation. The prognosis is good ; extirpation in these cases gives a rapid cure. This is the most frequent variety. The second kind, although they give the same outward appearance as the first variety, are, on the contrary, accompanied from the outset by ure- thritis and tubercular cystitis, of which variety these lesions consti- tute important symptoms." It is clearly evident to me that the two varieties described by Dr. Terrillon differ very essentially in their pathology. The first, or simpler forms correspond to the papilloma occasionally seen, and so easily cured by extirpation. The other variety has its origin in tubercular disease of the urethral glands, and is incurable by any treatment heretofore known, as the author states. Dr. Terrillon gives the full history of four cases observed by him. They are original, and of great value, but too long to be pro- duced here. Suffice it to say, that in all four there were present the excrescences at the meatus urinarius, due, as their clinical histories show, to disease of the glands, and, finally, tuberculosis of the ure- thra, bladder, and lungs, A careful post-mortem examination was made in the fourth case observed, which revealed tuberculosis of the urethra, bladder, right kidney, and lungs. Wlien I found infiamniation of these glands associated with tuber- culosis of other organs, it occurred to me that the disease of the glands might be of the same nature, or tubercular ; but I am indebted to the writings of Dr. Terrillon for the full knowledge of the patho- logical relations of the affection of these glands to tubei'culosis of the other urinary organs. We have studied the subject from different stand-points, and the combined results of our labors cover the ground pretty thoroughly. While he has clearly settled the relation of these excrescences to tuberculosis of the urinary organs, I have satisfied myself that these new growths are but the products of a tubercular infiammation of the urethral glands, the existence of which were, I presume, unknown to him. The treatment of the various forms of inflammation of these glands may all be discussed at the same time. It is settled upon the best evidence that when these glands be- come inflamed there is no natural tendency to their recovery. Those who have read the history of my first published case will remember that I employed all the recognized treatment for caruncle, but at the DISEASES OF THE GLANDS OF THE FEMALE URETHRA. 945 end of a year my patient M'as no better. Dr. Terrillon has had a similar experience. On this point he says : " A characteristic more important, and to which I desire to call especial attention, because it indicates well, in my opinion, the consecutive development of these excrescences, is their tenacity and the facility with which they recur. Really, one can see in the observations " (meaning his cases) " in which continued surgical intervention has been practiced, it brought about either no relief or only a momentary amelioration." The treatment which I employed at first was to inject the tu- bules with the ordinary solutions used in the treatment of inflam- mation of mucous membranes, using for the purpose a hypodermic syringe, with the point of the needle rounded off. This method I found useful but very tedious. It then occurred to me that laying oj)en the tubules their whole length and keeping them open would prevent the purulent accumulation (which acts so effectually in keep- ing up the inflammation), and also bring the affected parts within easy reach of the necessary treatment. This method was suggested in my paper, published seven years ago, and since then I have tried the method in quite a number of cases, and found it entirely satis- factory. In the majority of cases it is ail that is required to effect a complete cure. The method of operating is as follows : The pa- tient is placed upon the left side, and a Suns's speculum used to keep the labia apart and retract the perinceum. This brings the j)arts well into view, and within easy reach of the operator. The position and depth of the tubules having been first ascer- tained, the probe-pointed blade of a very fine scissors is then intro- duced, and the posterior wall divided its whole length. To prevent the parts from reuniting, a small piece of cotton, saturated with persulphate of iron, should be packed in between the divided edges. Brushing the surfaces over with the iron, without using the cotton, will answer, although less certainly, to prevent reuniting. Later still in my practice I have opened these ducts with the cautery. The method is as follows : A probe is passed into the ducts, and the wall to be divided is made tense by making pressure outward with the probe. The tissues are then divided. This method has the ad- vantages of preventing haemorrhage, and also of preventing the parts from reuniting. Yery little after treatment is required. In the majority of cases recovery follows the operation of laying open the canals. Sometimes the inflammation lingers in a modified form, but yields to a few applications of nitrate of silver or sulphate of zinc. In several eases in which the excrescences were abundant, they remained after the operation, although very much reduced ir 61 946 DISEASES OF WOMEN. size. An application of nitric acid destroyed tliem, and they have not sho\vn the least disposition to return. ILLIJSTEATrV'E CASES. Gonorrhoeal Inflammatioii. — The patient was a married lady, thirty years of age. She was well developed, and had always enjoyed good general health. "With the exception of a mild form of dys- menorrhoea, she had had no disease of the sexual organs until one year before she came under my observation. At that time she was abruptly attacked with a profuse leucorrhoea and other symptoms of inflammation of the vulva and vagina, including painful urination. She placed herself at once under the care of the family physician, who treated her locally until she came to me. Her leucorrboea had by that time diminished, and the painful urination had passed away, but otherwise she had not improved. At my first examination I found traces of the former inflammation of the vulva and vagina. The meatus urinarius was everted and surrounded by a number of papillary projections, of a deep-red color, and altogether presenting an appearance resembling that which is known as vascular tumor, or carbuncle of the meatus. See Fig. 282, Plate lY. The diagnosis then made was subacute vaginitis, perhaps of gon- orrhoeal origin, and inflamed papilloma of the meatus urinariuSc The vaginitis was treated in the usual way, and soon terminated in complete recovery, but the inflammation and tenderness of the meatus remained unchanged, and annoyed the patient exceedingly. She could not walk or sit without pain, and coitus had to be avoided entirely. I presumed at first that the disease of the meatus was kept up by the irritating discharge from the vagina, and I hoped that when the one was removed the other would get well, but such was not the case. I then thoroughly cauterized the elevated and tender points about the meatus with nitrate of silver. This caused very great pain at the time, and was followed by no improvement. Pure nitric acid was used in the same way, but with no better result except to destroy elevations of the mucous membrane around the orifice. The same areola of inflammation around the meatus continued, and the symptoms remained the same. A full account of the progress of the case would be tedious and useless. Sufiice it to say that for eight months I treated the disease with diligence and care, but at the end of that time she was very little better. Caustics and cauteries being unsatisfactory, I tried sedatives and alteratives, including iodoform, iodine, mercury, and bismuth. At DISEASES OF THE GLANDS OF THE FEMALE URETHRA. 947 times the inflammation subsided slightly, and the elevated points became smaller, but in a short time fresh proliferations sprang up and the muco-purulent secretion continued to bathe the parts. Toward the end of this long period of treatment, and while making a critical examination, I observed that on each side of the meatus there were two depressions tilled with a yellowish gray matter, look- ing like minute ulcers, but upon probing them, wdth a view to deter- mine their depth, I found that they admitted the probe over half an inch. After withdrawing the probe, I made pressure ujDon the ure- thra from above downward, and succeeded in expressing a purulent fluid, which could be distinctly seen escaping from their orifices. Treatment was then directed to these canals ; tirst, they were in- jected with tincture of iodine, and subsequently they were cauter- ized by passing a probe coated with nitrate of silver along their en- tire depth. Prompt improvement followed this application. The inflammation around the meatus gradually subsided, and the pain and tenderness passed away. In less than two months from the time that a correct diagnosis was made and appropriate treatment em- ployed the patient recovered completely. The satisfaction which this gave to both patient and physician will be appreciated when the fact is recalled that she had been suffering for twenty -one months, and that for nine months she had been under my treatment without any marked improvement. Such was my experience with this disease before I knew any- thing about the presence and character of the structures involved. Since then I have seen several cases of the same kind, and have found the diagnosis easy and the treatment satisfactory. A brief history of another case will contrast agreeably with the former one : A delicate nervous lady, aged thirty-three years, married seven years without having had children. She had suffered for one year from symptoms resembling those of the case given above. At first her sufferings were not so severe, but in time they became intoler- able, and she was compelled to consult her physician, who exam- ined her, and found what lie supposed to be a vascular tumor of the meatus urinarius. He sent her to me to have it removed, I found that she had the disease now under consideration, and a subacute vaginitis limited mostly to the upper and posterior portion of the va- gina. The inflamed papillae around the mouths of the ducts were deep red, and so tender as to render it very diflScult to examine her. She was directed to use a vaginal douche of borax and warm water. The inflamed papillae were touched with equal parts of tincture of iodine and carbolic acid, and the ducts were injected with a solu- 948 DISEASES OF WOMEN. tion of 3 ii of nitrate of silver to 3 i of water. Twice a week sub- sequently they were injected with a solution of two grains of nitrate of silver to the ounce of water, and finally borax and water were used. Under that treatment she recovered in six weeks. For injecting these ducts, I use a hypodermic syringe with the needle made probe pointed. The history of these two cases may possibly convey the impres- sion that inflammation of these glands is easily cured. That is only true in some cases ; I have seen others that were exceedingly obsti- nate. The disease would subside, but not fully disappear, and as soon as all applications were suspended would return. This has led me to think that other methods of treatment may yet be discovered, and has induced me to lay open the ducts of these glands in the way already described. Tuberculosis of the Urethral Glands. — The first case of this kind which I remember having seen came under the care of Prof. E. N. Chapman at the Long Island College Hospital while I was his assist- ant. She ])resented at her first visit the history and physical signs of what was then supposed to be caruncle, which was treated with caustics. Very little relief followed. She soon gave evidence of cystitis which was also treated for several months without success. The diagnosis was inflammation of the bladder. After a time she disappeared, but I subsequently learned that she died in the City Hospital, of pulmonary tuberculosis. Upon reflection I am satis- fied that the primary disease was tuberculosis of the urethral glands. The next case came under my own care in the Long Island Col- lege Hospital. When first seen she had papillomatous excrescences at the meatus and cystitis, presumed to be non-specitic. I was at that time unaware of the presence of the urethral glands, and there- fore did not at first suspect tuberculosis. Treatment gave her no relief, and her sufferings were beyond description. In the hope of curing her, I made an artificial vesico -vaginal fistula, which relieved her very much, but her general condition became more and more like that of a consumptive. She died, and a post-mortem examination revealed complete destruction of the left kidney from tuberculosis. The bladder and urethra were covered throughout with tubercular ulcerations. Since I discovered the urethral glands I have seen two cases of tuberculosis affecting them. The history of one of them is as follows : A young single lady first consulted me for dysmenorrhoea and frequent and painful urination. I found by examination that she had anteflexion of the uterus and inflammation of the urethral i DISEASES OF THE GLANDS OF THE FEMALE URETHRA. 949 glands. The painful menstruation was partially relieved by correct ing the flexion. The inflamed glands were treated in the manner to be hereafter described, and the inflammation at that point disap- peared. Her frequent urination did not subside, however ; on the contrary, she developed a marked cystitis, which did not yield to treatment. Her lungs at the same time gave evidence of tubercu- losis, which proved fatal. Recurring Gonorrhoea from Gonorrhceal InflammatioK. of the Ure- thral Glands. — Dr. H. C. Howard, of Campaign, Illinois, has re- cently had a series of cases in which gonorrhoea had been communi- cated by the husband to the wife, and cured in both, but repeatedly returned in the case of the husband, although he had not been im- properly exposed. Careful examination of the wife showed that the disease had persisted in the little glands of the female urethra, flrst described by Dr. A, J. C. Skene, of Brooklyn ("American Journal of Obstetrics," April, 1880), and fully noticed editorially in the " Chicago Medical Gazette," May 5, 1880. Dr. Howard, be- lieving that these little glands were continuing to pour out true gonorrhoeal pus, although the patient presented no other evidence of the disease, and that this pus had produced recurrent gonorrhcea in the male, directed his treatment to them, which consisted in the application of carbolic-acid crystals. In each case the discharge disappeared permanently under this treatment, and the disease in the male now having been cured, did not return. Dr. Skene in his original paper, expresses the opinion that in the case which he had observed, the inflammation was caused by gonorrhoea, which per- sisted in the glands long after the original trace of the disease had disappeared. Dr. Howard seems to have been the first to note this condition as a cause of gonorrhoea recurring as often as cured in the male. His observation is important as showing that the female may communicate the disease long after it would previously have been pronounced cured. — Chicago Medical Review, August 5, After reading the account of Dr. Howard's cases I gave atten- tion to the subject and found cases to correspond with his. The following is a fair example and has additional value because confirmed by another observer. A widow who had children and was perfectly well, contracted a gonorrhoea which was supposed to be cured. She married again and her husband developed a gonorrhoea which he supposed was a recurrence of the disease, having had it before. He was led to this conclusion because his wife had no evidence of being simi- larly affected. He was treated by Prof. Charles Jewett and soon 950 DISEASES OF WOMEN, recovered, but again and again the disease returned. Dr. Jewett suspected that his wife might have gonorrhea without the usual acute symptoms. He sent her to me for examination. I could not find the slightest evidence of any disease of the urethra, vagina, or uterus, but I noticed that the orifices of the urethral glands were rather deeper in color than normal. To make sure I laid the ducts open, and found pus in both of them. They were thoroughly cau- terized with carbolic acid and tincture of iodine. From that day till the present time, now four years, there has been no further evi- dence of gonorrhoea in that family. CHAPTER LII. VESICAL AND URETHRAL FISTULJE. Classification and Pathology. — The classification of fistulse which I shall adopt is as follows : I. Vesico- Vaginal. — This is subdivided into (a) those occurring in the trigone, the opening being situated at the neck of the blad- der ; ih) those occurring at the bas-fond, the opening involving the inferior portion of the bladder. II. Urethro-Yaginal. — The opening being between the urethra and vagina. III. Utero-Yaginal. — The opening communicating with the bladder, vagina, and cervix, or with the body of the uterus. lY. In this variety the entire vesico-vaginal wall is destroyed, and sometimes the urethro-vaginal wall also. This variety is for- tunately quite rare. The relative frequency of these varieties is about in the order in which they are given in the classification. The last and rarest one is attended with extensive destruction of tissue, and includes the first three classes. In fact, it covers the ground occupied by all the other varieties. The direction of these fistulas may be transverse, oblique, or longitudinal, and their form may be oval, round, linear, angular, or irregular. The dimensions of the opening also vary from one so small as barely to admit an ordinary probe to one measuring two inches in diameter. The direction of the fistula may possibly be determined by the cause of the primary injury. The form of the opening depends upon the arrangement of the muscular fibers of the vagina. This influences the line of laceration, and also the healing process, which latter modifies the final shape of the opening. The condition of the borders of the fistulas and their form differ much at first; sometimes they are thin, inverted, quite pale, and 951 952 DISEASES OF WOMEN. smooth ; this is especially the case with the upper border. In other instances they are thick, soft, and muscular, or, again, they may be hard, inelastic, and anaemic. The mucous membrane of the bladder often projects through the opening if it is large, forming a red erect- ile tumor. Symptomatology. — The chief symj^tom is incontinence of urine. This is always the same, no matter how small or how large the open- ing may be. In some cases, indeed, this is the only symptom. In others there is much pain in the pelvic region, and irritation from the constant flow of urine, the pelvic pain being most marked at first, and in those cases in which there is much scar tissue. Sometimes there is inflammation of the bladder and urethra, which causes pain. If the fistula is due to 23arturition, the state of the bladder im- mediately succeeding the labor is such that for two or three days there is an inability to evacuate its contents without some pain or uneasiness, requiring perhaps the use of the catheter. After this the urine may escape through the urethra, or it may do so from the very beginning. In from five to ten days after confinement the urine begins to escape entirely from the vagina. A sense of something giving way is sometimes felt at that time. The labia, the inner surface of the thighs, and the perinseum, being constantly bathed in the urine, become red, inflamed, and cov- ered with pustules, which sometimes form ulcers of considerable depth. The external genitalia and the surface of the vagina fre- quently become incrusted with a saline deposit consisting of urates, and there is also a strong urinous odor about the person and the clothing of the patient. These symptoms and physical signs, while they are strong evi- dences of fistula, are not sufficient to base a diagnosis upon. A physi- cal exploration of the parts must be made to ascertain with certainty the presence or absence of a fistula. Physical Signs. — The patient should be placed upon a table in Sims's position in a good light, Sims's speculum should be used to open the vagina, and the perinseum should be drawn well back toward the sacrum until the entrance of the air distends the vaginal cavity. The fistula, if one exists, will most likely be at once detected, unless it is very small. If it is not found in this way, a probe should be used to explore any pockets or depressions that may exist in the vaginal wall. Should this fail, milk may be injected through the VESICAL AND URETHRAL FISTULA. 953 urethra into the bladder to distend its walls, and special attention given to see if any of it passes into the vagina. Incontinence from some muscular lesion of the neck of the blad- der, which allows the urine to find its way back into the vagina after escaping passively from the urethra, is the only affection which simulates fistula, but a careful examination made in the manner just described will determine the diagnosis. Complications. — These are stricture of the vagina, recto- vaginal fistula, obliteration of the urethra, and cicatrices of the vagina and cervix uteri. Inflammation of the edges of the fistula and deposits of urinary salts in the vagina may be present ; cystitis, vaginitis, and m°ethritis may also be found accompanying the fistulse. Prognosis. — If the fistula is of such a nature that it can be closed by an operation with any reasonable hope of success, and in the great majority of cases this is possible, the chances of a perfect recovery are excellent. Good operating will generally insure success, except in extraor- dinary cases, and these are very rare. Causation. — Pressure of the foetal head is the most common cause of vesico-vaginal fistula. Almost all authors agree in attribut- ing about ninety per cent to this cause. Compression of the soft parts in tedious labor causes death and sloughing of these tissues, and the edges of the opening thus made failing to unite, the fistulous opening results. If the vitality of the parts is not completely destroyed, but is greatly diminished, inflam- mation and ulceration may occur, and lead to the same result as in the case of sloughing. The best evidence that pressure of the foetal head in delayed labor is the chief cause of fistula is obtained from the fact that since the progress and improvement in the obstetric art, by which difficult labors are more promptly terminated, fistula is far less frequent than formerly. Wounds of the vesico-vaginal wall may occur during the use of instruments or long-continued efi:orts in manual delivery. The slip- ping of a perforator in cases of craniotomy may be especially men- tioned as likely to open the vesico-vaginal septum. The forceps have come in for a large share of blame in times past, but they have little agency in producing such an accident ; the earlier and the more frequent that they are employed by educated hands, the fewer fistulse will occur. This is a fact obtained from the records of obstetrics and gynecology. Foreign substances in the bladder — vesical calculi, for example —may cause fistula by perforating the vesico-vaginal septum. Many 954 DISEASES OF WOMEN. years ago I saw a case, with Dr. J. H. Hobart Burge, of Brooklyn, in which this happened. The fii'st calculus formed in the bladder was discharged through the vesico- vaginal septum, and several more were discharged through the fistula. Badly fitting pessaries, worn for too great a length of time, may also be mentioned among the causes inducing this lesion. Then there are a number of cases re- corded in which a pessary has destroyed the vesico- vaginal septum. The process by which the opening is made is no doubt ulceration from pressure and irritation. The process of ulceration is probably favored by the deposit on the instrument of the salts of the urine, and the irregularities of this deposit produce destruction of tissue. There is no doubt that this accident happened more frequently in past times when the material used for pessaries was unsuitable, and the methods of adapting them were not so well understood as they are now. The vesico-vaginal septum is often destroyed by malignant dis- ease in the advanced stages, but this does not belong to the subject on hand, and ^vill not be discussed here. Treatment. — The treatment of fistula is either palliative or cura- tive by surgical means. Palliative treatment is little more than an attempt to make the patient comfortable by protecting her from irritation and filth con- sequent upon the constant flow of urine. The curative treatment includes the jireparation of the patient, the operation, and the subsequent management. Preparatory Treatment. — The operation for the cure of fistula should not be done until after the lapse of at least three months from the date of its occurrence. Some have operated earlier with success, but these early operations can not be expected to result suc- cessfully. It requires at least three months before the system has completely recovered from the influence of gestation and parturi- tion, and complete involution of tlie sexual organs is secured. In case of fistula the process of involution is apt to be delayed from the local irritation and general depression which usually attend such injuries. If the patient is feeble, with loss of appetite, and is nervous, months of preparatory treatment may be necessary, con- sisting of good diet, fresh air, attention to the intestinal and other secretions, with the use of tonics. It is certain that no one familiar with the treatment of this form of fistula will be rash enough to subject his patient to the incon- venience of such an operation before attending to these preliminary measures. There is no operation in surgery which depends more VESICAL AND URETHRAL FISTULA. 955 for its success on good general health than this one. As regards the local treatment, all inflammation must have subsided, and good gen- eral nutrition of the tissues about the fistula sliould be secured in order to give a fair chance to obtain union after the operation. To secure all this, due attention to cleanliness should be given and the vaginal douche of hot water frequently employed. The excoriation due to the urine flowing over the parts can be relieved by Lister's ointment of boracic acid. The saline incrustations which form on the edges of the fistula and other parts can be removed with the forceps, and their reformation can be checked by tonics, the min- eral acids being specially indicated. About one week after menstruation has ceased is the best period to operate. If it is delayed until near a menstrual period the anses- thetic which must be given and the irritation produced by the oper- ation itself are liable to induce premature menstruation. Besides, the tissues are in the best condition to undergo the healing process at that time. The complication most commonly met with is stricture of the vagina and scar tissue at the edges of the fistula. No operation should be undertaken until these are disposed of as far as possible. The methods of relieving stricture of the vagina, and also of treat- ing scar tissue, are by dividing the cicatricial bands and dilating. For a fuller discussion of this subject the reader is referred to the section of this work on cicatrices of the cervix uteri and vagina. It may be remarked that in cases where the scar tissue can not be removed entirely, the best results are obtained by dilatation with the tampon. OPERATION FOR THE CURE OF FISTULiE. An exceedingly interesting chapter might be written on the many methods suggested and practiced to close vesico-vaginal fistula but, while interesting, it would not be sufliciently profitable to oc- cupy time in this connection. It may be briefly, yet comprehen- sively, stated that all operations and all methods of treatment tried were failures until Dr. J. Marion Sims by his genius solved the problem. Furthermore, it may be stated that all modifications of Sims's method suggested and practiced by others have not been im- provements worthy of notice. A very few changes of a trivial character have been made which simplify some of the details of the operation, but beyond this the operation in principle and practice remains the same as when given to the profession by Dr. Sims, to 956 DISEASES OF WOMEN. whom the world is indebted for this grand triumph of surgical science and art. In describing the operation I shall first give Sims's method as closely as I can, and then note such slight changes as have been made by other operators. I will be permitted to state here that before undertaking this important operation the surgeon should have acquired facility in the practice of Sims's methods of operating upon the cervix uteri and vagina. The placing of the patient in the proper position, the management of Sims's speculum when held by an assistant, and the use of gynecological instruments should all be familiar to the operator. The success of the operation involves so much to the patient, that all reasonable efforts should be made to se- cure success, and perfect operating is the first essential to that success. The treatment is divided into four parts : first, the placing the patient in the proper position and in a good light ; second, the par- ing the edges of the tistula; third, the introduction of the sutures and tying them ; and fourth, the after management. The first pro- cedure is presumed to be familiar to the reader, but if not, refer- ence should be made to the chapter in which a detailed account of Sims's position is given and also the management of Sims's speculum. The operation is naturally divided into two parts — first, paring the edges of the fistula, second, passing the sutures and tying them. The patient having been placed in Sims's position upon the oper- ating table, and Sims's speculum having been introduced, one assistant holds the speculum while another does the sponging and assists with the instruments and sutures. A thoroughly competent physician should be secured to give the anaesthetic. Very much depends upon the patient being kept perfectly quiet, and still free from the dangers of a too profound anaesthesia. Paring the Edges of the Fistula. — The lower edge of the fistula is seized with a Sims's tenaculuni (Fig. 283), or a tissue forceps (Fig. 74), according to the preference of the op- . , , erator. Then with a Fig. 283. — Sims s tenaculum. . curved scissors (r ig. 75) a strip is removed all around the fistula, extending from the mucous membrane of the bladder out upon the vaginal membrane at least three eighths of an inch (Fig. 2S4). Care should be taken not to wound the mucous membrane of the bladder. It is better to keep unbroken the piece that is removed, if possible. If upon care- ful inspection there is any portion of the vivified surface that is not completely and uniformly pared, it should be trimmed until a perfectly smooth and beveled surface is obtained. Fig. 28'1 shows VESICAL AND URETHRAL FISTULA. 95Y the beveling of the vivified edges of the fistula. The paring should be done with a view also of making the edges of the fistula, when Fig. Operation for vesico-vaginal fistula : paring the edges. brought together, form a straight or slightly curved line. The direction of the line of coaptation will of necessity depend upon the size and long diameter of the fistula. "When it is possible, I prefer to make this line correspond with the long diameter of the vagina, but in case the long diameter of the fistula is at right an- gles to the axis of the vagina, the edges must be brought together in that position. While the surgeon is paring the edges the assist- ant sponges the wound with sponges held in Sims's long-handled sponge-holders (Fig. 285). Fig 285. — Sims's sponge-holder. When the scissors are used to do the paring there is not much hiaemorrhage. Occasionally there is troublesome bleeding which re- quires to be arrested by hot water either injected or applied with sponges. This will arrest all troublesome oozing, and if any vessel is found that persists in bleeding it can be closed by passing a cat- gut or silk suture under it from the vaginal surface some distance from the vivified edge. Introduction of the Sutures. — Dr. Sims employed silver-wire sut- ures in this operation, and by this he secured one great element of success. At the time that he introduced this metallic sutm-e it was 958 DISEASES OF WOMEN. Fig. 286. — Emmet's needles. the only one that was aseptic and without irritating qualities, both of which were absolutely necessary to secure union in the operation. Since that time a better knowledge of all that pertains to aseptic and antiseptic surgery has made it practicable to render silk as reliable as the silver wire. I have fully discussed this subject in the preced- ing pages, so that I need only say here that I use the silk in this operation. Long before I had given up silver-wire sutures, Simon, of Germany, had employed silk in operating for vesico-vaginal fistula, and with success. This fact, and my own experience, which has been just as favorable as when I used wire sutures, lead me to be- lieve that silk will be the suture of the future, and hence I will dis- cuss the exclusive use of it in this operation. That the silk is as successful as silver wire I have proved to my own satisfaction in many cases, and it is much more easily managed both in the introduction, tying, and removal. No. 5 braided silk, or No. 3, if the walls of the septum are thin, prepared as heretofore directed, is used with Emmet's needle. The length of the needle varies according to the thickness of the tis- sues to be sutured and the fancy of the operator. The needle is grasped in the forceps (Fig. 82) so that the two are at right an- gles, if the line of coaptation is parallel to the axis of the vagina, but if the line runs across the vagina, the needle and forceps are arranged in a line. The tissues are held with a tenaculum, and the first suture is introduced at the angle farthest from the operator. The needle is carried through one side, and when its point emerges it is caught with Emmet's coun- ter-pressure instrument (Fig. 119). The first suture is then held by the assistant who holds the speculum, and this fixes the edges so that the other sutures can be passed with more facility. Fig. 288 shows the first sutures tied, and the others introduced. The majority of sur- geons introduce the suture about half an inch from the incision on the vaginal side, and at the edge of the mucous membrane of the bladder. I much prefer to pass the suture in a curved line from Fig. 287. — The curved track of the needle; b, bladder surface ; v, vaginal surface. VESICAL AND URETHRAL FISTULA. 959 one edge to the other of tlic vivified surface (Fig. 287). If I find that this does not draw the surfaces together with facility, I pass Fig. 2SS. — Operation for vesico-vaginal fistula : the sutures in place : method of using the counter-pressure instrument in tying the sutures. half of the sutures a quarter of an inch back from the incised surfaces, and then introduce superficial sutures between them to keep the edges from curving inward when the sutures are tied. The method of introducing sutures was fully described and illustrated in the chapter on injuries of the pelvic floor, but so much depends upon the accuracy with which this is accomplished that I refer to it again. The great point is to make the needle grasp more tissue in the central portion of the vivified surface than at the edges, so that when the suture is tightened the opposing surfaces will make two straight lines in place of two concaves, as would be the case if the needle was passed straight through the tissues. One can tell how the sutures will tie by observing how the free surface appears when the needle is in place. "When the needle is introduced completely, the tissues resting upon the needle should give a convex surface. The number of sutures to be used should be sufiicient to bring the edges accurately together. This requires that they should be about three sixteenths of an inch apart, if No. 3 silk is used. Hav- ing introduced all the sutures, the bladder should be thoroughly washed out, in order to free it from all blood that may have accumu- FiG. 289. — Two sutures tied. 960 DISEASES OF WOMEN. lated in it. Special care should be taken to make sure that no blood- clot is left in the bladder. The sutures should then be tied in the same manner as has already been described in the directions for restoring the cervix uteri after laceration. After Treatment. — The after treatment is very simple indeed, as I now conduct it. The patient is placed in bed, and, if there is pain of a severe nature, opium is given to relieve it. This is very seldom necessary, the pain being very shght, as a rule. During the first twenty-four hours the catheter is passed every four or six hours, and oftener if the patient has a desire to urinate ; after that, she is allowed to urinate when she desires to do so. If there is vomiting after the anaesthetic, sips of hot water are given. The tampon is removed on the second day, and the bowels are moved by enema on the third day. I keep the patient in bed, but, after the first twenty- four hours, she is permitted to change her jjosition whenever that is necessary to secure her comfort, but she is not permitted to leave the recumbent position. On the eighth day the sutures are removed, and, if the result is perfect, the patient is permitted to gradually resume her usual duties. In some cases there is a slight cystitis, in- dicated by the presence of mucus in the urine and frequent urina- tion. This should be managed by washing the bladder as directed under the head of the treatment of cystitis. The after treatment described above is nearly the same as that practiced by Simon, and I am satisfied that it gives as good results as any. It has also some great advantages. The patient escapes the great discomfort of wearing the catheter and remaining absolutely in one position, as she must do if the catheter is retained. There is also much less danger of cystitis or calculus if the catheter is not retained. Should any one feel disposed to use the catheter, I may say that Sims's new style, as figured on page 251 of Thomas's work on " Diseases of Women," is the best in general use. I have also employed a soft-nibber catheter, which is very comfortable. It is retained in the bladder by passing around it a piece of adhesive plas- ter, to which silk threads are attached and fastened to a strap carried around the waist. ILLUSTRATIVE CASES. The Simplest Form of Vesico- Vaginal Fistula. — In the -winter of 188f) my associate, Pi-of. Nilscn, brought a patient to my clinic, at the New York Post-Graduate School, who had a bilateral lacera- tion of the cervix uteri and a vesico-vaginal fistula a quarter of an inch in diameter, located in the median line midway between the neck of the bladder and the cervix uteri. These injuries resulted VESICAL AND URETHRAL FISTULA. 961 from her last confinement, wliich was a veiy tedious one. The tis- sues around the fistuhi were in a perfectly healthy condition. A tenaculum was passed through both edges of the fistula exactly in its center, care being taken not to include the mucous membrane of the bladder in the grasp of the instrument. Traction was then made with the tenaculum, which raised a cone-shaped projection in the vagina, the fistula being in the apex of the cone. While the parts were held in this position, the edges were pared with one clip of the curved scissors. The piece of tissue removed was oblong, with the fistulous opening in its center. The wound left was more than an inch long, and nearl}^ three quarters of an inch wide on the vaginal side, while the opening in the mucous membrane of the bladder was not much larger than before. At the upper and lower angles of the wound, a little more tissue in the vaginal wall was removed with the tenaculum and scissors, and that completed the vivifying. Seven prepared silk sutures were introduced and tied, the bladder being first washed out, and the operation was comj)leted. The lacerated cervix was then restored in the usual way. The two operations occupied less than an hour. The patient was then put to bed, and she rested fairly well during the night. About five hours after the operation, which was performed between eight and nine o'clock in the evening, the patient expressed a desire to urinate, and the nurse passed the catheter. After this the patient passed urine about every five hours for the first three days and nights, and subsequently at longer intervals. There was no other treatment except that the patient was kept in the recumbent position. At my next clinic, one week afterward. Prof. Nilsen removed the sutures from the fistula and cervix, and found the result perfect in both operations. When the sutures were removed there was scarcely a trace of the point of union where the fistula had been. Fistula complicated with Laceration of the Anterior Wall of the Cervix Uteri. {By T. A. Emmet, M. D.) — Ann Murphy, a native of Ireland, aged forty-one, was admitted to the hospital, October 5, 1864, from the city. In May, 185Y, she had been discharged cured from the hospital after an operation by Dr. Sims for the relief of a utero-vesico- vaginal fistula resulting from a laceration directly through the anterior lip into the base of the bladder. Nine months after her discharge, she had a miscarriage at the third month, and a year afterward another at two months. In her second pregnancy, at full term, labor commenced by a 62 962 DISEASES OP WOMEN. sudden rupture of the membranes on Tuesday evening, December, 1861. Until 9 p. m. of the Thursday following the pains were slight and irregular. Labor then came on regularly, and within an hour afterward she was delivered naturally of a still-born infant, of the average size, with the feet presenting. The urine began to escape involuntarily after delivery. No slough was passed, and she recovered as from a natural labor. Pathological Condition. — Laceration had again taken place along the line of the previous operation, through the anterior lip, directly in the median line. The fissure through the cervix had, however, closed nearly to the uterine canal, leaving a small fistula in the base of the bladder a few lines in front of the neck. October 5th. — The opening being so small, little more than its edges were denuded, and the raw surfaces were brought together with three sutures. On removing these an opening of about the same size was found near the cervix, leading forward into the fistula. In closing the fistula, a portion of the vaginal surface around the opening had been scarified, as well as its edges, for the purpose of increasing the breadth of surface brought together. As the opera- tion was so simple, either care had not been taken to pass a sufli- cient number of sutures to obliterate entirely the fold formed just in front of the cervix, on doubling the surfaces together, or else the sutures at this point had been twisted too tight, so as to cut out from below upward. October 30th. — For some distance around the opening the tissue was excavated with a pair of scissors, so that the surface was made to slope inward to the opening of the fistula in the bladder. The rest of the fistulous edge was then removed, as well as a portion of the cervix, and the old cicatricial tissue was got rid of by this means. But before these surfaces could be brouo;ht together, it was necessary to make an incision on each side to relieve the tension which would otherwise have existed. "When the surfaces were folded together, the line of union extended to such a distance beyond each extremity of the fistula that the fold thus formed was lost in the neighboring tissue. Nine sutures were used. The patient Avas dis- charged cured November 18, 1864. It is frequently more difiicult to close a small fistula than to close one where a large portion of the base has been lost. On account of its size, the temptation is always great to remove simply the edges of the opening, instead of extending the scarification in the pro- posed line of union in the form of a long oval, so as to obviate the formation of the fold at each end. VESICAL AND URETHRAL FISTULiE. 963 This woman, about a year after her discharge, gave birth by a natural lal)or to her hrst living child. Some eighteen months sub- sequent to the operation she came with her child to see me. I made an examination for the purpose of ascertaining whether lacer- ation of the anterior lip had again occurred, and was pleased to find that the line of union was perfect. On passing a sound into the uterine canal, I was surprised to find a suture, Avhich, from its length, I was unable to remove until it had been bent upon itself. It proved to be the one which had been passed nearest the os, and which by some means had been turned over backward into the canal, with its end in the direction of the fundus. The portion nearest to the fistula had become buried in the cervix, with over half an inch of the other end free in the uterine canal. She had given birth to her child, and the suture had remained for over eighteen months without its presence causing her any trouble. It has occurred to me that the remaining of this suture, which was passed deep through the neck on a line with the vaginal junction, may have been a for- tunate circumstance in preventing a recurrence of the laceration. URETHRAL FI3TULA. Dr. Emmet has had the largest experience with this form of fistula, and has been, of all the surgeons I know, the most success- ful in its management. I regard him as the highest authority on this subject. The only fistulse of the urethra that I have seen have been those made by myself and others by urethrotomy. In my own cases the fistulas were made for the relief of dilatation of the middle third of the urethra accompanied by ulceration. The others were made for various purposes — one for the cure of cystitis, one for the purpose of making a diagnosis, and so on. At least this is according to the information received, taking the clinical history given in the litera- ture of the subject. There is nothing in the jDathology or method of treatment of fistula in this location that difiers from that of vesico- vaginal fistula. It is, however, very much less troublesome, there being no incontinence of urine unless the fistula involves the neck of the bladder, the operation for closing the urethral fistula being the same as in the vaginal fistula. There is no need of anything more being said on this subject. Cases of urethral fistula such as I have referred to would add noth- ing of value ; hence I shall give the history of the following case, which will illustrate urethral fistula caused by injury inflicted dur- ing; labor. 964 DISEASES OF WOMEN. ILLUSTRATIVE CASE. Fistulae involving the Urethra from Laceration or Sloughing. (By T. A. Emmet, M. D.) First pregnancy ; the head born at the end of seventy-four hours ; pains then ceased : body delivered fifteen hours afterward by traction. The urethra lacerated entirely through, half an inch from the meatus. The distal portion of the canal so dilated that a large portion of the mucous membrane protruded. The difficulties of the operation consisted in passing the sutures so as to bring perfectly into apposition the two sections of the canal of diiferent diameters. Operation successful. Mrs. IL, aged eighteen, was admitted from Cold Spring, Long Island, April 27, 1867. She had been married two years, and had given birth to a still-born child. Labor at full term conmienced Wednesday, January 24, 1867. The pains, however, were not very strong or freqnent until the following Sunday. At 2 p. m. the head was born, but the pains entirely ceased afterward, and the body remained undelivered until Monday morning, when the labor was terminated by tractioiL Previous to delivery, the bladder had not been emj^tied for forty- eight hours ; four days afterward the urine began to dribble away. It was not noticed that any sloughs were passed from the vagina. Pathological Condition. — Directly across the urethra, al)out half an inch from the meatus, a fissure extended from one ramus to the other, dividing the urethral canal entirely through. The distal por- tion of the urethra was so dilated that the index-finger could be introduced for some distance within the canal. The mucous membrane anterior to the neck of the l)ladder pro- truded in a hypertrophied mass as large as an almond, resembling a prolapsed anus. In the center of the prolapse, the orifice of the canal just in front of the neck of the bladder remained undilated, and corresponded in diameter to the portion of the urethral canal through tlic anterior flap. This condition was an unusual complication, as the prolapsed mass filled up the sulcus, and, although it could easily be returned, it was with great difficulty kept within the canal for the purpose of scarification. The temptation was strong to remove a portion of it with the ecraseur, and wait until the surface had healed before operating; this was, however, deemed unadvisable from the extent of cicatricial tissue, and the uncertain amount of contraction which would have resulted. Operation. — May 7tli. — The whole extent of the sulcus was denuded around the edge of the urethra on each side with care, so VESICAL AND URETHRAL FISTULA. 965 as not to wound the mucous membrane of the canal. Thirteen sutures were introduced. The only point of interest was in regard to tlie manner of pass- ing those nearest the urethra. The sutures 1, 2, and 3 correspond in relation to their entrance and exit on the vaginal surface, Nos. 2 and 3 div^erge from the edge of the undilated portion of the urethra to enter at a corresponding point on the margin of the dilated portion. Six sutures on each side, from the angles toward the urethra, were first twisted ; a large sound was then introduced into the blad- der to keep back the prolapsed portion while securing Nos. 2 and 3 on each side of the urethra. Lastly, No. 1 was twisted, but, before doing so, the slight prolapse was pushed back and kept from pro- truding by the point of a blunt hook passed under the suture, and retained untd it was secured. On reflection, it will be evident that, in securing tlie sutures on each side of the urethra, they must necessarily aj^proximate to a parallel course in relation to each other, and in so doing the excess of tissue would be rolled thus into tlie bladder. "While the dilated outlet was doubtless folded somewhat on itself between the five sut- ures which embraced the diameter of the urethra, yet, as they were passed so as to bring the edges of the canal at each point into exact apposition, the catheter met with no obstruction, and the excess of tissue soon retracted. May 17th. — The sutures were removed, and the operation was found successful. May 29th. — A sound was passed along the urethra, and, after a careful examination, it was found impossible to detect the line of union, as not the slightest irregularity existed. The case was dis- charged by Dr. Emmet, cured, June 1, 1867. VESICO-UTERINE FISTULA. In this variety of fistula the opening extends from the bladder into the utei'us, usually into the cervix uteri. It is generally caused during labor, in which the anterior wall of the cervix is torn, and the laceration extends into the posterior wall of the bladder. During the healing which follows the injury, the lower portion of the wound in the cervix heals, leaving a fistulous communication running from the bladder into the canal of the uterus. The same fistulous opening may be formed in the operation for the purpose of closing the opening in the bladder, and at the same time restoring 966 DISEASES OF WOMEN. the laceration of the cervix. Union is secured on the vaginal side of the wound, but a iistulous opening, as described, is formed by the failure to obtain union in the deeper part of the wound. A case of this kind has already been quoted from Ennnet. The chief points of interest in this form of fistula are in diag- nosis and treatment. The symptoms are the same in tliis as in all fistulas of the urinary tract, but the physical signs and diagnosis differ. No physical evidences of the presence of the fistula are obtained by examination with the speculum, except that the urine may be seen flowing from the canal of the uterus. If the urine does not flow at the time of the examination, the bladder should be filled with water colored witli carmine, which will escape through the canal of the uterus, thus proving the presence of tlie opening. To determine its exact location, and obtain some idea of its size, one sound should be passed into the bladder and another into the canal of the uterus, and by careful manipulation the points of the instruments can be made to meet. This will show where the open- ing is situated, and, by moving the sounds to and fro, an idea of the size of the fistula can be obtained. Treatment. — The method of closing a fistula of this kind is to divide the cervix uteri and the vaginal wall down to the track of the fistula, and then pare the edges thoroughly, taking care to remove the scar tissue as completely as possible. Sutures are then intro- duced to close the entire wound in the bladder, vagina, and cervix. I believe that in this operation there is more likelihood of hav- ing troublesome haemorrhage than in vesico-vaginal fistula, but it can be arrested in the way already described. The following case will make the whole subject clear and complete. ILLUSTKATIVE CASE. A lady living in the country was delivered with forceps after having been in labor for forty-eight hours. When the forceps were used the cervix was not fully dilated, and the operator stated that he had much trouble in applying the instrument and delivering. She had incontinence of urine after her confinement. One year after- ward she came under my care. There was then a sear running down about three quarters of an inch in the vagina, from a partially healed laceration of the anterior wall of the cervix uteri. The urine could be seen flowing from the cervical canal. A sound passed into the bladder entered the canal of the cervix near the os internum^ and could be felt with another sound in the canal of the cervix. The operation was performed by passing a sound through the VESICAL AND URETHRAL FISTULiE. QQ^ bladder into the canal of the cervix, and then, by cutting down through on eacli side of the scar tissue, a wedge-shaped piece was removed which exposed the track of the fistula. The edges of the fistula were then carefully pared, and the w'ound closed with sutures first introduced into the wound of the bladder and vagina, and then into the cervix. The catheter was kept in the bladder for five days, and at the end of the eighth day the sutures were removed, and the union was found to be complete. CHAPTER LIII. DISEASES AND INJURIES OF THE TEETERS. Injuries to the ureters during ovariotomy and hysterectomy are referred to in the description of these operations. The diseases of the ureters caused by various forms of cystitis are discussed in con- nection with diseases of the bladder. There still remain for consideration the injuries of the ureters which occur during labor, and ureteral affections caused by neo- plasms and other diseases of the pelvic organs. Affections of the Ureters due to Infiammation of the Pelvic Perito- nseum and Cellular Tissue. — Pressure from inllammatory products in the pelvic cellular tissue or on the pelvic jDeritonseum may so obstruct the ureter as to cause hydro-ureteritis and pyelitis, and, in rare cases, fatal renal disease. In other cases the ureter may become inflamed from the inflammation of the tissues surrounding it. In that case obstruction and its consequences follow in natural order. The completeness and the duration of the obstruction appear to be most marked when the pelvic inflammation runs its course very rajDidly and the exudate is large and extensive. Syrn2)tomatolo(jy. — The indications of obstruction of the ureter are very obscure. The symptoms and physical signs of a cellulitis or peritonitis so fully command the attention of the observer that the ureter is very often overlooked. During the progress of the primary disease I have observed that the pelvic pain and tenderness extended up the tract of the ureter to the kidney, and that the dis- turbance of tlie digestive and nervous systems was more severe than the pelvic inflammation, uncomplicated, accounted for. From this it will be seen that I have, so far, been unable to ol)serve anything in the symptoms diagnostic of ureteral obstruction from this cause. Phynical Signs. — Products of inflammation may sometimes be found by an examination of the urine. All that I know of the physical signs of ureteral diseases and the methods of examination 968 DISEASES AND INJURIES OF THE URETERS. 969 I have'Ol)taincd from the writings of Professor Howard A. Kelly. I will therefore (juote from his article on this subject in the "Trans- actions of the American Gynaecological Society" for 1888 : " By I) I ^jf n't ion.— Inspection is the method proj)Osed l>y Dr. T, A. Enmiet, and is conducted by splitting the vesico-vaginal septum and everting the edges of the wound until the ureteral orifices are exposed, when the ureters may also be catheterized, and their secre- tions compared. This method resembles the practice of introducing a catheter into the exposed orifices of the ureters in the margin of a vesico-vaginal fistula. It is one of value in serious cases warrant- ing operative interference ; nor is the oj^eration, skillfully conducted, to be estimated as in any way grave. The edges of the incisions can be brought together after the examination, and the wound healed at once. ^'JSy Catheterization. — The method of Professor Karl Pii),wlik, of Prague, of catheterizing the ureters free-handed, without prelimi- nary preparation of the patient, beyond the occasional distention of the bladder with a bland fluid, is the one deserving most attention. This method I have both practiced and seen at the hands of Pro- fessor Pawlik during the past summer (1888). The patient is placed in the dorsal position, with legs strongly flexed on the abdomen, and a Simon or Sims's speculum introduced, retracting the posterior vaginal wall. The eye at once ol)serves a series of divei'gent folds starting just back of the neck of the bladder and sweeping laterally and back toward the cervix uteri, corresponding very closely at their point of union to the inter-ureteric ligament, and following in general outline the course of the ureters. A delicate catheter, a cut of which is shown in Fig. 290, is then carried into the bladder, dis- tended with about four ounces of urine, and poised between thumb and index-finger. The position of the end of the catheter is plainly noted by the eye, observing its movements in the vagina as the point sweeps gently along the floor of the bladder. The ureteral orifice is to be sought for about an inch back of the neck of the bladder, and about half or three quarters of an inch from the median line on either side. This position of the ureter, however, is not con- stant, and can not be relied upon alone. Far more characteristic is t)ie slight tripping sensation given to the point of the catheter as it glides over the ureteral prominence. As soon as this sensation is 970 DISEASES OF WOMEN. perceived, the catheter must be at once brought back to the place where it was felt, and gentle attempts made to engage its point by repeatedly carrying the handle upward and outward, and the point consequently in the opposite direction. Once caught, the catheter sweeps readily in, and, if lightly held, directs its own course, the lingers sim[)ly following. It thus passes some distance unrestrain- edly, parallel to the pelvic wall, and the eye observes the anterior vaginal wall being lifted up in advance and to one side of the cer- vix, forming a distinct pocket on the side on which the ureter is catheterized. This is a point to which my attention was specially called by Professor Pawlik. " On withdrawing tlie stopper in the end of the catheter, a few drops of urine run out, wdien the flow ceases ; after a few seconds a few more drops run out, and then cease, keeping up in this way an intermittent discharge entirely characteristic. The catheter can not with safety be pushed beyond the brim of the pelvis. On with- drawing it the sudden drop of the anterior vaginal wall is very char- acteristic. I have found, as Pawlik states, that very slight force in the cadaver is apt to make false pockets in the mucosa of the blad- der. This was especially marked in a subject upon which I experi- mented this summer in Professor Yirchow's laboratory. The ureters were displaced backward to an extreme degree, and, in sjiite of the fact that I knew exactly where they were, and the catheter would constantly glide over the orifices, it was almost impossible to intro- duce it. I have at other times succeeded in introducing it at the very first attempt, and yesterday morning, in my office, catheterized the right ureter of a patient who did not know that I was doing more than making an ordinary vaginal examination. I have made a change in Pawlik's catheter, substituting a series of holes for the long fenestrum, which caught and cut the mucous membrane of the urethra in introducing it into the bladder. ''''By Palpation. — The finger is passed into the vagina be. hind the internal orifice of the urethra, at the end of the rugose promontory on the anterior vaginal wall, and carried with some exertion up toward the brim of the pelvis, displacing the vaginal wall upward and outward until the pulp of the finger reaches the highest point it can touch, often as high as the brim, but varying according to the greater or less laxity of the tissues and their fixa- tion by pelvic pathological processes. It is then carried downward, stroking the pelvic wall, carefully estimating the character of all structures felt rolling under it. As soon as the observer thinks he has felt a ureter, he catches the cord again with the hooked finger DISEASES AND INJURIES OF THE URETERS. 971 and pulls it down a little, and then slides the finger first toward the bladder, where the ureter is felt to lose itself at the trigoinim, and then backward, where it loses itself sweeping around the cervix. I have found that in a certain number of cases the ureter can be felt most distinctly in this position just in advance of the cervix, by- placing the patient on her left or right side, when the vagina bal- loons out and applies itself closely to that side of the pelvic wall which lies undermost ; here the ureter can, by a slight effort dis- placing the vaginal vault upward, be hooked and brought down under the finger, felt with the utmost distinctness, and compressed. " By Bimanual Palpation. — I found, after examining a certain number of cases in which it was impossible to displace tlie vagina sufiiciently to feel the ureter against the pelvic wall, or to feel the ureter with one hand lying like a cord in the connective tissue alongside of the vagina, that it was still possible to outline its whole course with distinctness by a bimanual examination, when it could be picked up between the tips of two fingers and traced from cervix to bladder. In speaking of this to Dr. Sanger recently, he called my attention to the fact that he had mentioned the bimanual exami- nation, and stated that he was daily more fully appreciating its possi- bilities. The best position to feel for the ureters at the beginning of the bimanual examination is in the oblique diameters of the pel- vis, bringing the tips of the fingers as closely as possible together, and rolling them to and fro, keeping near the j)elvic wall, watching for the characteristic sensation, when the cord may be traced in either direction. In late pregnancy, the ureters are especially dis- tinct, and seem often to be enlarged. Under favorable circumstances, a thickened ureter can be felt through the thin abdominal walls as it leaves the j^elvis and crosses the brim." Treatment. — As a matter of course, the treatment must be chiefly directed to the primary inflammation which caused the obstruction of the ureter. I am satisfied that in many of the cases recovery takes place with- out any direct or specific treatment. Should the ureteral disease per- sist, relief may be obtained by catheterizing and dilating the ureter and washing it out with a, mild solution of borax or sulphate of zinc. Obstruction of the Tlreters by Uterine and Ovarian Neoplasms. — It may be stated here that the ureters become occluded most frequentl}^ in patients suffering from cancer of the uterus in its last stages. I have seen several such patients die from ursemia. There is but little that can be done for their relief, and hence nothing more need be said on this subject. 972 DISEASES OF WOMEN. Obstruction of the Ureters due to Uterine Fibromata. — I have sev- eral times seen this condition. The symptoms are, pain on the affected side (one ureter only is obsti'ucted, as a rule) ; the pain extends upward in the line of the ureter to the kidney, a dull, aching pain in the back on that side ; there is usually tenderness on press- ure, and often a slight sensitiveness on bimanual examination of the kidney on the affected side ; by that I mean, when one hand is placed on the back and the other on the abdomen, and pressure is made over the kidney with both hands. Digital examination of the vagina reveals nothing of value except tenderness. The treatment in this condition must largely be directed, as in obstruction from other causes, to the neoplasm that gives rise to it. If the fibroid is impacted in the pelvis, efforts should be made to raise it up into the abdominal cavity. Electricity should be employed in mild cases; Ijut when there is danger, land relief is not obtained, hysterectomy should be resorted to. Indeed, I consider this as one of the most important indications for the removal of the uterus. ILLUSTRATIVE CASES. Obstruction of the Ureter from Pelvic Cellulitis. — The j^atient suf- fered from mcnorrhagia ; a sponge tent was used to dilate the cervix, after which curetting was performed. This was before I knew how dangerous and useless such tents were, and before antisej^tic surgery was fully practiced and taught. The result was a circumscribed cel- lulitis on the left side. About the fifth day the constitutional symp- toms increased decidedly, and the pain extended upward on the left. There was dithculty in urinating, and the catheter was used. The urine was at first clear, but rather abruptly became turbid. This led to an examination which showed the presence of pus. I sup- posed that a cystitis had been caused by the use of the catheter, but further investigation proved that the pus came from the ureter and kidney. The case was under observation at the time M'hen I was learning how to tell when pus or blood, that was found in the urine, came from the bladder or kidney ; and, on that account, I made a number of examinations, all of which indicated that the trouble was in the ureter and })elvis of the kidney. A friend, who also ex- amined the urine, made the diagnosis of pyelitis and acute nephritis. The cellulitis ended in resolution, and the patient recovered and has remained in good health. Obstruction of the Ureter from Uterine Fibroma. — A lady forty- three years old, who liad a very large uterine fibroma which she had carried for years without being much embarrassed by it, was taken DISEASES AND INJURIES OF THE URETERS. 973 with backache and some ill-defined constitutional symptoms, which for the first time compelled her to give np her duties to a great ex- tent, but she did not seek medical aid. She died suddenly, after a convulsion, which was not very well described by the friends who were with her at the time. In fact, there was no clear history ob- tainable. Post-mortem, I fonnd a large fibroid, and in tlie cellular tissue aronnd the npper part of the cervix uteri there was much oedema, and what looked like an exudation. Both ureters were dilated, and there were hydro-nephrosis and acute nephi-itis. All the other organs of the l)ody were normal. Injuries to the Ureters during Labor. — While engaged in obstetric practice, both hospital and jirivate, I attended several cases which differed from any of the puerperal diseases i-ecorded in obstetrical literature. During the early years of my investigation very little was learned about these cases except that there was something in their pathology which was not known to me. The manifestations of the affection, as observed clinically and at post-mortem examinations, led me eventually to infer that injury to the ureters during parturition was the cause of the phenomena which I witnessed in these cases. Pathology. — From a considerable study of the subject clinically, and a meager one of its morbid anatomy, I feel warranted in stating that the pathology of this affection is a contusion or laceration of one of the ureters by the head of the child, the hand of the obstet- rician, or more often by the forceps. This contusion gives rise to swelling of the walls of the ureter and the cellular tissue around it, and perhaps some degree of inflammation. This is suflficient to obstruct the ureter and cause hydro-nephrosis, and subsequently pye- litis. As the swelling, and perhaps inflammation, at the point of original injury subside, the pressure of the urine and pus above forces a way through the ureter, and relief follows. This is the ex- planation of the sudden discharge of pus with the urine. In case the obstruction lasts long, the kidneys become involved to an extent that varies according to the duration of the obstruction. Whenever the ureter is completely blocked and remains so, there is nephritis, and then acute ursemia, which may prove fatal, as already stated. In a given number of cases, there are some in'which there is cys- titis, but no marked disease of the kidneys. In others, the bladder is not involved, but the kidney is ; while in others all three organs — bladder, ureter, and kidney — are affected. When, as is not infre- quently the case, there are some of the usual injuries of the cervix uteri and pelvic floor, and metro-cellulitis follows, the ureters become 974 DISEASES OP WOMEN. secondarily affected. Under such circumstances the order of de- velopment of the pathological lesions is reversed to some extent, and lience the clinical history is changed, so that the ureteral obstruction and consequent renal disease come later and generally are less dan- gerous, owing to being less acute and of shorter duration. Causation. — Predisposing Causes. — There are certain conditions which predispose to injuries of the ureters during labor. When the bladder and terminal ends of the uretera^rest low in the pelvis toward the end of gestation, there is more liability of their being caught between the child's head and the brim of the pelvis during labor. In many cases the ureters suffer some impairment of nutrition dur- ing gestation (and are more susceptible to injury) that is produced by passive hypersemia and oedema, and hence a softened state of the pelvic tissues follows. There is in such cases a want of elasticity and resistance to injury. This is seen in the friable condition of the cervix uteri, vagina, and pelvic floor, which renders them so easily damaged. In brief, then, the location of the bladder and ureters, the pre-existing lesion or functional derangement of the ureters, and malnutrition of the tissues in the pelvis, are the conditions which predispose to graver injuries during labor. Direct Causes. — The fact that the uretei's escape injury when dilatation of the cervix uteri is complete before expulsion proceeds, gives a clew to the causation of such injuries. When the mem- branes rujiture before dilatation is complete, and consequently the cervix uteri and bladder are carried down into the pelvis before the advancing head, the ureters are exposed to undue jjressure and traction also, and hence are sure to be more or less injured. The dangers are much greater when it is necessary to use the forceps or perform version under these circumstances. The presence of hard fiecal matter in the rectum may also be mentioned among the causes. Faulty methods of operating no doubt add to the dangers. Undue lateral motion of the forceps during extraction must certainly do more or less damage to the adjacent tissues and ureters. Especially is this likely to occur if the cervix uteri and bladder are permitted to descend before the advancing head. Symptomatology . — The patients are usually primiparae, or at least have not had many children, the labor tedious, instrumental or manual, and the progress after delivery fairly satisfactory for several days. The lochial discharge may be normal, and the secretion of milk also. The bowels may act well, and the kidneys apparently so. In some patients there is retention of urine or frequent and painful urination. Pelvic pain and tenderness in the lower part of the DISEASES AND INJURIES OP THE URETERS. 975 abdomen are present, but are not always sev^ere at first. These symptoms become more acute after a time, the pain and tenderness increase rather abniptly, and a chill or rigor may occur ; distention of the bowels takes place, the temperature runs up, and tlie pulse is also increased in frequency. An increase in the severity of the symptoms supervenes in from three to five days, and soon thereafter a quantity of pus, and some- times blood, appears in the nrine. When the discharge of pus begins, the patient is generally relieved to some extent. The pain is less, and the temperature and pulse are reduced a little. In con- nection with pus and blood renal casts may be found, but this is not invariably the case. The pus continues to be discharged in dimin- ished quantity for a week or more. The bleeding generally subsides in a day or so, and most of the cases gradually recover. In others, acute disease of the kidney appears about the time that the pus be- gins to be discharged fi-om the bladder, and uraemia follows, and sometimes uroemic coma. Such cases end fatally, as a rule, but I have known one to recover. Physical Sigiis. — There is tenderness to the touch along the line of the nreter, and bimanual manipulation of the kidney upon the affected side usnally causes a sense of distress rather than pain. In nncomplicated cases a vaginal examination gives nega- tive signs, except that tenderness is detected high np on the side involved. The diagnosis of injuries of the ureters must be made by the exclusion of the more common puerperal affections, such as peri- tonitis, cellulitis, or general septicaemia. Metiitis is excluded on the grounds that the lochia are normal, that tliei-e is absence of ten- derness, and that involution progresses as it should. The sympto- matic fever is too mild in character to indicate general peritonitis, and the physical signs of that affection are wanting. The tenderness on pressure on the side affected, and the constitutional disturbance not otherwise accounted for, are suggestive of cellulitis, but the evi- dence, so far as relates to physical signs, of that affection is insufii- cient, and the subsequent history effectually excludes it. The sudden appearance of pns and blood in the urine leads one to suspect that an abscess has formed in the cellular tissue and dis- charged into the bladder. This condition is excluded on the ground that there have been no physical signs of cellulitis; and, further- niore, an abscess never discharges into the bladder in so short a time after the inception of pelvic cellulitis. In cases complicated with traumatic cystitis, it might be pre- 976 DISEASES OF WOMEN. sumed that an abscess had formed in the wall of the bladder ; but that is excluded for the reason that the violent symptoms and physi- cal signs found in traumatic and interstitiid cystitis are absent. In short, the history of injury to the urettrs differs from that of all the puerperal diseases hitherto described in medical literature, so far as I know. Prevention. — These injuries being difficult to manage, their pre- vention is of prime importance. When the presence of renal trouble is detected before labor, and it is presumably due to partial obstruction of the ureters, much may be done by rest in the recum- bent position, and the judicious use of cathartics, diuretics, and vaginal douches. By improving the circulation and general nutrition of the organs and tissues, the existing ureteral trouble may be relieved and further injuries avoided. During labor much may be accomplished. Full dilatation of the cervix before rupture of the membranes, so that the bladder and ureters may rise out of the pelvis when the head descends, yisures comparative safety. In view of these facts the judicious obstetrician, being fairly conscious of the danger to the ureters, will find an- additional reason for looking after their interests My attention was first given to this matter in order to save the bladder from contusions and disj^lacements, and later I found that this w^as one of the surest ways of saving the ureters also. I have many times called attention to the necessity of supporting the bladder during labor, and indirectly the ureters also, but so much attention is bestowed upon management of the perin.pum, that tlie more important dangers to the urinary organs are very largely ignored. This supporting of the parts during labor should be more carefully watched when delivery with forceps is practiced. Lacerations of the cervix uteri and pelvic floor are unfortunate complications, but they do not compare with injuries of the ureters in gravity of results. The fact is, that the possible danger to the ureters has not occurred to obstetricians, as a rule, but when fully appreciated will have due attention. The lateral motion of the for- ceps, referred to, is happily not necessary, nor is it practiced by experts, I believe ; still it should be avoided, for the sake of the ureters as well as for the reasons given in obstetric works. This would T)e an uncalled-for statement, svere it not for the fact that wdiile the science of obstetrics is most mature, and the art is practiced by the few in a perfect way, yet the practice of the many is often insufficient, to say the least. Treatment. — The management of injuries of the ureters which DISEASES AND INJURIES OF THE URETERS. 977 have occurred is, I fear, in a very immature state. At least, I liave never read or heard of any suggestion regarding treatment, and can only give the results of personal observation. Being without precept or example, and for years not knowing the j^athology of the cases under observation, I treated them as in- flammatory affections, without special regard to the location and character of the inflammation, for they were unknown. When a clear comprehension of the nature of the affection was obtained, the treatment was still rather expectant. There is one thing which has appeared to be of advantage, and that is, keeping the bowels free. In fact, free catharsis may be tried if the patient is able to stand it. This I discovered by seeing a case in consultation, in which the at- tending physician, suspecting septicaemia or obscure peritonitis, had adopted the modern treatment — saline cathartics. The results were good, and I feel confident that it is a useful treatment. When the bladder is involved, much is gained by washing it out repeatedly ; this relieves the ])ain in the ureter and kidney to some extent. Retention of the urine for an unusual length of time increases the suffering, and no doubt also the traumatic inflammation. The catheter does much good if used by a skilled nurse or obstetrician. The unclean metallic catheter, in general use when I first observed such cases, always did harm. Hot vaginal douches have been tried, and when they relieve pain they are curative ; but when they increase the suffering at the time of their use, or immediately after, as is often the case, harm may result. In a word, the treatment has been to relieve pain, sustain the patient, and trust that the damages would be repaired before the kidneys were fatally involved. The question of surgical treatment has occupied some time and thought, without my arriving, however, at any definite conclusions. Catheterizing the injured ureter seemed to be indicated, but I had had no experience with it in acute injuries, because I gave up ob- stetrics about the time that the practice of catheterizing the uretei's was introduced, and I had not acquired facility in the operation ; and, lastly, I doubted the safety of such treatment, and felt that it should be tried by an expert first, if at all. In the class of cases due to inflammation of the tissues around the ureter, the use of the catheter, in the hands of an expert would be of the greatest value. This has been proved by Kelly, Engel- mann, and others. But when the ureter is the primary subject of the injury, it is doubtful whether catheterization would be possible, and there would be much danger of the instrument perforating the ureteral wall. 63 978 DISEASES OP WOMEN. ILLUSTRATIVE CASE. The history of this patient, from the time of her confinement until her death, was characterized by the symptoms and signs whicli are given above. The patient died two weeks after confinement, and, post-mortem, I found an injury of the left ureter about an inch and a half above its lower end. Its walls were so broken down that they could not be separated from the surrounding tissue. The ureter was occluded at the point of injury. There was a circumscribed exudation in the cellular tissue around the injured part. Suppuration had begun at the site of injury, showing that the starting-point of the inflamma- tion was a traumatism of the ureter. Above the occluded portion the ureter was dilated, and filled with pus and urine. There was acute nephritis on that side, together with inflammation of the ureter on the right side, and some infiltration of the cellular tissue around it. The right kidney was also inflamed, or at least markedly hyper- ffimic. Circumscribed cystitis of a mild character existed. There was not enough in the clinical history, nor in the lesions found, to indicate a grave form of septicsemia. The cause of death was, no doubt, uraemia. i:^DEX. Acute endometritis, 183. ovaritis, 485. After treatment of vesico-vaginal fistula, 960. Albert Smith pessary, 333. Alexander's operation, 328, 339. Allantois, 82. Amenorrhcea, 52. Amputation of cervix uteri, 418. Anaesthesia in diagnosis, 19. Anassthetics, mode of administration, 19. Anatomy of bladder, 659. cervix, 660. coats, 660. corpus, 660. form, 660. fundus, 660. glands, 661. intei'-ureteric ligament, 662. ligaments, 669. nervous supply, 663. openings, 662. ostium, urethral, 662. position, 660. relations to urethra, 668. sphincter, vesical, 661. trigone, 660. ureters, 662. vascular supply, 663. of Fallopian tubes, 586. coats, 586. length, 586. orifices, 586. relation to uterus and broad liga- ments, 586. of ovaiy, 469. blood-supply, 471. minute anatomy, 474. Anatomy of ovary, ovulation, 477. relation to broad ligament, 470.. thickness, 469. weight, 469. width, 469. of pudendum, 77. clitoris, 77. glands, 77. hymen, 82. labia majora and minora, 76. vestibule, 78. of urethra, 663. coats, 664. diameter, 663. length, 663. meatus urinarius, 666. relation to bladder, 668. Skene's glands, 664. sphincter, 667. of uterus, 177. arbor-vitse, 180. body, 177. cavity, 178. cervix, 177. fundus, 177. length, 177. mucous membrane of cavity, 178. mucous membrane of cervical canal, 180. Nabothian glands, 180. OS externum, 178. OS internum, 178. peritoneal covering, 178. utricular glands, 179. walls, 178. width, 177. of vagina, 100. coats, 101. 979 980 DISEASES OF WOMEN. Anatomy of vagina, connection with cer- vix uteri and pelvic floor, 100. length of walls, 100. orificium, 81. Anteflexion of the uterus, 54, 56. acquired, 57. causation, 61. congenital, 57. illustrative cases, 71. of body, 58. of cervix, 57. of cervix and body, 58. pathology, 58. physical signs, 60. symptomatology, 59. treatment, 64. Elliott's adjuster, 67. pessaries, 67. surgical methods, 64. Anterior-labial hernia, 93. Anus, atresia of, 83. Arbor-vitae uterina, 180. Areolar hyperplasia of uterus, 225. Atlee, W.L., 319. Atresia of anus, 83. of vagina, 102. of vulva, 83. Atrophy of muscular tissue of vaginal walls from abuse of pessaries, 346. of uterine walls, 343. Bimanual method of examination, 8. Bladder, anatomy of, 659. atrophy, 871. development of, 670. diseases, 702. dislocation of, 812. distended, 498. foreign bodies, 831. function of, 696. haemorrhage from, 756. hernia of, 823. hyperemia of, 754. hyperplasia, 869. malformations of, 677. neoplasms, 858. paralysis of, 723. rui)ture of, 847. Bleeding disease of uterus, 363. Bulbi vcstibuli, 79. Byrne's galvano-cautery, 417. Calculus, 834. Cancer, 403. of cervix, 403. of body of uterus, 421. causation, 422. diagnosis, 422. pathology, 421. physical signs, 421. I)rognosis, 422. symptomatology, 421. treatment, 422. vaginal hysterectomy, 422. Carcinoma, 403. Carunculag myrtiformes, 82. Catheter, use of, 143. Catheterization of ureter, 750, 969. Cauliflower excrescence of cervix uteri, 406. Cautery clamp, 548. Paquelin's, 115. Cervical canal of uterus, 180. Cervical endometritis, 183. exanthematous, 182. gonorrhoea), 183. puerperal, 182. Cervix uteri, hypertrophy of, 350. laceration of, from parturition, 244. operation for restoration of, 254. Chlorosis, 40. Chronic corporeal endometritis, 207. cystitis, 767. cervical endometritis, 184. Chronic inversion of uterus, 278. ovaritis, 492. Cicatrices of cervix uteri and vagina, 264. causation, 264. Illustrative cases, 264. symptomatology, 264. treatment, 265. Clamp, hasmorrhoid, 160. Classification of neoplasms of ovary, 506. Clitoris, 78. Cloaca, 83. • Coccyodynia, 172. causation, 173. illustrative cases. 174. pathology, 172. physical signs, 173. prognosis. 173. symptomatology, 172. treatment, 173. Nott's, 173. INDEX. 981 Coccyodynia, treatment. Simpson's, 173. Coccyx, removal of, 173. Condyloma, 411. Corporeal endometritis, 207. Corpus clitoridis, 78. Courty's method of restoring inverted uterus, 279. Croupous cystitis, 808. Curette, 21, 204, 362. Curetting, method of, 214. Cusco's speculum, 11. Cylindrical-celled epithelioma, 406. Cystic degeneration of cervix uteri, 186. Cystitis, 754, 761. acute, 716. causation, 783. chronic, 767. croupous, 808. diagnosis, 778. diphtheritic, 808. epi-cystitis, 761. gonorrhoeal, 761. pathology, 762. symptomatology, 771. treatment, 788. Cysto-carcinoma, 506. Cysto-fibroma, 513. Cysto-sarcoma, 506. Cystoscope, 746-750. Cysts of vagina, 110. Depressor, Hunter's, 14. Dermoid cysts, 512. Development of bladder, 670. of Fallopian tubes, 22. of ovaries, 472. of sexual organs, 22. of urethra, 670. of urinary organs, 22. of uterus — primary, 22. secondary, 24. of vagina, 22. Dilatation of cervix uteri, 69. of urethra, 9, 908. Dilators : Goodell's, 17. Hanks's, 17. uterine, 17. Diseases of Fallopian tubes, 586. of ovaries, 469. of pudendum, 85. of urethral glands, 873. Diseases of urethra, 873. of vagina, 100. Dislocation of urethra, 920. Displacements of ovaries, 500. of uterus, 292. Double vagina, 101. Drainage in ovarian tumor, 564. Ducts, Miiller's, 22. Dudley's method of treating fistula in ano, 170. Dupuytren's operation for atresia, 104. Dysmenorrhosa : inflammatory, 209. membranous, 234. neurotic, 60. obstructive, 60. ovarian, 487. Bcraseur, 373. Ectopic gestation, 650. Electrolysis, 371. in the treatment of fibroids, 371. Elliott's uterine adjuster, 67. Endometritis, 182. senile, 458. Epithelioma, microscopical appearances, 406. of the cervix uteri, 406. pathology, 406. pavement-celled, 406. physical signs, 409. rodent ulcer, 406. secondary invasion, 407. symptomatology, 407. treatment, 417. amputation, 417. galvano-cautery, 417. local, 417. Erosions of cervix uteri, 411. Eruptions of vulva, 98. diphtheria, 99. eczema, 98. acute, 98. chronic, 98. treatment, 98. erysipelas, 98. treatment, 99. gangrene, 99. causation, 99. prognosis, 99. treatment, 99. herpes, 98. noma, 99. 9S2 DISEASES OF WOMEN. Eruptions of vulva, prurigo, 98. treatment, 98. Erythema of vulva, 85. Ether inhaler, 19. Examination of patients, 7. anaesthesia, 19. method of administration, 19. aspirator, 17. classification of facts, 4. concave mirror, 18. curette, 16. Recamier's, 16. Skene's, 16. dilators, Goodell's, 17. Ilanks's, 17. uterine, 17. examining table, 8. history of reproduction, 7. inspection, 3. investigation of diseases of sexual sys- tem, 5. microscope, 18. palpation, 10. palpation and percussion conjoined, 10. diametrical method, 10. fluctuation, 10. interrupted pressure. 10. peripheral method, 10. percussion, 10. physical signs, 17. position, 11. dorsal, 8. Sims's, 11. resume of methods. 19. sound and palpation combined, 16. sound and probe, 14. elastic, 15. •Jenks's, 15. Simpson's, 14. Sims's, 15. speculum. 11. Cu.sco's bivalve, 11. Sims's, 11. introduction, 13. movements, 13. symptomatology, 6. tents, 17. compressed sponge, 17. sea-tangle, 17. tupelo, 17. touch, 8. bimanual, 9. Examination of patients, touch, by dila- tation of urethra, 9. rectal, 10. Simon's method, 9. single, 8. TOsico-rectal, 9. vesico-vaginal, 10. Excrementitious plethora, 450. External genital organs, 77. Extroversion of bladder, 686. Facts, classification of, 4. Fallopian tubes, 586. anatomy, 586. anomalies, 586. development, 22, 586. diseases of, 586. hjematosalpinx, 591. laparo-salpingotomy, 591. tuberculosis of, 590. Fibroma of the ovary, 513. of uterus, 356. synonyms, 356. bleeding disease of the uterus (Duncan), 356. fibroid, 356. fibrous myoma, 356. fibro-myoma, 356. hysteroma, 356. varieties, 357. conglomerate. 358. interstitial, 357. multiple, 358. single, 358. submucous, 357. subperitoneal, 357. within folds of broad ligament, 357. calcareous degeneration, 360. causation, 367. clinical history, 359. density, 359. diagnosis, 366. effects of, upon the uterus, 361. fatty transformation, C60. osseous degeneration, 360. physical signs, 365. prognosis, 368. symptomatology, 363. treatment. 369. medicinal. 370. ergot. 370. surgical, 373. INDEX. 983 Fibroma of uterus, surgical treatment, curette, 373. ecriiseur, 373. electrolysis, 371. hysterectomy, abdominal, 377. supra-vjiirinal, 375. Keith's cases. 394. ovariotomy. 544. traction and morcellation, 381. Fissure, vesico-urethral, 888. Fistula in ano. 167. operation, 167. Dudley's, 170. treatment, 167. new method, 171. urethral, 927, 963. vesico-vaginal, 950. Flexions of the uterus, 54. • causation, 61. diagnosis, 61. pathology, 58. physical signs, 60. symptomatology, 59. treatment, 64. varieties, 57. Fluctuation, 10. Foreign bodies in bladder, 831. calculus, 834. causation, 835. diagnosis, 834. prognosis, 835. symptomatology, 837. treatment, 836. hydatids, 833. in urethra, 875. Fossa navicularis, 79. Fourchette, 77. Frajnulura vulvje, 77. Function of bladder, 696. Functional diseases of bladder, 702. derangements of function in which there is no recognizable organic lesion, 703, causation, 709. diagnosis, 708. illustrative cases, 712. neuroses, 703. due to disorders of sexual func- tions, 704. due to hysteria, 703. due to malaria, 705. due to ovarian affections, 706. Functional diseases of bladder, prog- nosis, 708. symptomatology, 707. treatment, 709. derangements of function due to dis- eases cf the nutritive and nervous systems. 723. paralysis, 723. causation, 726. diagnosis, 725. enuresis nocturna, 729. illustrative cases, 733. prognosis, 726. symptomatology, 724. treatment, 726. incontinence of urine, 729. prognosis, 729. treatment, 729. derangements of function due to ab- normal condition of urine, 734. causation, 736. diagnosis, 736. illustrative cases, 728. prognosis, 736. symptomatology, 736. treatment, 736. derangement of function due to affec- tions of the pelvic organs other than the bladder, 740. Functional diseases of urethra, 877. Functions of uterus, 181. gestation, 181. impregnation, 181. menstruation, 30. Galvano-eautery of Byrne, 417. Gartner's duct, patency of, 873. Genital cleft, 83. eminence, 83. Gestation, ectopic, 650. Glands of Naboth, 180. vulvo-vaginal, 86. Glandulae vestibulares minores, 79. majores, 79. Gonorrhoea, 85. Goodell's dilator, 17. Granular erosion of urethra, 884. Hfematosalpinx, 591. etiology, 591. symptomatology, 591. treatment, 591. 984 DISEASES OF WOMEN. Hsemorrhage of the bladder, 756. illustrative cases, 760. treatment, 758. secondary, 140. Haeraorrhoid clamp, 160. Haemostatic forceps, 427. Hawk-bilL scissors, 254. Hermaphroditism, 83. Hernia of the bladder, 821. of the pudendum, 92. anterior labial, 92. diagnosis, 93. posterior labial, 92. treatment, 93. History of reproduction, 7. Hunter's depressor, 14. Hydatids in the bladder, 833. Hydrocele of round ligament, 94. treatment, 94. Hydrosalpinx, 588. Hymen, 82. imperforate, 53. Hyperemia of the bladder, 754, causation, 755. diagnosis, 755. symptomatology, 755. treatment, 756. Hypencsthesia of vagina, 110. of vulva, 94. causation, 95. treatment, 95. Hyperplasia of bladder, 869. diagnosis, 8V0. treatment, 870. symptomatology, 870. Hypertrophy of the cervix uteri, 350. causation, 353. pathology. 350. physical signs, 352. prognosis, 353. symptomatology, 350. treatment, 353. Hypospadias, 83, 673. Hysterectomy, a])dominal, 377. supra-vaginal, 375. vaginal, 422. clamp operation, 424. author's method, 427. French method, 426. Keith's cases, 394. Hysterotome, Skene's, 75. Illustrative cases of abuse of pessaries, 344. Illustrative cases — Bladder, atrophy, 871. cystitis, 804. dislocations, 814. displacements, 823. functional diseases, 712, 738. bladder, foreign bodies in, 837. malformations of, 686. paralysis of. 733. prolapsus of, 823. rupture of. 851. cellulitis, pelvic, 605. cervix uteri, cicatrices of, 267. lacerations of, 257. coccyx, removal of, 174. endometritis, 194. eorporejil, 214. fistula in ano, 167. urethral, 964. vesico-vaginal, 960. membranous dysmenorrhoea, 242. menopause, 448. menstrual derangements caused by ar- rested growth of uterus, 41. chlorosis, 44. deranged innervation, 49. deranged conditions of life, 47. malformations of uterus. 32. ovarian neoplasms, 506. pelvic ha^matocele, 644. pelvic peritonitis, 628. pudendal ha^matoma, 92. ureter, obstruction of, 972-978. urethra : dislocation, 923. functional diseases of, 878. organic disease of, 885. stricture of, 931. urethral glands, gonorrhoeal inflamma- tion of, 938. tuberculosis of, 948. uterus, anteflexion of, 71. fibronux of, 382. inversion of, 271. retroflexion of, 336. retroversion of, 340. Imperforate vagina, 102. hymen, 53. Incontinence of urine, 723, 729. Infantile uterus, 23. Inflammation of bladder, 761. of ovary, 485. INDEX. 985 .liinainiTiatiou of ovaiy, aoute ovaritis, 488. causation, 493. diagnosis, 491. pathology, 489. physical signs, 490. prognosis, 491. symptomatology, 490. treatment, 492. chronic ovaritis, 493. causation, 496. pathology, 493. physical signs, 495. I^rognosis, 495. symptomatology, 494. treatment, 496. hypera^mia, 485. causation, 488. pathology, 485. physical signs, 487. prognosis. 488. symptomatology, 486. treatment, 488. of urethra, 880. of vagina, 106. acute, 106. chronic, 106. gonorrhoeal, 106. erysipelatous, 106. erythematous, 106. of vulvo-vaginal glands, 86. physical signs, 86. prognosis, 87. symptomatology, 86. treatment, 87. Inflammatory affections of uterus, 177. endometritis, 183. acute corporeal, 183. causation. 184. prognosis, 184. treatment, 184. cervical, 184. causation, 189. cystic degeneration, 186. pathology, 184. physical signs, 189. prognosis, 190. symptomatology, 188. treatment, 190. constitutional, 191. local, 191. chronic, 184. Inguinal labial hernia, 92. Inhaler, ether, 19. Injuries of pelvic floor, 116. Instruments u&ed in ovariotomy, 556. Intraligamentous ovarian cystoraata, 535. I)athology, 530. physical signs, 537. symptomatology, 537. treatment, 539. Inversion of bladder, 838. Inversion of uterus, 271. causation, 275. chronic, 378. diagnosis, 274. physical signs, 373. prognosis, 375. symptomatology, 271. treatment, 376. methods of reduction, 279. Barren. 379. Byrne, 381. Courty, 279. Noeggerath, 279. Thomas, 279. Knee-chest position, 329. Labia majora, 77. minora, 77. Lacerations, cervix uteri, 347, causation, 351. consequences, 347. frequency, 347. importance, 347. treatment, 354. operation, 354. varieties, 348. antero-posterior, 350. incomplete, 350. lateral, 348, 350. multiple, 350. levator-ani muscle, 133. perineum, 152. through sphincter-ani muscle, 134. Laparo-salpingotomy, 591. Laparotomy: after-treatment, 551. preparatory treatment. 551. peritonitis and septicaemia after, 566. Lesions of formation of ovary, 484. absent, 484. rudimentary, 484. supernumerary, 484. 986 DISEASES OF WOMEN. Levator-ani muscle, causes of injuries to, 127. Malformations of bladder, 677. anaspadias, 678. double bladder, 678. diagnosis, 676. epispadias, 678. etiology, 679. eversio vesica;, 678. exstrophia per urachum, 678. exstrophia vesica^ 677. extroversion, 676. fissure, 677. fistula- vesico-umbilicalis, 677. inversio vesicae cum prolapsu per fis- suram, 678. prognosis, 676. treatment, 676. of uterus, 25. absence, 27. at puberty, 25. during embryonic life, 25. illustrative cases, 28. uterus bipartis, 25. uterus bicornis, 26. bifundalis unicollis, 26. duplex, 26. hypertrophy, 25. rudimentary, 27, 30. unicornis, 26. of urethra, 672. atresia urethras, 673. defectus urethra? externus, 672. defectus urethra^ internus, 673. defectus urethra; totalis, 672. diagnosis, 675. double urethra, 674. hypospadias, 673. symptomatology, 674. treatment, 676. of vagina, 101. atresia, 102. acquired, 102. causation, 103. complete, 102. congenital, 102. illustrative cases, 102. partial, 102. physical signs, 103. symptomatology, 103. treatment, 104. Malformations of vagina, Dupuytren's operation, 104. Pouteau's trocar, 106. Sims's dilator, 106. double vagina, 101. impei'forate hymen, 53. imperforate vagina, 102. perpetuation of septum, 101. prognosis, 104. Malignant disease of uterus, 403. cancer, 403. cancer of cervix uteri, 403. cancer-juice, 404. colloid, 405. encephaloid, 405. epithelioma, 404. melanotic, 404. pathological effects, 405. hydronephrosis, 405. rectitis, 405. vesico- vaginal fistuLT. 405. pathology, 404. scirrhus, 405. definition, 404. sarcoma, 404. Meatus urinarius, 79. Medullai-y cancer, 410. Membranous dysmenorrhcea, 234. causation, 238. illustrative cases, 242. pathology. 234. physical signs, 237. symptomatology, 236. treatment, 240. Barker's, Fordyce, case, 245. Menopause, 439. illustrative cases, 448. premature, 442. symptomatology, 443. treatment, 444. Menstruation, 30. composition of menstrual flow, 31. derangement from arrest of develop- ment, 30. illustrative cases, 32. derangement from causes independent of sexual organs, 46. illustrative cases, 49. laws of, 31. premature, from deranged condition of life and delayed innervation, 47. INDEX. 987 Methods of exploration of bladder and urethra, 743. cystoscope, 740. Skene's bivalve urethral speculum, 700. Skene's endoscope, 744. urethroscope, 745. Metritis, interstitial, 183. acute, 182. chronic, 183. Metro-elytrorrhaphy, 335. Microscope in diagnosis, 18. Minute anatomy of ovary, 474. Mons veneris, 77. Miiller's ducts, 23. filaments, 33. Multilocular cyst, 509. Myoma. 357. Naboth, glands of, 180. Needles, Emmet's, 958. Keith's, 557. Peaslee's, 134. Skene's, 355. Needle forceps, 147. Neoplasms of bladder, 858. benign, 858. fibi'oma, 858. myo-fibroma, 858. myoma, 858. myxoma, 858. tubercle, 866. malignant, 858. encephaloid, 858. epithelioma, 858. sarcoma, 858, 868. scirrhus, 858. of Fallopian tubes, 587. carcinoma, 587. cystoma, 587. fibroma, 587. lipoma, 587. , Morgagni's hydatid, 587. myoma. 587. papilloma, 587. sarcoma. 587. tubercle, 587. of ovary, 506. adenoid cystoma, 506. carcinoma, 506. cystic tumors, 506. cysto-carcinoma, 506. fibroma, 506. Neoplasms of ovary, cysto-sarcoma, 500. dermoid cystoma, 506. follicular cyst, 500. filjrous cyst, 506. multilocular cystoma. 506. multiple cystoma, 500. multiple follicular cystoma, 506. papillary cystoma, SOU. sarcoma, 506. simple follicular cystoma. 500. simple unilocular cystoma. 506. of urethra, 894. areolar, 896. compound, 897. epithelial, 897. glandular, 895. papillary, 895. vascular, 896. of vagina, 110. carcinoma, 115. cysts, 110. fibroma, 114. fibromyoma, 114. myoma, 114. sarcoma, 115. Nymphae, 77. Observation, methods of, 1. Oophorectomy, 544. Orificium vaginjB, 81. Ovarian cysts, 507. classification, 506. complex cystoma, 510. compound cysts, 509. complications, 517. cystitis, 520. dragging of pedicle, 519. perforation, 520. rupture of cyst, 519. contents of, 515. cyst-wall, 514. cysto-fibroma, 513. dermoid, 513. diagnosis, 535. ascites, 534. cyst of broad ligament, 534. distended bladder, 533. encysted dropsy of peritonjeum, 533. enlargement and cysts of liver, spleen, and kidneys, 533. parovarian cyst, 534. pregnancy, 531. 988 DISEASES OF WOMEN. Ovarian cysts : uterine fibroids and fibro- cysts, 535. fibroma of ovary, 513. intraligamentous, 535. microscopic contents, 526. multilocular cysts, 509. ovarian granular cell (Drysdale), 517. papillary cysts, 511. paroophoritic, 511. physical signs, 523. simple cysts, 508. symptomatology, 523. ovariotomy, 544. Ovarian neoplasms, 506. hypersemia, 485. Ovaries, anatomy and physiology of, 469. displacements, 500. prolapsus, 501. Ovariotomy, 544. after-treatment, 565. assistants, 558. complications, 561. drainage, 564. emptying cysts in complicated cases, 562. list of instruments needed, 556. preparation of patient, 551. steps of operation, 559. Ovaritis, acute, 485. chronic, 492. Ovulation, 477. Palma plicata, 23. Palpation and percussion conjoined, 21. Papillary cysts. 511. Paquelin's cautery, 115. Paralysis of bladder, 723. Parovarian cysts. 534. Pelvic cellulitis, 596. causation. 599. illustrative cases, 605. pathology, 597. physical signs, 603. symptomatology, 601. treatment, 603. Pelvic colpo-hysteropaxy, 335. Pelvic floor : anatomy, 116. bulbo-cavernosus muscle, 117. coccygeus, 116. injuries, 116. lovator-ani muscle, 116. transversus perinaji muscle, 116. Pelvic floor : sagging of, 127. sphincter-ani muscle, 118. hajmatocele, 637. causation, 640. illustrative eases, 643. intra-peritoneal, 638. pathology, 638. physical signs, 641. subperitoneal, 638. symptomatology, 640. treatment, 642. peritonitis, 620. causation, 623. illustrative cases, 628. pathology, 621. symptomatology, 624. treatment, 625. Percussion, 10. Perinasum, 116. anatomy, 116. bulbo-cavernosus muscle, 117. levator-ani muscle, 116. sphincter-ani muscle, 118. transversus perinjei muscle, 116. functions, 120. injuries, 121. causation, 131. diagnosis, 124. illustrative cases, 144. symptomatology, 129. treatment, 133. Perineorrluiphy, 133. conditions necessary for healing of wounds, 137. conditions unfavorable for healing of wounds, 133. description of operation for rupture in median line, 143. denudation, 145. instruments, 144. introduction of sutures, 148. description of operation for the res- toration of sphincter-ani muscle and perinanim, 152. introduction of sutures, 155. vivifying, 154. primary operation, 133. Peaslee's needle, 134. silk sutures, 135. silver wire, 135. Peri-salfjingitis, 548. Pessaries, abuse of, 343. INDEX. 989 Pessaries, adaptation of, 323. Albert Smith's, 333. glass globe, 303. lever action of, 328. Peaslee's, 303. Skene's, for prolapsus of bladder, 819. stem, 69. Physiology of ovary, 438. Pregnancy tubal, 651. Premature menopause, 442. Preparation of silk sutures, 146. Preputium, 78. Probe, uterine, 14. Probing, uterus, 16. Process of vivifying tissues, 154. Prolapsus of ovary, 501; causation, 504. physical signs, 503. prognosis, 503. symptomatology, 502. treatment, 504. uteri, 293. first degree, 293. second degi'ee, 293. third degree, 293. treatment, 301. Pruritus of vulva, 95. pathology, 95. physical signs, 95. symptomatology, 95. treatment, 96. by galvano-cautery, 308. Pseudo-hermaphroditism, 84. Pudendal haematoma, 92. Pudendum, 77. anatomy, 77. development, 82. diseases, 85. wounds of, 88. Pyosalpins, 587. Rectum, digital touch by, 10. examination of pelvic organs through, 9. Recurrent fibroids, 436. Reproduction, history of, 7. Retroflexion of the uterus, 336. causation, 338. pathology, 336. physical signs, 337. prognosis, S39. symptomatology, 337. Retroflexion of the uterus, treatment, 340. Retroversion of uterus, 310. treated by pessaries, 318. Round ligaments, 329. Rudimentary uterus, 34. Rupture of bladder, 847. causation, 850. complete, 847. incomplete, 847. pathology, 847. prognosis, 849. symptomatology, 848. treatment, 850. Sagging of the pelvic floor, 131. Salpingitis, 587. acute, 587. causation, 589. chronic, 588. illustrative eases, 593. pathology, 587. jjhysical signs, 589. prognosis, 589. symptomatology, 588. treatment, 589. Sarcoma of uterus, 436. causation, 438. diagnosis, 438. pathology, 436. physical signs, 437. prognosis. 438. symptomatology, 437. treatment, 438. Scirrhus, 404. Scissors for removing sutures, 151. hawk-bill, 254. Sclerosis of uterus, 224. causation, 227. illustrative cases, 228. pathology, 224. prognosis, 227. physical signs, 227. symptomatology, 226. treatment, 228. of cervix uteri, 228. following puerperal meti'itis, 229. resulting from endometritis and gen- ei*al congestion, 231. Senile endometritis, 458. Sexual organs, development of, 22. Silk sutures, preparation of, 146. Silver wire, 135. 990 DISEASES OF WOMEN. Simple cyst, 508. Sims's vaginal dilator, 106. sponge-holder, 957. Skene's glands, G64. hemostatic forcejjs, 427. hysterotome, 75. needles, 255. scissors, 254. Sounds, uterine, 14. Jenks's, 14. Sims's, 14. Speculum : Cusco's, 11. method, 752-903. movements of, 13. Sims's, 11. Sponge-holders : Sims's, 957. Stricture: at junction of urethra and bladder, 929. of urethra, 927. Subinvolution of uterus after parturition, 219. causation, 219. pathology, 219. physical signs, 220. prognosis, 220. symptomatology, 220. treatment, 221. Superinvolution of uterus, 222. Sutures, 141. Syphilis, 85. Systems, 5. muscular, 5. nervous, 5. nutritive, 5. sexual, 5. Tenaculum, Sims's, 956. Tents, 17. Touch, examination by, 8. Tubal pregnancy, 651. Tubes, Fallopian, 22. Tubo-ovariotomy, 554. Ureters, diseases and injuries of, 968. catheterization of, 750, 969. Urethra, anatomy of, 663. development, 670. digital dilatation, 9. diseases of, 878. fistula, 927, 963. malformation of, 672. neoplasms, 894. Urethritis, 880. Urethroscope, 745. Uro-genital sinus, 83. Use of catheter, 143. Uterus, 23. absence of, 25. anatomy of, 177. at puberty, 24. bicornis, 25. bifundalis unicollis, 25. bipartis, 25. bleeding disease of, 363. development of, 22. dislocations of, 284. displacements of, 292. anteversion, 292. prolapsus, 293. retroversion, 310. double, 28. duplex, 26. functions of, 181. hypertrophy of, 25. infantile, 23. inflammatory affections of, 183. malformations of, 25. mature, 24. retroversion of, 310. rudimentary, 25. unicornTs, 25. Uterine dilator, 17. fibro-cysts. 360. fibroids. 356. probe, 14. sound, 14. Vagina : anatomy of, 100. atresia of, 102. cysts of, 110. development of, 22. double, 28. imperforate, 102. malformations of. 101. neoplasms of, 110. Vaginal dilator, Sims's, 106. enterocele, 93. causation, 93. diagnosis, 93. treatment, 94. Vaginismus, 110. Vaginitis, 106. acute, 106. catarrhal, 107. INDEX. 991 Vaginitis, causation, 108. chronic, lOG. diphtheritic, lUG. erysipelatous, lOG. erythematous, 106. exudative, 107. gonorrhoeal, 106, idiopathic, 106. patliology, 106. physical signs, 108. prognosis, 108. purulent, 107. secondary, 106. subacute, 107. symptomatology, 107. treatment, 108. Varicose veins of vulva, 88. causation, 88. physical signs, 88. symptomatology, 88. treatment, 88. Ventral fixation, 333. Vesical and urethral fistuliB, 951. causacion, 953. classification, 951. urethro- vaginal, 951. utero-vaginal, 951. vesico- vaginal, 951. complications, 953. illustrative cases, 960. physical signs, 952. preparatory treatment, 954. prognosis, 953. symptomatology, 953. treatment, 954. Vesical fistula?, after-treatment, 960. operation, 955. Emmet's needles, 958. introduction of sutures, 957. paring the edges of fistula, 956. Sims's sponge-holder, 957. Sims's tenaculum, 956. Vesico-rectal examination, 21. Vesico-urethral fissure, 888. Vesico-uterine fistula, 960, 905. Vesico-vaginal examination, 10. fistula, 950. Vestibule, 78. Vulvitis, 85. causation, 85. diagnosis, 86. due to cancer of uterus, 85. due to vaginitis, 85. erythematous, 85. follicular, 85. gonorrhoeal, 85. physical signs, 85. primary, 85. purulent, 85. secondary, 85. symptomatology, 85. syphilitic, 85. treatment, 86. Wounds of pudendum, 88. contused, 90. incised and punctured, 89. causation, 89. symptomatology, 89. treatment, 89. THE END. y%i ' '\ DATE DUE i MAI 16 1995 JUN6 IS 95. -t. . "-*• -r" ' ' PrInIM inUSA COLUMBIA UNIVERSITY LIBRARIES 0037566776 ■^^: >i;\L^ -yt RGlOl 1900 Skene Treatise on diseases of women. U'U^.ns . ..^A »:■ .1M. Py^.H MiM