/ r L f cAA^ « t-A^ O ir : Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/practiceofmedicOObyfo THE PRACTICE MEDICINE AND SURGERY/ APPLIED TO THE DISEASES AND ACCIDENTS INCIDENT TO WOMEN. By W. H. BYFORD, A.M., M.D., PROFESSOR OF GYNECOLOGY IN RUSH MEDICAL COLLEGE, AND OP OBSTETRICS IN THE WOMAN'S MEDICAL COLLEGE ; SURGEON TO THE WOMAN'S HOSPITAL OF CHICAGO ; EX- PRESIDENT OF THE AMERICAN GYNECOLOGICAL SOCIETY ; EX-VICE-PRESIDENT OF THE AMERICAN MEDICAL ASSOCIATION, ETC. AND HENRY T. BYFORD, M.D., SURGEON TO THE WOMAN'S HOSPITAL OP CHICAGO ; GYNECOLOGIST TO ST. LUKE'S HOSPITAL ; PRESIDENT OF THE CHICAGO GYNECOLOGICAL SOCIETY ; MEMBER OF AMERICAN MEDICAL ASSOCIATION ; OP ILLINOIS STATE MEDICAL SOCIETY ; OF CHICAGO MEDICAL SOCIETY, ETC. FOUKTH EDITION. REVISED, REWRITTEN AND VERY MUCH ENLARGED WITH THREE HUNDRED AND SIX ILLUSTRATIONS. PHILADELPHIA: P. BLAKISTON, SON & CO., No. 1012 Walnut Street. 1888. /o/ COPYEIGHT, 18S7, BY P. BLAKISTON, SOX & CO. X ^^^ PREFACE TO THE FOORTH EDITION, In no other branch of medicine or surgery has there been more rapid and greater advances made during the past few years than in gynaecology. This has necessitated a complete revision of my book, entailing the rewriting of many sections, the addition of much new material, and the consequent enlargement of the volume. The principal additions are the chapters on " Practical Observations upon the Anatomy and Physiology of the Female Pelvic Organs ; " " Examination of the Female Pelvic Organs " ( three chapters ) ; '' Displacements of the Uterus " (three chapters) ; " Affections of the Ovaries " and " Fallopian Tubes ; " and the paragraphs upon "Oojoho rectomy," " Tumor of the Broad Ligament," etc. While Chapter I is intended to supplement the general knowledge of anatomy and physiology obtained at the medical colleges, Chapters II and III are intended as a study of the anatomy and relation of the pelvic structures as they are encountered clinically. The value of a proper understanding of the anatomy, physiology and topography of these special organs cannot be overestimated, and it is hoj)ed that this section will be found of service both to practitioner and student. The chapter on " Lacerations of the Perineum and Pelvic Floor " has been rewritten, with the end in view of enabling the young practitioner to treat these accidents with discriminating intelligence, instead, as is so often the case, of learning to carve all injured perinsea to suit one stereotyped operation. Chapters XXIX, XXX, and XXXI, on " Displacements of the Uterus " have been rewritten and Chapter XXXII revised with a similar intention. The chapters on the "Affec- tions of the Ovaries " and " Fallopian Tubes " have also been revised, and the subject of oophorectomy rewritten. New matter concerning tumor of the broad ligament and pelvic abscess (see chronic perimetritis) has been added, and some additions to Chapters III, XII, XXV, XXXV, XXXVI, XXXIX, XLVIII, and others, made. IV PEEFACE. Some subjects, such, for instance, as cancer of the uterus, might have been more extensively revised, but it has been thought better, in view of the indefinite state of our knowledge upon them, to limit the alterations to correspond to that which is most settled and useful from a 23ractical standj)oint. The illustrations, over one hundred and fifty of which are new, have been carefully selected, a majority of them (excepting cuts of instru- ments) being from original drawings made especialh^ for this edition. A large part of the work of revision and editing having been done by Henry T. Byford, M.D., I feel that an ordinary acknowledgment of his ser\dces would be inadequate; I, therefore, believe it only just to place his name on the title-page as one of the authors. Acknowl- edgment is also due to Dr. Robert J. Hess, of Philadelphia, for his services in reading proof and preparing the indexes. AVe have endeavored throughout the book to give the proper credit to all workers in this field whenever referred to, but I wish here to render my general acknowledgment to all. W. H. B. Chicago, December, 1887. CONTENTS. CHAPTER I. PRACTICAL OBSERVATIONS UPON THE ANATOMY AND PHYSIOLOGY OF THE FEMALE PELVIC ORGANS. I. PELVIC ROOF, 18. Musculature of the pelvic roof, 19. Peritoneal covering of the pelvic roof, 22. Pelvic connective tissue, 23. The ovaries and their relations, 2.5. Ureters, 27. Vagina, 28. Plane of the pelvic roof, 31. Relation of uterus to bladder, 31. Relation of pelvic roof to pelvic floor, 32. II. THE PELVIC FLOOR, 32. Relation of the muscles of the pelvic floor and interposed tissues, 34. Abdominal pressure, 35. Requirements for the closure of the pelvic floor insufficiency, 38. III. PERINEUM, 39. Perineal body, 42. Measurements of the perineal body, 42. Characteristics of the perineal body, 43. Action of the perineum as a support, 44. The rectum, 46. The bladder, 50. The bloodvessels, 51. Nerves 53. Lymphatics, 53. CHAPTER IT. EXAMINATION OF THE FEMALE PELVIC ORGANS. Position of patient for examination, 56. Percussion of the pelvic organs, 58. Palpation of pelvic roof — digital examination through the vagina, 58. Characteristics of the cervix uteri, 59. The virgin cervix, 59. The cervix uteri of the child-bearing woman, 59. The senile cervix, 60. Location of the cervix uteri, 61. Corpus uteri, 63. Palpation of the displaced uterus, 63. Palpation of the pregnant uterus, 64. Examination of the uterus during general anaesthesia, 65. Digital exploration of the pelvic roof through the vagina, 67. The advantages of a gentle touch, 67. When not to examine, 68. Precautions necessari^ during examination, 68. Difiiculty of difi"erentiating pelvic tissues by the touch, 68. The starting point in digital explorations of the pelvic roof, 69. How to palpate the ovaries, 69. Table of position of ovaries, 72. Palpation of the ovarian ligament, 72. The infundibulo-pelvic hgament, 73. Palpation of the round ligament, 74. ' Palpation of the Fallopian tubes, 77. Palpation of the ureters, 78. How to find the ureters with cervix in normal j^osition, 79. Palpation of the ureters when the cervix is displaced backward, 80. Palpation of the ureters when the cervix is displaced forwards, 80. Difter- entiation, 81, Palpation of the broad ligaments, 81. Vaginal palpation of VI CONTEXTS. the sacro-uterine ligaments, 83. Palpation of the pubo-vesico-uterine ligament, 86. Palpation of the vagina, 88. Rectal examination of the pelvic roof, 90. Method of rectal indagation, 91. Digital exploration through the upper rectum, 93. The recto-vaginal grip, 95. Circumdigita- tion of the uterus from the abdomen, vagina and rectum, 95. Palpation of the interior of the bladder, 96. CHAPTEE III. EXAMINATION OF THE FEMALE PELVIC OEGANS — CONTINUED. The pelvic floor and perineum, 98. Vaginal jDalpation of the pelvic floor, 98. The small sacro-sciatic ligament, and ischial spine, 99. The pyriformis, 99. The great sacro-sciatic foramen and sacral promontory', 100. The coccygeus, 101. The levator ani, 101. Control of the pelvic floor muscles by will, 102. The obturator internus, 103. Rectal examination of the pelvic floor, 104. Palpation of the arteries of the pelvis, 104. Vaginal palpation of arteries, 105. Rectal palpation of the pelvic arteries, 107. Palpation of pelvic nerves, 107. Examination of the perineum, 108. Examination of the vaginal orifice, 108. The levator vaginae and levator ani, 108. Examination of the vulval orifice, 110. The constrictor cunni or vulval sphincter. 111. The pubic fossa, 111. Transversus perinjei, 112. Characteristics of the perineal body, 112. Rectal palpation of the perineal body, 113. Digital aversion of the vagina, 113. CHAPTER lY. INSTRUMENTAL EXAMINATION OF THE FEMALE PELVIC ORGANS. Object in using the sound or probe, 114. Size and length of sound, 114. Mode of using, 117. Length of the cervical and uterine cavities, 117. Speculum, 120. Position of patient for speculum, 121. Mode of using the speculum, 122. How to find the os uteri, 123. Appearance of the os and cervix in the virgin, 125. Appearance of the multiparous uterus, 126. Appearance in the aged, 126. Exceptions to these appearances, 127. Color, 127. Appearance of secretion, 127. Indication of mucus in abundance, 127. Indication from pus, 128. Probe and speculum conjointly, 128. Dilata- tion, 128. Exploratory curetting of the uterus, 133. The use of the female catheter, 134. The urethral speculum and endoscope, 135. Cath- eterization of the ureters, 136. General manner of conducting an examina- tion in making a diagnosis, 138. CHAPTER V. DISEASES AND ACCIDENTS OF THE LABIA AND PERINEUM. Wounds, 142. Sanguineous infiltration, 143. Varices of the labia and vulva, 143. Qlldema, 144. Phlegmon, 144. Abscesses of the labia, 146. Labial hydrocele, 146. Labial tumors, 147. Hypertrophied labia, 147. Cancer of the labia, 149. CONTENTS. Vll CHAPTER YI. DISEASES OF THE VULVA. Condylomata of the vulva, 150. Treatment, 150. Inflammations, 150. Treat- ment, 151. Follicular vulvitis, 152. Causes, 152. Treatment, 152. Pruritus pudendi, 153. Treatment, 154. Corroding ulcer, 155. G-angre- nous vulvitis, or noma, 156. Urethral excrescences, 157. Vascular urethra, 158. Hypertrophy of the clitoris and nympha, 159. Treatment, 159. CHAPTEE VII. LACERATION OF THE PERINEUM AND PELVIC FLOOR. Preliminary observations upon the conditions leading to injuries of the parturient canal, 160. The mechanism of laceration and injuries of the perineum and pelvic floor, 161. The sciatic and coccygeal surface, 161. Plane of obturato- coccygeus, 162. The levator coccygei, 163. The plane of the levator ani proper, 164. Plane of the levator vaginse or vaginal sphincter, 164. Plane of the constrictor cunni or vulval sphincter, 167. The vulval plane or ring, 167. Lacerations extending into the transversus perin?ei and sphincter ani, 168. Lacerations of the perineal septum, 168. Lacerations of the deep pelvic fascia, 168. The flap lacerations, 168. Central ruptures, 169. Irregular lacerations, 169. Concealed lacerations, 170. Contusions about the bony walls, 171. Lacerations extending into the rectum, 171. Effects of perineal and pelvic floor lacerations, 171. The immediate eff"ects or those incident to the puerperal state, 171. Eemote eff'ects, 172. Effects upon the uterus, 172. Effects upon the bladder, urethra, and rectum, 173. Effects upon the vagina, 174. Other effects, 174. Symptoms of perineal and pelvic floor lacerations, 174. Secondary symptoms, 174. Varieties of laceration, 175. Degrees of laceration, 176. Diagnosis of perineal and pelvic floor lacerations, 177. Palpations of old perineal lacerations, 180. Diagnosis by rectal palpation, 181. Diagnosis by inspection, 183. Combined palpation and inspection, 184. Diagnosis of old lacerations extending into the rectum, 184. Diagnosis of lacerations of the pelvic floor, 184. Deeper portions of the pelvic floor, 185. Method of diagnosis, 186. Prognosis, 187. Prevention of lacerations, 187. Perineal incisions, 188. Colpotomy, 189. Episiotomy, 189. Perineal tenotomy, 190. Delivery after perineal incisions, 192. Choice of methods, l92. After management, 193. Treatment of perineal lacerations, 193. Superficial lesions, 193. Treat- ment by coaptation, 193. Immediate perineorrhaphy, 194. Reasons for failure of the immediate operation, 194. Contraindications, 194. The operation, 195. Lacerations into the rectum, 199. Secondary perineor- rhaphy, 199. What is to be accomplished, 200. When to operate, 200. Methods of restoring the perineum when the rectum is not opened, 200. The median triangular operation, 200. The modified triangular operation, 201. The bilateral operation, 202. Crescent operation, 204. Emmet's crescent operation, 205. Transverse denudations, 205. Star operation, 205. Flap operations, 206. The triangular flap operation, 206. Bischoff's operation, 207. Modified Freund's operation, 208. Crescentic flap opera- Vlll CONTENTS. tion, 208. Unilateral flap operation, 209. Operations upon uncicatrized lacerations, 210. Lacerations involving the sphincter ani but not the rectum, 210. Closure of lacerations extending a short distance into the rectum, 210. Flap operations, 211. Lacerations extending high up into the rectum, 214. Choice of methods, 215. Preparation of the patient, 216. Prepara- tions for operating, 216. Operative detail, 217. Sutures, 218. The quilled suture, 219. Incision of sphincter ani, 221, After-treatment, 221. CHAPTER yill. DISEASES OF THE BLADDER. Paralysis of the bladder, 223. Prognosis, 223. Symptoms, 223. Diagnosis, 224. Treatment, 224. Hemorrhage from the bladder, 22.5. Hypersesthesia of the bladder and urethra — irritable bladder and urethra, 225. Causes, 226. Treatment, 226. Chronic inflammation of the bladder, 227. Nature and progress, 227. Symptoms, 227. Diagnosis, 228. Prognosis, 228. Treatment, 228. Stone in the bladder, 231. Symptoms, 232. Diagnosis, 232. Treatment, 233. Foreign bodies, 234. Inversion of the bladder, 235. CHAPTER IX. AFFECTIONS OF THE VAGINA. Absence of the vagina, 236. Causes, 236. Diagnosis, 236. Atresia vaginae, 237. Diagnosis, 237. Prognosis, 238. Treatment of atresia and absence of tlie vagina, 238. Tumors in the vagina, 240. Vaginismus, 241. Diag- nosis, 242. Prognosis, 242. Treatment, 242. Acute vaginitis, 243. Diagnosis, 244. Prognosis, 244. Cause, 244. Treatment, 244. Chronic vaginitis, 245. Symptoms, 245. Diagnosis, 246. Causes, 246. Prognosis, 246. Treatment, 247. Puerperal vaginitis, 248. Sj^mptoms, 249. Treat- ment, 250. Urinary fistula, 251. Diagnosis, 252. Prognosis, 253. Treatment, 254. Simon's method, 264. Kolpokleisis, 268. Bozeman's method, 271. Entero-vesical fistula, 274. Entero-vaginal fistula, 275. Recto-vaginal fistula, 275. Treatment, 275. CHAPTER X. MENSTRUATION AND ITS DISORDERS. Puberty, 278. Amenorrhoea, 282. Pathology and morbid anatomy, 283. Symptoms, 283. Amenorrhoea from retention, 286. Diagnosis, 286. Diag- nosis of retention, 288. Prognosis, 289. Treatment, 290. CHAPTER XI. MENORRHAGIA AND METRORRHAGIA. Treatment of menorrhagia, 300. Palliative treatment, 301. Curative treatment, 304. CONTENTS. IX CHAPTER XII. DYSMENORRHCEA. Diagnosis, 309. Prognosis, 309. Treatment, 309. The inflammatorj' form of dysmenorrhoea, 310. Symptoms, 310. Diagnosis, 311. Prognosis, 311. Treatment, 311. Membranous dysmenorrhoea, 312. Symptoms, 313. Diagnosis, 313. Treatment, 314. Obstructive dysmenorrhoea, 314. Symp- toms, 316. Diagnosis, 316. Prognosis, 317. Treatment, 317. Superficial trachelotomy — Peaslee's operation, 322. (a) Representing stenosis of the internal os, 322. (b) Representing stenosis of the external os, 323. Dilatation, 326. CHAPTER XIII. METATITHMENIA, OR MISPLACED MENSTRUATION. PERIUTERINE HEMATOCELE. Symptoms, 332. Diagnosis, 334. Prognosis, 335. Treatment, 336. Chronic Retrouterine Hasmatocele, 338. Diagnosis, 341. Treatment, 342. CHAPTER Xiy. CHANGE OF LIFE MENOPAUSE AND SENILITY. CHAPTER Xy. ACUTE INFLAMMATION OF THE UN IMPREGNATED UTERUS. Causes, 346. Symptoms, 346. Prognosis, 347. Diagnosis, 347. Treatment, 348. CHAPTER XVI. GENERAL CONSIDERATIONS ON " UTERINE DISEASE," OR HYSTEROPATHY. CHAPTER XVII. SYMPATHETIC OR REFLEX SYMPTOMS OF UTERINE DISEASE. Sympathy of the stomach, 353. Sympathetic disease of the bowels, 354. Sympathetic affection of the liver, 354. Sympathetic affections of the ner- vous system, 355. Accompanying manifestations of moral and intellectual perverseness, 356. Syncopal convulsions — hystero-epilepsy, 356. Moral and mental derangement, 357. Cephalalgia, 358. Affections of the spinal cord, 360. Hypersesthesia, 360. Anaesthesia, 361. Spasms, 361. S3'm- pathetic pains in the pelvic region, 361. Extension of inflammation to the bladder and rectum, 361. Affections of the sciatic and anterior crural nerves, 362. Muscular weakness, 362. Circulatory system, 363. Respi- ration, 364. Sj^mpathy of the excretory organs, 365. Mammary bodies, 366. X CONTENTS. LOCAL SYMPTOMS, 369. Pain in the sacral or lumbar region, 369. Pain in the loins, 370. Liability to walk, 370. Pain in the iliac region, 370. Soreness in the iliac region, 371. Pain in the side, above the ilium, 37]. Weight, or bearing-down pain, or uterine tenesmus, 371. Leucorrhoea, 371. Amount of leucorrhoea not always proportioned to extent of disease, 372. Yellow leucorrhoea, when there is abrasion or ulceration, 373. How is the pain produced? 373. Bearing-down not always caused by displacements, 373. Severity of suflPering not commensurate with amount of disease, 374. Effects on the functions of the uterus, 374. Pain during menstruation, 375. Kind of pain attendant upon uterine inflammation, 375. Cramping pain, 375. Effects of partial closure of the os uteri on menstruation, 375. Manner of flow modified by inflammation and congestion, 376. Duration of the flow, 376. Menorrhagia, 377. Menorrhagia frequent in endocervicitis, 377. Amenorrhoea sometimes results, 377. Function of generation affected by it, 378. Sterilit3^, 378. Abortion, 379. Conditions of the uterus in abortion, 379. Effect upon labor, 380. Effects upon the post-partum con- dition, 380. CHAPTER XVIII. PATHOLOGY OR HYSTEEOPATHY. Mucous inflammation, 386. Seat of mucous inflammation, 387. Cavitj' of the body of the uterus, 387. Endocervicitis, 387. Endocervicitis with dimin- ished size, 388. Endocervicitis in virgins, 388. Endocervicitis in aged women, 388. External inflammation combined withinternal in child-bearing women, 388. CHAPTER XIX. ETIOLOGY OF UTERINE DISEASE. CHAPTER XX. DIAGNOSIS OF UTERINE DISEASE. Characteristic signs of inflammation, 392. Diagnosis of endocervicitis, 392. Diagnosis of submucous inflammation, 393. Complication of mucous with submucous inflammation, 393. Size of the uterus ordinarily increased — exceptions, 393. Atrophy as the result of inflammation, 394. CHAPTER XXL GENERAL TREATMENT OF UTERINE DISEASE. Main objects of general treatment, 397. Greneral symptoms requiring special attention, 399. Nervous prostration, 399. Food, etc.; 401. Nervous excitability, 401. Anaemia, 403. Plethora, 4()4. Local congestions, 404. Constipation, 405. CONTENTS. XI CHAPTER XXII. SPECIAL TREATMENT. Baths, 415. Hip-bath, 416. Temperature of bath, 416. Shower-bath, 417. Sponge-bath, 417. Vaginal injections, irrigation, douches, 417. Accident in injection, 419. Should thejf be used in pregnancy ? 420. LOCAL TREATMENT, 422. Local alteratives, 426. Treatment of endo- metritis, 429. CHAPTER XXIII. LACERATIONS OE THE CERVIX UTERI. Causes, 435. The degree, locality and direction, 436. Effects of the laceration, 436. Effects on the body of the uterus, 437. Complications, 437. Symp- toms, 438. Diagnosis, 438. Treatment, 438. Preparatory treatment, 439. The operation, 440. CHAPTER XXIV. OCCASIONAL UNTOWARD EFFECTS OF UTERINE MANIPULATIONS AND OPERATIONS. CHAPTER XXV. HYPERTROPHY OF THE CERVIX. Diagnosis, 446. Elongation of the supravaginal cervix, 447. CHAPTER XXVI. ACUTE PERIMETRITIS. Causes, 454. Symptoms, 454. Diagnosis, 457, Prognosis, 459. Local peri- tonitis, 460. Causes, 461. Symptoms, 461. Diagnosis, 463. ' Prognosis, 464. Treatment of perimetritis, 464. CHAPTER XXVII. CHRONIC PERIMETRITIS. Causes, 469. Varieties, 469. Symptoms and diagnosis, 471. Treatment, 473. CHAPTER XXVIII. DISPLACEMENTS OF THE VAGINA, BLADDER AND RECTUM. Urethrocele, cystocele, 479. Rectocele, 479. Symptoms, 479. Diagnosis, 480. Causes, 480. Treatment, 481. XU CONTENTS. CHAPTER XXIX. DISPLACEMENTS OF THE UTERUS. What constitutes a displacement of the uterus, 486. Causes of uterine dis- placements, 486. Of descent and lapse, 486. Of prolapse and procidentia, 487. Of displacements forward, backward, sideways, 487. Of versions, 487. Of flexions, 489. Torsion or twisting, 493. Symptoms of uterine displacement, 494. Diagnosis of uterine displacements, 495. CHAPTER XXX. DISPLACEMENTS OF THE UTERUS CONTINUED. Treatment of uterine displacements — prophylactic, 498. Treatment of simple dislocations, upward, forward, and backward, 498. Descent or lapse, 500. Prolapse and procidentia, 501. Measures for diminishing the weight of the uterus, 501. Measures to strengthen or elevate the pelvic roof supports, 501. Cauterization, 504. Partial closure of the vagina, 504. Abdominal section, 505. Measures to supplement or restore the pelvic floor and perineal supports, 505. Hysterophores or pessaries, 505. Plastic operations upon the perineum or pelvic floor, 509. Choice of methods, 51 1. TREATMENT OF VERSIONS, 511.* I. Anteversion, 511. Vaginal tam- ponment, 512. Anteversion pessaries, 51 2. II. Retroversion, 514. In the acute and subacute stages, 514. Replacement, 514. Adhesions, 515. The vaginal pack, 516. Breaking up of adhesions, 516. Mechanical support, 517. Pessaries acting in front of the cervix, or barrier pessaries, 518. Pessaries acting behind the cervix, or traction pessaries, 521. Pessaries acting both in front and behind the cervix, 522. Pessaries acting within the cervical canal, 523. CHAPTER XXXI. DISPLACEMENTS OF THE UTERUS — CONTINUED. Operative procedures for retroversion, 525. To restore the uterus to its natural condition, 525, To restore the function of the uterine supports, 525. Shortening of the sacrouterine ligaments, 525. Shortening the round liga- ments, or the Alexander- Adams operation, 527. Indications, 528. Contra- indications, 528. The operation, 528. After-treatment, 531. Results of the operation — cases, 531. Dangers and difficulties, 534. Raising of the perineum or pelvic floor, 534. Operations of expedience, 535. Abdominal section for fixing the fundus forward, 535. Operation for holding or fixing the cervix backward, 535. Treatment of uterine flexions, 536. CHAPTER XXXII. DISPLACEMENTS OF THE UTERUS — CONTINUED. Retroversion and retroflexion of the uterus during pregnancy, 539. Causes, 539. Symptoms, 540. Diagnosis, 541. Termination, 541. Treatment, 541. CONTENTS. Xin CHAPTER XXXIII. DISPLACEMENTS OF THE UTERUS — CONTINUED. Inversion of the uterus, 543. Symptoms, 544. Diagnosis, 545. Prognosis, 546. Treatment, 546. The treatment of the chronic form, 549. CHAPTER XXXIV. DISEASED DEVIATIONS OF INVOLUTION OF THE UTERUS. Causes, 558. Symptoms, 559. Prognosis, 559. Treatment, 559. Subinvolu- tion of the uterus, 562. Causes, 565. Frequency of its occurrence, 565. Symptoms and diagnosis, 566. Diagnosis, 566. Prognosis, 567. Treat- ment, 567. Hyperinvolution, 570. Causes, 570. Symptoms, 570. Diag- nosis, 571. CHAPTER XXXY. CANCER OF THE UTERUS. Symptoms, 574. Causes, 576. Diagnosis, 577. Prognosis, 578. Treatment, 579. PaUiation, 575. CHAPTER XXXYI. EPITHELIOMA, CANCROID, EPITHELIAL CANCER OF THE UTERUS. Diagnosis, 592. Prognosis, 593. Treatment, 594. CHAPTER XXXVII. SARCOMA. Symptoms, 607. Diagnosis, 608. Prognosis, 609. Treatment, 609. CHAPTER XXXVIII. TUMORS OF THE UTERUS. Fibrous tumors, 610. Their nature, 612. Symptoms, 614. Diagnosis, 617. Prognosis, 619. CHAPTER XXXIX. FIBROUS TUMORS OF THE UTERUS — CONTINUED. Treatment, 624. Cases, 628. Summary of cases cured by absorption, 641. Modes of using ergot, 642. Different preparations, 644. Auxihary treat- ment, 646. Corrective treatment, 646. Modus operandi, 647. Treatment by electricity, 654*. Apostoli's method, 655. Modes of action, 656. Dan- gers attending its use, 657. XIV CONTENTS. CHAPTER XL. SURGICAL TREATMENT. Removal of polypoid tumors, 658. Enucleation, 663. Laparotomy, 667. Laparo-hysterectomy, 668. Oopliorectomj' — Battey's operation — spaying, 673. Operation, 678. Physical and psychical results, 680. CHAPTER XLI. AFFECTIONS OF THE OVARIES. Congenital atrophy, 682. Hypertrophy, 682. Displacement, 682. SjTuptoms, 684. The diagnosis, 684. Causes, 685. Effects, 685. Prognosis, 685. Treatment, 685. Acute ovaritis, 688. Treatment, 689. Chronic ovaritis — ovarian irritation, 689. Etiology, 690. Symptoms, 691. Diagnosis, 692. Prognosis, 693. Complications, 693. Treatment, 693. CHAPTER XLII. AFFECTIONS OF THE OVARIES CONTINUED. OVARIAN TUMORS. Anatomy, 695. Theories of their origin, 704. Modes of termination, 710. Causes, 712. Prognosis, 713. Diagnosis, 714. Remarks on diagnosis of ovarian tumors generally, 714. Physical examination, 715. Palpation and percussion, 716. Exploration, 719. " On the granular cell found in ovarian fluid, ' ' 720. Differential diagnosis, 723. CHAPTER XLIII. OVARIAN TUMORS — CONTINUED. Treatment, 730. Curative treatment, 736. Surgical treatment, 736. Injection of the sac, 740. Electrolysis, 745. Vaginal ovariotomy, 746. CHAPTER XLIV. ABDOMINAL OVARIOTOMY. General observations, 748. Treatment of the pedicle, 748. The ligature, 749. Drainage, 750. CHAPTER XLV. ABDOMINAL OVARIOTOMY CONTINUED. Preparation of the room, 761. Preparation, 761. Oixiration, 762. Second step, 764. Ovariotomy, 765. Third step, 769. CONTENTS. XV CHAPTER XLVI. OVARIOTOMY CONTINUED. Accidents that may occur during the operation, 771. CHAPTER XLVII. OVARIOTOMY CONTINUED. After-treatment, 774. Treatment of the wound, 775. Attention to clotliing, 775. Vomiting, 776. Tympanites, 777. Hemorrhage, 778. Traumatic peritonitis, 779. Septicaemia, 781. Treatment, 782. Remarks, 783. Tumor of the broad ligament, or parovarian tumor, 784. Etiology, 785. Symptoms, 785. Diagnosis, 785. Prognosis, 786. Treatment, 786. CHAPTER XLVIII. FALLOPIAN TUBES. Salpingitis, 789. Symptoms, 790. Diagnosis, 791. Prognosis, 792. Treat- ment, 792. Surgical treatment, 795. Hemato-salpinx, 796. CHAPTER XLIX. COCCYGODYNIA, COCCYALGIA. Neuralgia of the coccyx, 798. Structure affected, 798. Symptoms, 798. Diag- nosis, 799. Prognosis, 799. Treatment, 799. INDEX OF ILLUSTRATIONS. Fig. 1. Sagittal section of pelvic organs in the virgin, . . . Byford " 2. Sagittal section of pelvic organs of child-bearing woman, " 3. Position of the uterus when the bladder is full, " 4. Schematic representation of the ligaments about the internal OS uteri, " 5. Round ligament, ......... " 6. Schematic representation of round ligaments, " 7. Coronal section of the pelvis, Luschka " 8. Sagittal section of the pelvic connective tissue, . Wm. A. Freund " 9. Horizontal section of pelvic connective tissue, " 10. Position of the ovaries, Schultze " 11. Relation of ovary to posterior surface of broad ligament, Modified from Henle ' " 12. Positions of ovaries and Fallopian tubes, Byford " 13. Manner of insertion of the cervix uteri into the vagina, " 14. Horizontal section of pelvic floor near the pelvic outlet, . Henle " 15. Internal obturator muscle, . . . . . Tarnier and Chant reuil " 16. Pelvic floor outlet, Byford " 17. Pubic attachments of the levatores ani et vaginae muscles, . Savage " 18. Muscles of the pelvic floor, " 19. Horizontal section of pelvis, " 20. Illustration of the action of abdominal pressure upon the uterus, Byford " 21. Voluntary contraction of the pelvic floor during straining and lifting, ........■• " 22. Perineal muscular system. (Schematic), . . . . " 23. Dissection of the muscles of the perineum and pelvic floor, . Savage " 24. Perineal fascia laid open, " 25. Pelvic floor and perineal fasciae, Byford \ " 26. Perineal triangles of virgin, " 27. Of married nullipar, " 28. Of old woman, " 29. Of old maid before menopause, " 30. Shape of relaxed perineal triangle, " 31. Relations of muscles and fasciae to perineal body, . " 32. Folding of the perineal body in normal labor, " 33. Flattening of the perineal body in labor, B XVlll INDEX OF ILLUSTRATIOXS. Byford Luschka Hyrtl Sargent Byford Fig. 34. Muscular fibres of rectum, " 35. Distended rectum, " 36. Relation of the ureters to tlie bladder and uterus, . " 37. Distribution of the ovarian, uterine and vaginal arteries " 38. Operating chair, ....... " 39. Byford' s operating table, ■ " 40. Position for Sims's speculum, .... " 41. Virgin uterus and vagina, " 42. Uterus of the child-bearing woman, " 43. Senile uterus and vagina, ... .... " 44. Digital examination in the dorsal position, . . . . ' " 45. Bimanual palpation of the uterus from the posterior vaginal v^'all, • • " 46. Bimanual palpation of the uterus through the anterior vaginal fornix, ........ . • " 47. Uterus artificially turned back against the hollow of the sacrum, for palpation of the posterior wall, ... " 48. Positions of ovaries as seen from the pelvic brim, Modified from Schultze " 49. Artificial tension of the round ligaments, using the sacro-uterine attachment as a fulcrum, ....... Byford " 50. Position of the uterus produced by contraction of the round ligaments, ......... " 51. Position of the ureters. (Schematic), " 52. Uterine torsion produced by contraction of the sacro-uterine ligament of one side, .... Modified from Schultze " 53. Position of uterus produced by contraction of the sacro-uterine ligaments, " 54. Method of introducing the finger into the rectum, . " 55. Bimanual examination of the posterior surface of the uterus and the posterior pelvic spaces from the rectum, " 56. Recto-vaginal grip of the retroverted uterus, .... " 57. Bimanual circumdigitation from the rectum and vagina, . " 58. Palpation of the uretral orifices, " 59. Grasping the coccyx, " 60. Anterior surface of the sacrum, " 61. Vaginal entrance of the virgin, " 62. Vaginal entrance of the married nullipar, .... " 63. Vaginal entrance of the married nullipar, with contracted or short levator ani, " 64. Vaginal entrance with greatly relaxed or destroyed levator vaginse, ........•• " 65. Same as above, except that the levator ani is short, ' ' 66. Shape of vulval orifice, . " 67. Same, of married nullipar, " 68. Same, of child-bearing woman, " 69. Simpson's sound, . " 70. Sims's sound, .... '' 71. Jenks's uterine probe, " 72. Fitch's measuring sound, " 73. Introduction of the uterine sound, Byford Winckel Byford Gray Byford Trnax Byford IXDEX OF ILLUSTEATIONS. XIX Fiff. 7 4. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101. 102. 103. 104. 105. 107. 108'. 109. 110. 111. 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. 122, the side, s method of examining the Byford Truas Sargent Tiemann Byford Truax Sargent Hysterometer, Method of applying hysterometer, Higby's speculum, Nott's speculum, . Nelson's speculum, closed, Nelson's speculum, open. Nelson's tenaculum, Double tenaculum forceps, Tenaculum forceps, Speculum introduced, . Dressing forceps, . Sims' s speculum, . Sims' s depressor, . Tenacula, .... Nott's tenaculum forceps, Simon's speculum, Simon's retractors, Lever for dilating the vagina from Action of the instruments in Sims uterus, .... Sponge tent, .... Laminaria tent, Tupelo dilators (hollow), Compressed slippery- elm tents, straight and carved Compressed slippery-elm tent, hollow, . Tent mounted on tent-holder, Molesworth's dilator, .... Hanks' dilators, Probe curette, ..... Thomas's wire curette, .... Byford 's finger curette, . . . . Sims's sigmoid catheter, Groodman-Skene's self- retaining catheter, Skene's urethral endoscope, ....... Tiemann Simon's urethral catheter, Winckel Elephantiasis of the labia, Scanzoni Cancer of the labia, McClintock Folding of the perineal body in normal labor, . . . Byford Flattening of the perineal body due to rigidity. Diagonal flap laceration of perineum, left side, Triangular lacerations of the perineum, Diagonal lacerations of the perineum, . Diagonal bilateral laceration with vulval extension Same, with extension into the rectum, . Double diagonal and transverse laceration, Same, with both vulval extension and transverse, Degrees of median laceration through perineal raphe, Degrees of extension of diagonal laceration through the raphe, Byford Sargent Tiemann , Truax a Sargent u Truax XX INDEX OF ILLUSTRATIOXS. Fig. 123. " 124. " 12.5. " 126. " 127. " 128. " 129. " 1.30. " 131. " 132. " 133. " 1.34. " 135. " 136. " 137. " 138. " 139. " 140. " 141. " 142. " 143. " 144. " 145. " 146. " 147. " 148. " 149. " 150, " 154. " 155. " ].56. " 1.57. " 158. " 159. " 160. " 161. " 162. " 163 " 165, " 166, " 167, " 168, ■' 169, Deformity produced bj'tlie traDSverse or deep double diagonal laceration. ....... Incisions to be made in perineal tenotomy, . Perineal tenetome, double, ..... Deep suture entered near edge of wound. Deep suture entered at a distance from edge, Edges of wound pared to prevent compression, Fla]3 stitcli, ........ Triangular denudation of perineum. (Schematic), 3Iodified triangular denudation of perineum, x\ppearance of the modified triangular denudation between separated labia, . ..... Bilateral denudation with stitches passed. Same, with vaginal stitches tied, .... Martin's modification of the bilateral denudation, . Crescentic denudation with vaginal stitches passed, Same, with vaginal stitches tied, .... Crescentic, modified, ...... [ Star denudations, . . . Lines of incision in triangular flap operation, Same, with flaps raised and sutures passed, . Byford Truas Bvford Zweifel Byford u jNIartin Bvford Hart and Barbour Bvford f Denudation, as made by Bishofi", .... Unilateral flap denudation, " Hegar's triangular denudation, Hegar Freund's bilateral denudation, ..... Kuestner Triangular flap operation, applied to lacerations extending into the rectum, ...... Hart and Barbour Same, with flaps raised and stitches passed, . . " " 151, 152 and 153. Unilateral flap operations applied to lacera- tions extending into the rectum, ..... Byford Emmet's method of passing sutures in lacerations deep into the recto-vaginal septum, ..... . Emmet Splitting of perineum and flap stitches passed after the manner of Lawson Tait, Zweifel Perineum scissors, Truax Langenbeck serres-fine for compressing arteries, . . . " Silver sutures, properly bent, ...... Byford Silver sutures twisted without being properly bent, . . " Method of securing twisted ends of silver sutures, . . Emmet Quilled sutures, tied, Zweifel Skene's double perforated catheter, Truax and 1 64. Urinary fistulte, ....... Byford Tenaculum, with which to hold the edge of fistula while being pared, .......... Sargent Curved scissors, for paring edge of fistula, . . . . " Wire adjuster, ......... " Speculum, for dilating vagina, . . . . . . " Forceps, for twisting the wires, . . ... . . " IXDEX OF ILLUSTEATIOXS. XXI Fig. 170. The catheter, Sargent " 171. Needle forceps, ...... " 172. Sponge-holder. The instruujents are represented half-size, " 173. Method of paring the edges of a urinarj' fistula, . . . Byford " 174. Method of passing the needle, " 175. Method of using the tenaculum, etc. , . " 176. The fistula, with edge pared and sutures placed, " 177. Wire adjuster, " 178. Twisting the wire sutures, .... " 179. RemoAnng the sutures, ..... " 180 to 185. Simon's method of operating upon urinary fistula, . Simon " 186 and 187. Kolpoklesis, " 188. Bozeman's apparatus, Bozeman " 189. Bozeman's button, . . . . " 190. Same, with sutures tied, .... " 191. Strong retroflection, favoring gravitation to the fundus, . Bj-ford " 192. Retroflexed uterus, with fundus raised by a pessary, " 193. Sims's method of dividing the cervix, Sims " 194. Emmet's knife, for dividing the cervix, Emmet " 195. Division of the flexed cervix, Sims " 196. Peaslee's metrotome, Peaslee " 197 to 200. Uterine cavity after different methods of division " 201. Goodell's uterine dilator, Truas " 202. Fountain syringe and douche pan, " 203. Ointment syringe, ..... ." 204. Uterine scaiificat or, Sargent " 205. Dr. Buttle's uterine scarificator and leech, .... Truax " 206. Slippery-elm tent, Byford "207. Slippery-elm tent, introduced, " 208. Same introduced in case of anteflexion, " 209. The cervix, with threads passed, . " 210. Lacerated cervix, after denudations, Emmet " 211. Byford's uterine scissors, Sargent " 212. Mode of passing the sutures, Byford " 213. The sutures properly placed and twisted, " 214,215. Hypertrophy of the cervix uteri, . " 216. Supravaginal elongation of the cervix, . " 217. Amputation of the cervix by Sims's method, . . . Sii " 218. Same, with sutures tied, .... " 219. Amputation of cervix, bj' Simon's method, .... Simon " 220. Stoltz's denudation for cystocele, Munde " 221. Pathological changes in location of the uterus. Dislocations, Bj'ford " 222. Pathological anteflexion caused by shortening of the sacro- uterine ligaments, ....... Schultze " 223. Anteflexion, produced by a contraction of the round ligaments, Byfird " 224. Puerile anteflexion, Schultze " 225. Anteflexion, with retrolocation and retroversion, . . . Byford " 226. Extreme retroflexion of the uterus, " 227. Natural position of the body, " 228. Unnatural, or stooping position of the body, XX 11 IXDEX OF ILLUSTRATIONS. Fig. 229. 230. 231. 232. 233. 234. 236. 237. 2.38. 239. 240. 241. 242. 243. 244. 245. 246. 247. 248. 249. 2.50. 251. 252. 253. 254. 256. 257. 258. 259. 260. 261. 262. 263. 264. 265. 266. 267. 268. 269. 270. 271, 273. Antevevsion and retroversion, Anteflexion and retroflexion, Soft rubber inflated pessaries, Peaslee's elastic ring. The Sims-Emmet denudation for C3"Stocele and procidentia Lateral denudation in the uretliral fossae and anterior vaginal sulci, ........ Denudation for raising and strengthening the whole vaginal septum, Suture passed so as to catch up the bottom of the wound, Same, united, ..... Suture passed and tied in the usual manner, Fitch supporter, .... Silk elastic belt, .... Schultze's sleigh pessary, Zwank's pessary, .... Mcintosh uterine supporter, jMcIntosh supporter applied, Thomas's modified Cutter pessary, Scott's pessary, .... Pessary, with tapes for attachment to a belt, Outlines of denudation for procidentia, . Denudation for procidentia, after Fritsch, Denudation for procidentia, after Ileamj", Grehrung's pessar}' for anteversion, Hewitt's antevei'sion i)essary, Thomas's anteversion i>essary, Bj'ford's pessary, with the neck elevated, for the relief o anteversion, .... Anteversion pessary, acting by holding the lower end of th cervix forward, .... Byford's retroversion pessary, Byford's retroversion and prolapse pessary, Byford's retroversion pessary in place, . The Albert Smith retroversion pessary, Hodge's closed lever pessary, Hewitt's cradle pessary, . . Thomas's retroflexion pessarj'. Fowler's pessary, H. Marion Sims's retroversion stem pessary, Needle mounted upon needle-holder, for introducing sutures into the sacro-uterine ligaments, Byford's probe-pointed scissors for cutting fascia, Byford's broad hook, ..... Curves of posterior vaginal walls, after a poorly ])erf perineon-haph}', .... Jackson's intra-uterine stem, Thomas's bulb retroflexion pessary, elastic, 272. White's repositor, .... Beduction of inversion by the elastic bagt Schultze Byford Truax Bvford Tiemann u Triiax Sargent Truax Sargent Byford Winckel Fritsch Beamy Sargent Tiemann Bvford Truax Byford Sargent Truax Reynders Truax Ford Byford Truax Byford Truax Sargent Tiemann Bvford INDEX OF ILLUSTRATIONS. Fig. 274. Sharp curette, " 275. Simon's curette, . . . ■ " 276. Epithelioma of uterus, " 277. Epithelioma of the cervix, " 278. Fungus growing from the cervix, " 279. Structure of epithelioma, " 280. Dr. Paquelin's thermo-cautery, " 281. Byrne's cautery battery, " 282. Byrne's cautery ecraseur, " 283. Byrne's cautery electrodes, . " 284. Structure of sarcoma, . " 285. Origin of fibroid tumors, " 286. Fibroid polypus, . " 287. Submucus fibroid tumor, " 288. Sub-peritoneal fibroid tumor, " 289. Intramural fibroid tumor, " 290. Chassaignac's ecraseur, " 291. Small vulsellum forceps, " 292. Medium-sized vulsellum forceps, " 293. Large vulsellum forceps, " 294. Sims's enucleator, " 295. Sims's guarded hook, to aid in drawing " 296. Thomas's serrated spoon, " 297. Aspirator, .... " 298. Microscopic examination of fluid fr " 299. Fitch's trocar, '" 300. Trocar, " 301. Nekton's forceps, . " 302. Sponge holder, " 303,304. Rubber coil, . " 305, 306. Enucleation of cysts of the broad ligament, Shepard and Dudley . Byford Cornil and Ranvier Codman and Siiurtleff" Shepard and Dudley Cornil and Eanvier Byford Sargent Truas the tumor, Codman om ovarian tumors. and Sargent Tiemann Shurtleif Atlee Sargent Truax Byford DISEASES AND ACCIDENTS INCIDENT TO WOMEN, CHAPTER I. PEACTICAL OBSEEVATIONS UPON THE ANATOMY AND PHYSIOLOGY OF THE FEMALE PELVIC OKGANS. The uterus is normally situated in the median line of the body, between the bladder and rectum, just below the pelvic brim (Figs. 1 Fig. 1. Sagittal Section of Female Palvic Organs in the Virgin (l/Q. U, uterus ; B, bladder ; R, rectum ; pt, perineal triangle ; pf, perineal floor ; pfe, perineal floor edge ; S, symphysis pubis ; P, promontory of sacrum ; ppr, plane of pelvic roof; prp, pelvic roof projection ; ss, superior strait ; ass, axis of superior strait. and 2). It is often found so twisted upon its long axis as to bring the left side a little farther forward than the right, and the cervix some- 2 18 AXATOMY AXD PHYSIOLOGY OF FEilALE PELVIC OEGAXS. what to the left of the median position. It has three systems of sup- ports : the pelvic roof, or the sustaining ; the pelvic floor, or retaining ; and the perineum, or supplementary support. I. Pelvic Eoof. The pelvic roof is formed by the expansion and reduplication of the peritoneum upon and between the pelvic viscera, with whose Fig. 2. Sagittal Section of Pelvic Organs of Child-bearing Woman (}/Q. ij), vaginal promontory. (See Fig. 1 for further explanation.) walls, and the circumposed connective, muscular, vascular, and glandular tissues, it unites to form an exceedingly elastic and per- fectly adec^uate uterine support. These duplicatures or folds are called the pubo-uterine, or pubo-vesico-uterine, in front, stretching from the pubes to the anterior surface of the uterus ; the sacro-uterine or sacro-recto-uterine (folds of Douglas, or posterior suspensory liga- ments) behind, passing from the posterior walls of the uterus and vagina to the sacrum ; and the broad ligaments (ligamenta lata, alar ligaments) on the sides passing across the anterior and posterior MUSCULATURE OF THE PELVIC ROOF. 19 uterine surfaces to the sacro-iliac synchondroses (Fig. 4) ; and the round ligaments, reaching in a curve from the sides of the uterus near the fundus forward to and through the inguinal canals. Musculature of the Pelvic Roof. The round ligaments (Figs. 5 and 6) are muscular cords about the size of a large goose-quill, given off from the external muscular coat Fig. 3. Position of the Uterus when the Bladder is full (H). ppr, plane of pelvic roof; prp, pelvic roof projection ; ss, superior strait ; ass, axis of superior strait. of the uterus under the Fallopian tubes. They pass a short distance between the layers of the broad ligaments, emerge from their anterior surfaces to enter the inguinal canals, where they receive a connective tissue sheath. A portion of the muscular fibres, with others from the sheath, form an intimate attachment to the external pillar of the external ring, and a looser attachment to the internal pillar, while the remainder pass on to the pubic bone. The connective tissue sheath affords an elastic attachment of the ligaments througliout the canals. They pursue a curved course, but are somewhat straightened and put slightly upon the stretch, when the fundus uteri and the broad liga- 20 ANATOMY AXD PHYSIOLOGY OF FEMALE PELVIC ORGANS. ments, or either, are lifted upwards and backwards by the filling of the bladder, or by improperly applied abdominal or other pressure. Unless misplacing forces have acted too long they will promptly bring the fundus and, to a certain extent, the broad ligaments back into normal unconstrained relationship with their surroundmgs. Muscular fibres can also be traced from the bladder and uterus into the pubo-vesico-uterine connective tissue, aiding in drawing and hold- ing the cervix sufiiciently forward. The muscular walls of the base Fig. 4. Schematic representation of the Ligaments about ilie Internal Os Uteri, at the plane of the pelvic roof. Drawn upon Schultze's diagram of the female pelvis, one-third the natural size.* E P M., edge of psoas muscle; B B L., base of broad lig.; I O., int. os.; S U L., sacro-uterine lig.; S P P., sacral peritoneal pouch. of the bladder, and particularlj'- the anterior wall of the vagina, as long as the intervening connective tissue is firm, add materially to the strength of these anterior supi^orts. Quite an abundance of mus- cular tissue also extends from the posterior cervical and vaginal walls under the sacro-uterine folds to the rectum, to the periosteum of the second sacral vertebra, and to the neighboring tissues. Thus strength- ened these folds reach in a semicircle partly around the rectum, and suspend the cervix almost directly underneath the second sacral vertebra, in such manner that the weight of the corpus with the trac- tion of the round ligaments acts to keep the fundus over the bladder. Some of these posterior fibres, with others from the uterus and vagina, also run into the broad ligaments, and strengthen them in their lateral traction upon the cervix and vaginal walls. Sometimes they form * Schultze's outline 6gures of the pelvis are freely copied in many of the schematic drawings in this book as being the best and most available for the purpose. MUSCULATURE OF THE PELVIC ROOF. 21 two bands : one passing outward in front of the vessels and nerves to the anterior peritoneal fold of the ligament, and the other back of the p:l, Round Ligament passing under the anterior layer of the Broad Ligament. P.L., round ligament; I. P., infundibulo-pelvic ligament; F.T., Fallopian tube; U, uterus; 0, ovary upon opposite side ; M.S., meso-salpinx. vessels and nerves to the posterior fold (William A. Freund). The upper portions of the broad ligaments, held forward by the round Fig. fi. Schematic Representation of Round Ligaments {}/Q. a, fundus uteri behind symphysis pubis: 6, fundus uteri against the sacrum ; c, fundus uteri when the bladder is full ; ov'^, ovary belonging to b ; or^, ovary belongingto a, with relaxed round ligament; oz;3^ ovary belonging to a, with tight round ligament; arc, 6rc. cro, round ligament belonging to a, b, and c, represented as somewhat contracted, or tense ; ar, br, cr, round ligament relaxed. 22 ANATOMY AXD PHYSIOLOGY OF FEMALE PELVIC ORGANS. ligaments, present their posterior surfaces to the superincumbent abdominal viscera, and thus also tend to keep the ovaries and the fundus . uteri forward. It is not improbable that, being thus elastic and attached to the sides of the pelvis a little behind the transverse central diameter (farther back on the right than left side), they are rendered sufficiently tense, when the bladder is empty, to help hold the fundus up from the vesico-vaginal septum. Peritoneal Covering of the Pelvic Roof. Behind the uterus the peritoneum dips below the vaginal junction from a few lines to an inch or more (Fig. 1), forming the recto-uterine pouch (cul-de-sac of Douglas), and is reflected back upon the rectum, which it covers from this level upward. Over the posterior surface Fig. 7. Diagram of Coronal Section of the Pelvis (Luschka). a, peritoneal cavity ; h, subperitoneal cavity ; c, ischio-rectal fossa ; d, uterus. and fundus of the uterus the peritoneum is firmly attached ; on the anterior surface it becomes less firmly adherent as it passes down, and in the neighborhood of the internal os where it is reflected over the bladder, forming a vesico-uterine pouch, permits itself during filling of that viscus, during pregnancy, and in some pathological conditions, to be strijDped from both the uterine and vesical surfaces PELVIC CONNECTIVE TISSUE. 23 for quite a distance. Between the bladder and anterior abdominal wall the peritoneum does not reach down quite as low as the upper edge of the symphysis pubis, is loosely attached here also, and may be stripped from its lower connections the same as between the bladder and uterus. Under favoring conditions it allows the bladder and vagina to be approached extra-peritoneally through the abdominal walls. At the time of parturition the peritoneum is said to be entirely separated from the bladder (Hart). Behind the broad ligaments — in the sacral pouches — the peritoneal cavity reaches down to about the level of the internal os ; in front of them in the para-vesical pouches it does not dip quite so low. Pelvic Connective Tissue. As connective or fibrous tissue exists everywhere in the body, form- ing one continuous network, penetrating and surrounding, strength- FlG. 8. Sagittal Section of Pelvis through the Connective Tissue Chamber, tlirough Left Broad Liga. ment near the Uterus, cutting off a corner of the Bladder and of the Left Vaginal Fornix (W. A. Freund). ening and supporting the various structures, it naturalh'' plaj^s an important part in the pathology of the pelvic organs. It exists in 24 ANATOMY AND PHYSIOLOGY OF FEMALE PELVIC ORGANS. small quantities everywhere under the peritoneum ; in larger quanti- ties between the bladder and the symphysis in the median line, along the vesico-vaginal septum, between the bladder and uterus, and be- tween the layers of the broad ligaments ; while under the sacro-uterine Fig. 9. 2m7 Scixral VertehvO' Ccnriectt^e Tcssu^ zive Tissue Tfreierr cgy-v/x s, Ut&rL ^ Slaiktsr Pitbis Horizontal Section of Pelvis through the Second Sacral Vertebra and Pubis (W. A. Freuud). and broad ligaments on either side it is so abundant as to form a large connective-tissue chamber (Figs. 7, 8, 9). These chambers are Ijounded above by the reflected peritoneal folds of the broad ligaments over the para-vesical and sacral pouches, below by the levatores ani and coccygei muscles, internally by the rectum, vagina, cervix and base of the bladder, posteriorly by the sacrum, an- teriorly by the pubes and superior attachments of the levator ani, and THE OVARIES AND THEIR RELATIONS. 25 laterally by the iliac bones and upper edge of the obturator internus. More properly speaking, there is only one such subperitoneal connec- tive tissue chamber which extends across the vesico-vaginal septum and contains the cervix, vagina, rectum and base of the bladder in its centre. Fig. 8 represents a sagittal section on the left side of the uterus ; Fig. 9 represents half of a horizontal section through the second sacral vertebra and pubes. The extent of the chamber is shown, although the shape and relationship of parts is not exactly such in the living body. Innumerable bloodvessels, nerves and lymphatics traverse this tis- sue in every direction, to and from the different organs and structures, and depend upon its integrity for the healthy performance of their functions. About the cervix the connective tissue contains no fat but receives muscular fibres from the uterus, rectum and bladder, and is, there- fore, unusually elastic and displaceable, allowing the cervix to be moved in every direction without violence. This is the parametrium of Virchow. Around the pelvic walls the connective tissue contains an abundance of fat which gradually diminishes in quantity toward the centre. In front and at the sides it disappears abruptly at the ureters. The fat adds to the firmness of the tissue, and, hence, to its supporting and resisting power; but it diminishes its elasticity and thus increases its liability to contusion and laceration from great violence. About the pelvic viscera the connective tissue, receiving fibres from them, becomes more dense so as to form a sort of sheath (hohlcylinder of W. A. Freund) or external fibrous coat ; about the muscles it is condensed into firm fascia and tendon, and supports muscular con- traction. In fleshy people the abundance of fat renders the whole connective tissue' stronger and less elastic without strengthening the fascise ; while in people of great muscular development the fascise become firm, and the connective tissue, although less resistant and rigid than when over- filled with fat, is more powerfully retractile and better capable of normal and vigorous function. In the young adult female there is usually an abundance of fat in the tissue, combined with great elasticity of fascia, producing a condition of strength and retractility ; in the middle-aged nullipara there is usually an increase of fat and a progressive harden- ing of the fascia, producing a condition of great strength and rigidity ; in the aged there is an absorption of fat and a shrinking of the fascia, diminishing the strength but increasing the rigidity (or brittleness) of the tissue. The Ovaries and their Relations. The ovaries lie on the posterior surfaces of the broad ligaments with their long axes inclined from their lateral attachment to the psoas 26 ANATOMY AND PHYSIOLOGY OF FEMALE PELVIC ORGANS. fascise, forwards and inwards towards the symphysis. Schultze's schematic representation (Fig. 10) shows the position in which I have frequently found them. Yet I have also found them sagging down or back a little, or swinging a trifle around their external attachments even in cases of normally placed uteri, and, therefore, think that their Fig. 10. rip Position of tlie Ovaries (after Sehultze) (V^). 0, fundus of uterus behind pubes ; 6, fundus when the bladder is full ; c, sacrum ; ap, anterior superior spine of ileum ; ps, edge of psoas muscle ; ip, infundibulo-pel^ic ligament ; ov^, nor- mally placed ovary ; ov", ovary drawn back into the hollow of the sacrum by displaced fundus uteri ; (yifi, ovary drawn back beside cervix by the replaced fundus ; ov^, ovary pressed or held forward when fundus is back ; ft, Fallopian tube ; ol, ovarian ligament. position is within physiological limits a slightly variable one, and is affected b}^ abdominal pressure, and by temporary alterations in the conditions and relations of the abdominal and pelvic viscera. Fig. 11 represents the broad ligament and its contents, modified from Henle. Sehultze teaches that the ovarian ligaments, which pass from the anterior-inner end of the ovaries to the uterus just below the Fallopian tubes, and are four inches across (including the uterus), do not change the position of the ovaries during lifting of the fundus by the filling of the bladder (Fig. 10). But when the fundus leans back against the sacrum, the anterior inner ends of the ovaries are drawn to the back part of the pelvis ; they pass from ov" to qv\ The infundibulo-pelvic ligaments (Fig. 11) or outer upper end of the broad ligaments are folds of peritoneum extending from the Fallopian tubes and ovaries to the pelvic wall, and contain a little fibrous tissue, which passes, some- times in visible quantities, upward uj^on the outer surface of the peri- toneum. They limit the motion of the peripheral end of the ovary and the fimbriated extremity of the tubes to a small area at the sides of the pelvis (Figs. 10 and 12). Ov^, Fig. 10, indicates the position of URETERS. 27 the ovaries as dragged back by the replaced fundus before the abdomi- nal pressure has had an opportunity to press the broad ligaments for- ward. On account of the looseness of attachment of the peritoneum to the psoas and iliac muscles, the infundibulo-pelvic ligament may be drawn out so as to allow the ovary to get away from the pelvic wall even into the recto-uterine pouch. (See Fig. 48 ou*.)* The Fallopian tube, being too long for the space it occupies, pursues an undulating course and floats loosely at the pelvic brim, over the Fig. 11. 'Relation of Ovary to Posterior Surface of Broad Ligament (modified from Henle). 1, infundibulo-pelvic ligament. meso-salpinx — that part of the broad ligament between it and the ovary and ligament behind, and the uterine end of the round liga- ment in front (Figs. 5, 8 and 11). Thus while the lower or cervical portions of the broad ligaments are somewhat resilient and act the part of true supports to the cer- vical end of the uterus, their upper portions are somewhat volumi- nous and movable and do not act efficiently until the fundus falls far forward or backward. Ureters. The ureters enter the base of the bladder at the basal angles of the trigone, an inch apart, and are connected by a continuation of their own structure (Garriguez) forming the inter-uretric ligament (see Fig. 36). They pass (as traced from the bladder toward the kidneys) * See " How to Palpate the Ovaries," chap. TI., p. 59. 28 ANATOMY AXD PHYSIOLOGY OF FEMALE PELVIC ORGANS. divergingly backward for about three-fourths of an inch between the coats of the bladder to emerge from one and a half to two inches apart and from one-half to three-fourths of an inch in front of the cervix (Savage). From their points of emergence they pass in slight curves backward, outward and upward, under and behind the bases of the broad ligaments, near the spina ischia. They then turn sharply up- ward, behind the external attachments of the ligaments and external to the internal iliac arteries, pass up behind the lateral sacral perito- FiG. 12. Positions of Ovaries and Fallopian Tubes when the Fundus a is behind the Pubes ; and b when against the Sacrum (^). oyi, ovary and Fallopian tube held normally forward with a; ov^, ovary and tube pressed back while a is held forward ; ov^, ovary and tube carried back with 6 ; ov^, ovarj- and tube held forward while b, to which they belong, is back against the sacrum. neal pouches, across the anterior surface of the external iliac and behind the sigmoid flexure, or ileum, up over the psoas muscle, be- side the main bloodvessels, to the kidney. The ureters thus run through the subperitoneal connective-tissue chamber and mark the boundary of the fat containing tissue externally, and that without fat internally (W. A. Freund). They pass under and behind, but not into the peritoneal cavity, and are practically inseparable from the outside surface of the peritoneum behind the broad ligaments, and the dense connective tissue under them. Vagina. .The vagina is attached posteriorly to the cervix, the sacro-uterine ligaments, the rectum, and by the recto-vesical fascia to the levator ani muscles ; superiorly to the anterior portion of the cervix, the bases of the broad ligaments and to the pubo-uterine tissues ; and anteriorly and inferiorly by the recto-vesical fascia to the pubes, and to the VAGINA. 29 levator vaginae muscle, which passes around the vaginal introitus like a sling or sphincter (Fig. 13) and mingles with the longitudinal mus- cular fibres of the external vaginal coat. Behind the symphysis on either side of the urethra the vaginal wall is drawn up behind the posterior surfaces of the pubes and the pelvic fascia, forming, to the touch, an oval fossa on either side, which we will call the urethral fossae. The urethra, passing as a ridge down between these urethral fossse Fig. 13. ^ppr Manner of insertion of the Cervix Uteri into the Vagina, showing the relation of the Vagina to the Pelvic Roof (Schematic— 3^). ppr, plane of the pelvic floor ; su, sacro-uterine ligament ; Iv, levator vaginae fibres, passing up to posterior surface of pubes ; pu, connective-tissue attachment of anterior vaginal wall to pubo- uterine system ; ass, axis of the superior strait of pelvis ; ahc, division of cervix into the infra- vaginal portion (a), the intermediate (6) and the supra-vaginal portion (c) (after Schrceder). and under the pubic arch, leaves a depression or notch on either side, the urethral notches, leading from the arch back into the fossffi. (See Fig. 14 UN, and Fig. 16.) Farther back the anterior wall becomes flat and forms, at the junction with the lateral walls, the anterior vaginal sulci or grooves, which lead from the urethral fossse back to the lateral fornices. The vagina is thus suspended from the pelvic roof in the subperito- neal or pelvic connective tissue chamber. It may be likened to a col- lapsed cylinder into whose upper side the cervix is inserted at a right or acute angle with its longitudinal diameter, and near its upper ex- tremity. Fig. 14 (from Henle) shows the manner of collapse at .the vaginal entrance in the cadaver. In the living subject the contraction of the levator vaginse would tend to shorten both the rectal and vaginal slits, and thus slightly differ from the figure. The posterior vaginal wall above the introitus is from a half-inch to an inch and a half above the pelvic floor in the median line, is applied to the flat anterior wall by the action of the levator ani muscles, the rectum, atmospheric 30 ANATOMY AXD PHYSIOLOGY OP FEMALE PELVIC ORGANS. pressure and elasticity of the surrounding tissue. The rectum in pass- ing under the vagina forms a broad longitudinal ridge a little to the left of a median position. On either side of this ridge the mucous mem- brane of the introitus vaginas forms a notch, which may be called the Fig 14. Horizontal Section of Pelvic Floor near the Pelvic outlet (Henle). JJa, Urethra ; Va, vagina ; R, rectum ; UN, urethral notches ; RN, rectal notches. rectal notches, the right one of which is deeper and broader than the left (Figs. 14 and 16). These rectal notches also lead into posterior vaginal grooves or sulci corresponding to those in the anterior walls. The elevation or projection of the lower end of the posterior wall where it is held up by the levator vaginse and rectum forms the recto-vaginal promontory of Prof. T. G. Thomas. The vagina passes backwards at an angle of from 30 to 45 degrees with the horizon, according to the ten- sion of the muscles and fascise about the vaginal entrance and uterine ligaments.* In the child-bearing woman the posterior vaginal wall * A measurement of D. B. Hart's figure upon wlijch he bases his statement that the vagina passes back at an angle of 60° with the horizon, will show that the uterus and vagina are both reduced J in length and the perineum prolapsed and distorted, either by spirit hardening or other post-mortem clianges, and cannot stand for the position of the parts in life. A normal uterus 3 inches long placed with the vagina at an angle of 60° would lift the os two inciies from the coccyx, and project the anteverted fundus above the pelvic brim upon, instead of beliind, the symphysis pubis. Tiie difference in the inclination of the vagina in the living and the dead would seem to be caused largely by the greater sagging of the lower end of the vagina. The recto-vaginal pro- montory is depressed by relaxation of tissue, and the urethra, with its bed of connec- tive tissue, being unsupported, comes down with the anterior vaginal wall. RELATION OF UTERUS TO BLADDER. 31 often lies on the rectum or pelvic floor, especially when depressed by a heavy uterus, and partially unfolded by the examining finger. The vagina, by lining or cementing together the pelvic roof, also materially adds to the strength of the suspensory uterine supports. The uterus not unfrequently receives some support by resting upon a contracted posterior vaginal wall, but hardly ever rests with the whole weight upon the pelvic floor, unless it, or its superior supports, have lost their healthy and natural condition and relationship. Plane of the Pelvic Roof. The chief plane of the pelvic roof is thus described by Savage (Female Pelvic Organs, 3d ed. p. 26) : *' A plane passing from the pos- terior surface of the pubis, about its middle to the junction of the third and fourth sacral bones — the sacral attachments of the utero- sacral muscles, cutting the uterus at the junction of the uterine body and uterine cervix, would upon the whole, with trifling exceptions, divide the pelvic cavity into peritoneal and subperitoneal cellular pelvic spaces." Also (p. 27) : " For the rest, as well remarked by Henle, the relations of the peritoneum with the pelvic organs above the pelvic plane exactly agree with the supposition that they were thrust up- wards against its under surface in attaining their respective positions." (See Figs. 1 and 2, pr and prp.) The result of this kind of support, 'viz., a suspension of the uterus near the junction of the corpus and cervix, is as if the uterine body rested on a ball-and-socket joint, and as if the neck hung from a support of the same character. Being joined at the point of support the cervix and body must move together, although always in opposite directions. The plane of the pelvic roof holds this cervico-uterine plane in place, but does little to hold the fundus and external os in place. The upper portions of the broad and the round ligaments are the only direct support of the fundus, while thej)osterior wall of the vagina as applied by its own elasticity or by atmospheric pressure is the only direct support of the external OS. But all checks upon the fundus act as checks upon the distal end of the cervix, whose action, however, is modified by the flexibility or rigidity of the uterus according to the case. The relation of abdominal pressure to the pelvic roof is one of the chief factors to be considered in the supports of the fundus, as will be explained hereafter. Relation of Uterus to Bladder. The uterus, which in early life is made up mostly of the cervix, and lies upon the posterior wall of the bladder, retains, in adult life, its original and main supports at the cervix where the peritoneum is reflected. As its body develops above the cervical attachment toward the peritoneal cavity, so as to deeply indent it and receive a peritoneal 32 ANATOMY AXD PHYSIOLOGY OF FEMALE PELVIC ORGA^'S. covering of its own, the bladder and cervix sink from the pelvic brim down into the pelvic cavity. The fmidus uteri becomes loosely sus- j)ended in the broad 'ligaments, or folds of the indented peritoneum on either side, and is held forward over the bladder by the round or spermatic ligaments. It will thus be noticed that the uterus lies from the beginning against the bladder, and that the fundus is provided with no ligament to prevent it from resting upon the bladder until the broad ligaments are i3ut upon the stretch. Relation of Pelvic Roof to the Pelvic Floor. As the heavy abdominal viscera are hung up in the abdominal cavity, and the weight of the remainder is not in a direct manner borne by the tilted pelvic roof, but little other supj)ort is necessary when the body of the individual is in a state of rest. But during muscular exertion a jjressure equal to one or perhaps several hundred pounds is sometimes brought to bear upon it. Hence it is necessary that there should be a firm floor upon which the organs may be piled, and retained within the pelvic cavity until the extraordinary force ceases to act, and the retractility of the natural supports of the displaced organs can draw tl^m back in position. Such a support is the pelvic floor. II. The Pelvic Floor. The pelvic floor is made up of the lower end of the sacrum, the coccyx, portions of the ischia, the sacro-sciatic and coccygeo-anal Fig. 15. SACPO PUBIS. MTERNAL OBTURATOR LARGE SAC RC -SCIATIC LIG. Internal Obturator Muscle and Sacro-sciatic Ligaments (Tarnicr and Chantreuil). ligaments, portions of the gluteal, internal obturator (Fig. 15), pyram- idal, levatores ani and coccygeal muscles with their fascia?, the recto- THE PELVIC FLOOR. 33 vesical, levator, obturator, etc., and some looser connective tissue. The upper surface formed anteriorly of the levatores ani, has a sort of resemblance to the shape of the bottom of a boat. (See Figs. 7, 18, 19.) Its centre in the meridian line is formed by the lower end of the sacrum, the coccyx, the coccygeo-anal ligament, and the meeting of the levatores ani muscles behind the rectum. This is the portion shown on the median sections (Figs. 1, 2, 3). The rectum is seen to pass down over it and then turn suddenly back, at the rectal promon- tory, to reach the anus. Such a section can, however, show but little of the pelvic floor and give but a very imperfect illustration of its urethra- gluteub coccyx Pelvic Floor Outlet and Vaginal Entrance. All tissue beneath it removed except rectum and anal sphincters. Rectum is seen passing forward under the pelvic floor and over its edge into the pelvic cavity p.f. e corresponds to pfe of Fig. 1. u. n., urethral notch; v., vagina; t. v., levator vaginae; e. I. a., edge levator ani; r. n., rectal notch; r. p., rectal promontory; r., rectum; p.f. e., pelvic floor edge. complete relationship. From this rectal promontory, as a median sec- tion (Fig, 1, pfe) makes its lower border appear, the edges of the levator ani muscles pass up to the rami of the pubes like the sides of the letter V, forming the lower edge of the pelvic floor, as represented in Fig. 16 (edge levator ani), leaving an inverted triangular insuffi- ciency or outlet. The. rectal promontory or anterior edge of the leva- tores ani in the median line thus represents the bottom or angle of the V. 3 34 ANATOMY AND PHYSIOLOGY OF FEMALE PELVIC ORGANS. Relationship of the Muscles of the Pelvic Floor and Interxjosed Tissues. Fig. 17 gives a view of the attachment of the levator ani and the levator vaginae behind the piibes. Fig. 18 shows the levator vaginae of one side passing between the vagina and rectum as a small bundle, a continuation of the levator ani proper, which in turn passes to the lateral and posterior surfaces of the rectum, to the median line behind the rectum, and to the ano-coccygeal ligament and coccyx. It also shows the coccygeus muscle, which is the continuation posteriorly of the levator ani, spreading from a small attachment to the spine of the ischium like a half-expanded fan, towards the internal lateral edge of the coccyx. Fig. 19 portrays the superior aspect of these muscles, Fic. 17 Pubic Attachments of the Levatores Ani et Vaginae Muscles (Savage). View from behind. S, symphysis pubis; U, urethra; V, vagina; 1, pubic attachment of bladder; 2, pubic attach- ment of levator vaginae; 3, line of attachment of levator ani; 4, pudic vein; 5, urethral-pubal venous plexus; 6, posterior face of perineal septum; 7, levator vaginae. constituting the main upper surface of the pelvic floor. The attach- ments anteriorly to the posterior surface of the pubic bones, laterally to the white line, or dividing of the pelvic fascia into the obdurator and recto-vesical, and posteriorly to the ischial spines, are plainly in- dicated. The median line attachments, also shown, must be consid- ered as a little more depressed below the level of the lateral attach- ments than would appear from a hasty glance at the figure. To get the plane of this muscular part of the pelvic floor which closes the bony pelvic outlet, and the part displaced or retracted in labor, com- pare with Fig. 7 (l). ABDOMINAL PRESSURE. 35 Above the levator plane lies the subperitoneal connective tissue chamber, below it the ischio-rectal fossa or vault (cavum ischio-rectale) filled with cellular tissue, affording, above and below, elastic support for the constantly varying plane of the pelvic floor, and guarding against any interference with, or from, surrounding organs. The ischio-rectal fossa stretches between the rectum and ischium (Fig. 7) : its apex runs up along the levator ani muscle to the white line or Fig is Muscles of the Pelvic Floor (Savage.) 1, 2, levator ani; 3, coccygeus; 4, white line (arcus tendineus, Luschka); 5, coccyx; 6, median line raphiS; U, bladder; F, vagina; J2, rectum; P, pubic symphysis. obturator attachment ; its base is the skin and superficial fascia from the lower edge of the perineal fascia (transversus perinei) in front, to the lower edge of the gluteus maximus behind. The pyriformis muscles, whose chief clinical importance lies in the fact that more important structures lie around and upon them, and that when contracted their bellies may be mistaken by the examining finger for more important structures, are situated farther back, behind the coccygeus muscle and smaller sacro-sciatic ligament (Figs. 18 and 19), and pass from the anterior surface of the sacrum about half an inch on either side of the median line, through the sacro-sciatic fora- men, to the major trochanter. Abdominal Pressure. The abdominal pressure, when the abdominal walls are relaxed or not strongly contracted, is considerably modified by gravity and by 36 ANATOMY AND PHYSIOLOGY OF FEMALE PELVIC ORGANS. the elasticity of the pelvic tissues. During muscular activity it is partly reflected around the hollow of the sacrum in the direction of the pelvic axis curve, and partly exerted directly downward behind the symphysis pubis. In Fig. 20, the arrows indicate in a general way the Horizontal Section of Pelvis, giving a view of the Muscles of the Pelvic Floor from above. B, neck of bladder; V, vagina; E, rectum; P, pubic symphysis; C, coccyx; S, sacrum; A. acetabu- lum; 1, ant. vesical lig.; 2, 3, levator ani ; 4, white line; 5, coccygeus muscle; 6, smaller sacro-sciatic lig.; 7, pyriformis muscle; 8, obturator muscle. directions of abdominal pressure. The resultant of these two forces (the direct and the reflected pressure) which meet at the pelvic floor outlet from almost opposite directions, will be weak as compared with the original one, and will be through the V-shaped outlet (Fig. 20). The reflected pressure coming around the hollow of the sacrum, but for the pelvic floor projection, or rectal promontory in front of the coccyx, would be expended upon the anus, as indicated by the dotted arrow. But when this anterior edge of the pelvic floor is firm, it not only overlaps the anal region, but still farther reflects the pressure towards the apex of the pubic arch to meet the direct pressure higher up as indicated by the heavy arroAvs. With the forefinger in the vagina, curved so as to extend from the symphysis back toward the ABDOMINAL PRESSURE. 37 coccyx, and the thumb externally over the ano-coccygeal region, while the patient* stands and bears down forcibh^, we may detect the two forces, one depressing the coccyx and coccygeo-anal ligament, and the other the urethral region. This play of abdominal pressure on the muscles of the pelvic floor and perineum (which are voluntary muscles, and contract during any general muscular exertion) develops and strengthens them in propor- tion to the activity and development of the whole muscular system, and partly explains the presence of varying degrees of firmness of the Fig. 20. Illustration of the Action of Abdominal Pressure upon the Uterus {^). The clotted arrow indicates the direction of the strain upon the pelvic floor. The crossed arrows show the meeting of the direct pressure and that reflected by the pelvic floor. parts in different persons of the same age at their first confinement. The control of the pelvic floor by the will also explains how during excessive straining early in labor, before these muscles are stretched, the parturient is liable to firmly contract them and induce a state of artificial rigidity exceedingly difficult for her to overcome; and also explains how the pelvic floor may temporarily support with impunity, a pressure many times greater than that of labor, pressure * A nullipara with uninjured pelvic viscera must, if possible, be selected for this experiment. 38 ANATOMY AXD PHYSIOLOGY OF FEMALE PELVIC ORGANS. which without such vokmtary contraction would overstretch all the ligaments of the pelvic organs and, if frequently repeated, lead to displacements* (See Fig. 21.) Requirements for the Closure, of the Pelvic Floor Insufficiency. We are now prepared to understand the problem which is left to be solved, viz., to close up this V-shaped opening without interfering with the evacuations of the viscera or the progress of parturition. The abdominal pressure during muscular relaxation being but small in quantity at this point, and during muscular exertion almost entirely counteracted by the contraction of the pelvic floor, all that is called Fig. 21. Voluntary Contraction of the Pelvic Floor during Straining and Lifting {%). Uterus is carried down in the direction of the pelvic axis while the pelvic floor edge and perineum are drawn toward the pubis so as to close the pelvic outlet. Compare with Fig. 1. for to close the V-shaped insufficiency is a mass of tissue firm enough to support the walls of the outlets of the bladder, vagina and rectum, and elastic enough to allow of great distension without losing its power of retractility. This we have in the perineum, the classical object of wonder to the ignorant, and of confusion to the wise, yet whose only wonderful quality is its simplicity of structure and function. * See "Control of the Pelvic Floor Muscles by the Will," p. 106. PERINEUM. 39 III. Perineum. The perineum or pelvic portico is an entirely supplementary support as far as the uterus is concerned. Constructed on a muscular frame- FlG. 22. lv~ urethra ps Perineal Muscular System (Schematic). Iv, levator vaginse ; cc, constrictor cunni ; ps, perineal septum ; /, fourchette. work below the pelvic floor, it guards the pelvic floor insufficiency, Fig. 23. Dissection of the Muscles of the Perineum and Pelvic Floor (Savage). A, anus; B, bulb of vagina; C, coccyx ; L, larger sacro-sciatic lig.; P, perineal body; U, urethra ; V, vagina; G, vulvo-vaginal gland; 1, clitoris; 2, its suspensory lig.; 3, crura clitoridis; 4, erector clitorldis muscle; 5, constrictor cunni; 7, transversus perinei; 8, sphincter ani, ext.; 9, 10, levator ani; 11, coccygeus; 12, obturator ext. 40 "anatomy and physiology of female pelvic organs. and supports the projecting visceral outlets. During great abdominal pressure, labor, etc., the pelvic floor is brought in contact with the perineum and temporarily strengthened. This temporary union, having been so often observed by gynecologists and obstetricians, has led them to describe the pelvic floor and perineum as an anatomical and physiological unit, and has thus given rise to infinite confusion. Fig. 22 shows its muscular framework in a schematic way. It will be seen that the levator vaginae, or vaginal sphincter, comes down Pig. 24. Perineal Fascia laid open and part of the muscles cut out. Inferior surface of pelvic floor (levator fascia), forming the upper boundary of the ischio-rectal fossa. The fossa is shown with fatty connective tissue removed. a, gluteus maximus; L, larger sacro-sciatic lig.; T, tuber ischii; A, anus; C, clitoris; M, urethral meatus; 6, sphincter ani, ext.; d e, transversus perinei and constrictor cunni ; g, erector clitoridis; V, vagina;/, muscular fibres of perineal septum, the remainder scraped away; I, bulb partially cut away to show its sheath. from the internal or posterior surface of the pubis to be attached to the upper posterior part of the raphe in the median line at the vaginal entrance. It may be said to be hung (or fitted) in the pelvic floor in- sufficiency. The constrictor cunni or vulval sphincter (bulbo caver- nosus) comes down from the external or anterior surface of the pubis to be attached to the raphe in the vulva under the fourchette. Thus the upper part of the so-called triangle of the perineal body is pro- PEEINETJM. 41 vided for. The transversiis perinei comes from the tuberosity of the ischium to be attached to the same raphe between the sphincter ani and the fourchette. The sphincter ani, attached posteriorly by a liga- ment (foreshortened in the illustration) to the coccyx, passes forward to the same tendinous raphe. Fig. 23 shows a superficial dissection of the parts. The perineal muscles are strengthened by the three layers of the perineal fascia which cover all but the sphincter ani, and pass laterally to the pubic rami. Fig. 24 shows them laid open, in dis- section. Between the two posterior layers of these fasciae, which are Fig. 25. Pelvic Floor and Perineal Fasciae. rv, recto-vesical fascia, internal layer of pelvic floor fascia ; I, levator fascia, external layer of pelvic floor fascia (see Fig. 31) ; ps, perineal septum, or triangular ligaments, the internal layers of perineal fascia ; el, external layer of perineal fascia. (In the median line the external or vulval layer of the perineal fascia is close to the perineal body as represented, but on either side it is a little more voluminous.) (For more exact relationship of the fascite to the perineal body, see Fig. 31.) sometimes called the anterior and posterior layers of the triangular ligament, lies the constrictor urethrse, constituting with these two layers of fascia the perineal septum of Savage (Fig. 22). The lower portion or edge of the constrictor urethrse on either side, which is situated just behind the transversus perinei, is often called the trans- versus perinei internus. Fig. 25 shows the pelvic floor and perineal fascise in median sagittal section. The sphincter ani is between the ischio-rectal fossae or vaults, but 42 AXATOMY AXD PHYSIOLOGY OF FEMALE PELVIC OE,G-AXS. entirely below the pehdc floor. The permeum is connected with the pelvic roof by the vaginal attachments of the levatores vaginse and the perineal fasciae, and to the pelvic floor by the ano-coccygeal ligament, and by the fascial coverings and pubic attachments of the levatores ani et vaginae. The perineum is separated from the pehdc floor by the ischio-rectal vault (Fig. 7) and the backward curve of the rectum from the rectal promontory, or pelvic floor edge, to the anus (Figs. 1 and 2). The pelvic floor lies as a whole within or above the external conjugate or pubo-coccygeal line, while the perineum lies below or external, al- though their points of meeting lie anteriorly above and posteriorly at or a trifle below it. Hence I would call the projection of these parts below the external conjugate, not the pelvic floor projection (Schroeder, Foster, Hart and Barbour, etc.), but the perineal area or projection. This pro- jection varies with the age, weight, muscular vigor, and the position of the woman, as well as with the condition of the parts, as resulting from pregnancy, child-bearing, inj ury , or local disease. My conclusions, based wpon examinations and measurements, would make Foster's estimate of one inch (2.5 centimetres) a liberal average for healthy women, the healthy extremes being about half an inch and an inch and a half. Perineal Body. The convergence of the perineal muscles and fascia about the median line raphe forms what has been called the perineal body. The rectum, cur^dng backwards between the perineum and pelvic floor, gives the body the shape of a muscular band a little thicker anteriorly than poste- riorly, and about an inch and a half long, stretched across the pelvic floor outlet or insufficiency. Its inner surface is covered by the rectum, its outer by the skin, and its upper by the skin and mucous membrane of the vulva and introitus vaginae. Quite a quantity of cellular tissue, continuous with the ischio-rectal vaults, is found under the rectal sur- face, and a smaller quantity under the skin at the posterior commissure. Measurements of the Perineal Body. The median line raphe is about one-eighth of an inch (30 mm.) in width. A median section through it shows what has been called the perineal triangle (Fig. 1). Fig. 26 shows, by means of dotted lines, the shape of the raphe in the triangle, natural size. I have measured the perineal triangle in five young virgins ; ten married women, be- tween twenty and forty years old, who had either not yet conceived, or had miscarried under three months; and two married women of fifty and fifty-four years respectively. The accompanying table represents the average measurements of the sides of the triangles in these cases : 5 virgins. 10 married 2 senile multiparas. muUiparte. Vulvo-vaginal side, . 4 1 2 and f Cutaneous side, . . . l| u Uand U Eectal side, • If H 1| and 1^ CHAEACTERISTICS OF THE PERINEAL BODY. 43 The first measurements of the senile cases belonged to a small thin sterile woman fifty -four years old ; the other to a fleshy one about fifty, who claimed to have had miscarriages. Figs. 26, 27, and 28 represent the perineal triangle as constructed from these figures. Characteristics of the Perineal Body. The character of the perineal bod}^ as a support is derived from the perineal muscles and the double layer of internal perineal fasciae, the perineal septum; and its shape varies with their tension and firm- ness. In many virgins of firm muscular fibre the fourchette is pulled Fig. 26. Fig. 27. • c^ ' f cl\\ CI Perineal TriaBgles of Virgin (life size). Fig. 28. Married Xulliper. Fig. 29. Old Woman, 50-54 years, rectal side ; ct, connective tissue ; CV Old Maid before Menopause.* fi, hymen; /, fourchette; pc, posterior commissure; a a, sphincter ani. Dotted lines indicate size and shape of tendinous raphe. up so as to form an acute angle (Fig. 26), while in married women the relaxation of the constrictor cunni usually drops the fourchette so as to form a right or obtuse angle (Fig. 27). Contraction of the levator vaginae draws the hymen, which seems to be a continuation, or per- forated edge, of the posterior triangular ligament or j^erineal septum, into the pelvic floor outlet, so as to stretch the posterior commissure over the edge of the tendinous raphe, and round off or flatten the angle (Fig. 29). Great relaxation of the whole perineal structure produces a sagging of the tendinous raphe as indicated in Fig. 30. Fig. 31 illustrates the relative position? of the muscles and fascise in the perineal body. * This form also occurs in the young who have irritable or tight sphincters. 44 ANATOMY AND PHYSIOLOaY OF FEMALE PELVIC ORGANS. Fig. Action of the Perineum as a Siipi^ort. The resisting power of the perineum varies with the character and direction of the force acting upon it. If a destructive pressure bears upon it so as to put all its muscles upon the stretch to an equal degree? the median raph6 will be the first portion to part asunder. When any muscle or pair of muscles are sub- jected to a greater strain than the others, such muscles must usually give way before the raphe. Calling the sphincter ani the ajDex of the perineal triangle or pyramid, its base is in relation with the urethra in front. Its greatest efficiency as a sup- port is to a force or weight bearing or resting upon the base or vulvo- vaginal side, for the resisting powers of the levator vaginae, constrictor cunni, and, later, the transversus perinei are enlisted, and the fascise Shape relaxed Perineal Triangle {\). ,xr Fig. 31. * Relations of Muscles and Fascia to Perineal Body {\). cc, constrictor cunni or vulval sphincter; tp, transversus perinei; tp, rectal promontory or pelvic floor edge ; Iv, levator vagince or vaginal sphincter; ps, perineal septum ; //, levator fascia and posterior layer of perineal septum ; el, external layer of perineal fascia ; rv, recto-vesical or the internal or visceral layer of the pelvic fascia ; is, internal sphincter ani ; a a, sphincter ani. are stretched in a direction almost parallel to their surfaces (Fig. 31). Pressure from the apex or rectal side meets the resistance of the sphincter ani, transversi perinei, and lower or posterior edge of the perineal fascia. The ordinary reflected abdominal pressure is deflected from the rectal promontory of the pelvic floor, so that the perineal body re- ceives the final resultant near its base, or stronger portion (Fig. 20). If the pressure, however, be through a fluid or semi- fluid medium in the rectum, it will be exerted around the pelvic floor edge or rectal promontory, and have only the resistance of the sphincter ani to overcome. If it be exerted through a large solid body of conical shape in the vagina, as in labor, the levator vaginns will be pushed downwards and backwards with the levator ani, and the perineal ACTION OF THE PERINEUM AS A SUPPORT. 45 body doubled or folded upon itself at the posterior commissure, or a point just external to the relaxing constrictor cunni (Fig. 32), and a folded or double tendon will be opposed to the descending occiput to Fig. 32. Folding of the Perineal Body in Normal Labor when Dilated by means of the Bag of Waters or Caput Succedaneum {%). The dots on the perineal body indicate connective tissue containing fat. p. c, post, commissure ; e. c. c, edge constrictor cunni or vulvar sphincter ; e. I. v., edge levator vaginae or vaginal sphincter; a., anus; e.l.a., edge levator ani ; e.l.c, edge levator coccygei ; e. c, edge coccygeus ; s, s. I., smaller sacro-sciatic ligament. direct it up through the dilating vulva. The pressure upon the peri- neal body will be from base to apex. The internal perineal fascia (perineal septum) will be stretched in a direction parallel to its sur- faces, and will suffer but moderate attenuation, or loss of resisting power. In cases of rigidity of the perineal tissues in labor, or in absence of a suitable dilating cone or wedge, such as the pouch of membranes or a large caput succedaneum, the levator ani will still be pressed back by the head, but the levator vaginae and constrictor cunni, not being thus pushed back, will be pressed forward before the head, away from the levator ani, and in a direction at right angles to their plane of contraction, and will swing out or bulge at their perineal or movable attachments in proportion to the stretching of 46 ANATOMY AND PHYSIOLOaY OF FEMALE PELVIC ORGANS. the lower weaker portions of the perineum (Fig. 33). The anterior edge or base of the perineal body will thus be left to be pulled back by the stretched and depressed lower portions. Already torn from its connective tissue relations with the levator ani and rectum, the Fig. 33. Flattening of the Perineal Body in Labor due to rigidity of the outlet or improperly directed force (%). p. c, post, commissure; e. c. c, edge constrictor cunni; e. I. v., edge levator vaginse (Hymen) ; a., anus; e. I. a., edge levator ani; e. I. c, edge levator coccygei; e. c, edge coccygeus; e. s. s. I., edge smaller sacro-sciatic ligament. perineum is drawn and flattened into a thin nicmbrane with the line of advance (or pelvic axis) passing through it, somewhere near its centre. As injuries of the perineum and pelvic floor are largely due to the pressure of the head in labor, an understanding of the various changes occurring in the perineum during labor is necessary to a full under- standing of the difl'erent lesions of the parts and their restoration to normal relationship. The Rectum. The female rectum is an organ of great interest to the gynecologist, sinee for almost the whole eight inches of its length it is in intimate relation with the generative organs. Just inside of the external sphinc- THE RECTUM. 47 ter ani, the circular muscular fibres of its middle coat form a supple- mentary or internal or second sphincter (Fig. 34). From the anus, the rectum passes forward directly behind the perineal body (Fig. 31), making a very small angle with the horizon until it reaches the poste- rior vaginal wall and recto-vaginal angle of the perineal triangle, an- teriorly, and the pelvic floor edge or rectal promontory, posteriorly. Fig. 34. Muscular Fibres of the Rectum. Rectum of a male subject, cut open longitudinally, and the mucous membrane dissected off so as to show the circular muscular fibres. DD' correspond to same letters in Fig. 35, and indicate the aggregation of fibres constituting the anterior and posterior segments of the superior Detru- sor Fsecium (Third Sphincter). S, is the inferior Detrusor Feecium (Internal Sphincter). A, Anus ; t and * correspond to same marks on Fig. 35. This drawing shows the muscular fibres passing from the anterior to the posterior segment of the superior Detrusor, by the action of which they may be approximated to each other.— (After Chadwick.) It then takes a sudden turn up around the pelvic floor edge, in through the pelvic floor outlet or insufficiency, and, bearing a little to the left, passes backwards again at an acute angle with the horizon (Fig. 1) along the coccygeo-sacral groove. At this lower turn or promontory of the rectum, the levator ani, when contracting, draws the bowel for- ward against the anterior vaginal wall and practically constitutes a 48 ANATOMY AND PHYSIOLOGY OF FEMALE PELVIC OEGANS. third sphincter. After passing under and a little to the left of the cervix the rectum curves up behind the uterus between the sacro- uterine ligaments or folds. Its lateral deviation corresponds with the twisting of the uterus upon its axis so as to bring the left side a little in front of the right. The rectum, receiving its peritoneal covering Fig. 85. Distended Rectum. Rectum from a male subject tied below at the anus and inflated. DD' are the anterior and pos- terior segmentsof the superior Detrusor Fsecium (Third Sphincter). Uis the a?npo«t?e )-cctafe, t and * correspond to same marks in Fig. 34. This drawing shows the sinuosities of the rectum main- tained by the action of the longitudinal fibres at the points where the circular fibres are collected in bundles, notably the two lower ones.— (After Chadwick.) over the anterior and lateral surfaces at the Douglas cul-de-sac and sacro-uterine folds proceeds upward to join the sigmoid flexure of the colon near the left sacro-iliac synchondrosis in the false pelvis. It is normally empty and lies on its bed as an irregular or flattened cylindrical mass of movable tissue, partly filling the pelvic floor out- let so as to press the posterior vaginal wall against the anterior (Fig. 16). It is attached by loose connective tissue to the vaginal wall as far back as the cul-de-sac of Douglas or recto-uterine peritoneal pouch THE EECTUM. 49 and as far back as the coccyx is held in position by the action of the levator ani. Where the rectum curves up behind the cervix, and just under or behind the sacro-uterine folds, an augmentation of the cir- cular muscular fibres on its anterior surface produces a slight semi- circular band or constriction, which, when rigid, may be mistaken during " digital " examination of the rectum for the semicircular out- line of the sacro-uterine folds. Fig. 35 gives the apj)earance of this constriction (D) in the inflated male rectum, removed from the body. In the healthy relaxed female rectum, in the living subject, these con- strictions, lying in the rectal folds, are not always easily felt. Just above this anterior constriction is another on the posterior side (D').^ Fig. 33 represents the course of the muscular fibres through these parts. When both bands are contracted they do not completely close up the rectum, but are apt to be approximated in such a manner as to overlap and close the passage, and constitute, in an imperfect manner, a fourth sphincter which may give the examining finger some trouble in finding its wa}^ past them. According to Chad wick, during the rhythmic contractions of the rectum these constrictions or half sphinc- ters contract separately and consecutively so as to aid in expelling the fseces. As will be seen in Fig. 34, these constrictions are merely con- tinuations and exaggerations of smaller constrictions above, all of which act to hold the fseces firmly while passing them on, and are admirably adapted to prevent over-distension of the gut by agglom- erated excreta. In the pouch, between the rectum and uterus, are often found intestinal folds and peritoneal fluid. It will be readily perceived how, although normally empty, the rectum, at the bottom of the subperitoneal chamber and in direct relationship with the uterus, the sacro-uterine peritoneal folds and sub- jacent tissue, is apt, during even moderate distension by gases and de- scending fseces, to press injuriously upon the pelvic tissues that are in a state of inflammation ; and also why it so frequently becomes the avenue of escape of pus from pelvic abscesses. At the left sacro-iliac synchondrosis, the sigmoid flexure of the colon, or fifth sphincter of the bowel, marks the region above which fseces are normally lodged. When this portion is over-distended the fecal tumor may so press upon the uterus and its surroundings as to weaken its supports, dis- turb its circulation and interfere with its nervous supply. The pas- sage of fecal matter from the csecal valve (sixth sphincter) through the colon to the rectum is normally a slow one, and in females of seden- tary or indolent habits is often accomplished with great delay and difficulty. The result is a continuous state of fulness of the lower terminus and sometimes of almost the whole extent of the colon, with its baneful influence. The late Dr. J. S. Jewell,t of this city, has re- * Transactions Am. Gynecological Soc, vol. ii., p. 43. t Transactions Chicago Medical Society, 1886. 4 50 ANATOMY AND PHYSIOLOaY OF FEMALE PELVIC OEGANS. moved, inside of thirty hours by means of bland enemata and mas- sage, two gallons of fecal matter from the colon, over and above the quantity introduced into the bowels. The almost immediate relief from cold feet, indigestion, ofFensiveness of the cutaneous secretions, muddiness of complexion, nervous depression, etc., and the astonish- ing fact that he has records of over five hundred cases of a similar kind, would make it appear that disorders of the colon and rectum are more important factors in the etiology of uterine diseases, and the accompanying symptoms, than has been generally suspected. The Bladder. The bladder in the female is largely supplied by the same vessels and nerves as are the generative organs. Connected with the vaginal wall below and the uterus behind, it is more exposed to injury than Fig. .S6. Relation of the Ureters to the Bladder and Uterus, (J)— (Luschka). in the male, and at the same time is more easily accessible for surgical treatment. When empty it is drawn together in a flattened, flabby mass, lying between the anterior vaginal wall, symphysis pubis and corpus uteri (Fig. 1), and projects into the para-vesical pouches. As it becomes filled with urine it tends to press the fundus upward and BLOODVESSELS. 51 backward toward the pelvic axis (Fig. 3). In so doing it also presses back the internal os a little, so that while the external os is turned forward by the rising fundus, it remains in nearly the same location. If the corpus uteri be heavy, or the fundus deprived of its usual mobility, the filling bladder becomes indented by it, and rises on both sides of the uterus, or if the fundus be drawn to one side rises on the opposite side, and thus forms either one or two fluctuating tumors later- ally situated. When greatly distended the bladder rises over the symphysis pubis, pushes up the small intestine and lower edge of the peritoneum and impinges against the abdominal walls. The trigone (Fig. 36) lies over the anterior vaginal wall. Its base, the inter-uretric ligament, is from an inch to an inch and a half in front of the cervix, and may be felt as a ridge between their vesical open- ings. Its apex is from an inch to an inch and a half beyond the meatus urinarius at the opening of the urethra into the bladder. Bloodvessels. The pelvic connective tissue is traversed by vessels which run tortuous courses, and anastomose freely, and therefore accommo- date themselves easily to the great stretching and displacement to which such tissue is sometimes physiologically subjected. The largest bloodvessels of the female genital organs are situated posteriorly on either side (Figs. 8 and 9) and in the broad ligaments. The internal iliac artery comes down from the pelvic brim and divides above the upper border of the greater sacro-sciatic foramen behind the sacral pouches. The branches found in the pelvis from the anterior trunk are : the superior vesical passing under the peritoneum and, after giving off the middle vesical to the bladder, continuing as the oblit- erated hypogastric artery ; the uterine, passing into the broad ligament above the spine of the ischium, giving off the vaginal artery near the cervix, and sometimes the middle hemorrhoidal; the obturator, pass- ing over the ischial spine forward to its point of exit from the pelvis at the upper anterior portion of the muscle of the same name, and giving off branches anteriorly to the pelvic brim and pubis ; the middle hemorrhoidal, passing along the upper surface of the pelvic floor in- wards and forwards to the rectum — often giving off, near its origin the inferior vesical ; the internal pudic, passing out between the coccygeus and the pyriformis muscles ; and the sciatic, passing out between the same muscles, but just behind and internal to the pudic, between the first and second sacral nerves. The main branch of the posterior trunk is the gluteal which leaves the pelvis just behind or above the edge of the pyriformis muscle and first sacral nerve. The ilio-lumbar branch, given off at the pelvic brim, passes back to the lumbar region and iliac fossa anastomosing with the last lumbar artery, the glu- 52 AXATOMY A^-D PHYSIOLOGY OF FEMALE PELVIC OEGAXS. teal, circumflex iliac, external circumflex and epigastric arteries. — (Gray). The rectum does not lie against any of the large arteries, below the upper edges of the sacro-uterine folds ; above them it passes over the left iliac. It has no large arteries upon its anterior surface except the hemorrhoidal which can be easily felt by the finger, and avoided in operations. Behind the rectum high up lies the sacra-media. The ovarian or spermatic arteries, branches of the abdominal aorta, do not enter the true pelvis, but pass over the brim between the folds of the broad ligaments to the ovaries and upper portion of the Fig. 37. Arterif Distribution of tlie Ovarian, Uterine and Vaginal Arteries— (Hyrtl). uterus. The uterine artery passes into the base of the broad liga- ment, not far from the spine of the ischium, across to the side of the uterus near the internal os, and then up between the folds of the peritoneum to anastomose freely with the ovarian artery (Fig. 37). The internal pudic passes out of the subperitoneal connective tissue chamber and the pelvis through the greater sacro-sciatic foramen, across the ischial spine externally, enters the ischio-rectal vault through the lesser sacro-sciatic foramen, passes across the inner sur- face of the tuberosity and ramus of the ischium, up along the pubic ramus to the perineum and vulva. The ol;)turator arteries frequently arise from the posterior branch of the internal iliacs. The veins of the LYMPHATICS. 53 pelvis follow the arteries, and are particularly alDundant iDetween the layers of the broad 'ligament external to the arteries, and in the pos- terior wall of the vagina. They are unprovided with valves and apt to bleed excessively when cut or ruptured. Nerves. The spinal nervous supply of the pelvis is derived chiefly from the sacral plexus, the fourth and fifth sacral, and the coccygeal nerves. The sacral plexus lies upon the anterior surface of the pyriformis muscle. The pudic is given off from the sacral plexus, and with its hemorrhoidal and three perineal branches affords the chief nervous suppty to the perineum, vulva and vagina. The small sciatic supplies the integument of the perineum. The fourth and fifth sacral, coccy- geal and hemorrhoidal branches supply the pelvic floor. The hypo- gastric plexuses and lower ganglia of the sympathetic nervous system supply the internal pelvic organs, and are particularly liberal in their allowance to the uterus and its appendages. The uterus itself depends for its spinal nervous supply upon the filaments that accompany the sympathetic nerves, and is, therefore, in the unimpregnated state, almost devoid of ordinary sensation, and can be subjected to great irritation and even affected with organic disease without giving ap- parent inconvenience to the system. It seems to r(;quire a participa- tion of the peritoneal or fibro-cellular surroundings of the uterus, or a sufiicient change in its submucous and muscular substance to decidedly interfere with the functions of these nerves, or else an abnormally debilitated state of the nervous tissue, for the production of any appre- ciable resentment on the part of the general nervous system. How- ever, let this vast accumulation of nervous elements finally become involved in pathological changes, and the lack of sensibility will not prevent the most profound, far-reaching, mysterious and often disas- trous reflex efi'ects. The abundance of the spinal nerve supply to the perineum, pelvic floor and vulva, explains how uterine and ovarian irritation, congestion and inflammation, instead of being felt at their seats, may be symptomatized by a reflected irritability of the sphinc- ters, by pruritis vulvee et vaginae, vaginismus, coxalgia, etc. Lymphatics. Lymphatic glands are chiefly found about the cervix uteri, in the upper portion of the pelvic connective tissue chamber, behind the broad ligaments and on the sacrum at either side of the rectum, be- tween the large bloodvessels, and along the obturator artery. Lym- phatic vessels are abundant everywhere in the pelvis. Those about the cervix communicate directly with the connective tissue chamber and lower portion of the broad ligament. Hence infection from the 54 ANATOMY AND PHYSIOLOGY OF FEMALE PELVIC ORGANS, cervix is apt to lead to pelvic abscess, while infection from the uterine body may give rise to extensive peritoneal inflammation without sup- puration. For the structural anatomy of the pelvic viscera and external genitals, the student is referred to the text books upon anatomy and histology. Space does not here permit a i-epetition of these things, which are, or should be, a part of the mental equipment of every graduate in medicine. CHAPTER II. EXAMINATION OF THE FEMALE PELVIC ORGANS. FoKTUNATELY for suffering woman, we may arrive at demonstrative knowledge of the locality of her several pelvic organs and of the nature and extent of the diseases which affect them, and consequently treat them with the certainty which a positive diagnosis always in- sures. The evident advantages of a physical diagnosis will render it quite unnecessary for me to use any argument in favor of it, or to in- duce medical men to resort to it. A physical examination, however, of the genital apparatus of females, is quite a different matter from a physical examination of the chest, eye, or ear, or any other organ of the body ; and hence the necessity of approaching and conducting it under conditions rendered imperative on account of the circumstances connected with it. The education and natural sense of modesty, so ap- propriate to female character, and which always commands the respect of gentlemen, make such examinations disgusting and disagreeable above almost all others demanded by the necessities of woman's circum- stances. AVith a view to this fact, it is our duty, by our conduct toward our patient, and the management of the examination, to divest it as nearly as possible of every disagreeable feature. Medical men generally, I think, are, as they should be, actuated by the above consid- erations, and I fear that they are often so influenced by their ov/n sense of delicacy as too frequently to abstain from the enforcement of essen- tial investigations. This is an error we should always bear in mind, and, I think, we shall less frequently regret a thorough, although somewhat indelicate examination when dictated by an honest and intelligent conviction of its necessity, than a neglect of such exam- ination from too great a deference to a sense of shame. We should not, in important cases, take things for granted. Our bearing to a female patient should be deferential, candid, and modest. She should be convinced by our demeanor that everything we do and say is strictly necessary and relevant to her case, and has its foundation in our solicitude for her welfare. Nothing, therefore, should be said or done but what is called for and obviously proper. This sort of treatment from her medical adviser will always command the confidence and earnest co-operation of an intelligent female pa- tient. There should be a full and explicit understanding, when pos- sible, between the physician and the patient, as to the necessity of a physical examination, in what it consists, and how it is to be conducted. The good sense of the practitioner will enable him to judge whether 56 EXAMINATION OP THE FEMALE PELVIC ORGANS. he should commit the detail of explanation to the husband, or some other appropriate second party, or whether he impart it directly to the patient ; all the circumstances of the case will enable him to determine this matter without much difficulty. After the preliminaries are dis- posed of I would insist upon conducting the examination without exposure. It is needless in ordinary uterine examinations, and should be permitted only when the disease is upon the external parts. One position and kind of jDreparation, so far as the patient is concerned, will suffice for most cases, whether we wish to make a manual or an instrumental examination. There is no necessity for the patient to unclothe herself. Position of Patient for Examination. In the ordinary work of an office I think there is nothing more con- venient than Wilson's chair. It can be made to assume so many forms Fig 38. I Cuicago. Operating Chair. that it can be used as a chair or table either, and is easily moved into any position in relation to the light. For many purposes, however, a table will afford us more satisfaction. It is very much to be preferred in surgical operations. While the gynecological table represented in Fig. 39 is very conve- nient for an office, an ordinary table such as can be found in any dwelling can be made to answer every purpose. There are three positions of which we may avail ourselves in making examinations or performing operations: the dorsal, the latcro-abdomi- nal, or Sims's position, and the knee-chest position. In the ordinary dorsal position the patient is placed on her back with the breech very near the end of the table or chair, the knees POSITION OF PATIENT FOR EXAMIXATIOJST. 57 flexed and the thighs drawn up close to the abdomen, the feet resting by the side of the nates or in the stirrups, and the shoulders elevated upon j)illows. In this position the abdominal walls are relaxed and Fig. 39. Byford's Operating Table. brought near the pelvic organs (Fig. 44), and both hands may be used with great freedom in exploring them. It is, in fact, indispensable to a perfect bimanual examination, and is very convenient for the use of the sound, and almost every form of Fig. 40. Position for Sims's Speculum. speculum. Even Sims's speculum can be made to do effectual service in this position. For many minor operations and uterine applications it is a very convenient position. This was a favorite position with the late Pro- fessor Simon. When the hips and shoulders are greatly elevated, the knees extended, and thighs forcibly flexed upon the abdomen, this is called Simon's position, and is not inferior to any other for examination or surgical operations on the vagina and uterus. 58 EXAMIXATIOX OF THE FEMALE PELVIC ORGANS. Sims's position consists in placing the patient on her left side, with the left arm under and behind the body, and both knees drawn up close to the abdomen ; the right, flexed to a greater degree, and overlying the left, rests on the table in front (Fig. 40). The abdomen becomes some- what dependent and draws the pelvic organs away from the external outlets. When the perineum is drawn back the vagina is distended by atmospheric pressure, and the vaginal wall and uterus brought into view. The knee-chest position is also Sims's position, and produces the same effect in dilating the vagina obtained by the other, only perhaps in an exaggerated degree (Fig. 92). Peraission of the Pelvic Organs. Percussion gives us but little information concerning the healthy pelvic organs, but may be valuable in determining the absence of such enlargements and misplacements as are known to bring them within the field of such an examination. Intestinal resonance usually exists over the pubes, but during great distension of the bladder is replaced by dulness, extending some- times almost or quite to the umbilicus. In case such dulness be due to a distended bladder, firm pressure will produce a feeling of tension or pain on the part of the patient at the neck of the bladder, or a sensible depression of the anterior vaginal wall, or fluctuation, upon a finger placed in the vagina. An accumulation of feeces high up in the rectum often produces a decided dulness on percussion over the left iliac region. Palpation of the Pelvic Roof — Digital Examination through the Vagina. The mode of examining the pelvis with the fingers is of the utmost importance. After oiling the fore and middle fingers (Fig. 44) the index should be very gently introduced, and the examination con- ducted as far as possible with it ; then the two may be introduced and nearly all of the cavity of the pelvis explored. The index finger will not reach as far as the two together, but it is more delicate and intelligent in touch, and is less hampered by vaginal resistance. The rectum, as it curves over the pelvic floor edge into the pelvic cavity, lies immediately under and to the right^ of the finger. When partly filled with freces it is felt as a soft round ridge upon the floor and posterior wall of the pelvis, when empty as a loose or easily dis- placed fibrous cord or bundle of cords; or it may be almost unrecog- nizable through the resistant vaginal walls and surrounding connec- tive tissue. Sometimes one or more hard fecal lumps just below or * Left side of the patient. THE CERVIX UTEEI OF THE CHILD-BEARING WOMAN. 59 behind the cervix uteri, in an otherwise empty rectum, will indicate its course ; at other times a fecal mass as large as an egg will project from the pelvic floor in front of the cervix ; or a large accumulation may be felt, tumor like, behind and over the uterus. Inflammation, induration, or stricture of the rectum will be re- vealed by sensitiveness, hardness, or a point of contraction. Indeed, this easy and painless method of examining the rectum, and elimi- nating as far as possible, rectal disease from our diagnoses in gyneco- logical cases, should receive careful attention and study. Next we should turn our finger forward, pass it up behind the symphysis pubis, and along the front wall of the vagina, and as defi- nitely as practicable ascertain the condition of the bladder. The examination is more complete if the fingers of the left hand are pressed into the pelvis just above the symphysis pubis, and approxi- mated to the finger behind the pubis. Any foreign body, morbid deposit, displacement of the bladder from its median position, any thickening, inflammation or hypersesthesia of its walls, etc., can thus be detected. Characteristics of the Cervix Uteri. After palpating the rectum and bladder we should, as a starting- point to a farther exploration of the pelvis, locate the neck of the uterus. - In passing through the vaginal canal, the uneducated finger is im- pressed with a soft intestinal sensation, and can distinguish nothing but loose folds, that are dissipated and lost in the surrounding soft- ness by the slightest pressure, until it comes to the neck of the uterus, which has consistence enough to retain its shape under considerable pressure. If pushed upward, backward, or downward, it retains the same characteristics. The finger can be carried up beside, before, or behind, and around it in every direction except above. This, being unlike anything else in the vagina, will be easily recognized. The Virgin Cervix. The virgin cervix uteri is almost cylindrical in shape, slightly compressed from before backward, and not far from three-quarters of an inch in diameter in every direction. It projects half to three- quarters of an inch into the vagina, a little deeper behind than in front (Fig. 41). It points toward the coccyx, and at the projecting or free end is apparently cut nearly square off, so as to present almost a flat surface, with a dimple in the centre corresponding to the os uteri. The Cervix Uteri of the Child- Bearing Woman. The cervix uteri of the child-bearing woman is about an inch wide, or often a little more, and from half to three-quarters of an inch in 60 EXAMINATION OF THE FEMALE PELVIC ORGANS. its antero-posterior diameter. Instead of being truncated it feels as if formed of two projections at its inferior extremity, the anterior and Fig. 41. Virgin Uterus and Vagina. posterior labia separated by a distinct fissure, which runs transversely and represents the os (Fig. 42), The Senile Cervix. The OS uteri in advanced age does not project into the vagina, and often feels more like a pit at its termination (Fig. 43). There is often a cord or frsenum-like projection in the vaginal walls, which is planted into the external surface of the anterior and posterior lips of the mouth of the uterus, and thus extends backward and forward to be lost in the anterior and posterior median lines of the walls of the vagina. This fraenum becomes more apparent, if not more developed, as women advance in age ; but I have known it to be so prominent as to be mistaken for disease, even in the middle aged. In one case an intelligent practitioner thought it an evidence of the injurious effect of strong caustics. The consistence of the virgin and parous cervix uteri is tlie same. To the sense of touch it gives the idea (which is a correct one) of LOCATIO:S OF THE CEEVIX UTEEI. 61 deep fibrous tissue, almost as hard as cartilage, covered over thickly with areolar tissue. Dr. Bennett compares it to the feel of the cartilage Fig. 42. Fig. 43. Uterus of the Child-bearing Woman. Senile Uterus and Vagina. of the lower end of the nose. It seems to me not quite so dense^ although nearly -so. Location of the Cervix Uteri. The location of the cervix varies with the position of the patient. When she stands erect its anterior wall is at or a little back of the axis of the superior strait, and hence about two and a half inches, or a little farther, from the inferior pubic ligament. When she assumes the dorsal position the lower end of the cervix is, on account of the altered abdominal pressure, from a quarter to a half inch nearer to the vulva. In the Sims's position the cervix is draAvn farther away with the receding abdominal viscera. If, in the dorsal position, the index finger be introduced along the anterior vaginal wall until the middle of the third phalanx just touches, or is a little beyond, the inferior pubic ligament, the anterior wall of the cervix (Fig. 44) will be touched. By raising the finger well up at one side of the urethra the exact place of impingement 62 EXAMINATION OF THE FEMALE PELVIC ORGANS. against the ligament can be felt, and the distance measured. Passed on under the cervix the finger end will have the os upon it, and the rectum immediately under it. The distance between the os and the coccyx, after pushing aside the rectum, should be about equal to double the thickness of the finger, i.e., the finger should occupy half of the space. In child- bearing women the os is usually down a little nearer to the coccyx, in old women up a little farther from it. On either side of the cervix the finger should pass nearly an equal distance outward before encountering the ischial bones ; or if the sur- rounding tissue be firm, should encounter only elastic resistance on either side. When much lateral displacement is present, the finger- FlG. 44. Digital Examination m the Dors>al Position —Touching the Cervix (J^) tip beside the lower end of the cervix, finds the pelvic wall so near as to leave space for but little lateral motion on one side ; while on the opposite side it may move about freely, and reaches bony resistance only after being pressed two or three times as far from the cervix as was possible on the side of the displacement. A slight amount of lateral displacement may be more easily estimated by laying the finger end on the coccyx, and then raising it up until it touches or glides by the cervix. With the finger tip against the cervix, and the finger touching the inferior pubic arch, first in one urethral notch, and then in the other, the distance from the notch to the cervix is less on the side to which the latter is displaced. PALPATIO^'^ OF THE DISPLACED UTEEUS. 63 Corpus Uteri. When the uterus is normal in size, shape and position the finger in the vagina may be pushed high up in the fornices without encounter- ing any check except the elastic counter-pressure of the vaginal walls and surrounding connective tissue. The hard body of the uterus, when the bladder is empty, may be felt for a short distance along the anterior vaginal walls, gradually receding forwards and upwards beyond reach. Any considerable quantity of fluid in the bladder should lift the uterine body entirely out of reach of the finger in the vagina (see Fig. 3), and give a sensation of semi-elastic or characterless resistance. Palpation of the Displaced Uterus. If the fundus be displaced towards the symphysis the uterus may be felt as a smooth pear-shaped body, three inches long, lying flat over, or down upon the anterior wall of the vagina with the os, at the smaller end, pointing backwards.* If the fundus be displaced back- wards the same pear-shaped body may be felt over the posterior fornix vaginae, lying with its larger end against or near the sacrum, and the smaller end turned forward, so that the os looks toward the perineum or the pubis. An elevation or concavity of the anterior fornix is caused by a backward displacement of the fundus, and is in propor- tion to the displacements. The resistance of the connective tissue at the bases of the broad ligaments prevents palpation of the body of the normally placed uterus through the lateral fornices. When, however, the fundus is displaced laterally, the os is turned to the opposite side, and thus sec- ondarily displaced, and the finger can feel the lateral uterine wall on the side of the displacement to be continuous, almost in a straight line, with the side wall of the cervix. Pressing high up in the anterior fornix, on either side of the median line, it loses the corpus uteri on one side, but can trace it for some distance toward the lateral pelvic wall on the other. The lateral fornix having a definite relation to the side of the cervix, must be shallower and wider than its opposite on the side towards which the fundus (or from which the cervix) is displaced. When only the cervix is displaced laterally, the os is felt turned toward the side of displacement so as to be entirely to one side of the rectum and coccyx, and the body to extend toward the median line, sustaining about the same relation to the direction of the pelvic^axis as in displacement of the fundus to the opposite side, but it will reach * B. S. Schnltze calls attention to the fact that the uterus is larger during life than after death owing to the amount of blood its vessels contain. During the ante-menstrual congestion it is still larger. 64 EXAMIXATIOX OF THE FEMALE PELVIC ORGANS. only a little be3''ond its normal median position. The fornix is also higher and narrower on the side of the cervical displacement — unless altered by a growth or appreciable deposit — but the disparity of the lateral fornices is greater in width but less in height than that accom- panying primary fundal displacement. In extreme lateral displacement of either end of the uterus, the other end while turned in the opposite direction is drawn to, or over, the median line, so as to be mainly in the same side of the pelvis. In co-existent primary displacements of the fundus to one side and the cervix to the opposite, both are nearly equidistant from their median positions, but the direction of the long axis of the bod}'- of the uterus will be felt to be more transverse than the amount of primary displacement of the cervix or fundus alone would produce. The long axis of the body points toward the iliac fossa rather than merely to one side of the pelvic axis. The fornix on the side of the cervical dis- placement will be very much higher and narrower than its opposite. Lateral displacement of the whole uterus may be recognized by the nearness of the cervix to one lateral pelvic wall, or by its position en- tirely to one side of the rectum and cocc3^x, accompanied by a nearly normal direction of the uterine axis or lateral walls, as determined by passing the finger-tip up into and in front of the lateral fornices. The fornix on the side of the displacement will be very much narrower, but of almost the same height as its opposite. While examining for lateral displacements, when the fundus lies back of the pelvic axis, we of course palpate its posterior surface and lateral edges through the posterior and lateral fornices (see Fig. 47). The spaces between the sides of the fundus and the pelvic walls are narrow and easily measured by the finger pressed well back on either side ; while the direction of the long axis of the uterus, and the amount of displacement of the os, are easily recognized by passing the finger straight back under the pubic arch along the anterior vaginal wall to, and under, the cervix. The coccyx under the finger maj^ be used as a guide to the median line. Palpation of the Pregnant Uterus. The pregnant uterus assumes, even during the first three or four months, qualities that otherwise belong to pathological states. The cervix feels soft and oedematous about the external os, is down nearer the coccyx, and a little farther away from the inferior pubic liga- ment. The body is felt to recede less rapidly upward from the anterior vaginal Avail, is softened and more bulging above the cervix, and is more easily grasped bimanually. The partly filled bladder is depressed in the centre or on one side by the heavy fundus so as to form a broad, flattened fluctuating tumor. EXAMINATION OF THE UTERUS DURING GENERAL ANESTHESIA. 65 Examination of the Uterus during General Ansesthesia. Examined in connection with the administration of an ansesthetic or during an unusually relaxed and insensitive state of the tissues, the uterus can be grasped bimanually and turned in all directions. By pushing the cervix back with the finger in the vagina, the uterine body may be brought down upon the anterior vaginal wall by the hand over the abdomen, so that the thickness, and the conformation of its anterior and lateral walls, will be readily determined. Fig. 45 shows the relation of the fingers to the uterus. Fig 45. Bimanual Palpation of the Uterus from the Posterior Vaginal Wall (J), By drawing the cervix forward with one or two fingers in the vagina — first pressing upward in the anterior fornix, and then drawing for- ward under and behind the free end of the cervix — and pushing the fundus back with the hand above the pubes, the cervix and lower por- tion of the corpus can be grasped between the fingers outside and those in the posterior fornix as represented in Fig. 46. When it becomes necessary to palpate the whole posterior wall, the 5 66 EXAMINATION OF THE FEMALE PELVIC OEOAXS. vaginal fingers, after the fundus has been pushed as far back as pos- sible by the external hand, may press the lower, or free end of the Fig. 46. Bimanual Palpation of the Uterus, through the Anterior Vaginal Fornix (J). cervix, up toward the pelvic brim and thus turn the fundus into the hollow of the sacrum, or the recto-uterine pouch, as represented in Fig. 47. The posterior wall of the whole body will then be accessible. In replacing the uterus the cervix is pulled down by the finger upon it, or drawn down by pressing the posterior fornix vaginae toward the coccyx, and then the fundus uteri pushed up toward the sacral promontory. The natural supports, if normal, Avill do the rest. In pushing the fundus backward into the holloAV of the sacrum we must press just over the pubes, so as to get under the fundus ; in bringing the fundus forAvard over the anterior vaginal Avall Ave press deep into the abdomen just under the umbilicus and then doAVUAvard over the fundus. The uterus, as thus felt, should be smooth, hard and slightly flat- tened upon the anterior and posterior surfaces, without ridges or jDro- THE ADVANTAGES OF A GENTLE TOUCH. 67 jections except at the upper angles or horns, where the Fallopian tubes and the ovarian and round ligaments pass off laterally. Fig. 47 Uterus artificially turned back against the hollow of the Sacrum, for palpation of the Posterior Wall (J). Digital Exploration of the Pelvic Roof through the Vagina. By pressing with one hand firmly down over the abdominal walls to one side of the artificially anteverted uterus, and with the other upward against the anterior vaginal wall on the same side, Ave may make both hands meet with only the abdominal and vaginal walls, and broad ligament with its contents, between them, and palpate against the external hand or make the approximated fingers (external and internal) glide together successively over small contiguous areas of the pelvic roof, until the whole is explored. The skin and mucous membrane move with the fingers and each tissue as it slips between them may be recognized by its shape and position, or be traced throughout its course in the pelvis. In bimanual examination of the right side of the pelvis we should use the right hand for the vagina, for the left side the left hand. As a rule when the fundus uteri is low in the pelvis the abdominal walls should be depressed as much as possible ; when the fundus is high the vaginal walls should be pushed well up. In this way the parts are more easily reached, and are not much disturbed in their relations. The Advantages of a Gentle Touch. A rough finger in the vagina may press upon the tissues of the pel- vic roof a thousand times without recognizing them, while the touch 68 EXAMIXATION OF THE FEMALE PELVIC ORGANS. of a gentle hand will locate ligaments, ureters, bloodvessels and nerves without difficulty. The so-called tactus eruditus is in fact nothing but a gentle attentive touch guided by a thorough knowledge of the anatomy of the parts. It may be acquired by almost any one in a short time, yet must remain forever out of the reach of many j^rac- titioners and specialists. JJ^en not to Examine. There are many cases in which rigidity of the abdominal walls, smallness of the vagina, rigidity of the perineum, abnormal sensitive- ness, menstruation, disease, etc., render a thorough exploration of the pelvic roof unendurable and frequently injurious or dangerous. When acute or subacute inflammatory changes exist, a knowledge of the location and general character of the inflammation must often suffice until subsequent improvement renders a thorough exploration prac- ticable. Precautions Necessary During Examination. It is often better to examine successive portions of the pelvis at different times (without anaesthesia) being careful always to desist be- fore irritation is produced. Unless the patient's confidence in her physician be well grounded, he will justly lose what she may already have given him in proportion as he hurts or injures her. It is also well to remember that, under anaesthesia, not having the patient's sensations to guide us, we are es23ecially liable to manipulate tender or inflamed tissues until irreparable injury may be done. We should, therefore, when a complete exploration is necessary, examine such parts as we can by one or several examinations, with the patient's feelings to guide us in finding and avoiding tender parts ; and, then, on another occasion, complete the examination with the aid of an anaesthetic. The value of an examination is not in proportion to the amount, but rather to the intelligence of the manipulations. Some gynecologists by their attempts at thoroughness in diagnosis produce more irritation by their fingers than their treatment can remove; others with seemingl}^ superficial examinations, yet adequate to the end, are able to quickly cure the patient. Difficulty of Differentiating Pelvic Tissues by the Touch. Nothing would seem easier than to approximate the fingers of the two hands in bimanual examinations and locate each structure as it comes between them. Yet when we consider that the round ligaments, ovarian ligaments, Fallopian tubes, ureters, inter-uretric ligaments, edge of the collapsed bladder, enlarged lymphatics, vaginal cicatrices, sacro-uterine peritoneal folds, and some aponeurotic bands about the HOW TO PALPATE THE OVAEIES. 69 abdominal muscles, all give more or less the same sensation as of cords or ridges passing through the pelvic roof; and that one of these may be over or almost parallel to another, we can appreciate the doubt entertained by many as to the possibility of differentiating them. Yet if we have in our mind the characteristics, and different positions and directions, of the structures as they accommodate themselves to the position of the fundus, and will patiently and carefully trace them to their attachments we may usually overcome the difficulties. The Starting Point in Digital Explorations of the Pelvic Roof. The starting point, then, of our explorations of the pelvic roof should be the fundus uteri which, by carrying a portion of the struct- ures with it in its ceaseless physiological variations, and by frequent pathological alterations of position, and twisting, to a greater or less degree, the broad ligaments upon their transverse axes, determines the mutual relationship of nearly all of the pelvic structures. How to Palpate the Ovaries. (1) When the Fundus is in Front of the Pelvic Axis. If the fundus be found in front of the pelvic axis, we may find the ovary (Figs. 10, 12 and 48) by introducing the index finger (two Fig. 48. Positions of Ovaries as seen from the Pelvic Brim {%). Modified from Schultze. a, fundus of uterus with empty bladder ; b, fundus of uterus with full bladder ; e, horn of uterus displaced laterally, belonging to ov'' ; ip, infundibulo-pelvic ligament ; ot'i, ordinary posi- tion of ovary ; ov", ovary against the sacrum ; ov^, ovary over lateral vaginal fornix ; ov», ovary in the pouch of Douglas ; of", ovary in or over the sacral pouch ; ov', ovary in transverse position by lateral traction of uterus, c; ap, anterior superior spinous process; ps, psoas muscle. fingers if the index be short) to the anterior wall of the cervix, then passing it at right angles along the anterior edge of the base of the 70 EXAMINATION OF THE FEMALE PELVIC ORGANS. broad ligament to the pelvic wall, and pressing upward just in front of the attachment. Another way to find the ovary is to carry the finger around the pelvic wall until the obturator artery is felt (see Palpation of Vessels and Nerves of the Pelvis, pp. 104, 107), viz., around the pubic attachments of the levator ani to the upper edge of the obturator muscle along which the artery runs, and then straight back along the side wall of the pelvis over the ischial spine. A little in front of the spine, and just anterior to the resistant base of the broad ligament, the finger when pressed upward above the artery should touch the ovary. Un- usual firmness of the connective tissue and a free mobility of the organ may, however, prevent its easy recognition. Another way to find the ovary is to trace the ureter to where it passes under the broad ligament (see Palpation of the Ureters, p. 78) and press up in the angle between the ureter and the pelvic wall. A firmly placed ureter may run so nearly under the ovary as to prevent the finger reaching it. If, as must often happen, there is doubt as to whether the ovary is over the finger, the other hand may be pressed into the abdominal walls on and below a line connecting the anterior superior spinous processes of the ilea, and about two and a half inches from the median line. The fingers will thus come against the psoas muscle passing over the pelvic brim, and if brought inward toward the pelvic cavity, will press into it just over the nor- mally located ovary, and form with the depressed abdominal walls a resistant surface against which the vaginal finger can palpate. A sudden complaint of being hurt, or of a sickening pain, from the pa- tient, will usually give us early notice that we are successful in our search. In case the uterus is drawn against or over the symphysis, the ovary may be found a little farther forward (Fig. G,ov^). Or it may be found farther back just over the outer end of the base of the forward leaning broad ligament. The finger then finds it by pressing up back instead of in front of the base of the ligament (Fig. 6, ov^). This position of the ovary is not uncommonly found on one side when the fundus is farther back than normal, and the broad ligament of the same side is slightly shortened ; or on both sides when the sacro-uterine ligaments hold the middle of the uterus well back, and the fundus curves forward yet remains elevated from the pubes and anterior vaginal wall. In the first case the ovarian and infundi- bulo-pelvic ligaments are relaxed, in the second the upper parts of the broad ligaments are either slightly relaxed or shortened (since the corpus uteri is more directly in a line between their peripheral attach- ment). The ovary in either case sags down but is kept in almost its normal axis by normal abdominal pressure. Occasionally the ovary sinks downward and forward and lies against HOW TO PALPATE THE OVARIES. 71 or over the obturator artery and the white line of insertion of the levator ani into the fascia of the obturator muscle. It can then, if not too tender, be easily caught between the finger and the pelvic wall in front of the base of the broad ligament without pushing up toward the pelvic lDrim, as is necessary in palpating the normally located ovary. Especially is this so on account of the flabbiness of the tis- sues that usually accompanies such disj)lacement. When the ovary leaves the lateral pelvic wall it may often be found beside the cer\dx, just over the lateral fornix vaginee (Fig. 10, ov^ and 48, ov^), and is detected by pressing the finger up beside the fornix with or without a forcing of the abdominal walls down over it by the ex- ternal hand. Another not very rare place to find the ovary is the recto-uterine cul-de-sac of Douglas (Fig. 48, ov^). It may then be felt behind the posterior or lateral vaginal fornix and usually hanging over the sacro- uterine fold of the side from whence it came. Finally the ovary may be found floating or hanging back in or over the sacral peritoneal pouch, neither against the lateral nor jiosterior wall of the pelvis (Fig. 48, ov^). It is palpated here with great diffi- culty per vaginam. But if enlarged and accompanied by a relaxed pelvic roof it may occasionally be felt somewhat as the foetal head is felt by ballottement. Although it does not settle upon the finger as dis- tinctly as does the head, yet by successive touches it is each time detected back from where it had receded at the previous touch. (2) When the Fundus lies against or near the Sacrum. When the fundus is in the back part of the pelvis the ovary often lies back transversely on either side of the fundus in the bottom of the sacral peritoneal pouch (Fig. 6, ov^) or against the sacrum (Fig. 48, ov^), and if the vagina be sufficiently relaxed it may be palpated against the posterior pelvic wall by the finger, or fingers, pressed back and high up on either side of the fundus. When- in the recto-uterine pouch (or cul-de-sac of Douglas), it is felt under the body of the retroplaced uterus, slippery to the touch but confined in its motions to the space in which it is held. The ovary may in other cases be felt over the lateral fornix by the finger pushed high up l)eside the corpus, especially if the abdominal walls be depressed by the hand externally (Fig. 12, ov' and 10, ov^). (3) When the Fundus is displaced toward one side of the Pelvis. When the fundus is drawn toward one side of the pelvis, the ovary, on the same side, sagging backward or forward from a relaxation of its ligaments, is often reached with difficulty because of the greater density of the contracted tissue under it. Upon the opposite side the anterior end is often drawn with the uterus towards the middle so that the organ lies somewhat transversely across the upper part of the broad liga- ment. Its supports being drawn a little more tense, it is more firmly 72 EXAmXATIOX OF THE FEMALE PELVIC OEGAXS. held, and hence more easil}^ palpated. Fmally, the ovary may be found at the inguinal ring. We may thus find the ovary in eleven different positions, viz.. four against the side wall of the pelvis — ^the parietal ; two about the cervix — the central ;. two in and one above the sacral peritoneal pouches — the posterior ; one turned across the side of the peMs — the transverse. Tahle of Position of Ovaries. I. Parietal : 1. Normal. 2. Displacement forward. 3. Displacement backward. 4. Displacement downward. II. Central : 5. Over lateral vaginal fornix. 6. In the recto-uterine or Douglas pouch. III. Posterior: 7. At the bottom of the sacral pouch. 8. Against the sacrum. 9. Floating over the sacral pouch (changeable). IV. Transverse : 10. Extending across the side of the pelvis between the psoas muscle and the displaced uterine horn. V. Extea-Abdomixal or Herxlil : 11. At the inguinal ring. In the parietal positions the long axis of the ovary is only slightly changed, in the other positions it is greatly changed by a swinging of the organ upon the lateral attachment. A lump of fseces has been mistaken for an ovary in or near the recto- uterine cul-de-sac. This mistake, although easily made, may be avoided by remembering that a lump of faeces in the rectum is neither so smooth, tender, elusive to the touch as the ovary, nor pro%Tided with ligaments. A fecal mass can be displaced only with the rectal folds about it, but can be worked in part down into the lower rectum, can usually be mashed by moderate pressure and without pain, and is apt to be accompanied by one or more lumps above or below it, along the course of the \uscus. Palpation of the Ovarian Ligament. The chief value of palpation of the ovarian ligament lies in the fact that it leads to the anterior or inner end of the ovary, and that the Fallopian tube may usually be found floating above it, or not far off. It is of firm fibrous structure, short and ciuite inelastic. It feels larger, THE IXFUXDIBULO-PELVIC LIGAMEXT. 73 harder, and more resistant than the round ligament, Fallopian tube, or ureter, to bimanual palpation. When the fundus is forward we may, by moving the bimanually approximated fingers of both hands slowly forward beside the uterus, feel the ligament, as it is pulled forward, suddenly slip from the grasp back to its position, and away from the fingers, with a jerk or snap that is so decided as to be almost characteristic. This almost trans- verse direction of the ligament with the fundus forward shows the ovary to be normally forward (Fig. 48, ov^), and but little, if at all, out of place. A more diagonal direction of the ligament indicates a sag- ging back of the ovary (Fig. 6, of^), or a leaning forward of the fundus uteri (Fig. 6, ov^). When the ovary lies beside the cervix the ligament, although not easily accessible, may be felt passing along beside the uterus from the fundus to the cervix, whether the fundus be forward (Fig. 48, ov^, and Fig. 10, oi'O, or backward (Fig. 10, ov'^). When the ovary lies in the recto-uteriue pouch the ligament will curve around beside the uterus toward the fundus, and ma}' be felt passing over the correspond- ing recto-uterine peritoneal fold (Fig. 48, ov*). When the fundus is back in the pouch of Douglas the ligament, although relaxed, may be palpated against the uterus over it or the sacro-uterine ligament beside it. When the fundus and ovary lie against the sacrum the ligament may be felt connecting them by pressing the finger back against the sacrum beside the fundus. When the ovary floats over the posterior lateral peritoneal pouch the ligament can seldom be detected unless the ovary can be pressed back against the sacrum or pulled forward with the fundus and palpated bimanually beside the corpus uteri. It then goes from ov". Fig. 48, to positions corresponding to that repre- sented on the oj^posite side by ov^ and ov^. The Infundibulo-Pelvic Ligament. The infundibulo-pelvic ligament may in some instances be palpated. When the ovary lies at the side of the pelvis the fimbriated extremity of the Fallopian tube serves as a guide to it, and can occasionally be traced to it, and recognized bimanually as a ribbon-like fold extend- ing to the belly of the psoas muscle at the side of the pelvic brim. When the ovary lies in the pouch of Douglas it may be felt passing from the ovary over the sacro-uterine ligament along with the larger, harder, but more relaxed ovarian ligament. When the ovary is against the sacrum, or low in the posterior lateral peritoneal pouch, the infun- dibulo-pelvic ligament may occasionally be palpated against the pelvic wall by hooking the finger over it just external to the ovary. When both this and the ovarian ligament proper are traced to or from the ovary, the place, position and relation of that organ is determined, and 74 EXAMINATION OF THE FEMALE PELVIO ORGANS. the condition of the upper and outer portion of the broad ligaments may be inferred, especially when taken in connection with the condi- tion of the round ligament. Palpation of the Round Ligament. As the round ligament is high up in the pelvic roof, and composed of muscular tissue, it offers, unless contracted or unusually tense, only an indistinct sensation of resistance to the finger in the vagina. Bimanually, however, it is easily found running almost straight out- Avard from under the uterine horn, and assuming a constantly increas- ing curve forward until behind the internal inguinal ring, when it passes almost directly forward into it. It feels somewhat larger when contracted than when relaxed, seldom quite as large as the ovarian ligament, and does not slip with such a decided snap through the fingers and out of the way. When relaxed it sags outward and forms a larger curve, thus tending to get out of reach of the vaginal finger (see Fig. 6). On account of the frequent difficulty experienced in differentiating it from the structures about it, we will briefly indicate how to pick it up bimanually and trace it from the internal abdominal ring to the uterine horn. The internal abdominal ring is at the pelvic brim about as far from the pubic arch or vaginal entrance as the index finger can conveniently reach, and as high or a little higher than the natural resistance of the tissues will allow it to go. If we insert the index finger of our right hand into the vagina, and slip it upon the posterior surface of the right pubic bone along the upper edge or pubic attach- ment of the levator ani, we will come upon the groove of the white line or reflection of obturator fascia (Fig. 17) forming, where it strikes the bone, a distinct depression or fossa. Above and just external to this, the round ligament passes into the ring ; and if it be contracted and firm may be felt as a ridge passing backward from the ring by pressing up the point of the finger to the pelvic brim and then veering it outward as far as possible. But on account of the sensitiveness of the parts thereabout, the resistance of the displaced tissues and tVie mobility of the ligament, it is advisable to depress the pelvic roof and inguinal ring toward the finger. Accordingly we press with the out- side hand down over Poupart's ligament from two to two and a half inches (about four fingers' breadth) from the pubic spine until the liga- ment comes within reach of the finger inside. The ring may some- times be recognized by the pulsations of the epigastric artery under it and extending up the abdominal wall, but most usually b}^ the round ligament itself as palpated against the depressed tissues. The most satisfactory way is to thus approximate the fingers of the two hands, and move them sideways until the ligament slips between them, and then trace it forward and around its curve, always moving PALPATION OF THE ROUND LIGAMENT. iO the fingers at right angles to it. The amount of tension and degree of curvature of its outer end will usually enable us to calculate the rest of its course to the uterine horn. When relaxed it seems farther from the symphysis and is not so readily made to slip through the bimanual grip. Fig. 6 shows the difference in the curves of the contracted and relaxed ligaments. They may sometimes be made tense, and palpated through a voluminous vagina by hooking the lower end of the cervix forward with the index finger, thus prying back the fundus upon the Fig. 49. Artificial Tension of the Round Ligament, using the Sacro-uterine Attachment as a Fulcrum Q/Q. r, round ligaments ; su. sacro-uterine ligaments ; u, uterus. sacro-uterine attachments as a fulcrum and then pressing the middle finger toward the side of the pelvic roof. (See Fig. 49.) The external hand may be made to increase the tension by pressing into the ab- dominal walls just above the pubes and then upward under and against the fundus. When the ligaments are contracted so as to be firmer than the sacro-uterine ligaments, the fundus in the above-mentioned mani- pulation becomes the fulcrum and the whole lower end of the uterus, 76 EXAMINATION OF THE FEMALE PELVIC OEGANS. instead of only the external os, will be pulled toward the vaginal out- let. Contraction of the round ligament may be thus recognized, and also by several other signs. The fundus lies behind, or over, and very near the pubes (Fig. 50) and presents a resistance to upward pressure behind the pubic arch much greater than its weight, yet one which readily yields to steady pressure. The upper portion of the broad ligament is rendered tense as indicated by the firmness of the pelvic roof or either side of the fundus behind the body of the pubis, and sometimes by a ridge corresponding to the course of the ligament. Fig. 50. Position of Uterus produced by contraction of the Round Ligaments Q). pubes. (Case 21, ofBce record of 1886, Mrs. W.) Fundus behind When the contraction is extreme even the base of the broad ligament on either side of the internal os is felt to be drawn into a characteristic prominent ridge. Contraction of only one ligament draws the fundus and body toward the same side, and points the external os toward the opposite side of the pelvis. When the fundus lies against the hollow of the sacrum the round ligament may be trnced bimanually from the internal abdominal ring almost straight back to where it passes over the twisted broad liga- ment (Fig. 6, hr and hrc) ; and occasionally may be traced forward from the uterine horn near the sacrum to the base of the broad ligament. PALPATION OF THE FALLOPIAN TUBES. 77 The ovarian, round, and infundibulo-pelvic ligaments, ureters, arteries, Fallopian tubes, etc , are larger in life than in death, on account of the blood in them, and seem still larger to the vaginal touch from being covered by the vagina and layers of peri- toneum or connective tissue. Contraction also increases their apparent size to the touch. Palpation of the Fallopian Tubes. When the fundus uteri is forward behind the pubes and the ab- dominal walls lax, the Fallopian tubes may be quite easily felt bi- manually. From their uterine ends, which are then over the lateral edges of the empty bladder, they pursue a slightly serpentine course over the paravesical pouches to the sides of the pelvis, where they curve backward toward the ovary (Fig. 12, ov^). Bimanually they are felt to be soft flabby cords, with apparently several twists or zigzags in them, which are characteristic. They yield to forward or backward traction (bimanually) without that feeling of elasticity or firm resist- ance which causes the round and ovarian ligaments to return rapidly to the position from which they are drawn, but with a characteristic drag upon their broad ligament attachment. We may differentiate them from the edge of the bladder by tracing them laterally or pos- teriorly around a long curve whose convexity is forward, instead of a short curve whose convexity is backward, by their greatest resistance to forward traction, instead of backward, by their entire independence of the folds of the bladder, and by their attachments to the fundus uteri. When the fundus is not, or cannot, be pressed forward behind the pubes, the tubes are farther removed from the abdominal wall mova- ble, flabby, and sometimes surrounded by intestinal loops. Such is probably the most natural position. If the uterine horn and position of the ovary has been found, we may calculate that the tubes will pass in a curve between it, a little in front of the shorter and straighter ovarian ligaments. By placing two fingers in the vagina, one upon each side of the cervix, and pressing as high up as possible, the middle finger may often be approximated to those externally pressed down into the abdominal walls and then all pulled forward together. The ovarian and round ligament, and then the Fallopian tube, may thus be made to slip between the fingers, like three cords of progressively diminish- ing size and elasticity. Even when these structures lie directly over each other (or together), the shortness and rigidity of the ovarian ligament causes it to become tense and slip between the fingers first, while the flabbiness of the tubes usually permits them to be drawn forward so as to escape last. If the ovary and fundus uteri be situated posteriorly, so will ordi- narily the Fallopian tube (Fig. 12, o-y^), and may often be palpated against the sacrum. If the fundus be forward and the ovary back. 78 EXAIIINATIOX OF THE FEMALE PELVIC ORGANS. (Fig. 12, ov^), or the fundus back and the ovary forward beside the cervix (Fig, 12, ov^), the tube will pass backward or forward from the uterine horn toward the ovary, either almost directly over the ovarian ligament or a little external to it. If the fundus be forward or central, and the tube extend into one of the sacral peritoneal pouches, its fimbriated end may sometimes be pushed back upon the sacrum where its irregular contour can be easily appreciated. Whether the fundus be forward or backward, the fimbriated extremity, or a loop of the Fallopian tube, may be felt hanging over a sacro-uterine fold into the pouch of Douglas. Its length, limpness, and slightly irregular or undulating course over the sacro-uterine ligament, will distinguish it from the ovarian ligament. By bringing the fundus well forward, and then dragging the tube forward bimanually, it may in some cases be brought anteriorly from the sacro-uterine into the para-vesical pouch, and there palpated. In a general way it may be said, that if the ovarian ligament be first found, the tube being longer and looser, will be found in front of it when the fundus uteri and broad ligament are forward, so as to receive the abdominal pressure on their posterior surfaces ; behind or above it when the parts are back so as to receive the abdominal pres- sure on their anterior surfaces ; or floating over it before or behind, indifferently or alternately, when the pressure is parallel to the long axis of the uterus. Of all the normal tissues of the pelvic roof which may be said to be always or almost always palpable, the normal Fallopian tubes are probably the most difficult to detect. When hardened or enlarged, however, they are proportionately easy. The following table of the positions in which the non-adherent tube is most frequently found, may be useful to the student : 1. Normal. 2. In or over the para-vesical pouch. 3. Upon the posterior surface of the broad ligament. 4. In or over the sacral pouch. 5. In the retro-uterine pouch. Palpation of the Ureters. When surrounded by healthy tissue the ureters, at their lower or pelvic portions, are among the most readily and uniformly palpable of the smaller tissues of the pelvic roof — much more so than the ovary^ the ovarian and round ligaments. Fallopian tube, arteries, nerves, etc. In seventy-five consecutive gynecological cases in office practice the ureters were examined by simple vaginal indagation, with the following results: At least one ■ureter was recognized in every patient: both were felt in all but eight, i.e., 142 of the HOW TO FIND THE URETERS WITH CERVIX IN NORMAL POSITION. 79 150 ureters. Of the eight not felt, two belonged to the right, and six to the left side. The causes of failure to recognize them were chiefly tenderness, induration, contrac- tion, cicatrization and tension of the vaginal walls or contiguous connective tissue. In three of the cases the os was drawn back from 3J to 4 inches from the inferior pubic ligament; in four cases it was turned forward by backward displacement of the fundus; in one case the ureter was displaced By a tumor growing from the uterus. The ureters are easily felt during pregnancy, for several reasons: such as increased tension produced by the sinking of the uterus and broad ligament upon them ; soften- ing of hard tissues under them ; apparent increase in their volume due to the serous infiltration and vascular turgescence in and about them; and later, the presence of an enlarged uterus against which to palpate them. How to find the Ureters ivith Cervix in Normal Position. Having touched the anterior wall of the cervix, the index finger is brought forward along the anterior vaginal wall, from an inch to an inch and a half, until the inter-uretric ligament is felt passing across. Fig. 51. Positions of Ureters {}4)- Schematic. Those on the right side are relaxed ; those on the left are somewhat tense. • a, belongs with cervix displaced backward; b, belongs with cervix in about normal position; c, to cervix dis- placed forward and upward with fundus turned into the hollow of the sacrum (retroversion), ai, &i, ci, same as a, 6, c, but relaxed. If this be not felt the place where the smooth soft upper end of the anterior vaginal wall merges into the rougher and firmer lower portion indicates about where it lies. From the end of the inter-uretric liga- ment, viz., a point about half an inch to the side of the median line the ureter is felt to run as an elastic cord, seemingly the size of a small goose quill, almost straight towards the ischial spine, where it curves up under and behind the broad ligament. The finger end pressed gently (sometimes firmly) up into the yielding parametric tissue beside the cervix, and hooked or drawn forwards toward the pubic 80 EXAMINATION OF THE FEMALE PELVIC OEGANS. bone of the same side, will readily feel the ureter slip over it, marking the boundary between the softer parametrium and the harder periph- eral zone of fat-containing connective tissue. Sometimes by placing the side of the finger flat along the course of the ureter w^e may feel quite a stretch of it at once. The pulsation of the middle vesical artery, which lies near it, and is often large enough and near enough to the vaginal mucous membrane to be felt at the same time, may, by the hasty finger, be mistaken for it. Fig. 51, h and 6^, shows approxi- mately the j)osition of the ureters when the cervix is in a normal position. Palpation of the Ureters v)hen the Cervix is Displaced Backward. AVhen the cervix is drawn far back in the joelvis, the base of the trigone usually follows the cervix, and allows the ureter to retract into a quite firm cord easily felt (Fig. 51, a and a^). When, however, the trigone does not follow back the cervix, the ureter drawn upon by the retroposed base of the broad ligament, is stretched and attenu- ated, and having a stretched firm parametric tissue behind it cannot always be as readily recognized. By pressing up along the lateral edges of the uterine body (which in this case is generally turned forward) the lower end of the ureter may be got between the finger tip and the uterus as if it were a small cord, and then be traced laterally. Palpation of the Ureter ivhen the Cervix is Displaced Forwards. When the cervix is displaced forward, the lower edge of the broad ligament, drawn forward with the cervix, usually relaxes the ureter, and permits it and the base of the trigone to sag forwards over the relaxed vaginal walls so as not to be felt in its ordinary place (Fig. 51, c and &). Its flabby condition may also prevent it being recognized when pressed upon by the finger. In such case it may be hooked forward toward the pubes and rendered tense, or hooked against the pubes, under the bladder, and palpated upon the inner surface of the anterior pelvic wall ; then traced upon the pelvic walls around to the base of the broad ligament, and from there back across the trigone to the opposite side. The bimanual examination is seldom necessary for finding the ureter, although it is very easily palpated in this way. On account of being felt first and easiest it is liable to be mistaken for other tis- sues sought, but other tissues, except an artery or a cicatrix, are sel- dom mistaken for it. In bimanual palpation of the other structures of the pelvic roof it is desirable, in order not to disturb their relations, to press the finger in the vagina well up into the pelvic roof where PALPATIOX OF THE BROAD LIGAMENTS. 81 they lie, while in that of the ureter it is better to press the hand over the abdomen well down into the pelvic cavity near where it lies. Differentiation. The ureters are easily known from other structures of the pelvic roof by being found so near to the vaginal walls ; by being traceable forward to and across the trigone instead of to a uterine horn, as the round and ovarian ligaments and Fallopian tube ; by ]3assing under the base of the broad ligament instead of over it, as do the round and ovarian ligaments, and Fallopian tube ; and by their direction, which is normally more nearly backward than these other structures. In a forward position of the cervix with a turning back of the fundus the ureters are dis]3laced forward, and often palpable against the pubis, while the other structures of the pelvic roof are displaced backward, and sometimes palpable against the sacrum. • Palpation of the Broad Ligaments. (1) The Upper or Uterine Portions. The absence of intestinal loops in the para- vesical peritoneal pouches while the patient is in the dorsal position indicates that the up|)er parts of the broad ligaments are forward; while the presence of any con- siderable amount of intestine felt anteriorly and causing a bulging down of the pelvic roof on either side indicates that the upper por- tions are either relaxed or forced back, or both. As the upper portions of the ligaments are not easily felt, we must often, in order to determine their position and condition more defi- nitely, locate their internal or changeable uterine attachments, and the tissues which pass through or over them to their external fixed ends. When the fundus is forward while the cervix, the ovary and its liga- ment, the Fallopian tube, and the uterine end of the round ligament are in their normal positions, so must be the broad ligament. It thus receives the greatest amount of abdominal pressure upon its posterior surface. When the fundus is high out of reach above the vesico- vaginal septum, the ovary beside a normally located cervix, the Fal- lopian tube curving back or over it, and the round ligament extending from the abdominal ring in a slight curve to one side of, or back of, the pelvic axis, the broad ligament is relaxed and receives the prin- cipal abdominal pressure almost in the direction of the uterine axis. When, however, the cervix has settled down within half an inch or so of the coccyx, but the ovary and the tube normal in position and the round ligament firm, the upper 23ortion although necessarily carried down with the depressed uterus is stretched rather than relaxed. When the whole uterus and its appendages are pressed back against 6 82 EXAMINATION OF THE FEMALE PELVIC ORGANS. or near the sacrum, and the round ligament lax, and the uterus straight, the upper portion of the broad ligament must be relaxed and receive the abdominal pressure mainly upon its anterior sur- face. Lateral displacement of the fundus with contraction of the upper part of the ligament is recognized by a hardening beside the horn holding it with more or less rigidity ; lateral displacement with relaxa- tion is known by the flabbiness beside the horn and the sagging back of the ovary and tube. Tension of the ligament opposite the dis- placed fundus is known by the tension and transverse direction of the ovarian ligament drawing the uterine end of the ovary away from the pelvic wall, the more diagonal direction of the round ligament bring- ing it nearer the vaginal entrance, and the ease of recognition of the appendices. A general tension of the ligament is in such cases recog- nizable unless the vaginal tube be narrow. When the cervix is forward and the fundus in the hollow of the sacrum, the broad ligament is twisted upon its transverse axis and receives the abdominal pressure entirely upon its anterior surface. If, at the same time, the ovary and its ligament be against the sacrum the upper uterine portion must be relaxed or stretched. When the fundus is drawn or pressed back against the sacrum and the os for- ward, and the broad ligaments at the same time held forward, the ovarian ligament will pass forward to the ovary, which will be beside the cervix (Fig. 12, ov") or floating near it (Fig. 6, ov^)^ and the Fallo- pian tube over or near it. The round ligament will generally be somewhat tense, and pass almost straight from the abdominal ring to the fundus (Fig. 6, hrc). (2) The Bases, or Cervical Portions. The base of the broad ligament may usually be directly palpated either through the vagina or rectum. Ordinarily the finger can feel an indefinite ridge on either side of the cervix extending laterally. When the base is quite firm and resistant, or a little stretched, two ridges may even be felt corresponding to the fibres running from the cervix to the anterior and to the posterior peritoneal layers. When drawn upon so as to become unusually tense these two fibrous ridges are drawn into one layer, but a much more definite and prominent one. With relaxation of the base of the ligament the ridge at the side of the cervix ceases to be distinctly felt. But as palpation for any distance from the cervix is occasionally rendered unsatisfactory by a small vagina or the general firmness of the supra-vaginal tissue, we may find it convenient to calculate the condition of the base of the broad ligament from the position and mobility of the cervix and ureters. When the cervix is down near the coccyx or forward near the vaginal entrance the base of the liga- ment, as already intimated, must be stretched or relaxed. In the first VAGINAL PALPATION^ OF THE SACEO-UTERINE LIGAMENTS. 83 case, if stretched, it will be easily felt, if relaxed, it will not. In the second case its lower edge will be turned forward and upward and will afford little or no characteristic resistance. Pressing the cervix from side to side, the amount of resistance en- countered informs us of the amount of relaxation, stretching or rigidity of this portion of the ligament. The relaxed ligament affords practically no resistance to lateral displacement of the cervix, and allows the cervix to settle slowly back towards the median line ; the normal ligament affords but little resistance, and admits of a consid- erable displacement, yet by its elasticity brings the cervix back into position immediately and rapidly ; the stretched ligament affords considerable elastic resistance, and admits of only slight lateral dis- placement ; while the rigid ligament allows of little or no displace- ment without such violence as to cause the patient great discomfort. When the base of the broad ligament is much relaxed the ureter is no longer held normally taut, but becomes more or less flabby, runs a little nearer the pubis, and may be hooked forward near to the anterior pelvic wall. When the base of the ligament is turned forward and upward as in twisting of the whole ligament from a backward ver- sion of the uterus, the ureter may be dragged forward so as to be easily palpated against the anterior and lateral pelvic wall. When the bases of both broad ligaments are relaxed and turned forwards the inter-uretric ligament and the trigone are found considerably nearer the pubes than otherwise (see Fig. 51, c^). With relaxation of the base of only one ligament the cervix, when it sinks down or moves forward, must, of course, swing slightly toward the opposite side since the normal ligament only allows the cervix to swing upon its attachment to the pelvic wall as a radius. The direc- tions already given for determining the position of the corpus and cervix uteri when laterally displaced, will also aid in the diagnosis of contraction and stretching of one ligament at a time. Vaginal Palpation of the Sacro-uterine Ligaments. Two fingers carried high up in the posterior fornix vaginae can usually feel the semi-circular folds of the sacro-uterine ligament ex- tending outward, backward and upward. If contracted they will pass straight towards their sacral attachments, and form a well-defined V whose angle is at the cervix. If they cannot be thus reached the cervix may be hooked forward by the finger as represented in Fig. 49, in artificial tension of the round ligaments, except that the middle finger is kept behind the cervix and in the posterior fornix, against the ligaments (s u) stretched so as to assume the V-shape (see Fig. 52, *). In case the cervix be forward so as to stretch them, and the fundus turned back upon or between them, they will often be so 84 EXAMINATION OF THE FEMALE PELVIC OEGANS. attenuated, and hug the sides of the corpus uteri so closely, as not to be felt. The finger may then, by pressing high up in the posterior fornix, tilt the body of the uterus forward and upward, and reach over one of the folds from which the uterus has been lifted. The position and mobility of the cervix is sometimes of great value in estimating the condition of these ligaments, since they are some- times difficult to reach. When they are retracted the upper part of the cervix is drawn up toward the second sacral vertebra and the os, if no flexion exist, will be turned backward facing the lower sacral Fig. 52. uterine Torsiou produced by Contraction of the Saero-uterine Ligament of one Side (1, 2, 3). Straightening of sacro-uterine ligament by traction (4) causing them to assume a V-shape Q/^). vertebrae. The external os may then be from three to three and a half inches from the inferior pubic ligament and more than an inch above the coccyx (Fig. 53). When the retraction is permanent the os and lower end of the cervix often points forward more than natural, but remains in the back part of the pelvis. The distance of the cervix from the coccyx and inferior pubic liga- ment is almost in proportion to the amount of shortening. The fun- dus is at the same time pressed downward by the abdominal pressure acting more effectively on the upper longer arm of the uterine lever, so that the body is easily felt through the anterior vaginal wall. When the contracted round ligaments draw the fundus down near the symphysis the position of the uterus seems the same to the inexperi- enced or hasty finger ; but a measurement will show that although the OS is turned backward the end of the cervix is not drawn up from the coccyx and is but little farther from the inferior pubic ligament than normal (see Fig. 50) and the internal os is drawn toward instead of from the subpubic ligament, as in contraction of the sacro-uterine VAGINAL PALPATION OF THE SACEO-UTERINE LIGAMENTS. 85 folds (compare Figs. 50 and 53). The resistance to upward pressure by the fundus so noticeable in contraction of the normal ligaments (see Palpation of Round Ligaments, p. 69) will be absent and the uterus will have its fulcrum at the attachments of the sacro-uterine ligaments (Fig. 49) instead of at the fundus. The length and the resistance of the latter may also be tested bimanually by hooking the vaginal finger behind the lower end of the cervix, and bringing the external hand down over and behind the fundus. By thus pulling the fundus and cervix forward simultaneously, we draw directly upon the ligaments. Fig. 53. Position of Uterus produced by contraction of the Sacro-uterine Ligaments (J^). Compare with Pig. 50. (Case 118, office record of 1886, Mrs, McC). When they are normal or relaxed the vaginal finger will sometimes reach up between their cervical attachment so as to pull the cervix forward toward the symphysis. In nullipara they lose little by little their distensibility, and as age advances become firm and compara- tively inelastic. The presence of the external os down near the coccyx, or forward near the pubes, is proof of relaxation or stretching of their substance. Direct palpation behind and on either side of the cervix is then easy and affords more definite evidence of the condition. Contraction of only one of the ligaments is attended by displace- ment of the cervix backward, upward and toward the same side. In 86 EXAMIXATIOX OF THE FEMALE PELTIC OEGAXS. addition to tins the cervix, as B. S. Schultze has taught us,* is tmsted so that the side toward the contraction is turned forward, i.e., the pos- terior surface of the cervix faces toward the direction of the contraction, and does so in j^roportion to the contraction. Fig. 52, ^, \ ^, shows the direction of the transverse slit of the os with the different degrees of contraction. The uterus if pressed in all directions will be felt to move upon the contracted ligament as upon a pivot, in a manner that is striking and characteristic. Palpation of the Pubo-Vesico-Uterine Ligament. The firm connective tissue union between the bladder and vagina, and bladder and uterus, and the attachments of the bladder and vagina to the pelvic fascia behind the pubes, constituting the pubo-vesico- uterine ligament, form a large and important part of the pelvic roof. In the dorsal position the finger on either side of the urethra may be brought up without interference of the soft parts, against the inferior pubic ligament and carried straight back to the cer^-ix, along the an- terior vaginal wall a distance of about two and a half inches. With the cervix at or in front of its normal position a want of retrac- tility is generally revealed by a transverse fold extending across under the base of the trigone, and along the course of the ureters, forming a crescent whose convexity is forward. If the relaxation be in the parametrium the anterior vaginal wall will be flat and firm under the trigone, but there will be a furrow around the cer\dx. The relaxation is then due to the forward position of the cervix, especially its lower portion, and is due to the altered axis of the uterus. An unusual dis- tance of the base of the trigone and inferior ends of the ureters from the cervix would be diagnostic of true relaxation or lengthening of the parametric end. If the relaxation be in the peripheral portion the fold will consist more of a depression about the trigone and urethra and pubic arch instead of a raising of the parametrium. An unusual flabbiness is also found in the latter class of cases, permitting the fino-er to press high up behind the pubes before encountering much resistance. Temporary vaginal folds are produced by the emptying of an overfilled bladder, changes in the position of the body, etc., chiefly by their effect upon the jDosition of the cervix. When the cervix is much farther back than normal the pubo-uterine ligament must be either stretched or relaxed. If stretched it will be flat, firm and smooth ; if relaxed it will be soft and somewhat convex. The base of the trigone will indicate by its increased distance from the cervix, the pubes, or both whether the stretching or relaxation be in the peripheral or deeper portion of the whole ligament. * Die Pathologie und Therapie der Lageveraenderungea der Gebaermutter. Berlin, 1881. PALPATION OF THE PUBO-VESICO-UTEEINE LIGAMENT. 87 When the ligament is overclistended or displaced downward by pressure or by a loss of integrity, it becomes convex instead of flat to the touch. If the parametric portion alone be distended and bulging down, we will notice an increase in the distance from the vaginal por- tion of the cervix to the trigone and to the pubes, and be obliged to press deep into the parametrium before reaching the upper end of the cervix. The convexity commences at the cervix. Distension of the parametric portion to an extreme degree, accompanied by a separation of the cervix and bladder, is recognized bj^ the pressure of intestinal loops, and borborygmus, over the upper bulging end of the anterior vaginal wall beyond the base of the trigone and between the ureters. Pressure high up in the lateral fornices, or a bimanual examination, shows the whole uterus to be pressed back behind the pelvic axis. The prolapsed parts may be felt at the vaginal entrance when standing, yet can be made to sink back deep into the vagina when the dorsal de- cubitus is assumed. In such case the lower end of the ureters, base of the trigone, bladder, and the upper end of the urethra are displaced forward toward the symphysis but not much downward. If, however, the anterior or peripheral end of the ligament be relaxed or injured so as to be displaced downward, the last-mentioned struct- ures will swing around under the pubic arch into the vaginal entrance. Intestinal borborygmus or resonance will not be felt as the bladder must come down in front of the bowel, nor can the prolapsed parts readily sink back deep into the vagina. There will also be a short stretch of firm parametric tissue (flat or concave) in front of the cervix, through which the upper end of the cervix can be felt. If the displacement and relaxation involve the whole pubo-uterine ligament the urethra, trigone, bladder and parametric portion will all be felt to be bulging down together from the cervix to the pubic arch. If the chief relaxation and displacement be laterally in the i)ara- vesical region the anterior vaginal grooves (or sulci) instead of being elevated as high or higher than the centre of the anterior vaginal wall will be depressed and rounded off, apjDarently narrowing the wall. Contraction of the pubo-uterine ligament draws the cervix forward, and renders the anterior vaginal wall firm and rough. It sometimes makes the anterior lip of the cervix seem shorter than natural, and may produce a distinct fraenum extending from the anterior lip into the vaginal wall, not unlike that felt in front of the atrophied senile cervix. (See Senile Cervix, p. 60.) If the cervix be turned forward by the displaced fundus the ligament may be flabby to the touch, and will only develop the above qualities when an attempt at replacement is made. The replacement of the cervix accompanied by palpation of the base of the trigone will show by its position whether one end only, or the whole ligament, is contracted. Contraction laterally in the para-vesical region is apt to be unilateral, 88 EXAMIXATION OF THE FEMALE PELVIC OEGAXS. and draws the vaginal groove or sulcus upward and outward, making it deeper and narrower, and unless the cervix be also drawn to the same side, gives it a curve whose concavity is inward. This is easily- recognized by the finger tip in passing from the urethral notch to the lateral fornix. Palpation of the Vagina. During vaginal palpation of the pelvic organs it is necessary to take into consideration the natural characteristics and varying conditions of the vagina itself. In the parous woman the vagina is often suffi- ciently voluminous and relaxed to offer no obstacle to the explora- tion of the whole pelvic interior, while in the nulliparous or ^drgin state it sometimes lies close around the finger like an elastic tube, pre- venting the recognition of anything except the cervix uteri. Thus we have a vaginal resistance or elasticity to be diiferentiated and sub- tracted from that of the other tissues, and which gives rise to different sensations according to the distance of the tissues, and the amount of force used in reaching and palpating them. Although the character of vaginal resistance is usuall,y of a slightly elastic nature, sometimes the vaginal walls act as an inelastic bag-like check to the progress of the finger, which vaaj be compared to the check experienced by the extended fingers in putting on a short, loose mitten. This check may be so sudden or complete, especially to lateral upward pressure into the anterior vaginal grooves, as to lead to the belief of having encountered a boggy tumor. Continuous steady pressure in such cases gradually draws the vagina toward the part to be exam- ined, overcomes the interference, and gives time and opportunity to detect the characteristic sensations afforded by contact with each tissue as it is reached. (Resistance of the submucous or supravaginal tissues has other characteristics, viz., that of a stretched cord or band, as an ureter, an artery, a cicatrix, a round or ovarian ligament; of a flat or convex surface, as the body of the uterus, base of a broad ligament, pjelvic wall, the trigone, levator ani muscle, etc. ; of a lump or ridge, as the ovary, rectum, a fecal mass, a contracted muscle, the uterus, etc. ; or of a varying character, as when passing from the peripheral connective tissue into the parametrium, from the flat pubo-uterine ligament to the tissue upon the side, or from the base of the broad ligament under the sacral peritoneal pouches, etc.) Resistance in the fornices, except in a very short vagina, depends upon the firmness of the overlying connective tissue to which it is intimately attached, and affords some knowledge of the firmness or tension of the ligaments inserted over -and into them. To the gentle touch, they should feel smooth and firm. As the finger glides forward from the anterior fornix, the anterior vaginal wall feels smooth, flat and elastic for about an inch. Here in passing from the soft elastic PALPATIO?^ OF THE VAGINA. 89 parametrium across the inter-uretric ligament and under the trigone, a sensation of increased firmness and roughness is experienced. Towards the pubes this roughness is developed into distinct transverse rugae which cover the urethra to the meatus. Frequently one or two rugee extend under the inferior pubic ligament across the urethral notches where the mucous membrane is closely adherent. At the centre of the urethral fossae and back along the anterior vaginal grooves, or lateral edges of the pubo-uterine ligament, to the lateral fornices, the mucous membrane becomes smooth and concave to the touch. These rugae are caused by the contraction or retraction of the fibrous tissue of the vaginal wall, and render it practically shorter, thicker and firmer, without destroying its distensibility. When the nuUipa- rous cervix has been displaced forward for a long time the rugse become large and firmer, shortening and straightening the vaginal wall and taking the place of the transverse fold that results from such tempo- rary displacement. Such shortening finally may prevent replacement of the cervix, and is generally an evidence of a long continuance of the malposition. We may distinguish physiological retraction from atrophy or pathological contraction by practicing long-continued mod- erate pressure upon the cervix. In the first condition the cervix will draw out the vaginal wall and go back to place, in the second it will not. In case of atrophy the rugse are either small or absent. Pathological changes are apt to be accompanied b}^ more hardening of the deeper tissues and to be more pronounced upon one side, or over a more limited area, or along a ridge. Contraction of the anterior vaginal wall tends to bring forward the centre of the projecting trans- verse crescentic fold found in forward displacements of the cervix, until its posterior or concave edge is at or in front of the base of the trigone, and thus increases the curve, while contraction of only the deeper connective tissue draws the side as well as the centre forward, and tends to place the ureters in or over the fold instead of at the pos- terior edge. Contraction of the anterior vaginal wall is also known by unusual difficulty in detecting the trigone and ureters through its hard, rough, thickened substance. Infiltration may cause the same difficulty, but will be known by the smooth, soft, and only slightly elastic, or doughy feel of the mucous membrane. Extreme or long-standing contraction of the vaginal wall is also accompanied by an extension of the rugse backward to the cervix and laterally into the anterior grooves and urethral fossae so as to narrow them, while a con- traction of only the connective tissue separates and elevates the grooves, and slightly increases their areas of smooth mucous membrane. The main signs of a relaxation of the anterior vaginal wall are smoothness and flabbiness of the mucous membrane without much change in the deeper tissues. When such relaxation occurs indepen- dent of the deeper tissues it is usually inferiorly about the urethra 90 EXAMINATIOX OF THE FEMALE PELVIC ORGANS. and is known Idj an increased area of smoothness or flabbiness about the urethral fossse and notches. An extensive loosening of the relaxed vagina from the pubic connective tissue attachments is recognized by a widening and depression, or obliteration, of the urethral fossse, and a separation of the mucous membrane from its hard base at the notches, under the sub-pubic ligament, and a descent of the urethra under the pubic arch, with the apex of the trigone, the neck of the bladder. The inter-uretric ligaments are felt behind and near, but not below, the pubis. The posterior and lateral vaginal walls at the upper end of the va- gina feel soft and displaceable in the pelvic chamber about it, and only present firm resistance to deep pressure. Toward the introitus they become rugate and closely attached to the recto-vesical fascia, over the levator ani et vaginae muscles, on either side of the rectum. As upon the anterior wall, so here the rugse and closeness of attach- ment to the fascia at the introitus indicate the amount of contraction of the wall, and the condition of its underlying connective tissue. Deeper within the vagina the posterior wall may be held so high by the contractility of the structures that all characteristic resistance of underlying structures will be lost, as we frequently find in old nulli- para, and imperfectly developed young women. Or the tissues may be relaxed here as elsewhere and allow the finger to lie flat upon the pelvic floor. The rectal notches become deeper from relaxation of the vaginal entrance, for the mucous membrane is then no longer held up from the rectum. The posterior vaginal grooves, which are short in the virgin vagina and are soon lost to the touch in the elastic vaginal tube, become larger, deeper and more noticeable as the relaxed vagina allow^s the posterior wall to sink to the pelvic floor on either side of the rectum. Firm contraction, on the contrary, may render the posterior grooves so shallow as to be imperceptible to the finger. A softness, smoothness and puffiness of the posterior wall, forming a loose transverse fold at the introitus into which the examining finger is apt to catch, indicates a relaxation of the Avail and a loosening from its connective tissue attachments to the rectum and pelvic floor. The posterior vaginal grooves and rectal notches then become either lost in the folds or displaced by being loosened from their base. In ex- treme cases the vaginal wall protrudes externall}-. The finger slipped into the rectum can easily ascertain if the whole recto-vaginal septum is prolapsed, as in that case the anterior rectal wall is felt to pass into the mass. Rectal Examination of the Pelvic Roof. In cases of small, or contracted vaginae, imperforate hymen, displaced pelvic viscera, or diseases in the back part of the pelvis, it not unfre- METHOD OF RECTAL INDAGATION. 91 quently becomes desirable or necessary to examine through the rectum. The advantage of such examination lies not only in the frequent un- fitness of the vagina, but in the shortness and directness of the route to the posterior superior parts of the pelvic cavity. Rectal indagation may be practised with one or two fingers or the half hand. The latter method usually requires either local or general anaesthesia. The introduction of the whole hand, as is often recom- mended, has been known to permanently impair the tonicity of the sphincters, and should not be resorted to unless the hand be small, the anus and rectum easily dilatable, and an accurate diagnosis be imperative and unattainable by milder measures. Method of Rectal Indagation. As the rectal mucous membrane is sensitive, comparatively dry, and collapsed into soft folds, the examining finger should be abundantly lubricated with an absolutely unirritating ointment, and introduced riG 54 MaLwJ of L.trv.JuCx.,g tL^ 1 ...ger wxt^ tl... Lactam (i). /I. Touching internal sphincter ani and lower edge of perineal septum ; J-, finger passed through the interior sphincter under the pelvic floor edge ; f^, finger turned back over pelvic floor edge for the examination of the pelvic interior. slowly with the palmar surface forward or to one side. The sphincter ani dilating toward the perineal body allows the finger to come in contact Avith the lower edge of the perineal septum where the rectal wall containing the second sphincter is attached (Fig., 81 is, also 34, s), and from which it can be traced around the anus, a trifle farther from the external anal orifice behind than in front. Introduced straight upward in the axis of the body, the finger comes squarely against the posterior rectal wall which here passes almost directly forward under the pelvic floor from the anus to the rectal promontory or pelvic floor 92 EXAMINATION OF THE FEMALE PELVIC OEGANS. edge. If the finger be directed slightly forward (Fig. 54,/^ and/^) the edge of the fibres of the levator ani at the promontory, which are normally relaxed and offer but little resistance, may be felt and pressed back out of the way (Fig. 54,/^). Should, however, much irritation exist, or be ]3roduced by rough fingering, the levator ani may con- tract and lift up the folded rectum against the posterior vaginal wall (Fig. 21) and effectually resist the unwarranted or awkward intrusion. The levator ani, holding the collapsed and closed rectum loosely forward, not only forms a boundary below which faeces never lodge, but has the power of firm voluntary contraction, and may, under pathological influences, contract so tightly and continuously as to interfere with the circulation and enervation of the parts passing through the pelvic floor outlet. Hence it would be in accordance with its function to call the anterior portion of the levator ani (the levator ani proper) the rectal sphincter or third sphincter of the bowel. (See Fig. 17). It is in reality the sphincter of the pelvic outlet. The finger as it enters the anus should therefore be gently directed forward along the perineal body (see Palpation of the Perineum) until the recto-vaginal septum is reached. Then by turning the finger end so as to make the perineal body recede upward and the pelvic floor edge backward the road becomes straight (Fig. 54, /^). When the palmar surface is turned forward the finger, almost as soon as it has penetrated beyond the pelvic floor edge into the inner pelvic or subperitoneal connective-tissue chamber (see page 68), usually encounters the cervix which, being nearer the anus than the vulva, seems to the inexperienced touch too far forward, and, being covered by both a rectal and vaginal wall and a little intervening connective tissue, too large. If any doubt exists as to what is thus felt, a finger of the other hand, or a thumb of the same hand, may be slipped into the vagina to the cervix and serve as an indicator. When the cervix is far back and the fundus uteri turned down over the vesico-vaginal septum the corpus is felt as if it lay upon the elevated anterior rectal wall. When the cervix is forward and the fundus turned back the finger end passes under and back of the cervix, instead of in front, and reaches under the corpus more readily than per vaginam. Although we may reach the smaller structures of the anterior half of the pelvic roof, such as the lower end of the ureters, round ligament, etc., in somewhat the same manner as through the vagina, they are obscured by more intervening connective tissue, and the resistance of the rectal walls. Hence, unless the vagina be closed or contracted, and the rectum quite lax we need not attempt such an exploration, but pass the finger on to the side of the cervix and hook it under the base of a broad ligament. This will be usually felt as a firm, well- defined band stretching to the side of the pelvis. In many cases the posterior peritoneal layer extending under and forming the sacral DIGITAL, EXPLOEATIOIS" THROUGH THE UPPER RECTUM. 93 peritoneal pouch feels firm and is traceable back to where it is reflected up to form the sacro-uterine fold. The finger passed back under the pouch will, if the rectum be voluminous and lax, readily glide up into the Douglas pouch, and may be hooked over one of them. If the body of the uterus be turned back upon the recto-uterine peritoneal folds it may be pushed up from them. If the uterine appendices be in the pouch, they will be above and in front of the finger, instead of above and behind it, as in the vaginal examination, and can be palpated against the posterior wall of the cervix in front, instead of against the rectum behind ; or, if the fundus be turned back, they will be felt against the corpus uteri over and in front of the finger, instead of over and behind. Sometimes masses of fasces in the upper rectum may be felt pressing down behind and over the uterus, but separated from the finger by a rectal fold caused by the contracted fourth (called the third) sphincter, so as to feel something like the appendices, or some foreign substance, in the sacro-uterine pouch. Beside the possibility of mashing and working down such substance, there is always the possibility of getting beyond the rectal fold or constriction and in direct contact with it. In all these manipulations the rectal mucous membrane should feel soft and folded and freely movable upon the finger. Any alterations of its walls such as hardening, cicatrization, immobility, narrowing, inelasticity, unnatural heat, sensitiveness, and granular, hemorrhoidal or polypoid growths, etc., should be noticed, since they often have a material influence upon the condition of the sexual organs and upon the interpretation of the vaginal examination. If the connective tissue about the sacral peritoneal pouches be soft, ovaries or tubes lying low in them may be felt, and, if at the same time the abdominal walls be lax and depressible, almost the whole of the posterior half of the pelvis may be examined bimanually. In those who have borne many children this may frequently be accom- plished, in old nullipara very seldom. Digital Exploration through the Upper Rectum. As both the sacro-uterine ligaments and fourth sphincter, usually called the third (Figs. 34 and 35, D and D'-), are sometimes contracted and present openings of almost the same size, it is necessary, that the finger may not get lost in the rectal folds, to be able not only to find the rectal sphincter, but to know it from the ligament. It must, there- fore, be borne in mind that the contracted sacro-uterine ligaments have an oval or semicircular aperture against or inseparable from the cervix, and may be felt to pass upward toward the second sacral vertebra, while the contracted fourth sphincter is circular, separated or separable by a stretch of rectal wall from the cervix, and is against or near the lower end of the sacrum ; also that the ligaments are not, like the sphincter, completely enveloped in puckered mucous mem- 94 EXAMINATION OF THE FEMALE PELVIC OEGANS. brane, inseparable from it, and dilatable by traction upon it. Hence, instead of pushing the rectal wall up behind the cervix, we must direct the finger back toward the sacrum until it enters the sphincter. If the latter be closed, forward traction upon the rectal wall will usually dilate it sufficiently for the finger to enter it and pull it open in the direction of the cervix, and thus open up a direct route between the sacro-uterine folds to the sacral promontory out upon the pelvic roof. Two fingers of the right hand are best for such an examination. Fig. 55. --:-.-,-.,///#'>'^'%*////*/A'-^>«^^^ W//.>///,//:->'^y.'//y^ Bimanual Examination of the Posterior Surface of the Uterus and the Posterior Pelvic Spaces from the Rectum. (After a case of Hematoma.) If, while we press well up behind the uterus with the rectal fingers, we bring the fingers of the other hand down behind the fundus from the surface of the abdomen, we may approximate them behind the uterus. When the parts are relaxed and not irritable, this can occa- sionally be done with one finger in the vagina, and without an an- esthetic. Fig. 55 represents such an examination made with one finger in the rectum without an anjcsthetic, in a case of hematoma extending from one broad ligament across the posterior wall of the CIRCUMDIGITATION OF THE UTERUS, ETC. 95 uterus into the other. The broad ligaments can be examined at the same time in the same way, and the changes which occur be quite accurately estimated. With two fingers higher in the rectum, and the patient anaesthetized, the uterus is not pulled so far forward as repre- sented in Fig. 55. In all central and posterior positions of the ovaries they are found within easy reach of the fingers passed into the upper rectum. The fingers seem right among and against the ovaries, tubes, ligaments, arteries, small intestines, etc., and can, with a little experience, map them upon the mind. Indeed, when thus carefully and intelligently examined, the pelvis has no secret places, except those of a micro- scopic kind. The Recto- Vaginal Chrip. When the fundus is turned into the hollow of the sacrum the uterus may usually be firmly grasped between the forefinger in the Fig. 56. Kecto-Vaginal Grip of the Retroverted Uterus {}4). rectum behind the fundus and the thumb in the vagina in front of the cervix, and its flexibility, mobilit}^, and sensitiveness accurately and satisfactorily determined (Fig. 56}. Circumdigitation of the Uterus from the Abdomen, Vagina, and Rectum. A combination of these different methods of examination is useful in some cases. By introducing one or two fingers into the rectum and behind the cervix, the thumb of the same hand into the vagina in front of the cervix, the thumb of the other hand against the de- pressed abdominal wall below the fundus, and the fingers similarly 96 EXAMIXATIOX OF THE FEMALE PELVIC OEGAXS. over the fundus, the uterus can be grasped simultaneously by the fundus and cervix in a firm double grip, as represented in Fig. 57. Fig. 57. Bimanual Circumdigitation from the Rectum and Vagina, by means of the Abdominal and Recto- Vaginal, or double, Grip. Thus not only the size and shape of the organ can be estimated, but also its hardness, flexibility, and mobility. The ovaries may, during ansesthesia, be similarly grasped. Palpation of the Interior of the Bladder. When abnormal or pathological conditions interfere with ordinary methods, it may become necessary to introduce the finger into the bladder to ascertain the condition of its mucous membrane, or to reach the anterior part of the pelvic cavity. The urethra should be dilated first with sounds or dilators (see " Use of the Urethral Speculum," chap. IV.) and the little finger. After the little finger, the index may be gradually forced into the bladder. About an inch back of the vesical sphincter and about an inch apart will be felt the slightly elevated mouths of the ureters (see Fig. 58). The thumb of the same hand, or a finger of the other, introduced in the vagina can, by locat- PALPATION OF THE INTERIOR OF THE BLADDER. 97 ing the ureters in the vagina and passing up the vesico-vaginal septum, sometimes aid the index in the bladder. The bladder being high up in the pelvis gives access to the vesico-uterine tissue and pelvic brim better than does the vagina. But the skill required to palpate through Fig. 58. IbBW TtL ion of Uretral Orifices (after Wlnckel). the constricting urethra, the violence necessarily done to the i3arts, and the rarity of the occasions demanding such an examination must make it possible for but few to derive much benefit from it. For the palpation of the vessels and nerves of the pelvic roof see "Palpation of the Arteries of the Pelvis," Chapter III. p. 104, and the following paragraphs. CHAPTER III EXAMINATION OF THE FEMALE PELVIC ORGANS {Continued). The Pelvic Floor and Perineum. As a rule the pelvic floor of the child bearing woman may be suffi- ciently examined from the vagina. When, however, the vagina does not permit of as satisfactory an exploration as is desirable, rectal indagation may become necessary. Hence, we will take up each in turn, first the vaginal, then the rectal. Vaginal Palpation of the Pelvic Floor. The Coccyx. — One or two fingers, introduced to the cervix uteri as a starting-point, may commence the palpation of the pelvic floor by pressing downw^ard and backward in the median line until the knotty Fig. 59. Grasping the Coccyx between the thumb externally and the index in the vagina. The rectum is pushed to one side. ridge of bone corresponding to tlie anterior surface of the coccyx is reached. The rectum, if in the way, should be pushed to one side, usually to the left. By bringing the finger forward along the ridge to the point where it glides over upon softer tissue the end of the bone will be distinctly recognized. In a young or poorly developed nulli- THE PYEIFORMIS. 99 par, and in one who has recently borne children, the tip of the coccyx is depressible and elastic. In the fully developed nullipar and in the aged this mobility diminishes year by year and is sometimes imper- ceptible. A rigidity or temporary contraction of the levator ani, by raising and hardening the pelvic floor, makes the recognition of the tip of the bone quite difficult unless firm pressure be used. When a more definite knowledge of the size, mobility and position of the coccyx is desired, the thumb should be brought externally against the coccyx, an inch or a little further back of the anus, so that the bone comes between the index finger in the vagina, and the thumb on the integument externally, as represented in Fig. 59. Unless the patient be very fleshy and the perineum very rigid the bone will be grasped without difiiculty. The presence of rigidity, ankylosis, displacement, tenderness, hyper- sesthesia, etc., of the coccyx can thus be definitely ascertained. In the young and the parous woman the tip of the bone may be moved forward and backward like a piece of soft whalebone ; in nuUiparous middle age, and in old age in general, it may be moved but little and only by considerable pressure. If there be immobility due to contrac- tion of the muscles of the pelvic floor, their resistance may be overcome by firm pressure, or relaxation may be brought about by changing the position of the j^atient. The Small Sacro- Sciatic Ligament^ and Ischial Spine. By passing the finger back on either side of the rectum the small sacro-sciatic ligament is felt running from the lower end of the sacrum and upper end of the coccyx to the ischial spine. When the pelvic floor is relaxed the flnger immediately recognizes it, for its anterior edge is raised and hard as compared with the softer muscles in front. When the pelvic floor is contracted the posterior edge of the ligament is the only part of it to attract attention as the finger passes over it into the great sciatic foramen. The ischial spine is felt, at the converging outer ends of its hard edges, as a small bony projection in front of the foramen, with a slight linear depression (the white line or arcus ten- dineus) leading forward, and marking the junction of the pelvic wall and pelvic floor. (Figs. 18 and 19.) The Pyriformis. Behind the small sacro-sciatic ligament may be felt the pyriformis muscle which, in a state of rest, is flat, and considerably softer than the ligament; but which, during contraction, feels like a small pear- shaped tumor lying upon the sacrum, filling the upper part of the sacro-sciatic foramen and reaching with its smaller tapering end diagonally downward and outward behind the ischial spine. By 100 EXAMIXATIOX OF THE FEMALE PEL^TlO OEGAXS. directing the patiert to rotate the thigh inward and outward or raise her hips a little, or by slightly changing her position, or that of her feet, or approximating her knees, contraction and relaxation of the muscle may be successively evoked. The Great Sacro-Sciatic Foramen and Sacral Promontory. Pushing the finger from the ischial spine across the smaller end of the muscle, upward and backward, the bony upper border of the great sciatic foramen at the sacro-iliac synchondroses is felt, and may be m Fig. 60. '^^ill&§i;i.'*K^'^ f£z£g-2-? :» t-1 S52<^j w- ^BS^m M Anterior Surface of the Sacrum, showing the Attachment of the Pyriformis. (After Gray.) traced toward the median line. Farther up the promontory may be felt. The upper border of the great sacro-sciatic foramen may often be reached with two fingers in ordinary ofi&ce examinations, whereas the promontory can be thus touched only when the vagina and perineum are relaxed and the j^arts behind the uterus are devoid of any unusual sensitiveness. The ijrojecting edges of the sacral foramina can also be easily felt, the first one just above the internal and upper angle of the THE LEVATOR ANI. 101 raised belly of the contracted pyriformis muscle, the second and third at the depressions or scallops of its internal border, and the fourth just internal to its lower angle or edge. (See Fig. 60.) The Coccygeus. Coming forward over the small sacro-sciatic ligament the finger barely detects the fibrous structure of the flattened coccygeus lying upon it, until it has passed the ligament, when it immediately recog- nizes the clepressible semi-elastic character of the relaxed anterior por- tion of the muscle. Its anterior edge or border is often prominent as compared with the levator ani in front of it, and may be known by locating the ischial spine and last coccygeal articulation, between which it runs in a straight line. The anterior border of the ligament may be known from that of the muscle not only by its rigidity, but also by its direction, which is more backward from the ischial spine toward the middle or upper part of the coccyx than the muscle. In the ordinary dorsal position the border of the ligament seems to run from the ischial spine inward and slightly backward, that of the muscle inward and slightly forward. When the coccygeus is contracted, firm pressure will be required to reach and recognize the anterior edge of the ligament through the substance of the overlapping muscle. The Levator Ani. The levator ani, occupying almost the entire pelvic floor in front of the coccygeus, lies directly under the finger pressed flat upon the pelvic floor beside the rectum. When relaxed it is soft, concave and depressible, and can be excited to partial or irregular contractions by- hooking the finger tip into it at various points. When contracted in all its parts it renders the pelvic fioor hard, less concave and holds it up firmly against the anterior vaginal wall. Simultaneous contrac- tion of the coccygeus produces a smooth, hard floor as far back as the great sciatic foramen. If, as often happens in ordinary exami- nations, the central portion alone is contracted, the finger after en- tering the vagina comes upon a large ridge of muscular fibres, ex- tending from the posterior surface of the pubic bone, at the anterior end of the white line backwards and inwards straight to the end of the coccyx forming a levator coccygei rather than a levator ani. This is theposterior half of the pubo-coccygeus of Savage. (Fig. 18, \) Behind it is felt the relaxed posterior portion as a triangular depression whose base is the white line (arcus tendineus), whose apex is at the lower coccygeal bone and whose sides are the anterior edge of the coccygeus behind and the contracted portion in front. This is the obturato- coccygeus of Savage. (Fig. 18, \) If the coccygeus be also soft and relaxed, the depression including it will be quadrilateral.. If the 102 EXAMINATION OF THE FEMALE PELVIC OEGANS. middle section of the levator ani be very strongly contracted, the tri- angular space often becomes narrower by a participation of some of its anterior fibres in the contraction. If the fibres in front of this con- tracted band or central portion of the muscle be relaxed, the finger presses down with the rectum against the coccygeo-anal ligament ; if they be greatly relaxed this central band becomes more prominent, and the finger lies upon an almost flat surface having an entirely dif- ferent plane from the deeper pelvic floor, and turning abruptly from it, instead of continuing forward. As thus felt the anterior portions of the levatores ani of both sides taken together form a large triangle whose apex is at the tip of the coccyx, and whose basal angles are at the pubic attachments of the contracted central portion or levatores coccygei. When the posterior section alone is contracted it seems to form a continuation forward of the contracted coccygeus, and sometimes whether contracted alone or with the whole floor draws the white line into a slight curve whose concavity is outwards. A contraction of only the anterior portion, which has no central bony attachment, raises the pelvic floor edge and recto-vaginal promontory over it so as to place a distinct fleshy ridge across the vaginal inlet behind which the finger end passes abruptly back to the deeper and softer parts. Contraction of the central with the anterior portion makes this ridge much wider. (See Fig. 21.) Figs. 18 and 19, from Savage, show quite truthfully the origin and insertion of the different sets of fibres of these muscles and are worthy of a close study. The finger-end by pressing into the muscles at vari- ous points as already directed can easily determine the direction and action of the fibres during the irregular contractions thus induced. Control of the Pelvic Floor Muscles by Will. As the levator ani and, to a certain extent, the coccygeus are volun- tary muscles, the patient can be made to elevate this part of the pelvic floor as the finger lies upon it. My attention was called to the con- trol of the will over the levator ani by an interesting article by Budin* in which he asserts that some women can voluntarily contract the levator ani. For the purpose of getting at the facts I tested the mat- ter in seventy-five consecutive gynecological patients in office practice. I asked them, while holding my finger in the vagina, to contract the anus as after a stool, or as to prevent a passage from the bowels. By telling them that I was trying the strength of the uterine supports I succeeded in getting all but one to make the effort. All but this one succeeded in raising the anterior or middle portions ; nearly all raised also the coccygeus ; and about ten per cent, raised the whole plane of * Obstetriqne et Gynecologie, 1886. Le Progres Medical, Angnst, 188L THE OBTURATOR INTERKUS. 103 the pelvic floor from the coccygens forward. In a few cases the ante- rior and middle portions were raised along with the levator vaginse so high that the finger had to pass up behind the pubes to get over them, i.e., the pelvic outlet was voluntarily closed up. Fig. 21 represents in section a contracted jDclvic floor through the median line or lowest part. Virgins seemed to have as good control over the pelvic floor as multipara and married nullipara. Injuries during labor impair the contractile power of the pelvic floor and perineum in many, as will be explained in describing the injuries of these parts. The Obturator Internus. The relaxed internal obturator muscle is seldom felt in an ordinary examination unless especially sought for. It lies flat over the obtu- rator foramen, partly under the levator ani and white line of division of the obturator fascia, and 23artly above them on the lateral pelvic wall. (See Fig. 15.) Its higher portion is easily detected above the white line cushioning the pelvic wall, while the remainder may be reached by depressing the relaxed middle and posterior portions of the levator ani downward and outward through the ischio-rectal fossa until firm resistance is encountered. When contracted, however, the obturator internus feels like a hard hemispherical tumor on either side of the median line, over the obturator foramen, filling the ischio-rectal fossa, and elevating the pelvic floor. Between the two bellies there extends a narrow, deep characteristic groove along the median line whose bottom is the coccyx and ano-coccygeal ligament. By pushing aside the rectum which loosely fills the groove, the borders of the hard belly of the contracted muscle may be easily traced. We may distinguish these muscles from adventitious growths by the fact that they are bilateral, or may be made so by causing the patient to rotate the trochanters outward against counter-pressure ; and that at the same time the pyriform muscles are generally found contracted, tumor like; while the depressed flat surface of the small sacro-sciatic ligament lies normally between the two rounded tumors. When in addition to contraction of the obturator internus and pyriformis, the levator ani and coccygeus are also contracted, the finger finds the pos- terior vaginal wall and whole pelvic floor elevated and extending as a hard mass almost straight back from the recto-vaginal promontory to the small sacro-sciatic ligament. This ligament, instead of a raised, flat, hard surface in front of a soft and yielding, somewhat concave pelvic floor, is now a narrow, depressed surface behind a firm flat or convex surface, and in front of the raised, tapering belly of the pyri- formis. When the levator ani, the coccygeus and the pyriformis are contracted but the obturator internus relaxed, the ligament is depressed compared with the pyriformis behind, but is about on a level j)lane with the muscles in front. 104 EXAMINATION OF THE FEMALE PELVIC ORGANS. Rectal Examination of the Pelvic Floor. As already indicated in speaking of the rectal examination of the pelvic roof, p. 90, the finger, as soon as it has passed the anal sphinc- ters comes in contact with the posterior wall of the rectum as loosely held forward by the anterior portion of the levator ani. This is the part that is often felt per vagina m to be soft and depressible in front of the contracted middle portion, or levator coccygei. When it is re- laxed its resistance is scarcely felt by the well oiled and properly directed finger; but when contracted it forms a firm edge or projection almost closing the passage (Fig. 54). In order to get over it upon the pel- vic floor without exciting it to rigid contraction, the finger, after being introduced forward to the anterior rectal wall, or near it (Fig. 54,/''), should be turned palmar surface backward (unless it has been so in- troduced), and bent as it passes further in, so as to hook around and depress the pelvic floor edge or rectal promontory. The rectum will be felt to lie immediately upon the pelvic floor so as to afford, practi- cally speaking, a direct palpation of its centre and often of its left side, and if it be voluminous or relaxed, of the whole pelvic floor. The ischio-rectal fossa on either side is separated from the finger by less tissue than in the vaginal examination. On the contrary, the junction of the jDelvic floor with the lateral pelvic walls anteriorly cannot be reached as easily through the vagina which lies higher in the pelvic connective tissue chamber. The nearness of all parts of the i^elvic floor, the apparent narrow- ness of the levator ani et vaginae which is partly in front of the finger, the distinctness of the sensations of touch, and the absence of certain parts that are felt in the vaginal examination, may be somewhat con- fusing to the beginner, but constitute in reality the reason for such an examination. Having located the coccyx, ischial spine and smaller sciatic ligament as per vaginam, the location of the other parts becomes easy. With one finger the sacrum can be explored as high up as the pelvic roof, its curve and that of the coccyx be estimated, and the lower contents of its hollow be examined with the gentlest and most discriminating touch. Contraction, relaxation, irritability, inefficiency, etc., of the muscles of the pelvic floor are more easily appreciated and studied than Avhen felt through the vagina, where the levator vaginae, vaginal wall, rectum, and connective tissue, as well as the greater distance of the parts, render the sensations less distinct. Palpation of the Arteries of the Pelvis. In palpating an artery in the pelvis, we hold the finger perfectly still, after finding the tissues through which the vessel runs, until we detect its pulsations, and then trace it by them in both directions. VAGINAL, PALPATION OF ARTERIES 105 When pressed against a hard or resistant surface it feels like a cord, and may, if passed by in haste, be mistaken for other structures, such as the ureters, a deep cicatrix, a nerve, a tendon, ligament, etc. Vaginal Palpation of Arteries. The pulsating uterine artery is found on either side of the cervix by pressing high up in the anterior or posterior fornix and then around to the side of the uterus, or by pressing straight out from the lateral fornix and up under the base of the broad ligament. The firmness of the connective tissue about the artery, or the resistance of the vagi- nal walls, may, however, frustrate such attempts. When the cervix is situated well back the artery is often found farther back than would be supposed. By hooking the finger up behind the outer attachment of the base of the broad ligament the uterine artery may occasionally be felt entering the broad ligament. When found beside the cervix it may sometimes be traced to its origin above and behind the ischial spine. A vaginal branch may nearly always be felt pulsating near or against the cervix, in front and to the side of it, and can be traced laterally almost to the main vessel and forward down the anterior vaginal wall. Sometimes it dips into the connective tissue, or divides irregularly and is lost to the touch near the cervix. The middle vesical artery is often felt traversing the pelvic roof near . the ureter, and may be known from it by its pulsations. The internal ej)igastric artery can also be reached and recognized by depressing the abdominal wall with the hand externally over the mid- dle of Poupart's ligament, and pressing up the vaginal finger about the internal abdominal ring. (See Palpation of the Round Ligament, p. 74.) The pulsations may be traced from the ring a short distance up the abdominal walls. Numerous small tendons on the under surface of the transversalis, passing in various directions, tend to confuse the touch, but may be known by the absence of pulsations in thein. The internal pudic, escaj)ing at a point above and behind the ischial spine, may be felt by passing the finger tip over and behind the ischial spine along the pelvic wall below the uterine artery, or by placing the finger end upon the pyriformis muscle and carrying it forward to the spine. It is felt to pass into (really out through) the great sacro- sciatic foramen in front of the muscle. Just internal and back of the pudic, usually separated by a sacral nerve running between them, is felt the sciatic also passing out. Being large arteries and so near together they may be both felt at the same time and recognized by being together and disappearing so near together. When they are given off very low, only one artery, the anterior trunk of the internal iliac, may be felt in their place pulsating strongly as far down as the sacral plexus. 106 EXAMIXATTOX OF THE FEMALE PELVIC OEGAXS. By pushing backwards across the pj^riformis the gluteal artery is felt to pass down and disappear behind and external to it. "When the upjjer border of the greater sciatic foramen can be reached, the gluteal will be found pulsating strongly as it comes between the finger and the bony edge. It may be traced downward to the edge of the muscle and upward to the internal iliac. The middle hemorrhoidal is easily traced downward and inward from behind the ischial spine toward the rectum, to disappear at the recto-vaginal septum near where the os uteri impinges against the posterior vaginal wall. The inferior vesical, given off from the middle hemorrhoidal, or near it, is felt internal to and below the ischial spine and can be palj^ated upon the levator ani laterally a short distance below the obturator to the sides of the pelvic floor outlet. The finger introduced into the vaginal entrance and laid flat upon the belly of the levator ani on either side will almost immediately feel the artery pulsating and can trace it backward. The obturator artery is easily felt running forward along the lateral pelvic wall, over the spine of the ischium near the upper edge of the obturator internus toward the opening through which it leaves the pelvis. Its course lies a little above and almost parallel with the white line. From here a branch can usualh^ be traced along the posterior surface of the pubic bone to join its fellow from the Of)posite side. An obturator branch of the epigastric can generally be traced from the foramen upward and forward toward the internal abdominal ring, to which it may sometimes serve as a guide. The sacra-media may often be recognized per vaginam by pressing firmly against the sacrum in the median line high up behind the cervix. On account of its bony bed the pulsations seem quite strong. Satisfactory palpation of the smaller arteries situated at a distance from hard or bony surfaces is only possible when the connective tissue is not too firm, or when their course is near the mucous membrane of the vagina;, or when the abdominal wall can be pressed down so as to form a resistant surface over them. The main trunks of the internal iliacs can, under favorable circumstances and under ether, be found by tracing the anterior and posterior branches upward. The irregularities in size and origin of the vesical, uterine obturator, and pudic arteries in dififerent subjects, and in the two sides of the same subject, and the occasional crowding together or union of the points of origin of two or more, or of all, of the branches of the internal iliacs, make it often impossible to trace them all to and from their sources. In a dissection made for the purpose of a description I found both sides unnsnal and at the same time as diflerent from each other as possible. Tlie places of division of both internal iliacs were higli up, and both obturator arteries were given off from the PALPATION OP PELVIC NEEVES. 107 posterior trunks. On the left side the anterior trunk was less than an inch long to where it bifurcated into the sciatic and pudic. The uterine and superior vesical arose by a common track, the first giving off" the vaginal, the second the middle vesical. The middle hemorrhoidal gave off" the inferior vesical. On the right side the anterior trunk extended as an almost straight tube for more than two inches and divided into the internal pudic and sciatic just over the sacral plexus. The only other branches given off were the superior vesical, with its middle vesical branch, and the uterine artery. This last was given off" high up, and descended beside the long anterior trunk of the internal iliac for about an inch before turning into the broad ligament. All of the other arteries arose from the posterior trunk. This variability in the diff"erent subjects, and in the sides of the same subject is a strong reason for the practice of digital palpation of the arteries, so that the operator need not depend upon his knowl- edge of where they ought to be, but may map them out with the finger as they happen to be before cutting in among them. Rectal Palpation of the Pelvic Arteries. When the rectum is of moderate size, and normally located a trifle to the left, the index finger of the right hand introduced into it scarcely notices any arteries except the sacra-media, unless it presses far toward the right side of the jDclvis ; but the left index, if introduced and allowed to lie still a moment, is apt to feel as if in a nest of j)ulsat- ing arteries, and to get confused at the number of vessels about it — more particularly so as smaller branches are here palpable. The small sciatic ligament and pubic sjpine should in such a case be located, or, if the pelvic floor be raised so as to hide them, the contracted pyri- formis and great sacro-sciatic notch. The vessels before and behind the pyriformis may then be sought the same as directed above in the vaginal examination, and will be reached with greater ease. Those passing across the pelvic roof are, however, not so easily recognized. The middle hemorrhoidal will be above instead of below the finger, and may often be pressed against the cervix. Palpation of Pelvic Nerves. Nerves to be felt in the pelvis must usually be pressed against a hard surface. As a rule they are to be sought near the arteries of the same name. Thus the obturator nerve may be reached from the vagina lying against the hard pelvic wall, a little above and parallel to the obturator artery, and the superior gluteal and pudic nerves beside the arteries of the same name. The sacral plexus lying upon the pyri- formis feels like flat, slightly movable bands connected together, coming from the sacral foramina and disappearing with the tendon of the muscle behind the ischial spine. The mobility of this plexus and the ease of its detection also affords a sort of index to the firmness of the connective tissue about them. Although thus exposed to easy pressure by the finger in the vagina, they are in reality well protected by lying in the sacral concavity, with large arteries about them, and the sacro- 108 EXAMINATION OF THE FEj\IALE PELVIC ORGANS. uterine and broad ligaments and sacral pouches extending above and over them. Inflammatory exudations cause pressure upon them more often than anything else, although I have seen one case of pressure from a suddenly dislocated fundus uteri upon the superior gluteal, caus- ing intense suffering throughout the extent of the nerve, until as sud- den and permanent relief was afforded by a replacement of the organ. Pain upon pressure running along the course of the nerves is often a great help in hunting for them. Thus in palpating the superior edge of the greater sciatic foramen (p. 100), when we pass over the pulsating gluteal artery we can feel the nerve as a smaller cord running alongside it, and will know it by the sudden sharp pain felt by the patient as the nerve slips under the finger. The pain is referred to the hip and gluteal muscles. Similarly in front of the pyriformis, and near the respective arteries firm pressure upon the small sciatic or pudic nerves will sometimes be referred to the posterior and inner side of the upper thigh or about the external genitals. Pressure upon or above the coccygeus near the median line frequently causes acute jDain in the pelvic floor along the course of branches of the 4th and 5th sacral nerves. Examination of the Perineum. In considering the perineum as separated from the pelvic floor (see Chapter I.) the levator vagin&e portion of the levator ani was described as a separate muscle attached anteriorly to the posterior surface of the pubes, just external to the urethral notch, and poste- riorly to the recto-vaginal septum just behind the hymen. (Figs. 16, 17, 22 and 31.) Examination of the Vaginal Orifice. The Hymen. — The hymen extends from the urethra just behind the meatus urinarius down, on either side, along the perineal septum to the perineal body, forming a curtain or screen at the vaginal orifice across the lower ends of the urethral and rectal notches. (See Fig. 16 for these notches.) According as its aperture is central or peripheral, high or low, single or double, etc., the shape of the ridge of membrane around the vaginal orifice varies, but to the finger passed into the vagina it usually feels like a firm, narrow ridge or elastic ring. When dilated or partially ruptured from coitus it is felt as one or more loose ribbon-like folds of membrane extending partly or quite around the vaginal orifice; when destroyed by parturition its remains are felt as a series of soft projections (the caruncles) in the same place, or a trifle external to it; when absorbed or atrophied from injury or age it may leave no trace of itself to the touch, and but little to the sight. The Levator Vaginse and Levator Ani. In the virgin the posterior and lateral vaginal walls sliould, by the action of the levator vaginse or vaginal sphincter, be firmly approxi- THE LEVATOR VAGII«r^ AND LEVATOR ANI. 109 mated to the finger introduced through the hymen. The muscle ex- tends around the vagina and feels like a broad band or sling instead of a narrow rigid edge like the uninjured hymen (Figs. 17 and 22), Above on either side of the urethra are felt, upon upward pressure, the urethral notches giving the orifice a crescent shape (Fig. 61). In the married woman the levator vaginae is ordinarily somewhat relaxed, and sinks slightly into the rectal grooves on either side of the rectum, causing the latter to present a broad elevation, the recto-vaginal pro- montory just behind the hymen in the median line (Fig. 16) where it passes over the pelvic floor edge into (or out of) the pelvis. The orifice then is felt to be transversely oblong with the upper and lower sides depressed by the urethra and rectum (Fig. 62). To the touch the vaginal entrance feels a little wider over the rectum than in Fig. 16 (which represents the parts collapsed), because when the parts are examined by the finger they reveal the shape and capacity only when dilated to the extent of affording a characteristic resistance. When Fig. 61. Fin. 62 Fig. 63. ]i.Ur^th.aZJiotc7u 'PiCbieAreh J ■ A ? Vrethra .., \ '■■" V''' " -- . . ,/--' /T'^^'X. y''*'^^TX'^'' fv^i^ Avclv Fig. 61, — Vaginal Entrance of the Virgin. Fig. 62. — Vaginal Entrance of the Married Nullipar. Fig. 63.— Vaginal Entrance of the Married Nullipar with contracted or short Levator Ani, draw- ing forward the rectal and recto-vaginal promontories. the anterior portion of the levator ani, that portion which passes to and under the rectum, is contracted or normally short, the rectum is pressed firmly up against the urethra, leaving a little space on either side between the rectal and urethral notches (Fig. 63). When the levator vaginae and its surrounding fasciae are relaxed to an extreme degree, so as to give no resistance whatever, the urethral notches are considerably widened to the touch, for the finger before encountering resistance comes against the fibres of the levator ani proper, whose pubic attachments are farther away from the urethra. These fibres, instead of passing almost straight back at their commence- ment, like the levator vaginae, assume from their origin a diagonal direction and converge quite rapidly inward towards the sides of the rectum. The finger finds itself in a V-shaped orifice with the rectum filling the angle and the urethra projecting into its open end. Fig. 64 shows approximately the shape as ascertained by the touch. When 110 EXAMINATIOX OF THE FEMALE PELVIC ORGANS. the levator vaginae is greatly relaxed, and the levator ani short or con- tracted, the rectum is brought up against the urethra and the borders of the levator ani or arms of the V are more transverse and form a larger angle, as in Fig. 65. The rectal notches are well marked, and broad but shallow. AVhen the levator vaginse is extremely relaxed the finger entering the vagina along its posterior wall on either side of the recto-vaginal promontory comes against the under surface of the pelvic floor edge or levator ani instead of being directed imme- diately over it, as is the case when the vaginal entrance is drawn to- gether at the pelvic floor edge by the levator vaginse. Each of these forms denotes a particular condition: the first (Fig. 61), a contracted or tonic condition of the vaginal coats, in the levator vaginse, the fascia and the surrounding connective tissue, and is found Fig. 64. XTrdhrai notches TJr^tl%TCL JiiieteCLTiraAuixtitoxif Fig. 64.— Vaginal EntraDce, witli greatly relaxed or destroyed Levator Vaginse. Fig. 65.— Same as Fig. 64, except that the Levator Ani is short and practically closes the Vagina (just behind its entrance). in virgins and some married nullipara; the second (Fig. 62), a normal relaxation of these tissues, and is found in some virgins and most married women; the third, contraction of the anterior edge of the levator ani so as to raise the pelvic floor edge (Fig. 63); the fourth, complete relaxation of the levator vaginse with a normal levator ani, as is found after over-distension or injury at childbirth (Fig. 64) ; the fifth, complete relaxation of the levator vaginse with shortness or con- traction of the levator ani anteriorly (Fig. 65). With the last condi- tion we may have a firm closure of the vagina just behind the hymen coexistent with relaxed or patent vaginal or vulval orifices. Examination of the Vulval Orifice. The vulval orifice usually feels larger than the vaginal. Anteriorly it is slightly indented by the urethra but extends posteriorly beyond the rectal promontory to the fourchette. THE PUBIC FOSSA. Ill The Constrictor Cunni or Vulval Sphincter. The principal variations in the shape of the vulval orifice are occa- sioned by the condition of the constrictor cunni. When this muscle and the surrounding fasciae are firm, as in some virgins, the opening feels almost circular to the finger sweeping around it, except at the anterior portion or lower end of the urethra (Fig. 66); when normally relaxed, as in married nullipara, it is about the same shape but large and flabby, and slightly indented below by the median line raph6 (Fig. 67) ; when u.nusually relaxed from overdistension in labor, mus- cular debility, frequent coitus, etc., it allows the finger to pass from the inferior pubic ligament down along the inner surface of the pubic ramus for a considerable distance, and then against the perineal body Fig. 66. Fig. 67. Fig. 68. \ ^"^^ Cfredira. H^aofcohicrictarcwml Tottrche-ftc gloved Constrictor Ccotn^ Fig. 66.— Shape of Vulval Orifice of Virgin as expanded by the Examining Finger. Fig. 67.— Same, of Married Nullipar. Fig. 68. — Same, of Childbearing Woman. in a slight depression between the median line raphe of the perineal body and the bone (Fig. 68). The sagging of the muscle on either side makes the fourchette and raphe between them feel like a raised ridge. The figure then traced becomes wider below than normal and has a distinct indenture both anteriorly and posteriorly, viz., the urethra and median line raphe. The Pubic Fossa. Extreme relaxation or a loss of integrity of both the levator vaginae and the constrictor cunni with their fasciae not only enlarges the vulvo- vaginal outlet so as to allow the pubic rami to be palpated down some distance below the superior pubic ligament, but gives rise on either side to a distinct well-defined fossa between the muscles. The base or bottom of this pubic fossa is the inner surface of the pubic ramus ; its external border is the relaxed constrictor cunni and the labium 112 EXAMIXATIOX OF THE FEMALE PELVIC OEGAXS. majus ; its internal border is the levator vaginae and underlying anterior edge of the levator ani ; its anterior end is the inferior pubic ligament, and its posterior end the raised or projecting perineal raphe at and behind the fourchette.* The distance below the inferior pubic ligament to which the pubic ramus can be traced is in proportion to the relaxation or destruction of these tissues. In the virgin the bone cannot be felt because the hymen and perineal se]3tum keep the tissues between the levator vaginae and constrictor cunni raised from their level instead of depressed between them. When the hymen and perineal septum are stretched, the mucous membrane sinks slightly into this fossa and divides it into two narrow grooves, continuous in front with the fossa navicularis, and behind with a corresponding fossa behind the hymen. A rupture of the hymen involving a little of the perineal septum about it, allows the tissues to sink laterally against the pubic rami so as to form the fossa without any relaxation of the muscles, except such as must result from the rupture and the consequent fascial deficiency. Transversus Perinsei. When the pubic fossa is well marked the transversus perinsei can be palpated. A prolongation of the pubic fossa backward, allowing the finger to j^ass back along the pubic and ischial rami beyond the median line raphe and beside the anal sphincter, is presumptive evi- dence that the transversus perinsei has lost either its tonicity or its integrity. By placing the finger of the unemjDloyed hand in the rectum and drawing the anus to one side, the muscle of the opposite side becomes tense if it be normal, and can be felt as a ridge deep in the jjosterior end of the fossa. AVhen the fossa does not reach to the muscle the finger maj- detect its tense ridge b}^ pressing into the cuta- neous surface of the perineum beside the anterior edge of the abducted sphincter ani. The transversus perinsei seems farthar back than normal, because the anterior edge of the sphincter is stretched forward by the rectal finger. When the perineal septum is relaxed the rectal finger may, if the vulva be pushed to the opposite side, detect the resistance of the muscle. Detection of the muscle in this way is a sign of a relaxed perineal sej)tum. Complete relaxation of the trans- versus perinsei of only one side allows the sphincter ani to be drawn a little to the opposite side. Characteristics of the Perineal Body. Relaxation of the whole perineum, including the perineal septum, fascise and connective tissue, is recognized by a sinking down and back of the perineal body, more particularly its anterior end or base, * These characteristics are best determined by palpation, and require no insoection. DIGITAL EVERSION OF THE VAGINA. 113 SO as to increase the projection below the external conjugate. The hymen, instead of being drawn up under the pubic arch, sags down and becomes more exposed posteriorly between the separated labia and is encountered before the finger gets into the vaginal entrance. The fourchette projects but little above the surface unless the labia are stretched widely apart. The finger introduced into the rectum along its anterior wall, instead of being directed by the perineal body up behind the pubes, passes forward under or in front of the arch. Such relaxation, even when co-extant with a relaxation of the sphincter ani, is not necessarily occasioned by nor accompanied by any exten- sive lesion of tissue, and may be followed by a return of the parts to a normal condition. Fig. 30 represents a section of the perineal body thus relaxed. Rectal Palpation of the Perineal Body. The thickness of the perineal body is easily determined by the finger in the rectum, the thumb on the cutaneous surface, and the forefinger of the free hand on the vulvo-vaginal surface. Figs. 26 to 30 show the shape of the tendinous portion, or that affording firm resistance to the touch. Straightening by tension (28 and 29), curving by relaxation (30), or loss of substance from injury, can thus be easily appreciated. The amount and firmness of connective tissue on the three sides is known by the amount and the resistance of the tissues over the tendinous raphe. The firmness of the structure as a whole can be approximately determined by drawing down, with the finger in the rectum, and thumb or finger of the other hand in the vaginal orifice, both together. The amount of resistance to such manoeuvres is by no means in proportion to the mere amount of the perineal body that may have been destroyed, as will be explained in discussing perineal ruptures. (See Chapter VII.) Digital Eversion of the Vagina. The finger introduced into the anus and passed palmar surface for- ward along the anterior rectal wall, comes in contact with the recto- vaginal septum at the recto-vaginal promontory, and can, with but slight inconvenience to the patient, evert the recto-vaginal angle of the perineal body, and lower end of the posterior vaginal wall, for inspection. This is particularly easy when the perineum is relaxed or lacerated. (See diagnosis of perineal lacerations. Chapter VII.) CHAPTER IV. INSTRUTVIENTAL EXAMINATION OF THE FEMALE PELVIC OEGANS. Dr. Simpson recommended and practiced the use of the sound for the purpose of examining the uterus, and he has given to it a certain appropriate shape, size, and adjustment, which adds materially to its adaptability to this particular use. Object in Using the Sound or Probe. The main objects in examinations with the sound in such cases as I have now under consideration are, to measure the size and length of the cervical and uterine cavities, the mobility and position of the uterus, and 7 if need be, the connection of that organ with pelvic growths. At the present time a number of flexible sounds, or, more accurately speaking,, probes have also been constructed for cases in which the alterations in size and shape of the uterine cavity render the larger and move rigid saund almost useless. Size and Length of Sound. It should be ten or twelve inches long, with one end fixed to a flat handle, and the ather terminated with the ordinary probe point en- largement, aboirt one-eighth of an inch in diameter. The wire behind tha bulbous termination should be one line in diameter, round and smooth, and should gradually increase in size to the handle, where it might be about a quarter of an inch in diameter. The best material is copper, galvanized. Simpson's sound is larger and less flexible than Sims's, and is grad- uated or marked by notches, indicating inches. Jenks's flexible sound possesses the advantage of easily adapting itself to the shape of the uterine cavity. Fitch's measuring sound is less flexible than Jenks's, but has a similar sliding sheath for marking the depth of the uterus. Sims's small flexible silver probe and Thomas's whalebone sound are valuable substitutes for the heavier sound when we wish to explore a tortuous or very deep uterine cavity. Accidents of serious character sometimes occur in using the probe in the uterus. Dr. Engelman, in the St. Louis Medical and Surgical Journal, says that he was present when Professor Carl Braun, of Vienna, pushed the uterine probe through the tissues of the uterus into the peritoneal cavity. Dr. Noeggerath, of New York, mentions a case where the sound had been passed five inches, going through the fundus SIZE AND LENGTH OF SOUND. 115 Titeri, as shown by the discovery of a cicatrix at a post-mortem exami- nation made several months afterwards. Other unquestionable instances of this accident are on record. Of these cases I have heard of none in which any untoward consequences followed what would seem to be at least a serious occurrence. As all the cases published were in the care of skilful and practical practi- FiG. 69. Fig. 70. Fig. 71. Fig. 72. Simpson's Sound. Sims's Sound. Jenks's Uterine Sound. Fitch's Measuring Sound. tioners, their occurrence must therefore be attributed to some other circumstance than rashness. The probability is that on account of disease the uterine structure had become too frail from attenuation or softening to resist the slight force used to introduce the probe. It is interesting as well as surprising that so little effect followed the forci- 116 INSTETJMENTAL, EXAMINATION OF FEMALE PELVIC ORGANS. ble entry of the probe to the uterine wall or the contents of the peri- toneal cavity. The Fallopian tube is sometimes so patulous from disease as to permit the sound to pass through it into the cavity of the peritoneum. Where the whole of the uterus is enlarged, as it is found for many days and sometimes weeks after parturition, the uterine orifice of the tube is large enough to admit the probe. This may be the case also from the enlargement caused by uterine catarrh. When the opening to the tube is thus enlarged it requires but a slight inclination of the uterus to one side of the pelvis to bring the Fallopian orifice in a Introduction of the Uterine Sound, showing the movement of the handle (3^). direction to be easily entered by the instrument. When once it has entered the tube it will find no resistance to its farther progress. In a discussion before the Obstetrical Society of New York, January 17th, 1871, reported in the Journal of Obstetrics of August, 1871, Drs. Budd, Thomas, and Noeggerath, all speak of cases in which the sound seems to have enterejd the peritoneal cavity to a long distance through the Fallopian tube. Dr. Rosa Engert was kind enough to show me a case quite recently in which she repeatedly passed the sound through the Fallopian tube. When the end of the instrument had reached the fundus it required LENGTH OF THE CERVICAL AND UTERINE CAVITIES. 117 but little inclination to the left to cause it to enter the tube. The patient experienced no inconvenience from the examination. Another accident, and one of more importance because of its almost invariably fatal effects upon the embryo, and also because of its more frequent occurrence, is the damage done sounding an impregnated uterus. Too great caution cannot be observed in making investigation of the condition of the uterus before passing the probe into its cavity. I have known two instances, however, in which the impregnated uterus was probed to a depth of several inches without interrupting gestation. When a suspicion of pregnancy exists, there can hardly be a circumstance so grave as to justify the use of the probe. In such cases we should unhesitatingly wait until time solves the question of pregnancy. The probe should not be used during menstruation, nor in the presence of great tenderness in or about the uterus. Mode of Using. After oiling the instrument, and introducing the index finger of the right hand, and placing it upon the os uteri, the sound may be carried along the palmar surface of the finger until the point arrives at the mouth of the uterus, when, by depressing the handle, its point may .be carried forward into the cavity of the cervix. In order to insure its passage through the cavity of the cervix into the cavity of the body, the probe must be bent to the same degree as the male catheter. Great gentleness must be observed in the use of this instrument, be- cause it is an easy matter to do violence to the mucous membrane by a very little rudeness of management. After the sound has passed to the OS internum, a sense of constriction is felt through the instrument, which feeling soon gives way, and the point then goes to the fundus without further resistance. Length of the Cervical and Uterine Cavities. The cervical cavity in the virgin is about an inch and a quarter in depth, and the cavity of the body from a half to three-quarters of an inch ; the former in the multipara is one and a half inches, and the latter an inch deep. In old age both are nearly or wholly oblit- erated. I do not often use the probe in this way for the examina- tion of the uterus in cases of inflammation and ulceration, but have adopted the suggestion of Professor Miller, of Lnouisville, and use it through the speculum, and shall consequently have more to say about it in connection with the use of that instrument. It often happens, with the present means, that there is great diffi- culty in determining the thickness of the uterine walls, and even the 118 INSTRTJMEXTAIi EXAMIIS^ATIOX OF FEMALE PELVIC OEGAXS. presence of a small growth in the anterior or j^osterior parietes. For the purpose of enabling the inexperienced to arrive at what, in many instances, is valuable information in this respect, I have devised what may be called the hysterometer, a cut of which is here given. It consists in the adaptation of two uterine jDrobes to each other, with handles and scale for measurement, in such a way that one may be Fig. 74. The Hysterometer. introduced into the bladder, and the other into the rectum. Thus approximated on the uterus, as represented in Fig. 75, the handles and scale may be so arranged as to make the measurement. AVhen this is done the instrument may be detached, withdrawn, and the exact thickness of the uterus is ascertained. If we wish to measure the posterior wall, one probe is introduced into the cavity of tbe uterus, and the other into the rectum, and the scale and handles ad- LENGTH OF THE CERVICAL AND UTERINE CAVITIES. 119 justed, the measurement taken, and the instrument withdrawn, "When the anterior wall is to be aaieasured, one is introduced into the uterine cavity, and the other into th-e bladder. In this way, the length of the uterus and the thickness of the walls may be easily measured. This instrument will enable us to be much more accurate in our estimate of the shape of th-e uterus than any other means we can employ. The handles of the probes are adapted to each other by means of a slot, running from one end to the other, in one of the handles, while the other is of a size to fit into this .slot closed}^ knd Fig. 75. The Method of Applying the Hjsterometer for Measuring the Thickness of the Uterus. accurately. The scale is mad« movable, and may be easily adjusted after the probe portions of the instrument are in their projDer place. In cases of distortion of the cavity of the uterus, or where there is a tumor to measure, the probes wall be bent in different directions, until they adapt themselves to the shape of the parts. In consequence of the necessity of variance in the curvature of the probes in making such measurements, the scale can serve only as an index to the rela- tive position of the two probes, and cannot be relied on for the exact size of any growth or other cause of thickness of the walls. After 120 INSTRUMENTAL EXAMINATION OF FEMALE PELVIC ORGANS. having adjusted the scale, therefore, and observmg the figures, we must withdraw the instrument and readjust by the scale, and then measure the distance between the points of the probes. This will give us the true measure. Often the instrument may be withdrawn without loosening it, which fact will facilitate the process very much. In cases of retroversion or retroflexion, when we wish to diagnos- ticate these displacements from a small tumor, which they sometimes very closely simulate, one of the probes in the bladder, so curved as to follow downward and backward the anterior wall, the other in the uterine cavity, will clearly make out the difference. In like manner, only with reversed curves, and one probe in the rectum, the tumor may be diagnosticated to be present or absent. 4, Speculum. Since the speculum has come into such general use, it has assumed a variety of shapes, and been composed of quite a number of different sorts of materials. For different purposes it is convenient, if not necessarj^, to be provided with different shapes, sizes, etc. ; but for or- dinary use we ought to have three different sizes : one small, one large, and the Higby's Speculum. " ^ other of medium size. The bivalve, trivalve, and Sims's speculum and its modifications are the most useful forms. Fig. 77. Fig. 76. Nolf s Speculum. Nelson's, Nott's, and different sizes of Higby's are popular instru- ments. POSITION OF PATIENT FOR SPECULUM. 121 To aid us in getting a good view of the cervix, we may draw it into view, and, if necessary, depress it somewhat by the single or double tenaculum. Fig. 78. Nelson's Speculum (closed). Fig. 80. Fig. 79. Nelson's Tenaculum. Nelson's Speculum (open). Position of Patient for Speculum. To be prepared to use this instrument to the best advantage, our patient sliould be placed in the position I have heretofore described, viz., before a large window, through which as much daylight should Fig. 81. Double Tenaculum Forceps. be freely admitted as possible. The better light the better view, and unless we have plenty, we cannot be certain of correct results in our Fig. 82. Tenaculum Forceps. examinations. The bed and patient should be so placed that the light may fall straight through the instrument and full upon the parts at 122 IJS^STEUMENTAL EXAMIXATIOX OF FEMALE PELVIC OEGANS. its internal extremity. We should also have some cotton-wool, sweet oil, and a couple of napkins, together with the dressing forceps I have before spoken of. 3fode of Using the Speculum. In commencing the examination, we should oil our speculum, and our middle and index fingers. Sitting before the patient, we should introduce the index finger, and, if need be, the middle one also, to ascertain the position of the cervix uteri. This precaution will enable us to know in what direction, and how far, to introduce the siDCCulum. After this preliminary examination, the forefinger and thumb of the Fig. 83. Speculum introduced (J^). left hand should be placed upon the edge of the labia, one upon each side, with which they should be gently separated ; and holding the speculum in the right hand, somewhat like a pen, we may introduce it b}'- the guidance of the thumb and finger placed as above. In intro- ducing it, we should push it forward sufficiently to reach the cervix, and direct it upward, downward, or to one side, as we may have ascertained, by digital examination, to be the position of tlie os and cervix. HOW TO FIND THE OS UTERI. 123 How to Find the Os Uteri. If we have not made digital examination, we may use our probe, and gently push the parts from one side to the other, turning tlie speculum in different directions until it is found. If the neck is too large to enter the speculum, we may spread the blades still more until it is brought into full view. Most frequentlj^ the parts are covered with some sort of secretion, and we should always, with cotton-wool or lint, with the dressing forceps, remove all of it, so that the naked mucous membrane alone presents itself to our view. Without this precaution, Fig. 84. Byford's Dressing Forceps. we may overlook an obvious and extensive ulceration ; for as the parts are covered over with this thick, opaque secretion, it either completely hides them from view or much modifies their appearance. I have often met with cases which I have observed attentively, for the pur- pose, if possible, of detecting ulcerations without this step, but failed, until the cotton was used, when extensive ulceration appeared. In- deed, I never think of coming to a conclusion of any kind by the use Fig. 85. Sims's Speculum. of the speculum without this precautionary measure. By this means we can see the color, size, shape, and some other conditions of the parts, and the color, consistence, and derivation of the secretions. When the mucus, pus, or blood comes from the mouth of the uterus, we can see it issuing from it. The shape and size of the neck and os of the uterus differ in different individuals, according as they have been impregnated or not. The late J. Marion Sims has instructed us in a different method of making examinations. He prefers a table. The patient is placed on 124 INSTRUMENTAL EXAMINATION OF FEMALE PELVIC ORGANS. the left side, the left arm under and behind her, the legs strongly flexed upon the thighs, and these again upon the abdomen, while the Fig. 86. Sims's Depressor. Fig. 87. right knee is thrown forward, and over the left one on the table; this turns the patient over on the chest and partly on the abdomen. In this position his speculum is introduced by placing the forefinger of the right hand in the concavity of the extremity to be used, and the finger and instrument are introduced together. When well inserted, the perineum is drawn backward and the instrument is given to an assistant to retain in place. This will generally expose the cervix uteri completely ; but if it does not, the depressor is placed upon the anterior wall, and this latter is pressed out of the way, as represented in Fig. 92. Great freedom of examination is thus obtained in most cases. Still, if the OS uteri is not seen plainly, it is seized with a tenacu- lum and drawn toward the external orifice. Many practi- tioners prefer this method of exposing the organ for all ordi- nary purposes of inspection and application. Dr. Emmet has modified the speculum of Dr. Sims by constructing it in a fashion that renders it self-retaining, and thus does away with the necessity of having an assistant. Many other self- retaining instruments have been invented, that answer an admirable purpose, among which I mention those of Fallen, of St. Louis, Nott, of New York, and Thomas, Hunter, Studley, Munde, Gillette, Erich, etc. Of course it is necessary to have the patient so placed that the light will fall into the dilated vagina and on the cervix. Dr. Sims drew the cervix down, when necessary, by means of a tenaculum; thus facilitating the Fig. 88. Tenac- ula. Nott's Tenaculum Forceps. examination, and enabling the practitioner to make applications or operations upon it with much certainty. APPEARANCE OF THE OS AND CERVIX IN THE VIRGIN. 125 Appearance of the Os and Cervix in the Virgin. The virgin uterus is small ; the cervical end is nearly round, and terminates in a truncated extremity. Through the speculum it does Fig. 89. Simon's Speculum, different sizes. not present the appearance of labial projections^ and the os is either a small slit, about a quarter of an inch long, or a round opening into 126 INSTRUMENTAL EXAMIXATIOX OF FEMALE PELVIC ORGANS. the middle of the truncated extremity. It is about large enough to admit with facility the end of a female catheter, and the neck projects, in relief, from the bottom of the parts exposed by the speculum, something like half an inch. Appearance of the Jlfultiparous Uterus. The appearance of the multiparous uterus is quite different from this; the cervix terminates in labial projections, which divide its extremities into an anterior and jDosterior half, and it does not project Simon's Retractors. Lever for Dilating the VaRiua from the Side. with SO much prominence into the speculum. The os is re23resented by the cleft between these labial projections, and is large enough, in many instances, to admit the tip of the index finger. Appearance in the Aged. In the aged the labial projections seem to have atrophied to obliter- ation, and the speculum shows a round opening in a funnel-shaped depression, surrounded by the walls of the vagina. IIsDICATION OF MUCUS IN ABUNDANCE. 127 Exceptions to these Appearances. Although the above is an accurate description of these appearances under the different circum&tances, there are many natural deviations from it. Color. The color of the mucous membrane covering the cervix, and enter- ing the OS uteri, may be compared to that of the inside of the lips of the mouth, a pale rose-red. Appearance of Secretion. The parts are merely lubricated, not smeared or inundated, with mucus. There is just enough of this secretion to keep the membrane Fig. 92, This figruxe represents the Axtion of the Instruments in Sims's method of Examining the Uterus. moist, but not enough to hide the surface from view. I speak now of the cervix uteri. Indication of Mucus in Abundance. An aljundance of mucus must be regarded as an evidence of ex- citement; its constant and persistent abundance as an evidence of disease. " Remember, that in spite of their name, it is not the busi- ness of mucous membranes to secrete mucus ; the more perfect their condition, the more favorable the surrounding circumstances, the less they do so. . . , The greater the diminution of their life, the greater 128 INSTEUME^^TAL EXAMINATION OF FEMALE PELVIC ORGANS. the secretion." The more disease, the greater the secretion, until their integrity is destroyed, when the secretion becomes modified. The source whence this mucus is derived will show the point of dis- ease ; if it comes from the os uteri, the disease is in the cavity of the cervix or body of the uterus. Indication from Pus. It is extremely doubtful whether pus can be produced by a mucous membrane without destruction of the epithelium at least. Temporary congestion often increases the amount of mucus to be found in the vagina, but gives origin to no pus. The color of the mucous mem- brane, in cases of congestion, is a livid or a dark purple-red, instead of the scarlet of abrasive inflammation. Probe and Speculum Conjointly. When the neck of the uterus is exposed in the speculum, it will often be profitable to use the probe. If proper attention is paid to appearances under the use of the probe, much information may be gained. When the mucous membrane of the cavity of the cervix or body is inflamed, it is generally much more fragile than natural, so that it bleeds upon slight contact with the end of the probe. In cases where the inflammation extends to the cavity of the uterus, the probe passes the os internum without obstruction, and passes farther up than natural from the increased size of the cavity. Dilatation. By properly dilating it, we ma}'- subject the cavity of the uterus to a digital examination. Sufficient dilatation may be effected by the use of tents and dilating instruments made for the purpose. The compressed sponge, laminaria, tupelo, and slippery-elm tents are all employed as means of dilatation. The sponge tents, as prepared and sold by instrument makers, are of various sizes and lengths. They are, or ought to be, perforated lengthwise, carbolized, and covered with a lubricant to facilitate their introduction. The sea-tangle or laminaria and the tupelo tents should also be of different sizes and lengths, smoothly polished, and very slightly taper- ing. All of these materials can be made in a flexed form to suit the curves of the uterus. When an}'' of these tents are introduced in a dry state into the uterus, they absorb the moisture of its cavity and increase in size, and as they do so they dilate it. The sponge expands more rapidly than the tupelo or laminaria tents, and is less powerful in its dilating influence. There is not much difference in these respects between tlie tupelo and laminaria DILATATION. 129 tents. Perhaps the latter expand more strongly and act more power- fully. As the sponge dilates, it presents a rough surface to the mucous membrane, and to a considerable extent impairs its epithelial cover- FlG. 93. Sponge Tents. ing. Serious inflammatory reaction has been known to follow the use o'f two or more sponge tents in immediate succession. The surface of the tupelo and laminaria tents do not become rough as they expand, Fig. 94. Laminaria Tent. and consequently are not as likely to be followed by injury to the mucous membrane. As the laminaria becomes moist it exudes a mucilage that serves as a protection to the mucous membrane. Fig. 95. Tupelo Dilators (hollow). Compressed slippery-elm bark makes a less powerful, yet very useful dilator. The solid tents made of this material expand to twice their 9 130 INSTRUMENTAL EXAMINATION OF FEMALE PELVIC ORGANS. diameter or more, in from one to two hours, when placed in the cervix — the hollow ones in much less time. Their rapid and comparatively safe action adapts them to office practice when we only seek for a moderate but rapid dilatation. When the cervico-uterine canal is tortuous, the smaller elm tents, whether curved or straight, may be Fig. 96. Compressed Slippery-elm Tents (straight and curved). rendered slightly flexible by being moistened and compressed between the blades of a dressing forceps so as to mash or break some of the fibres. All of these tents should be w^ell secured by having a strong thread attached to them. This thread enables the patient or practitioner to Compressed Slipperj^-elm Tent (hollow). remove them by simple traction, and does away with the necessity of the introduction of an instrument for that purpose. Tents intended to widely dilate the cervix, of whatever kind, should be introduced at the home of the patient, because perfect quietude in bed is one of the best measures to prevent the untoward effects some- times caused by the use of them. Siras's position is the most convenient for the introduction of the tent. In this position the cervix may be exposed by Sims's specu- lum, drawn slightly forward, and fixed by the uterine tenaculum or DILATATIOX. 131 a small vulsellum (Fig. 87). The tent, mounted on a tent-bolder, or seized by tbe dressing forceps, is passed in until it bas entered tbe OS internum. Tbe upper part of tbe vagina must be packed witb cotton placed against tbe end of tbe tent, upon wbieh it is made to rest. This will secure it in position, otberwise it might be more or less completely dislodged and thus fall short of its fullest effects. The first tent should be of a size that will permit it to pass easily into, and j^et snugly fit tbe cervical cavity. If sponge, it will generally require about twelve hours to fully expand, and should the Fig. I Fig. 99. Tent mounted on Tent-holder. Molesworth's Dilator. dilatation not be sufficient to admit the finger, the vagina and cervical cavity may be thoroughly cleansed with carbolized water, and a second sponge introduced in the same manner as the first, but suiTounded by small slippery-elm tents. This second filling must be large enough to fill up tbe expanded cavity, and secured in the same way as the first. A somewhat longer time must be allowed if we use either of tbe other kinds, but tbe management of them is tbe same as that of the sponge. The wounded condition of the cervical mucous membrane caused by tbe sponge tent renders it very susceptible to inflammation, and calls 132 INSTRUMENTAL EXAillNATION OF FEMALE PELVIC ORGANS. for the strictest quiet and the avoidance of all co-operating morbific causes. The same condition favors the absorption of septic material, and thus exposes the patient to the danger of septicsemia. This can only be avoided by strict cleanliness. In using the tupelo and laminaria tents, the main danger consists in the liability to produce inflammation of the uterus, which may be propagated to the surrounding tissue, because of their very unyield- ing pressure upon the submucous structures of the organ. From these considerations the student will learn that the use of tents is fraught with much danger, and should not be resorted to except under such circumstances as seem to render them indispensable to correct diagnosis and a perfect course of treatment. The patient should be kept warm and in the recumbent position for several hours after a large dilating tent has been used. There are other means of dilating the uterine cavity, that in some cases may be resorted to with much advantage, especially when it is desirable to perform dilatation in a short time. Moles worth's dilator (Fig. 99) is one of the most simple and effective instruments for this purpose. The small-sized dilator may be made to enter the unimpregnated uterus, and when expanded by filling it with Hanks' Dilators. water, under strong and gradually increasing pressure of the cylinder, it will, in favorable instances, open the cervical cavity sufficient to admit the second size. By succeeding one size with another I have, in less than an hour, been able to pass my finger into the cavity of the body. The uterus can also be dilated rapidly by hard rubber instruments, a very con- venient form of which is Hank's rapid dilators. The smallest size may be passed into the cervix bj^ slow and gradu- ally increasing pressure. It may be succeeded by the second, and that by the third, and so on until the cavity will admit the finger. When the uterus is especially hard and undilatable, the gradual method, consisting of the use of tents, is the proper one to employ. When, however, the mouth of the cervix is softer and more yielding, EXPLORATORY CURETTING OF THE UTERUS. 133 the rapid method is preferable, and in most cases Molesworth's is the instrument to be used. I would remind the student that great care is necessary to avoid damage from the use of any of these instruments or processes. The object in dilating the uterine cavity is to enable the sense of touch to discover its contents and condition. Sometimes, with the patient in the dorsal position, we may depress the uterus, by placing one hand above the symphysis, sufficiently to bring its cavity within reach of the finger; but usually it will be necessary to draw it down by a tenaculum or vulsellum until the finger will pass up to the fundus. Polypoid or submucous tumors, excrescences, and cancerous ulcera- tion may be discovered in this way when they could not be diagnosed with precision by any other method of examination. Exploratory Curetting of the Uterus. When it is inexpedient or undesirable to expand the uterine cavity sufficiently for the introduction of the finger (a procedure which re- quires considerable violence unless the uterus be enlarged), the dull curette may be used for its exploration. If fungosities, granulations, Probe Curette. or otherwise disorganized mucous membrane exist, the dull curette will detach specimens for a microscopic examination ; if there be no such conditions the negative result will also be valuable. Thus, in cases of enlargement of the uterus with hemorrhage, when we are in doubt as to whether we have to deal with cancer, sarcoma, mucous ^^^^^g^^^^^^ Thomas's Wire Curette. polypus, or an interstitial fibroid, the dislodgment of specimens gives evidence of the first three conditions, the absence of anything to be dislodged is of diagnostic value in the latter. A loop of bent copper wire with the ends twisted into a stem and covered with a small rubber tube may serve for this purpose. There is a dull curette in the market made to imitate a uterine probe bent at the end into a loop. Thomas's wire curette is also a very popular instrument. I have had one constructed something after the pattern of Sims's sharp curette, but perfectly dull, and quite strong, although flexible 134 INSTRUMENTAL EXAMINATION OF FEMALE PELVIC ORGANS. in the shank, with the end in view of being able to use considerable force without doing injury. We may obtain with it some information as to the size of the uterine cavity, the smoothness, roughness, or fria- bility of its mucous surface, and the firmness, sensitiveness, and con- tour of the uterine walls, and thus make of it a sort of substitute for the finger. A weaker shank would give unreliable information, while a finer loop might produce unpleasant or dangerous results. I con- sider this curette so safe when properly used, that I occasionally employ it in office diagnosis, but would be afraid to use any of the others with the same freedom. Two larger sizes are manufactured for (1) diseases involving enlargement of the uterus and (2) retained secun dines in abortion, which are more useful as therajjeatic agents, but less so as diagnostic. A hollow compressed elm tent. Hanks' or Peaselee's dilators, or a flexible male bougie will sufficiently dilate Fig. 103. Byford's Finger Curette. the cervix in a few minutes for the smallest size, unless the uterus be too small to recjuire exploratory curetting. A curette should not as a rule be used if there be much uterine or peri-uterine tenderness, nor during menstruation, nor during jDregnancy. The Use of the Female Catheter. The female catheter usually passes in a slight curve backward and upward behind the pubis toward the neck of the bladder. When the urethra is dilated or sacculated the end of the catheter passes readily in almost any backward direction, and, instead of taking its own course into the bladder, must be carefully guided. In case of prolapse of the neck of the bladder the instrument passes back toward the recto-vaginal promontory away from the pubis. When the parts cannot or ought not to be exj^osed the catheter can be introduced by the touch. The index finger is placed along the urethral ridge between the urethral notches and drawn forward until the depression at its lower end, and just external to the pubic arch, corresponding to the meatus, is recognized, and the point of the cath- eter is slipped along the finger into it. Its withdrawal should be slow THE URETHRAL SPECULUM AND EXDOSCOPE. 135 that the lower portion of the bladder may have time to be em23tied. The finger should be pressed over the mouth of the instrument as soon as the other end has passed out of the bladder into the urethra, for the purpose of retaining the last drops, and keeping them from running out on the bedclothes, and also of preventing the suction of air into the bladder by an inopportune inspiration or movement of Fig. 104. Fig. 105. Sims's Sigmoid Catheter, Self-retaining. Goodman-Skene's Self-Retaining Catheter. the patient. Winckel warns against depressing the outer end of the catheter too much for fear of the entrance of air-bubbles. Sims's sigmoid catheter (Fig. 104) and the Goodman-Skene's self- retaining catheter (Fig. 105) are useful when it becomes necessary to keep the bladder drained, as they remain in place. The Urethral Speculum and Endoscope. In rare instances it become necessary to inspect the mucous mem- brane of the bladder. The necessary dilatation of the urethra may be accomplished by using almost any of the uterine or urethral dila- tors to begin with, and the fingers afterward. (See " Palpation of the Interior of the Bladder," Chapter II.) The little finger can thus be got into the bladder without doing much damage. Dilatation, to the extent of admitting a large index finger, or Simon's largest dilator, has frequently been followed for a long time, sometimes permanently, by incontinence of urine. The way to avoid such an accident is to commence with small dilators, and dilate very gradually, consuming from half to one hour for the extreme dilatation. Incontinence has usually been the result of haste or carelessness. An anaesthetic must of course be administered. A small test-tube may be made to answer the purpose of a urethral speculum, and, with a small rhinoscopic mirror and reflector, also, of an endoscope for the inferior portion of the bladder. Skene, Barnes, A. R. Jackson, and others have invented special specula, but the dilated urethra can usually be pretty well inspected by stretching open the lower end with the finger or blades of a dressing forceps. Skene's endoscope is a valuable instrument for occasional use. By first distending the bladder with air, as recommended by Rutenberg, quite a satisfactory exploration can be made. Moderate distension of the bladder with air does not seem to add much to the danger of the examination, although it must be remembered that thorough instru- 136 INSTRUMENTAL EXAMINATION OF FEMALE PELVIC ORGANS. mental examinations of this kind are seldom entirely without danger. Moderate mucous irritation, and even inflammation, have frequently followed, cellulitis occasionally, and in two instances death. The mucous membrane of the collapsed bladder appears of a dirty grayish red through the endoscope, but when distended with air, a brighter red. The slits corresponding to the urethral orifices cannot Skene's Urethral Endoscope. usually be seen until entered by a probe or catheter. If the surface be wiped off and the walls of the bladder pressed so as to produce lateral traction, the trickling urine sometimes indicates the exact loca- tion of the orifices. Catheterization of the Ureters. Catheterization of the ureters was first performed by Simon'=* and after him by others. The object in view was usually to draw urine Fig. 108. gi'; *";^tej!"'.^ '' /^,'JM ' .JiVJ !rff^ Simon's Uretral Catheter. from one kidney for examination, in cases of suspected unilateral ,yelitis and pyo-nephrosis. The uretral catheter is small, long and straight, with a longer and more gentle curve on the end than the female urethral. * Chirurgie der Nieren. CATHETEEIZATION OF THE URETEES. 137 There are four ways of catheteriziiig the ureter : 1. By the vesical touch. 2. By vaginal inspection. 3. By vesical inspection. 4. By the vaginal touch. 1. Simon made use of the vesical touch through the dilated urethra. The inter-uretric ligament, which connects them, is one inch beyond the sharp border of the mouth of the bladder, and the uretral ori- fices about half an inch to either side of the median line. They are felt as slight elevations instead of depressions, over one of which the finger is laid as the catheter, guided by the touch, is pushed into it. (See Chapter II, Fig. 58.) The handle, or external end of the catheter must of course be raised and carried a little to the opposite side, as the ureter takes the diagonal direction. It is possible to pass it to the pelvis of the kidney.* 2. Pawlickf exposes the anterior vaginal wall in the Sims's position, and introduces the uretral catheter under the direction of the eye. The upper end of the urethra is marked by a small prominence not far from an inch behind the meatus in the median line. From this prominence two diverging ridges run backward and are joined by slight furrows. The sj)ace thus included corresponds to the trigone at whose posterior angles the mouths of the ureters are to be sought. The catheter is introduced so that its end turns back against the base of the bladder and followed by the prominence it produces on the anterior vaginal wall. As the exact point of opening of the ureters is difficult to strike, he is careful to make the direction of the catheter correspond to the direction of the ureter, so that it will more easily slip into the minute orifice when it passes over it. A thorough knowledge of the anatomy of the parts, and considerable gynecological experience is necessary to execute this difficult although simple manoeuvre. The limitation of the motion of the catheter and the trickling of urine announce the successful passage. 3. Inspection of the uretral orifice requires, of course, extreme dila- tation of the urethra and the introduction of a speculum into the bladder so as to bring the orifice of the ureter into view. The only, and the great, difficulty lies in getting a view of the orifice. Some- times the urine can be seen issuing from one ureter by pressing the speculum blade over the other. Arthur Lewer thus describes his method of exposing the orifices: J "The urethra is dilated; then one piece of Bryant's rectal speculum is passed along the urethra into the * For a more detailed account of the method see Winckel's Diseases of the Female Urethra and Bladder. f Archiv fiir Gynekologie, vol. xviii. J London Lancet (American Reprint), January, 1887, p. 27. 138 INSTRUMENTAL EXAMINATION OF FEMAF.E PELVIC ORGANS. bladder and so placed that, seen from the front, it occupies one lateral half of the urethra and bladder beyond. When in this position the speculum divides the bladder into two compartments ; for example, supposing the speculum occupies the right lateral half of the urethra and bladder, then the orifice of the left ureter is in view." With the orifice in view the introduction of the catheter can be accomplished by sight. 4. The simplest of all methods, however, is to find the interuretric ligament or else the junction of the ureter and the trigone by vaginal indagation, according to the methods explained in Chapter II. (Palpa- tion of the Ureters). The jDoint of the catheter is then introduced into the bladder and turned down upon the trigone where it can be felt by the vaginal finger. With the end of the catheter on the vesical surface of the vesico-vaginal septum, and the finger on the vaginal, we should have but little trouble in getting the inter-uretric ligament between them, and tracing it to the uretral orifices, which are about an inch apart. The direction of the ureter having been determined by vaginal palpation, the catheter is given a corresponding direction, and guided as far as possible up the ureter by the vaginal finger. In attempting this manoeuvre for the first time an anaesthetic should be given, and great care be taken to keep the end of the slightly curved catheter upon the base of the bladder, and to avoid using force or poking about too freely. As the bladder walls yield to pressure there is some danger of thinking that the catheter or probe is a couple of inches up the ureter when it is only in the bladder, and of poking it into or through the walls or against inflamed pelvic tissues. It should be felt by the vaginal finger to pass under the broad ligament. Moderate dilatation of the urethra including the neck of the bladder renders the introduction easier. If folds of the bladder interfere, a few ounces of water may be injected into it. The end of the catheter, being on the finger, can be guided with great delicacy, and there is not so much danger of doing harm as in Pawlick's method, which requires either sufficient pressure upon the base of the bladder for the end of the instrument to produce a projection on the septum, or else a nice judgment in determining when the instrument arrives at the point in the bladder opposite that marked by the eye ujDon the vaginal wall; nor as in Simon's and Lewer's methods., which require considerable rough handling of the urethral walls. As it is hardly possible to catheterize or probe the ureter in every instance, it is better to desist after a few unsuccessful attempts, and wait for another opportunity. General Manner of Conducting an Examination in Making a Diagnosis. Having, from the history of the case, located the disease in some portion of the pelvis, and having determined that an examination GENERAL MANNER OF CONDUCTING AN EXAMINATION. 139 must be made, we first resort to a digital exploration. If the rectum seems to be the seat of the trouble, we should put the patient on her side with the knees drawn up, and explore the rectum and if necessary the pelvic interior as much as possible through the anus. When the patient is a young virgin such an exploration maybe made to indicate where the disease resides, and sometimes may do away with the neces- sity of a vaginal examination. If, however, she have had previous vaginal examinations, or have borne children, and have symptoms that leave no doubt as to the existence of pelvic disease outside of the rectum, she should be put, preferably, in the dorsal position and exam- ined per vaginam. In the unmarried the finger will, in passing, recog- nize the condition of the hymen and amount of contraction of the orifices. In the childbearing woman it is sufficient at first to pass the finger slowly so as to be able to recognize the amount of relaxation or contraction of the orifices, sensitiveness or flabbiness of the mucous membrane and lower portions of the urethra and rectum. If extensive alteration be found the parts may be immediately inspected ; if not, the manipulations about the vulva are better left until the close of the examination, that irritation or contraction of the sensitive parts, as well as disagreeable impressions upon the patient, may not be pro- duced at the outset. My practice is to note the general condition of the vulvo-vaginal entrance as I introduce the finger, and to press the finger end into the tissues as I withdraw it after the palpation of the deeper structures, but to leave the inspection, vaginal eversion and grasping of the perineum between the fingers in the rectum and the others over the skin and vulvo-vaginal surface, until after the speculum is withdrawn. If a digital exploration through the rectum be desirable, it may be made as soon after the vaginal examination as the hands can be cleansed or after the speculum has been used. Examinations of the urethra should usually be delayed until toward the end, as they are apt to cause irritation and unnerve the patient. As the instrumental examination gives us but a small part of our information, it is well, before using it, to determine as nearly as possible the position and condition of each pelvic organ by the various forms of intra-pelvic and bimanual palpation. The probe or sound can seldom give us any accurate information as to the position of the organ unless the cervix is turned forward, or unless the uterus is fixed by adhesions; hence in ordinary cases I wait until I have exposed the OS by the speculum before using it. The speculum usually turns the axis of the uterus so that the sound or probe may, unless con- tra-indications exist, be introduced with safety until it meets with resistance. The experienced gynecologist can usually determine by the digital exploration the appearance to be presented through the speculum, and 140 INSTRUMENTAL EXAMINATION OF FEMALE PELVIC ORGANS. needs the instrument chiefly for treatment. The general practitioner will require it, however, to diagnose the amount and character of uterine ulceration and congestion and the discharge. The character of ulceration, whether simple erosion, granulating or dissecting; the color, whether normal, pale, dark red or dark blue; the shape of the OS and labia, and position of deposits or enlargements, etc., should be accurately noticed. The condition of the vaginal mucous membrane should also be noted. In pregnancy and in some cases of pelvic disease it is altered in color to correspond with the cervix. In cases of uterine disease it is altered in color either independent of the cervix, or is not altered as much as the cervix, if at all. An examination of the interior of the bladder, or a dilatation of the uterine cavity, or in fact any long-continued manipulation, should be avoided if possible at a first examination, or at the ofiice. Our endeavor must be to benefit the patient, and to do that we should study to avoid doing any harm. For particulars as to examinations see Chapters II. and III. CHAPTER Y. DISEASES AND ACCIDENTS OF THE LABIA AND PERINEUM. Adhesion of the labia, and consequent occlusion of the vagina, sometimes occurs in infancy, or early childhood, as well as in adult life. The adhesions of infancy are so feeble and easily broken up, that they may be considered a trifling affair. Upon examining the parts, it will be found that there is no development of adhesive tissue, but the mucous membrane of the two sides is merely glued together b}'^ the mucus accumulating and drying between the parts, when in close contact, from want of cleanliness. The vaginal orifice is closed up to the urethra above, and down to the fourchette below. The treat- ment consists in separating the labia, by forcibly pressing each in opposite directions, until the adhesion gives way, and waehing and oiling them once a day afterwards to keep them from adhering again. Should we not be able to separate them in this way, the point of a silver catheter may be passed down so as to effect it. There will be no need of any other instruments in the case. On one or two occasions I have seen firm tissual cohesions of the labia in childhood as the effect of ulcerative vulvar inflammation. This form of adhesions may be so firm as to require the use of the knife. They are, however, always superficial, and we may generally introduce a bent probe or director behind the adhesions from above. When this is the case, it is, I believe, the best plan to separate them, by drawing the bent director through the adherent part. The same care as in the infant will prevent them from adhering again. The most grave labial adhesions we meet are in the adult, as the effect of neglected inflammation of the vulva after childbirth. They may entirely close the vaginal orifice by the coaptation of the entire inner surfaces of the labia. I have met with more than one instance in which the hairy margins of the labia were so nicely adjusted to each other, that it was difficult to distinguish the point of original separa- tion, from the posterior commissure to the urethral orifice, and the finest probe would not reach the vagina anywhere. The depth of the adhesion may be very great, involving much of the vaginal cavity. These cases are very embarrassing, and are seldom perfectly reme- died. It is decidedly the best plan not to interfere with them until the menstrual accumulation fills up all the vaginal cavity remaining inadherent, and then our object should be to reach the accumulation with a small trocar as near the middle of the adherent parts as pos- sible. Placing our patient in the lithotomy position, the catheter 142 DISEASES AND ACCIDENTS OF THE LABIA AND PERINEUM. should be introduced into the urethra, the urine all drawn off, and the urethra held as near the symphysis pubis, or as far from the middle line of the vagina, as practicable. The catheter should be thus held by an assistant, while the forefinger of the left hand should be placed in the rectum. With this preparation we may safely introduce the trocar into the collection of fluid as felt by the finger. The fluid being drawn off, the outer extremity of the perforation may be increased by laceration as far as may be desired, and as deeply as the surgeon may consider it safe. The whole cavity should be thoroughly cleansed by a syringe with soap and water and the opening may be maintained by a glass plug. If the opening is superficial, the treat- ment will not be protracted ; but if it is deep, it will be tedious. It should be continued until all danger of closure is past, and it will be best to keep the patient under our supervision for sometime after this appears to be the case. Wounds. The labia are sometimes wounded by external violence and some- times torn during labor. When the wound is deep enough to reach the bulb of the clitoris, alarming and sometimes fatal hemorrhage is the result. Professor Meigs gives an instance of great hemorrhage from these parts in a woman who had fallen upon a chair so as to cut through one of the labia. A case of fatal hemorrhage was caused in this city about four years since, in the following manner, as well as it could be learned from a legal investigation : A drunken husband returned home late at night, and, as was his wont under such circum- stances, beat and kicked his wife, who was probably also inebriated. He kicked her with great violence in the genitals, and the square-toed heavy boot, in penetrating the pelvis, had cut off one labium and deeply wounded the other. In six or eight hours after the occurrence the woman Avas found dead, with such copious effusion of blood from the wounds as, in the opinion of the examining jury, to account for the fatal result. I saw a case many years ago, where the patient was wounded by a knife in one labium so as to cause very profuse hem- orrhage. As hemorrhage is the important effect of these wounds, our efforts should be directed to its suppression. The bleeding part should be pressed by the hand firmly against the pubic ramus of the side upon which it is situated until temporarily arrested, when an elastic air-bag or plug of oiled cotton or lint may be introduced to fill up the vagina, and a hard compress placed and held firmly by bandages, so as to press the wounded part between the two. When wounds of the labia are large and gaping, the hair should be removed, and tlie wound treated according to ordinary rules for external wounds. The rents occurring in labor do not, in the great majority of cases, require any special treatment, cleanliness and quiet being all that is required. VARICES OF THE LABIA AND VULVA. ]43 Sanguineous Infiltration. During labor, when the parts are stretched to their utmost extent, some of the arterial twigs occasionally give way and extravasate the blood in the loose structure of one labium. The infiltration usually shows itself after the child has been delivered; but sometimes, before the head has passed, the swelling becomes very great, and proves an obstacle to its expulsion. When this last is the case, the blood is effused from a large branch of the pubic artery, and the forcible injection into the tissues is so extensive as to fill a large part of the space between the vagina and the pelvic walls. This is a very seri- ous state of affairs, and calls for prompt and judicious interference. I once saAV, in consultation, a case of this kind, so extensive as to ar- rest labor for several hours. These effusions, however, do not always call for surgical treatment, but when, as in the case here alluded to, the effusion is extensive, we must make a free incision in the inner surface of the labium and allow the blood to escape ; if it is coagulated, we should introduce the fingers and dislodge it. Water- dressing, some evaporating lotion or cooling discutient will be sufficient, and absorb- tion will be effected in from one to four weeks. Suppuration occasion- ally, I think not frequently, is excited by a small amount of effusion. This should be treated as an abscess. If the amount of blood is great and the parts are tensely distended even after the child is expelled, it is better to liberate it by incision, for fear of sloughing or extensive suppuration and serious damage. Varices of the Labia and Vulva. This condition of the vulva may be of greater or less extent. Gen- erally the varicosities are scattered about on the inner side of the greater labia ; sometimes only one or two exist of any size, but occa-- sionally one labium is permeated by large blue veins in every direc- tion until they seem to have almost entirely replaced the other tissue. When the venous enlargement is great there is danger of rupture and profuse hemorrhage, even enough to bring about fatal results. The veins are especially large during pregnancy, and if wounded re- quire prompt and energetic treatment. For the emergency, pressure on the point of rupture will enable us to immediately arrest the hemorrhage. The ligature, however, will be necessary to secure the patient from an immediate repetition of the accident. This should be applied so as to completely control the loss. The radical cure re- quires the obliteration of the veins, effected in the same manner as elsewhere, by injection Avith the persuljDhate of iron, ligating with or without pins, etc. A radical cure should never be attempted in the absence of pregnancy, unless demanded by some great emergency. 144 DISEASES AND ACCIDENTS OF THE LABIA AND PERINEUM. (Edema. The distensible nature of the structure of the labia renders them liable to great oedematous infiltration in cases of general dropsy. Ordinarily, such distension is a matter of trifling importance, but the supervention of labor at a time when they are very largely swollen is often an embarrassing condition. They are sometimes so swollen as to occlude the vaginal entrance, and yield only after protracted eflforts, and even then, sometimes, only after one of them has been more or less torn. When excessive oedema is discovered before the head presses upon the external parts, or even then, no time should be lost in taking measures to lessen their size. This may be best done by everting first one and then the other, and making from ten to twenty small punctures through the mucous membrane only. A very sharp- pointed knife, taken between the thumb and finger of the right hand, so as to show only about the eighth of an inch, is the best instrument. Several quick, smart strokes with the instrument thus held, suffice for the operation. The serum exudes from the punctures, and in half an hour the swelling is very much reduced. Phlegmon. Abscesses in the labia are apt to occur in three different forms. The first is common phlegmonous inflammation, occurring in the central part of one labium, very rarely in both. The heat, swelling, and pain are very great, and the inflammation runs its course quite rapidly, generally suppurating and discharging in from six to eight days. This form of inflammation results from bruises, acrid discharges from the vagina, or the extension of inflammation from that cavity. It is lo- cated about the centre of the labium, and the swelling and tenderness are great from the beginning. The second form originates in overdis- tension of Duverney's gland, from a stojDpage of its excretory duct. It is situated deeply at the lower or posterior end of the labium, and 'generally more slow in its progress. If the patient is intelligent, and has observed the case with care, she will tell us that there was a little ttumor in the seat of disease for several days, sometimes weeks, slightl}'' ^tender at first, but gradually becoming moi'e so until the abscess was fully formed. In this stage the labium is enlarged, tender, and hot, but there is not the acuteness of inflammation that is seen in the first variety. If the surgeon has an opportunity to examine the j^arts during the progress, he will jDerceive a well-defined tumor, pyriform in shape, with the small extremity directed to the vulva, while the larger passes beneath the ramus of the ischium. It will not seem to be, as it is not, in the central part of the labium, but beneath its under surface. It will bear handling somewhat freely, and by pressing against the iramus, and directing the pressure toward the vulvar end of it, the con- PHLEGMON. 145 tents may sometimes be pressed out. The contents in the early stages are, for the most part, mucus. If examined later, the surrounding parts, and the labium particularly, will be found in a state of phleg- monous inflammation, which, in ten days or two weeks, suppurates, and the pus is evacuated spontaneously. In this form of inflammation, if the duct of the gland can be opened before the inflammation becomes considerable, suppuration may be avoided. This may be done by pressing the fluid out, or introducing a very small probe into the canal of the gland, thus opening it. If these are both impracticable, it is better to puncture it and squeeze the contents through the outlet thus made. If inflammation has begun, we may treat it like the former variety, with leeches, purgatives, evaporating lotions, etc., in the earlier period, and afterwards by poultices and anodynes until the suppura- tion is complete, when it should be evacuated by puncturing it on the mucous surface of the labium. The third variety is characterized by a succession of small furunculi. They first show themselves as small points of induration immediately below the mucous membrane or skin, are very tender, and in the course of a few days suppurate. One scarcely passes through these stages before it is succeeded by another, and thus a continuation of them prolongs the march for weeks, and even months, before they cease to return. This condition has existed only in such of my patients as were the subjects of some form of ute- rine disease, attended with leucorrhoea. They are generally anaemic, constipated and dyspeptic. The radical treatment consists in curing the disease of the uterus, correcting the state of the bowels by mer- curial and saline cathartics, and reinvigorating the patient by the ju- dicious employment of tonics. We may palliate the sufferings of the patient by cleanliness, as bathing the parts thoroughly several times a day with pure cold water, and using cold-water injections per vaginam, and making such application to every hardened point as soon as it shows itself as will arrest its progress. I have used successfully the strong tincture of iodine applied to the part, and the solid nitrate of silver. If either of these applications is used as soon as the inflamma- tion begins, it will sometimes be arrested, and the patient escape for several days, or until another furuncle begins to form. Should we be unable to thus cut short the inflammation, we must use poultices of bread mixed with a solution of acetate of lead, and anodynes, until suppuration is perfect. These small points of suppuration usually break themselves, and they will seldom be lanced. Notwithstanding the fact that inflammation of the labia is very painful, the patient will in almost all cases bear her distress until suppuration is complete, or at least unavoidable, so that our treatment is generally confined to that appropriate to the suppurative stage. The Avhole process of inflammation is rapid, and this may be an additional reason why the first stage is not the subject of observation. 10 143 DISEASES AND ACCIDENTS OF THE LABIA AND PEKINEUM. Abscesses of the Labia Sometimes become chronic, especially such as find their origin in Huguier's gland. An interesting case of this kind is recorded in the Gynecological Journal of Boston, second vol., p. 136, by Dr. H. R. Storer: " For many years the lady had found coitus almost impossible, owing to occlusion of vulval opening by lateral pressure. She was now sevei'al months pregnant, and the labial tumor was rapidly increasing. The tumor was very irregular in outline, with lobulations and depressions such as might easily have been occasioned by convolutions of intestine within a thin hernial sac. There were present many symptoms of strangu- lated hernia, and the patient's distress and local suffering were extreme. It was im- possible, by the most careful examination, to make a positive differential diagnosis though Dr. Storer was strongly inclined to believe it was a labial abscess of many years' standing, taking its rise from inflammatory obliteration of the duct of Huguier's gland. He cut carefully down upon the most presenting portion of the tumor, and obtained a free discharge of fetid pus. The sac was treated by carbolized tents, and the patient made a rapid recovery." Labial abscesses become chronic in another waj^ ; the duct of Hu- guier's gland becomes obliterated; an abscess and discharge of pus take place by spontaneous eruption ; the opening closes, and this is followed by reaccumulation, rupture, etc., and this is repeated for an indefinite length of time. This form of chronic abscess is best treated by laying the sac open freely and emptying at once, or keeping it open until the contents are evacuated, and then every second or third day injecting a solution of nitrate of silver or tincture of iodine, or some other irritant that will awaken granular inflammation in the lining membrane of the sac. This kind of treatment should be persevered in until the cavity is obliterated completely. Labial Hydrocele. A collection of serum sometimes found in the labium of the female has received the denomination of hydrocele, suggestive of its simi- larity to dropsy of the scrotal cavity. The serous fluid occupies two different positions in the labial structures. In some persons the peri- toneum is protruded through the inguinal rings and down into the upper portion of the labium. In the pouch formed by this descent of the peritoneal membrane, serum sometimes collects in considerable quantity, and when adhesion at the external ring takes place it be- comes confined. Thus an ovoid tumor is found with one end at the external ring, and the other extending more or less in the upper part of the labium. When filled to great tension it becomes to a consider- able extent translucent and very firm. I have seen two of these tumors decidedly larger than a hen's egg. As this protrusion is abnormal the tumor is very rare. Winckel in his new book on gynecology says it s oftener seen in the right side and very seldom on both sides. LABIAL TUMORS — HYPERTEOPHIEl) LABIA. 147 But another tumor receiving the same appellation is developed lower down in the labial structures, and occupies the imperfect cavit}^ in the substance of the labium formed by the prolongations of the two layers of the superficial fascia of the abdomen. Between these layers is a large amount of loose cellular tissue into which serum may be infil- trated in such quantities as to give rise to quite a large tumor. This tumor lies deeper in the substance of the labium and is farther re- moved from the external ring than the others. It distends the whole labium, enlarging in every direction, and sometimes overrides the labial fissure so as to give the patient much inconvenience. The diagnosis of these collections is usually not difficult. They are slow of growth, unaccompanied by evidence of inflammation, and of little importance in any other respect than by reason of their bulk. The upper one is pronounced, and, unhke hernia, it cannot be returned into the abdominal cavity. When the patient coughs it does not re- ceive the abdominal impulse as does hernia. The lower one is distin- guished from the upper by its more spherical shape and the fact that it does not approach the inguinal ring as closely as the upper one. They can generally be promptly cured by incising them freely, in- serting a small drainage tube, and washing out the cavity daily. Eight or ten days will usually suffice to induce a granulating condi- tion that will destroy the secreting character of the cavity and finally obliterate it. If the patient is kept quiet there need be no apprehen- sion of unfavorable conditions. Labial Tumors Do not differ in any important respects from those observed in other parts of the body. In structure they may be fibrous, fatty, or encysted fluid. The latter kind I have met with more frequently than either of the others. The fibrous are next in frequency, and the fatty per- haps least. In no respect does the treatment differ from the treatment of the same kind of tumors elsewhere. They should be dissected out thoroughly, no portion of tumor or cyst being left behind from which to be reproduced. The vulvo- vaginal gland is occasionally developed into a cystic tumor by the closure of the duct through which its con- tents are evacuated. This and the other forms of encysted tumors of the labia may be treated by evacuation and stimulating injections until the sac is obliterated. Hypertrophied Labia. The labia are sometimes hypertrophied, without much alteration of structure, to such a degree as to become cunibersome and troublesome, requiring amputation. This may be done by the knife or ecraseur according to the shape and size of the superfluous part. 148 DISEASES AND ACCIDENTS OF THE LABIA AND PERINEUM. These organs are very rarely the seat of elephantiasis, Fig. 109 (Scan- zoni). They sometimes are enlarged by this disease to an enormous size, extending down to the knees, as shown in the figure taken from Scanzoni. If we meet with this affection before it has involved too much of the substance of the parts to be completely excised, we are justified in re- moving it ; but if the skin on the thighs or abdomen is affected, so as Fig. 109. Elephantiasis of the Labia.— From Scanzoni's IXseascs of Women. to require extensive and dangerous dissection, we should not operate for this purpose, but content ourselves by palliative treatment, clean- liness, anodyne lotions, etc. It should be remembered while consid- ering the propriety of removing small tumors of this kind that they very often return and resist every species of treatment. CAIfCER OF THE LABIA. 149 Cancer of the Labia Is not of unfrequent occurrence. I have only seen the epithelial variety in this locality. Two cases have come under my observation within three years. The last one was a Scotch woman fifty-one years of age. The disease was located on the left side. When I first saw it the whole left labium (Fig. 110) presented an appearance so similar to a case illustrated in Dr. McClintock's work on women, that I have availed myself of that figure. In my patient the disease was on the opposite side. When the disease has not advanced so far but that it Fig. 110. Cancer of the Labia. — McClintock. may all be removed, we are justified in excising it. We should be very particular to remove all the morbid substance. Scirrhus probably very rarely invades the labia majora. Dr. McClintock gives one case only. It does not appear that other authors have often met with it. The soft or fungoid variety seems to occur with even less frequency than the hard form of cancer. Cancer of the labia is attended with similar symptoms, and presents the same appearances that it does in other organs. I need not stop to give it more attention in this place. Absence of the labia is very rarely observed. CHAPTER VL DISEASES OF THE VULVA. Condylomata of the Vulva. Warty excrescences in great variety make the vulva the seat of their growth. They are often flat, smooth elevations, small usually, but sometimes as large as filberts, isolated or congregated. Sometimes they are sparsely scattered over the cutaneous surface of the labia and the mucous covering of the vulva, but not unfrequently they are thickly crowded together, with deep fissures between them and exco- riations on their surfaces, that give origin to acrid sanious discharges, which excoriate the neighboring skin and soil the linen. The smell from' this sanious discharge is sometimes very offensive. These excres- cences are not always smooth and rounded even when isolated, but oc- casionally are rough and ragged, and in a few instances those spring- ing from the margin of the vagina are arborescent, slender, and from half an inch to an inch in length. We again find them yellow, flat and fragile. In most instances these growths are confined to the vulva and labia, but sometimes they cover a large part, if not the whole of the mucous membrane of the vagina and cervix uteri. I saw a case quite recently in which arborescent excrescences — many of which were three- fourths of an inch in length — sprang from the whole of the vaginal mu- cous membrane. This patient was pregnant by a syphilitic husband. The cause of these growths appears to be the syphilitic taint. So far as I now remember all observers agree that syj)hilis is the only cause of them. Treatment. We may very properly trust the alterative course calculated to remove the syphilism under which our patient is laboring for the relief of the milder forms of these excrescences, and we should not fail to institute alterative treatment for even the more harassing vari- eties ; but in many cases we will relieve the patient more readily by removing a part or the whole of the larger growths with scissors, and afterwards dressing the wounded surfaces with mercurial ointment. Inflammations. Erythematous, papular, vesicular, and pustular inflammations of the vulva are not unfrequently observed, as are also squamous diseases. They resemble the same form of disease in other muco-cutaneous cavities and the skin, and hence will not here claim a separate description. A INFLAMMATIONS. 151 disease somewhat more distinctive, however, and yet resembling a dis- ease of the mouth, is known as jjurulent vulvitis. This affection is characterized by severe inflammation of the mucous membrane of the vulva, attended with minute points of ulceration, numbering from one to two dozen. The ulcers are small, an eighth of an inch in diame- ter, slightly excavated, and almost always covered with pus. The vulva is intensely red, and Bathed in pus and mucus. The inflam- mation sometimes extends into the vagina and causes a copious flow of pus and mucus from that cavity. Not unfrequently the labia are very much swollen, and occasionally the deeper tissues are involved in phlegmonous inflammation. This form of inflammation is not unfrequently, in its early stages, attended with considerable febrile excitement. To a superficial observer it strongly resembles gonorrhoea, from the swollen labia, burning pain, copious muco-purulent discharge, and the difficult and painful micturition. Its occasional sudden and unexpected development adds to this similitude, and legal proceed- ings have been instituted against parties supposed to have been in- strumental in imparting the disease to little girls. It occurs in children generally from two to ten or twelve years of age, and probably results from want of cleanliness, heat, and local irritants accidentally aj)plied. If allowed to pursue its course undisturbed by treatment, other than cleanliness, it will generally subside spontaneously in two or three weeks, or in the course of that time become very much subdued, and run into chronic inflammation without ulceration. This last is often extended into adolescence, and, as vaginitis, gives origin to the leucor- rhoea of girlhood, and finally to the endometritis of the woman. It sometimes attends upon a debilitated and scrofulous constitution, and is complicated with indigestion, constipation, and ascarides ; but it is hot likely originated, though aggravated and fostered, by these atten- dant circumstances. Treatment. The treatment is general and local. In the beginning, where the inflammation is high, it should be antiphlogistic and soothing. We ma}^ administer a mercurial cathartic, and quicken its action by a saline laxative, and after the bowels have been thoroughly moved, nitrate of potassa may be given internally, every three or four hours, in doses to suit the age of the joatient. The parts should be frequently bathed or fomented with a decoction of poppy-heads, or with the watery extract of opium. In the course of four or five days the acute symptoms will begin to subside, when, in addition to attention to the bowels, we may administer an acid solution of quinine internally, and begin the use of astringents locally. A solution of tannin, sulphate of zinc, acetate of lead, or other astringent, Aveak at first, and after- wards increased in strength, may be applied freely to the parts four or 152 DISEASES OF THE VULVA. five times a clay. These remedies will generally remove the inflam- mation in a reasonable time. The astringent should be increased in strength to a sufficient degree for the purpose. If those mentioned are not strong enough, the chloride of zinc, sulphate of copper, or even nitrate of silver, may be very properly resorted to. Should the inflammation extend into the vagina, the astringent may be injected into that cavity by means of a small hard-rubber syringe. We ought to be careful to use a very small syringe, and not to introduce it too far. The nurse should be carefully instructed in this kind of application, I feel impelled to insist upon the complete removal of the inflamma- tion as early as it can reasonably be done, believing that if it continues until puberty, the inflammation extends into the body of the develop- ing uterus, and entails a very distressing train of suffering upon the patient, that might have been avoided by an early and complete cure of the vaginitis. I am persuaded that too much importance cannot be attached to these views. Follicular Vulvitis. Inflammation of the vulva, instead of affecting the mucous mem- brane, as in the purulent form, is sometimes confined to the follicles and glands of the vulva. In this form of the disease minute papil- lary elevations on the mucous surface of the labia majora, the nym- phse, the prepuce of the clitoris, and elsewhere in the orifice of the vagina are first observed. These increase in size and become red, while the intervening mucous membrane is often very much inflamed. In many instances a number of these elevations become pustules, their bases hardened, red, and very tender. Oftener there is only a copious flow of mucus stained with pus-corpuscles from the follicles. The acute form will generally run its course and subside in a few weeks, sometimes in from ten to twenty days. But follicular vulvitis occasionally becomes chronic, and then is exceedingly obstinate and difficult of cure. Causes. Want of cleanliness, vaginitis, pregnancy, and malignant afFections of the vagina and uterus are the most frequent causes. Tj'eatment. The treatment should be rest in the recumbent posture, alterative and saline cathartics, cleanliness, first emollient poultices, and afterwards astringent washes and applications. If the patient be debilitated, the bitter tonics, quinine especially, will be found useful. The subjects of this form of vulvitis generally require supporting and tonic treat- ment. When the secretions are offensive, carbolized glycerin should be freely applied, two or three times a day. PRURITUS PUDENDI. . 153 When it is chronic, tliere will be necessity for the use of stimulants so strong as to modify the inflammation. Nitrate of silver in substance applied once in seven or eight days to the whole of the inflamed sur- face will sometimes cause the disease to yield. In connection with this glycerin, with tannic acid dissolved in it, or impregnated with creasote, may be used between the applications. Alteratives are often found to be very beneficial. Iodide of potas- sium, sarsaparilla, stillingia, and, in plethoric patients, mercury are the ones on which most reliance may be placed. Dr. Thomas speaks of having made a cure by '' dissecting off the whole mucous membrane lining the vulva." Pruritus Pudendi. A very annoying and often obstinate affection of the genital organs is an inordinate itching of the vulva. The itching returns in paroxysms. The patient may be free from it except when standing by a warm fire, or when heated by exercise, passion, etc. Or she may be affected only at or near the menstrual period. Again, the paroxysms return without any apparent cause. In one variety of the disease the sensa- tion sometimes is that of a burning glow, attended with an irresistible desire to rub or scratch the parts, a desire which the most delicate sense of propriety cannot always keep within due bounds. In another the sensation is such as might be produced by the crawling of pediculi, and the patient is sure that thousands of these insects are moving upon her person, and will be convinced to the contrary only by in- spection. This feeling of formication, although very disagreeable, is a slight inconvenience compared to the sufferings of the other variety. The former variety is almost always attended with inflammation of the mucous membrane of the vulva. The accompanying inflammation may be simply erythematous, papular, or vesicular. Dr. Dewees describes a variety of vesicular inflammation resembling aphtha, attended with pruritus. I am sure that neither the papulae nor vesiculse are always present in very distressing cases, although I have not seen this affection when the parts were not in some way inflamed. It may be observed that, in the formication variety of pruritus, the itching is generally in great part if not wholly confined to the cutaneous surface of the labia. It will be inferred that I consider pruritus but a symptom of several diseased conditions, generally of the genital organs but sometimes undoubtedly caused by irritation in the intestinal tube, particularly the rectum, or by some other remote cause. An intelligent scrutiny of the cases as they arise will most frequently result in the discovery of the originating condition. It is often an obstinate affec- tion, lasting in bad cases for weeks, months, and even years, but more frequently it is amenable to a judicious course of treatment. 154 DISEASES OF THE VULVA. Treatment. The first thing to be done is to remove the cause, when practicable. In order to do this, the abdominal organs will require attention. The sluggish secretions and bowels must be corrected by alteratives and laxatives. A mercurial, say five grains of blue pill, may be given at night, to be followed in the morning by a saline laxative, sufficient to cause one or two stools. This may be repeated at intervals of from one to four days, until the object is gained. Meantime, if the stonipch is weak and digestion imperfect, the bitter infusions, with alkalies or acids, as the condition may require, will be demanded ; and should the patient be anaemic, iron may be given. Sometimes the patient will be plethoric, when the alteratives, with spare diet, will do better. With the above treatment, if the health be faulty, or without, if this is not the case, we will generally be obliged to resort to local remedies. And first of all is cleanliness. The parts, externally and internally, must be subjected to thorough and frequently repeated ablutions. The sj^ringe may and should be brought into use for this purpose from three to a dozen times a day. The water used for ablutions may be impregnated with sal soda very appropriately, or some fine toilet soap. I have found much advantage, when there was no eruptive accompaniment, from two drachms of the tincture of the chloride of iron in a quart of water, three or four times a day. This is especially useful when there is leucorrhoea, and a congested, dark ai^pearance of the mucous membrane. When there is a vesicular eruption, the recommendation of Dr. Dewees, to sj)rinkle the parts with powdered borax, and keep, them exposed as much as possible to the air, will be of great service. Professor Simpson uses chloroform, in the forms of vapor, liniment, or ointment, with good effect. TJie infusion of tobacco, applied freely, two or three times a day, is recommended by the same author. Simple cerate, or oxide of zinc ointment containing 5 to 10 per cent, of carbolic acid is a good palliative. When the mucous membrane is much inflamed, a solution of hydrocyanic acid, ten drops to the ounce of water, often gives great relief. A strong solution of tannin and aqueous, extract of opium is also applicable to this class of cases. An excellent palliative is pure glycerin. It may be introduced into the vagina b}' saturating a plug of cotton, passing it up through a glass speculum and allowing it to remain there for ten or twelve hours. We should take the precaution to attach a thread or cord to the cotton so that it may be readily removed. One of them introduced every twelve or twenty-four hours is. often enough. We should also apply it between the labia in the same way. As explained by Dr. Sims, who first recommended its use, the glycerin induces copious serous deple- tion from the congested mucous- membrane, thus relieving it. In cases of some duration I have often been enabled to produce a CORRODING ULCER. 155 decidedly favorable change by applying the tincture of the chloride of iron in full strength with a brush once a day to all the mucous mem- brane of the vulva, and. as far in the ostium vaginae as I could pass the hair-pencil. The first burning sensation is succeeded by great amelioration of the sufferings, and finally, in many cases, by a cure. When this fails, we may sometimes succeed by making a similar application of a solution of nitrate of silver in the strength of 3ss to §j of water. This last ajjplication should not be used oftener than once in two days. In the use of all these remedies we must not lose sight of the ablutions, nor fail to search for particular local causes, and try to remove them. As has been very judiciously remarked by Professor Simpson, we will find great advantage in alternating the use of appro- priate remedies, instead of using the same kind all the time. The obstinacy of this affection will require great patience in many instances, as well as ingenuity in using remedies. Corroding Ulcer. I have met with a number of cases of corroding ulcer of the vulva in children, which have been the cause of great suffering and appre- hension. It occurs most frequently in children, but is occasionally met with in adults. There is in each case usually but one ulcer, and it is most commonly situated on the lesser labia at first, and spreads to surrounding j^arts. The ulcer is ragged and irregular, not much excavated, with a dark foul-smelling covering, and the discharge from it is sanious, fetid, and excoriating. It is not generally rapid in its progress, and sometimes lasts for months, creeping from one part tO' another until the anatomical features of the vulva are almost entirely effaced. I have not met with this form of disease except in very debilitated, sallow, and badly nourished persons. The state of the system leading to this sort of ulceration I have thought to be more- particularly the result of living in poorly ventilated houses, but coupled also with imj)erfect nourishment, or with nourishment of an. improper character. It is generally obstinate, and yields but slowly to judicious treat- ment. We should endeavor, as one of the main objects, to correct the con- stitutional condition as speedily as possible. To this end the circum- stances of the patient should be changed to the most favorable sort. Good ventilation at home, frequent and prolonged exposure to the fresh air, nourishing diet, of which animal food should be a large ingredient, and comfortable clothing, with thorough cleanliness, are indispensable to success. The bowels should be kept in as correct a condition as possible by gentle laxatives. The digestion, Avhich is alwaj^s feeble, if not otherwise faulty, may be improved by the admin- ]56 DISEASES OF THE VCLVA. istration of infusion of cinchona, quassia, or colomba, with the mineral acids, the sulphuric being perhaps the best. The chlorinated tincture of iron is also an excellent general remedy., The next thing to be accomplished is to convert the ataxic, half-sloughing, and corroding chronic ulcer into an acute inflammatory one. This is done by pro- foundly stimulating it with the stronger caustics. The one which has seemed to me to be most successful is the caustic potassa. It should be applied to the whole surface by passing a stick, not very rapidly, all over it. After this burning we may dress the ulcer with calamine ointment twice a day. This will almost immediately improve the condition of the sore. Unless there is some considerable firmness around and beneath it, caused by the effusion of fibrin in the submu- cous substance in thirty-six or fortj^-eight hours after the application of the caustic potassa, not much good will result from it, and it will be necessary to resort to it or some other in a few days. The strong nitric acid is also very useful. I have not tried the actual cautery, but should expect it to be very useful. We may often cure this ulct)r by the weekly application of the solid nitrate of silver, dressing it between times with lint saturated with black wash, calamine ointment, or with iodoform gauze. We ought not to be afraid of strong treat- ment, nor to continue it in conjunction with a highly roborant general course of exercise and diet. Gangrenous Vulvitis, or Noma. This is a very severe and generally fatal affection of the genital organs, occurring usually, if not wholly, among children. It may attack one or both sides simultaneously. In the few cases I have seen there appeared a bleb or blister on the inside of the mucous sur- face of the labium, which at the same time became enlarged, hard, tender, and painful. In a few hours the blister breaks, and from its side a not very abundant but acrid serum is discharged. At this time a peculiar odor is emitted from the parts. All around the ash- colored surface, which represents the place where the blister was de- veloped, the substance of the labium is very hard and much swollen. In two or four days the affected side is in a state of gangrene, the discharge is very much increased, the parts upon which it runs are excoriated and inflamed, and an intolerable stench is exhaled. I have not seen an instance in which the gangrenous parts were cast off, the patients having died beforehand. Generally, though not always, in the very beginning, the circulation and nervous system are very much disturbed. The pulse is quick and feeble, the patient nervously restless, or else stupid, the extremities cool, the body — particularly about the pelvis — hot, the tongue furred, generally brown, and the skin dingy and sallow. As the disease advances the pulse URETHRAL EXCRESCENCES. 157 becomes still more rapid and weak, the extremities cold, the mind wandering, and the restlessness amounts to the frantic efforts of some sort of delusion. The tongue becomes dark brown or black, the teeth are covered with sordes, and in the end the patient often sinks into profound coma, and dies. The disease runs its course sometimes in forty-eight hours, and again, in milder forms, it may last five or six days. The causes, although unknown, must undoubtedly be of a depressing nature, overwhelming the organism very rapidly. It occurs sporadically, when it is comparatively mild, and epidemically when severe. In this last state it is very rapidly fatal. The prognosis is very bad, as it is always, or pretty nearly always, fatal. The profession, so far as I am aware, has not decided whether the disease is a general one, and the affection of the genital organs an incident, or whether the local disease inaugurates the general symp- toms. The former is most likely the truthful interpretation of the phenomena. In such a disease there is little prospect of a cure by treatment ; we should, nevertheless, institute a course clearly indicated by the symp- toms and signs. The general treatment should be strongly stimulant, tonic, and supporting ; quinia, brandy, tincture of cantharides, and beef essence, as much as the patient can bear, should be administered. I do not think the strong caustic local treatment, generally advised, any better, if as good, as the charcoal and yeast poultices, chloride of lime, anodyne fomentations, and cleanliness. Much attention should be devoted to thorough ventilation, isolation of the patient, and the neutralization of the fetor by disinfectants. Urethral Excrescences. Caruncles of the urethra; vascular tumor at the orifice of the urethra: These names have been given to small tumors springing from the mucous membrane of the vulva, immediately around the urethral orifice, or from the lining of the urethra itself. They are generally solitary, but sometimes there are several. Sometimes they are sessile, and seem to be a hypertrophied fold of the mucous mem- brane of the orifice ; at others they are polypoid in their attachment. In size they vary from a pin's head to a small nut. They also vary in their appearance. As before remarked, they sometimes resemble in color, consistence, and polish the mucous membrane upon which they are planted ; while in other cases they are quite red, almost scarlet, very soft, and easily broken. They differ in their anatomical properties quite as much as in appearance, seeming in some instances to have no more vessels and nerves than other portions of the neigh- boring tissue, while in others they are formed mostly of capillary 158 DISEASES OF THE VULVA. bloodvessels and loops of nerves. They are a morbid develojDment of existing tissues instead of a growth of abnormal substance. These tumors are often observed, particularly the more dense and light- colored varieties, without giving origin to any symptom that would lead to their detection ; on the other hand, in many instances, they often produce the most excruciating suffering. The kind of caruncle that has seemed to me to be the important one is the blood-red tumor projecting from the mouth of the urethra and attached by a small neck. A few weeks since I met with one of these of crescentic shape, attached by a neck that arose from the concave margin, and had its other attachment inside the urethral orifice. It would not have weighed two grains, but it caused agonizing symptoms. It must not be supposed that all of the varieties will not occasionally cause great 13ain. The symptoms of their presence are almost always connected with the evacuation of the bladder and attempts to handle the part. The passage of urine causes the most excruciating suffering from pain and tenesmus, the patient often straining for several minutes after the complete discharge of the urine. The slightest touch, also, is the cause of great pain. The diagnosis cannot be clear without an ocular examination. If the parts are exposed to a good strong light, and the labia separated, the excrescence will be at once discovered, unless it be quite inside the urethra. If any doubt exists, we should intro- duce the finger into the vagina, and press the urethra forward. It is difficult to say, with truthfulness, what are the causes of these carun- cul£e. My cases have been in patients ob^dously deficient in cleanli- ness. This seems to have been the cause in that which came under Dr. "West's observation. The treatment is simple, and consists in two main objects : 1st, the thorough removal of them ; and 2d, the production of a profound imjDression upon the point of origin. In fact, the tissues from which they spring should be destroyed to a slight depth. The first object may be most readily gained by snipping off deeply with scissors ; and the second by holding nitric acid, or applying the actual cauter}-, to the place until the nidus is destro3'ed. Vascular Urethra. Analogous to the caruncle is the vascular urethra. It gives rise to the same train of symptoms, though not so intensely distressing, and is very persistent. It occurs more frequently in patients near the climacteric period, although I have seen it in much j^ounger persons. When the labia are se^Darated, and the parts exposed to a good light, the urethra is seen to be patent, and the tissues around the orifice swollen and of deeper hue than usual. The mucous membrane of the urethra is of an intensely scarlet color, and, upon minute inspection, HYPERTROPHY OF THE CLITORIS AND NYMPHA. 159 the vessels may be seen enlarged ; it is very tender and sensitive to the touch, slight contact producing exquisite pain. There is great burning and sense of cutting when urine is voided, and all the symp- toms, even the sympathetic nervous derangements, attendant upon caruncle. This condition is not incipient caruncle, for there is no elevation, no protrusion, and the condition lasts for years without material change of substance. The treatment I have found most effective is dilatation and the use of strong nitric acid, applied cau- tiously to the membrane inside the urethra. The passage of a large urethral sound twice a week sometimes exerts a beneficial alterative influence. Hypertrophy of the Clitoris and Nympha. It is very rare that we meet with hypertrophy of these organs without morbid change in the tissues. There is either cystic devel- opment in their substance or degeneration of the membranous tissues. The two diseases that seem to contribute most frequently to this en- largement are syphilis and eleiDhantiasis. Treatment. Removal by the thermocautery. CHAPTER VII. LACERATION OF THE PERINEUM AND PELVIC FLOOR. The structure of the perineum and pelvic floor, and their relation to each other and to the uterus, have been briefly considered in the first and third chapters. A few preliminary observations about their relation to labor will also be necessary to prepare the way for a dis- cussion of the treatment of injuries of these parts. Preliminary Observations upon the Conditions leading to Injuries of the Parturient Canal. At the beginning of normal labor the occiput projects into the pelvic cavity below the level of the pubic arch. As the external os uteri di- lates and is drawn up over the head, elevating with it the pubo-uterine, sacro-uterine and broad ligaments, the bag of waters presses down against the pelvic floor, dilates the vagina, fills the pelvis, and in some cases protrudes at the vulval orifice. The fetal head, following the bag, dilates the more rigid parts, and is directed by the conformation of the pelvic cavity over the folded and retracted perineal raphe into the dilating vaginal and vulval orifices. One of the most frequent deviations from this method is a prema- ture rupture of the membranes. In a much larger percentage than has -been supposed they rupture at or before the beginning of labor,* and allow the amniotic fluid to drain off. As soon as it has escaped active labor pains come on, drawing the cervix rapidly over the head, and often producing a laceration of the cervix that may extend into the vagina, and thus inaugurate a series of lesions. Having neither its normal protection, the pouch of membranes, nor an oozing amniotic fluid to lubricate it, the vagina is dragged down toward the vulva, and, if the upper part be thus lacerated or the head be proportionately too large, may be torn loose from the receding uterine ligaments and their surrounding connective tissue. As the head descends the mucous mem- brane may be loosened from its intimate fascial connection with the levator vaginse and pubic arch, and perhaps torn asunder along with the weaker perineal tissues. The rectum may also be dragged loose * According to G. W. H. Kemper (Am. Jonrn. Med. Science, April, 1885, p. 412) and J. C. Bliss they occur in from seven to ten per cent, before the onset of labor. In iny private obstetrical practice, which is mostly among delicate or sickly primipara, and multipara who have uterine disease, the percentage of such premature ruptures has been during the past year as high as forty per cent. THE SCIATIC AND COCCYGEAL SURFACE. 161 from its naturally firm and unyielding sacral attachments, behind and below the sacro-uterine ligaments. If the membranes rupture later, at any time before reaching the vulva, a similar unfavorable change occurs in labor, but it involves chiefly the ijarts lower down. Other things being equal, the greater the amount of perineal dilatation at the time of the rupture of the membranes, the more will any injuries that may occur be confined to the lower and superficial structures. When the head remains at the pelvic brim during the first stage of labor, the upward traction upon the cervix, vaginal fornices, and con- tiguous structures separates and attenuates them, and deprives both the cervix and vagina of their connective-tissue support. This length- ening of the parturient tube from the internal os down diminishes also its transverse distensibility and predisposes to laceration. Expulsive efforts during the first stage are very commonly employed by multipara, and occasionally by misdirected primipara. This forces the foetus down before the maternal parts have had time to retract, and unduly hastens dilatation while interfering with retraction. A rapid instrumental delivery, by affording too little time for moulding of the head and the dilatation and adjustment of the ma- ternal tissues, must lead to a laceration in all but the previously lacerated or abnormally relaxed outlet. The greater number of forceps are so constructed that one or both blades press or cut into the vaginal levator vaginse and constrictor cunni of one or both sides and, by the irritation they produce, tend to bring on disastrous expulsive efforts. Imperfect development of the pelvis, vagina and perineum, pelvic deformity, cicatrices, rigidity from age, fetal abnormalities, etc., consti- tute conditions that must also be understood by the gynecologist, and which should be carefully studied in treatises on obstetrics. The Mechanism of Laceration and Injuries of the Perineum and Pelvic Floor. Whether it be admitted or not that the bag of waters can as a rule be preserved to dilate the vaginal and vulval outlets,* a reference to Figs. Ill and 112 will show the advantage the perineum gained by such preservation. The Sciatic and Coccygeal Surface. The curved lines (Fig. Ill), marked to represent the anterior edges of the smaller sacro-sciatic ligament and coccygeus muscle, run from * In nine-tentlis of my private obstetric cases during the past year in which the membranes remained intact until complete dilatation of the external os uteri, they protruded from the vulva before rupturing. In one-third of these cases the head was born with the membranes intact. 11 162 LACERATIOX OF THE PERINEUM AND PELVIC FLOOR. the ischial spines to the coccyx. They may be felt, at the beginning or subsidence of a pain, as the anterior edge of the flat surfaces upon which the frontal region rests while the perineum is being dilated. It will be noticed that the vulval orifice is larger in Fig. Ill than in Fig. 112, while the frontal region is still comj^letely supported upon Fig. 111. Folding of the Perineal Body in Normal Labor when Dilated by means of the Bag of Waters or Caput Suecedaneum (%). The dots on the perineal body indicate connective tissue containing fat. p. c, post, commissure ; e. c. c,., edge constrictor cunni or vulval sphincter ; e. I. v., edge levator vaginse or vaginal sphincter; a., anus; e.l.a., edge levator ani; e.l.c, edge levator coccygei; e. c, edge coccygeus ; s. s. I., smaller sacro-sciatic ligament. these planes. This part of the pelvic floor is dilated but little, and is seldom injured except by contusion. Schatz diagnosticated one lacera- tion extending by the side of the coccyx.* Plane of Obturato-Coccygeus. From this plane to the curve marked in the figure as the edge of the levator coccygei, and which can often be traced as a ring around the head extending from the pubic bone on either side to the tip of the * Archiv fiir Gynecologie, vol. xxii., p. 302. THE LEVATOR COCCYGET. 1G3 coccyx, lies the posterior section of the levator ani, or ohturato- coccygeus. It is less rigid, and has only fascial attachment laterally. Direct lacerations here are seldom observed, except after forceps de- liveries, as but a moderate dilatation is required. A loosening of the Fig. 112. Flattening of the Perineal Body in Labor due to rigidity of the outlet or improperly directed force {%). p. c, post, commissure ; e. c. c, edge constrictor cunni ; e. I. v., edge levator vaginae (hymen) ; a., anus ; e. I. a., edge levator anl ; e. I. c, edge levator coceygei ; e. c, edge coccygeus ; e. s. s. Z;, edge smaller sacro-sciatic ligament. reflected obturator fascia about the white line, sometimes occurs on one side. Contusion from the blade of the forceps, or a diffuse uni- lateral laceration of fibres are the usual forms. The Levator Coceygei. The levator coceygei fibres may be lacerated by forceps blades, by extension backward from the levator ani, or by a general overdistension from a large head, abnormal mechanism, malposition, etc. A slight laceration is often sufficient to relax the anterior edge and save the posterior fibres unless the forceps blades project, or labor be completed too rapidly. 164 LACERATION OF THE PERINEUM AND PELVIC FLOOR. The Plane of the Levator' Ani Proper. From the coccyx forward to the anus extends the true levator ani. Its anterior edge can generally be felt during labor by a little manipu- lation and careful palpation a little lower than that of the levator coccygei, and going to the sphincter ani. This portion is but seldom deeply lacerated, for it is not only powerful enough to resist a too rapid dilatation, but its dilatation commences early or before the head gets far enough down to be delivered suddenly. And as it is dilated during rotation of the head, it is usually lacerated laterally instead of at its median attachment — either by the occiput upon one side or the parietal protuberance on the other. The tear usually commences at or in front of the ring and extends backwards beside the rectum, and occasionally into it. In fact the majority commence in the levator vaginae and will be considered in connection with lacerations of that muscle. Plane of the Levator Vaginse. or Vaginal Sphincter. The ring corresponding to the inferior edge of the levator vaginae or vaginal sphincter is the most easily felt of any, after the fetal parts have begun to dilate it, and may be felt to reach from the posterior surface of the pubic bone a little at one side of the median line, around the occiput in an almost complete circle to the other side. Being the shortest muscle that completely surrounds the emerging head, and at the same time so intimately connected with, and supported by, the perineal septum and deeper pelvic fascia, the levator vaginae is frequently the starting-point of deep and complicated lacerations. On account of the lateral position of the occiput the greatest strain is brought to bear upon it, as upon the levator ani at the sides. If, then, a laceration occurs before the head has rotated to a median position, it will be at one side ; if it be delayed until after that time, the strain will be equalized and the tear will occur along the median line raphe. If the levator vaginae resists rupture and yet remains but little dilated, until the occiput has rotated to the centre, a diastasis of the different muscles antero-posteriorly is apt to occur. Fig. 112 represents about the limit of the separation of the rings representing the anterior edges of the muscles before they must be torn apart. Thus we may have a transverse laceration or antero-posterior diastasis of the levator vaginae either from the levator ani behind, or from the perineal septum and constrictor cunni in front. It follows, of course, that if the rings of the levator ani and levator vaginae be sufhciently dilated before the larger presenting diameters engage in them, as in Fig. Ill, these trans- verse lacerations will never occur, and the lateral ones very seldom. As the lacerations at one side of the median line through the levator vaginae always swerve toward tlic median line, I shnll call them diago- nal lacerations. PLANE OF THE LEVATOE VAGIX^ OR VAGINAE SPHINCTER. 165 The diagonal lacerations, if they occur before an ample dilatation of the levator ani, may extend back into that muscle, beside or into the rectum, or forward into the fourchette. It is quite common for the levator vaginaB and levator ani to become bruised and weakened, but to remain intact until the head has rotated pretty well to a median position, and then to split back diagonally on both sides, somewhat farther and deeper on one side than the other. A V is thus formed which is usually converted into a Y by an extension along the median line through the median line raphe. Sometimes one side of the Y is so short as to be scarcely noticeable, and we have an imperfect f. When a diagonal laceration of one side extends into the perineal body it may, if the extension be gradual, assume the character of a flap laceration, and present a sort of S-shape when drawn together. V Fig. 113. tz-reilzra. ■7\^ anus Diagonal Flap Laceration, left side (unilateral), drawn together, c, fourchette ; 6, position of rupture into levator vaginae ; d, lower end of laceration externally in the skin ; a, vaginal extremity of laceration ; abed, line of superficial laceration ; a I d, bottom of laceration under the flap. The flap may be raised beyond this line. When the parts are not drawn together the interrupted line aid is xisually drawn toward the sound side beyond the median line. It occurs in about the following manner: The head produces a super- ficial diagonal laceration and then, in rotating, strips up the mucous membrane and the contiguous fibrous tissue to or beyond the median line, at the same time that it deepens the lesion diagonally backward. After having come to press more centrally the head ruptures the con- strictor cunni a little nearer the median line, and then having rotated to the middle extends the laceration either directly into the raphe, or through the trans versus perinei into it, and out through the external skin. Thus a large flap is raised and an oblique as well as diagonal lacera- tion is produced. Fig. 113 represents the laceration when the parts are brought together after labor. ^ 6 c is the rent along the vulvo- vaginal surface, and represents the portion which was within the vulval orifice and in contact with the head. C d is the cutaneous 166 LACERATION OF THE PERINEUM AND PELVIC FLOOR. surface, b is the point on the ring of the levator ani, and c the point on the ring of the constrictor cunni. The interrupted line indicates the bottom of the tear. Thus the upper end is through the levator vaginae and sometimes the levator ani, the middle portion slants through the constrictor cunni and sometimes the transversus perinei to the raphe, while the external end is partly in the median line. As the tear com- mences before much dilatation of the lower end of the parturient canal, it is apt to be deep and destructive, and yet to present quite an inno- cent appearance, for the flap drops into the wound and partly covers it up. Schatz has described a laceration of the levator vaginee et ani at their bony pubic attachments.* I have often noticed the falling away of the tissues at the pubic attachment, alluded to by him, but have almost invariably found the condition due to extreme relaxation or to a laceration at some distance from the bone. This falling away of tissue at one side is quite common, laceration at the bony attach- ment exceedingly rare. The transverse lacerations behind the levator vaginae are usually submucous, and are more of the character of an attenuation of the submucous tissues ; those in front of the muscle are apt to be accompanied by one or more of the other varieties. For instance, as the constrictor cunni and levator vaginae are separated by the transverse rupture of the raphe, the head, suddenly relieved of a part of the resistance, produces a slight backward diagonal laceration at one side, or both, and then, in passing the vulva, produces a median laceration forward. If such a laceration is drawn together a peculiar figure is produced I . If the levator ani give way in the median line, as is apt to be the case after the head has got so far down, the re- sulting figure would be an inverted T J_ , which by extension may be converted into a cross -}-. Or, if the median laceration of the levator vaginae be fan-shaped, we have a fan upon a transverse line ^^ . By an extension into the vulva the fan may get a handle y . The V- or Y- shapes may also occur with the transverse and give rise to correspond- ing figures -^ -_/-. If the transverse rent be unilateral, half of these figures ma}^ be produced with half of the transverse line wanting p-. When a V-shaped laceration occurs before the transverse, the trans- verse laceration through the raphe may be merely represented on the surface by a deepening and widening of the V, especially about its angle. A transverse laceration accompanied by a short diagonal lacera- * Op. cit. THE VULVAL PLANE OR RmG. 167 tion backward at either end may assume the shape of a crescent or bow. When the head rotates to the median line before lacerating the levator vaginse, we may get a superficial laceration in or about the median line either single or fan-shaped, with or without an extension through the vulva. These are apt to commence at the constrictor cunni and extend backward and forward. Plane of the Constrictor Cunni or Vulval Sphincter. The constrictor cunni or vulval sphincter is not only longer than the levator vaginae, but is less intimately connected with the deeper muscles and fascia, and, therefore, is normally more easily dilated and less frequently ruptured. The ring marking the anterior edge of the constrictor cunni is readily felt by depressing the softer tissues of the labia and posterior commissure at the vulval outlet, as the head re- cedes after a pain. It extends from the anterior surface of the sym- physis, near the superior junction of the labia minora, to the four- chette. When the vaginal and vulval orifices are dilated gradually by a proper wedge, the fascial union at the raphe is maintained, the vul- val muscle expands with the vaginal, and is safe as long as the latter maintains its integrity. But when there is no dilating wedge, and the muscles are stretched and flattened over the presenting part, as in Fig. 112, the vulval and vaginal rings become separated, and the raphe is o'ver-stretched antero-posteriorly, or even torn across. The ring at the constrictor cunni is left undilated, and when the levator vaginae gives way or becomes sufficiently dilated, may be obliged to stretch so rapidly before the released head that it must part asunder. Such is usually the case in primary lacerations of these superficial parts. The great majority of deep lacerations into the constrictor cunni are secondary to lacerations of the vaginal entrance. When they occur primarily, or without any foregoing lesions, they are commonly median lacerations, for they are produced after the head has rotated to a central position, and it is after the pressure has become equalized that the strain upon the perineal tissues centres in the raphe. Lacera- tions commencing in the levator vaginae also tend to be completed externally through the median line. Primary lacerations commenc- ing in the median line at the constrictor cunni may extend straight back into the levator vaginae, but usually very superficially. Trans- verse lacerations external to the constrictor cunni occasionally occur, but are of little practical importance. The Vulval Plane or Ring. Even when the parts are normally relaxed and dilated, the vulval ring through the labia and posterior commissure is not sufficiently dilated 168 LACEEATIOX OF THE PERIiSrEUM AND PELVIC FLOOR. for the head to pass quickly, and unless the expulsive efforts are mo- derated or the head held back, must usually rupture transversely or in the median line. If the external parts be rigid, the condition rep- resented in Fig. 112 results. Thus quite an extensive superficial rup- ture of the vulval and external cutaneous surfaces may occur without invading anything else but fatty connective tissue. But as the skin is the most extensive and extensible of all perineal tissues, it would, if given time, seldom lacerate at all. Lacerations Extending into the Transversus Perinei and Sphincter Ani. Unilateral diagonal lacerations extending out through the vulva may extend through the transversus perinei at the side of the raphe and even through the sphincter ani. The double diagonal may also extend along the raphe down to or through the sphincter, without necessarily involving the lining membrane of the anus. The earlier the deeper lacerations commence, and the more rapid the delivery, the greater the liability to such extension. Lacerations of the Perineal Septum. The perineal septum is nearly always slightly ruptured in several places with the hymen which fringes its perforated edges. An early deep diagonal laceration may extend forward from the levator vaginae through the hymen and septum, and so relax the perineum as to pre- vent farther injury. A laceration through the transversus perinei at one side of the median line usually goes through the lower border of the septum also (see Fig. 22) and thus practically divides it in twain. Such an accident must of course completely relax the whole fascial circumference of the vaginal orifice and leave the lower end of the urethra uiisupported. In conjunction with a laceration through the levator vaginae it leaves almost the whole urethra and periurethral connective tissue unsupported and sagging down into the vulva. Lacerations of the Deep Pelvic Fascia. The deep fascia is reflected over all the muscles, and is lacerated with them, and only without them when the laceration takes the direction of the muscular fibres. Hence the mechanism of the lacera- tions of the muscles will suffice for the fascia also. The Flap Lacerations. One of the most complicated of the flap lacerations, the unilateral or S-shaped, has been described among the diagonal ; yet almost any laceration, except the median, is liable to be complicated by the rais- ing and displacement of a flap of mucous membrane or skin. Such barking of the tissues occurs during the movement of the head over a CENTRAL EUPTUEES — IRREGULAR LACERATIONS. 16& superficial laceration that is slow to extend into the deeper tissues^ and particularly so if the line of the tear makes a curve or an angle. The tongue of vaginal tissue in the V-shaped laceration is sometimes stripped back enough to allow of considerable retraction. The pro- jecting parts in angular tears, or tears crossing one another, as when a transverse laceration is compounded by an antero-posterior, may be stripped back by the head if it advances before extending the lacera- tion deeper. The deep or essential part of the tear does not always correspond with the superficial lesion, and the displaced flap may be retracted from where it belongs and grow over and into the lacerated surface, and thus converts deep structures into submucous tissue. They show how mistakes may be made in depending entirely upon the cicatrices for the diagnosis of lacerations. Central Ruptures. Ruptures through the perineal centre, leaving an untorn bridge of tissue about the fourchette or posterior commissure, are usually a combination of lacerations, extending in various directions. They occur when the vulval rings are rigid, and hold up the fourchette while the head is driven rapidly against the perineal centre. When the advance of the head is arrested before being driven through the perineal centre, it may be made to pass through the vulva over the untorn bridge of tissue. This is especially the case if the central rupture be produced by a projecting foot, knee, or elbow, that can be pushed up out of the way. According to Charpentier,* who collected the reports of fifty-six cases, the factors in their production are : 1. Exaggerated height of the symphysis pubis. 2. Condition of the perineum, viz., smallness and rigidity. 3. Irregularity and exaggerated intensity of the painsv. Irregular Lacerations. When the vulval and vaginal rings remain long midilated, so that the perineum becomes stretched over the head like a membrane, the maternal structures involved may finally lose all of their normal characteristics, and burst in a stella^te or otherwise irregular manner, producing, when drawn together, all sorts of figures, - 4 p X-VV J. Such forms are generally accompanied by considerable bruising of the parts, and show but little tendency to primary union of surfaces, but on the other hand are ajDt to cicatrize extensively, and leave a very firm, although small and mutilated, perineal body. * Archives de Tocologie, November and December, 1885. 170 LACERATION OF THE PERINEUM AND PELVIC FLOOR. Concealed Lacerations. Lacerations of the deeper structures, that do not involve the skin or mucous membrane, are almost invariably of the transverse variety, or are made up of a number of minute lacerations in the muscular fibres and fasciffi over a limited (but not linear) area, or over a half or the whole of the perineum or pelvic floor. This latter is the diffuse variety due to over-distension, and may thus be regional or general. The reason why the diagonal or transverse lacerations scarcely ever occur, without involving the mucous membrane or skin, is because internally the levator vaginae is so intimately connected with the vaginal wall, that they must tear together ; and externally the parts become so flattened and pressed together before laceration primarily occurs, that the vulval skin, if not the external, must rupture with the raphe. I have sought scores of times for a submucous or subcu- taneous parting, or diastasis, of the muscles and fascia in the median line raphe, but have never yet failed to find evidence, either of a co-existing superficial laceration, or else of the unbroken attachment of the muscles to the median line. When, however, a laceration re- mains uncicatrized, the new skin or mucous membrane is apt to make it appear subcutaneous or supravaginal. Difi'use laceration and re- laxation also, in consequence of the falling away at the sides, gives a deceptive appearance of diastasis along the median line. An unusual mobility and flabbiness of the rectum is also apt to give the inexpe- rienced a notion of the parting of muscles. But strangely enough the condition that is usually mistaken for such a laceration is one which extends transversely through the raphe between the levator vaginse and constrictor cunni, and leads to a diastasis of these muscles for each other along the transverse tear. The levator vaginae is thus separated from the lower perineal tissues, relaxing the vulval and rectal sides of the perineal body, and leaving the cutaneous side to sustain the full force of the abdominal pressure. As a consequence the constrictor cunni relaxes until it lies against the pubic ramus like a retracted curtain, and allows the loosened rec- tum, covered by the attenuated vaginal wall, to bulge over the sagging fourchette. The levator vaginse is drawn up but not lacerated. More or less diffuse laceration jarobably occurs in the great majority of first labors. In the levator ani it may occur along the course of the occiput in occipito-posterior deliveries or of the forehead in nor- mal presentations of a large head. It may involve any one of the planes of the perineum or pelvic floor of one or both sides, or even the whole perineum and pelvic floor, as during capping of the head. The muscular fibres lacerate separately and irregularly throughout the given area like the rubber threads in a worn-out elastic suspender. The skin or mucous membrane is seldom lacerated to any extent in any one place, although it may present slight abrasions or lesions. IMMEDIATE EFFECTS OR THOSE INCIDENT TO PUERPERAL STATE. 171 Contusions about the Bony Walls. Contusions about the bony walls ordinarily involve the mucous membrane and vulval skin and their underlying connective tissue. They result from pressure of the head during its passage. The mem- brane may be stripped from its base in several different places. J. Matthews Duncan in one case counted as many as eight separate lacerations of the vagina, perineum, and vulva. Lacerations Extending into the Rectum. A laceration extending into the rectum seldom commences as a median one, for, as the head must have rotated under the pubic arch before a median laceration can occur (excluding those which are ex- tensions of the diagonal or transverse varieties), the rectum will usually be pushed back out of the way before the tear begins. Generally a single or double diagonal laceration occurs, first involving the levator vaginae, and extending into the edge of the levator ani of one side at least, and so exposing the rectum. The head, bearing through the rent toward the anus, flattens the perineum, including the sphincter arii, and, as it rotates to the centre, splits the remaining perineal structure through or beside the raphe, down into the rectum and out through the anus and skin. A large head delivered rapidly by for- ceps is apt to drag down the rectum and lacerate into it. > Effects of Perineal and Pelvic Floor Lacerations. The immediate effects of pelvic floor and perineal laceration vary greatly according to the amount of injury done, while the remote effects depend less upon the amount of injury than upon the subse- quent repair brought about by an immediate union, or by the process of cicatrization. The Immediate Effects or those Incident to the Puerperal State. The ijnmediate effects are a weakening of all pelvic tissues by a des- truction of the inferior stay to the pelvic viscera, and thus a removal of that support which the inferior portion of the connective-tissue frame- Avork and their inclosed viscera afford by contiguity, to those above it. In addition to this the direct support which is afforded by the pelvic floor to the puerperal uterus, until it becomes small and light enough to be held up by the superior or pelvic roof structures, is weakened and sometimes partly taken away. As a result congestion of the uterus and pelvic viscera, delayed or arrested involutions, loss of control over the rectal and vesical dis- charges, a general weakening, and an inability to assume with comfort the sitting or erect postures within a natural period are frequently noticed. When the rectum is opened the subsequent alvine discharges 172 LACERATIOX OF THE PERIXEUM AND PELVIC FLOOR. are apt to increase and prolong the inflammation and suppuration about the lacerated surfaces and so give rise to a state of great suffering. I knew one young woman to commit suicide within two weeks after confinement to escape her misery. Other secondary results, such as septicaemia, inflammation of the neighboring connective tissue, etc., belong to such wounds, as to those which occur elsewhere. Remote Effects. Were there no attempts at repair on the part of nature, the remote effects of injuries to the parturient canal would be sad indeed. For- tunately they are nearly all repaired to a certain extent, so that but a small percentage of them, except those which open into the rectum, give rise to much trouble afterward. And now that the accoucheur is learning how to repair them immediately, the cases left for subsequent treatment may be expected in the near future to appreciably diminish. Among 150 consecutive gynecological cases among childbearing women examined in my office, the perineum was carefully inspected in all but seven, viz. : in 143. Evidences of laceration were dis- covered in all but eight (135). Of this number all but ten lacerations had cicatrized. Of the 125 that had cicatrized only five were operated upon, and not more than five others seemed to require it. Of the ten uncicatrized, five, or all except the very slight ones, required an opera- tion. About twenty-five per cent, of the lacerations were slight, in- volving only the vulva superficially or the edge of the levator vaginae of one side. It was thus determined that, no matter how extensive the laceration, if it did not involve the sphincter ani, there was seldom a sufficient displacenaent of parts in those cases in which cicatrization had occurred to require an operation, Avhile all lacerations of an}'- extent which were not cicatrized required an operation. In two cases the external anal sphincter was lacerated, once entirely through to the mucous membrane, yet the cicatricial tissue acting in conjunction Avith the internal sphincter and levator ani gave the patients control of their evacuations. In but one of this series was the rectum opened. Effects upon the Uterus. After extensive injury involving the pelvic floor, unless some kind of repair occurs, the uterus remains enlarged and congested, the vagina voluminous and lax, and the connective tissues soft and but feebly elastic, and sometimes infiltrated by deposits. As a consequence the uterus sinks low in the pelvis, or is drawn out of position by contract- ing deposits in the connective tissue. If such contracting deposits be in the upper part of the broad liga- ments the fundus will be drawn towards the same side, forward or backward according as it extends along the round ligaments or back- EFFECT UPON THE BLADDEE, URETHEA, AND EECTUM. 173 wards over the infundibulo-pelvic ligament. If the deposit be about the cervix in the sacro-uterine ligaments, the cervix will be drawn up- wards and backwards, and the fundus pressed downwards and forwards over the bladder by abdominal pressure (Fig. 53). If the deposit be in the vesi co-vaginal septum or anterior layer of the broad ligament, the cervix will be drawn forward or to one side, and the fundus in some cases pressed by abdominal pressure back against the sacrum. The inefficiency of the pelvic floor, or secondary support to the uterus, not only throws the weight of the organ but also the entire abdominal pressure upon these inflamed and rigid supports. The effect is often disastrous, and renewed attacks of inflammation follow every attempt at active exercise. As the superior uterine supports are only firm enough to hold the uterus in position while the involuntary or constant abdominal pres- sure is equalized by an efficient perineum and pelvic floor, extensive injury of these parts unaccompanied by inflammatory deposits or compensating cicatrices will allow the uterus to sink upon the bladder, or the cervix to slide downward and forward and stretch the sacro- uterine ligaments, until either the os uteri appears at the gaping vulva, or the abdominal pressure comes to bear upon the anterior surface of the uterus and turns the fundus back against the holloAV of the sacrum. Sometimes the uterus remains unusually movable and at one examina- tion may be found with the fundus against the sacrum, and at another with the fundus behind the symphisis pubis. In extreme cases the subinvoluted uterus finds its way out into or entirely beyond the vulva. Effect iqwn the Bladder, Urethra, and Rectum. When the head becomes deeply engaged in the pelvic cavity before the external os is sufficiently dilated to allow the structures about the pubo-uterine ligaments to be drawn up, the bladder and urethra are liable to be caught between the head and the pubes and either dragged loose from their attachments, or directly lacerated, or else so contused that the tissues will part asunder from the force of mere pressure, or in consequence of subsequent necrosis. If now the perineal and pelvic floor support to the abdominal pressure be to any considerable extent removed, the bladder will be forced by the direct abdominal pressure down behind and under the pubic arch and remain there in a state of congestion. Similarly if the perineal raphe be torn entirely through, the rectum may be forced by the reflected abdominal pressure into the vulva. In either case the pressure exerted through the prolapsed viscera prevents efficient cicatrization, and particularly so if the patient be allowed to sit up before the cicatrix can form and contract. 174 LACERATION OF THE PERINEUM AND PELVIC FLOOR. Effects upon the Vagina. Subinvolution, chronic congestion, plastic enlargement and increased weight of the vaginal walls are also the results of the lacerations in question. And not only does this weighty and redundant tissue find its own way out of the vulva, but it drags upon the uterus, bladder and rectum, and aids in bringing about that complete series of changes in the pelvic viscera whose final sequence is a lodgment of the pelvic organs entirely outside of the body. Cicatrices in the vagina and supra-vaginal connective tissue may not only prevent prolapse of the vaginal walls but may draw them higher up in the j^elvis. But as the cicatrix will thus have both the weight of the vagina, and perhaps the uterus and abdominal pressure to bear, the patient may suffer more than if such cicatricial support did not exist. Other Effects. Thus cicatrices of large size may be sometimes sensitive and trouble- some on account of traction and pressure upon them, particularly so if previous hypereesthesia or tenderness have existed. Reflex pehdc pains and discomfort have been traced to them. Yet when primary union does not take place cicatrization is desirable as a healing process, and as a prevention of displacement of the structures above it. Sterility from a want of retention of the semen, and impotence from a want of copulative power, attend only upon the rare and severer forms of lacerations. The levator ani is the chief muscle concerned in the copulative act, and is scarcely ever sufficiently involved to be thus functionless unless the rectum be laid open. Laceration through the external sphincter but not through the mucous membrane of the rectum is not as serious as would be supposed, since the levator ani and internal sphincter ani aided by the cicatrix about the anus often aflFords satis- factory retentive power. Even when the internal sphincter is torn through, the levator ani aided by a firm cicatrix may enable the patient to control all but liquid or semi-liquid passages. Symptoms of Perineal and Pelvic Floor Lacerations. The symptoms of immediate lacerations are great soreness of the parts to the touch immediately after labor, painful defecation and micturition, and, if the rectum has been opened, incontinence of faeces. Occasionally hemorrhage may give rise to symptoms of weakness and prostration. Later on symptoms of local or general pysemic infection may occur as after wounds in general. (See Effects of Perineal and Pelvic Floor Lacerations, above.) Secondary Symptoms. After the wounded surfaces have healed, the most characteristic symptoms are those belonging to imperfect involution of the parts, VAEIETIES OF LACEEATIOJST. 175 viz., leucorrhoea, constipation or else an inability of the rectum to com- ^ pletely expel the faeces, hemorrhoids, weakness or irritability of blad- der, feeling of weight about the pelvic outlet, a want of general strength, reflex nervous symptoms, etc. Lacerations of the perineum allowing of prolapse or inversion of the parts are attended by local irritation, ulceration, and the formation of soft projections between the labia ; those of the pelvic floor sufficient to take away a part of its support to the pelvic connective tissue give rise to such symptoms as are usually connected with a sinking of the pelvic organs below their normal plane. A strained or sore condition of the superior or pelvic roof supports, and a displacement of the pelvic organs are common symptoms. In making the examination of a patient complaining of symptoms which we recognize as due to pelvic diseases, we should by palpation and if necessary by inspection always investigate the condition of the pelvic floor and perineum as a possible direct or indirect cause of some of them. Varieties of Laceration. A careful examination of the displacements and cicatrices in the series of cases already referred to was made, and the following table constructed : Median laceration, slight and extensive ( j j, . Right diagonal (\ ), through right levator vaginfe, Left diagonal ( /), through left levator vaginae, Double diagonal or \V -shaped through both levator vaginae, Double diagonal with forward extension, y -shaped, Right diagonal with forward extension, an incomplete Y ( \ j, Left diagonal with forward extension, an incomplete Y ( / ), . Diagonal fan-shaped (^^^ ),....... Diagonal fan-shaped, with forward extension ( N' )> - Left diagonal flap laceration, the S-shape ( \ )) • Right diagonal flap laceration, the S-shape f / j, . Transverse (— — ), Transverse with median forward or | -shaped, Transverse with median backward or inverted T ( J_), • Transverse with median backward and forward, or cross shaped ("t") Transverse across double diagonal ( \/ ), .... 25 17 13 10 15 176 LACERATIOX OF THE PERINEUM AND PELVIC FLOOR. Transverse across double diagonal with median extension ( V ) 1 Median joined to left diagonal (Y), 2 Median and left diagonal separate ( )> 1 Eight transverse with median forward and backward, crossed by- right ant€ro-posterior backward ( ■ II ' ), . . • . .1 Transverse joined at right with diagonal ( \__ ), . . . . 1 Transverse joined at right and left with diagonal, and centrally with stellate (\-^^), 1 Median joined to I'ight diagonal and right transversely -H ), 1 131 However cumbersome such a verbose nomenclature of perineal lacerations may at first sight appear, a close examination of the figures will show how an accurate differentiation cannot be made of such a combination of cicatrices without a corresponding combination of terms. To students and beginners such a detailed nomenclature must be of value as giving a more definite idea of the nature of such lacera- tions than by merely dividing them into degrees according to their extent, but without reference to their character. In ordinary descrip- tions they may be designated as the median, the diagonal, the trans- verse, the central, and compound^such as the V shaped, Y shaped, inverted T ( J_ ), cross ( -f- )? double cross ( Tj" ), L, fan shaped, imperfect Y f f J , etc. When tbe tear extends into the rectum the same characters can often be discovered and named in connection with a mention of the exten- sion into the rectum in order to be properly classified. These are also called the complete lacerations, those not opening into the rectum the incomplete or partial ones. Degrees of Laceration. The degree of laceration can best be made ititelligible by mention- ing the structures involved. In median ruptures the cutaneous portion of the raphe may alone be lacerated down to the sphincter ani or through it, or into the rec- tum ; or only the vulv'al portion, or fourchette may be involved ; or only the vaginal portion (the recto-vaginal septum) ma}' be torn a given distance beyond the hymen; or two or all of these portions. Again, the skin or mucous membrane may alone be torn, or the raphe may be slightly involved, or ruptured through, to or into, the anal and rectal mucous membrane, for any given distance. Antero-posterior DIAGNOSIS OF PERINEAL AND PELVIC-FLOOR LACERATIONS. 177 lacerations to one side of the median line maj' involve the hymen or perineal septum, the levator vaginse, the constrictor cunni, transversus perinei, the cutaneous surface, rectum, one or all. The transverse lacerations may be to the right or left of the median line, or entirely across from one pubic fossa to the other. They may extend barely through the skin or mucous membrane, or partly or quite through the raphe. Or they may be external or internal to the vaginal or vulval sphincter, or perineal septum. The diagonal lacerations may partly or completely sever one or both levatores vaginse, and the hymen or edge of the perineal septum ; or the transversus perinei; or may extend into the edge of the levator ani ; or may extend to or into the rectum. Diagnosis of Perineal and Pelvic-floor Lacerations. I. Of the Recent Lacerations. — As after prolonged labor the perineum remains relaxed for a short period, a flabby or large vulvo-vaginal outlet is of little importance as evidence of laceration, unless the sec- ond stage has been short, or unless the enlarged state of the outlet Fig. 115. C Triangular Lacerations (schematic). V, vaginal end; I, labia or the sides ; c, cutaneous end. The interrupted line vc represents the bottom of the laceration or common base of the triangles. Half of the dotted line U represents the depth of the laceration or altitude of the triangles. The lines constituting these figures are all more or less concave or convex when the surfaces are in apposition, but become straight when widely separated by traction. continues for several hours. A complaint of great soreness at the re- moval of the after-birth, and upon the lightest touch about the pos- terior commissure and vaginal entrance is one of the first and most reliable signs. A light touch is not painful to the parts after labor unless there be a raw surface. If there be no laceration the parts will be smooth and either normal in relationship, or evenly flattened about the fourchette and posterior commissure. Upon inspection through the separated labia and after removal of the blood by a soft cloth we can easily detect the triangle formed by a median laceration. The yellowish gleam of the subcutaneous fat, and 12 178 LACERATION OF THE PERINEUJI AND PELVIC ELOOE. the white fibrous tissue of the raphe are easily recognized, and may be easily traced along the median line into the vagina. Sometimes nearly all of the laceration will be external to the hymen, or cutaneous ; at other times nearly all internal to it, or vaginal. The extent of the perineal laceration is not determined by the length of the sides of the triangle, but by the altitude or distance from a lower caruncle or the lacerated edge of the fourchette to the bottom of the rent. Convexity of the bottom denotes shallowness, concavity denotes depth, of the tear. Fig. 114 is a long shallow rent convex at the bot- tom, Fig. 115 is a short deep one concave or flattened at the bottom. When the whole lacerated surface is a uniform expanse of fatty tissue, the essential perineal structures are not involved, no matter how long, ragged and formidable-looking the edges ; when the bottom of the sur- face shows the white torn bands of connective tissue, or the reddish ends of muscular fibres, the deejjer structures are affected, no matter how small the cutaneous or vaginal lesion. When the triangular sur- faces are separated at the bottom by an expanse of dark red or dark blue membrane, and are made up of the red muscular, white fibrous and yellow fatty tissue, the rectum has been oi3ened. The extent of the invasion of the rectum may be followed by the edges of the tear. IT/ethTcL Fig. 116. Diagonal Lacerations of the Perineum (unilateral and bilateral), as seen through separated labia right after labor. As the median laceration seldom extends beyond the external sj)hincter, the red color may be absent from the bottom, but it will be replaced by the lighter bluish cutaneous lining of the anus. When a transverse, diagonal, V-shaped or irregular laceration occurs without an extension into the skin, it may easily be overlooked by the inexjierienced, since the vulva apjjears normal from without, and the bruised mucous membrane at the vaginal entrance is often about the same in color as the raw surfaces. The finger should be introduced first to ascertain if sore places be present and to grasp the perineal body with the help of the thumb externally. When the finger gets into a rent the thumb and finger will notice the absence of the normal thickness, and can determine how much of the perineal body is left DIAGNOSIS OP PEEINEAL AND PELVIC-FLOOE LACERATIONS. 179 unruptured. Sometimes only the skin will intervene between them. When the rupture seems deep the thumb may be introduced into the rectum and then approximated to the finger in the vagina and thus Fig. 117. JucCbvit-rrf^ Slttn ^■^' its' 'jSh,Tt Jhius Fig. 117.— Diagonal Bilateral Laceration with Vulval Extension through Median Line Raph6 as expanded for inspection after labor (Y). Fig. 118.— Similar Laceration extending into Rectum. (It is difficult to accurately represent a laceration into the rectum on a flat surface, as its contour varies with the amount of separation of the labia.) determine the condition of the raphe, and the amount of tissue left over the anus and anterior rectal wall. Inspection reveals an oval crescentic or irregular gaping wound, whose edges are often ragged and which needs a thorough willing out to be estimated (Fig. 116). When a median laceration is united with one or two diagonal ones near the fourchette so as to form an incomplete or complete Y, the figure when expanded for inspection will present the fusion of the double triangle with a half or whole crescent (Fig. 117). AVhen the Fig. 119. Fig. 120. Tourchette Jucchtvcnv Fig. 119.— Double Diagonal and Transverse Laceration combined (n^), expanded for inspection. Fig. 120.— Double Diagonal Laceration with Vulval Extension combined with a Transverse one (^). rectum is invaded there will be a projection of anal skin and mucous membrane into the external cutaneous edge (Fig. 118), and a more extensive raw surface on either side. 180 LACERATION OF THE PERINEUM AND PELVIC FLOOR. The compounding of a V-shaped and transverse laceration looks something like the Y-shape, but is much further away from the anus (Fig. 119). The conjunction of the transverse and Y-shaped makes a star (Fig. 120). White fibrous and muscular tissue, sometimes the rectal wall and, if the rectum be opened, the rectal mucous membrane will be seen at the bottom. II. Of Old Lacerations. — As. the cicatrized edges of lacerated peri- neal tissues are not drawn up to their former position, but down into the granulating surface, the cicatrix holds them out of place and often creates a vulval gap or opening filled with collapsed tissues. The first thing then to seek for in diagnosticating old perineal lesions is to hunt out by palpation the displaced and relaxed parts. For informa- tion upon this point see Chapters I. and III. Palpations of Old Perineal Lacerations. To determine whether or no the relaxation or displacement be due to laceration requires farther attention. When the relaxation is greater on one side than the other, or the elevation corresponding to the median line raphe (Figs. 67 and 68) is felt drawn to one side, or one portion of the perineum, as, for instance, a levator vaginse or con- strictor cunni, is flabby and the rest of the perineum firm, the relaxa- tion is probably due to a laceration. When the median line elevation or raphe is absent, or represented by a depression of hardened tissues, and the levator vaginee and constrictor cunni, while relaxed and forming a large deep pubic fossa at each side, do. not form a depression on either side of the median line, there must have occurred a median laceration. When the tear extends along one side of the median line, the peri- neal fossa (See Examination of Perineum, Chapter III.) on that side will be the better developed of the two, and will extend down or through the transversus perinei. The edge of the laceration and the contiguous median line raphe may often be detected by the experi- enced finger on the sound side of the median line. Such laceration deep enough to involve the transversus perinei, or its central attach- ment, leaves a wide depression of hardened tissue in the place of the fourchette, which, if the anal sphincter be torn, leads back to the membranous edge of the anus. A diagonal laceration extending only through one levator vaginae gives a deep, but not wide, pubic fossa on the same side. A double diagonal, or V-shaped, laceration is accompanied by a deepening of both perineal fossae, and sometimes by a raised central tongue or vagi- nal mucous membrane which can be felt behind the depressed cicatricial tissue situated at or behind the hymen. The Y-shaped lacer- ation is known by the same signs in addition to those of a median DIAGNOSIS BY RECTAL PALPATION. 181 laceration, viz., a median line depression and widening and lengthen- ing of the pubic fossse. A transverse laceration usually produces a transverse depression internal to the commissure or fourchette extending into the pubic fossa on one or both sides. A wide V-shaped laceration produces a similar depression, but it is felt to extend to the bellies of the levatores ani around the tongue of mucous membrane instead of into the pubic fossae. T-shaped lacerations have a slight transverse depres- sion, a widening of the perineal fossa forward, and the longitudinal depression instead of elevation of the fourchette or commissure. The inverted T (jj has a transverse depression with a normal fourchette, but has the perineal fossae deepened and widened backwards only, and has a cicatricial line or depression that can sometimes be felt over the rectum in the median line, or else allows the finger to feel the folded rectum more easily than natural. Stellate, cross-shaped and other compound lacerations may be partly diagnosticated by the alterations mentioned above, and partly by the large extent of firm cicatricial tissue at their site. Occasionally we find a lacerated vulvo-vaginal outlet that is as nar- row or narrower, and perhaps firmer at the sides, than normal, so that the pubic fossa is as difficult or more difficult to detect as in the virgin, yet the fourchette is gone, and its place taken by the sagging urethra and vaginal walls. Below the narrow elongated orifice upon the shx)rtened but firm perineal body is felt a large firm scar with a nar- row extension through the separated carunculse at or a little to one side of the median line. This condition is produced by the contrac- tion of a large cicatrix drawing the ends of the torn muscles and fascia down toward the posterior end of the wound but not toward the median line. All of the perineal tissues may be firm, but they do not close the vulvo-vaginal outlet. The recto- vaginal promontory may also be flattened as far back as the coccyx. - Diagnosis by Rectal Palliation. As the perineal body in section is triangular (Figs. 26 to 31), its size and form may be quite accurately estimated (without reference to the superficial or visible tear) by a finger in the rectum on its rectal sur- face, another on the vulvo-vaginal, and the thumb on the cutaneous surface. Among the most common losses of substance in the perineum are those external to the perineal septum and levator fascia. They are due usually to median lacerations which shorten the cutaneous side of the triangle and enlarge the vulval angle. This shortening of the external cutaneous side and enlarging of the angle goes on progres- sively with larger tears, until the sphincter ani occupies the whole 182 LACERATION OF THE PERINEUM AND PELVIC FLOOR. cutaneous side, or until the entire body is represented by a fiat fascial or cicatricial band along the anterior rectal wall, containing portions of the perineal septum and levator fascia. Fig. 121 represents by lines the parts of the triangle lost by lacerations of different extent. Another common form includes primarily the perineal septum and recto-vaginal end of the raphe, viz., the diagonal. In the milder grade there is merely a shortening of the rectal side depressing the recto- vaginal angle, as in the single or double diagonal. In the next grade the raphe is destroyed below the constrictor cunni attachment and the triangle is cut almost or quite square off as in the deep Y-shaped or the T-shaped. When there is but little cicatrization the transversus perinei is easily reached on either side by drawing the rectum to first one side and then the other so as to render it tense, while the finger Fig. 122. Fig. 123. Fig. 121.— Degrees of Median Laceration through the Perineal Raphe represented by curved lines 1,2, 3,4. The curves may be increased or diminished at the ends, altering the superficial extent without altering the depth or degree. Fig. 122.— Degrees of Extension of Diagonal Laceration through Perineal Raphe. The lines 1, 2, 3, instead of leading from the Raphe into the Rectum, lead to one side of it. Fig. 123.— Deformity produced by the Transverse or deep Double Diagonal without forward ex- tension. presses back along the pubic ramus. The next grade leaves only the sphincter ani. In this form we have colpocele,rectocele and cystocele unless sufficient cicatrization occurs to act as a substitute for the raphe. It is also possible for the lacerations at the upper part to go entirely through the raphe, divide the perineal body in two, and de- stroy its function without much diminishing its bulk or shape as pal- pated or inspected. Fig. 122 represents by lines the portions of the perineal triangle destroyed by such lacerations as ascertained by the combined rectal palpation. The ease with which the vagina can be everted by the finger in the rectum, and the thin membranous nature of the tissue over the rectal finger are also characteristic. In the transverse laceration when cicatrized or only partly through the septum, the transverse groove in the base of the triangle can be DIAGNOSIS BY INSPECTION. 183 easily felt and measured (Fig. 123). A cicatrized V-shaped laceration with a retracted angle or tongue of tissue often produces the same depression in the centre. When an uncicatrized transverse laceration with rectocele, or tend- ing to it, is present, the absence of the attachment of the levatores vaginae is known by the attenuation and want of resistance of the recto-vaginal angle of the perineal triangle when caught between the rectal and vaginal finger, and by the ease with which the base or vul- val side of the triangle or body can be swung or pulled outward under the pubic arch. By penetrating deeper into both vagina and rectum, the levator vaginse at the top of the rectocele can be caught between the fingers, and its length and resistance estimated by dragging it for- ward and from side to side and putting its pubic ends upon the stretch, so as to render them distinctly palpable. When a laceration extends beside the raphe the extent of tissue involved may be determined the same as if it were through the raphe. The strength of the perineum as a whole may be tested by ajoproxi- mating the vaginal and rectal finger at the recto-vaginal promontory and pulling them together in various directions, forward, backward, downward, from side to side, etc. We thus often find a small remnant of the perineal body quite firm and effective as a support. Diagnosis by Inspection. Inspection alone gives a less complete idea of the amount of perineum or pelvic floor injury than palpation. It however reveals the position, shape and extent of the cicatrix, and the amount of destruction, separation or distortion of the superficial landmarks. If the caruncles be continuous around the vaginal entrance, without an intervening scar, the laceration has not involved the vaginal orifices or levator vaginse to any considerable extent. If they be small and all or nearly all of them widely separated from each other around a gaping orifice that presents no scar tissue, there has been probably submucous diffuse laceration. If the cutaneous median line raphe extend up above the junction of the labia majora, the external perineum is not much affected. If the labia majora, however, pass straight downward and backward and do not converge to form a posterior com- missure, we know that there has been a median laceration. If the urethra and anterior vaginal wall sag down into the vulva, or the posterior vaginal wall project, we know that the parts about the in- troitus have been injured and imperfectly repaired, whether the vulva be firm and gaping or flabby and collapsed. If the perineum present the ordinary landmarks but sags downward so as to project farther than natural from the pubo-coccygeal line, or conjugate of the outlet, a general relaxation, diffuse submucous laceration, or transverse laceration may be inferred. 184 LACERATION OF THE PERINEUM AND PELVIC FLOOR. As the labia are separated, evidences of a deep lesion will be in- dicated by the altered appearance of the deeper pstvis. If no signs of any tear be present, the sight may not be able to distinguish between the simple relaxation from the pressure of displaced organs that is not necessarily a result of parturition, and the diffuse submucous and uncicatrized lacerations due to labor, A unilateral or localized relaxation greater than that of the remain- ing parts, a participation of muscles distant from the vaginal orifice (as the sphincter ani),a greater relaxation or softness of the perineum than that due to the amount of pressure of the displaced organs, and a want of retractability when these organs are sujiported, indicate the lacerated condition. Either a decided eversion or turning under of rugate mucous membrane at an edge of the scar, especial!}^ if the scar be angular, curved or unilateral, indicates a flap laceration. Combined Palpation and Inspection. Having determined by palpation what portions of the perineum are relaxed and out of place, and by inspection the superficial variations, we may by combining paljjation and inspection find the relations of the cicatrices and superficial lesions to the relaxed or separated deeper structures. By everting the vagina by the finger in the rectum not only can the thickness and resisting power of the perineal body be estimated, but the cicatrices, stretched over the anal finger, appear blanched in the softer tissues beside them and can be traced to their minute ends. Hidden lesions may thus become plainly visible. Rectal eversion of the vaginal walls also informs us how high above the sphincter ani the perineal body supports the rectum, and of the extent of loss of the raphe above. Diagnosis of Old Lacerations Extending into the Rectum. The history of fecal incontinence usually makes the diagnosis of laceration into the rectum an easy one. Upon palpation the rectal and vaginal outlets will be found to be in common. The perineal body will be completely divided and allow the finger to glide back along the pubic rami to the anus. At the upper and inner end of the lacera- tion the thin curved edge of the recto- vaginal septum will be felt about the median line ; or there may be a deep extension on one side, and a shallow one on the other, with a median projecting tongue of recto- vaginal septum between them. Inspection will reveal the red rectal mucous membrane posteriorly. Diagnosis of Lacerations of the Pelvic Floor. 1. Of the Anterior Edge. — Lacerations of the anterior edge of the levator ani are accompanied by a relaxed levator vaginte and widening of the DEEPER PORTIONS OF THE PELVIC FLOOR. 185 urethral notches, the more so on the side lacerated. The finger, in- stead of feeling the pubic attachment of the muscle near the internal edge of the pubic ramus, traces it upon the posterior surface of the bone and farther from the median line. The rectum at the recto- vaginal promontory is scarcely as prominent as normal and is flabbier, and makes a gentler backward curve, but it is more easily palpated through the relaxed tissues. II. OJ the Levator Ani Proper. — When a large part of the levator ani proper is lacerated, the vaginal outlet is large and flabby, the recto- vaginal promontory thrown further back from the pubic arch toward the anus, and the most prominent part further in towards the coccyx. In lacerations involving the whole anterior section, or levator ani proper, the lower rectal curve (Fig. 31) is long and low instead of high and short, as it normally feels in the dorsal position. The urethral fossae are wide, and their lateral borders, usually formed by the levatores ani, feel soft and receding instead of hard and resistant. The rectal promontory and anterior edge of the levator ani are soft, flat and unusu- ally depressible and indefinite to the touch as far back as the coccyx. The rectal promontory as felt per rectum is almost or entirely absent. The posterior vaginal sulci or grooves are wide and often deep beside the flabby recto-vaginal promontory. The power of lifting this por- tion of the pelvic floor at will (by an effort to draw in or contract the anus) is diminished according to the amount of laceration. Finally, the most striking peculiarity in extreme cases is the pronounced pro- jection of the ordinarily buried tip of the coccyx, and of the ridge of levator coccygei fibres extending from the posterior surface of the an- terior pelvic wall near the anterior end of the white line on either side,, to the coccyx, and forming by their junction an angle or inverted Y ( ^ ). (See Palpation of the Levator Ani, Chapter III.) Thus a very- pronounced false promontory is found deep in the pelvis. If the patient is put in an uncomfortable position or requested to draw in the anus so as to hold back the faeces, this ridge will become hard if not already so. If the laceration be unilateral the rectum and ano-coccygeal ligament will be drawn slightly toward the sound side. Such a com- plete relaxation of the levator ani proper is occasionally found without a tearing open of the rectum, and nearly always when the rectum is deeply lacerated. This condition was found four times in the series of cases already cited in this chapter, beside the case in which the rectum was lacerated. A failure to diagnosticate this kind of lacera- tion would be to fail in either understanding the symptoms or curing the patient. Deeper Portions of the Pelvic Floor, A generalized diffuse laceration (so-called overdistension) is known by the relaxation. (See Palpation of the Pelvic Floor, Chapter III.) Relaxation from laceration is usually unilateral or locahzed.. Lacera- 186 LACEPvATIOX OF THE PERIXEUM AXD PELVIC FLOOR. tion extending back into the levator coccygei fibres diminishes the size of tlie ridge on the lacerated side, or may place the anterior edge of the ridge back in the posterior section of the levator ani. If both sides of the muscle are torn to the same extent, the ridge will be less prominent, and displaced higher up and farther back on both sides. If the levator coccygei fibres be lacerated without par- ticipation of the anterior fibres of the levator ani, the vaginal entrance will be normal, but the recto-vaginal promontory will be high in front, but fall away more abruptly backward, and thus be narrow antero- posteriorly. The tip of the coccyx will not be as readily felt from the vagina as when the anterior muscles are lacerated. Unilateral lacera- tion of this portion alone increases the size of the depression, or de- pressible area, corresponding to the obturato-coccygeus muscle, as compared with the sound side. The softened area is increased forward. Lacerations of the obturato-coccygeus are nearly always unilateral, and are characterized by unusual softness of the fibres on one side, or an unusual prominence of the anterior edge of the coccygeus behind. If the tear extend into the coccygeus the greater sacro-sciatic ligament will be unusually high and prominent. Possibly a line of laceration or separation may be occasionally found. I have never found such, although I have in a few instances found the relaxed condition. A loosening or laceration of the fascia about the white line is known by the greater amount of curvature produced in it during voluntary contraction on one side. Sometimes a finger can be hooked into the curve, and almost get under its edge. In seeking for laceration in a relaxed muscle we must take the fact into consideration that extensive lacerations may, by removing fascial support, relax the whole pelvic floor. Voluntary contraction will often show which muscles are torn, and which merely relaxed. The first do not contract, the latter may. Unasual roominess of the upper vagina, with softness of the deeper pelvic floor musculature, unusual mobility of the cervix in a forward direction, a low position of the uterus, and a marked tendency of the abdominal walls above the pubes to sink back toward the promontory of the sacrum when the dorsal position is assumed, are general signs of relaxation of the pelvic floor from extensive injury. Method of Diagnosis. The finger should be so educated as to be able to recognize in a general way the presence and location of pelvic floor and perineal lacerations at the first touch. In passing into the genitals it should notice the amount and shape of the tissues at the fourchette, the con- dition of the hymen or caruncles, the depth and size of the pubic iossse, the size and shape of the urethral and rectal notches and vag- inal grooves or sulci, the height and width antero-posteriorly of the PREYENTIOX OF LACERATIONS. 187 recto-vaginal promontory, and the absence or presence of an elevation of the tip of the coccyx and levator coccygei fibres. If we find the last-mentioned structures prominent, and the promontory flat, we look for a lacerated levator ani. If these parts are normal, but the parts below them relaxed, or otherwise altered in shape or relation- ship, they should be more carefully examined, after the usual intra- pelvic examination has been made. It is well in all cases of multipara with a relaxed posterior vaginal wall to touch all of the principal landmarks of the pelvic floor in rapid succession, as it takes but a moment. (See Palpation of Pelvic Floor, Chapter III.) Prognosis. The chances for a complete ideal cure are favorable only by the immediate operation. After the time for that has passed, the shorter the delay after inflammation and suppuration have subsided, the better the opportunity for restoring the parts as they were before. The longer the separated parts are left to degenerate from loss of func- tion, and the longer the support to the inferior portion of the pelvic connective tissues remains impaired, the less chance is there to secure a normal coaptation of the parts that belong together, or to secure perfect union after such coaptation, or to relieve the effects of the long- continued laceration upon the surrounding tissue. Indeed, the re- sulting changes due to the laceration may finally become permanent, and be but little or very slowly benefited by perineorrhaphy. Prevention of Lacerations. The prevention of perineal and pelvic-floor lacerations should be studied in the works on obstetrics. Yet from the standpoint of the gynecologist, who is chiefly concerned with cases in which injury of the parts is pretty sure to result, it is well to give the matter a little farther consideration. The first thing to be thought of in such cases is to so manage the perineum and pelvic floor that they will, if lacerated, be in a condition for immediate successful repair, or an ultimate restora- tion of function. The management of the deeper pelvic-floor muscles consists mainly in securing a passage of the presenting part slow enough to allow of the requisite dilatation. Nature's way of doing this is by persistence of the bag of waters until they burst at the vulva. To imitate this natural mechanism the accoucheur has but to let things alone, and assist his patient to take things as easily and calmly as possible. The advice given by teachers and text-books to diagnose by palpating the fontanelles is harmful in its influence, and leads younger practitioners to spend a large part of the time of their attendance upon the confine- ment in pokhig the finger about in utero, bruising the cervix, and destroying the resisting power of the membranes. 188 LACEEATION OF THE PERTXEUM AND PELVIC FLOOR. The next important service of the membranes is to prevent that superficial bruising and ecchymosis about the vaginal entrance which often lead to the deeply penetrating lacerations, and also the so-called inevitable one. Another is to provide the wedge to prepare the vulval and vaginal rings for the head. AVhen the membranes do not persist long enough, a slow advance gives time for the formation of a caput succedaneum, which will act as a wedge in the vaginal and vulval outlets (Dumas) in place of the membranes. A rapid advance over the deeper parts leaves the caput succedaneum to be formed after, instead of before, the whole perineum is pressed upon and bruised, and thus often too late to prevent the laceration. When the normal method of dilatation of the pelvic floor and perineum does not occur, the assistance of the accoucheur must sup- ply the wedge, the restraining force, and the directing force. The latter is lost when the perineum is not normally folded at the four- chette, so as to give the ;groper slope to the pelvic floor (Figs. Ill and 124). As we work for a vigorous condition of the parts after labor, we should not supply this force by pressing upon the perineum in front of the anus, nor by fingering the delicate rectal walls, but should choose the post-anal cutaneous surface for pressure, as was taught by Ritgen. If the head needs also to be temporarily retarded, the finger of the unemployed hand may be passed into the vulval or vaginal entrance instead of being placed against the perineal body. If the perineum be not too rigid the fourchette and posterior commissure may be digitally drawn back toward the anus at the beginning of the pain, and the raphe be held back until, but only until, the head advances upon it. This is necessary where there is a tendency to a wide sepa- ration of the vulval and vaginal rings (Fig. 112) threatening a diastasis of the muscles, or a transverse perineal laceration. Should, however, too much be attempted in the way of digital dilatation, the perineum will be bruised, and the condition we are so anxious to prevent will be produced. Rather than delay the head after it be determined that laceration must eventually occur, we should deliver it before too much bruising has taken place, thus precipitating the laceration at a time when its immediate repair can be successfully accomplished. But as a lacera- tion heals less perfectly by first intention than a well-chosen incision, it may sometimes be better to, perform colpotomy, episiotomy or perineal tenotomy. Perineal • Incisions. In imitation of nature's method of relaxing the perineum by a laceration through the smallest of the perineal rings (the obstructing one), it has been proposed to make an incision through the internal COLPOTOM Y — EPISIOTOM Y. 189 perineal ring or levator vaginse (colpotomy) or the external perineal ring or constrictor cunni (episiotomy), according as one or the other fails to exhibit the requisite distensibility for the passage of the head. Considerable judgment must be used in performing either of these operations, for from the moment the incision is made a weak point is created which will lacerate deeply under strong pressure. But little more stretching can then be expected, and the dilatation of the orifice will be in proportion to the depth of the incision. Therefore, if the ring be not already dilated almost to the required extent, the incision will be inadequate, and will be enlarged by tearing, and may even extend into the rectum. The only laceration into the rectum of the series reported in these pages occurred after an incision in the perineum.* On the other hand, if we wait too long the parts may become too much bruised for primary union. Hence the proper time is as soon as the ring has ceased to enlarge — or enlarges so slowly that but little more dilatation can be expected — and before complete dry- ness and numbness of the vaginal entrance has occurred. Colpotomy. The place for the incision is at one side of the median line, and the greater the amount of dilatation required the farther to the side should be the incision. Its direction should be diagonal, extending forwards towards the median line intersection of the external or constrictor cunni ring, or fourchette. When one incision does not afford the re- quisite amount of dilatation, another on the opposite side may be made. By rectal indagation between or just after pains we may ascer- tain by the direction of the raphe, which is easily recognized on the anterior rectal wall, the side that is stretched the most and make an incision accordingly. I prefer to cut first on the least dilated side, as that part is the less bruised and will have less traction upon it when united subsequently. A straight blunt-pointed bistoury is the best instrument for the operation, although a pocket-knife may be used. Just as a pain is subsiding the left index finger should, as soon as it can find room, be slipped between the ring and the head, and the incision made with the other hand into the edge of the ring as held tense by the head and finger. Care should be taken not to extend the incision along the su- perficies any farther than necessary, as such extension would increase the size of the wound without aiding in the dilatation. Episiotomy. When the constrictor cunni is the unyielding part of the perineum, or when the levator vaginae and hymen have been so slow in dilating * Patient's testimony. 190 LACEEATION OF THE PERINEUM AND PELVIC FLOOR. that any further bruismg must destroy the elasticity of the parts, episiotomy may be performed. It is done at one side of the median line, but not so far to one side as colpotomy. The incision or incisions are also less diagonal, and extend or converge toward the posterior commissure of the labia majora. Care must be taken not to incise the labial ring, for the skin, if given time, will almost always stretch sufficiently. Perineal Tenotomy. When the dilatation has reached such a degree that one incision will afford all of the dilatation needful, then perineal tenotomy, or an in- cision into the median line raphe or tendon, is preferable. According to the place and amount of such incision the superficial, the deep or the whole perineal tissues (muscles, fasciae and superficies) can be re- laxed. The disadvantage of perineal tenotomy is that it cannot be 'pOStirlor vaffinaL Wall . , Incisions to be made in Perineal Tenotomy.— Compare with Figs. 32 and 111. Cv anterior edge of constrictor cunni ffoureliette) ; I, anterior edge of levator vaginse ; ac, depth of large incision, and course of tenotome in the subcutaneous incision ; da, incision for relaxing levator vaginae et ani ; 6 c, incision for relaxing constrictor cunni and slightly the levator vaginae. made to relax any one ring quite as much as the other operations. Its chief advantages are that with a moderate incision it can be made to relax the whole perineum better, and that the stitches draw together the whole perineum more nearly as it was before. The operation may be performed very much as is colpotomy Qd. 189), except that the incision must be made in the median line. If the vaginal or internal perineal ring be the part chiefly at fault, the inci- sion is mostly vaginal and should penetrate into the tissues until an appreciable relaxation is produced ; if the vulval rings be the offending ones, the incision should be mainly in the vulva; if the whole peri- neum be rigid, the incision should be through both. Fig. 124- shows by curved lines the place and extent of the incisions. The interrupted lines show the extent of the fmaller incisions. In order to avoid wounding the rectum, its course should be determined by rectal inda- gation. When the conditions are favorable the tenotomy should be performed PERINEAL TENOTOMY 191 subcutaneously and antiseptically. At the subsidence of a pain the rings are held b}^ the index placed at one side of the median line, and if necessary the middle finger at the other. A very narrow tenotome should be used whose blade or cutting portion is no more than a half inch in length (Fig. 125). For relaxation of the whole perineum the blade should be entered flat (with cutting edge turned to one side) just external to the ring of the constrictor cunni (Fig. 124, c). The blade point should pass straight down almost parallel Avith the posterior vaginal wall, or deviating slightly toward it, for half an inch. Then the cutting edge is turned backward toward the vaginal wall and the point carried to a point in the vaginal wall opposite to, or back of, the ring of the levator vaginae (6 or a) according as much or little effect upon the internal perineal ring (I) is desired. When the vaginal finger placed over the vaginal 'portion of the raphe feels the point of the in- strument under the mucous membrane, the knife is thrust no farther but is made to cut upward through the raphe at the same time that it is being withdrawn. If, however, the point of the knife makes an appreciable wound through the vaginal mucous membrane, the re- FlG. 125. Perineal Tenotome. mainder of the incision should be out through the mucous membrane and vulval skin, so as to make an open wound of it. If the constrictor cunni be dilatable, the tenotome should be entered internal to the muscle (at d). The knife enters along the curved lines representing the bottom of the incisions in Fig. 124, and makes about the same-sized wound as in the other method, but the cutting is upward instead of downward. The knife may in some cases be passed the required depth under the vulval skin and mucous membrane and the cutting be made just toward instead of from the joerineal centre. We can then stop as soon as we feel the desired amount of relaxation to have occurred. It is also possible, by introducing the knife nearer the posterior commis- sure or labial ring and giving it a direction parallel with the skin, to divide the perineal centre, or attachments of the transverse perinei above the sphincter ani — but such is seldom necessary. Just before operating the parts should be well cleansed, and the- knife and fingers, after also being cleansed, dipped in a five per cent, aqueous, or ten per cent, oleaginous, solution of carbolic acid, or their equivalent. Immediately after operating the parts should be kept 192 LACERATION OF THE PERHsTEUM AND PELVIC FLOOR. compressed between the thumb and fingers, to prevent hemorrhage, and two or three applications of collodion be made to close the opening. As soon as the head advances the fingers may be taken out of the vagina, and the parts pressed against the head. Should the head recede too much between pains to allow of such pressure, it can be held down against the perineum by the fingers placed in front of the coccyx. An aneesthetic, local or general, will oftener be required in this last operation than in the others, which are less delicate. Delivery after Perineal Incisions. After the perineum has been incised it must of course be carefully managed. The directing and restraining forces must be supplied by the accoucheur, and the head slowly and carefully delivered between pains. An anaesthetic should be given to the extent of suppressing voluntary efforts, unless the co-operation of the patient can be obtained. Choice of Methods. When the levator vaginse cannot be safely dilated to form a ring three inches in diameter, bilateral colpotomy should have preference over the other incisions, since a median incision of moderate size could scarcely afford the requisite amount of dilatation. When the diameter of the ring reaches three inches and the head has rotated almost or quite to the median line, a median incision or tenotomy is the prefer- able jDrocedure. This last incision should extend through the ring of the constrictor cunni in case that muscle is also undilated. \Vlien in addition to the bilateral colpotomy the constrictor cunni also needs relaxing, the diagonal incisions may be made to meet at the ring of that muscle, and be extended slightly downward through the raph6, thus completing the Y. Or, when the ring of the levator vaginae is three inches and that of the constrictor cunni requires a slight incision, the diagonal single incision may take a direction toward the posterior commissure and pass through both rings. Thus the two operations are performed by a single cut (colpo-episiotomy). This does not prevent us from making another diagonal incision on the other side, and is the operation most usually performed under the name epis- iotomy. When the levator vaginae is almost or quite dilated or dilatable, and the constrictor cunni is entirely at fault, the best method is to incise the raphfe, and if the levator vaginae be then found to afford resistance, to extend the cut backward. A rigidity of the external muscle precluding a safe dilatation to a diameter of three inclics would make it necessary to extend the median incision to the perineal centre (at the meeting of the transverse perinei) and would call for a bilateral episiotomy. TEEATMENT BY COAPTATIOlSr. 193 After Management. Incisions passing deep into the raph6, or more than half way through the belly of a muscle should be united soon after the labor is completed. Slight subcutaneous incisions in the raphe may be left alone; deep ones should be sewed up along the line of incisions by deep stitches. One or two vulvo- vaginal and possibly a cutaneous stitch will be needed. Silk- worm gut taken directly out of a five per cent, solution of carbolic acid, and introduced with aseptic precautions, is preferable as being noncon- ductive of germs, and subsequently unirritating. It may be removed on the fourth or fifth day. The puncture made by the tenotome is to be kept closed by a stitch or covered by the flexible collodion. Treatment of Perineal Lacerations. Immediately after labor a laceration may be united by sutures, by coaptation, or treated as an open wound. After the wound has healed without restoring a satisfactory condition of the parts, the only treatment left is by support or by secondary perineorrhaphy. Superficial Lesions. Wounds that do not extend into the muscles or raphe should be treated upon the same principles as open wounds upon any other part of the body. Treatment by Coaptation. The great majority of gynecologists of to-day advise the suturing of extensive perineal lacerations after labor; yet there are some of the best authorities, such as Fordyce Barker and Charpentier, who advise against operative measures. Charpentier^ washes off" the wounded surfaces, carefully places them in accurate coaptation, ties the thighs together and then keeps the patient on the back. A compress dipped in a one per cent, solution of carbolic acid is kept against the perineum, and the parts gently irri- gated with the same solution four times in the twenty-four hovirs, and also after urinating. The bowels are controlled by opiates until the fourth day, when a dose of oil is administered. At the end of forty- eight hours the patient is placed for the first time on her side and the edges of the wound examined. He has always found union by first intention in the posterior part of the cutaneous wound, followed by a rapid closure of the remainder. After, the examination the thighs are again tied together by a ribbon. As the posterior part of the tear, viewed externally, is often only through the skin and fat ; as this is the only place where Charpentier clainas to get union by first inten- tion ; as no mention is made of the parts in the vaginal entrance whose restoration * Traitd des Accouchements. 13 194 LACERATIOX OF THE PERIXEr^I AXD PELVIC FLOOR. is of the greatest value ; and as he seems to regard a cicatrized perineum all that is to be desired, it is impossible to consider his success so satisfactory that all attempt at anything better should be abandoned. Immediate Perineorrhaphy. The following personal observations have long since led nie to regard the imraediate repair of extensive perineal lacerations hy suture not only a benefit but a necessity to the parturient woman. (1) When the laceration is sutured, union by first intention occurs as far forward as the front stitch and no farther (^thus proving the action of the stitch) ; the resulting perineum is as large and complete in most cases as that in the nullipar; even when only partial primary union is obtained, the support to the contiguous parts of the pehdc floor is such as to restore to it and to the vagina their pre^dous tonicity and vigor. (2) "When not sutured the perineum is scarcely ever normal or complete. Flaps of mucous membrane and ends of fascife, muscles and nerves are drawn down into the cicatrices instead of being drawn to the parts from which they were severed ; cicatrization may not occur ; either subinvolution or atroj^hy of tissues is apt to result. The fact that the majority of cicatrized lacerations do not require a subsequent opera- tion is no proof that the parts would not be in a better condition if they had been successfully repaired by the primary operation. The chief reason why a secondary operation is often not advisable is that the harm has all been done, and the operation would put the patient to considerable expense and trouble without undoing that harm to a compensatory degree. Reasons for Failure of the Immediate Operation. The reason why the immediate operation has shown so unfavorably is because of poor surgery. Superficial parts alone have been united, edges have been pared so that the subsequent retraction has drawn upon the stitches, proper coaptation has not been attempted, and the wound, although in an unftivorable place for cleanliness and aseptic treatment, has not received even the ordinary attention given to wounds in other parts of the body. Let the care be given that Charpentier recommends for those not sutured, and the results will give no cause for complaint. Contraindication s. As a rule it is useless to sew a perineum upon which the head has impinged for hours, since capillary extravasation of blood has occurred and subsequent inflammation, suppuration, necrosis of tissue, one or all, may be expected to result. To operate under such circumstances without success is the fault of the operator. The quicker the passage of the head the better the chance of primary union. A general condition of the patient that would prevent primary union, THE OPEEATIOX. 195 and circumstances that interfere with approiDriate after-treatment are also counterindications. The Operation. The operation for immediate perineorraphy consists in a neat and accurate closure of the wounded surfaces so that every part lies in di- rect but unconstrained contact with that from which it was separated. A needle, silk thread, a pair of scissors, and a few strips of old linen or muslin cloth, are necessary. A needle-holder, silkworm-gut, two or three sharp hooks, a powder-insufflator, iodoform, carbolic acid, lint, absorbent cotton, etc., are desirable. I generally use a semicircular needle 2^ inches long and 1^ from eye to point, threaded with 12 or 14 iron-dyed silk, or with coarse silk- worm gut, or hardened catgut. A small piece of old muslin, wrapped around the blunt end of the needle, may serve as a needle-holder. As soon after labor as the patient can be made clean, not later than twelve or fifteen hours, she should be placed across the bed on her back with the hips at the edge, and the knees held up or elevated. The parts are often so numb that the oiDcration is not painful, yet in a few instances an anaesthetic may be required. A few drops of a fifteen per cent, solution of cocaine applied to the wounded surface and around the edges by a pledget of cotton, and repeated in four or five minutes has sometimes enabled me within ten or fifteen minutes to obtain com- plete local ansesthesia. The vaginal contents are first allowed to flow out, and then a piece of absorbent cotton or soft muslin stuffed into the vagina and the cocaine pledget placed in the wound. After clipi^ing the hairs from the labia, wiping out the vaginal en- trance, ins23ecting the wound and paring any ragged edges, some fresh strips of soft cloth, a wad of absorbent cotton, or a small sponge should, be introduced beyond the rent. Before the stitches are introduced the edges should be brought together to show just how they belong.. Whether, vaginal portions be diagonal or median, enough vaginal stitches should be used to coajDt the edges perfectly. The point of the needle should be introduced about one-thirty-second of an inch from the edge of the wound, should pass not parallel to its surface, but slantingly so as to grasp deeply into the retracted ends of the torn fibres of the levator vaginae and levator ani, then out over a small strip of the bottom of the wound, into the tissues opposite the point of exit and out again through the mucous membrane exactly opposite its first entrance. The finger should be introduced into the rectum when a deejD stitch is introduced in order to avoid including it. It is usually most convenient to introduce the first stitch in the upper end of the wound. If Ave have no sharp hooks or cannot, on account of the rounded edges (Fig. 117), determine just where the upper angle should be, we can put in a stitch just behind the carunculee and, witliout tying 196 LACERATION OP THE PEEIXEUM AXD PELVIC FLOOE. it, use it to draw the laceration into better shape. If we find a double diagonal laceration with a forward extension through the vulva, we may introduce a stitch from the external skin along the extreme upper edge of the tear on the left side, bringing it out at the angle of junction of the median and transverse portions, catch it into the fibrous coat of the projecting tongue of the lacerated posterior vaginal wall in the median line, and bring the point across to the opposite labium and out through the skin of the upper edge of the tear. This stitch, like all others taken from the skin, should enter near the edges of the wound and pass deep into the sides in order to include and draw together the deeper and more important tissues. It should not be tied until the last, but may be made to draw the wound together and show where the other stitches belong. When the stitches are passed in this way near the edge, there is less tendency to compression, eversion and sup- puration. Fig. 126 shows the stitch thus passed; Fig. 127, passed in the ordinary way. Fig. 127 also shows why it is sometimes necessary Fig. 126. Fig. 127. Fig. 126.— a. Deep Suture entered near edge of Wound to avoid Eversion and Compression; 6, same, tied. Fig. 127.— o, Deep Suture entered at a distance from the edge of Wound ; 6, The Same, tied . Com- pression of edges and tendency to eversion above the interrupted line. Primary union is apt to fail above this line. to pare the edges of the wound, as in Fig. ] 28, to prevent constric- tion, eversion and want of union of the surface, and explains the paradox that to cut away the edge gives a thicker perineal body. As each stitch is passed, starting at the upper end, the raw surface should be thoroughly cleansed, and, if practicable, touched with a three per cent, solution of carbolic acid or one two-thousandth solution of cor- rosive sublimate, or dried and sprinkled with iodoform, and the stitch tied tight enough merely to draw the parts together. The anterior ex- ternal stitch must be the firmest, since that one sustains the chief strain and protects the others. Vaginal lacerations in the median line may be united by a few fine stitches or a continuous catgut suture. Flaps in the vulva and va- ginal entrance are similarly stitched to the opposite side from which they were torn, and the sides of the open cavity under them brought together by the deep cutaneous sutures. Thick flaps are best united by Tait's flap stitch. The needle is passed into the flap at the edge of the mucous membrane or skin, through almost its entire width, THE OPERATION. 197 then out across the bottom of the wound, into the opposite side, and out again at the edges of the mucous membrane opposite its first intro- duction. Fig. 129 gives a profile view of the stitch passed. If the sphincter ani is not ruptured, I first place the upper external stitch at the very upper end of the laceration and draw the parts to- gether. It will then be easy to see just where to put the next one and how deep it need be to entirely close the wound. One stitch at the top will seldom hold the ends of the transversus perinei unless it be placed too low to keep the upper edges together, hence two or three must generally be used. If the sphincter ani be lacerated the first external stitch should be devoted to it, and should grasp deeply into it so as to include the fibres at the bottom of the wound and thus bring the whole muscle together. The next stitch should be a little above it, and should reach Fig. 128. Fig. 129. Fig. 128.— a, Edges of Wound Pared to prevent compression by stitches and suppuration of edges. b, The same, tied. Fig. 129.— Flap Stitch, entered into edge of Flap and brought out at opposite edge of Wound. out well into the retracted tissue to get a good hold upon the trans- versus perinei and restore the perineal centre. One or two deep ones above these will usually close the wound completely, provided the vaginal stitches have been placed. When thus perfectly coapted under thoroughly aseptic precautions, the parts adhere almost immediately, and are quite firm in four or five days, and as there is an abundance of tissue about the puerperal genitals there will be but little traction until the union will have become firm. Although silkworm gut is hard to tie properly, I prefer it for the main vaginal stitches, and leave it from ten to fifteen days, or until the perineal body is firm. Well-prepared catgut is more easily used, and just as efficient for the higher vaginal stitches provided the lower and external ones are properly placed so as to sustain all traction. I have frequently used silk for all sutures, removing them in four or five days, with equal success. Waxed silk sometimes gives pain in passing through the tissue, but is easily tied, and the best adapted for the flap stitch. There is no object or justification in putting the woman through the mild but prolonged torture attending the use of silver sutures. When the parts are properly united the after-treatment is more watchful than active. The knees are bound together so that they 198 LACERATION OF THE PERINEUM AND PELVIC FLOOR. cannot be separated more than ten or twelve inches, and the permeal skin covered by a folded piece of iodoform gauze, or lint soaked in a ten per cent, solution of carbolic acid in castor oil. The vulva is cleaned three times a day by squeezing hot water over it from a sponge, and also each time after the patient urinates, or is catheterized. With such precautions she may urinate in a flat bed-pan from the begin- ning. On the third day I commence vaginal injections of hot water, substituting a two per cent, solution of carbolic acid as soon as there be found a decided odor or appearance of ]3us in the discharges. The parts should be inspected in a good light on the third and each suc- ceeding day or two. On the third or fourth day a dose of castor oil or a mild saline is given. On the fifth all silk stitches are removed and the knees liberated from the bandage, but the patient forbidden to separate them. If silkworm-gut stitches have been used, they need not be removed for several days or a week later, unless they are too tight and commence to ulcerate. Frequently, however, there is more to do than this. The inflamma- tory reaction may go on to suppuration. If so, after each carbolated douche the labia should be separated, and the edges of the wound washed and touched with a five per cent, solution of carbolic acid or sprinkled with iodoform. If pus come from the vagina a three per cent, solution may be thrown in upon the stitches with a little piston syringe, after having placed a little cotton on the meatus urinarius to protect it. A very small strip of lint dipped in carbolated oil, but squeezed out so that the oil will not get on the urethra, should be laid over the edges of the wound in the vulva, and on the external cuta- neous surface. The parts should be thus dressed twice a day except that a three per cent, solution of carbolic acid will be strong enough after the first dressing or two. If the suppuration increases the parts should be dressed every eight hours. After the stitches are removed the wound should be cleansed with the carbolated water and protected with the carbolated oil or lint three times a day, until suppuration has pretty well ceased, then twice a day. In this way, even when the condition is not favorable, I always get union of the deeper and important tissues by first inten- tion, and usually of the whole. In most cases in which the stitches include much skin, as in Fig. 127, there will be a little suppuration in the fatty tissue about the external cutaneous edges, and occasionally a little about the bruised edges near the hymen, which scarcely ever diminishes the length, but may slightly diminish the thickness of the resulting perineal body. I have twice introduced a deep stitch to hold granulating perineal surfaces together, but have only produced irritation and increased suppuration, and now content myself with binding the knees and dressing the surface as an open wound. If, however, we have a nurse SECONDARY PERINEOREAPHY. 199 who will thoroughly and frequently syringe out the depression or gutter between the wounded surfaces, the granulations may be ex- pected to meet and unite more quickly, and draw the parts in better shape, than without the stitch ; but without such attention the inclosed pus decomposes and does harm. Lacerations into the Rectum. I have not yet had an opportunity to sew up a laceration opening into the rectum by immediate operation, but consider that the advan- tages of an immediate operation are greater for such a lesion than for the incomplete variety. As such a laceration usually occurs rapidly, and before much dilatation of the inferior parts, the probabilities are that the amount of bruising will not usually be sufficient to prevent union by first intention. The edges should be trimmed perfectly smooth, the parts drawn together by hooks, and the shape of the tear accurately determined. The rectal mucous membrane is then united accurately by a continuous catgut suture, or a series of silkworm-gut interrupted sutures, which include but little beside the rectal mucous membrane. The remainder of the rent is then united as directed for lacerations not extending into the rectum. It must be borne in mind that no traction is allowable on the rectal stitches ; the vaginal and cutaneous must be depended upon for holding the parts together. The after-treatment is the same as for the lesser lacerations, except that the bowels are kept constipated for four or five days at least, and not disturbed by a laxative unless a rectal pressure is complained of by the patient. The less opium that accomplishes the purpose the better. In finally moving the bowels I prefer to give five or six grains of blue mass, followed, if necessary, in twenty-four hours by a mild saline, so as to give time for a softening of the faeces. If lumps are felt in the rectum they should be broken up against the sacrum by the well-oiled finger introduced along the posterior rectal wall. As rectal tubes or catheters are liable to be directed by the rectal promon- tory forward against the wound, they should not be used except by the physician. (See Figs. 31 and 54.) The silkworm-gut vaginal stitches should be allowed to remain for two or three weeks, and if not easily accessible without stretching the parts, may be left two or three weeks longer. Secondary Perineorraphy. An ideal secondary perineorraphy should be the same as the imme- diate operation, with the additional preliminary step of cutting out the cicatrices, and denuding the tissues that were exposed at the time of the laceration. That the older methods of restoring the vulvo- vaginal outlet and forming a new perineal body were unsatisfactory, is attested by the number, complication, and confusion of methods that 200 LACERATION OF THE PERINEUM AND PELVIC FLOOR. have been recommended. The first and fatal fault consisted, and still consists, in treating the perineum as so much plastic tissue to be cut and fitted as a tailor fits a coat. For the sake of simplicity it is also customary to recommend one form or fashion of perineorraphy as the usual operation. It would be much more reasonable to recommend, for the sake of simplicity, one amputation of the leg for all kinds of injuries requiring an amputation, for the leg is a much simpler struct- ure than the perineum. What is to be Accomplished. It is not only necessary to remove a cicatricial tissue and unite torn surfaces in performing perineorraphy, but to so unite them that the characteristics of the perineal body will be restored. The recto-vaginal promontory must normally close the pelvic outlet. The V-shape of the edge of the levator ani, the sling shape of the levator vaginae, the convergence of the labial tissues at the fourchette, the size and pyra- midal shape of the perineal body, and the approximation of the median line attachments of the levator vaginae and constrictor cunni to the perineal septum, are all to be restored. WJien to Operate. The operation should be performed as soon as the parts can be brought into a healthy state and the patient's general health will per- mit, for the longer the delay the greater the reaction and atrophy of tissue, and the less the chance of restoring the contiguous unsupported deeper parts to their normal place and condition. (See Prognosis.) Methods of Restoring the Perineum ivhen the Rectum is not Opened. From the time when perineorrhaphy meant the denudation and uniting of a narrow strip of labial tissue there has been a long series of operations devised, many of which still survive as useful thera- peutic measures. Yet none of them has, or can, become the one ideal operation. The Median Triangular Operation. The oldest of the surviving methods of closing the rent is by a triangular denudation. A line is drawn along the edge of the skin external to the laceration from a point on one labium major above the lacerated portion to a corresponding point on the other labium, and two other lines joining the ends of this line to a point in the median line of the posterior vaginal wall above the cicatrix or relaxed portion (Fig. 130). The surface included in these lines is to be denuded. Two denuded triangles are thus formed whose common base (the dotted line) is the median line. They to be brought together THE MODIFIED TRIANGULAR OPERATION. 201 SO that the labial angles (I I) will meet, and be so stitched by vaginal and cutaneous stitches. By comparing Fig. 130 with Figs. 114 and 115 it will be seen that the denudation corresponds with the appearance of certain median lacerations after labor. This is the ideal operation in median lacerations of the vulva with but little or no extension into the vagina. But as such lacerations seldom require attention after having cicatrized, the operation is seldom to be performed. The Modified Triangidar Operation. In extending the denuded triangles far enough up the posterior vaginal wall to cover a median laceration extending through the levator vaginse, it has been found that the traction ujDon the stitches at the in- troitus vaginse prevents primary union between them. In consequence a pus pocket forms at the recto-vaginal promontory and a subsequent depression remains at or in front of the recto-vaginal promontory Fig. 130. Fig. 131. -/Skin ^/Jr Triangular Denudation (Schematic). vv, vaginal stitches, not always required : cec, cutaneous stitches ; 1 1, labia. Modified Triangular Denudation (Schematic.) I V, anterior edge of the levator vagina. something like that in Fig. 123. Too much of the levator vaginse has been excised and the perineal body is of course but imperfectly re- stored. In order to obviate this the triangles are made to extend only to the levator vaginse, and a smaller triangle or notch is denuded on the posterior vaginalwall as far as desirable. Fig. 131 shows the triangle thus modified, Fig, 132, the surface as it appears between the labia. The reason why the raw surface in the secondary operation is nar- rower than that found immediately after the laceration has occurred, is because the parts are, in the latter case, all drawn apart to an equal degree for inspection, whereas when cicatrization occurs the edges of the shallow and but slightly retracted vaginal portion are drawn over the wounded surface in a proportionately greater extent than those of the many times deeper and strongly retracted vulval portion. This operation is then the ideal one for median lacerations extend- ing up the posterior vaginal wall. But the proportion of such extended median lacerations requiring a secondary operation is small. 202 LACEEATIOX OF THE PEEIXEUM AND PELVIC FLOOR. The Bilateral Operation. Having noticed from a study of the cicatrices that lacerations extend- ing beyond the vaginal entrance assumed a diagonal direction on one or both sides instead of following the median line, W. A. Freund rec- ommended to extend the vaginal triangles or tongues along the cic- atrices on either side, and leave the sound vaginal wall about the Appearance of the Modified Triangular Denudation u- viewed between the separated Labia with stitches passed (Zweifel.) median line. As the cicatrix does not always represent the entire ex- tent of the tear, he removes sufficient tissue around it to normally close the vaginal orifice. The resulting raw surfaces have almost the same shape as that which is found immediately after the laceration. Com- pare Fig. 117 with Fig. 133. The edges of the vaginal denuded strips are first drawn together (Fig. 134), and afterwards the resulting vulval triangles. Even when one of the arms of the Y is almost or entirely wanting in the cicatrix, a short strip must be denuded in order to bring the parts together symmetrically. For instance, if the shorter vaginal strip were entirely gone in Fig. 133, and the edge of the denuded figure were at the dotted line instead, it will readily be seen THE BILATERAL OPERATION. 203 that the edge of the vaginal portion on the side of the dotted lines would be too long for the other side. This method is the ideal one for the incomplete Y-shaped lacerations which are so frequently met with. Martin has modified Freund's me- FlG. 134. Bilateral Denudation with stitches passed. vvv, vaginal stitches ; ccc, cutaneous stitches ; Z, labia. The Same, with Vaginal Stitches tied. thod by extending the vaginal tongues deep into the vagina and the vulval denudations higher up. It is, however, intended more as an Martin's Modification of the Bilateral Denudation. operation for prolapse when the parts cannot be permanently restored to their normal relations, and gives a small firm vaginal entrance. (See Fig. 135.) 204 LACERATION OF THE PERINEUM AND PELVIC FLOOR. Crescent Operation. As in many cases the vaginal entrance only is lacerated, the cicatrix may be removed and the lacerated parts united by removing a crescent from the vulvo-vaginal entrance whose angles extend into the posterior vaginal sulci or grooves (Fig. 136). The centre of the convex external edge of the crescent reaches almost or quite to the fourchette. The centre of the concave inner edge is at the lower end of the sound posterior vaginal walls behind the cicatrix, or in the absence of a cicatrix it is located just below the median line attachment of the levator vaginse. The angles of the crescent include the cicatrices of the diagonal laceration. The stitches are so placed as to draw the two edges together com- mencing at the angles (Fig. 137). When they are drawn together a labial notch is left from the longer side of the crescent to be united by one or more sutures. This is the ideal operation for the V-shaped lacerations. It draws together the torn edges of the levator vaginae, or shortens it if it be Fig. 136. Fig. ]37. Fig. 138. W --^Fazrjrchette^ yyytejtr ^^: JT^ZtS (The laceration is supposed to IhtS Fig. 136.— Crescentic Denudation with Vaginal Stitches passed, have been larger on patient's left side.) V, vagina; ss, sulci of post- vaginal wall. Fig. 137.— The Same, with Vaginal Stitches tied. Fig. 138.— Crescentic Denudation modified to close a Transverse Laceration without narrowing the Vulva. Same lettering as Fig. 136. (The laceration is a little larger on left side (of patient) than on right.) relaxed from diffuse laceration ; it restores the recto- vaginal end of the raphe; and it brings together the separated ends of the constrictor cunni in case that has been reached by the tear. Much or little vulval tissue may be included, and the labial notch left after passing the vaginal stitches may be increased if the vulva remain too much relaxed. When the V is very wide open or the rent is a transverse one with a slight diagonal extension on either end {\ • x x )^ it is better to place the ends of the external convex curve low down at the outer side of the sulci, and make the inner curve pass deeper into the sulci and then turn back to meet it. Thus the inner side, b}^ the extra con- vex curve at each end, becomes as long as the external side, and may be united without leaving a redundancy anywhere (Fig. 138). emmet's crescent operation — STAR OPERATION. 205 Emmet^s Crescent Operation. Emmet operates upon posterior colpocele and rectocele by drawing without undue traction the crest of the rectocele and the two lower caruncles together by tenacula, denuding the tissue thus folded together as far into the sulci as the folds extend, and uniting the edges of the resulting figure in the shape of a crescent by stitches " passed in a direction from the centre towards the circumference,"* somewhat as in Fig. 137. This operation holds about the same relation to the operation just described as Martin's operation does to Freund's. It removes the vaginal tissue that cannot be replaced and closes the vaginal entrance to the desired extent. Its chief peculiarity is that it unites the ends of the levator ani (from which a median piece has been removed) to the vulval tissues, instead of to each other in the median line. The danger lies in drawing down the relaxed levator vaginae so that too much of it will be removed. It is a good operation for uncicatrized lacerations through the peri- neal raphe that have resulted in rectocele, and prolapse of the posterior vaginal wall, to an extent that cannot be remedied by anything short of cutting off the protruding vaginal tissues. It is also an excellent procedure for transverse lacerations through the raphe, with or with- out rectocele, in which the levator vaginae, although torn loose from the rest of the perineum, is not relaxed. It will not then be pulled far enough down to be involved in the denudation, and will be reattached to the perineal body and vulva. Transverse Denudations. A transverse laceration at the vaginal entrance, whether superficial or submucous, cicatrized or not, should be closed by a transverse strip from half to one inch wide along the cicatrix, or by a removal of the whole of the relaxed tissue between the levator vaginae and constrictor cunni. The width of the strip is determined by the amount of pro- trusion between the muscles or by pressing them apart by the finger in the rectum. The stitches are passed antero-posteriorly. That such a denudation would cure any considerable misplacement of the parts above is scarcely to be expected, for the amount of relax- ation of the levator vaginae and constrictor cunni is usually such that a shortening of these muscles and a removal of redundant vaginal tissues is required. Star Operation. , When such is the case a median triangular or bilateral figure may be drawn across the transverse strip (Figs. 139 and 140). . The edges of the longitudinal vaginal strips are first brought together by trans- * Am. Journal of Obstetrics, vol. xviii., p. 173. 206 LACERATION OF THE PERINEUM AND PELVIC FLOOR. verse stitches, then those of the transverse strips by stitches passed antero-posteriorly, and finally the vulval portions. When but little or no laceration of the vulval tissues exists the vulval denudation Fig. 139. Fig. 140. 7^ Amis star Denudations for complication of Transverse Lacerations with other varieties- Sutures passed. The interrupted lines indicate the shape of the larger labial denudation when required. may be reduced to a small triangle, or nick, whose apex is at the foar- chette or posterior commissure of the labia majora ; or the labial de- nudation may be left out altogether. The following cicatrices taken from the table on pages 175 how some of the lacerations for which this form of denudation is applicable. ■Y-A^^^^-H- +T J. As a rule the star-shaped denudations should give way to the sim- pler forms when the latter can be made to remove cicatricial and use- less tissue only, and restore the natural relation of the parts. In some cases the crescent denudation, or Emmet's, or Freund's bilateral can be made to answer. But a simpler form should never be preferred on purely mechanical principles, to the sacrifice of anatomical and physi- ological desiderata. Flaip Operations. One reason of the imperfect results attained in secondary peri- neorrhaphy is that traction upon the edges is caused by a cutting away of too much superficial tissue. This may be avoided by raising flaps. The Triangular Flap Operation. The simplest form of flap operation is that devised by John Duncan, of Edinburgh ,^^ and which is practically a modified median triangular' operation. An incision is made in the median line from the upper end of the laceration in the posterior vaginal Avail to the posterior com- missure, or as far back toward the anus in the median line as the laceration may extend. From the lower end of this median incision, * Hart and Barbour, Manual of Gynecology. BISCHOFF S OPERATION. 207 one is made on each side along the vulval border of the laceration to a point on the labium major as high as the denudation is to ex- tend. A flap is then dissected up on each side whose edges are these incisions. In Fig. 141 c 6 is the median incision, and a b the external. a b c forms the flap to be raised up as far as a c. The flaps are raised, trimmed, and stitched together in the median line by superficial Fig. 141. Fig. 142. Fig. 141.— Lines of Incision in the Triangular Flap Operation. (Hart and Barbour.) a 6, labial incisions ; c 6, median line incision passing to posterior vaginal wall ; abc, flap to be raised. Fig. 142. — Flaps Raised and Sutures Passed in same Operation. (Hart and Barbour.) stitches, and then the labia brought together by ordinary deep cuta- neous sutures. Fig. 142 shows the sutures passed. Lawson Tait merely turns the flaps into the vagina without stitching them, and then passes the deep sutures under the edges of the skin so that after they are tied none of the threads but the knotted portions at the edge of the wound are visible. Bischoff^s Operation. In Bischoff's operation a denudation is made similar to Freund's (Kuestner*) except that the tongue of vaginal tissue left in the median line is narrow, and the denuded strips on either side are wider and nearer together. Then the tongue of the posterior vaginal wall is dis- sected up and brought forward over the median line raphe, stitched between the labia and lateral walls, and the perineum united by deep external sutures, commencing behind. Fig. 143 represents the figure * Zeitschrift f. Geb. und Gyn., xiii., 1. 208 LACERATIOX OF THE PERINEUM AND PELVIC FLOOR. to be denuded; Fig. 144 the denuded figure after tlie flap has been drawn forward. The operation, like Martin's, is more of an operation for prolapse than for restoring a normal condition of the perineum. The denuded figure extends far out on the labia and near the anus. Fin. 14?.. Fig. 144. Denudation as made by Bischoff. The Same, with Flap Raised and drawn forward. Modified Freimdh Operation. Freund's operation is, I think, improved by cutting away only the cicatricial tissue, and raising a short, thick flap from the wide tongue of the posterior vaginal wall in the median line. The flap should commence at the upper end of the denuded vaginal strips on the median side and gradually increase in width and thickness until at the end it is from a quarter to a third of an inch wide. This must be stitched well forward toward the fourchette, and will make up for the previous retraction of the posterior vaginal wall. It is also well, when the denudation extends laterally beyond the cicatrix, to leave the normal membrane and raise a narrow thick flap at the sides. This enables us to get a firm deep hold upon the levator, and without undue traction upon the levator vaginse and mucous membrane, such as must result from a wide superficial denudation. The upper end may be united by superficial catgut sutures, but that near the hymen requires one or two deep stitches, preferably flap stitches, one each side. The cutaneous stitches must, of course, bring the tissue external to the hymen in apposition. The anterior or upper one should be placed well forward, and may grasp the flap of vaginal wall just under the mucous membrane. Crescentic Flap Operation. The crescent operation already described may, when done for a V-shaped laceration, be usually performed as a flap operation. The vaginal tongue, and if necessary the opposite edges, are dissected up as flaps the same as just described for converting Freund's bilateral operation into the flap variety. The flap is then stitched to the anterior curve of the crescent, either as in Fig. 136 or 138. UNILATERAL FLAP OPEEATION. 209 Unilateral Flap Operation. The S-shaped lacerations at one side of the median line (Fig. 113) are usually flap lacerations, and the edge of the flap is usually drawn or turned in at the edge of the cicatrix. In this case a line is drawn along the edge of the vulval skin and mucous membrane at the median side of the cicatrix from the external skin as far up the posterior vaginal sulcus as it goes. (See Fig. 145.) The denudation is carried from this line laterally so as to remove the entire cicatrix. If the denudation is then not high enough on the side, the vaginal wall and vulval skin are dissected up as a narrow thick flap. Then, instead of removing any more tissue the vulval skin and mucous membrane are dissected up as a flap /, toAvard the opposite side as Fig. 145. Unilateral Flap Denudation. V I' i; 2) z), vaginal flap sutures; vl,'vl,y\i\v&\ superficial sutures; c c o, cutaneous deep sutures, passed under flap (/) after the vaginal and vulval stitches have been tied ; /, flap. The inter- rupted lines on either side show extent of denudation under the flap/, and the edge opposite. far as the laceration is known to have extended, or sufficiently, when the surfaces are united, to restore the size to the vaginal entrance and perineal body. The interrupted lines on both sides show the extent of denudation under the flaps. As the bottom of the laceration is mainly on one side, the denudation must be so. The edge of the flap, however, usually comes out longer than the other side. This is remedied by making the top of the laceration at the inner side of the vaginal strip and placing the stitches so as to draw in the flap toward the larger curves of the other side from where it has been prolapsed. I have noticed this same disproportion in the length of the sides in sewing up such lacerations after labor, and have remedied it in the same way, and without removing any tissue. At the vaginal end and in the labia, superficial catgut stitches may be used to unite the edges of the flap, but at the hymen and levator vaginae one or two deep flap stitches are of advantage. The external 14 210 LACEEATION OF THE PERINECJM AND PELVIC FLOOR. stitches should, as in the modified Freund's operation, be made to close the parts as deej) as the hymen. Operations upon Uncicatrized Lacerations. Sometimes it is possible to diagnose the character of an uncicatrized laceration from the appearance of the mucous membrane. But usually it is necessary to diagnose the amount of primary relaxation and displacement, as distinguished from the secondary relaxation and displacement in the uninjured parts. Having then calculated or as- certained by direct palpation just how and where the lesion occurred, the apj)ropriate ojDeration can be chosen, to restore the separated j^arts to their original relationship. Lacerations Lnvolving the Sphincter Ani bid not the Rectum. When the laceration extends into or through the sphincter ani but not through the cutaneous membrane lining the anal canal, the denu- dations are made the same as if the sphincter were not invaded. But greater care must be taken that the first stitch be introduced far enough back beside the anus to catch into the whole thickness of the retracted sphincter. The next stitch should be just at the external edge of the sphincter. Above that they are passed as in other smaller lacerations. Closure of Lacerations Extending a Short Distance into the Rectum. Lacerations passing through the sphincter into the anus and rectum need more careful attention in getting the parts about the anus in ap- position, but otherwise may be united very much as already described for the incomplete varieties. The denudation should include the edges of the rectal rent and the vaginal cicatrices, and should extend to the edges of the strijD of anal skin lying upon the opened and straightened sphincter at the bottom of the field. The vaginal denudation must be extensive enough for the needle to reach the lacerated ends of the levator ani on one or both sides of the rectum. Hegar applies the principle of the median triangular operation. The figure when denuded has a butterfly shape (Fig. 146). Closure of the rectal rent alone would leave the figure of the shape of the modi- fied triangular operation for incomplete lacerations (Fig. 132). The rectal and vaginal stitches are placed in the deeper portions so as to close the upper part of the tear both in the vaginal and rectal side. This gives the operator an opportunity to place some of each deep and some superficial, according as he wishes to elevate or support the tis- sues. The objection to this method is that the tears are seldom median, and healthy tissues are removed and cicatrices left. An equally valid FLAP OPERATIONS. 211 objection is that it does not, unless the vaginal strip be too wide, give a hold in the levator ani fibres beside the rectum ; and, therefore, although exerting great traction upon the vaginal entrance and levator vaginse, does not raise the pelvic floor edge or rectal promontory, and thus does not sufficiently protect the perineum against the reflected abdominal pressure. Freund's bilateral denudation is applicable when the bilateral vagi- nal laceration is found (Fig. 147). The rectum is first sewed up by Fig. 146. Fig. 146.— Hegar Triangular Denudation applied to Lacerations extending info Rectum. V, vaginal wall ; I, labia. Fig. 147.— Freund's Bilateral Denudation (Kuestner) for Laceration into Rectum. 1 1, labia ; v, vaginal wall (posterior) ; r, rectal mucous membrane ; c, vaginal denudation around cicatrix ; n, nick of tissue removed to render the vaginal edges more symmetrical. The shaded portion indicates the size and shape of the cicatricial tissue. stitches extending only one-third through the septum, and then the vaginal by stitches extending about two-thirds through.* When only one arm of the Y extends up the vagina, a compensating small strip may be denuded on the sound side. (See Bilateral Operation.) The first external stitch should, as pointed out by T. A. Emmet, be introduced below and a little internal to the ends of the sphincter in order to get a deep hold of the fibres, and should pass obliquely to the edge of the anus across the strip of the anal skin into the edge of the muscle and out at a corresponding point opposite. As the course of the needle is not straight, great care must be taken to penetrate deeply into the muscle. The next suture is passed opposite the outer edge of the sphincter and catches up the external fibres. Above this they are passed in the ordinary way. Flap Operations. John Duncan, A. R. Simpson, Lawson Tait, and Hart and Barbour close these operations by a modification of the triangular flap opera- tion. They make a labial incision from the posterior edge of the end * Kuestner Zeitschr. fur Geburtsh. u. Gyn., vol. xiii., No. 1. 212 LACEEATION OF THE PERINEUM AND PELVIC FLOOR. of the anal sphincter (Fig. 148, b) up along the outer edge of the laceration as in the incomplete variety. Another incision, S 1, is made on each side from the top or apex of the rectal opening, along the recto-vaginal septum to the first incision, a b, so as to pass across the perineal hody a little in front (or above) the edges of the anal skin. The recto-vaginal septum is split by knife or scissors at the apex of the rectal opening along the line of the incision, and flaps raised both in front and behind it. The anterior flap, a 1 S, is raised, pared and attached by superficial sutures to its opposite, to constitute the poste- rior vaginal wall, fourchette and posterior commissure of the labia. Fig. 148. Fig. 149. Fig. 148.— Lines of Incision of the Triangular Flap Operation applied to Lacerations extending into Eectum. (Hart and Barbour.) a 1 S, flap to be raised and united to its opposite to form posterior vaginal wall ; 6 25, flap to be raised and united to its opposite to form anterior rectal and anal wall. Fig. 149.— Flaps raised and Sutures passed in same Operation. (Hart and Barbour.) The posterior flaps b2S are united over the rectum to constitute the anterior rectal and anal walls. Fig. 149 shows the flaps raised and united. The sides of the perineum are brought together by superflcial and deep sutures. Tait turns the anterior flaps into the vagina and the posterior into the rectum without the superficial stitches. This method of denudation is useful, but from a strictly scientific standpoint is only applicable to cases of median lacerations into the rectum, which are the exceptional ones. By cutting a^vay the cicatricial tissues from the vulva and vagina and then raising flaps, the largest one from the side opposite the uni- lateral diagonal vaginal extension, the principle of the unilateral flap operation (Fig. 145) can be applied (Figs. 150, 151, 152 and 153). FLAP OPEEATIONS. 213 Thus the vaginal Hue of sutures at the recto-vaginal promontory will be diagonal, that of the vulva slightly diagonal while that of the rectum will be almost median. Fig. 150. Fig. 151. JI/[]iB.latij Tina 'iiiv Fig. 150.— rnilateral Flap Operation applied to Lacerations into Rectum. Rectal superficial sutures (r s) passed ; vf, flap raised from posterior vaginal wall. The interrupted line shows how far the flap is raised. Fig. 151.— The Same. Rectal sutures tied, flap stitches (fs) passed. When the vaginal rent is bilateral two strips should be denuded and the tongue of vaginal tissues in the middle raised around its edges. Fig. 152. Fig. 153. of Fig. 152.— The Same. Vaginal Flap Sutures Tied. Vulval superficial sutures {&&) passed. Cuta- neous deep sutures (c s) passed. Fig. 158.— Vulval Sutures Tied. Lower cutaneous stitch (through the sphincter) tied. 214 LACERATION OP THE PERINEUM AND PELVIC FLOOR. After closure of the rectum by superficial stitches it is closed the same as recommended for the modified Freund's operation for incomplete lacerations (p. 208). Bischoff' s Flap Operation has been applied with some success to the complete lacerations. After closure of the rectal opening the flap is brought forward (p. 207). Langenbeck's operation, which is the oldest, is similar to the last. The edge of the recto- vaginal septum is denuded and then split for some distance. A flap is then simply cut out of the vaginal side and, after closure of the rectum, is stitched forwards over the new perineum by vaginal stitches. The external stitches are placed from before backward. Lacerations Extending High up into the Rectum. Lacerations deep into the rectum usually pass on one or both sides of the median line, as the S, V or Y-shaped, whereas in the lesser forms of rectal lacerations the rectal portion is rounded and may be treated as a median one. Fig. 154. Emmet's Method of passing the Sutures in case of a Bilateral Diagonal Laceration extending through the Recto- Vaginal Septum. In such a case it is all the more necessary that the denudation follow the lateral cicatrices in order not to remove the healthy tissue. Freund's method is the same as just described (p. 211) except that more rectal stitches are required. Emmet removes the tongue of vaginal tissue, denudes beyond both rectal tears on the sides, and then draws the whole together by stitches passed completely across and directly through the tongue of rectal mucous membrane (Fig. 154). CHOICE OF METHODS. 215 Tait o]3erates upon these deep rectal lacerations by splitting the recto-vaginal septum (without removing any tissue) into thick flaps. He introduces the stitches at the vaginal edge of the raw surfeces parallel with the surface of the flap, carries them into the deeper structures and out at the rectal flap, introduces them at the rectal flap opposite and brings it out at the vaginal edge. In this way a Fig. 155. Splitting of the Perineum and Recto-Vaginal Septum with Flap Stitches passed, after the manner of Lawson Tait. Copied from Billroth and Luecke's Handbuch der Frauenkrankheiten. large surface is united, the deeper structures are brought together, the rectal edges protected by the folding flaps and the operation very much simplified. The results are generally conceded to be good. Fig. 155 represents the stitches passed. The external parts are united similarly. ' Choice nf Methods. The surgeon should vary his method according to the case, and be guided by the amount of displacement and destruction of parts, and the shape and character of the cicatrix. The cicatrix should as a rule be excised and the denudation completed by the raising of flaps. Old 216 LACERATION OF THE PERINEUM AND PELVIC FLOOR. cases may present so much shrinkage and retraction that flaps must be made of the cicatricial tissue. Flaj)S made in part of cicatricial tissue should generally be united by the Tait's flap stitch ; flaps of healthy mucous membrane by ordinary superficial stitches in the vulva, and deep or flap stitches in the vaginal entrance. Preparation of the Patient. For a week before an operation, in a case in which the rectal sphinc- ter is involved, a mild laxative should be administered every two or three nights, supplemented if necessary by daily enemas. A drachm of Comp. Tinct. Cardamom, or a grain of Piperin combined with a third of a grain of extract of nux vomica, may also be advantageously given every night for four or five nights before the operation. The diet throughout the week should be light and easily digestible. On the day before the operation the colon should be as completely emptied as possible by two or three copious enemas of weak soapsuds, or glycerine and water in the proportion of one to ten or fifteen. If the contents of the colon be not brought down, the enemas should be given in the knee-chest i30sition. After each evacuation the genitals should be bathed with water, and anointed with some simple oint- ment. The last enema should be of plain water, and should be given from three to twelve hours before the operation. A little later a small dose of an opiate with an aromatic should be given to protect the rectum and anus against the seeping of watery faeces. When the sphincter ani has not been lacerated, nor the rectum opened at any point, all of this treatment may be dispensed with. A thorough evacuation of the bowels the day before, and an enema two or three hours before the operation will be sufficient. Preparations for Operating. The instruments necessary are a scaljDel, a pair of sharp-pointed long-handled scissors, small and large curved needles, three tenacula, Fig. 156. Perineum Scissors dressing-forceps, sponge-holder, needle-holder, catgut, silkworm-gut, wax, heavy and fine silk, silver wire, wire-twister, sponges, three or four of the Langenbeck serres-fines for compressing arteries. OPEEATIVE DETAIL. 217 We should have an assistant for the ana3sthetic, two to support the knees, separate the labia and hold tenacula, and another for instru- ments and sponges. Fig. 15 Langenbeck Serres-flne for Compressing Arteries during the Operation. The patient should be placed in the dorsal position with the knees drawn up. The operator should be comfortably seated with a good light shining over his shoulders, and his instruments on a table at his right within easy reach. Operative Detail. Before commencing the denudation the operator should ascertain by palpation just what parts are out of place and relaxed, and by hooking the tissues together with tenacula how they can be best brought into place. Having then determined by inspection of the cicatrix and attenuated tissues what portion is to be excised and what to be turned up as flaps, an incision around that to be removed is made, and after its removal an incision along the edge of the flaps to be dissected up. Flaps should not extend into the muscular tissues unless there be cicatrized tissue or other evidence of an oblique lacera- tion into it, as, for instance, in the unilateral flap laceration. It is better to begin the denudation at the lower superficial parts which do not bleed as profusely nor soil the parts to be denuded above. Large vessels may be clamped by the serres-fines, or they may be tied with fine catgut, and thus time for a careful preparation of the surfaces be gained. After having performed the same operation a number of times, the outlining of the part to be denuded will be unnecessary, and the denudation can be so rapidly made, that little trouble will be experi- enced from the hemorrhage. Experience may often enable us to prepare the deeper vaginal portion first, and unite the edges before going any farther, as Martin recommends in his Elytrorrhaphia Duplex Lateralis. Either the knife or the scissors may be used for removing or raising the tissues. With the latter we can, however, work more rapidly and with less hemorrhage. Various special forms of knives have been invented, but have failed to come into general use. After the surface has been prepared it is well to bring the parts into apposition by tenacula. If they do not fit to each other they may 218 LACERATION OF THE PEEIXEUM AXD PELVIC FLOOPv. then be made to do so. But the great mistake should never be made of trying to increase the size of the perineal body beyond the normal by remo^dng healthy skin and. mucous membrane, for the traction upon the stitches will prevent union of the superficies, and, perhaps, of some of the deeper essential parts. When redundant it is better to dissect up the skin or mucous membrane as flaps, and unite them by superficial stitches, for by their resulting amplitude they vill add to the distensibility of the structures, and tend to prevent laceration under subsequent distension, rather than to favor it, as would be the case when too much is removed. Sutures. I use a semicircular needle like that described for the immediate perineorrhaphy, for the external stitches (p. 195). I hold the ends of the first two fingers within the curve, and the thumb against them from without, and carry the point completely around through both sides before drawing it through. For the vaginal and vulval stitches Fig. 158. Fig. 159. Fig. 158. — Silver Suture Bent so as to lie Flat upon the Skin. Fig. 159.— Silver Suture Twisted Without being properly Bent at the point of Emergence from the Skin, showing the harmful pressure upon the edges. The wound above the dotted lines usually suppurates. a smaller curved needle used with a needle-holder is sometimes more convenient. Needles mounted on a handle are not to be recommended as they make too large a puncture, are liable to break, require thread- ing after being passed, and possess no advantage over a good needle- holder. It is better to introduce the needle at or near the edge of the wound or flap, and pass it obliquely deep into the tissue, in order to grasp deeply, and at the same time take a circular direction when the sur- faces are coapted (see Fig. 126). The deeper the wound the nearer the edge should the needle be entered. Silver sutures (see Chapter IX. " Urinary Fistula,") may, however, be made to include a liberal portion of the skin, for when twisted they can be bent at right angles at the points of emergence from the skin so as to lie flat upon the surface. (Fig. 158 shows the silver stitches properly twisted, Fig. 159 improperly.) Deep stitches should only be drawn tight enough to bring the surfaces together, as the subsequent inflammation will tighten them still more. THE QUILLED SUTUEE. 219 For the rectal stitches catgut should nearly always be used. For the deep vaginal stitches silkworm gut or silver are preferable, that they may be left in place as long as desirable. For the vulva, silk- worm gut or silk are best, although catgut will do for vulval flaps. For the external stitches waxed silk or silkworm gut are the best, and will, if properly placed, give as good results, and much less trouble, than silver. Silk is usually preferable for the flap stitch, as it accom- modates itself better when tied to the direction of the surfaces. Silk- worm gut when tied draws the parts into its circle, and requires to be passed through the tissues in a circular direction. When silver sutures are used the twisted ends should be left from two to three inches long, and made to converge near the ends to a common point, and then fastened into a piece of rubber tubing. Fig. 160. . Method of Securing the Twisted Ends of the Silver Sutures (Emmet). Catgut stitches should be left to be absorbed. Silkworm-gut may be left in as long as desirable, and will not ulcerate, nor be absorbed for a long time. Silk absorbs secretions, and may commence to ulcerate in from five to six days, and should be removed as soon as an increasing redness or commencing ulceration about the stitch is noticed. Silver, if properly placed, may be left for a week or more, but is liable to ulcerate, and require removal in five or six days when there is much traction upon it, or when it is twisted too tight. The Quilled Suture. Although somewhat antiquated the quilled suture is one of the most useful and rational ones. It brings the deeper parts in apposition 220 LACEEATION OF THE PERIXEUM AXD PELVIC FLOOR. without compressing or depressing the superficial edges. It is called for when there has been sloughing after labor, or removal of tissue by previous unsuccessful operation, producing great lateral traction. The suture (Fig. 161) consists of a double thread passed through the skin about half an inch from the edge of the wound straight down into the deeper tissues, out over a small space at the bottom, and through the other side so as to emerge opposite the first point of introduction. Two, sometimes three, such double threads are passed and secured by- slipping a quill or flexible bougie, or the like, into the loops of the Fig. 161. 6 B Quilled Sutures, Tied (Zweifel). double ends on the side of introduction, and after drawing them tightly so as to grasp the quill, tying them over a quill on the opposite side. Before being tied the sutures must be drawn tight enough to approximate the bottom of the w^ound. The cutaneous edges are then united by several superficial stitches. The traction upon the quilled sutures is often very great, and in a few days causes some ulceration upon the skin under the quills. As soon as this occurs, after the fourth day, they must be taken out. The superficial ones should be left a little longer. Many prefer to secure each suture to a button i3late on either side. INCLSION OF SPHINCTER ANI — AFTER-TREATMENT. 221 Incision of Sphincter Ani. As the great barrier to success in the operations for complete lacera- tions seems to be the traction of the sphincter ani, one or two incisions (open or subcutaneous) through the posterior part of the muscle are sometimes made over it. This effectually relieves the traction, and is a desirable safeguard in very old lacerations ; but is not necessary in lacerations of only a few months standing, provided the entire thick- ness of the sphincter has been coapted by the two lower external sutures. It is, however, sufficient in any case to cut about two-thirds through the muscle, and thus gain a partial relaxation. Or the in- ternal fibres may be relaxed by an incision half-way through the muscles posteriorly on one side, and the external fibres also relaxed by a subcutaneous incision on the other side involving only the ex- ternal fibres. After-Treatment. When the rectum is not involved the patient is put to bed for eight days, and then kept quiet for another week, A napkin should be pinned about the knees of restless patients so that they cannot be separated farther than twelve inches. The wound is kept smeared with any bland ointment to protect it. A piece of lint or iodoform gauze may also be laid over it to absorb the discharges. It is well, but not absolutely necessary, to draAV the urine with a catheter for the first two or three days, after which a flat bed-pan may be used. After each time that the urine is drawn or passed the nurse should slightly separate the upper ends of the labia, so as to barely expose the edges of the wound, and squeeze warm water over the vulva and perineum, for the purpose of removing all traces of urine and vaginal discharge. When no inclination is felt to evacuate the bowels, they need not be disturbed for four or five days. A dose of castor oil or a saline should then be given, and an evacuation secured every two days thereafter. The parts must, of course, be thoroughly cleansed after each passage. Until the bowels move the diet should be mostly liquid. The parts must be inspected every day or two after the third day, and if any odor or discharge of pus be noticed vaginal douches be used. One or two per cent, solutions of carbolic acid in water twice or three times a day according to the amount of suppuration, will be found very effective. If the parts are found healthy I usually order a douche of plain warm water twice a day after the third or fourth day, and direct the patient to make use of that opportunity for urinating. When the sphincter has been lacerated and the rectum opened the patient should remain longer in bed and subsist mostly on fluids for a week at least. Milk on account of its tendency to produce curdy 222 LACERATIOX OF THE PERIXEUM AND PELVIC FLOOR. stools should be used sj^aringly. Great pains should be taken to pre- vent a movement of the bowels for the first three or four days, for be- fore that, fluid f£eces are liable to invade the edges of the wound and prevent primary union. If hard lumps come down into the rectum while the bowels are being moved they must be mashed against the sacrum by the finger introduced into the rectum. AVhen the colon has previously been completely emptied, as already directed, the bowels may just as well be kept quiet for eight or nine days, when the introduction of the finger to feel for lumps will be safe. Undue swelling and painfulness about the perineum may excep- tionally require the local application of ice-bags. The patient should be kept in bed from ten days to three weeks according to the extent of the laceration. CHAPTER VIII. DISEASES OF THE BLADDEE. Paralysis of the Bladder. Paralysis of the female bladder is often an accompaniment of hemiplegia or paraplegia from cerebral or spinal affections, and be- comes a part of these more extensive affections. From my own ob- servation, however, I should say that in women, retention of urine in such cases is not so uniformly a troublesome symptom as it is in the paralysis of men. Women have paralysis of the bladder more frequently associated with hysteria, probably, than with cerebro-spinal disease, which con- dition, of course, is a part of the hysterical affection. Again, it may arise from reflex causes. I once saw paralysis of the bladder caused by the presence of a tapeworm. Still more frequent is the paralysis succeeding tedious, difficult, or instrumental labor, as the result of injury to the muscular structure of the bladder from long-continued direct pressure on the organ, or to the nerves supplying the bladder, by the use of instruments, or by long-continued pressure of the head. The inflammation succeeding labor may also affect the organ sufficiently to cause paralysis. Prognosis. Usually paralysis occurring as the result of labor is temporary, and amenable to judicious treatment, if it does not spontaneously subside. Unfortunately, however, this is not always so. I know of two in- stances that have resisted such management as could be devised for them by several able practitioners, one for twelve years and the other for seven years. Both of these patients use the catheter for themselves when there is an accumulation of urine. Symptoms. The main symptoms indicating paralysis of the bladder are inability to pass urine and distension of the organ. The retention is not always absolute ; in some instances the urine dribbles away constantly by drops, keeping the clothing wet. The patient and inexperienced friends often believe that there is incontinence instead of retention, on account of this continued dis- charge.- In other cases, however, where the paralysis is more pro- found, there is no discharge. The distension sometimes becomes very 22-i DISEASES OF THE BLADDEE. great, extending beyond the umbilicus half way to the ensiform car- tilage. Retention of the urine sometimes occurs as the etfect of inflamma- tion of the urethra. This canal becomes so sensitive to the passage of that fluid through it, that the sphincter closes spasmodically when there is any attempt to urinate. Diagnosis. Paralysis of the bladder may be diagnosticated without much diffi- culty generally. The patient is conscious of inability to exert suffi- cient power to expel the urine, but often has no sensitiveness or pain upon voiding it. The hysterical form is usually attended with other symptoms of this affection, appears quickly and disappears as suddenly, while the urine is copious and clear. There is something in the manner of the patient which will often lead the inexperienced to think that she de- su'es to have it drawn by the catheter. Cases resulting from injury at the time of labor may be traced to that event. Treatment. Treatment for temporary relief will consist mainly in the use of the catheter. I think this instrument is generally used at too long inter- vals, especially in the form arising from injury during labor. I have often known cases of this kind to be neglected for twenty-four hours at a time. As a general rule, to pass the catheter ever}^ six hours is not too frequent. The muscular fibres should not be stretched by a consider- able and prolonged distension, as that will prevent them from recover- ing their tone. And if the organ is kept well emptied, there is no danger of decomposition of the urine and the consequent irritation and inflammation of the mucous membrane. An intelligent nurse can be taught to perform catheterism very easily, and may be trusted to do so according to instructions as to time and other circumstances. If the paralysis is connected with any general condition, as hysteria, this latter should be attended to by general treatment. If the paralysis is general, the vesical affection will share in the general treatment of that affection. The general health is usually impaired even when the paralysis is purely local in its origin, and often it is one of prostration. "When this is the case, generous diet, exposure to, and when practicable, exercise in the open air, with tonics and proper alteratives, will be indicated. Strychnia, quinine, and iron, separately or combined, will be useful remedies. The strychnia is particularly indicated as giving tone especially to muscular fibre and hence operating favorably on HYPERESTHESIA OF THE BLADDER AND URETHRA. 225 the debilitated tissue of the bladder. Phosphoric acid is also usually an excellent tonic in such cases. The bowels should be kept in a soluble condition by the gentlest of laxatives. When there is evidence of inflammation of any of the pelvic viscera, we should remove it by the proper means before resorting to direct remedies to remove the paralysis. After all inflammation is removed, we may employ electricity to stimulate the muscular fibres to contrac- tion. An electro-magnetic current may be passed through the bladder in various directions, so as to stimulate all the fibres successively, applying the positive pole over the spine and across the posterior part of the loins, iliac and sacral regions, while the negative may be brought in contact with the symphysis, perineum, and labia, and by means of a catheter introduced into the urethra, passed slowly into the bladder. The whole of this faradization should not last more than five minutes at first, and should be repeated once a day. After the patient has had three or four sittings, the force of the current and the duration may be gradually increased. It is sometimes ver}^ beneficial to pass the current from the anterior part of the abdomen into a metallic speculum in the vagina. I have seen many cases yield to this plan of treatment. A remedy that seems to have a very ready efiect, and to which I think I may attribute a cure in some cases, is the secale cornutum. The fluid extract of ergot administered in decided doses, once in a half hour for four or five doses, when the bladder is somewhat distended, often acts very promptly. A good way to admin- ister the ergot is to induce decided ergotism, or to give enough for that purpose every day and suspend the remedy in the intervals. I have been in the habit, also, of administering biborate of soda in doses of twenty grains four times a day with benefit. It is probable that all the substances that induce uterine contraction will influence the bladder similarly. Hemorrhage from the Bladder. A bloody discharge from the female bladder, not the result of organic lesion of that viscus, is far from infrequent. It occurs more frequently, judging from my own observation, about the time of the menstrual period and in persons whose flow is small in quantity. It is seldom, if ever, sufficiently copious to cause alarm, and the treatment of it may be trusted to the remedial measures required for the accomj^anying disease, whatever it may be. Hypersesthesia of the Bladder and Urethra — IrritaMe Bladder and Urethra. An irritable condition of the bladder and urethra is a very common occurrence among women, and is sometimes very distressing and per- sistent. The symptoms are frequent desire to urinate, with the dis- charge of but a small quantity at each time, vesical tenesmus, heat 15 226 DISEASES OF THE BLADDER. and weight, together with a scalding sensation at the time of passing the water. This irritable condition may sometimes last, with varying severity, for weeks and even months without being attended with any considerable amount of apparent disease in the parts. Causes. It is many times associated with inflammation and hypereesthesia of the vagina, with chronic metritis in some of its various forms, with displacements of the uterus, and irritation of the rectum from hemorrhoids, fissures, etc. But sometimes we meet with it when we can assign no cause whatever. Treatment. When it is possible to discover and remove the cause, that, of course, should be done. It will often subside under the treatment for the vaginitis that often attends it, or that made use of to remove ulceration and inflammation of the cervix uteri. So, also, when displacements are corrected. When we cannot trace it to an}^ of these causes, the urine should be examined, and if found of strong acid reaction this condition should be corrected. This irritable condition of the bladder is quite common in women advanced in age, as the result of a highly acid state of the urine, and may generally be relieved by the alkalies, of which the preparations of potassa are probably the best. The liquor potassse, in doses of from ten to fifteen drops, before and after eating, is often very efficacious. In young women of sedentary habits the vegetable acids will often imjDrove the condition of the urine and render it less irritating. In either case the bitters may generally be given with advantage. There are some medicines that seem to have a peculiar influence upon the urinary organs, and may often be given in cases of this kind with great benefit. Among such are pareira brava, buchu, and uva ursi. The fluid extracts of these medicines are the most convenient forms for administration ; but sometimes the extracts are not good, and hence I have been in the habit of relying more on the decoction than any other form. I often combine the buchu and uva ursi with, I think, excellent effect. When the distress is consider- able we may very properly use belladonna suppositories, per vaginam, at night. A half grain of the extract in cocoa butter, the same amount of sulphate of morphia, will often quiet the patient and enable her to rest, when otherwise she would be annoyed by frequent desire to urinate. Vaginal injections of tepid or warm water often relieve the suftering, so do hip-baths and water compresses over the lower part of the abdomen. The daily introduction of a number 12 steel sound will often cure very obstinate cases. CHEONIC INFLAMMATION OF THE BLADDER. 227 Chronic Inflammation of the Bladder. Although women are subject to acute cystitis,— probably not as often as men, — there is nothing in the course of the disease, or the treatment, that requires special consideration in a work of this kind. The chronic form, however, so far as I can judge from my own observation, is more frequent in women than in men, and its course and treatment are both, in some respects, quite different, so that I am induced to give it distinct consideration here. It often complicates the various diseases of the uterus and vagina, and the displacement of these organs. It is also caused by foreign bodies in the bladder, as calculi, and substances introduced from without, and by chronic cellulitis. Nature and Progress. In the beginning the inflammation in most cases is confined to the mucous membrane ; after awhile the muscular tissue becomes affected. In the early stage of the affection, while the inflammation is confined to the mucous membrane, the bladder empties itself completely but with great pain. As soon as the muscular structure is injured by the processes of inflammation, especially by the deposition of fibrin, the walls become thickened and uneven, contraction is imperfect, and hence the urine is retained, at first in small quantities and afterwards in larger ; decomposition of this fluid takes place, the inflammation is aggravated, and ulceration follows in many instances ; the patient some- times dies from protracted suffering, or life is suddenly terminated by the ulceration perforating the wall entirely and causing fatal inflam- mation in the peritoneum or cellular tissue. Occasionally the inflam- mation spreads to the ureters, and through them to the kidneys. The urethra may or may not be involved in the inflammation. Generally the cystic portion is more or less affected, and the ulceration in this direction will, in extremely rare instances, perforate the vesico-vaginal septum and thus cause fistula. The inflammation from foreign bodies contained in the bladder would be more likely to effect this condition, than inflammation arising from any other cause. Symptoms. Dysuria, if not the most frequent symptom, is certainly one of the most frequent. The presence of even a small quantity of urine in contact with the inflamed mucous membrane irritates and causes a desire to evacuate it. There is also heat, a sense of weight or drag- ging in the loins, the region of the bladder, and in the pelvis, with a great amount of general suffering; constipation, indigestion, some- times nausea, and various nervous symptoms being among the general symptoms. The urgency of the symptoms will depend, iu; a great measure,. 228 DISEASES OF THE BLADDER. upon the amount of inflammation, but somewhat also on the consti- tutional peculiarities of the j^atient. The frequency of the discharge becomes very great, as there is constant pain and desire to urinate on account of the irritating character of the urine. With the urine is discharged a large amount of mucus, and as the disease advances pus and blood-globules are found in the urinary sediment. The ap- pearance of the sediment is almost characteristic. It occupies the bottom of the vessel, is pellucid, tinged with yellow if there is pus in it, or red if it contains blood-corpuscles, and when poured out either comes in a jellj^-like mass or in long strings of mucus that may be drawn out to great lengths. At the bottom of the sediment are usually found an abundance of the phosphatic salts. As the disease advances, the odor of the urine becomes highly ammoniacal and not unfre- quently fetid. Generally the odor is quite unnatural. Diagnosis. The diagnosis is not difficult. The sediment of the urine, under the microscope, will show the presence of pus-globules in grave cases, and sometimes blood-globules. When pressed upon above the pubis the bladder will be found tender. This tenderness will be more evident upon introducing two fingers into the vagina and elevating the bladder upon them, while pressure is made above the pubis. The bladder may be thus included between the two hands. The tenacious ropy sediment, the pus and blood-globules, especially the former, and the tenderness of the bladder upon bimanual pressure are the main diag- nostic symptoms. Prognosis. Chronic inflammation of the bladder is an obstinate disease, and is very difficult of cure ; yet it probably does not often prove fatal. Treatment. The complicating conditions — as the disease is associated with others in the majority of instances — should be attended to Avith great diligence. The pelvic viscera are so near each other that inflammation seldom exists in one for a great length of time without spreading to others. I believe this affection is often the result of extension from the vagina or uterus, and in many instances it arises from pelvic peri- tonitis and cellulitis. Many of the remedies used for the cure of one of these affections will benefit the others also. The use of the hip-bath once or twice daily, copious warm-water injections as often, poultices, compresses, iodine ointment, vaginal suppositories, — of anodynes especially, — will all have the effect of relieving intra-pelvic hypersemia and hyperesthesia. Counter-irritants of a decided character may fre- quently be made of great service. One or twosetons introduced just CHRONIC INFLAMMATION OF THE BLADDER. 229 above Poupart's ligament, in one or both sides, are very effective means of making it. They may be controlled better than blisters or eruptive ir- ritants. We have a number of articles in the materia medica that exert a curative influence by contact with the mucous membrane of the bladder. They are eliminated from the blood by the kidneys, and held in solution or suspension in the urine, thus becoming applied to the diseased surface. Probably chief among these is pareira brava. I think the best way to administer this is in decoction, although the fluid extract, lohen properly made, is a good form; buchu, uva ursi, and juniper are also very useful. I think more good, in most cases, results from the use of buchu and uva ursi together than from either alone. Iodide of potassium, permanganate of potash, and some other salts of this alkali, the acetates and nitrates, for instance, exert an excellent alterative eflFect upon the mucous membrane of the bladder. The tere- binthinates may be used with great advantage in the milder forms of this inflammation. Perhaps balsam copaiba is the most uniformly beneficial of this class of remedies. Cubebs may also be employed occasionally with good efiect. The above treatment is applicable and Fig. 162. Skene's Double Perforated Catheter. often suflicient in the earlier stages and milder forms of chronic in- flammation of the bladder ; but after contraction of the organ is im- paired by the extension of the inflammation to the muscular structure, surgical treatment becomes indispensable to a successful issue. It is necessary that the acrid urine be completely removed from the bladder before it enters into chemical decomposition, which it does very quickly. At the same time the direct application of medicine to the inner surface can and ought to be made while alterative and tonic general treatment is instituted to overcome interstitial inflammation and remove the fibrinous deposit. Often we may accomplish the processes of emptying the bladder and applying the medicinal agents by means of the double catheter. To insure the efficacy of these measures the organ may be washed out by warm water thrown through the catheter by a David- son syringe, and after all the urine is Avashecl out the medicinal solu- tion may be introduced, and allowed to remain until its action is accomplished. When there is much pain a quarter or half grain of morphia once in twenty-four hours will secure immunity from suffer- ing. We may combine with the morphia a solution of iodide of potas- sium, permanganate of potash, tannic acid, acetate of lead, or other astringent : or we administer in the same way a small amount of an 230 DISEASES OF THE BLADDER. emulsion of balsam copaiba. Nitrate of silver will also frequently cause a better condition of the inflamed surface. The ingenuity and experience of the practitioner will generally suggest remedies of the above character best suited to the particular case. Due caution must be observed not to use the remedies in too concentrated strength until the tolerance of the inflamed surface is ascertained. These medica- tions should be applied once a day at first, and afterwards as often as may be required. It should be borne in mind that the mucous mem- brane of the bladder is very sensitive and that medicines are readily absorbed by it. In connection with this surgical treatment ergot and strychnia may be given to insure tone in the muscular structure. They ought not to be administered, however, until the activity of the inflammation has somewhat subsided. Dr. J. L. Papin, of St. Louis, has practiced a plan for relieving the irritable and inflamed condition of the bladder by dilating the urethra so as to paralyze the contractile fibres and leave the canal patulous, thus allowing the urine to pass out as fast as secreted, instead of permitting it to remain in the bladder to irritate it. The treatment is described in a paper written by Dr. M. Yarnall for the January (1872) number of the Medical Archives, pub- lished in that city. The operation is thus described : The urethra is dilated " with a long pair of dressing-forceps to such an extent as to produce a temporary incontinence of urine, by rupturing a few of the fibres of the sphincter of the bladder, and repeating the operation when necessary, at intervals of a week or more, until the patient is completely relieved." Twenty cases are mentioned as having been treated in this way, and the report is : " In nearly every instance the relief afforded is almost immediate ; but in the course of a few days the irritability of the bladder usually returns, when the operation has to be repeated, and, if necessary, again repeated until a cure is accomplished." In one case the operation was repeated five times, in some others three and four times. The experience of Dr. Papin is such that he does not fear incontinence of urine. " The operation being at first very painful, it will usually be found necessary in performing it the first time to place the patient under the influence of an anaesthetic ; but its subse- quent performance being much less severe, as a rule the anaesthetic will not be necessary, unless the patient be of a very nervous tempera- ment." This dilatation will much facilitate the use of medicated in- jections and preclude the need of a double catheter. This operation is very simple, and, according to the report of Dr. Yarnall, very efficacious. I have practiced dilatation of the urethra quite frequently with re- sults not inferior to those here reported. I invariably use the finger in place of any other instrument. One of the dangers of dilatation of the urethra is laceration of the circular fibres of that canal, and consequent incontinence of urine. I have not STONE IN THE BLADDER. 231 met with an instance of this kind, nor have I seen any other serious consequences follow dilatation. The finger may be passed through so slowly that the fibres will stretch, and endowed as it is with a delicate sense of touch, it easily recognizes the unyielding tension which indi- cates care. In this it would be entirely preferable to any kind of in- strument. Compressed sponge or laminated tents dilate so slowly and remain in contact with the canal so long as to induce inflammation and softening of the muscular fibres, and instead of preparing the way for further safe dilatation would predispose to laceration. Dr. Goodman, of Louisville, uses a catheter with a small bulb on the vesical extremity of it, with which he secures an empty state of the bladder. (Fig. 105). Dr. Sims's well-known practice of incising the vesico- vaginal septum has for its support the favorable report of its distinguished originator and Dr. Emmet, his successor in the Woman's Hospital of New York. The latter gentleman has written, and read before the Academy of Sciences of New York City, quite an elaborate paper advocating the propriety of making a fistula through which the urine will pass without accumulating in the bladder, and through which very effective medicinal application may be made to the inflamed surface. The patient may be placed in the position advised to operate for vesico-vaginal fistula, and the parts exposed by Sims's speculum. The surgeon may then pass a grooved director into the urethra with the groove toward the ,vaginal septum, and cut down upon the director until an opening is made large enough to answer the purpose. There is probably more danger of having the opening too small than of getting it too large, as the parts contract and have a strong tendency to close up before the cure is effected. The opening should be about an inch in length. With this free communication with the interior of the bladder the medication may be complete. Tincture of iodine, a solution of nitrate of silver, and the various astringents may be applied through the arti- ficial opening. The injections for washing out the bladder can be used with such freedom as will insure cleanliness. Dr. Emmet assures us that this method of treatment has been almost uniformly successful in his hands. The operation to cure the fistulous communication be- tween the bladder and vagina is so well understood and so generally successful, that the surgeon will not dread the consequences of this plan as it would have been dreaded some years ago, and I need hardly say that the opening should not be closed until the inflammation is entirely cured. It often closes spontaneously. Stone in the Bladder. Vesical calculus in the female is of very rare occurrence, absolutely and relatively. Of all the cases of vesical calculus only about one in twenty is met with in the female sex. This may be accounted for by 232 DISEASES OF THE BLADDER. the size, straight form, and dilatability of the urethra, and consequent direct escape of small sanguineous and mucous accumulations, and even sandy concretions. Indeed, quite large stones are expelled through the urethral canal, making their way out, in some instances, in a few moments with acute suffering, while in others they are many hours in forcing a passage. It would seem that these hard substances are evacuated more readily during the state of pregnancy than at any other time ; doubtless, because of the urethra partaking in the general increased dilatability of the genital organs which precedes labor. Symjotoms. There are probably no S3'mptoms attendant upon stone in the blad- der in woman but what are produced more frequently by other causes, hence they are quite unreliable, and can be taken only as suspicious instead of diagnostic evidence of its presence. They are great and persistent irritability of the bladder, severe pain after voiding the urine, sudden cessation of the flow while there is yet a desire to urinate and evidently some fluid in the organ, enlargement or relaxation of the urethra, and incontinence of urine. The urine is also charged with mucus, pus, or blood, or all three of these in greater or less quantities. The symptoms will be more strongly marked if the calculus is rough and jagged in shape, and less so if the surface is smooth and even. All these symptoms are not present in an}^ given case, but some of them are certain to be prominent and very distressing. Diagnosis. The only way to positively determine the diagnosis is by physical examination of the cavit}" of the bladder. This is done b}' means of the fingers and the sound. If two fingers be passed deeply into the vagina, as far as the cervix uteri, the most dependent part of the bladder may be pressed strongly up against the internal face of the pelvis, or lower portion of the anterior abdominal wall. If this latter be pressed well down into the pelvis with the other hand, while the fingers are still in the vagina, careful manipulation will scarcely fail to distinguish a calculus of moderate size. When the bladder is full of water, if the calculus is large, it may be raised, and its presence pretty conclusively determined by ballottement. The stone is felt, how- ever, more distinctly through the urethra by the sound, used the same as in the male. The operation may be facilitated by the fingers in the vagina moving the stone around. The same difficulties in making a perfect diagnosis are met with, as in the male, if the stone be encysted or adherent to the upper or anterior wall of the bladder; but if the instrument is sufficiently curved and moved about in various directions it will be detected, and its position and size ascertained with more precision and certainty than in the male. STONE IN THE BLADDER. 233 Treatment. The only means of relief available is the entire removal of the calculus. This may be done by dilating the urethra, and extracting through it ; by lithotomy or lithotrity. All these operations are less hazardous in the female than in the male, in fact, we scarcely take the subject of danger to life into consideration in operating for stone on a woman ; but one very great inconvenience likely to follow dilatation of the urethra and lithotomy is incontinence of urine, and the atten- tion of recent operators is turned mainly to the matter of avoiding this most distressing sequel. The preference is given by some surgeons to lithotomy, because they think this evil less frequent after it, while for the same reason others resort to dilatation of, and extraction through, the urethra. Very few now practice lithotrity in the female, and this operation is looked upon as attended with more hazard than either of the others. It is astonishing with what facility the female urethra may be largely and rapidly dilated. I have seen it stretched so as to admit the index finger in ten minutes without violence to its integrity. Where the stone is not very large, not over half an inch in diameter, we may expect to succeed by dilatation without much damage if proper caution and gentleness are used. When the stone is much larger, and especially if it is rough, we should cut. The operation of dilatation is simple. It may be performed by the finger more readily and safely as directed in chronic inflammation of the bladder. As soon as the finger can be made to enter the bladder freely, other fingers should be passed into the vagina and caused to press the stone forward so that its size, shape, consistence, and the character of the surface may be ascertained. If there is a long diameter, the end must be directed to the urethral opening, and retained with as much security as may be until the forceps are introduced and the stone seized. Traction should be made in the direction of the urethra with the instrument, while with the fingers in the vagina the efforts may be governed so as to keep up the right direction and steadiness, and also to push the stone into the urethra. Swaying the instrument in different directions, and performing slight rotation, the force used should be very gently applied and slowly increased, giving the parts time to stretch, and no more exerted than is just sufficient to accom- plish the extraction. We should not be in a hurry, but take plenty of time ; more damage is done by too great hurry than too great dilata- tion, I think. The parts are torn instead of being stretched. If the stone is too large to be removed in this way, we may perform lithotomy. H. Marion Sims proposed and performed lithotomy through the ves- ico-vaginal septum. He exposed the parts as for operation for vesico- vaginal fistula, introduced a curved director through the urethra, and cut into the bladder upon it until the opening was large enough to 234 DISEASES OF THE BLADDER. permit the stone to pass. The finger was then passed through the arti- ficial opening by which the forceps was guided, the stone seized and extracted through it. The wound need not and ought not to be im- mediately closed, nor until the cystitis is cured, then it will generally spontaneously close. If not it should be treated as a fistula. Foreign Bodies. Are sometimes introduced into the bladder by accident or design. Lead-pencils, hair-pins, quills, etc., are found in the bladders of hys- terical girls. They may be generally easily extracted by dilating the urethra, seizing the substance with strong forceps, and withdrawing them. Several instances are recorded of the open-barred pessaries of Dr. Hodge being removed from the bladder, where they had been in- troduced by mistake. The practitioner, starting one limb of the instrument into the urethra instead of the vagina, and afterwards manipulating in the ordinary way, would easily pass the whole into the bladder without observing any difference in the passage through the parts. Dr. H. R. Storer, of Boston, has now had three cases of this kind, and others have also met with them. I have seen but one in- stance of the accident, or rather mistake. In that case the instrument was introduced by an intelligent physician, who was sick and stupefied by opium. As he died a few days afterward there was no opportunity of hearing his account of the matter. The pessary remained in the bladder several months, during which time the patient was married and became pregnant. Three months after conception the instrument was discovered and removed without interrupting gestation. The re- moval was not attended with much difficulty. The urine was all drawn, and as the bladder emptied and contracted the pessary, coming down upon the anterior wall of the vagina, was distinctly felt, and its shape and size easily distinguished. The little finger was first pressed into the urethra until it passed into the bladder, then the index, by which the end of one of the branches of the instrument was drawn to the vesical end of the urethra. The finger was then withdrawn, and Ricord's phimosis forceps introduced until in contact with the limb of the pessary. To facilitate the prehension of it by the forceps, the in- dex finger of the left hand in the vagina held the pessary against the pubis. In this way it was not at all difficult to fasten the forceps on the end of the limb lying in contact with the neck of the urethra, and extract the whole instrument. This was done by first bringing the point of the branch seized upon out of the meatus, depressing it toward the perineum until the angle at the junction with the cross-bar ap- peared, after which the changes were the same as removing from the vagina. This case was recorded by Dr. Bulkley, of Freeport, Illinois, in the Medical Record. Essentially the same plan enabled Dr. H. R. INVEESION OF THE BLADDER. 235 Storer, of Boston, to relieve his patients. A foreign body that has been introduced through the urethra can, by this kind of manipulation, be removed through it. Inversion of the Bladder. In childhood the bladder sometimes becomes inverted and partially expelled through the urethra. Dr. John Croft, in " St. Bartholomew Hospital Reports," American Practitioner, gives the following methods of diagnosticating and treating inversion of the bladder : " A small, red, pyriform, vascular, elastic tnmor, situated between the labia below the clitoris, and in front of the vaginal orifice; the urethra not distinguishable ; the ureters may be exposed, and perhaps distilling urine; a history of more or less incontinence previous to the appearance of the tumor: these symptoms should lead one to recog- nize an inversio vesicce, and to distinguish such an affection from a solid polypoid growth. Mr. Holmes has described a vaginal hernia in his work on Diseases of Chil- dren. In that malady the urethra can be found in front of the tumor, which has not the red vascular appearance of an inverted vesical membrane. The best mode of reduction seems to be by taxis, and the thumb and fingers the best compressors. They should be used gently. If the child struggle much, it would be better to employ chloroform." A properly constructed compress will retain the parts in position until the urethra attains its normal tone. CHAPTER IX. AFFECTIONS OF THE VAGINA. Absence of the Vagina. We observe absence of the vagina when the tissues and organs in near relations to it are in one of two conditions : First, when the rectum, bladder, and vagina are all absent and replaced by one great cavity, through which the urine and feeces are passed. This cavity is called by authors cloaca, being a common excretory canal for the urinary, genital, and alimentary organs. Sometimes the vagina is imperfectly formed, and the rectum perforates it posteriorly, while the urethra enters it anteriorly. Secondly, the vagina may be absent while the rectum and bladder are properly situated, perfect in their formation, and the anus and meatus urinarius both also occupying their normal places and performing their functions properly. In this last condition of the parts the vulval organs are generally all present; in one case the hymen was to be seen. In by far the most instances there is an absence of the uterus when the vagina is not found, but this is not always the case. Causes. Absence of the vagina is, of course, always a congenital condition. Diagnosis. In cases in which there is a common cavity for the rectum and blad- der, we shall have no difficulty in ascertaining it by inspecting the parts with the eye and passing the probe into the rectum and bladder if necessary. The discharges, however, will generally enable us to decide without this last measure. When all the adjacent organs are normal, we are to distinguish between occlusion by an abnormal hymen, rudimentary vagina, and this condition. Physical examination alone will enable us to do this. We shall not often be called upon to determine the question of diagnosis until there is a collection of menstrual fluid in the cavity of the uterus, or the patient is married. When there is occlusion by the hymen, with a collection of fluid in the vagina, the vulva will be occupied by a tumor formed of the pouting membrane, generally of a dark-purple color and hemispherical in shape, giving the sense of fluctuation when pressed upon at the ATRESIA VAGINA. 237 time the hypogastric region is j)ercussecl. "When the vagina is absent, there will be a tumor perceptible between the bladder and rectum, but no protrusion between the labia. The ordinary sign so often mentioned of a cord-like hardness extending from the vulva upward is of no use, as this is obscured by the globular mass between the rectum and bladder. The treatment of absence of the vagina will be given in the treat- . ment of atresia. Atresia Vagin%. This condition arises very much more frequently from puerperal inflammation of the vaginal parietes than any other cause. But any- thing that j)roduces inflainmation enough to destroy the epithelium of the mucous membrane may cause atresia, as mechanical or chemical agencies, scarlatina, measles, syphilis, etc. After extensive ulceration from these or other cases, if the denuded surfaces are allowed to remain in contact and at rest for a time, the}'' contract adhesions, thus narrowing, or even at times completely closing, the cavity. In atresia occurring as the effect of inflammation every variety may be observed. The vagina may be closed at the vulva and not above, the centre may be contracted and the upjDcr and lower ends be of normal dimensions, or the adhesion may take place at the upper part, including or not the os uteri. In all these varieties, how- ever, the parts not involved in the ulceration are but little affected. Atresia may also be a congenital defect in the organization. Con- genital atresia is more frequently caused by the formation of a mem- brane across the cavity, closing it in some part, as the hymen occa- sionally closes the vulva, and which is often so low down as to be confounded with that membrane. Such a closure, however, is usually farther up the cavity, sometimes near the os uteri. Partial congenital atresia is sometimes represented by a very narrow canal, only large enough to admit a probe, and which seems a very imperfect outlet for the menstrual discharge, and is so small as to prevent sexual inter- course. This form of atresia may be complete and " the organ changed into a solid cord," extending in part or the whole of its length. Diagnosis. Judging from my own observation we are more frequently called ui^on for a diagnosis in atresia after jDuberty than before. Previous to puberty the closure of the external ojjening to the vagina would be the only condition likely to lead to its discovery. The diagnosis in such cases is of little importance comijared to what it becomes after adult age, as the defect does not interfere with the function of the organ. The failure in the appearance of the menses at the proper time in life, pain in the pelvic region, and enlargement of the abdo- 238 AFFECTIONS OF THE VAGINA. men generally call for physical investigation. If it has originated in ulcerative inflammation, the retention of menstrual fluid, pain and enlargement would soon excite suspicion ; or, if the patient is married, the husband would be likely to discover the unusual state of things. Practically a very large majority of the cases we meet with will be attended with an accumulation of fluid. The history of the case, the fluctuating tumor between the bladder and rectum, felt by the finger in this last cavity and the catheter in the first viscus, and the presence of some part of the vagina in a distinguishable condition will enable us to decide as to the nature of the difficulty. Prognosis. There are very few cases of acquired atresia which do not admit of more or less complete relief. Congenital atresia with membranous formation across the cavity is generally curable, and when the vaginal cavity is so contracted as to be nearly but not entirely obliterated, we may hope for a cure, but when it is attended with defective de- velopment of the other genital organs we may expect much difficulty, even if a cure be practicable. Treatment of Atresia and Absence of the Vagina. The object of treatment is to overcome by surgical means the ob- struction to the discharges from the uterus. The vagina is a viaduct for the uterine discharges. This, to be sure, does not express all the uses of that organ, but to make it an efficient channel for the menses is really almost the only reason for operation in the graver varieties of vaginal atresia. We are not, therefore, justified in submitting our patient to the dangerous operation of opening up the vaginal canal for any other purpose. In cases, therefore, in which the uterus is absent we are not justified in attempting to form an artificial vagina, or in any way endeavoring to perfect the organs for conjugal purposes merely. I have known but one attempt of this kind, and in that case no success attended the persevering and ingenious eff'orts of Dr. Brainard. The patient was a married woman, who said she assumed matrimonial relations without knowing that she was not like other women. The vagina terminated in a cul-de-sac about an inch in depth. Her husband complained of her incapacity to fulfil the duties of a wife. They visited Dr. Brainard for surgical aid, and he had the kindness to allow me to witness his operations. Although the artifi- cial canal that resulted from his efforts was two inches in depth, it had a constant tendency to contract, and required the steady employ- ment of a glass plug to keep it open. The husband was not satisfied, and the law allowed him to separate from her. The occlusion should not be operated upon until the menstrual TEEATMENT OF ATEESIA AND ABSENCE OF THE VAGINA. 239 fluid fills up the uterus and distends the parts between its cavity and the vulva. Ordinarih^, when the vagina is absent, the uterus is bound by areolar and fibrous tissues to its usual situation in the pelvis, and as distension occurs the lower portion of the organ approaches very near the vulva, — in two instances of absence of the vagina it was not more than an inch and a half from the vulva. In thus approaching the external organs it widely separates the bladder and rectum ; press- ing the former up behind the pubis, and the latter strongly into the hollow of the sacrum. This condition of things makes an operation for the opening of the vagina, or making an artificial canal, comparatively easy and safe. To attempt to reach the uterus of a girl before puberty has estab- lished the menses, by cutting up toward that organ from the vulva, is to undertake a task of very great difficulty and hazard, which, after the distension has brought about the changes above described, may be accomplished with great certainty and facility and much less risk. Much delay, permitting of great distension, should also be avoided, for Puesch tells us that in 258 cases of atresia 18 died of rupture of the Fallopian tube. The right time, then, to operate for complete atresia is as soon as the uterine tumor fairly fills the pelvis, and when by touch through the rectum with the finger, with a catheter in the urethra, we can assure ourselves that the uterus can be easily reached without endan- gering any important organ. Scanzoni was so impressed with the danger of wounding the bladder and rectum that he advised evacuating the imprisoned menstrual fluid by introducing a curved trocar, of large calibre, into the rectum, and plunging it into the most dependent part of the tumor. After the flow of blood has ceased, the canula should be left in the place for some time in order to establish a permanent opening. I think the danger of this operation was overestimated by Scanzoni, and cannot recommend the student to follow his teaching. With the precautions as to time and circumstances, and the proper care, the hazard is much less than he has estimated it. The patient may be placed in the lith- otomy position, a catheter introduced into the bladder and a finger into the rectum. The catheter will be directed strongly up behind the symphysis pubis, and the finger pressed firmly back against the sacrum. These preliminary measures being instituted, an exploring trocar may be passed into the central line of the vulva about half an inch below the urethral orifice, and pushed backward into the tumor. If the trocar has entered the cavity containing the menstrual fluid, this will begin to pass the canula upon the withdrawal of the stilet. When thus assured of the right direction, we may be guided by the trocar in making an incision that should be run along the lower side of it, until the opening is large enough to press the forefinger through 240 AFFECTIONS OF THE VAGINA. it. With this member we may tear the opening large enough to admit the middle finger with it. Through this opening the blood will soon be evacuated. As soon as this is the case, the cavity of the uterus and vagina ought to be thoroughly cleansed by tepid water thrown plen- tifully through a tube long enough to reach to the fundus. The arti- ficial opening thus made must be kept open by confining a glass plug large enough to keep it patulous. This plug should be worn for sev- eral weeks, and recourse be had to it when retraction threatens to obliterate the canal. Hewett recommends tearing through the obstructing tissue instead of puncturing or cutting. Others dissect through with the knife. Dr. T. A. Emmet advises us to use the scissors for incision into the tumor. And, again, a large trocar sometimes is used to penetrate the cavity at the point I have directed, and the finger used to enlarge the open- ing made by it. It happens in some cases that severe symptoms fol- low this operation for the sudden evacuation, such as peritonitis, metritis, etc. Dr. J. Marion Sims, to avoid this, evacuated the fluid very slowly, allowing the uterus to contract on the receding fluid as fast as evacuated. In cases where the hymen or other membrane closes the vaginal canal, the considerations above stated should induce us to wait until there is a moderate accumulation of menstrual fluid in the vagina. The division may then be made with scissors carried up to the mem- brane. The opening should be free. Not much danger of cicatrical contraction closing up the divided part will exist, yet for several days the finger should be passed above the obstruction daily to prevent any tendency of that kind. When the vaginal canal is contracted to very small dimensions, amounting to almost complete atresia, we may dilate this small opening by introducing rubber or metallic bougies graduated in size, the smaller first and larger afterwards. Sponge tents may be used after the dilatation has been fairly begun. Perseverance in the use of tents will enable us to succeed without cutting, and I would very much prefer it to any other method of procedure. The vagina may be kept open by the prolonged use of a glass plug. Tumors in the Vagina. Fibrous tumors in the vagina are occasionally met with. They are generally less firm, although resembling in most other respects the fibrous growths of the uterus. They grow in the anterior wall of the vagina so as to project into the bladder and vagina to about the same extent, or more or less in either of these cavities, according as they are developed nearest the membrane of the one or the other. Some- times they are pendulous or polypoid, hanging into the vaginal cavity by a neck of greater or less size. All I have seen of the intramural VAGINISMUS. 241 form of these tumors were encysted, and were removed by excision. The cyst was ojiened and the tumor turned out and the wound allowed to close by contraction and granulation. The polypoid form may be removed by the ecraseur or ligature. The 6craseur is very much to be preferred. Fatty encysted tumors of the vagina are more rarely met with, and may be dissected out, in the same manner as if situated elsewhere. Cysts of various sizes containing fluid are also not infrequent. These may be cured by cutting out a portion of the cyst wall large enough to keep the incision from closing until the lining membranes granulate. Vaginismus. J. Marion Sims described this affection first to the Obstetrical So- ciety of London, December, 1861, and afterwards gave it to us in his Clinical Notes on Uterine Surgery. It is an " hypersesthesia of the vulva and hymen, attended with involuntary contraction of the sphincter vaginse." The parts are so very sensitive that the slightest touch with the finger causes great pain, and in some instances, coition is entirely impracticable. In all the cases I have ever examined, there was very decided -redness and increase of the secretion of the parts exposed by separating the labia. Dr. Sims thought the sensitiveness confined to the vulva and hymen, but I apprehend that more extended observa- tion will establish the fact that the whole vagina is often involved. In one of my cases, now under treatment, the sensitiveness of the vulva has almost entirely disappeared ; the finger may be introduced into the vagina, but the upper part of this cavity is so exquisitely tender that the patient screams with pain as the finger approaches the cervix uteri. The general symptoms of this affection are grave according to the chronicity of the case. It generally shatters the constitutional energies of the patient, rendering her, according to the expression of Dr. Sims, a wreck. He considered it independent of inflammation. Mr. I. B. Brown agreed with him. It is, according to them, mere hypersesthesia. In my cases the parts were always in a state of inflammation ; but I cannot think the hypersesthesia was wholly of inflammatory origin. Of course I am not prepared to say that inflammation is even a general attendant. The observation of the profession will soon determine that point, as the disease is now fairly set before it, and, from the distress- ing symptoms, will attract much attention. My patients have appa- rently not been aware of their condition until married. The intensity of the suffering is not always sufficient to prevent coition, and some- times is much greater than others. The sensitiveness is greater near the menstrual epoch, occasionally in a very marked degree. My pa- tients have all been barren. 16 242 AFFECTIONS OF THE VAGINA. Diagnosis. The sensitiveness and contraction are characteristic, and hence there is no need of much labor in forming a diagnosis. The least touch of the mucous membrane of the vulva, with a feather, soft brush, or fingers, gives the patient great suffering, and sometimes agony unlike anything else. P7'ognosis. Judging from all I have seen and read upon the subject, there is very little, if any, tendency to spontaneous subsidence. Its duration, therefore, is perplexingly long. But all agree as to its curability. Treatment. The late Dr. Sims succeeded in curing all his cases by dividing the sphincter vaginse deeply on either side of the vaginal orifice near the fourchette. He made the division sufficiently deep to permit of free dilatation, and then kept the vagina open with large bougies until the wound cicatrized. The results of this operation are all that might be expected from it. The hypersesthesia disappears, and the obstacles to coition are removed, but there is necessarily great mutilation. A long time before Dr. Sims wrote on the subject, forcible dilatation was recommended to overcome the spasmodic contraction of the sphincter vaginse. Perhaps the best and most convenient way to dilate the vagina is to introduce the thumb of each hand into the vagina, with the palmar surface turned outward, and then forcibly separate them as far as possible. This will stretch the vulva, but not often rupture the muscular fibres to any great extent. After thus forcibly dilating, we should introduce the glass plug, recommended by Dr. Sims, twice a day, morning and evening, and allow it to remain each time from one to two hours. The plug ought to be from one to two inches in diam- eter. The introduction and presence of this hard substance at first gives great pain, and we may be under the necessity of using aneesthetics or anodynes, to enable our patient to bear it ; but after having been several times introduced, the parts tolerate it better, and finally we can use it without giving the patient any great inconvenience. The de- creasing sensitiveness thus manifested will be a guide to us in deciding when to discontinue it. Mr. I. Baker Brown, in his Surgical Diseases of Females, condemns Dr. Sims's operation as severe and needless, and gives two cases where the sensitiveness was cured by the relief of fissure of the rectum. He thinks the hypertesthesia is a symptom of some disease of the rectum, generally fissure ; and that by incision of the fissures it will disappear. Dr. Braun, of Vienna, according to Mr. Brown, has cured one case by removing the clitoris. A case of some severity is reported in the London Lancet, American reprint for March, ACUTE VAGINITIS. 243 1867, in the care of Dr. G. C. P. Murray, in which the hypergesthesia appeared to depend upon inflammation of the cervix uteri and vagina. It was cured by making a free application of the solid nitrate of silver over the inflamed cervix, and a solution to the vaginal surface. These applications were repeated in a fortnight, and were succeeded by the tincture of iodine. While there can be no doubt that Dr. Sims's plan is efficacious, I cannot think it necessary, and the success of other means by different practitioners bears me out in this opinion. We almost always find the patients in a state of unsatisfactory health, and, according to my observation, evident local disease besides that of sen- sitiveness ; and, from what we have learned from Mr. Brown and Dr. Murray, more than one kind of local disease. As in the treatment of all other diseases, therefore, we should carefully and diligently search for and cure the cause of the hypersesthesia. If it is fissure of the rec- tum, this should receive our first attention ; if inflammation of the vagina, uterus, or vulva, we ought to cure this. In all the cases I have seen, and I now have three under treatment, nothing I have tried has been of so much advantage as remedies directed against inflammation of the vagina and vulva. The course I usually pursue is to apply the solid nitrate of silver to the vulva every ten or fourteen days, and in the interval use glycerin and tannin. The first application reduces the sensitiveness very decidedly, and it becomes less after each successive touch, until finally cured. We should bear in mind that the hypera3sthesia does extend into the vagina and to the uterus, and that it is as necessary to treat the vaginal cavity as the vulva. I have been in the habit, at first, of managing it as I would vaginitis. The strong astringents, glycerin and narcotics, applied by means of medicated pessaries and injections, are valuable adjuncts. With the local treatment, rational general treatment is very beneficial. Attention to the bowels, the condition of the stomach,, and the secretions generally ; tonics, exercise, change of air, bathing, attention to clothing, and all the regiminal circumstances calculated to benefit the general condition of the patient. Acute Vaginitis. Begins generally in the lower part of the vagina, with swelling, in- tense redness, and dryness of the mucous surfaces of the labia, vulva and vagina. There is great heat in the parts, and the patient com- plains of burning pain in them. Difficult, painful micturition, pain in passing the faeces, sense of weight in the pelvis, and tenesmus are generally present also. Not unfrequently there is backache and pain, radiating down the thighs, into the hips, up the spine, and into the head. Sometimes the symptoms are so acute as to jDroduce general febrile disturbance. When this is the case, there is chilliness alternat- 244 AFFECTIONS OF THE VAGINA. ing with heat, an increased frequency of the pulse, furred tongue, pain in the limbs, etc. In the course of thirty-six hours the pain, redness, and swelling spread to the whole of the vaginal cavity, and soon there is a profuse secretion of mucus, which, after two or three days, or even sooner, is mixed with pus-globules in some abundance. When this last is the case, the discharge is either green or yellowish in color, and less tenacious. This state of things lasts for from ten to twenty days, when the inflammation gradually subsides, becomes less in quantity and lighter in color, until in four or five weeks the disease is entirely gone, or it merges into the chronic form. The inflamma- tion usually involves the urethra, and sometimes the bladder, and its greatest intensity is almost always in the lower third of the vaginal canal. The inflammation sometimes spreads to the rectum. Some- times it attacks the mucous membrane of the cervix uteri, and even invades the cavities of the corpus uteri and Fallopian tubes, remain- ing longer in these localities than in the vaginal cavity. Diagnosis. The diagnosis of acute vaginitis is not difficult, as the parts may be easily seen and touched. Prognosis. As has been heretofore intimated, it subsides spontaneously, and leaves the parts free from disease, or in a state of chronic inflamma- tion. The prognosis, therefore, is favorable. Cause. It is caused by contagion more frequently, perhaps, than anything else, but does doubtless arise from abuses, injuries, and want of clean- liness, and probably other causes. I have seen the non-contagious form in children very much more frequently than in adults, spread- ing usually from the vulva upwards. Non-contagious acute vaginitis is not a very common affection. At first it involves the mucous mem- brane and submucous tissue, but before many days it is confined to the membrane alone. Treatment. This at first should be slightly antiphlogistic. A few grains of calo- mel, followed in ten or twelve hours with a saline cathartic, should be the first step. This may be succeeded by nauseating doses of tartar emetic, until the dryness and swelling have subsided. In the mean- time, perfect quiet in the recumbent position should be enjoined, the parts bathed every hour or two thoroughly with tepid water, and the patient should abstain from stimulating or nutritious ingesta. As soon as the discharge has become copious, and yellowish or green, and CHEOXIC VAGINITIS. 245 the swelling of the parts has entirely subsided, the treatment should be changed for astringents, specifics, laxatives, and baths. We may give half a drachm of balsam copaiba in emulsion or capsules every six or eight hours, and have the vagina syringed copiously with a saturated solution of alum, or acetate of lead, two or three times in twenty -four hours. Every third day a few ounces of a solution of ni- trate of silver, the strength of ten grains to the ounce, may be advan- tageously used. The bowels should be kept open, and the patient should abstain from stimulants at all times during the treatment. The astringent injection ought to be changed every five or six days, using alum, sugar of lead, and sulphate of zinc alternately. Perseverance in this treatment will very materially shorten the course of the disease. Chronic Vaginitis. This is a more frequent form of disease than the acute, and its im- portance will be understood from this consideration. It is in many instances a ver}^ distressing affection, and often mistaken for diseases of the uterus, bladder, or rectum. Symptoms. There is generally jiain in the back, more frequently in the sacrum, and coccyx, but not seldom higher up ; pain in the groin, weight and sense of bearing down in the perineum, dragging in the hips and pelvis. A burning sensation in the vagina, extending all over the lower part of the person, very distressing and depressing, is sometimes the chief symptom complained of b}^ the patient. In married patients it is the cause of distress during the act of coition, to such a degree sometimes as to entirely preclude such indulgence. I am now treat- ing a patient who assures me that although she has been married fifteen years, she does not remember a single instance of sexual intercourse that did not give her discomfort ; generally it was the cause of decided pain, and sometimes was entirely intolerable to her. Leucorrhoea is a common, but not invariable symptom ; it may be yellow or white in color, but when the case is not complicated with cervical inflammation it is always thin. In chronic vaginitis there is generally a long train of sjmipathetic symptoms not unlike those observed in diseases of the uterus. The nervous centres are disordered in their functions, pro- ducing nervous symptoms of almost every description. The mind is sometimes affected by it to irascibility, despondency, suspiciousness, jDeevishness, and purposeless instability. In other, or perhaps, the same cases there is palpitation of the heart and large vessels to such a degree as to cause alarm for the life of the patient. Headache should be mentioned as quite common ; it is more commonly located in the occipital region, but may be in the top, forehead, temples, or all over 246 AFFECTIOXS OF THE VAGIXA. the head. The eyes are generally weak. The stomach is frequently deranged to a considerable extent, and in various ways ; and there is generally a constipated state of the bowels, though diarrhoea is an occasional symptom. There often is pain, too, in urinating, and in passing the fgeces through the rectum. The uterus is almost always affected also, and through it the symptoms may become greatly diver- sified and increased. We should expect this complication. Diagnosis. Upon examining the vagina, the introduction of the finger will give some pain, sometimes a good deal, and the speculum causes a great amount of suffering. There is general redness of the mucous mem- brane; sometimes it is smooth and moist merely, or covered with a copious secretion of mucus ; in some instances numerous granulations may be seen. The granulations may be situated at the uj)per end of the vaginal cavity entirely,- as I have often seen, or in the lower por- tion ; rarely they extend from one end of the vagina to the other. And again the membrane may be so raw as to bleed upon the use of instru- ments in making the examination. The sensitiveness, redness, and exaggerated secretion are conclusive and diagnostic symptoms when they are permanent. Causes. Chronic vaginitis is often the result of an acute attack. The inflam- mation only partially subsides at the time, and is continued indefinitely. Some of the most obstinate cases I have met with have thus resulted from gonorrhoea. Another set of cases are seen in i^atients whose hus- bands were the subjects of syphilis or gonorrhoea in early life, but who have been to all appearances cured. I am inclined to the ojoinion that chronic vaginitis is not an uncommon occurrence in women thus situated. It is more likely to follow recent cases of syphilis, and is some- times subacute in grade. Another form is apparently produced by abortions, colds, and other causes, with, at the same time, inflammation of the cervix uteri. Constipation causing sluggishness of the vaginal circulation, or other causes producing this vascular condition, as the pressure from pelvic tumors, phlegmonous effusion, etc., contribute to the production of chronic vaginitis. There is no doubt but that certain constitutional taints, as scrofula, rheumatism, and, as before intimated syphilis, are efficient co-operating causes. Prognosis. Chronic vaginitis, in its simpler forms, is apt to be obstinate and resist judicious treatment for years. It is more particularly so when origi- nating in constitutional diseases. When connected with incurable l;Uin.orj5 it will, of course, resist all treatment. CHRONIC VAGINITIS. 247 Treatment. The constitutional treatment of chronic vaginitis is sometimes of the first importance, while at other times it is unnecessary, or nearly so. The variety which seems to be connected with the syphilitic condition requires the alterative remedies which are found beneficial in this af- fection under other circumstances, the preparations of mercurj^, iodine. and the vegetable alteratives, for instance. When associated with scrofula the vegetable tonics, with alterative treatment, cod-liver oil, plenty of outdoor exercise, cold bathing, seabathing, etc., will be appro- priate measures to be employed. As it is not unfrequently complicated with rheumatism, or this diathesis, it may be necessary to prescribe for it with such a consideration in mind. But in more simple cases, where there are no such taints or compli- cations, conditions exist that require a judicious course of general treat- ment for their removal before we can be successful in our main object. Such is a torpid state of the bowels and portal circle, with scanty secretions. Mercurial and saline laxatives, vegetable tonics, as the bit- ters, also alkalies, will, when judiciously used, assist us very much. We should be particularly careful to avoid a loaded or impacted state of the rectum, as this is the cause of much vaginal congestion. An in- jection once or twice a day, when necessary, will suffice for this. In all forms, in addition to the general treatment, when that is necessary, we shall be under the necessity of resorting to local meas- ures. Much benefit will be derived from a sitz-bath twice a day. The bath should be tepid, as a general thing, as being more likely to agree with the- largest number of patients. When it is more agreeable, the bath may be cooler. It should be large enough to cover the hips, and the patient should remain in it for an hour at least, and often it is better to use it for a greater length of time. Of more importance are injec- tions. Simple water in large quantities is sometimes sufficient, but more frequently astringent substances will be found essential. The injections should be administered through a perpetual syringe, and the quantity should be large, say from one quart to a gallon of water at each time. The common astringents, as alum, sulphate of zinc, acetate of lead, of the strength of one drachm to the quart of water, will generally suffice. We find cases, however, in which none of these substances can be used, because they disagree with the pa- tient, producing dryness of the parts or increasing the inflammation. In such cases we must carefully search for the right local remedy. We may find it in tannin, tincture of the chloride of iron, astringent de- coctions, nitrate of silver in solution, etc. The last, used once in four or five days, with a glass syringe, and the other astringents between, often proves to be the best course. An excellent and very convenient mode of applying medicinal sub- stances to vaginal surfaces is to make small sacs of gauze or linen, and 248 AFFECTIONS OF THE VAGINA. fill them with the substance intended for use, and introduce them into the vagina. A sac the size of a small glove finger, with a piece of thread attached to it, will hold an abundance of almost any remedy we desire to use. Tannin in powder or ointment, gall ointment, bella- donna ointment, and other articles are used in this way. A mixture I have used very commonly consists of two drops of creasote, half drachm of tannin, and one grain of belladonna extract, introduced at bedtime each night. The little bag may be removed in the morning by traction on the string. There are, I think, some advantages in the use of these little bags over the other sorts of medicated pessaries used. I not unfrequently inclose copaiba capsules in these little sacs, and think it an admirable mode of making balsamic applications to the vaginal mucous membrane. Where the astringents or other remedies are thus used they will not replace the injections wholly. Indeed, the vagina should be well washed out before the introduction and at the time of the removal of them. Patients, of course, can manage these applications without aid. Perseverance and time are important items in the treatment. If we can remove this chronic inflammation in three or even six months, we ought to be satisfied. And we ought not to be surprised to have it re- turn once, or more times, after it is apparently cured. It is well, also, to teach our patient patience in this respect. Puerperal Vaginitis. It might not seem necessary to consider the vaginitis occurring after labor as a separate affection, but there is so much difference — in the causes, nature, symptoms, and termination — between ordinary vagi- nitis and this form that I think it may be profitable to do so. In some cases of labor, circumstances occur that induce a severe form of in- flammation of the vagina. The one most j^otent is long detention of the fetal head in the pelvis. The pressure thus exercised upon the vaginal walls interupts the circulation more or less completely; and if continued for a number of hours, violent reaction in the parts results when the pressure is removed. This pressure does not affect the mucous membrane of the vagina so deleteriously as the deeper seated tissues. The fibro-cellular part of the vaginal walls is the seat of the inflammation. I do not think the use of instruments, however awk- wardly, does so much damage as the long-continued pressure. It must not be denied, however, that instruments do give origin to this form of inflammation. When they do so, the inflammation is more circum- scribed ; it does not extend to all parts of the vagina, as is apt to be the case when pressure by the child's head has been the cause. On account of the nature of the causes, this form of vaginitis runs its course rapidly, and is most sure to end in structural lesions. It is in PUERPERAL VAGINITIS. 249 intense forms of this sort of vaginal inflammation that sloughs and deep ulcerations are met with, which open the bladder and cause vesico- vaginal fistula, recto-vaginal fistula, and cicatrices which result in con- tractions and even occlusions of the vagina. It is astonishing how much destruction is sometimes effected by intense post-partum inflam- mation. I remember being called to a case, in consultation, where the child's head had been pressing down sufficient to bulge the perineum and labia for sixty hours without any movement. I delivered her with the short forceps in a few moments, without any violence to the parts. The patient was then unavoidably left in the hands of the same care- less practitioner that had so outrageously neglected her before the delivery. I saw her three months afterwards, and found the whole septum between the bladder and vagina gone, the urethra terminating abruptly, as though it had been cut straight across, in a great irregular cavity, that was bounded by the pubis before and the uterus behind, and without any defined sides to it. In still a worse case, where shoulder presentation had prevented the passage of the child, the woman was in the second stage of labor six days. The woman arose from her bed with a large undefinable cavity, — without any bladder, apparently, but the very top portion, — and the loss of two inches of rectum, into which the urine and fseces were poured involuntarily. In more than one instance I have seen the whole vagina sealed up, from the fourchette to the urethra, and, — as far as lean judge, — to the os uteri, as the effect of intense and neglected puerperal vaginitis, arising from unaided difficult labor. Every practitioner must meet with cases in which the cavity of the vagina is misshaped, and partially closed, from the cicatrices resulting from it. Now, much of these direful effects may be averted by the rational management of inflammation after it has been initiated. Symptoms. When injurious pressure has awakened inflammation in the vagina, the labia and walls become swollen, hot, and very tender. The patient does not generally complain of mxuch severe pain, but there is a sense of soreness and heat. There is almost always fever, chilliness, and other evidences of disturbances of the circulation ; the tongue is coated, ordinarily white, sometimes yellow, or even brown, from the beginning. As the disease advances, two or three days from the begin- ning, the discharge from the vagina becomes more than ordinarily fetid, the labia excoriated, while the heat of the vagina is still very great, and there is much mucus and some pus issuing from it ; and later, shreds of decomposed substances, and sometimes considerable sloughs, are mingled with the discharge, increasing the fetor. The pulse is more accelerated, and sometimes becomes quite rapid ; the patient is much prostrated ; the tongue brown and dry, and the teeth foul with 250 AFFECTIONS OF THE VAGINA. a dark clammy mucus, while the skin is bathed in a copious perspira- tion. In from two to six or eight days, to these symptoms is added an evacuation of urine through the vagina, at first small quantities, and afterwards more considerable, until, in a short time, the contents of the bladder are passed in this way ; the parts around are excoriated by the urine and other acrid discharges, and a slow, uncertain con- valescence succeeds, with a permanent vesico-vaginal fistula. Occa- sionally, though not so frequently, the fseces pass through the vagina a fcAV days after the beginning of the inflammation, and we have a recto-vaginal fistula. If neither of these evils occur, there is extensive ulceration, not so deep, but extending over a large surface of the vagina ; thus pus and acrid ichor are poured out in copious quanti- ties, for a long time, gradually decreasing as the surface heals. As these ulcerations heal up, the tissue becomes condensed and contracted, until such strictures or occlusions result as are above mentioned. The practitioner should be wide awake to this frequent course of post- partum vaginitis. Treatment. As most damage from this form of vaginitis usually accrues to the bladder and rectum, our first and most solicitous care should be be- stowed upon them. The bladder should be frequently emptied with the catheter ; at least every few hours the urine must be drawn off. To appreciate this direction, we have but to remember that this organ may be considerably distended in that time, and as the septum between the vagina and bladder is in a state of intense inflammation, it is soft- ened, and therefore is easily ruptured. My impression is that fifty per cent, of the vesico-vaginal fistulse which now occur might be avoided by following this rule. Its importance cannot be overestimated. In very bad cases the catheter might be used even more frequently, or kept in the urethra. The rectum should be kept free from any accumulation of fseces by frequent injections of tepid water. In addi- tion to this prevention of fistula, the utmost cleanliness must be ob- served. The vagina should be washed out with soapsuds or other bland detergent fluid, from four to six times a day. For the first four or five days the parts ma}^ be kept lubricated thoroughly by the injec- tion, after the water, of very bland sweet oil, or almond oil. When the slough begins to be thrown off, or pus and sanies become copious, an injection of half a pint of tepid water, containing six or eight drops of creasote, twice a day, will serve to cleanse and stimulate the parts better than soap and water alone, which should be used between times. After the lapse of a week or ten days, if the ulceration is not healing, an injection of ten grains of nitrate of silver to the ounce of water may be used quite advantageously. This solution should be injected from a hard rubber or glass syringe, directed to the ulcerated part by URINARY FISTULA. 251 the finger. As the case still further advances, a solution of tannin, alum, sulphate of zinc, or other astringents, with the detergents, may be used. As the parts begin to contract by the advanced healing of the ulceration, the closure, partial or entire, should be anticipated by the introduction, daily or oftener, of wax, rubber, or other sort of bougies. It is well, when this last expedient is necessary, to smear them with ointment that may exert a healing influence on the ulcera- tion. The physician cannot be too attentive to these cases. He should see to it personally that his directions are carried out, and feel himself responsible for any serious permanent injury that can result from want of diligence. Women or their nurses cannot understand, and it is feared that physicians do not properly appreciate, the means of avert- ing the awful accidents which result from sloughing and ulceration in these cases. Urinary Fistula. Although generally resulting from puerperal vaginitis, fistula is sometimes produced by other causes. Extensive ulcerations from pessaries sometimes penetrate the septum between the vagina and Fig. 163. Fig. 164. bladder. Stone or other foreign bodies in the bladder may act as causes of ulcerative processes of sufficient gravity to do the same. Malignant diseases, as cancer of the uterus, vagina, or bladder, not unfrequently lay open these cavities; and, in some rare instances, perforations by the unskilful use of instruments have been observed. 252 AFFECTIONS OF THE VAGINA. Urinary fistula naay be: first, urethro-vaginal; second, vesico-vaginal; third, vesico-uterine; and, fourth, vesico-utero-vaginaL In the first variety the opening is through the urethra ; in the second through the septum between the vagina and bladder; in the third the vesical wall of the cervix uteri is perforated; in the fourth, two cases of which I have seen, the anterior and posterior portions of the cervix are both laid open. The cervix is sometimes involved with the vaginal septum, being torn up from the extremity through the anterior lip into the vaginal cavity. The whole urethra sometimes sloughs off", leaving the pubic arch unoccupied by that canal. In one case I have recently seen, the urethra and neck of the bladder were lost, leaving the re- mainder of the vesico-vaginal septum healthy and entire. In certain other instances the whole lower portion of the bladder is wanting, and the uterus more or less mutilated. To make the condition more deplorable, in some rare examples of the terrible destruction of the parts, the rectum is involved in the common ruin. The size of the opening in the urethra or vesico-vaginal septum is sometimes so small as scarcely to be perceptible, and from this it ma^^ vary through all grades of dimension to the irreparable loss of tissue above described. The direction may be lengthwise, diagonal, tortuous, or crosswise. The fistula, when established, is usually associated with other effects of the disease from which it is produced. Cicatrices and contractions of the vaginal walls are very common accompaniments. These, when extensive, embarrass examinations and operations very much. They also change the size, shape, and direction of the vaginal cavity. Diagnosis. The constant flow of urine through the vagina, instead of the urethra, is a sufficient symptom to decide the existence of fistula ; but we meet with cases where the flow of urine is not constant, the patient being able to retain for some time and then discharge her urine natu- rally. This circumstance is due to the plugging of a small opening by mucus, or the prolapse of some part of the bladder into the fistula. In all instances it is jaroper and necessary to make a clear diagnosis of the existence, size, shape, position, and complications of the fistula. This is usually easily done by the fingers and probe. The patient should lie on her back with her hips near the edge of the bed, and her legs flexed so that we may have free use of both hands. The fingers will readily pass through a large fistula into the bladder, and, by moderate care, be made to thoroughly survey it and the surround- ing parts. But the fistula may be so small or situated so as to entirely escape detection by the finger. We shall be aided in such cases by introducing a probe, slightly bent, through the urethra with one hand, while the fingers of the other are in the vagina. The bent URINARY FISTULA. 253 extremity of the probe is turned toward the septum, jaressed gently upon and passed over every part of it until it is made to pass through the opening, when it may be recognized by the finger in the vagina. When the perforation is very small, or vesico-uterine, this kind of examination will fail to find it. In such cases the vagina should be dilated as for operation, and exposed in a good light so that every portion may be seen. When thus exposed, the cavity should be sponged out and all the urine thus removed. After this perforation, usually, we have but to watch a few moments when we shall perceive the fluid making its appearance through a minute pore, which, per- haps, is hidden in an ulcer in some remote part, or we may observe it coming through the os uteri. If, however, no urine makes its way through in such quantity as to indicate the place of injury, we may inject the bladder with tepid water in such amount as to distend the organ somewhat. Soon the obstacle is overcome and the water will escape copiously into the vagina. If it comes through the mouth of the uterus, the fistula is situated in the cervical cavity. This may be made more conclusive by plugging the os with cotton and again injecting the bladder. The fluid will not escape, of course, until the cotton is removed, when it will pass in such abundance as to leave no doubt of its place of exit. German physicians, Veit especially, recom- mend the use of water colored so as to make its flow through the open- ing more obvious. Prognosis. Having found the fistula, ascertained its size, position, shape, direc- tion, etc., we ought to survey the vagina, to find strictures or other deformity, and ascertain the distensibility of this tube. We do this in part to determine the prognosis of the case. Can the fistula be cured? is a pertinent and important question, which will be decided by this kind of examination. Fortunately, noiv, thanks to Dr. Sims, almost anything short of loss of the whole septum may be cured. If the fistula consists of a defined opening, it matters little how large, we are justified in expecting success. If, as is sometimes the case, there are no sides, edges, or ends to it, but the vagina and bladder are one cavity, smooth, and continuous, we cannot reasonably undertake an operation unless it be to close the vulva, as has been suggested and practiced. Some circumstances, independent of the character and size of the fistula, are necessary to insure success. The vagina should be healthy. If the walls of this cavity are in a state of inflammation or congestion, the prospects of a cure are more remote. Great nervous susceptibility is sometimes difficult to overcome, and should be a reason to defer the operation. The general health of the patient is also a matter of the first importance. A highly nervous condition of the system, with an abundance of lithates in the urine, is a condition in which there are many chances of failure. 254 AFFECTIONS OP THE VAGINA. Treatment Naturally divides itself into palliative and curative. The palliative treatment is of great importance, and he would be a benefactor who should devise means of preventing the great suffering which results from these inevitable circumstances. The greatest amount of pain and suffering in such cases is caused by the flow of urine over the cutaneous surface. The salts held in solution by the urine, and the compounds resulting from their chemical decomposition inflame and excoriate the skin of the thighs, perineum, and external genital organs. Relief can be perfect only by preventing the contact of the urine with the skin. I think there would be little difficulty in making an instrument that would collect the urine, in most cases, before being discharged from the vagina. But the difficult}^ consists in getting one that would be tolerated in the parts. What we want is a sac that may be introduced and retained in the vagina with an opening in the upper wall opposite the fistula, large enough to i3ermit the urine to flow into it. The sac should have a tube leading out of the vaginal orifice in order to convey the urine into a reservoir outside, which should be attached to the person of the patient. The sac should be of india-rubber or other impervious material, and so soft and smooth as not to irritate the mucous membrane of the vagina, and so small as not to distend the vagina painfully. But the urine would not flow into and through this tube unless the sac was distended so that the opening is applied to the fistula. The distension may be eflPected sufficiently after the sac is introduced, by passing cotton up through the tube. In order to make the urine drain through the tube something like cancel- larise should extend from the cotton in the sac outside through the tube. The drainage will be started by wetting the contained material. By capillary attraction the cotton absorbs the urine until it becomes saturated, while the loose cord will carry it off like a siphon through the tube. If an instrument of this kind can be made that will be tolerated by the vagina, I think it will act well. In the absence of anything to prevent the urine from flowing on the person, the patient must depend upon frequent ablution with warm water externally, and upon warm injections in the vagina. After washing externally, the skin should be kept covered with simple oint- ment. The injections should be made four or five times in the twenty- four hours, and the external ablutions as often as the napkins become sufficiently saturated to replace by others. Another item in the palliative management of the first importance is one mentioned by Dr. T. A. Emmet, viz., never to use a napkin twice without washing. Sometimes to avoid labor patients will simply dry the napkins and then use them again, thus using a napkin several times without washing. In this way the salts of the urine are applied to the skin in double strength, and the mischief greatly increased. UEINAEY FISTULA. 255 The curative treatmsnt consists in the closure of the fistula. It is hardly necessary to mention any other method than the closure of the fistula by suture in some form or other. Cauterization was often resorted to before the present safe and sure plans of operation by Drs. Sims and Bozeman, but is now scarcely thought of. To Dr. J. Marion Sims we are indebted for the cure of vesico-vaginal fistula ; for although others had succeeded in making cures by the use of nearly the same means, his ingenuity and persevering industry gave such positiveness and intelligent definiteness to the different steps to be followed in order to succeed, as to convert the operation from one of great uncertainty, confined to experts and experienced operators, to an easy, almost invariably successful one, which any surgeon of ordinary skill may venture upon without fear of failure. The profession is also indebted to Dr. T. A. Emmet, for a very lucid demonstration of the principles upon which the operation is founded, in his work on that subject. In describing the very simple operation of Dr. Sims one can scarcely do otherwise than follow, if not copy, the graphic description given by Dr. Emmet. Very much depends upon proper preparation of the system of the patient and the parts concerned, in order to insure suc- cessful adhesion of the two edges of the fistula. The patient should be in the best possible general health. I think there is great propriety in the distinction insisted upon by some surgeons between the plastic and aplastic diathesis in patients subjected to surgical operations, and am anxious that my patients, for some weeks before the operation, be subjected to the best hygienic conditions for their general health. In the country, if possible, plenty of exercise in the open air, good nutri- tious diet, a contented and happy state of mind are all that are required to effect the desired preparatory condition. In patients whose blood is impoverished from nursing, hemorrhages or other debilitating cir- cumstances, the ferruginous and bitter tonics should be administered. If the general health is well established and maintained for a little time, the vagina will scarcely be otherwise than firm and sound in texture, and free from the troublesome urinary concretions that some- times adhere to the mucous membrane of the vagina, the vulva, and even the greater labia. During the preparatory constitutional treat- ment, where that is necessary, the local preparation may be attended to — by frequent cleansing by copious injections of warm water, stimu- lating the parts in the vagina that are red or excoriated with a weak solution of nitrate of silver every four or five days. The solution may be of the strength of 5j to f.?iv of distilled water. Dr. Emmet says that : " It is frequently necessary to pursue the same general course for many weeks before the parts can be brought into a perfectly healthy condition. This point is not reached until not only the vaginal wall, but also the hypertrophied and indurated edges of the 256 AFFECTIONS OF THE VAGINA. fistula have attained a natural color and density. This is the secret of success, but the necessity is rarely appreciated ; without which the most skilfully performed operation is almost certain to fail." The only other preparatory step will be the administration of a cathartic to evacuate the bowels. The catharsis ought to be entirely over at least twelve hours before the operation. With these prelimi- naries accomplished, we should have a large window on the sunny Fig. 165. Fig. 166. Fig. 167. \ Fig. 165.— Tenaculum, with which to hold the edge of Fistula while being pared. Fig. 166.— Curved Scissors, for paring edge of Fistula. Fig. 167,— Wire Adjuster. side of the house, a sun-shining day, four assistants, a table of conve- nient height, five feet long and two wide, and the necessary instru- ments. The table, covered with one or two quilts, is to be placed with the end toward the window, from four to six feet distant. The patient lies on her left side, the limbs drawn up, the right a little more than the left with the left arm behind her, so that she rests full on the front of the chest. One of the four assistants uses the anaesthetic, another the URINARY FISTULA. 257 speculum, a third the sponges, and the fourth attends to the instru- ments. The instruments should he placed on a tray, within easy Fig. 168. Fig. 168.— Speculum for dilating Vagina. Fig. 169.— Forceps for twisting the Wires. Fig. 170.— The Catheter. Fig. 171.— Needle Forceps. Fig. 172.— Sponge-hold jr. The instruments are represented half size. reach of the operator. They are the speculum, two tenacula, scissors, Emmet knife, two long sponge-holders, forceps for carrying the 17 258 AFFECTIONS OF THE VAGINA. needles, one wire adjuster, a blunt hook, forceps to twist the wire, half a dozen needles, slightly curved, about one inch long, armed with silk hgature, doubled so that the silver wire may be placed in the loop and thus drawn through the wound, an elastic male catheter, or one of Sims's S-shaped instruments, with an india-rubber tube, a little larger than the catheter, to carry the urine clear of the bed. The surgeon takes his seat at the end of the table next the window, near the breech of the patient, introduces the speculum, dilates the Fig. 17 Fig. 174. Method of paring the Edges. Method of passing the Needle. vagina, and thus brings the parts thoroughly in view, and then gives the instrument to the assistant to keep in that position. If the posi- tion of the patient prevents the parts from being thoroughly exposed and lighted, it should be changed until this difficulty is obviated, when the operator may proceed as follows: With the tenaculum in the left hand, the edge of the fistula is transfixed and held up to view, and, with the scissors, bevelled from the mucous membrane of the bladder outward. Dr. Emmet says the point of the tenaculum should be in- troduced toward the fistula, as shown in the figure. As much as prac- URINARY FISTULA. 259 ticable should be removed in this way, without changing the place of the tenaculum. Another 23lace on the edge of the fistula is then seized and trimmed in the same manner, and so on, until the whole circle is denuded completely of the cicatricial tissue. We may sometimes succeed after a little practice in removing a complete ring of the edge of the fistula. This will, of course, insure to us a more perfect opera- tion than if the parts are removed in pieces. As this part of the operation, is being accomplished, the assistance of the sponge will be required on account of the bleeding. I do not see the necessity of removing as much substance from the edge of the fistula as is directed by some authors. The main object, I think, is to have the edges evenly and thoroughly denuded of the mucous membrane. This much should be done with Fig. 175. Method of using the Tenaculum in giving aid to the Needle. a completeness that admits of no doubt, and if we have a good light, there need be no doubt, as we can see and examine the part suffi- ciently well to be positive. After the bleeding has ceased, we may insert the sutures. We commence at the angle of the wound most remote and difficult to reach. The needle is to be introduced first into the lip of the wound nearest to the operator, by starting it in about half an inch from the freshened edge, dipping it down, so as to make the point come out in the denuded portion, just at the junc- tion of it and the vesical mucous membrane. The needle being brought through at this point, is again inserted in the opposite edge, corresponding as near as possible with that part whence it emerged, 260 AFFECTIONS OF THE VAGINA. and carried forward far enough to emerge half an inch beyond the edge of the wound, and drawn through; the wire is then hooked in the double end of the silk and drawn through the wound, and de- tached from the silk and given to the assistant in charge of the speculum to retain in its place. The next suture is to correspond with and be placed within two lines of the first. They are thus placed in sufficient numbers to close the opening completely. (See Fig. 176.) Having all the sutures introduced, the one nearest the operator must be isolated and twisted by the forceps made for that purpose, ^^W The Fistula with Edge Pared and the Sutures Placed. until the angle of the wound is evenly coaptated. The next is to be managed in the same way, and so of the remainder in order. Great care must be taken to see, as the closure is effected, that the lips of the wound are drawn evenly and smoothly together. (See Fig. 177.) If we are not particular, the edge of one side or the other rolls slightly in and unrefreshened mucous membrane is brought up to the denuded surface. This, I think, is a circumstance that is very liable to occur in the hands of an inexperienced operator. Both the insertion of the sutures and bringing together the edges may be facilitated by the skilful use of the tenaculum and the adjuster. The tenaculum will URINARY FISTULA. 261 enable us to disengage and straighten the edges, iii adjusting them, and keep them firm in inserting the needles. The adjuster will place the twist of the wire in any position we may desire with reference to the junction of the wound. In twisting the wire there are two things to be avoided, — one is tightening it too much, and the other leaving it too lax. Experience will fix these items after a few operations, but I think that the operator may venture to tighten the twist of the wire UDtil it fixes but does not strangulate the part included in the stitch. After the twist is completed, we ought to be able to pass an ordinary probe through the circle of the stitch without much force, and yet, upon its removal, there should be no apparent space. If the stitch is drawn too tightly, the j)arts will be strangulated and early cut through Fig. 177. Wire Adjuster.- by ulceration ; if too loose, the urine will pass through as the bladder becomes filled and prevent adhesion. As each wire is. adjusted and twisted it should be bent over the tenaculum, so as to lie flat upon the surface of the mucous membrane of the vagina. The operation finished, the catheter may be inserted, the patient placed carefully in bed, on either side, and a grain of opium administered. The catheter will sometimes become foul with deposits, and require cleaning every twelve or eighteen hours, but as a rule, while the urine is running freely, it may remain in place. Great watchfulness will alone prevent this instrument from being misplaced. The great desiderata of the after-treatment, are to pre- vent an accumulation of urine in the bladder, and the bowels from being evacuated. The former can be certainly accomjolished in no 262 AFFECTIOXS OF THE Y AGIN A. other way than by having a competent assistant by the patient, or very near her all the time, who, when the catheter does not deliver the water freely, will remove it and replace a clean one, however frequently that may be required. Dr. Emmet directs that the patient be placed upon her back and so remain during the after-treatment. He causes a double inclined plane to be made by the bedding, so that the legs may be bent and the head and shoulders elevated. We may keep the bowels quiet by administering a grain of opium twice or three times a day. If the patient is very restless, we ought to give as much more as is necessary to quiet her. The only other important Fig. 178. Fig. 179. Closing the Wounds and Twisting the Wire Sutures. Removing the Sutures. item of treatment as a general thing is cleanliness, and for this pur- pose vaginal injections of tepid water, with fine toilet soap, twice or three times a day, will suffice. The vagina will thus be kept clean with much certainty. The diet should not be too sparing. The ordinary diet of the patient, in half or two-thirds of the quantity, I am convinced, is better than any considerable change in quality. The patient must remain quiet as practicable for nine or ten days. There will be no good in leaving the sutures in place longer than ten days perhaps, but there can no harm result from their longer presence. The removal of them is easily accomplished, by passing one blade of the scissors within the circle of the stitch, and dividing it, when the wire may be withdrawn by the forceps. The patient should keep URINARY FISTULA. 263 her position and wear the catheter for five or six days, after the sutures are removed, to allow the consolidation of the cicatrices and the closure, by contraction, of any minute opening that may have been left. Although the experience of Drs. Sims and Emmet have proven the propriety and efficacy of this kind of after-treatment for vesico- vaginal fistula, all of it is not absolutely necessary to success. In two instances operated on by the author, the patients were not con- fined to any position, and were permitted to rise . from the bed and sit up part of the time each day, from the time of the operation until Fig. 180. the sutures were removed. The catheter was not worn in either case, but it was used for the first four days, every two hours, to evacuate the bladder. At the end of four days, the patients were permitted and instructed to evacuate the bladder as often as once in two hours voluntarily. Both the patients were cured, and the comfort they enjoyed con- trasted very favorably with that of such as were confined to the posi- tion on the side or back, and were obliged to wear the catheter for ten or fifteen days. I have, from time to time, seen suggestions in medical journals, which I cannot now command, that led me to conduct the after-treatment in these two cases as above stated. 264 AFFECTIONS OF THE VAGI^'A. Simo7i''s Method. In Continental Europe the late Professor Gustav Simon, greatly dis- tinguished himself in plastic operations. His operation for vesico- vaginal fistula is, in many respects, different from that above detailed. He places his patient on her back with the breech very much ele- vated. In cases where the fistula is near the orifice of the vagina, the limbs are placed in the position usual in lithotomy. If the fistula is deep, however, the limbs are brought up and extended over the sides Fig. 181. of the abdomen and breast, as shown in Fig. 180. If the uterus is suf- ficiently mobile, Simon draws it down to the external organs of gen- eration, and thus places the fistula immediately under the hand of the operator. In order to ascertain the mobility of the organ, he seizes the cervix with Museux's forceps, and draws upon it until the vagina is inverted, or until it is evident that the forcible traction re- quired will do violence to some of the tissues. When the cervix is UEINAEY FISTULA. 265 drawn down sufficiently, two strong threads are passed through it by which it is held in place. Fig. 181 represents this stage of procedure ; the sides of the vulva being held out of the way by levers made for the purpose. When the uterus cannot be thus drawn down, Simon uses two specula, and the levers in the sides of the vulva, if necessary. This method of exposure is very plainly illustrated by Fig. 182. One large speculum draws back the perineum, and another, somewhat differently constructed, is placed under the symphysis pubis. The margin of the fistula is prepared by cutting away all the cica- tricial tissue, and the paring is done almost perpendicular to the sur- face of the vaginal mucous membrane. There is some slight inclina- tion or declivity in the cut edges, but they are very much less bevelled than in Dr. Sims's operation. Fig. 183 will give a correct idea of this part of the operation. A comparison with Fig. 182 will give the 266 AFFECTIONS OF THE VAGINA. reader an idea of the liberality with which Dr. Simon considers it necessary to pare away the tissue. The wound is closed with fine white silk, about' the size of a large horsehair. Each stitch is placed a little more than a line distant Fig 183 'Vr*^ m %' n ft ' \l ^6- ^' from the one next to it. The needle is carried entirely through the lips of the wound, so as to penetrate the vaginal and vesical mucous membrane. In large fistula, every alternate stitch is placed further from the edge of the wound. Fig. 184 also shows this method of in- troducing the stitches. The threads are carefully tied in a knot and the operation is completed. The closed fistula is well represented by Fig. 185. URIJfAllY FISTULA. 267 Vesico-uterine fistulse are operated upon in the same manner. Figs. 186 and 187 show how such fistulas are pared, the stitches in- troduced, and the wound closed. In the after-treatment, Dr. Simon thinks it superfluous, if not in- jurious, to leave the catheter in the bladder. He directs us to draw off the urine once in two or three hours, until the patient can volun- tarily discharge it, which she can usually do in the second or third Fig 184. day. He allows the patient to lie in any position, and on the eighth or ninth day she can rise from the bed. All straining at stool, before the eighth or ninth day, should be avoided, if necessary, by the ad- ministration of opium. On the fourth or fifth day the physician should examine the wound with a view to the removal of the stitches, and if they are cutting their way through the tissues they should be cut and drawn out. 268 AFFECTIOKS OF THE VAGINA. Of 43 fistulas in 40 women operated upon by Professor Simon, 35 were perfectly cure(;l, 2 of the women died, 5 more of the fistulse were nearly cured, and 1 was not benefited. KolpoMeisis. Cases of urinary fistula occur which cannot be cured by an opera- tion like the foregoing. Occasionally we meet with instances in which the damage is more serious, where the septum between the bladder Fig. 185. and vagina is nearly or completely destroyed, not enough of this structure being left to enable us to restore it. Surgery has successfully met these cases by closing the vaginal ori- fice or lower part of the vaginal canal, thus making a common receptacle of the posterior and lateral walls of the vagina, and the remaining portion of the bladder, into Avhich the renal secretions and the uterine discharges are received and from which they find their way UEINARY FISTULA. 269 out through the urethral canah The vagina may be closed by unit- ing the inner edges of the labia or the anterior and posterior walls of the vagina quite inside the orifice. The operation for uniting the labia will be necessitated in some instances. We occasionally meet with cases where the anterior wall of the vagina is entirely removed from the pubis, and nothing is left behind that bone to which the posterior wall of the vagina may be united. So complete is this removal of tissue that the posterior face of the pubis is covered with nothing but a thin cicatricial substance. The labial closure of the vagina is the only operation in this class of extreme cases. Fig. 186. The operation consists in removing a ring of mucous membrane from the inner margin of the labia, just behind the orifice of the urethra, three-quarters of an inch deep, and then by means of deep silver sutures making perfect apposition of the denuded surface. The sutures should be passed deep enough to include the whole of the raw portion of the parts, and extend on the outside three-quarters of an inch in the sub- stance of the labia bejroiid their margin. The sutures, to insure union, should be not more than three lines apart. The parts should be care- fully adjusted while the wires are being twisted, so as to make an even adaptation. 270 AFFECTIONS OF THE VAGINA. When there is sufficient of the vesico-vaginal septum behind the pubis to permit its coaptation to the posterior wall, the operation per- formed, and proposed about the same time by Simon and Bozeman, is preferable to the foregoing. Simon's method is simple and effectual in closing the vagina thoroughly. He denominates the operation Kolpokleisis. The vagina is held open by the instruments and by the method described for operating on fistulse, and a ring of mucous mem- brane is removed as represented in Fig. 187 and then united by the sutures. Silver wire is probably the best suture for this operation. Fig. 187. r- Dr. Simon operates as high up in the vagina as the disease will permit, and, instead of confining the operation to the urethral portion of the cavity, he sometimes operates so near the os uteri as to preserve al- most the entire length of the anterior wall of the vagina. After either operation the treatment will consist in perfect^quietude, the use of opium to relieve pain, and the fixed catheter to prevent an accumula- tion of urine until the parts are healed. URINARY FISTULA. 271 Bozeman's Method. Dr. Bozeman, whose operations have attracted attention in Europe as well as in this country, claims to have made improvements upon the operation for vesico- vaginal fistula as well as in the means and methods of performing it. As now employed his operation has for its distinctive characters the button suture, the position of the patient, and a self- retaining speculum. The figure which is here introduced will serve to illustrate the position of the patient and the self-retaining speculum. In paring the edges of the fistula Dr. Bozeman makes the extent of denuded surface rather greater than is recommended in the foregoing pages and does not place his sutures as near together. After having pre- pared the parts for coaptation he passes the two ends of each suture re- spectively through the opening in his adjuster, as represented in figures Fig. 188. C ^ 1 B Bozeman's Apparatus for Retaining the Patient in Position. taken from page 24 of M. Andrade essai sur le traitement defishdes vesico- vaginalespar leproc^d^ Americain modea^ par M. Bozeman. Thus ad- justed the wound is ready for the button, which should be made at the time and in accordance with the shape and size of the wound. The button is cut out of a thin sheet of lead, about one line in thickness, long enough to project about one-fourth of an inch beyond the sutures at either end of the wound, and a very little more than half an inch wide. If the wound is straight after it is closed with the suture, the button should be the same ; but if the wound is curved the button should be made to suit the curvatures. Then with the " button-form- ing forceps," the groove along the centre may be formed by clamping across the sides from one end to the other. Thus formed, the button is slightly concave on the side that goes next the closed wound, and 272 AFFECTIO^IS OF THE VAGIXA. has a groove of almost a line in depth along the centre, from one end to the other, and is ready to be perforated for the sutures, which, after measuring otf the distances accurately, is done by an instrument for the purpose. The operator should then assure himself that all the spiculse caused by the perforating process are removed, and proceed to adjust the button. Fig. 189 shows the sutures through the button as it approximates its future site on the wound. The button is pressed down evenly upon the wound by means of the blunt hook, and each suture, one after Fig. 189. Fig. 190. the other, passed through perforated shot, and fixed by clamping the shot with strong forceps for the purpose. Each suture should be care- fully fixed in this way separately. In adjusting the sutures the wire should be tightened by being drawn through the opening at the time the shot is compressed. Only so much traction should be made as Avill bring the lips of the wound well up into the groove, but not strangulate them. The button thus applied is well represented by Fig. 190. Dr. Boze- man claims for this suture : "1. Separate and independent action of the sutures. "2. Perfect coaptation of the edges of the fistula, and power (o hold them in a cer- tain relationship during the reparative process. "3. Perfect steadiness and support of the edges of the fistula. "4. Protection of the denuded edges of the fi-itula from the vaginal and uterine dis- charges, and from tlie urine, when there happens to be more than one opening, and it is not convenient or desirable to close botli at the same silling." We are indebted to Dr. Bozeman for a very ingenious and effectual method of diagnosing minute and otherwise indistinguishable fistula?. He calls it the linen test, and describes it as follows : UEINAEY FISTULA. 273 " Pus and mucus in small quantities adhere to and spread upon the surface of a piece of linen without being absorbed b}' it, while water or urine, on the contrary, even in the minutest quantity, when brought into contact with the same material, penetrates almost instantly the entire thickness of the fabric. The presence of these fluids, if the flow is continuous, is evidenced by increasing saturation of the spot acted upon, and the spreading of the moisture in every direction. Thus is presented a most valuable and reliable means of determining the presence of urine in the vaginal or uterine canal when the quantity is so small as to escape observation ; not only this, but the precise situation of its escape from the bladder can be made with the greatest certainty when it would be impossible to detect it by the ordinary means, owing to the minuteness of the orifice or its concealment by a fold of mucous membrane. "In using the test nothing more is necessary than to fill the bladder with water, and then wipe thoroughly dry the anterior wall of the vagina. A piece of old linen is now' rapidly spread out upon the latter, and pressed down smoothly, the patient being in the angular position, upon the knees. In a few moments the effect of the fluid upon the linen will be seen at the place of escape from the bladder, should the orifice be even no larger than a pin's point or a fine bristle. When the patient is placed in the dorsal position it is seldom necessary to inject the bladder ; the natural flow of the urine from the kidneys will be found quite sufficient to mark the situation of its un- natural escape into the vagina." With regard to the success of his method of operation, as now prac- ticed by him, he gives the following data : "For the period from 1867 to 1870, 17 cases, having 23 fistula;, got 24 operations, with the following results : " 21 fistulae completely closed. "1 fistula completely closed in a syphilitic subject and afterwards reproduced. " 1 death, caused by intense heat of the weather and consequent exhaustion of the patient. " 88 per cent, of permanent cures. " 87J per cent, successful operations. "The syphilitic case was cured as regards the result of the operation, and the death did not result from causes connected with the operation. It will be seen, therefore, that the percentage of permanent cures and of successful operations is not far below the maximum limit. Of these 23 fistulse 3 were vesico-uterine, 1 vesico-utero-vaginal, 1 utero-vaginal, 1 laceration of the urethra, 1 urethro-vaginal and recto-vaginal, the latter admitting easily three fingers into the bowel ; all of which were completely closed, with preservation of the functions of all the organs involved." In a recent letter he says, with reference to his oiaerations : " By examination of my reported cases, treated by this form of suture, you will find the inauguration of several new procedures in the following affections: "1st. Urethral lacerations extending from the meatus backwards, a part or the whole length of the canal. By a peculiar modification of my button, the catheter in these cases is supported and the closure of the rent made complete to the meatus. (See North Am. Med.-Chir. Review, July and November, 1857.) "2d. Vesico-uterine fistulae. A mode of treatment to close the fistula and preserve the functions of all the organs intact. The operation consists in dividing posteriorly the anterior lip of the cervix uteri down to the sinus, then paring the sides of the 18 274 AFFECTIONS OF THE VAGINA. latter and closing the wound. (See Case V., op. cit.) This was my first case, and here I got the idea I have since performed successfully this operation in three other cases. In one case the sinus opened so high up in the cervical canal that the utero- vesical fold of peritoneum was implicated in the operation. "The great value of this procedure cannot be overestimated. The procedure of Jobert, which consists in paring the two lips of the cervix and uniting them by suture, is almost universally adopted by surgeons in this class of cases. If the operation proves successful, the menstrual fluid is left with no other outlet than through the small sinus (usually no larger than the most delicate probe) into the bladder, there commingling with the urine and finally escaping with it through the urethra. In the journals I have seen the operation is claimed as a great triumph. The operation is frequently performed by leading surgeons. " With regard to this practice I unhesitatingly condemn it. It is unsurgical and unjustifiable, and should never be performed. " 3d. Vesico-utero-vaginal fistula. An original procedure for its cure. (See Case VIII., op. cit., 1857.) " 4th. Incarceration of the cervix uteri in the bladder. An original procedure for the disengagement of the cervix from its confined position and the closure of the fistula, with preservation of all the functions. (See Case XV., op. cit., and Cases XXVIII. and XXXVIII., New Orleans lied, and Surg. Journ., January, March, and May, 1860.) " I would add here that my cases are the only ones to be found upon record, and I venture the assertion, without the fear of contradiction, that no cure will ever be effected by any other form of suture than the button. The mechanism of this suture is peculiarly adapted to the successful treatment of this rare lesion." I am not aware that Dr. Bozeman's operation has been objected to on account of want of success, for when skilfully performed all acknowledge its success. The chief and perhaps only objection that has had any effect in preventing it from general favor and practice is complication and consequent difficulty. This need be no objection if the surgeon is prej^ared with all the instruments now used by Dr. Bozeman ; with them the different steps in the operation are easily accomplished. He requires no assistance during the operation, a consideration of no small importance. Entero-vesical Fistula. Occasional instances occur in which from cancerous degeneration of the tissues of the bladder and intestinal canal lying in contact they become adherent, and afterwards perforated in such manner as to permit the discharge of the excretions of one organ into the other, thus making an entero-vesical fistula, with the urine passing into the intestine and out at the anus, and causing what urine passed from the urethra to be mixed with fseces. The author had for several months under his care a recto-utero- vaginal fistula. This condition was caused by perimetritic inflammation. The abscess perforated the bladder, uterus, and rectum, and the escape of faces as well as urine was observed from all these cavities. The fistulous openings were ENTERO-VAGINAL FISTULA — RECTO- VAGINAL FISTULA. 275 small and must have been tortuous, as these excretions escaped in very small quantities. The patient, a young girl, died of tubercular consumption after having lived in this miserable state eighteen months. Entero-vagina I Fistula. This is of two kinds, colono- vaginal and recto-vaginal. The former is very rare, and is caused by malignant ulceration or grave perime- tritis. The inflammation, when sufficiently severe to cause commu- nication between the vagina and colon, usually extends up into the abdomen and involves the viscera in that cavity to a very serious extent. The suppurating cavity in this case is also large, and opens in one place into the intestinal canal, and at another point of ulcera- tion into the vagina, and as the cavity of suppuration is slowly filled by granulations a tortuous canal is left, leading from the bowel down into the vaginal cavity. If the opening into the vagina can be found, I see no objection to closing it with the silver suture. After a long time these opening would probably close spontaneously, as artificial anus will sometimes do. Recto-vaginal Fistula. This accident does not so frequently as vesico-vaginal fistula result from puerperal vaginitis. Stricture of the rectum, abscess of the recto-vaginal septum rupturing into both cavities, and accidents with instruments, perhaps, as often cause it. It is not so common or fre- quent as vesico-vaginal fistula, nor so distressing. The passage of the faeces, if jDroper cleanliness is observed, although disgusting, is not so productive of inflammation and excoriation as urine, and their dis- charge may be controlled by appropriate fixtures. A cure is also more easily accomplished; indeed, it is often spontaneous. As the contents of the bowels pass intermittingly, and, when in contact with, the raw surface, do not irritate it considerably, the ulcer has time to. contract, and healthy granulations, in a good state of the general health, result. The symptoms and diagnosis of this fistula are so obvious that I need not dwell upon them ; but we sometimes meet with cases where the opening is so small and tortuous, that great patience in the use of the probe will be required to satisfy ourselves as to its position and. direction. The injection of water into the rectum while the parts are under inspection will generally clear up all doubts. Treatment. If we are associated with these cases during the ulcerative condi- tion, we may conduct them to a cure with some certainty, and, per- haps, more readily than after the edges of the opening have cicatrized. The important items of treatment at such times are : 1st, proper atten- 276 AFFECTIONS OF THE VAGINA. tion to the bowels ; 2d, great cleanliness ; and 3d, maintenance of healthy granulations until the contraction obliterates the opening. The bowels should be kept quiet as much of the time as possible. To accomplish this, the diet should be concentrated and nourishing in character ; beef essence, milk, eggs, crackers, coffee, or tea, and if necessary on account of debility, wine, or medicinal tonics ; and if the bowels have a tendency to move, opium in such quantities as will restrain them. Every four or five days a gentle alterative, say three grains of blue pill, followed by a saline cathartic ; after the bowels have moved from this, the opium may be given to restrain them for four or five clays again, and so on until the opening is closed. During this treatment there should be frequent injections of water into the vagina. The part should be examined with the speculum every day, to see that the edges remain raw. Where there is any tendency to cicatrize, the edges may be freely touched with pure nitric acid. If the cure is protracted, the acid should give place to the actual cautery. Toward the last, as the opening becomes small, especially if it is tor- tuous, a piece of twine, or what is perhaps better, a silver or iron wire, may be passed through it, and the ends brought out through the anus and vagina. If the case is chronic and the opening small, the appli- cation of the acid may be made every day until the edges are denuded, and then the same course followed as above directed. Of course, these applications must be made through the vagina with a speculum that completely exposes the part touched. If the place is large and chronic, we shall very much shorten the process of cure by an opera- tion similar to that for vesico- vaginal fistula. After having thoroughly evacuated the bowels, the patient may be placed in the lithotomy position, and exposing the jDarts to a strong light, the perineum may be retracted by the rectangular speculum blade of Sims, while the vulva is held open by assistants. The edges are then to be pared thoroughly, and the aperature closed with silver sutures. It is neces- sary to make a larger raw surface on the vaginal than on the rectal side, that the rectal edges may lie together without traction. The bowels will require the use of from two to four grains of opium daily to keep them quiet. They should not be allowed to move for ten days, when a saline cathartic should be given, and after it has operated well, the stitches removed. During the time between the operation and the removal of the stitches, the patient is to remain quiet in bed, and have injections, per vaginam, of tepid water with soap, twice a day. If by this operation there is imperfect closure of any part, the treatment recommended for recent cases will suffice to complete the cure. Even these larger-sized fistula are sometimes cured by the caustic acids, the actual cautery, or tinct. lytta? ; but it takes a longer time, and is attended with more jDain and annoyance. The operation on these fistulae will be greatly facilitated by having the breech of the patient projecting somewhat over the end of the table. CHAPTEE X. MENSTEUATION AND ITS DISOKDEES. Several conditions are necessary to the healthy iDcrformance of the functions of menstruation. 1st. The ovaries must be present, and sufficiently healthy to pro- duce ova. 2d. The uterus must be sufficiently perfect, anatomically and physi- ologically, to be the medium of elimination. 3d. A certain, but not as yet very well-defined, state of the blood and nervous system must exist. These are, probably, not all the conditions necessary to perfect menstruation ; but they are the obvious and undoubted ones. The uterus, by virtue of the conditions upon which menstruation depends, is naturally a hemorrhagic organ ; and it is in consequence of its anatomical and physiologicaLpeculiarities that the ordinary and frequently acting causes of uterine hemorrhage are rendered so potent and effective. The more obvious phenomena of menstruation are doubtless the result of a definite reflex nervous influence exerted by the ovaries upon the uterus. Although this influence is more distinctly mani- fested in the great hypersemia which precedes the occurrence of the catamenial discharge, and the changes in the utricular glands and mucous membrane of the womb, yet it is unquestionably constant in its action and parallel to that which presides over the motions of the heart, the arteries, and the alimentary canal. Generated in the nerv- ous apparatus of the ovaries, and contemporaneous with the changes called ovulation in those organs, this influence is probably conveyed by afi"erent nerves to the genito-spinal centre (the existence of which was first established by Budge, of Greifswalde),* or to some other reflecting ganglion, whence it is sent back to the uterus, giving rise to a wonderful series of tissue changes during the month. Some of these changes have been lucidly described by Dr. John Williams, in the Obstetrical Journal of Great Britain and Ireland, and by our own talented young countryman, Dr. Engelman, in his recent essay upon the subject, published in the American Journcd of Obstetrics. These changes are aptly termed by Aveling, nidation and denidation. A few days before the menstrual flow makes its appearance, the * Ueber das Centrum genito-spinales des N. sympatheticus. Virchow's Arcliiv f. Path. Anat. und Klin. Med., Band xv., S. 115-126. 278 MENSTRUATION AXD ITS DISOEDEES. whole uterus, and especially its mucous membrane, becomes greatly hypertrophied and very vascular ; when the discharge begins, the membrane is invaded by fatty degeneration. This process is so rapid that, in four or five days, the entire mucous membrane disappears, leaving the muscular structure of the inside of the uterus exposed, while some remnants of the utricular glands are left, and found en- tangled among the denuded fibres. As soon as the monthly flow ceases, a reproduction of the membrane is commenced, and it con- tinues to grow until at the end of twenty-eight days its menstrual maturity is attained. Accompanying these changes in the cavity of the uterus are others equally remarkable, affecting all the other tissues of the organ. The bloodvessels become enlarged, and circulate an increased amount of blood ; the fibrous tissue is developed beyond its intermenstrual condition; while hypereesthesia indicates extraordi- nary nervous endowment. In fact a true hypertrophy of the uterus occurs. During the discharge, the process of involution reduces the organ to its smallest dimensions, and the hemorrhage ceases. The culmination of this hypertrophy in the discharge of blood from the uterus is doubtless not merely an accompaniment, but a consequence of the breach of capillaries in the mucous membrane. These of course are physiological phenomena, but the}^ strongly resemble pathological conditions, and would be so considered in any other organ in the human economy. Moreover, the dividing line between health and disease in uterine hemorrhage is as difficult to trace as that between sanity and lunacy.* Puberty. Puberty is the period at which the development of the human female renders her capable of childbearing. " An immense revolution takes place in the organization of the young girl. To her thin slender form succeeds a round and graceful contour. Her step, uncertain and hesitating, becomes firm and animated. The sweet and vivacious expression of her eyes evince the ardor with which she is endowed. Changes no less remarkable take place in the system. The chest, narrow and compressed, becomes expanded and full. The lungs act more freely, the heart, more developed, throws the blood with more energy to the remotest parts of the vascular system. The areolar tissue is in- creased in quantity, fills up depressions and rounds out angles, making those graceful curves in the form that constitute female beauty. Of all the organs that feel the in- fluence of puberty the uterus and its appendages are the most affected by it. In girl- hood of small volume, at this period, the uterus, the ovaries, Fallopian tubes, and the breasts become greatly developed. The bones and muscles partake in the general development. The moral qualities of the girl are no less the subjects of change. The young girl, before a mere child in her tastes, inclinations, and desires, experiences a complete metamorphosis. Restless and pensive, she does not know whence come the * The Causes and Treatment of Non-puerperal Hemorrhage of the Womb, Interna- tional Medical Congress, Philadelphia, September, 1876. PUBEETY. 279 novel thoughts that agitate her micd ; all her impressions are pleasurable ; she is penetrated by a glowing fervor ; an unaccustomed pruriency pervades the organs of generation. The most important phenomenon of puberty, its indispensable accora" paniment, that which transforms the young girl into a woman, the first menstrual flow, manifests itself." This is a translation of the description given by Brierre de Boismont in his Treatise on Menstruation. It is a true contrast between girlhood and womanhood. This change is not attained in an instant, but is the work of years, and the development, instead of always being regular, steady, and equable, is in many instances quite irregular, unsteady, and unequal. Imperceptibly (comparing short periods) the lithe, muscular, bony, and angular form of the girl is lost. The bones of the pelvis, the lower extremities, and chest expand and grow, but no faster than during some other periods of girlhood ; and the uterus, ovaries, and Fallopian tubes assume their places and acquire their size gradually. At ten years, perhaps, down is observed on the pubis, but does not become well-grown hair until seventeen or eighteen. In from four to eight years usually these changes are complete. Nor does the form assume the becoming loveliness of a mature maiden immediately at the time the menses are first produced. The general and even the genital development is not complete for years after the first effusion of blood. A description which portrays anything but this gradual change is fanciful and misleads the student. The sentiments and mental habits of the girl when she first begins to menstruate are still childish and imperfect compared with what they become after the completion of her first change of life. Nor do I think it any more correct to say that the changes in the genital organs bring about all the attributes that accompany their development; they are merely contemporaneous with the other and part of the whole. The development of the body generally, and of the sexual system to a perfect state, usually proceeds together, and ought to be com- plete at the same time and in the same degree. But these conditions do not always obtain. Occasionally the frame and all the organs but those belonging to the genital system are developed into vigorous womanhood, while the latter do not assume the size and energy neces- sary for the establishment of the sexual functions; or what is per- haps a more frequent condition, the individual is physically undevel- oped otherwise, but possesses great sexual activity if not vigor. In these, the general organization is feeble and imperfect, and incapable of meeting the requirements of womanhood, while the functions of menstruation and childbearing exist in perfection. The physiologist will have no difficulty in predicting, in instances of this kind, the in- fluences that will be exerted by the dominant sexual organs. He will see in advance the wreck that will be made of the mind, heart, lungs, stomach, nerves, and other organs by the overwhelming sympathies 280 MEXSTRUATIOX AND ITS DISOEDERS. that must arise from the midue development of the ovaries and uterus. When this latter system is subordinate in development and func- tion to the system at large, then the full health and vigor of the indi- vidual Avill not be disturbed by the discharge of the sexual functions. The circumstances by which the girl is surrounded during the time when these puberal changes are going on, have a great influence ujDon the future health of the woman. This is the turning period in the life of the woman. She is perfected or ruined in that time. According to her development and surrounding circumstances will be her future pathological tendencies. The development required for efl&ciency and health, is strength of muscle and heart, and large capacity of stomach and lungs. And it will require but a few moments' reflection to remind the intelligent phj^siologist that the conditions by which girls at puberty are usually surrounded are not the best adapted to this development. The little girl is generally allowed to exercise in the open air in the same un- restrained manner that her brothers are. She exercises her muscles as much as her brain, and this exj^ands her lungs and causes her heart to grow vigorous, and her stomach to digest well. She has no nervous ailments while such freedom lasts. She is, however, not more than ten or twelve years old before she is restrained in her childish sports. She is instructed that it will, become her more to deport herself like a little lady ; which means that her step must be quiet, her speech less loud and energetic. She must appear in the street only when well dressed, and must conduct herself as becomes a woman. She must learn to sew and draw, which means that she sit still in a stooping posture ; or she must go to school to sit and study in a close room with many others, breathing foul air for from four to six hours a day, and when she comes home get her lessons or " tasks " as they are properly called. If she has any more time she spends it in practicing on the piano or receiving company in the parlor. In this round of confining duties the lungs are not expanded to their full extent for many da3^s together ; the circulation is slow because there is not action enough to require quickness and energy in the distribution of the blood ; the muscles become weak and flabby from inactivity ; the nervous system is taxed by study at school and at home, while all the rest of the body is kept in great restraint. The consequences are that debility and excitability are predominant qualities, and the development of the lungs, heart, and muscles does not keep pace with the growth of the brain. If exercise is required, dancing or calisthenics is resorted to, because more lady- like than playing ball or running races in the open air. The amuse- ments of this period of life are not less injudicious. These children go to see the minstrels, go to theatres, ball-rooms, card parties, and PUBERTY. 281 other places, where they meet the opposite sex in such manner as will excite their emotional nature, thus encouraging early sexual develop- ment. About this time, between twelve and sixteen, the lungs are confined by corsets that fit '' snugly " about the chest, preventing free expansion and the easy play of the diaphragm. Other effects of tight lacing in early as well as later life, are to press the contents of the abdomen down into the pelvis, and prevent a free return of venous blood from the lower part of the body. This downward pressure causes an accumulation of blood in the pelvic viscera, the rectum, ovaries, uterus, vagina, etc., and encourages congestions and inflam- mations. These influences, and a long train of others similar in their effects, are kept up from this time forward until the girl is married, and if she is never married always afterwards. What is usually termed education is commenced too early, and falls short of its objects be- cause it is commenced too early. Mental culture is obtained too often at the sacriflce of the general health, and still more frequently at an expense of physical development that forever mars the usefulness of the woman. Physical culture should be more assiduous than mental, during physical growth. The mind does not mature as soon as the body, and mental culture should be behind physical growth instead of before it. Six hours' study and two hours' play should be re- versed ; it should rather be eight hours unrestrained exercise and two hours' study. In writing the above I have very feebly portrayed the evils that usually surround girls at the time when the puberal changes are going forward. Let any one visit our schools for girls of this age, public or private, seminaries or boarding-schools, and see the require- ments, restraints, and confinements of the day ; let him go home with them and witness their want of appetite, languor, and restiveness, and then see the training from mothers and fathers, who, in honesty of affection, prevent them from going out for fear of exposure or improprieties, and encourage them to learn their lesson or music to the complete neglect of their bodies, and he will be astonished that as many survive the ordeal as now do. More time is necessary for physical development than mental, and until this truth is acted upon our women will become steadily less capable of bearing the hardships of life. In addition to the want of balance in the development of the physical organization above mentioned, the circumstances of society often cause premature and undue development of the sexual organs. Girls of different ages are congregated in large schools ; the younger learn from the older practices and imbibe sentiments beyond their age, which stimulate their passions and encourage too early and too vigorous sexual desires. The dress, the free and easy association of very young people, taught to imitate their seniors, the literature easily 282 AMENOEEHCEA. accessible and eagerly sought after by them, and many other circum- stances incident to children raised in populous cities, are calculated to bring out prematurely and cultivate the amorous sentiments of young people of both sexes. Opportunity is frequently offered to medical men of large experience to see lamentable suffering in young girls, the result of some of these causes. Some of the most intractable cases of uterine disease I have ever seen have occurred in girls under- going puberal develoj^ment, traceable to undue excitement of the sexual organs while attending large schools or seminaries for young ladies. During the few years in which the girl is being developed into the woman, she is more suscejDtible to morbid influences oioerating upon the uterus and ovaries than at any other time in life, and con- sequently these organs should be kept as free as possible from the effects of all conditions which excite and stimulate them. During this time her education ought to be one that will keep her muscles occupied in the discharge of useful duties. This very brief summary of puberal pathology will do for a starting- point in the consideration of the disorders of menstruation. I shall consider the disorders of menstruation under four different divisions : 1st. Amenorrhoea. 2d. Menorrhagia. 3d. Dysmenorrhoea. 4th. Misplaced menstruation (Metatithmenia). Under these four heads may be included all the deviations met with in ordinary practice. It is usual with authors to make only three distinct divisions. My fourth division is spoken of by those who have described it as uterine heematocele, hsematoma, etc. ; but I shall give what I consider good reasons for classing it under the general head of menstrual disorders. In the march of pathological science it will not be surprising if, before long, these terms are entirely dropped from the category of disease, and these derangements mentioned as symptoms or errors of function under the circumstances in which they occur. All patholo- gists agree that they are only symptoms, and teach students to look to the diseases whence they emanate as the proper objects of treatment. The subject is not sufficiently clear, however, to do this now, and it is convenient yet to employ these terms as proper heads under which to group the various phenomena attending them. AMENOERHCEA. Amenorrhoea means simply the absence of menstruation, and may appear under several different circumstances. 1st. Menstruation may never make its appearance. 2d. After having occurred it may cease, or, as the term is, be SYMPTOMS. 283 " suppressed ;" and, again, this suppression may be suddenly brought about and attended with acute symptoms, and hence properly be denominated acute suppression ; or it may not be attended with acute symptoms, and may last long enough to be called chronic. 3d. I think it right to consider deficient menstruation as suppres- sion, although but partial. This partial suppression assumes two forms, viz., infrequency, when the intervals are uncommonly long ; and scantiness, the return being regular, but the quantity of the discharge much less than it should be. Or there may be both scantiness and infrequenc3^ 4th. The menses may be retained in the cavities of the uterus or vagina, or both, after having been effused. This retention is very different in many respects from the suppression, giving rise to quite a different set of symptoms, and requiring a separate sort of treat- ment, agreeing with it only in the non-appearance of the blood ex- ternally. Pathology and Morbid Anatomy. The pathological states upon which the symptom amenorrhoea is based are very numerous, and sometimes inscrutable. The more obvious are the following : Congenital absence of the uterus or ovaries, or both ; congenital or acquired atrophy of these organs ; acute or chronic disease of the uterus aud ovaries. The general conditions causing it are ansemia, cachexia, pregnancy, and nursing, serious dis- eases of any of the vital organs or nervous system, and occlusion of some part of the genital passage. Symptoms. The local symptoms which attend the absence of the menses will differ according to the conditions which give rise to it. In acute suppression we shall have signs of great congestion, or inflammation of the uterus. The patient, after commencing to menstruate, being subjected to the causes necessary to suppression, such as the partial or general application of cold, is seized with pain in the back, hypo- gastric region, and hips, attended with a sense of chilliness more or less intense. These symptoms are usually succeeded by febrile reac- tion, headache, pain in the limbs, general languor, white tongue, and a persistent pain of varied severity in the region of the uterus. There is, in this state of things, as there seems to be, inflammation of the uterus and ovaries. The symptoms may subside, and generally do in a very few days, leaving more or less local discomfort in the pelvis and neighborhood. At the next menstrual period, if the uterus is not much diseased, and the system not greatly deranged, the blood is effused, but seldom with the same naturalness in quantity, quality, and painlessness as before ; there is often more or less pain, which is manifested henceforth at each successive period. 284 AMENOERHCEA. At other times the discharge fails to show itself after having been thus suppressed, and the case becomes chronic, lasting an uncertain length of time. When this is the case, the non-appearance is likely to be attended by chronic inflammation of the uterus and ovaries, as the result of the acute attack, and the morbid effects brought about by uterine sympathies derange the stomach, bowels, liver, in fact all the chylopoetic organs, to such a degree as to render chymification or chylification imperfect. Sanguification will be thus vitiated, ansemia or cachexia results, and the patient becomes broken down and " mis- erable." We cannot but see in this catenation of circumstances the complicated effects resulting from inflammation of the uterus. Should the suppression be primary, — by this I mean to say, should the menses never have made their appearance, — the girl, if old enough and sufficiently developed, will suffer differently. And there is very nearly, if not quite, the same set of symptoms present in cases where they have made their appearance imperfectly in quantity and quality, or for a few times, and then ceased. The patient suffers under the symptoms of imperfect sanguification : inability to exercise, palpita- tion of the heart, shortness of breath, torpid liver and bowels, want of appetite, or an appetite for improper food at improper times, de- spondency, great apathy, and timidity. The surface is pale, and either white and translucent, or more commonly of a greenish hue. The sufferings are often very great and protracted, and not unfre- quently merge into those of tuberculosis, insanity, or other serious organic diseases. It is not unusual, even in cases where menstruation has never been perfectly established, to find the patient afflicted, also, with symptoms of inflammation of the uterus. The general symptoms accompanying scanty menstruation, when the scantiness is the result of imperfect establishment, are very much of the above character, viz., those connected with ansemia, etc. But the scantiness and infrequency, as also the entire suppression of men- struation, usually depend upon organic changes in the uterus grad ually brought about by chronic inflammation. What these are we cannot always determine. Sometimes, however, we find the fibrous structure condensed until the bulk of the organ is smaller and harder than natural; at other times it is greatly enlarged, as I have verified by examination. The most common alteration is condensation and atrophy. In such instances there will, of couse, be quite a different set of symptoms, in fact many if not all the symptoms found described in connection with chronic inflammation of the substance of the cervix and body of the uterus. I need not enumerate them here, but refer the reader to the article in which the general symptoms of these con- ditions are given. Chronic amenorrhoea, or scanty or infrequent men- struation, is in this way associated with the most miserable states of general health. SYiMPTOMS. 285 We are not to believe, however, that the absence of the menses is the cause of such nervous suffering as we often see associated with it, but that it is caused by the condition of the uterus and other organs upon which the irregularity depends. The non-appearance of the menses on account of the absence of the uterus is not usually attended with the chronic suffering I have here alluded to ; ordinarily, and indeed in all the cases of this kind to which my attention has been called, the patients appeared to be perfectly well. One of these patients was thirty-three years of age, another twenty-seven, and a third twenty-two, and all of them were in perfectly good health. This is an argument, I think, in favor of the opinion just expressed, that the serious and annoying symptoms arise from the pathological condition of the uterus, or general conditions giving rise to it. The only symptoms these patients complained of at any time that seemed to be attributable to amenorrhoea were the backache, weight about the hips, etc., which denote the 23resence of the menstrual molimen. In the cases where amenorrhoea exists before the organs are sufficiently developed to assume the function of menstruation, we often observe a good state of health, even after the person has attained to an age when the menses are expected. I have had occasion to see, examine, and watch for several years two cases of chronic amenorrhoea from deficient development of the uterus, and perhaps of the ovaries. They were both married. One of them is twenty-eight years of age, has been married nine years, has never menstruated, has no sexual desires, but lives happily with her husband, and desires to be like other women merely to have a child for him. There are no distressing symptoms in her case. Her breasts and uterus are developed to about the size in a girl of thirteen years of age. There is hair upon the pubes, the mons is well developed, as is also the clitoris. The other has been married three years, is twenty-five years old, and resembles the first completely. When tuberculosis or other serious diseases cause amenorrhoea they are usually well manifested before the suppression occurs, but some- times this symptom shows itself so early in the case that it is regarded as the cause, of the disease instead of the effect. From what is said above, the reader will see that suppression is a symptom of the absence^ iviperfection, or disease of some of the organs of generation, or is due to some grave deterioration of the blood or nervous energies, and that we are to look into all the circumstances which attend upon it, with a view to learn the causing conditions. We shall not always be fortunate enough to ascertain this, and we must then content ourselves with conjecture, and a necessary uncer- tainty in the treatment we adopt. 286 AMENOERHCEA. Amenorrhosa from Retention. If the retention dates from puberty the patient at the proper time began to experience the symjDtoms of menstruation. In instances where the retaining condition is acquired, the symptoms will be found to have followed close upon a severe inflammatory or ulcerated state of the uterus or vagina. After the retention is thus established by accident, the symj)toms do not differ materially from those manifested where the occlusion is congenital. At first there are very moderate pains in the region of the uterus at each menstrual period. From month to month the pains increase in severity until they become excruciatingly severe. The pains at each menstrual epoch resemble those of labor, and cause the patient quite as much suffering. They are doubtless caused by the presence of the blood in the uterine cavity, and have for their object the expul- sion of that fluid. Soon after the establishment of this train of symptoms there ensues interparoxysmal suffering, much greater in some instances than others. There is a sense of weight in the pelvis and about the hips, weakness and pain in the baclv, dysuria, difficulty in evacuating the bowels on account of pressure upon the rectum, etc. There is, after the first few months, enlargement of the abdomen, which increases more slowly than in pregnancy. The tumor is of the shape and in the position of the uterus, and fluctuates obversely upon percussion. Diagnosis. It is not usually difficult to determine positively when there is amenorrhoea, and yet there may be good reason to doubt in some instances. It is not necessary that there should be an effusion of blood to constitute menstruation, for there are periodical discharges from the genital organs which indicate tlie process of ovulation, and, under certain conditions of the system, are more appropriate than an effusion of blood. I allude to a periodical discharge of mucus or sero-mucus. The uterine congestion is not sufficient in quantity or force to give rise to hemorrhage, but causes effusion of the thinner portions of the blood. We are often obliged to treat patients for a time without having more than their statements as a basis for our diagnosis, but fortu- nately, in most cases, this is sufficient. We are not justified, how- ever, in continuing the care of an obstinate case for any length of time without making an effort to verify or ascertain the fallacy of the grounds for our opinion. And, if need be, we must resort to physical examination. The fact of our j^atient being a virgin should cause deference, but not forbid an examination indispensable to a DIAGNOSIS. 287 correct understanding of the cause of a condition that is destroying her life. I need only mention that suppression, attended with acute inflammation of the uterus and ovaries, will be attended with marked and almost invariably unmistakable symptoms. The pain, fever, tenderness, and sympathetic symptoms will leave no room for doubt. Anaemia, cachexia, nursing, etc., are obvious conditions, and will be easil}'- made out by very little attention. Correctness in diagnosis may be attained with great certainty when there is physical defect in the genital organs, by proper direct exami- nations of them, and they should be instituted when other means fail to satisfy us. The presence or absence of the uterus, in most instances, can be satisfactorily determined by introducing the finger into the rec- tum and a catheter into the bladder, and approximating them. If it is present, its thickness interposed between the two will prevent the finger from defining the shape of the instrument; if it is absent, they maybe made to touch with the intervention of the walls of the rectum and bladder. The catheter, in this examination, should be introduced deep into the bladder, and the finger as far up the rectum as possible. With this precaution, there can hardly be a mistake. I have met with several instances of congenital absence of the uterus, and in all the vaginae were absent, but each case presented all the external evidence of womanhood. The mons veneris was perfect and covered with hair, and the clitoris, labia majora, and breasts were well developed. The patients had the demeanor of women, and assured me that their desire for the society of men was as great as usual, and that they experienced strong sexual feeling. One of them had married, and was defending herself in a suit for divorce, upon the ground of her entire ignorance of any anatomical defect in organization ; another was about twenty- two years of age, and submitted to an examination with the hope of having a correction of the physical defect, preparatory to entering matrimony. It is possible that the vagina may be absent while the uterus is perfect in formation — the same examination will furnish us with proof — or the vagina may be occluded from defect of formation. This can be determined in the manner I shall presently describe. Ab- sence of the ovaries cannot always be determined by physical examin- ation, but there is generally such a complete absence of the signs of womanhood in these cases that we cannot long hesitate. The mammae are not prominent, the manners peculiar to the sex, desire for the society of males, and sexual j^ropensity, are absent. There is no hair on the pudenda, and the whole external organs are not developed. The signs are the same at any age. The patient at mature age presents no more evidence of sexuality than the little girl. I have very recently met with an instance of congenital atrophy of the uterus. The patient, although now twenty-eight years of age, has not menstruated, unless, as she doubtfully said,, twice very scantily when 288 AMENOEEHCEA. about seventeen years of age. She is rather above medium size, and possesses all the characteristic appearances of womanhood. She has enjoyed fair health until the last twelve months. For the past year she has suffered from distressing palpitation of the heart, which almost incapacitates her for business. She- has been married nine years, during which time she has enjoyed sexual intercourse indifferently. She has no monthly pains, no signs of menstrual congestion, and nothing by which to know when to expect that function. Her mammee are about the size in a girl of thirteen or fourteen years, the diameter being about two inches and a half, with a thickness at the nipple of about three-quarters of an inch. The nipples are very small. The labia and mons veneris are undeveloped, and the vaginal orifice is narrow. The uterus could be felt in its usual position or rather higher up in the pelvis, but was very light and small. When the fingers were placed under it in the vagina, and it was pressed down from above, it gave the sensation of diminutiveness, apparently not exceeding half its natural size. The ordinary uterine sound would not enter it more than half an inch. A probe with an extremity about a twelfth of an inch in diameter, freely passed up one inch and a half. From all this, it was plain that the uterus was in a state of atrophy ; and I infer that the ovaries were so, from the absence of the nervous signs of menstruation. The size of the organs, as measured by the plan above indicated, determines, together with the history of the case, that it is congenital atrophy. Acquired atrophy is confined generally to the uterus, while congenital atrophy generally involves all the genital organs, including the breasts and- nipples. I have met with a number of instances of acquired atrophy, which by carefully tracing their history, I could attribute to early miscarriage which it seemed to folloAV. And this atrophied condition, doubtless, was hyperinvolution of the organ after abortion. In looking over the men- strual history of these sufferers, there was a time when they menstru- ated normally, and the function was disturbed after having been thus established. When amenorrhcea is attended by chronic inflammation of the uterus, a not unfrequent occurrence, the speculum and probe will reveal the condition beyond the i3robability of making a mistake. I have seen the worst forms of indigestion, and very great emaciation, attend this condition ; in fact, I have seen no other benign disease of the uterus produce so much emaciation as this. The patient is sometimes bed- ridden for months. In two instances recently cured by local treat- ment and proper dietetics and hygienic regulations, the patients had been reduced to two-thirds of their ordinary weight. Diagnosis of Retention. Upon examining the genital canal it will be found occluded at some point between the external labia and the internal os uteri. If the hy- PROGNOSIS. 289 men is imperforate the vagina cannot be penetrated. If the occlusion is higher up, it may be found by the finger and probe. By intro- ducing the finger into the rectum and a catheter into the urethra, the bladder and rectum will be found widely separated, the catheter pass- ing up close behind the pubis, and the finger being pressed strongly against the sacrum. The finger in the rectum will easily determine how near the external organs the obstruction is. The history, the non-appearance of the menstrual fluid, the slow enlargement of the abdomen, periodic painful paroxysms, and the oc- clusion of some part of the vagina or uterine cervix, are quite enough to distinguish it in most cases. Auscultation and palpation will establish the diagnosis between re- tention and pregnancy. Prognosis. The curability of amenorrhoea will dejDend on the causing condi- tions. When occlusion of some portion of the genital canal prevents the discharge of the menses, we can usually, by surgical means, evacu- ate it, and establish an outlet for the future. Although simple and easy of accomplishment, the evacuation of a long-retained and consid- erable accumulation is always attended with hazard. In the first place, inflammation may foil our efforts to establish a permanent via- duct for the blood which may be discharged from the uterine vessels ; and in the second, this process may be so great and extend to the -peritoneum in sufficient intensity as to cause the death of the patient. Amenorrhoea from anaemia may be pretty surely cured ; it is the cur- able variety compared with those occurring from other causes. When arising from inflammation, it will also generally yield to apj)ropriate treatment, as the cure wholly depends upon the removal of the caus- ing conditions. The cachexia which may produce amenorrhoea are often entirely incurable, and, therefore, our prognosis must be unfavor- able when they are associated. In cases of absence of the ovaries or uterus, we cannot expect to do good by treatment. Where there is only atrophy of the organs, we may hope that some of the ingenious contrivances to increase their development which our profession of the present day affords (they have almost all emanated from, or been perfected by, the fertile genius of Professor Simpson, of Edinburgh), may enable us to succeed. It cannot be concealed, however, that these causing conditions will often resist every means within our reach. To sum up, then, according to my observation, when suppression arises from any other causing con- dition than general anaemia, or inflammation of the uterus or ovaries, the prognosis is not very promising, and we should be cautious in promising a speedy and permanent cure. Failure in the function of menstruation is pretty sure to be accompanied with an inability for 19 290 AMENOEEHCEA. conception ; imperfection of it is, likewise, very frequently an evidence of barrenness. This is particularly the case with scantiness. When menstruation is infrequent, but the function is otherwise perfect, the patient is often prolific. I have known a woman for several y^ars, who does not menstruate more than three times in a year, and then not at regular intervals, and yet in the last six years she has had two children, conception following immediately after one of these irregular menstrual discharges. Treatment. We should always bear in mind the fact that amenorrhoea is but a symptom, and endeavor to amend the condition or disease upon which it depends. This rational mode of procedure, however, is not always practicable, for unfortunately, as has been more than once stated, we cannot in every instance ascertain precisely the condition. In such cases we make use of remedies, or plans of treatment, which, from the success that has occasionally followed their use, have gained the title of emmenagogues. This term signifies promoter of menstruation. Are there any direct emmenagogues ? I think, in the nature of things, there cannot be. To cause a flow of the menses proper, which depends upon ovulation for its existence, they must produce or promote the evolution of ova. That there are remedies and plans of treatment which indirectly promote the menstrual discharge I think there is very little doubt. In a general way we ought to consider this class of remedies as producing their effects in two different modes, one by causing the growth and production of ova, and the other the discharge of blood as a hemorrhage. It would be better, then, to say that they are oviferous in their nature in the first case and hemorrhagic in the second. To the first order belong the preparations of iron and other mineral and vegetable tonics, nutritious diet, exercise in the open air? diversion of mind, travel, sea-bathing, and in fact, everything which, by correcting derangement of the vital organs and generating good blood and plenty of it, is promotive of healthy functional action gen- erally. To the second belong aloes, savin, cantharides, and any hy- gienic measures which determine blood to the pelvic organs, as foot-, hip-, and leg-baths, sinapisms to the feet or legs, etc. In many instances they may very properly be combined. When amenorrhoea results from cold applied to the surface or lower extremities, or from any cause suddenly acting to suppress the flow, the uterus and ovaries are bordering on, if not in, a state of acute inflammation, and the remedies for it should be directed to the relief of the diseased organ or organs. The question very naturally arises, can we, or ought we do anything to cause the return of the flow im- mediately upon its suppression, and if so, what? Experience teaches us that if the flow can be reproduced in a very few hours after its sup- TREATMENT. 291 pression, before general reaction occurs, the turgid and phlogosed con- dition of the sexual apparatus may subside into a condition of health, and that this can sometimes be done by judiciously managed stimula- tion ; but if the flow is not re-established in a few hours, we need not expect it to recur until the next period, if then, and it is injudicious to continue stimulation beyond a very short period. Then what is the proper course of stimulation? If our attention is called to the case within a few hours, and there is not much febrile reaction, we may very properly direct a hot bath to the whole person of the patient below the waist for half an hour. The patient should then be put in bed, and large sinapisms placed upon the inner portion of the thighs and hypogastrium, and allowed to remain until a strong rubefacient effect is produced, when they may be removed, and the whole replaced by a hot linseed-meal poultice. While these measures are being ac- complished, we should administer copious draughts of some kind of warm tea. I cannot approve of the gin-slings or toddies given so freely under these circumstances ; they often do harm by their excessive stimulation, rendering the inflammation a fixed evil. Should the flux not return in twenty-four hours from the time of suppression, it would be unreasonable to expect and injudicious to continue treatment to cause it to do so. It then remains for us, if possible, to remove the phlogosed condition of the organs, so that they may be in a state to resume their functions at the return of the next ensuing menstrual period. - It will be found, I think, that for the first month, in case of an acute suppression, especially in plethoric patients, the most successful course of treatment will consist in moderate antiphlogistic and alterative means, kept up steadily. The one I have ordinarily followed consists of counter-irritants to the hypogastric region ; the hip-bath of tepid water twice a day ; six to ten grains of blue mass every third night, to be followed in the morning by a seidlitz powder; and abstinence from all stimulants and highly seasoned food. If, however, the suppression continue beyond the second period after the suppression, it may be attended with chronic inflammation, with or without general anaemia etc., and will come under some of the conditions hereafter to be considered. Amenorrhoea connected with chronic inflammation of the uterus or ovaries may be treated as I have elsewhere directed those affections to be managed. I think that it is not very common for suppression, in the chronic form, to depend upon inflammation alone. More frequently the causes of amenorrhoea exist in the condition of these organs that remains after inflammation, such as condensation of fibrous tissue, either with or without atrophy. The same treatment, with little vari- ation, is applicable to both. I shall have occasion to detail the treat- ment in speaking of atrojjhy and want of development. 292 AMENORRHCEA. Another condition which succeeds inflammation of the uterus and ovaries, after an acute suppression, is ana?mia. For there certainly are cases in which an impoverished state of the blood succeeds an acute suppression, and in turn prevents the re-establishment of the flow. A tonic, roborant treatment, applicable to ansemia arising from other causes, may be instituted, if need be, even before the inflammatory condition of these organs has entirely subsided. Perhaps a little more attention to alteratives, in connection with the tonics, is necessary in this class of cases. When an£emia is the primary condition upon which amenorrhoea depends, it will almost always be found depen- dent upon some preceding affection. Indigestion, connected with a slow or depraved state of the secretions of the alimentary canal, often, by preventing the introduction of nutritious elements into the blood, induces ansemia. This condition arises, for the most part, in one of two ways, — either the nervous energy necessary to the sustenance of the functions is diverted toother objects, as mental training in the school-girl, or the circulation in the abdominal organs is too sluggish on account of sedentary habits, as with the sewing-girl. Sometimes want of exercise and too great a tax upon the brain from studies, anxiety, etc., co-operate in the same individual. Ansemia may be produced by a great variety of causes besides those above mentioned, but, according to my experience, these are far the most frequent. I would not have the reader believe, because I have given the school- girl and the sewing-girl as instances of amenorrhoea, that they are the only persons in whom the same character of causes operate in the same way. Very many fashionable young ladies, who might enjoy the blessings of relaxed, diverted, or healthily employed minds, and appropriate and enlivening exercise, become anaemic from sheer lazi- ness and the nervous anxiety connected with envy. Bearing in mind, then, the causes of indigestion and ansemia, we must, first of all, thoroughly revolutionize the habits and circumstances of the patient, making plenty of outdoor exercise one of the main conditions. Riding in a carriage is not outdoor exercise for these pa- tients ; they must ride on horseback, or, what is very well, walk, run and romp. An excellent sort of diversion for the mind is occupation in domestic duties, making beds, sweeping, cooking, washing, caring for and attending children, etc. The mind and body are both em- ployed in a varied and diverse manner in these household duties, and it will be found that exercise both of body and mind is most profit- able as it is most diverse and varied. While it is true that some kinds of exercise, as walking or riding, may be made to call into play a great many muscles, yet the whole routine of duties presenting themselves in the business of housekeeping, by personally doing the work, is more beneficial than all others devised. This lesson is taught by the con- trast between the young mistress and her servant. TEEATMEJST. 293 In addition to the adoption of a more rational course of habits for the patient, much may be done by the judicious use of medicines. Almost invariably the tonics must be preceded by, or accompanied Avith, alteratives and laxatives. The stomach will no more recognize and respond properly to a tonic that is introduced into it until pre- pared by correcting the secretions, quickening the gastric circulation, and unloading the bowels, than it will digest food under similar cir- cumstances. The alteratives suitable, generally, are mercury in some form, taraxacum, and turpentine. When the bowels are torpid, the stools dry and of unnatural color, particularly if the color is light, from three to six grains of blue mass given every third night, and fol- lowed next morning by a seidlitz powder, or sufficient sulphate of magnesia to cause one or two evacuations, is an admirable alterative. Ten grains of good extract of taraxacum, with a minute quantity, say the twentieth of a grain, of bichloride or biniodide of mercury, three times a day for two or three days, generally does very well. The mercury should not be given with the taraxacum longer than three days, and then intermitted for a week, but the taraxacum may be given steadily for weeks. An excellent alterative for the stomach is Venice turpentine. Ten grains three times a day after eating, on sugar, alter- nated or given with some of the mercurial preparations, proves often of great service. I cannot but mention the compound confection of black pepper, made in imitation of Ward's paste, as having frequently an excellent laxative and corrective effect on a weak state of the stom- ach accompanied with constipation. I have known it to cure some of the most obstinate cases of constipation attended with anaemia. If there is not scantiness of secretions, but slowness of peristaltic movement, we ought to depend on rhubarb and aloes. The compound aloetic pill is a good preparation. In the selection of tonics we should bear in mind the difference between the stomachic and blood tonics. Iron is, perhaps, the only direct blood tonic, while there are a great many articles that act as stomachics. Almost all the bitter vegetables ranged under that head in the books are useful under certain circum- stances. The stomach tonics, by improving digestion, are indirectly blood tonics, so that they are sometimes all that are necessary. In many instances, too, the stomach must be prompted by the bitters, or other stomachics, before it will absorb or assimilate iron. The bitter may precede the iron, or be administered simultaneously with it. It is sometimes convenient and profitable to combine the alterative and stomach tonic. A mixture of this kind, often used, is the compound tincture of cinchona, with bichloride of mercury dissolved in it. The tincture of gentian, or colomba, answers very well compounded with mercury. Extract of gentian and Quevenne's iron compounded in a pill produce good results on the ansemic patient. If we under- stand the principle that governs the treatment in such cases, we may 294 AMENORRHCEA. readily find the means to accom23lisli our ends, by alteratives, stom- ach tonics, and blood tonics. The each exiee, several of which interfere with the regularity of the function of menstruation, must be treated as if the menses were present in their normal quantity, and in these cases the amenorrhoeal compli- cation is of no importance, hence special efforts to restore the flow are injudicious, and in most cases injurious. In cases of defective nervous energy we may expect benefit from the direct application of electricity to the uterus, or to the nerves that supply it. In a paper read before the New York State Medical Society, by A. D. Rockwell, M. D.,* I find the following statement : "Amenorrhcea is a symptom that yields, perliaps, more readily to some one of the many formf^ of electrization than to any or all other methods of treatment. In cases dependent on, or associated with, general debility, general electrization is of course indicated ; but where all external efibrts have been fruitless, internal electrization is not infrequently followed by an immediate and satisfactory flow." He gives a case as illustrative of the efficacy of his method of per- forming local electrization : "I introduced a cup-shaped metallic electrode to the uterus, so that the os was com pletely surrounded, and appilied the positive pole firmly against the abdomen im- mediately above the pubes. The current, which was of considerable strength, I reversed rapidly a number of times during the seance, and on the following day repeated the application. In less than six hours after making the second attempt, slight signs of returning menstruation were manifest, and steadily increased until, as regards quantity, the flow was quite natural. The patient was immediately relieved of all her distressing spasmodic symptoms, and at the present time (three weeks having elapsed since the treatment) still remains free from them." Quer}'. Was this menstruation or metrorrhagia ? Dr. Parvin, in the same journal, says : " The positive electrode passed into the uterine cavity, the negative applied to tlie hypogaslrium, gives oftentimes a very prompt success in inducing a sanguineous dis- charge from the uterus; but in order that such result should follow, this means should be used only at a time when the other phenomena of menstruation manifest themselves, the flow only wanting." The faradic is the form of electrization recommended by both these gentlemen. In patients well developed in most respects, whose genital system is deficient, the menses cannot be produced unless these organs grow and become more active. Anything that will stimulate these organs will occasionall}' bring this result about. Wedlock is a remedy some- times. The indulgence in society, and the recreations of it, in com- pany with men, sometimes, through the moral faculties, stimulate the * American Practitioner, Mav, 1872. TREATMENT. 295 genital organs towards development. The stimulus thus afforded by society is one of the beneficial effects resulting from the change of habits in young girls who go to boarding-schools until sexually dwarfed by confinement to the uninteresting society of their own sex. Sir James Y. Simpson has recommended an instrument, which he calls an " intrauterine pessary," to bring about this development. It is equally applicable to cases of atrophy of the uterus arising after the menses have been established. I have had occasion to use it, and am now employing it in the interesting case to which I have alluded above. It is theoretically better, I am afraid, than it will be found practically ; yet no doubt much good may be done by it. The object of the intra- uterine pessary is that it may be the medium, or generator, rather, of galvanism, to stimulate the nerves of the uterus. Both of these effects are promotive of uterine hemorrhage, if not of correct menstruation. They are necessary to the development of an atrophied uterus, whether congenital or acquired. But this instrument is recommended and used in obstinate cases of amenorrhoea, where there is no apparent deficiency in the size and development of the organs concerned. It is in this class of cases that most may be effected by it, and yet it sometimes entirely fails to produce any effect. To do good in the cases of atrophy and want of development it should be used continuously. Where the development is good, I am inclined to think that the pessary will do more good by using it intermittingly. In these cases we may introduce the instrument one week before the time of the expected period, and allow it to remain, and then, after the time is passed, remove it, and again introduce it at the proper time. We should remember that we cannot use an instrument of the same size in all cases. In the uterus that is much atrophied it would be violence to use an instrument that is applicable to a fully developed organ. In the former we must have an instrument that will pass into it easily, and in a couple of months use one larger; and after the lapse of a similar time make another one still larger, etc., until development is complete. The instrument is made of copper and zinc, and consists of a stem and bulb. The bulb is hollow, in order to be light as pos- sible, flattened, and oval in shape, one inch long, three-quarters of an inch wide, and half an inch thick. It should be perforated through its thinnest diameter by a hole two-twelfths of an inch in diameter. Into this perforation the stem is to be inserted. . The stem should be two inches long for a uterus not atrophied, and as much less as is necessary, in the judgment of the attendant, when atrophy has taken place. It should be hollow and light like the bulb. The bulb, and one inch of the stem next the bulb, is made of copper, the extremity of the stem of zinc. This completes the instrument as made and used by Professor Simpson. I find', in some instances, great difficulty, if not an entire impracticability, in wearing it, on account of its tendency 296 AMENORRHCEA. to fall out. Sometimes, too, the galvanic stimulus is not sufficient. On these accounts I have made an addition to it, which, I think, adds to its efficiency as well as to security of position. This consists of a zinc ball, about an inch in diameter, attached to a copper rod four inches long. The ball is introduced into the vagina after the intrauterine pessary has been introduced, while the stem is attached to a frame- work outside the pelvis to keep the whole in position. As will be seen by a study of this apparatus we have quite a galvanic battery, the copper rod reaching from the framework of zinc outside to the zinc ball inside, this last lying in contact with the copper bulb of the pessary, etc. If we do not desire any galvanism the whole apparatus can be made of copper. Made in this way the instrument is quite efficient. The young physician or student may be embarrassed in his attempts to introduce the pessary without a little consideration. The plan I have found most convenient is, to expose the os uteri by means of the bivalve speculum ; secondly, to secure the pessary by in- serting a piece of whalebone, properly shaped, in the perforation in the bulb ; thirdly, thus mounted, to insert the stem, and with great gentleness urge it forward to its full length, or until it is arrested by the contracted internal os uteri or the end touching the fundus. If this arrest occurs the instrument is either too large or too long, and must be replaced by one more suitable in this respect. After the pes- sary is inserted we may withdraw the speculum, and, if necessary, apply the ball and external framework above described to keep it in position. All this direction does not include a fact which should ever be borne in mind by the student, viz., that sometimes the instrument is utterly intolerable ; and, at others, a good deal of address and pa- tience is required to habituate the parts to it. The patient should be forewarned that pain and inflammation are the possible effects, and that she must inform us should they be considerable. There is always some pain, sometimes a great deal. When the irritation is too severe the instrument must be removed, quietude observed, and, if necessary, anodynes, and even antiphlogistic treatment must be resorted to, to remove the symptoms. After all these have subsided it may be again introduced. A little perseverance and care will render most cases tolerant of its presence. During the time the instrument is used the vagina must be thoroughly cleansed, at least twice a day, with tepid, warm, or cold water, and fine soap, used as injections. For the treatment of Amenorrhoea by retention the reader is referred to the Treatment of Atresia and Absence of the Vagina. CHAPTER XL MENORRHAGIA AND METRORRHAGIA. Hemorbhage occurring at the time of menstruation beyond the usual quantity is menorrhagia. Hemorrhages occurring at other times do not belong to this denomination, but are called metrorrhagia. Often both metrorrhagia and menorrhagia occur in the same individual, which depend upon the same conditions of the system or reproduc- tive organs, and are alike symptomatic of some local or general dis- ease. It is not difficult to understand that an exaggeration of the hyper- semia, or an unusually rapid disintegration of the uterine mucous membrane, would cause more than a normal amount of flow, nor that a want of accordance in time might be followed by the same result. Indeed most cases of uterine hemorrhage are traceable to conditions which disturb the equilibrium of these phenomena. The causes which thus act are varied and numerous. Morbid nervous influences, which increase the discharge of blood from the uterus, sometimes emanate from the nervous centres, and hence may be properly termed centric; much more frequently, however, they are reflected through the nervous centres from other and sometimes distant organs, and these last are entitled to the denomination oi reflex or eccentric nervous influences. Mental and emotional excitement emanating directly from the brain, and cerebral and spinal excitement originating in inflammation or functional exhaustion of the brain or spinal cord, are examples of centric etiological influences. Many years ago I witnessed the ravages of an epidemic of cerebro-spinal inflammation, in which uterine hem- orrhage was of almost universal occurrence among those adult fe- males who fell under its influences. Morbid reflex nervous influences afford a more numerous class of causes. First among them, both in frequency and importance, are those arising from abnormal conditions of the ovaries, such as conges- tion, inflammation, displacement, and erotic excitement. Next to the influence of these bodies is that exerted by the mammary glands. Menstruation is generally more profuse when it occurs during lactation. The effect of mammary irritation in causing congestion of the uterus, and thus promoting hemorrhage from it, is well illustrated by the familiar fact that sinapisms or blisters applied to the breast will often cause metrorrhagia. Vesical irritation, or inflammation, which gives rise to tenesmus, rectal irritation, as from the presence of hemorrhoids 298 MENOERHAGIA AND METRORRHAGIA. or ascarides, and dysenteric inflammation, through the reflex influence which they exert upon the uterus, are generally recognized causes of uterine hemorrhage. Among other reflex causes may be mentioned certain forms of indigestion, hepatic congestion and inflammation, and some of the disturbances of the small intestines, as may also strong impressions upon the cutaneous surface, as from cold, or from the long-continued application of heat in warm climates and seasons. All of these last-mentioned causes I think act through the reflex system of spinal nerves, and perhaps also through the agency of the sympathetic ganglia, which perform a reflex function between the viscera. The morbid effects of the various reflex nervous impressions are rendered more effective and intense by the presence of such uterine diseases as predispose to hemorrhage by increasing the vascularity of the uterus. Many 'pathological conditions which conduce to the production of uterine hemorrhage, independently of direct nervous influence, act by increasing the hypergemia of the uterus. When the mucous membrane is granulated, or is the seat of inflammation, of fibrous polypus, or of malignant fungus, the circulation of the uterus is increased, and har- mony in the process of nidation disturbed ; and these conditions will be accompanied by an unusual and long-continued flow of blood. Subinvolution, congestion and inflammation, hyperplasia, tuberculosis, cancerous and fibrous deposits in the muscular structure, and chronic and acute endometritis, in addition to preventing the normal decidu- ous changes in the mucous membrane of the uterus, maintain a per- manent hj'perffimia, and thus render the womb prone to large losses at each return of the menstrual period. We have, in fact, abundant rea- sons for assuming that chronic hyperjemia, no matter how produced, will, by virtue of the malnutrition connected with it, prevent menstrual changes from being effected in an orderly manner, and thus render the mucous membrane more frail in organization, and consequently incapable of resisting the force of vascular pressure to which it is periodically subjected. Besides the causes of uterine hypersemia last alluded to, and exist- ing within the tissues of the womb, there are many other outside •patho- logical conditions acting in a different way. Some of these cause venous hypergemia by mechanical retardation of the circulation, while others give rise to both arterial and venous hypera?mia by nutritional attrac- tion, and others again cause arterial hyperemia alone, by forcing un- usual amounts of blood into the organ. Among the most frequent and important causes of venous retardation are displacements and flexions of the uterus — procidentia, retroversion, and retroflexion — the former by stretching the veins and rendering their course more tortuous, the latter by twisting them, and thus lessening their calibre ; exudations into the cellular tissue and peritoneal pouch, from cellulitis CAUSES OF MENORRHAGIA. 299 and local peritonitis, and effusions of blood in the cul-de-sac of Doug- las, in retro-uterine hsematocele, by pressing upon the veins, prevent a free return of blood from the uterus, and thus cause venous hypersemia. Retardation of movement in the uterine veins may also be caused by obstruction to the venous circulation quite remote from the womb, as by the pressure of a tumor upon the ascending vena cava, by a loaded condition of the large intestine, by dislocation or enlargement of the liver, by obstruction to the free passage of blood through the heart from vulvular disease, and even by certain pulmonary affections. In the class of causes giving rise to both arterial and venous hyper- semia may be mentioned fibrous, fibrocystic, polypoid, and fungous growths of the fibrous structure of the uterus. These all increase the flow of blood to and through the vessels of the uterus, both arteries and veins are increased in capacity, and to these changes is added general hypertrophy. In these cases the hypersemia of all the tissues is sometimes enormously great, and the losses of blood are propor- tionally large and dangerous ; the hemorrhage, unlike that from venous obstruction, is not checked by the emptying of the vessels, but contin- ues until the arterial and cardiac vis-a-tergo is weakened by approach- ing syncope. Causes producing arterial hypersemia alone are hypertrophy of the heart, general plethora, febrile excitement, and violent exercise. The uterine hypersemia in these cases is caused by unusual arterial and cardiac pressure alone. When not attended by local pathological con- ditions, the hemorrhage in these cases is not apt to be serious. Other not uncommon causes of hemorrhage from the womb are vari- ous diseases of the blood. Among these may be mentioned scurvy, leu- cocythffimia, chlorosis, albuminuria, and syphilis. It is not likely that the vice in the composition of the blood is the sole causative influence operating in the above named conditions. In scurvy, for instance, we know that the solid tissues, whether as a primary condition or as an effect of the blood-changes, are diseased, the capillaries more fragile than natural, and, consequently, less capable of resisting the cardiac impulse. As evidence that the vicious condition of both blood and solid tissues is the cause of uterine hemorrhage in scurvy, the well-known fact may be added that bleeding is very easily provoked in other mu- cous membranes. It is the more likely to take place from the mucous membrane of the uterus, because of the great normal fluctuations in the circulation of that organ, and also because the vitiated state of the blood would naturally cause disturbance in other conditions attendant upon menstruation, especially the decidual changes. It will be seen therefore that the peculiarity in the operation of this variety of cause is not due to the presence of local or general hj^persemia from retarda- tion of the venous circulation, or from arterial and cardiac pressure, but is due to the tendency of the blood to escape through the walls of 300 MENORRHAGIA AND METRORRHAGIA. the vessels, and to the inability of the capillar}^ tubes to resist the cir- culatory force ordinarily applied to them. As another cause of hemorrhage from the womb must be mentioned the well-known law of the human system, to continue a long-established hahit after the original cause is removed. This is probably the only rational explanation of those rare uterine losses which are sometimes observed in pregnancy and in cases where both ovaries have been re- moved. The habit of bleeding continues after the ovarian reflex ner- vous influence has been withdrawn from the uterus. Still another rare yet very dangerous cause of uterine hemorrhage is that known to surgeons as the hemorrhagic diathesis. The writer has seen one case in which he believes that the bleeding was clearly at- tributable to this mysterious condition, and which proved fatal. It was that of a young girl who died with her second menstrual flow. The wide range of causative conditions found connected with uterine hemorrhage is but an inverse exhibition of the sympathetic relations of the uterus. When diseased, it exercises an almost universal patho- logical influence upon other organs, and, as a consequence, it is sus- ceptible of being impressed to the same degree by certain morbid conditions of all important viscera. It will not be regarded as making an undue claim to say that the practice of gynecology requires a more thorough theoretical and practical familiarity with the details of all the branches of medicine than any other of the so-called specialties. We are not prepared to treat the most common of female diseases without being able to scan with scientific scrutiny every organ and function of the body. Nor until we can compete successfully with the general practitioner, the surgeon, the alienist, and the neurologist in the therapeutic processes of their respective departments may we hope to exercise in the highest sense the office of the gynecologist. These remarks apply with force to the comprehension of the causes and treatment of hemorrhages of the unimpregnated and non-puer- peral uterus. Treatment of Menorrhagia. I find it quite impossible to satisfy mj^self as to the best order in which to bring forward the various measures proposed for treating uterine hemorrhage. Those which have for their object the removal of the causing conditions, properly fall under the head of curative means ; while those which we employ to stop the bleeding tempo- rarily, until the remedies of the first order have accomplished their purpose, seem as naturally to belong to the category of 'palliative measures. We find in each of these divisions, however, remedies which act in both ways, and the palliative means are often radical and energetic. Notwithstanding the many obvious deficiencies in this arrangement, it seems to me to be the best that I can adopt. TREATMENT OF MENORRHAGIA. 301 Palliative Treatment. Before entering into a detailed description of the more essential remedial methods of curing the various forms of hemorrhage it will be profitable to consider some of the important minor measures which are applicable in almost all instances. As the great majority of hemorrhages occur at the menstrual periods, we often have oppor- tunities of adopting measures in anticipation of them. These meas- ures are sometimes calculated to entirely prevent an exaggerated flow, and at others to very much modify it ; and in all to greatly promote the action of more direct remedies. The patient should abstain from all causes of local or general vascular or nervous excitement. * Among these causes are mental and bodily fatigue, emotional excitement arising from certain social relations, sensational books, and the con- templation of erotic objects. The patient should also abstain from stimulating drinks and highly seasoned food ; her clothing should be loose and cool, so that no part of the body may be constricted, and the genital organs should not be too warmly covered. Her bowels ought to be kept regular, or rather free. The secretions from the skin, liver, and kidneys should be maintained as nearly as possible in a normal condition, and tonics, such as arsenic, strychnia, and quinia, with digestible, nourishing, and unstimulating diet, should be given in quantities sufficient to keep the health up to the normal standard. Other things which will contribute very greatly to good results are plenty of pure air, night and day, and moderate muscular exercise. Many other general directions will suggest themselves, which I cannot stop now to mention. When the time for the paroxysm has arrived, and the hemorrhage has commenced, isolation, quietude, and recumbency are very im- portant precautions to be enjoined. Position, indeed, may be made to do much good of itself. If the hemorrhage is not severe, mere recumbency will be sufficient; but if it is protracted, the hips should be elevated, and sometimes it will be beneficial to raise them so high as to cause the blood to gravitate to the fundus uteri, and to fill the whole genital canal before any of it passes out. To a considerable extent this may be made to act as a tampon. The position chosen to effect this object may be on the back, or upon the knees and chest. If the latter position can be commanded, it is much the best, as the reversal of gravitation is more complete. Cold and acid drinks, cold applications to the hypogastric and sacral regions, hips, and vulva, and in the vagina, are also among the remedies suitable to almost all cases. Many practitioners value astringents, administered in- ternally, in uterine hemorrhage, but I have found so little benefit from them when not given with opium or belladonna, that I seldom resort to them. Where there is much pain in the pelvis, and a dry state of the skin, opium and ipecacuanha are often very serviceable. 302 MENORRHA&IA AND METRORRHAGIA. Lobelia, gelseniium, digitalis, aconite, and veratrum viride, may also be mentioned as very frequently applicable where there is vascular and nervous excitement. Perhaps the medicine most generally applicable in paroxysms of uterine hemorrhage, is ergot. In all cases of local arterial hypersemia, as in tumors, hyperinvolution, etc., we may expect good from its employment. But it will generally fail to be useful when the uterine hypereemia is venous, as in retroversion, pelvic infarction from peri- uterine effusion, abdominal tumors, etc. It will not act efficiently in cases of carcinomatous deposit, granulations of the mucous membrane, or tuberculous degeneration of the fibrous texture of the uterus. In the more dangerous instances of hemorrhage, these moderate palliative measures are not sufficient. In some, the amount of loss is so great, and occurs so suddenly, as to threaten the life of the patient. Or, if life be not in danger, the discharge may be sufficient to lead to other very serious remote consequences. These emergencies are to be met by such means as will promptly arrest the flow, and keep it in check until curative processes can be instituted. Fortunately this may be clone with great certainty by mechanical and chemical appli- ances generally at our command. The genital canal, practically closed at its upper extremity, and conveniently open at its lower termination, admits of being impacted to an impermeable degree, and allows of topical applications to its whole extent. In using either form of these topical measures, the effort should be made to apply the remedy as near to the bleeding point as possible. When practicable, we may secure the best effects by employing the mechanical and chemical means conjointly. The mechanical means embrace the different forms of the tampon. Plugging arrests the hemorrhage by forcibly opposing the evacuation of the blood, and b}'' thus imprisoning it in the smallest cavity. The blood so confined, coagulates, and fills the space between the tampon and the bleeding surface with a fibrinous clot, which also closes the mouths of the vessels. When plugging is skilfully performed, the relief is tempo- rarily perfect, and gives us valuable time for other treatment, or allows the cyclical period to pass, when the hypersemia subsides. The chemical means consist in the use of powerful haemostatics. By their chemical action upon the solid constituents of the blood, the}" produce a much firmer coagulum than results from mere stasis, and, if applied to the ruptured vessels, seal them up with coagulated plastic material, while if further away the coagulum forms a chemical tampon which opposes the flow toward the vulva. Used with the mechanical tampon they may be made to fill the interstices of the material of which it is formed, and thus solidify the whole mass. In the greater number of dangerous cases of the kind of uterine hemorrhage, the mouth of the womb is sufficientl}" patent to permit TREATMENT OF MENORRHAGIA. 303 the introduction of the plugging material saturated with a haemostatic preparation into the cavity of the uterus. Dr. Sims's method of pre- paring the material and performing the operation of plugging the womb is admirable in its simplicity and efficiency. The substance used is the finest article of cotton -wool, saturated with a liquid com- posed of one part of the strong solution of the subsulphate of iron and two of water. After the cotton has been perfectly saturated, it is de- prived of the major part of its fluid by pressure, and is then allowed to dry until ready for use. The application is made by wrapping a sufficient quantity of the dried iron-cotton around a long, small piece of whalebone, and introducing it into the cavity of the uterus, Avhen the cotton is detached and left there. If the hemorrhage is compara- tively moderate, one of these pieces may be sufficient ; if severe, it will be necessary to stuff the uterine cavity full. This can be best accom- plished by having the patient placed on her side, and the uterus ex- posed by Sims's speculum. To facilitate the removal of this ferruginous tampon, the suggestion of Dr. J. R. Chadwick, of Boston, is, I think, a valuable one, viz., to wrap strong thread loosely around the cotton as it surrounds the whalebone. I prefer this method of using the haemos- tatic to its injection, because the shock from the application is much less. If the mouth and cervical cavity of the womb are not sufficiently open to permit of the introduction of this haemostatic preparation, we may plug the cervix with prepared sponge. The first sponge should 'be pushed through the cervix into the cavity, and up to the fundus uteri, so that when it expands its upper end may possibly reach and press upon the bleeding point. If large enough, the cervical cavity Avill be completely filled and the bleeding effectually checked. The sponge should be carbolized, and well secured, before it is introduced, by passing a strong piece of twine through it, from one end to the other. Neither the cotton nor sponge should be allowed to remain longer than twenty-four hours, and half of that time is usually long enough. After removal, the vagina may be cleansed, and the applica- tion repeated if necessary. I have sometimes been obliged to renew the sponge tampon several times in the same case, though this is not usually required. If these means are not at hand, or if the case is not sufficiently urgent to require plugging of the uterus, we may resort to the vaginal tampon. This may be made of cotton, of which pieces as large as pullet's eggs may be used, rolled somewhat solidly, and each secured with thread and lubricated with oil or lard. A sufficient number to perfectly fill the vagina should be prepared. The patient should be placed on her leftside, with the limbs flexed, and the upper one thrown forward over the other. The operator, standing at the back of the patient, inserts into the vagina two fingers of the left hand, with which 304 MENORRHAGIA AND METRORRHAGIA. he draws the perineum well backward. This will open the canal so that the clots may be easily removed with the fingers, when, with the right hand, the cotton balls may be placed in the vagina with great facility ; at first several on the os and around it, and then the whole vagina may be packed solidly under the eye of the operator. If Sims's speculum be at hand, it should be used instead of the two fingers to hold back the perineum. Or we may vary this according to the process described by Dr. Thomas in the American Journal of the Medical Sciences for July, 1876, page 147. After dilating the vagina, " pieces of cotton, soaked in water, pressed and flattened out by the fingers, each about the size of a very small biscuit, are pressed into the vaginal cul-de-sac by means of the forceps till this is filled. Then other pieces are packed firmly around the cervix until only the os is visible ; a smaller pad is then pressed firmly against or introduced within the cervical canal, and the whole vagina is then filled to its lowest portion." An ordi- nary surgeon's roller answers admirably for a plug, and may be intro- duced by first inserting one end, and then passing it up in short folds until enough has been placed in the vaginal cavity to fill it up com- pactly. In most cases, where we desire to leave the patient, the tampon should be retained by a compress and " T " bandage. When we have reason to anticipate a sudden occurrence of severe hemorrhage in our absence, we may instruct the patient or nurse how to make and apply a very safe vaginal plug. A sponge, large enough to fill the vagina closely, may be prepared by wetting it in a strong so- lution of alum, or in a weak solution of subsulphate of iron, passing a piece of strong twine or tape through the centre, and then wrapping it with tape in an elongated shape to its smallest dimensions. It may then be laid aside to dry. When the necessity for its use arises the tape is removed, and the sponge thus compressed may be passed with- out any resistance entirely into the vagina. It is soon expanded by the blood, and the vaginal cavity thoroughly filled. A few of these sponges prepared ready for instant use will enable the patient to pre- vent any material loss until the practitioner arrives. The plug may be removed by the tape or twine whenever desired. The plug may be allowed to remain from eighteen to twenty-four hours, when it should be withdrawn, and the vagina having been thoroughly cleansed with carbolized water, replaced if necessary. Curative Treatment. The central nervous disorders which cause uterine hemorrhage will, when recognized, require the treatment set forth in the various works upon these subjects. I need not, therefore, dwell here upon the man- agement of the spinal and cerebral inflammations and irritations, nor upon the numerous forms of emotional excitement which lead to metrorrhagia. The treatment of the reflex, morbid, nervous influences TREATMENT OF MENORRHAGIA. 305 belongs more particularly to gynecolog}^, and will call for all the in- genuity and varied knowledge taught in that branch of practical medi- cine. The ovarian derangements, being the more obvious and common of these may be noticed first. Our means for replacing and retaining in position displaced ovaries are very meagre. The patient must be confined to the horizontal position, with the pelvis elevated as much as practicable. The knee-chest position is the best, and may often be maintained for a considerable part of the twenty-four hours. Generally the displacement is accompanied by congestion or inflammation of the ovary, which increases its size and weight. When this is the case, the treatment, in addition to position and quietude, recommended during the intermenstrual period, will consist in the use of counter- irritants, hip-baths, hot-water vaginal injections, and alteratives, ad- ministered internally, or applied externally in the form of ointments or per vaginam as suppositories, injections, etc. Among the altera- tives, the muriate of ammonia will be found very valuable. When there is much debility, the bichloride of mercury, dissolved in the com- pound tincture of cinchona, is among the very best. Iodine, iodide of potassium, and iodide of iron should also be named as efficient altera- tives in these conditions of the ovaries. One derivative measure which I desire to mention as especially beneficial in these cases is dry cup- ping over the sacrum, often repeated. To be effectual the cups should be large and allowed to remain for a long time, say an hour or n;!ore. When there is much pain in the ovarian regions, suppositories of the , extract of belladonna and ergot, once or twice daily, will not only re- lieve the pain, but will do much towards allaying the inflammation. When hemorrhage occurs in a nursing woman, if it is of sufficient gravity, the child should be weaned. At the time of the paroxysm, if the breasts are tumid and tender, cold may be applied to them to relieve both the uterine hemorrhage and the mammary congestion. These patients require invigorating measures in connection with the local treatment of the breasts. The vesical or rectal tenesmus which gives rise to hemorrhage must be treated by the remedies found necessary after investigating the cause. So also, with diseases of the stomach, bowels, and liver, as well as with the effect of cold or of long-continued heat. Subinvolution and chronic congestion of the whole uterus require a treatment very much alike, the application of such remedies as condense the uterine tissues, — ergot, belladonna, quinia, electricity, cold injections, compresses, and sitz-baths. When there is no tender- ness, ergot will be found a very efficient remedy, if administered for a sufficient length of time — several months, for instance. If there be considerable tenderness and pain, belladonna and quinia will be best adapted to the case. Ergot in some instances induces sensitiveness and heat in the pelvic organs, and then it should be used very cautiously. 20 306 MENORRHAGIA AND METRORRHAGIA. This effect of ergot is especially noticeable when there is chronic local peritonitis or cellulitis. If there is a high degree of sensitiveness, a mercurial alterative may very properly be given in connection with the belladonna and quinia. A good form for administering it is the bichloride of mercury dissolved in the compound tincture of cinchona; or we may use mercurial inunction, or mercury in suppositories. I have not been able to do much good in these cases with iodine in any form. If given with iron, as the iodide of iron, it has occasionally a good tonic and alterative influence. These conditions of the uterus are very obstinate, and require a continuous treatment, oftentimes for many months. The treatment of endometritis, described elsewhere, consists mainly in a persevering continuance of stimulating applications to the dis- eased mucous membrane. I do not like the term caustic application, for even the strongest remedies used for this purpose are applied so sparingly that their effects are little more than strongly stimulative. In the light of our present knowledge of the processes of menstrua- tion, these remedies, as suggested by Dr. Atthill, should be resorted to immediately after the monthly flow has ceased. By common consent of the profession, in this country, the treatment of granulations of the uterine mucous membrane consists in scraping them off. If the mouth of the uterus be sufficiently patent to admit a small-sized curette, the scraping may be done effectually without dilatation ; if not, a tupelo, or sea-tangle tent, may precede it. The curette should be passed over every point in the uterine cavity with firmness enough to detach the soft excrescences, and yet there should not be force enough employed to wound the natural tissue. Suc- cess will generally be announced by the discharge of the soft elongated growths. These are sometimes very abundant. The scraping should be done during the flow. It is not necessary to wait for a protracted paroxysm to pass by. Although not curative, the same treatment may be mentioned as most efficacious in arresting the hemorrhages resulting from cancerous granulations. In a discussion of Dr. Hanks' recent paper. Dr. Peaslee gives the very judicious advice not to cut into the sound tissue in the process. In cases of malignant fungus, we may often arrest the ten- dency to hemorrhage by injecting alcohol, by means of a hypodermic syringe, deeply into the substance of the part. This process frequently repeated sometimes retards the growth very materially. The tincture of the chloride of iron, similarly used will often have the same effect. The various conditions which give rise to retardation of the venous circulation require to be treated according to the improved methods now so well understood by the profession. The displacements of the uterus, which are arranged among these conditions, must be corrected by the various ingenious appliances designed for this j)urpose. And TREATMENT OF MENORRHAGIA. 307 this may be done during the time of the preternatural flow with the expectation of moderating it at once. Dr. T. D. Fitch, of Chicago, has recently proven this last assertion in the management of a case occurring in a patient who had just passed the menopause. The uterus was retroverted, and all the means re- sorted to did not even moderate the metrorrhagia until the organ was elevated and retained in position by an appropriate pessary, when in a short time the bleeding ceased. After the subsidence of the flow, the patient removed the instrument, on account of some slight inconven- ience which it gave her, but the flooding began again in a very few hours, and continued, notwithstanding repeated eff'orts to arrest it, until the pessary was once more introduced, when the hemorrhage again subsided, and did not return. The extreme danger from hemorrhage connected with fibrous tumors of the uterus is not so often encountered since the profession has be- come acquainted with the great influence exerted upon certain condi- tions of the unimpregnated uterus by ergot. It is now understood that fully seventy-five per cent, of hemorrhagic cases of fibrous tumor of the uterus may be rendered free from danger, as far as the hemor- rhage is concerned, by an intelligent and persevering use of ergot, and that in twenty per cent, the tumors may be removed. In using ergot^ in these cases, the mode of administering it cannot be uniform. Some patients cannot take it in any sufficient doses to answer the purpose ; some cannot take it in the form of fluid extract, or wine, but can take the solid extract in the form of pills ; others can take it in any form. When the stomach will not tolerate the ergot, it may be given hypo- dermically, or per rectum in suppositories, and I believe that it can be made to act efficiently when given in any of these ways. Whatever method or form we may adopt in the aaministration of ergot, we should give it in sufficient quantities to produce a sensible efl'ect by causing contractions and pain, and there is no better rule to guide us, so far as I can judge, than to give it in increasing doses until that result follows. Twenty minims of the fluid extract, three times a day, will sometimes be sufficient, while some patients, on the other hand, will require twice or three times as much to produce the effect. The length of time required to obtain the ultimate effects of the ergot in these doses varies as much as the quantity required. The tumor will sometimes diminish very rapidly, but generally the decrease in size is quite slow. From one month to over a year may be required to accomplish a cure when it can be accomplished at all. Ergot is sometimes very violent in its action, but by withdrawing it tempor- arily, lessening the dose, or combining and alternating it with ano- dynes, it may be safely managed. Although I have given it exten- sively, and for a long time together, I have not seen anything worse than inconvenience arising from its use. CHAPTEEXIL DYSMENORKHOEA. This is a general term for painful and difficult menstruation, and includes conditions widely different in their nature. In some cases no appreciable morbid changes are discoverable in the organs which seem to be the seat of pain, either during or between the times of the menstrual flow. This condition is called neuralgic dysmenorrhoea. It depends upon a general state of the system, which is supposed by some to be rheumatic and by others purely neuralgic. It would be difficult to define with any accuracy either of these conditions, the rheumatic or the neuralgic diathesis, and yet we know enough about their manifestations to be able to detect their presence. The character of the symptoms of this form of dysmenorrhoea is determined by the conditions of the system. It generally occurs in patients who are manifestly subjects of one of these diatheses, and who in the intervals between the periods experience neuralgic symptoms, or symptoms referable to rheumatism. These features of the cases are sometimes so marked as to be easily detected, while at other times they are not well defined. Whether there is some permanent morbid condition of the nervous apparatus of the pelvic organs that is perpetuated from month to month, and thus constitutes the disease, or whether in neuralgic patients the vas- cular and nervous disturbance of the menstrual period is sufficient to excite and localize the morbific energies of this diathesis, we do not know. I have been in the habit of teaching the latter. The paroxysm of suffering is more irregular with reference to the commencement of the flow than in any other form of dysmenorrhoea. More frequently than otherwise the pain begins one, two, or even three days before the time of the flow, and continues in a subdued degree during a great part of the time of the flow. It is sharp and paroxysmal, but not generally accompanied with tenesmus. The pains do not seem to be influenced much by the flow. The intensity of the symptoms vary from slight and very tolerable pains in some patients to the greatest agony in others. This kind of dysmenorrhoea occurs in that class of patients of whom it is often said, "They suffer more than any one else from the same cause." They are very nervous patients. The seat of the pain is not always the same ; sometimes it is referred to the uterus exclusively, but generally the pain radiates to the ovaries, the back, in the region of the genito-spinal centre, and down the limbs. DIAGNOSIS — PROGNOSIS TREATMENT. 309 Diagnosis. A physical examination of the pelvic organs enables us to declare that there is none of the morbid conditions we usually find in the other forms. This, with the diathetic manifestations, are the only means of arriving at definite conclusions. Prognosis. This affection, although it is obstinate and resists treatment of almost every kind, and is apt to return after it is supposed to be cured, yet the effects of judicious treatment upon it are quite marked. Treatment. Change of climate, scenery, and modes of living are among the most promising remedies. I have known patients to be entirely free from dysmenorrhceal paroxysms during a long tour in Europe, and others to be relieved by moving from a northern to a southern climate. There is probably no better way to produce a decidedly salutary and lasting effect upon the nervous system of these patients than to revolu- tionize their surroundings by change of climate. A summer residence by the seaside, the bathing and exercise connected with it, will often suffice to interrupt the recurrence of these paroxysms if not cure the disease. If we cannot remove the patient from the circumstances under which her disease originated, we may do a great deal to get rid of the diathesis by outdoor exercise on horseback, or on foot, and if neither of these is possible, in a carriage. The diet should be regulated with a view to an exalted state of nu- trition. Medicines may also be made to exercise a powerful influence upon the diathetic condition. In cases where we can trace a rheumatic taint we should give med- icines with a view to relieve it ; among which are Dewees's tincture of guaiac. in drachm doses, three or four times a day, the tincture of ascle- pias tuberosa, or viburnum prunifolium. Ini the more purely neu- ralgic cases, tonics containing iron, strychnia, quinine, and phosphorus are serviceable. The phosphide of zinc and the oxide of zinc will also be found very useful remedies for this general condition. The manner of treatment of the paroxysm is also of great importance. As we can calculate with some definiteness the time when the par- oxysm will come, we may anticipate it with such remedies as will produce a strong impression on the nervous system. The late Dr. M. B. Wright taught his students that large doses of quinine given one or two days before the expected paroxysm, with a view to having the patient pass into it in a state of cinchonism, often mitigated her suffering very greatly, and sometimes entirely prevented 310 1 DYSMENOEEHCEA. it. If, as he supposed, many cases were due to malarial influences we might expect great good from this treatment. Arsenic is another remedy that will sometimes mitigate the sufifering if given so as to exert its full influence at the time of the paroxysm. To do this its administration must be commenced at least a week before the return, and be continued from small to increasing doses until characteristic effects appear. In giving remedies for the relief of pain during the paroxysms we should have in mind that patients afflicted with this form of dysmenorrhoea are easily fascinated with the effects of anodynes and give them up with great reluctance, and that there is therefore great danger of making opium-eaters of them. I could point out a number of patients who have abused the pre- scriptions given them for this purpose to their great sorrow. We should feel a proper sense of responsibilty in these cases, use anodynes as sparingly as possible, and place them beyond the reach of the patient when the urgency of the symj)toms has passed. Chloral, chloroform, and morphia are the anodynes upon which we will be obliged to rely in the extreme agony of a paroxysm. The Inflammatory Form of Dysmenorrhoea. In this variety of dysmenorrhoea the condition giving rise to the paroxysm is inflammation in some of the pelvic organs, generally the uterus, the ovaries, or both. Whether there is a pure ovarian dys- menorrhoea of this nature or not, I am not prepared to positively assert, but I think it very probable that there is. In most cases of inflammatory dysmenorrhoea, however, I believe the morbid condition exists in both the ovaries and uterus. In exceptional instances the inflammation may be located in the cellular tissue, and perhaps in other pelvic structures. Symptoms. Patients laboring under this form of the afl'ection are generally the subjects of intramenstrual symptoms of sufficient intensity to mark the nature of the causing conditions. They are the usual symptoms of uterine or ovarian disease. It is in this form that intramenstrual paroxysms occur midway between the menstrual periods. These in- tramenstrual paroxysms are sometimes very severe, but probably are not so intense as those occurring during the periods. The paroxysms usually commence some hours, and, occasionally, a day or two before the flow, and partially or completely cease as soon as the flow is established and becomes free. The pain is generally of a somewhat steady aching character, not so intense, but more contin- uous than the neuralgic form. The paroxysm is usually attended with febrile phenomena. Sometimes there is a sharp attack of fever, preceded by chilliness, and accompanied with furred tongue, headache, THE INFLAMMATORY FORM OF D YSMENORRHCEA . 311 and pain in the limbs. The pain is not always confined to the pelvis, but radiates upward and downward. The paroxysm is usually accounted for by supposing that the pain due to the existing inflam- mation is very much aggravated by the hypersemia and hypersesthesia attendant upon the occurrence of menstruation. However this may be, they are distinguished by this similarity to the pains of inflamma- tion. Diagnosis. A thorough physical examination, for which I will refer the reader to the Diagnosis of Uterine Disease, will enable us to discover the lo- cality, character, and grade of the morbid process. Prognosis. The prognosis of this form of dysmenorrhoea I believe to be more favorable than any of the others, because more amenable to treatment. It does not cause that intensity of suffering which we witness in some of the other varieties. It may not be irrelevant to state here that while we do meet with pure examples of neuralgic and inflammatory dysmenorrhoea there is often an obvious neuralgic element in the inflammatory form — a com- plication of the two varieties. Sometimes one of these morbid condi- tions predominates, and sometimes the other. Treatment. For the special treatment of the inflammation as the controlling element in this affection I must refer the reader to the methods of treatment elsewhere given. The progress of the cure of that element will be marked by the subsidence of the intensit}^ of the paroxysms^ until they fail to return. In this form we may often anticipate the paroxysms, and allay them-, by appropriate treatment. The patient should be directed to take her bed before it comes on, and remain quiet until the paroxysm is over. Particular attention should be directed to her bowels, and it will often be best to give her a small dose of a mercurial — two or three grains of calomel, and follow it in seven or eight hours by a saline cathartic. After this diaphoresis should be encouraged by the acetate of potash, and, as the pains begin, Dover's powder. The anticipatory local treat- ment consists in bloodletting by leeches or scarification the day before the expected paroxysm. Hot-water injections, continued through the attack as often as three or four times in twenty-four hours,, hot fomen- tations over the hypogastrium, and tepid sitz-baths. These will often do away with the necessity of using anodynes. When the pain is not relieved by these measures anodynes in sufficient quantities- to miti- gate it are permissible. 3 1 2 DYSMENOREHCEA. Membranous Dysmenorrhosa. The particular feature of this form of dysmenorrhoea is the discharge of a membranous cast of the cavity of the uterus. Sometimes the membrane comes away without losing its shape or integrity ; very much more frequently it is discharged in a broken condition, and ap- pears in shreds or large pieces, representing in shape and size the anterior or posterior wall of the cavity of the uterus. " The microscope shows that the discharges at times consist simply of fibrinous clots, which are with difficulty passed through the os uteri, when it is very small, as is frequently the case in females who have never borne children ; at other times the fibrin is in a fibrillated state, inclosing in its reticulum numerous lymph and epithelial cells. In other cases there are found irregular shreds, containing capillary vessels with embryonic walls, in the midst of connective tissue, infil- trated with lymph-cells. There are also frequently seen fragments of uterine glands. This is a genuine discharge of exfoliated mucous membrane. The mucous membrane may be expelled entire ; this, however, is not of frequent occurrence."* Numerous theories have been propagated to explain the formation of this membrane. It would seem that the ideas prevailing with reference to the formation of the deciduous membrane have influ- enced the profession in their opinions as to the conditions giving rise to this membranous formation. In the theory adopted by Dewees, Montgomery, and others, that it is a layer of plastic lymph spread upon the uterine wall, we see some- thing of the Hunterian explanation of the formation of the decidua. In another theory, advanced by Oldham and others, we see the results of the researches of Coste, who considers the decidua nothing more than the mucous membrane of the uterus, changed by impregnation. According to this theory it is the menstrual decidua which does not undergo disintegation as completely as in health ; in other words the membrane is the result of hypernidation. In the natural condition of the uterus the mucous membrane undergoes changes that render it suitable to become the nidus for and to embrace and fix the ovum in its development. When conception does not take place the disintegra- tion of the membrane and the flow are contemporaneous. If the membrane is overdeveloped by reason of a preternatural amount of connective tissue, then the membrane retains its integrity to a certain degree, and instead of flowing out as debris it is expelled as a whole or in large shreds. I believe with Scanzoni that the uterus in which the formation of this membrane occurs is in a state of hypersemia. Sometimes this ■* Cornil and Eanvier's Pathological Histology, translated by Shakespeare and Simes, p. 68ot. MEMBRANOUS DYSMENOREHCEA . 313 hypersemia is trophic, and then the membrane will contain capillary- bloodvessels and utricular glands, while in others it is inflammatory, and the discharge will contain fibrinous clots and false or fibrinous membrane, inclosing in its reticulum lymph and epithelial cells. This view of the subject will enable us to explain the microscopic appearances noticed in different cases. Clinical observation will also sustain the position that inflammation is the main factor in a portion of these cases at least. In the cases in Avhich there is trophic hypersemia, the initial or actuating condition is probably nervous, and the influence reflected through the ovaries, as in the production of normal menstrual conges- tion or the hypersemia of pregnancy. Symptoms. The paroxysm is sometimes ushered in by nausea, vomiting, rapid pulse, furred tongue, headache, and increased temperature, and in many respects resembles inflammatory dysmenorrhoea ; at other times there are no febrile symptoms ; but in most cases of membranous dysmenorrhoea the stomach sympathizes with the pelvic trouble. The pains usually begin after the commencement of the flow and continue until the membrane passes. They are at first sharp, and dart from the pelvis in every direction, afterward cramping, and finally tenesmic or expulsive. The pains have for their object the separation and expulsion of the membrane, and subside as soon as 'this is accomplished. The more complete the formation of the membrane, the more urgent and painful the efforts to get rid of it. The most distressing part of the suffering depends upon the eff'ort to overcome the resistance of the OS uteri to the evacuation of the membrane. Without this resistance it is uncertain whether there would be much pain, as I have known two cases in which the membrane was repeat- edly evacuated without pain. In both cases the internal os uteri was patulous. I have never seen the membrane expelled by parous women. Diagnosis. This depends upon the discovery of the membrane either in pieces or as a whole. While my observation has not been sufficiently ex- tensive to enable me to establish a rule even for my own guidance, I believe it will be found that in cases attended with febrile symptoms the membrane will be of a plasmic character wholly, and that in those unattended by these symptoms the membrane will partake njore of the deciduous character. The prognosis of membranous dysmenorrhoea is not very encourag- ing, as it is very difficult to overcome the disposition to the formation of the membrane. 314 DYSMENORRHCEA. Treatment. The paroxysm of membranous dysmenorrhoea, especially the more febrile form, should be treated with a view to removing the obstruc- tion. The cervix should be dilated by Hunter's or some other dilator as soon as the pains become severe and expulsive in character : this will generally very materially shorten the duration, as it facilitates the discharge of the membrane. In connection with the dilation, or with- out, an efficient dose of ergot will sometimes aid the process of expul- sion very materially. Sometimes we may prevent or mitigate the severity of a paroxysm by using a fasciculus of slippery-elm tents a day or two before it occurs, especially in the febrile form. If the paroxysm is attended with vomiting and fever, we should anticipate it by giving a cathartic the day before its occurrence and administer large doses of quinine. The administration of ergot between the paroxysms in the trophic variety will aid very materially in overcoming the hypersemic condi- tion of the uterus, and produce a favorable influence upon the nerve- centres that preside over the process of ovulation. Mercurial and iodine alteratives should take its place in the inflammatory variety. The ammoniated tincture of guaiac. may be given with great propriety when a rheumatic diathesis is suspected. The local treatment of the two is very nearly the same, viz., dilatation and applications to the mucous membrane of the cavity of the body of the uterus, as in cases of chronic inflammation and congestion of that organ. Obstructive Dysmenorrhoea. The clinical study of dysmenorrhoea will force upon the observer the conviction that, in the majority of cases, this symptom is the re- sult of uterine contractions, and that the contractions are efforts made by the uterus to expel its contents. As I have already shown, this is the case in the membranous variety, the real cause of the expulsive pains being obstruction, not because there is contraction of the os uteri or cervical canal, but because the substance expelled required more room for its passage than was afforded by the os of normal size. In the inflammatory variety the same kind of pains are often no- ticed. Doubtless the cause of the expulsive efforts in this variety is the temporary stenosis of the internal os uteri, caused by the tumefac- tion of the mucous membrane at that point at the time of the men- strual congestion. This explanation presupposes endometritis with the greatest intensity of the inflammation at that point. Between the menstrual periods the tumefaction subsides, and the os presents no evidence of stenosis. This is one form of temporary stenosis causing OBSTRUCTIVE DYSMENOERHCEA. 315 dysmenorrhoea. Another is spasm of the circular fibres surrounding the internal os uteri at the time of menstruation. We are prepared to understand how this may take place in patients of irritable fibre, when we remember the hypersBsthesia that accom- panies chronic inflammation of the uterus and the congestion preced- ing the eruption of the menstrual discharge. I have no doubt that the cause of temporary stenosis, even in the inflammatory form, is often spasmodic closure, as blepharospasm is caused by conjunctival inflammation. I think this spasmodic action is much more likely to occur in the inflammatory than in the neuralgic variety. There is one condition in which the expulsive pains of dysmenorrhoea manifest themselves with great severity where no stenosis exists. When there is a great degree of retroversion or retroflexion the cavity of the body is lower than the internal os uteri. In such cases the extravasated blood, instead of flowing toward the mouth of the uterus, gravitates into the fundal portion of the cavity and there accumulates until its presence excites uterine contractions. Fig. 191. &^;!!!M. if Strong Retroflexion favoring Gravitation to tlie Fundus, It would seem from these considerations that much of the suff'ering connected with retroflexion, and even anteflexion, with or without stenosis, is fairly attributable to the gravitation of the blood into in- stead of out of the uterus. I would call attention to the figure of retroflexion, here introduced to demonstrate this proposition ; Would it be possible, even if there was no stenosis, for the blood to flow out of a uterus in the position there represented ? And would not the accumulation of the blood in the dependent cavity, and perhaps coagulating there, as certainly pro- duce eflbrts at expulsion as any other foreign body ? Since my atten- tion has been directed especially to this item, in the pathology of dys- menorrhoea, I have been convinced that too much importance has been attached to simple stenosis. 316 DYSMENORRHCEA. Nearly all cases of obstructive dysmenorrhoea are associated with displacement or fiexional deformity of the uterus. When gravity fa- vors the outflow of the menstrual blood it requires only a very small passage through which to escape. I have repeatedly examined patients, in whom the external os uteri was not larger than a pinhole, whose menstrual flow was easy and copious. While thus expressing myself with reference to the importance of malposition and fiexional deform- ity of the uterus as offering a sufficient impediment to the discharge of the blood to induce the most distressing form of dysmenorrhoea, I would not ignore stenosis as one of the causes of it. Any cause that will give rise to retention of the menstrual flow will cause uterine contractions and pain. A typical case, in which dys- menorrhoeal symptoms from forcible retention of the menstrual fluid are manifested, is congenital occlusion of some portion of the genital canal. If the obstruction is at the orifice of the vagina, the pains will not be of this character until the vagina is filled and a portion of the blood is retained in the uterus ; but if the occlusion is at the uterus, the symptoms will begin with the first menstrual effort. To witness a case of this kind will convince the observer that obstruction to the flow will give rise to dysmenorrhoeal symptoms. If there is a great degree of stenosis in a part of the genital canal symptoms of a similar character will occur. Symptoms. The main symptom of obstructive or retentive dysmenorrhoea is ex- cruciating pain of an expulsive character. The pains are compared to colic, and the term uterine colic is quite appropriate. They generally come on before the commencement of the flow, and continue until the discharge is well established, when they gradually subside, and the flow continues from that time on without pain. In many instances the great congestion accompanying the effort at dis- charge, causing a sort of erection of the uterus, not only overcomes the stenosis, but it temporarily, to a great extent, corrects the position or deformity ; without this correction the relief would not be complete. If the attendant will take the trouble to examine patients carefully during the flow — which by the way is very seldom done — he can easily convince himself of the truth of this statement. Diagnosis. The diagnosis may be established by physical examination. Ob- struction of the vaginal orifice by the hymen, morbid adhesions, or congenital deformity may be detected by occular, digital, and instru- mental examination with the sound during the presence of the symp- toms. Malposition or flexions will be detected by physical examina- tion. OBSTRUCTIVE DYSMENOERHCEA. 317 Prognosis. Like the other forms of clysmenorrhoea, the obstructive variety is apt to be very obstinate and difficult to manage satisfactorily ; but as the corrective treatment is almost wholly mechanical or surgical, we may hope for good results. Treatment. In cases where there is retroflexion with dependent fundus, the first and most important corrective measure is to elevate the organ so that the blood will flow into the cervix, and thus escape from the os uteri. This may be done before or at the time of the paroxysm. If we see the patient for the first time during a paroxysm, we should place her in the knee-chest position, and lift the fundus uteri up with one finger. Eetroflexed Uterus with the Fundus raised by a Pessary. By this means we straighten out the cervix, and thus dilate the con- tractions and give the blood an inclined plane over which to flow and escape. This I am assured from repeated observation will often relieve a paroxysm. If this is not sufficient, with the patient still in the genu- pectoral position, we should introduce a sound to the fundus. In some cases elevating the womb, with or without the introduction of the sound, will relieve the patient for a few hours only ; but if the pain returns, it may be relieved in the same way until the paroxysm sub- sides. Between the paroxysms a suitable retroversion pessary should be worn, and, if properly placed and watched, will go a great way to- ward efi'ecting a cure. When there is stenosis, we may often relieve the paroxysm by dilat- ing the contracted point with a slippery-elm tent. There are two special methods of relieving stenosis, viz. : 1. By in- 318 DYSMENOREHCEA. cision. 2d. By dilatation or stretching the parts, with instruments made for the purpose, and tents. J. Marion Sims, in his work on Uterine Surgery^ propounds the fol- lowing opinions as to the causes of dysmenorrhoea, and bases his treatment on them. He says (page 142) : "It (dysmenorrhoea) is only a symjitom of disease, whicli may be caused by inflam- mation of the cervical mucous membrane, retroflexion, anteflexion, tibroid tumor in one wall of the uterus or the other, contraction of the os externum, flexures of the canal of the cervix, either acute or greatly curved, either at the os internum, at the insertion of the vagina, or extending throughout the whole lengtli of the canal, all of which are but so many mechanical causes of obstruction which must be recognized and remedied if we expect to cure the dysmenorrhoea." The following table is on page 132 : Of 100 cases of painful menstruation. Of 29 cases of excessively painful menstruation, OS was normal in but 6 OS was contracted in 90 - cervix was flexed in 61 congested in . . . 7 there were polypi in 2 OS was normal in OS was contracted in 26 - cervix was flexed in 23 had polypi in . . 2 was congested in . . 1 This tabular testimony of 129 cases is a strong argument in favor of Dr. Sims's theory, that dysmenorrhoea is almost always caused by obstruction. As I have given the opinion of Dr. Sims as to the causes of dysmen- orrhoea, I cannot complete this article without giving the reader an idea of the mode of treatment found most successful by him, viz., that of dilating and straightening the canal of the cervix. He exposes the mouth of the uterus by placing the patient in the same position, and using the same instrument as for vesico-vaginal fistula. With a tenaculum he seizes and firmly holds the cervix, and draws it into the most convenient position. If the cervix is not flexed but merely narrow, he introduces one blade of the scissors into the canal of the cervix far enough to divide it on one side up to the junction with the vagina, and then closes them. The other side of the cervix is divided to the same extent in like manner, then, by means of the knife repre- sented in figure, he divides the cervix up as high as the internal os. If the cervix is flexed, the lip of the uterus on the convex side is divided to the same height, and then the cervix opened with the knife. In this way the cervical canal is rendered rectilinear. This is represented by Fig. 195, taken from page 169 of Dr. Sims's work on Uterine Surgery. It shows the posterior lip already divided OBSTRUCTIVE DYSMENOERHCEA. 319 by the scissors, the tenaculum fastened into the anterior lip, and the knife being inserted as high as necessary : " The representation in the cnt is taken from the perfected instrument made by Wade & Ford, of New York City. To their ingenuity is due the application of the principle. The representation is half the size of the instrument, but the blade at full size is out of proportion, as it should be represented both longer and narrower." Fig. 193. Fig. 193 represents the Operation for Dividing the Straight Cervix when too narrow. The dark part is the portion cut. On one side the knife is shown in the act of dividing the tissues. This is Dr. Sims's plan. After having thus completed the operation Dr. Sims places in the wound of the lip of the cervix some cotton saturated with glycerin, Fig. 194. Emmet's Knife for Dividing the Cervix. From a cut in the June number, 1864, New York Journal of Medicine. and then proceeds to fill the vagina with cotton to guard against hemorrhage, which he regards as always imminent. If there be but 320 D YSMENORRHCE A . slight bleeding, it is not necessary to use more cotton than will keep the dressing in place. The patient should keep the recumbent post- ure for several days. The cotton in the vagina may be removed in twenty-four hours after the operation ; that in the wound remains from two to three days. Dr. Emmet recommends that the sound be Fig. 195. passed through the cervix every other day until the discharge ceases to prevent the parts from adhering. The sound need not be used for this purpose until the tampon is dispensed with. The following are the conclusions in practice of the late Dr. E. R. Peaslee :* " From the preceding facts I deduce the following conclusions : " I. The deep incision of the cervix throughout, the complete bilateral discission of the vaginal portion with deep incision above, are alike frequently attended by certain immediate dangers, and not seldom productive of certain serious remote consequences, viz., profuse and sometimes fatal hemorrhage, pelvic cellulitis, septic peritonitis (usually fatal), sterility, if not previously existing, and a tendency to miscarriage. " II. Those risks and efTects are all due to the extensive division of the walls of the cervix, and to the consequent enlargement of the cervical canal ; and the sole com- pensation for all of them which can be calculated upon is the relief, and very often the cure, of stenotic dysmenorrhoea. " It therefore becomes a question of very great practical importance whether the amount of cutting may not be so far diminished as to avoid all these risks, and at the same time be sufiBcient for the cure of stenotic sterility and dysmenoi-rhcea. But another inquiry antecedent to this is, how large a calibre of the cervical canal is actually re- quired for the relief of these two conditions; and a reply sufficiently definite for all practical purposes is not so difficult as might appear. " In the imparous woman, the narrowest point of the cervical canal, viz., the internal OS, is, when opened by the passage of the menstrual fluid, an ellipse, whose conjugate and transverse diameters average respectively one-sixth and one-eighth of an inch ; * A paper read before the New York Academy of Medicine, 1876. peaslee's method. 321 its area corresponding very nearly* with that of a circle one-seventh of an inch in diameter. The external os, also elliptical when moderately dilated, has diameters averaging one-fourth and one-sixth of an inch. It thus has an area exactly twice that of the internal os, and equalling that of a circle one-fifth inch in diameter.f The larger size of the external os doubtless has a special reference to conception, and favors the entrance of the spermatic iiuid into the cervical canal. It has no special influence against dysmenorrhcea, since the menstrual fluid, after having passed through the in- ternal os into the cervical canal, would pass just as easily from the latter through an opening of the same dimensions into the vagina. Hence, we not very seldom see im- parous women with tlie external OS no larger than a 'pin-hole,' and who, neverthe- less, do not suffer from dysmenorrhcea, though, as a rule, they are sterile. But if the lining membrane of the canal becomes thicker from congestion, or some other cause such patients suffer at once from stenosis at the external os. " In the pa)-ozts woman, the size of the external os varies within quite extensive limits, since it is exposed to so many of the accidents of parturition, while the internal OS is more nearly uniform. "I have deemed it desirable to ascertain the lowest average diameter of the two ora uteri in parous women, who are neither sterile nor have dysmenorrhcea, as a rational standard for determining the extent of incision actually required for the removal of these two conditions when stenotic. And, after a good deal of observation in this direction, I find that the inner os presents nearly twice the area of that of the im- parous woman ; in the majority of cases admitting a sound one-fifth of an inch in diameter, though, in a large minority, one from one-fifth to one-sixth of an inch only can be easily passed. I therefore regard a diameter of one-fifth of an inch as ample for the removal of sterility and dysmenorrhcea. I find the external os admits a dilator one fifth of an inch in diameter and upward — in some cases as high as one-fourth or even three-tenths of an inch — but, as a rulfe, I think one-fourth of an inch sufficient -for the purpose. It is of course to be understood that no nan-owing of the canal exists between the two ora. Since, however, there may be some degree of stenosis for the menstrual fluid, while not for the sound, it is sometimes judicious (and especially if congestion of the cervical lining membrane coexists) to increase the dimensions just named, by the use of a dilator of the next larger size. 1 do not assert that the preced- ing dimensions are always required in the treatment of stenotic sterility and dysmen- orrhcea, for they are not, nor that they are never to be exceeded, but that in almost all cases they will be found sufficient. "Should this precise specification of dimensions seem too minute for practical pur- poses, we must remember that dimension cannot here have a less important relation to function than elsewhere; and that enlarging the internal os to the diameter of half an inch, as is often done by the deep incision, is, as lias been seen, like permanently di- lating the urethra (if it could be done) to the size of the small intestine. And the im- portance of making an incision of the internal os, with a precise intention and a pre- cise knowledge of the mode of accomplishing what is intended, may be understood when I state that if the circle representing its area in the imparous woman be increased equivalently to surrounding it by a ring only one thirty-fifth of an inch wide, its area is increased as forty-nine to twenty-five, or almost exactly double. Or, if an incision be made on each side of it to the extent of half a line (one twenty-fourth of an inch), and it then be dilated to a circle, it is increased two and a half times. And if the cut should extend one line to the right and the left, or the added ring were one-twelfth of an inch wide, the area would be increased more than four times and a half. This last * The circle is smaller than the ellipse, in the proportion of 144 to 147. f Circle to ellipse as 72 to 75. 21 322 DYSMENOEEHCEA. increase is far more, in my experience, than is ever required in stenotic sterility and dysmenorrhcea. Superficial Trachelotomy — My own Operation. "III. Desiring to restrict the operation of trachelotomy in the treatment of stenotic sterility and dysmenorrhcea within the limits actually required, I, some ten years ago, devised and brought before the Xew York Obstetrical Society* a series of five steel cervical dilators, to be used instead of incision, where the stenosis is slight and the cervix is normally soft and pliable. These, in shape and size, have a precise refer- ence to the dimensions of the cervical canal, and especially of the two era uteri, as already specified ; and each is guarded by a bulb, so as to project through the internal OS into the uterine cavity only about one-quarter of an inch. " But finding that almost all cases of stenosis of the cervical canal are relieved more promptly, more permanently, and also with less pain, by incision, or this together with dilatation, than by any form of dilatation alone ; I next endeavored to restrict the extent of the incision within the absolutely necessary limits, having determined them ap- proximately by the preceding facts and calculations. To this end I devised a new method, and an instrument for executing it, which I also laid before the New York Obstetrical Societj'^ about eight years since ; but the former was so simple, bloodless, and unpretending, in comparison with the procedures of Simpson and Sims, that it excited but little interest. Meanwhile, however, it has been suSiciently tested, I think, by myself and my pupils in different parts of tiie country, to entitle it to a more general notice. " vSince the superficial incision, as suggested by myself, has for its direct object merely the removal of stenosis of the cervical canal, and is therefore proposed for the treatment of stenotic dysmenorrhcea and sterility only, it is previously to be decided whether stenosis actually exists. And the following propositions will aid in settling this question, it being understood that the exploration is to be made at least four days after, and at least three days before, the catamenial flow. A. Respecting Stenosis of the Internal Os. "1. If a sound one-fifth of an inch in diameter passes easily through the cervical canal, there is no stenosis at the internal os, and no incision is there required. Tiiis is the size, therefore, of my large sound. " 2. If a sound one-sixth of an inch in diameter be easily passed, as above, there is no absolute, though there may be relative stenosis of the internal os ; i.e., there may be stenosis for the passage of a fluid, though not of the sound ; and an incision to make it one-fifth of an inch may be required, but not unless the symptoms indicate it. "3. If the sound easily passed be but one-seventh of an inch in diameter, and there are no symptoms of stenosis, no incision of the internal os is required. This is the normal size in the imparons woman, and the average size of Simpson's sound. "4. If a sound but one-eighth of an inch in diameter cannot be passed through the internal os, there is either stenosis, or, what is very much more probable, one of the flexions. Prove, therefore, that there is no flexion in this and every case in which a sound of any size does not traverse the internal os before operating for stenosis. I consider an internal os of one-eighth of an inch or less to be stenotic. Ciirobak's highest limit for stenosis of the internal os is one-tenth of an inch (two and a Iialf millimeters). * Also described in the New York Medical Journal, July, 1S70, p. 478. PEASLEE S METHOD. 323 B. Respecting Stenosis of the External Os. " 5. On the other hand, there is no stenosis of the external os if a sound one-fifth of an inch in diameter easily traverses it. If there be congestion of the lining membrane, however, there may be stenosis, practically, in respect to conception ; and the opera- tion somewhat enlarging it (to one-quarter of an inch or more) may be required. " 6. If the external os will not easily admit a sound one-sixth of an inch in diameter, there is probably stenosis in respect to conception, and the operation is re- quired. If not more than one-seventh of an inch, the operation will also probably be required for dysnienorrhcea. " 7. In case of operation, the whole cervical canal must be made still to retain the normal fusiform sliape as far as possible. " I. My method consists in incising the internal os, if the stenosis exists at that part, — and the externa], if at the latter, — to such an extent as to give to each its precise average dimensions in the parous woman, neither more nor less, and, of course, also overcoming any other point of stenosis existing anywhere else in the cervical canal. In cases complicated with congestion, however, I have shown that a slightly larger opening may be required, and, therefore, that the limits may extend beyond one-fifth of an inch to nearly a quarter of an inch in the case of the internal os, and to three- tenths of an inch, and possibly more, of the external. " I do not, therefore, incise the internal or the external os to a given depth in all cases, but, taking them as I find them, cut just enough to give them their average normal size in the parous uterus. This is seldom one-half of a line and often not more than one-third of a line for the internal os, and not more than a line for the external. But, of course, there is far more variation in the latter. If the internal os admits a Fig. 196. Dr. Peaslee's Metrotome, half-size. sound of but one-eighth of an inch in diameter, a cut on each side of nearly half a line (but three-eightieths of an inch) is required ; and if but one-tenth of an inch in diameter, it must be one-twentieth of an inch deep on each side. The incisions are of precisely the same depth on each of the two sides. "Since the lining membrane at the internal os is at most one twenty -fifth of an inch thick, it is seen that I generally do not cut nearly through it. Indeed, when the os is but one-eighth of an inch wide, I cut almost through the membrane ; and when one- tenth of an inch, I divide it and one-hundredtli of an inch of the tissue beneath it* "II. The m.sf/-ume?i^ devised to secure this effect consists of a flattened tube, con- taining a blade. The former is eight inches long and seven-sixteenths of an inch wide, except its terminal one inch and three-quarters, which has a width of but one- eighth of an inch, as shown in Fig. 196. This portion is made curved by some in- strument makers, which is not an improvement. The blade is of such a width as to slide accurately within the tube, having a nut and a screw attached to its proximal extremity to gauge the extent of its passage into the cervical canal, and a blunt point * The details of all the preceding calculations are properly omitted here, as a slight acquaintance with mathematics will enable the reader to verify them. 324 DYSMENOREHGEA. and lateral cutting edges for an inch and five-eighths at the distal end. There are two blades for each instrnment, the cutting portion of one being a quarter of an inch wide, and of the other three-sixteenths of an inch. If the stenosis is confined to the internal OS, the narrower blade alone is used. If both ora are contracted, the wider instrnment is passed through the external os, and the other blade then introduced and the inner OS incised by it; and in cases of decided congestion, the wider blade alone is sometimes used for both ora. In this case, a sound one-fifth of an inch in diameter is easily passed through the inner os, wliile, if tiie smaller blade had been used, considerable force would be required to carry it through. "In hospital practice I place the patient upon the side, use the duck-bill speculum, hold the cervix by means of a uterine tenaculum, pass the tube into the canal up to tlie shoulder, and, therefore, one-quarter of an inch into the uterine cavity through the internal os, when the blade, previously gauged, is introduced into the tube and carried up the cervical canal as far as is required to overcome the stenosis. My large sound (No. 10, American scale), or, still better, the conical dilator of the proper size, is then passed up the canal, and the operation is completed. In private practice I generally place the patient on the back, and pass the tube into the cervical canal pre- cisely as I would Simpson's sound, and then pass the blade through it, as just described. "If the external os is too narrow for the admission of the extremity of my instru- ment, it may be enlarged by the introduction — generally one-eighth to one-quarter of an inch is far enough — of a narrow-pointed bistoury. I have not found the internal os too narrow to receive it, except in cases of flexion, or previous traumatic injury of the cervix. " The changes in the whole uterine cavity from this operation are shown by Fig. 198. Respecting its dangers I have but little to communicate. The hemorrhage following it seldom exceeds one or two drachms, and never requires any special atten- tion. The pain is ver}' slight and momentary, and no anaesthetic is ever required. The medullary structure of the cervix never being cut into, pelvic cellulitis and peri- tonitis do not ensue. The only exceptions to this statement in nearly three hundred cases are: one case in private practice, in which some febrile reaction and uterine tendeirness ensued, which subsided entirely, without cellulitis, in four days ; and two cases, in the Woman's Hospital, of slight cellulitis. But both the latter were patients who were known to have had cellulitis a short time previously, and I was obliged, by some peculiar circumstances, to operate sooner than I otherwise would have done. The final results were precisely as desired in each of these three cases. Otherwise I have never had any unpleasant symptoms follow the operation; and the only precautions taken are to keep the patient two days, and sometimes three days, in bed, and not allow her to walk out under a week. I use tlie dilator every second day after the operation for a week, and two or three times more once a week. I have very often performed the operation at my office on residents of the city, and sent the patient home to bed after half an hour's rest, and have never had to regret it. I decline to operate within four days after or six days before the catamenial period. "I claim for the method just described the following recommendations in the treat- ment of stenotic sterility and dysmenoiTlioaa. " I. It aims to restore the normal dimensions as existing in the parous woman throughout the cervical canal, nothing more and nothing less, unless where a slight exaggeration of size is required on account of coexisting congestion. "II. It effects tliis object definitely and with certainty, and with incisions exactly symmetrical, or equal on the two sides. " III. It gives no danger from hemorrhage, since the arteries nearest tlie internal OS, if that is to be divided, are never reached, and the whole thickness of the lining peaslee's method. 325 membrane even is generally not divided ; and there are no arteries within the portion divided at the external os. "IV. There is no danger of pelvic cellulitis, except in those patients in whom the least operative interference with the cervix, or the use of the sound or of a sponge- tent, will produce it. I consider the operation less dangerous in this respect than the last mentioned. Fig. 197. ' Fig. 198. Normal Uterine Cavity. Fig. 199. Ditto, as Modified by Peaslee's Method. Fig. 200. Uterine Cavity after Sims's Operation. Ditto, after Simpson's Operation. " V. There is no danger of septic peritonitis, since the medullary substance is not reached by the incision. "VI. It does not produce sterility or tendency to abortion by mutilating the cervical canal. The changes it produces in the latter, as compared with those from the opera- tions of Simpson and Sims, are shown by Figs. 197, 198, 199, and 200. 326 DYSMENORRHCEA. " VITI. It removes stenosis perfectly, and in most cases permanently, since there is very little tendency to closure of the slight incision made. I have had to repeat the operation only twice in my practice, except in cases in which there was cicatricial tissue to be divided, as after imperfect and partial closure following rupture of the cervix in parturition, or ensuing after Simpson's or Sims's operations. Here the opera- tion will usually have to be repeated in a year or two, unless pregnancy should occur, an event not to be expected in such cases, as we have seen. "Finally, then, since my experience has shown that a diameter of one-fifth of an inch for the internal os, and of one-quarter to three-tenths of an inch for the external OS, is sufficient in the treatment of stenotic sterility and dysmenorrhoea, I suggest the disuse of Simpson's and Sims's operation in the treatment of these conditions, and the substitution of a milder, safer and more efficacious method, of which, perhaps, ray own is, however, only the forerunner. At least, further experience in the line I have indicated will doubtless affijrd still more accurate conclusions." Dilatation. Dilatation is a very effective means of overcoming uterine stenosis, when either simple or complicated with flexions or displacements, when properh^ done. It is certainly safer, and I believe more effectual in most cases than any method of cutting. Dilatation may be accom- plished by repeated efforts, continued at intervals for several weeks or months, or at one sitting. According to the first plan, dilatation is effected once a week or oftener until the cervical cavity is sufficiently patent and so remains. This method has the advantage that it is not attended with much pain, nor followed by serious inconvenience of any kind. Indeed, with reasonable regard to the force used, there will be no danger in doing it in the office and permitting the patient to return home. In all cases, however, where moderate but decided dilatation is done, the patient should lie upon a lounge or bed until all pain and uneasiness have subsided. There is no doubt but that this trifling operation had better be done at the home of the patient. Tents, hard rubber or steel sounds may be used for this purpose. Of the tents I would recommend the slippery elm as being quite efficient and painless, and I know of no other tent now in use attended with the same immunity. The sponge, sea-tangle, or tupelo tents are fraught with much danger, especially when it becomes necessary to repeat their employment. The elm tent has the advantage of great flexibil- ity as compared with the others. (See description and mode of using, Chapter IV., Figs. 96 and 97.) The well-known success of Dr. Mackin- tosh with graduated steel sounds, as practiced fifty j^ears ago, if noth- ing more were said of them, has established their reputation. To effect sudden dilatation these instruments may be used quite advan- tageousl3^ To make sudden dilatation safe with these or any other instruments, the preparation and subsequent treatment should be the same as for any other important surgical operation, and no means left undone to prevent septic or inflammatory consequences. The operation of dilating the cervical canal with bladed instruments DILATATION. 327 is a simple mechanical procedure, easily executed, and on the whole more satisfactory than with sounds, tents, or bougies, except the slip- pery elm tents. There are a large number of instruments for this purpose, mostly two bladed, although some have three or more blades. Hunter's and Goodell's instruments are both excellent. The main difference between them is that Goodell's has blades with corrugated surfaces to keep them from slij)i3ing out while being separated. Dr. Goodell's is made in two sizes, the small one for cases in which mod- erate dilatation is required, and to precede the larger one when the passage is too small to admit it. For slow dilatation these instru- ments may be used through the common speculum three or four times a month, and the cervix dilated to one-fourth of an inch for the first few times, and afterwards half an inch. Each sitting should last ten minutes or more with the administration of an anodyne when there is pain, and the precautions of quietude always for at least half an hour after. When the blades of the instruments are passed beyond the internal os uteri, and the manipulations continued sufficiently Fig. 201. Goodell's Dilator. long, success is likely to follow. The operation for sudden and exten- sive dilatation is, of course, a much shorter way to the object than this, and while more hazardous, is very efficacious. After being etherized, the patient should be placed on her back on a table with the perineum projecting slightly over the end of it. The vagina should be dilated by Simon's instruments, and the cervix seized by a light vulsell, drawn slightly down toward the vulva and held firmly. This traction generally reduces the cervical flexion to such a degree as to permit the blades of the instruments to pass the contracted part and enter the cavity of the bod3^ After this com- plete entrance is manifest the blades should be slowly separated until the required amount of dilatation is effected. The instruments should be allowed to remain in this position for ten or fifteen minutes. They should then be introduced with the curve of the blades reversed, and also turned half around, and similarly expanded. The extent to which this distension should be carried will depend to a great 328 DYSMENOEEHCEA. extent upon the severity of the symptoms of obstruction. Dr. Goodell advises from three-quarters to one and a half inches. I think it ought also to depend on the condition of the cervix — very small pointed cervices dilate badly, and may be torn by extensive stretch- ing, while in patients who have had children, there is not so much difficulty. The time for operating is soon after the menstrual period has passed. After the operation the patient should be put to bed, and carefully guarded against attacks of pelvic inflammation or other evil consequences. Another means of dilating and straightening the uterus to overcome the stenosis caused by flexion, is the stem pessary. The value of this instrument has been the subject of much discussion; some gynecolo- gists condemning it altogether, and giving potent arguments against it, while others speak of it as the best of all means and, where prop- erly used, entirely harmless. There is no question that the difference in estimating its worth depends largely upon the manner of managing it. The danger and not the efficiency of the instrument is the point in the dispute. Winckel* puts the subject in its proper light when he says by careful preparation, and the proper selection of cases, the use of the intrauterine stem is free from danger, while from carelessness on the part of the physician or the patient it may give rise to months of sufiFering. He considers the evil consequences to be " hemorrhages, colicky pains, parametric exudation, and occasionally peritonitis," and he might have added metritis. In fifty cases in his own practice he has met with but two cases of parametritis. Prof. A. Reeves Jackson read a paper upon this subject before the Chicago Medical Society, June 7, 1886, giving the results of this treatment in sixty-four cases. Of the entire number, a cure of the flexion followed in forty, four were improved and relieved of dysmenorrhcea which before had been constant. In twenty the result was unknown. Dr. Jackson prefers Chambers's bifurcated vulcanized instrument. The short glass stem recommended by Dr. Chamberlin and Prof. Thomas, of New York, is a very neat and effective one, and will usually be toler- ated as easily as any other. The patient should be prepared for the use of the stem by remov- ing inflammation when present, by hot water douches and glycerine cotton tampons for a sufficient time. Immediately prior to introduc- ing the instrument the rectum should be emptied, and the vagina and vulva disinfected with carbolized water. To adapt the instrument, the patient should be placed in Sims's position, the vagina dilated with Sims's speculum, and the uterus drawn down and fixed by a small vulsell forceps. This will some- what reduce the flexion, when we may pass the sound and measure * Lehrbncli der Frauen Krankheiten. Leipzig, 1886, p. 331. DILATATION. 329 the length and size of the uterine cavity. A stem should be selected that is nearly half an inch shorter than the measurement, and with the dressing forceps placed in position. To keep the instrument from being expelled, a tampon of borated cotton should be placed against it, and left in that position for twenty-four hours. The tampon should then be removed by placing the patient under the same con- ditions with reference to position as for the introduction. After that the stem will generally remain in place. If it does not the tampon may be used again. The patient ought to remain in bed for several hours after the instrument has been placed. CHAPTEE XIII. METATITHMENIA {yurarceni,^ y.r,y) -. OR, MISPLACED MENSTRUATION. PERIUTERINE H.EMATOCELE. The accident to which I apjjly the above terms is an effusion of blood in tissues around and above the uterus, the effusion being some- times very extensive, at others limited to a small space. The effusion may take place in the vaginal wall, between the vagina and rectum, tearing up their connecting tissue, or in the posterior wall of the uterus, beneath the peritoneum, or between the peritoneal layers of the broad ligament beside the uterus, or in the jDeritoneal cavity. The mode of the accident varies somewhat, owing to the locality in which this blood is found. The blood is effused in interspaces beneath the peritoneum and elsewhere, as the effect of a rupture of some vessel; but while the effusion ma}^ be, and, perhaps, generally is, the result of a ruptured vessel of the ovary, the blood sometimes also arrives in the peritoneal cavity from the uterus through the Fallopian tubes. We are not yet able to decide which of these cir- cumstances is the more common. This accident happens most frequently at the time of menstruation, or very near it. As an accompaniment of menstrual congestion, the bloodvessels of the whole genital organs are greatly distended, and in certain cases this turgidity becomes too great for their capacity, and a rupture is caused at some particular place ; or, the cavity of the uterus being filled with a profuse flow into it, the blood regurgitates through the tubes into the peritoneum. It is not likely, however, that any considerable effusions are thus caused, so that the sudden and copious collections sometimes observed must be accounted for upon the supposition that a small arterial twig has given way in the ruptured ovisac at the time of the escape of the ovum, and poured the fluid rapidly into the sac formed behind the uterus by the descent of the peritoneum. The instances I have observed were more frequently connected with cases of disordered menstruation, but I have also seen the accident in patients whose menses seemed normal. Dysmenorrhoea may be regarded as the most common deviation accompanying misplaced menstruation. There can be no doubt but that effusions of blood, in every respect similar to misplaced menstruation, are caused by the condition of the uterus and appendages in abortion, after labor, and as the result of other causes of intense congestion ; but when so the modus in quo is precisely the same, the congestion being caused, not by the menstrual MENSTRUATION AND ITS DISORDERS. 331 molimen. but by the congestion of pregnancy and morbid excitement which sometimes attend these two states, — rupture of a small vessel or regurgitation being the immediate condition. Sanguineous collections arising in this way may be minute in size, but sometimes the quantity of blood is dangerously and even fatally large. The small collections are forced into places where distension is most difficult, as in the cellular tissue, while the large effusions are met with in the peritoneal cavity. Immediately after the blood is ex- travasated changes begin to take place in it and in the tissues occupied by it. Inflammation to a greater or less degree almost always is the result. In a mild grade the inflammation causes an eff"usion of serum? which augments the bulk of the accumulation and gives the appear- ance of much blood, when in reality there is but a small quantity. When this is the state of things, the disappearance of the tumor by absorption may be expected in a comparatively short time, and we often see it removed in a very few weeks. Dr. G. Bernutz has lately studied the pa,thology of uterine hemato- cele, and presents his views in a series of interesting articles (Arch, de Tocol, March, April, and May, 1880). The most important con- clusions of this study are summarized by Bernutz as follows : "1. Intraperitoneal uterine hsematocele may arise in two entirely distinct and different ways. "2. In one case, which may be termed ' classic ' hematocele, liemorrhage takes place from rupture of the products of extrauterine gestation, or from rupture of some of tjie internal organs of generation, or the escape of the blood which had distended tiie oviducts into the abdominal cavity, where a secondary peritonitis is set up by its presence, this inflammation leading to incapsulation of the bloody collection. "3. In other cases the hematocele is the result of a primary pelvi-peritonitis, the hemorrhage occurring at a period more or less remote from the incipience of the serous inflammation. In this case the disease is a secondary manifestation of inflam- matory action, audits true origin is found in the newly-formed membi'anes lining the pelvic peritoneum. "4. These neomembranous hematoceles may be symptomatic of vai-ious conditions. Thus they may indicate an acute pelvi-peritonitis in a woman who was previously attacked by a more or less severe inflammation of the pelvic peritoneum, or they may point to a repetition of former subacute inflammations, or, in fine, to a chronic pelvic peritonitis of a particular kind. There are, therefore, two varieties of hematocele symptomatic of pelvi-peritonitis, each of which has a pathogenesis of its own. "c. In the hematoceles denoting an acute or subacute peritonitis, the hemorrhage arising in the newly-formed membrane is from the outset rather profuse, being com- monly determined by menstrual congestion. For this reason an intraperitoneal hema- toma becomes at once manifest. Frequently it becomes a matter of difBcult}' to dis- tinguish between the two kinds of hematocele unless the period of incipiency has been observed by the physician. Fortunately the practical importance of this fact is not very great, since the treatment is essentially similar in both varieties of the disease. In the second form of hematoceles, which alone exactly corresponds to Virchow's de- scription, the hematoma is tlie result of scarcely suspected morbid action, which is very well indicated by the name of hemorrhagic pachy-pelviperitonitis. Under the influence 332 METATITHMENIA. of this chronic process the pelvic peritoneum is occupied by stratified patches of new- formed membrane. In this way it becomes thickened, as it were, and slight hemorrhage takes place between the superimposed lamellse, thus forming interstitial blood-cysts. These hematoceles are strictly analogous to similar tumors of the tunica vaginalis.* The intensity of the inflammation is frequently much greater, pro- ceeding through the stage of serous effusion to the production of fibrinous deposit. A hard tumor is the result. This again may re- main for a longer or shorter time, and then very slowly disappear, or only be partially taken away, leaving a permanent hardness, or, what is not unfrequently the case, proceed to suppuration and discharge in some way. I have seen as many as two cases terminate fatally by the exhaus- tion of suppurative fever without the discharge of the contents of the tumor. When suppuration is fairly established by the inflammation thus arising, exulceration and evacuation follow as a general rule. The vagina is most frequently perforated by the ulcerative process, but the jectum, bladder, or uterus may serve as the conduit of dis- charge. If the inflammation is of an acute character, and the steps in the process of evacuation rapidly succeed each other, the character of the discharge will partake largely of a bloody quality ; but should the time required by exulceration be considerable, pus will prevail in the composition. In any case, however, the discharge is a mixture of pus and changed blood. This last is sometimes very greatly changed, sometimes but slightly. In rare instances the j)eritoneum is inundated by rupture into its cavity of this mixture of pus and blood, and over- whelmed with a general inflammation, soon resulting in death. I have, seen cases of this kind, which were verified by post-mortem ex- amination. After absorption in cases attended with the milder grade of inflam- mation, very slight traces, if any, can be found by examination of the patient. When effusion of fibrin takes place, displacements, per- manent adhesions of the uterus and other parts, and deformity, will be left behind, slight or considerable, as the amount of deposit was small or great. These changes will, of course, be greater after the process of suppuration and discharge has been reached by the inflam- mation. Fistulous and tortuous openings may also embarrass the convalescence of the patient, or even by their long continuance ex- haust her. Symptoms. The symptoms vary in different instances. The attack is generally sudden and well marked. During the menstrual flow, or it may be just before or after, the patient is seized with severe pain in the hypo- * American Journal of Obstetrics, January, 1881. SYMPTOMS. 333 gastrium or one of the iliac regions. Frequently there is also a sense of faintness, sometimes slight, but often it amounts to complete syn- cope. In the place of faintness there are sometimes coldness, tremors and palpitation of the heart. The i^ain becomes persistent, and, per- haps, less severe, but not unfrequently it increases for a considerable time and then gradually diminishes. After the inception the pain usually spreads over the abdomen to the back and hips, and some- times down the thigh and leg. As the pain becomes greater or extends over a greater space, febrile reaction is developed, generally moderate in grade, but occasionally excessive; the pulse becomes rapid, the heat considerable, and the patient complains of great depression and thirst. The abdomen increases in size and becomes tympanitic, while there may be a distinct tumidity and hardness felt in one of the iliac regions ; sometimes the hardness extends over the hypogastric to the other iliac. This hardness and swelling may scarcely rise above the pelvic brim, but it not unfrequently is perceived extending as high as the umbilicus. It is not much, if at all, tender to the touch. It is irregular in its outline also. In very rare instances the etfusion takes place slowly, the symptoms are developed quite gradually, and the time of the beginning is not so definite, but the subsequent course is apt to be the same. After the symptoms are fully manifested, they pursue a course cor- responding to the grade of inflammation which is awakened by the eflFusion. In some cases the inflammation around the effusion is active and intense, and continues with severity until suppuration and exul- ceration end the process. Obstinate constipation is frequently present. Of course the fever is corresponding in grade and persistence, pass- ing through the high grade to hectic, attended with all its exhausting discharges. If the inflammation is less acute, the fever may be per- sistent for weeks, and sometimes for months, but of more moderate grade, until it gradually subsides, or slowly ends in suppuration and discharge. Active exercise aggravates the symptoms. Fortunately, in the large majority of cases, the amount of the effusion is small, the grade of inflammation slight, and the duration but a few days or weeks. There are two ways in which individuals are rendered miserable by the frequent recurrence of this trouble.. One is, when all the symptoms subside entirely for months, and then return. The tumor entirely disappears, the inflammation is wholly gone, and the patient feels that she has fully recovered her health, when, suddenly, during a menstrual flow, she is again seized with pain, swelling, fever, etc., which again subsides to be repeated more or less frequently. I have a patient who has suffered attacks of this sort perhaps twenty times in the last six or seven years, in whom the tumors have at different times been mistaken for ovarian or uterine tumors. In the other way the subsidence is only partial; there is all the time some tumidity. 334 METATITHMENIA. some inflammation, and more or less sympathetic suffering, with occa- sional severe returns. More blood is effused, the tumor is increased in size, and the inflammation intensified, and all subside to a partial extent and return again. When the tumor is much inflamed and suppurates, it may suddenly discharge through the vagina ; all the urgent symptoms readily sub- side, and the patient becomes convalescent. Again, the discharge is sometimes slow and difficalt, the relief is imperfect, and a protracted convalescence the result. But sometimes, after a course correspond- ing to the above description, sudden and general peritonitis is lighted up by extension of inflammation from the sac, or a discharge of some of its contents into the peritoneal cavity. The discharge is generally fetid and highly irritating, consisting of partially decomposed blood, pus, and ichor. It is always offensive compared with discharges from an ordinary abscess. I have seen one or two instances in which the general symptoms were not manifested at all, nor did the pain amount to anything more than an incon- venience, not very difficult to bear. It is interesting to observe the effects of this misplaced menstrua- tion upon the flow pe)^ vias naturales. Occasionalh'- no effect seems to be produced, the flow being natural in quantity and duration ; in fact, it is just at the time of the cessation of the discharge that effu- sion into the tissues takes place, but at other times there continues for many weeks a constant stillicidium of blood. Or, occasionally, — when the menses occur during the course of the symptoms, — the amount of discharge is very much increased. I knew one patient that had. a constant slight sanguineous discharge from the vagina for six months, and at the regular menstrual periods copious hemorrhages. In some cases the flow is more scanty than usual. Diagnosis. There are several conditions with which this sanguineous efllision may be confounded, if some caution is not observed. Inflammation of pelvic cellular tissue, or pelvic abscess, are the ones most likely to be mistaken for metatithmenia, or this last for the first. And as I have already shown, abscess is sometimes the result of misplaced menstrua- tion, the effusion in the tissues exciting intense inflammation, which proceeds to the stage of suppuration. In cellulitis the inflammation is not ordinarily ushered in by the same suddenly occurring acute pain and faintness. Chilliness and fever are more marked from the beginning, the pain usually com- mencing after the fever has begun, or, at least, increasing after the fever is established. The tumor above the linea ilio-pectinea is not perceptible for many hours, oftener one o,r two days ; it is extremely tender, and even in its outline. PEOGNOSIS. 335 In metatithmenia the tumor is observed in a few hours, and is not so very tender to the touch. It may be handled and pressed upon much more freely than the tumor of simple inflammatory origin. If examined per vaginam the inflammatory hardness and swelling is very firm. It is usually lower down and more to one side. The tumor from sanguineous efl'usion is quite elastic at first, and presents an edgelike projection down behind the uterus, entirely below the os and cervix. The finger may be pushed up between the cervix and the tumor, and the thick convex edge of the latter reminds one of a thick cake. There is very little tenderness, and vessels may almost always be felt pulsating over this projection. I need not say that this is never the case in the early stages of cellulitis. The vessels in this last are obliterated by fibrinous and serous effusion. If inflammation of a high grade speedily follows the effusion of blood in the tissues, the symptoms of the two may be so intimately blended as to make it doubtful how the tumor begau, and, in fact, it may be converted into pelvic abscess. Tumors of the uterus, under certain circumstances, may be con- founded with the tumor of sanguineous effusion; but their firmness, the want of conformity to the shape usually assumed by this last, the enlargement of the uterine cavity, our ability to isolate them by the fingers and probe, their gradual, unperceived growth, and their mo- bility, will almost always suffice to make the distinction manifest. From ovarian tumors it may be distinguished by the more regular outline, fluctuation on percussion, less grave symptoms, gradual de- velopment, absence of the projecting edge behind the uterus, the want of the beating vessels, etc., in ovarian growths. Displacements of the uterus may always be made out with great certainty by introducing the probe into its cavity to ascertain the di- rection of the fundus, and correcting its deviations. Hence the diag- nosis need not be long embarrassed by any question in reference to them. Retroversion of the impregnated uterus is constantly attended with great urinary distress, while metatithmenia seldom is. Extrauterine pregnancy, perhaps, in some instances, more nearly resembles it than any other, but the enlarged and flaccid cervix, open OS, dark color, and enlarged cavity, in this sort of pregnancy, and their absence in the accident we are considering, will suffice to dis- tinguish between them. Prognosis. The dangers to be apprehended in uterine ha3matocele arise from : 1st, the shock of the effusion in the peritoneal cavity, which, however, is not generally considerable ; 2d, fatal exhaustion from the amount of effusion in the abdominal cavity ; and, 8d, inflammation and its effects. From inflammation we may fear death, permanent damage to the organs about the pelvis, and great suffering. Very few patients 336 METATITHMENIA. escape without protracted suffering, often for weeks, and sometimes months. Damage to a greater or less degree frequently follows the displace- ments, adhesions, perforations, and thickening of the uterus, vagina, rectum, and bladder. The exhaustion of protracted febrile excite- ment; the perspiration, diarrhoea, and vigils not very seldom wear out the vital resistance, of the patient, who is often of a very delicate constitution ; or sudden and violent inflammation of the peritoneum overwhelms and destroys her. The prognosis in any given case will be governed by the intensity of the symptoms and the comparative strength of the patient If the amount of the effusion be large, and there be but little inflammation, the prognosis will be more favorable than if the effusion be small and the inflammation great. In fact, we may with great propriety form our prognosis by the amount and intensity of the inflammation alone, as it is almost the only source oi danger. As before observed, a cause of death, though not frequent, should nevertheless be mentioned as influencing the general subject of prog- nosis in misplaced menstruation, viz., a fatal amount of extravasation of blood in the peritoneal cavity. More than one case is recorded in which there was fatal prostration, coming on and pursuing its course in a few hours, which, when examined, revealed, as the source of an extensive and copious hemorrhage, the ruptured twig of an artery on the ovary. Of the many cases that come within our observation, how- ever, the number that thus prove fatal are extremely few. Treatment. The three great facts of this accident — hemorrhage, pain, and in- flammation — afibrd us sufficiently plain indications for treatment. It is very seldom that we are sent for, or in any way see these cases, until after the hemorrhage has exhausted itself or been stopped by backward pressure, after filling up the space into which the bleeding takes place. Should we, however, meet with an instance during the hemorrhagic stage, it would be very proper to make use of ice to the pelvic region, perfect quiet, and astringents internally, until the effu- sion ceased; but, as I said before, such opportunities seldom offer themselves. The cases as we ordinarily see them have proceeded through this stage ; the effusion, in fact, is generally accomplished in a few moments, or at most in very few hours. When we see the patient, she is either suffering with pain and prostration or coldness, the primary effects of the hemorrhage ; or pain, fever, and inflam- mation, and our treatment will be conducted according to the con- ditions in these respects. Our resources in the first condition will lie in the use of opium or other anodyne, to relieve the pain as much as may be necessary, and if the j)rostration or chilliness be considerable, TEEATMENT. 337 to stimulate sufficiently to establish equilibrium in the circulation, but not febrile reaction. In very many cases it will be sufficient to keep our patient quiet, and place her upon moderate anodyne treat- ment, good nourishing diet, and perhaps, after the first week or two, tonics, and she will slowly rally from the first shock, absorption of the blood will result, and she soon will recover her health. In these moderate cases we cannot be too careful not to overdo the treatment. The patients will generally recover spontaneously in a few days or weeks. But another class of cases occur, as I have already said, in which inflammation very soon succeeds the sanguineous effusion. A knowl- edge of the mischief which this inflammation' brings about should make us prompt in meeting it with appropriate remedies. If the inflammation runs high, adequate antiphlogistic measures will be indispensable to a favorable course. An active cathartic of calomel and jalap or some other alterative cathartic should begin at once, while at the same time, if deemed advisable on account of the force of reaction, we may apply a dozen or twenty leeches. These may be followed by the tincture of veratrum viride, in doses of two drops every hour, until the pulse is brought down to its natural frequency and volume, if not below these conditions, and then continue its use in less doses, or the same less frequently repeated, for some time. According to my observations, the most of adults will be held at this point by taking as little as one drop an hour ; some will require more and some less. The energy of this antiphlogistic course must be graduated by the force of inflammation ; but few cases will require as; much as is described here. Should the inflammation advance to sup- puration, the remedies required will be supporting ; at first^ sulphuric acid and quinine, and afterwards these with wine or other stimulants, nourishing diet, etc. These cases are often so protracted, the patients are so much prostrated, and suffer so much pain, that great skill will be called for to adapt the anodynes, tonics, and nutrients to the vari- ous conditions of the patient for so long a time. A question associated with the progress of inflammation, and one of great importance, is the propriety of evacuating the fluid. To evacuate the blood soon after its extravasation would seem to remove the cause of inflammation, and thus avoid it. To say that an early evacuation of the effusion would never be proper is perhaps to assume an extreme position, and there may be cases where such evacuation is advisable, but I think the number requiring it must be ver}^ few. Indeed, I should fear inflammation, from the sudden discharge of a large amount of blood from the peritoneal cavity, almost as much as if it were allowed to remain in it. There is another condition in which an operation for discharge of the contents of the tumescence is less a question of doubt, viz., when pus has become mixed with 22 338 METATITHMENIA. the blood, on account of inflammation. It is very important in some instances to puncture and discharge the fluid. When the pa- tient is being worn out by the protracted course of the disease, and the sweat and diarrhoea which so often attend it, we must interfere surgically for her relief. And again, when the fluid is increasing, and the tumor rising in the abdominal cavity, without showing any disposition to " point " in the pelvis, or any other place where it is desirable to have it do so, there is danger of the discharge of the pus and blood in the peritoneal cavity by rupturing the sac above, and we must anticipate it by choosing the place and mode. "When we have determined to relieve the distension by puncture, we ought to use an exploring-needle or trocar to ascertain the contents before evacuating them. After being satisfied by this corroboration of our diagnosis, we may plunge a large trocar, or even a knife, into the most dependent part of the tumor. This point will almost invariably be immediately behind the uterus, but occasionally it will be at the side of the pelvis. After free puncture, either with the trocar or knife, the discharge readily takes place, and the patient immediately experiences great relief. If the puncture is made to remove the blood before inflam- mation has begun, the evacuation may be more difficult, as it is often coagulated ; in that case the opening must be made large with a knife, and if the blood does not easily flow, the finger may be introduced to break up the clots and facilitate their expulsion. After the con- tents are thus expelled as near as can be, they sometimes reaccumu- late and are again discharged, and repetitions of these processes lead to still more chronic suffering, until the patient becomes a permanent invalid, or dies from such long-standing exhaustion. We may, with a good deal of certainty, cause contraction, granulation, and oblitera- tion of the cavity, by injecting it with iodine, wine, or other irritant. The best way to secure efficiency in injections is to introduce through the fistulous opening, or one made for the purpose, a small flexible catheter, so as to reach the bottom of the cavity and throw the fluid through this tube. We thus place the fluid used in full strength in contact with the walls of the cavity, while the injection thrown out of a common syringe will mix it up with the contents of the sac, and thus dilute it. Chronic Retrouterine Hsemotocele. 1 have met with a considerable number of hematoceles that did not terminate by absorption or suppuration, but remained in a latent condition, sometimes for years, and then became the subjects of change in their contents which rendered radical treatment indispensable. In the history of many of these cases the essential facts necessary to lead to a rational diagnosis are lost. CHROXIC EETEOUTEEINE HEMATOCELE. 339 The time when the effusion occurred is so remote that many of the symptoms have been forgotten, or, taking place contemporaneously with an abortion, or paroxysm of dysmenorrhoea, and the symptoms of hsematocele were so blended with those of the other condition that they escaped notice. Not unfrec|uently our attention is called to these cases for a long time passing for retroversion of the uterus, in the hands of inexperienced practitioners wdthout being recognized. After a greater or less length of time some of them undergo rapid increase of size, from an accumulation of serum, while others grow more slowly, but still become decidedly inconvenient tumors. One of the former kind has quite recently come under my notice. The patient was twenty-four years of age, the mother of two children, enjoyed good health until two years since, when she had, wdthout any assignable cause, severe flooding, and was thereafter confined to bed for several weeks. She gradually recovered sufficiently to very poorly attend to her household duties. She did not have the advice of an experienced practitioner until three or four months before she came under my notice. Her j^hysician at that time discovered a retrouterine tumor that extended above the brirh of the pelvis, with the most prominent elevation on the right side, wdiere it arose one and a half inches above the pubis. When first observed the lower portion of the tumor extended about an inch below the cervix uteri. From that time the tumor grew perceptibly until, at the time she came to me, the posterior cul-de-sac was very tensely distended. The lower end of the tumor was elastic, but too tense for undoubted fluctu- ation. The upper part of the tumor remained as above described. Dr. D. T. Nelson examined the patient on the same day, Thursday, the 24th of February, 1881. We requested her to call again on the 27th of the same month, or three da3's later. When she came again for examination we were both astonished at the rapid increase in size manifested at the lower end of the tumor. The lower end of the tumor w^as so much larger, and distended so far down as to begin to separate the external labia. The question wdth us was between a fungus or malignant tumor, behind and attached to the uterus, or an old hsematocele. She was at once admitted into the Woman's Hos- pital, and the next day a small trocar was thrust into the tumor for exploratory purposes. A large amount of reddish serum was ejected with great force through the canula. I then made a small incision by the side of the trocar, through which I introduced my finger, and enlarged it so that I could introduce two fingers into the cavity. The fingers at once en- countered large deposits of macerated fibrin clinging to the wall of the cyst. These were separated as far as practicable, the cavity thoroughly washed out, and several pledgets of cotton saturated with tincture of 340 METATITHMENIA. iron introduced. The serum contained albumen and the coloring matter of blood. A very remarkable case, with the commencement of which I was cognizant, is recorded in the first volume of the Transactions of the American Gynecological Society, by George H. Bixby, M.D., of Boston. I saw the patient and attended her for three or four months after the effusion occurred and diagnosed retrouterine hfematocele. During the time I attended her the tumor decreased decidedly, and I fully expected it to be entirely absorbed. The patient, as Dr. Bixby ob- serves, passed out of my care, but remained in Chicago, where I could know somewhat of her condition. She was an invalid during the whole seven years intervening be- tween my attendance and the time she went to Boston. As she was leaving Chicago for Boston she desired me to make an examination. The tumor was easily recognized at that time, but was not large. I subjoin Dr. Bixby's description of the case after she went to Boston: "Mrs. H , aged thirty-nine, a resident of Boston, consulted Dr. Mack, of St. Catharine's, Ontario, for an obscure pelvic tumor. On the following day I was called in consultation. The patient was of dark complexion and nervous temperament. Menstruation, which first appeared at eighteen and recurred at intervals of three weeks, was scanty and painless. In her youth she was unusually fond of outdoor sports, and later in life indulged in horseback exercise. She was married at twenty- one, and supposed she miscarried two years later. Seven years previously, while under the care of Professor Byford for uterine disease, she became the subject of hsema- tocele, but shortly after passed out of his hands. For two years Mrs. H. had been suffering from a peculiar pain in the left ovarian region, and also from renal and vesical derangements. She described the pain as occurring in paroxysms, at first light, gradually increasing in intensity until almost insupportable, then as gradually sub- siding. Soon after the recurrence of the above symptoms her attention was directed to a tumor the size of a small orange at the seat of pain. In the dorsal position, with the limbs flexed, percussion gave evidence of a well-defined dulness in the left ovarian and superpubic regions; by bimanual palpation unmistakable fluctuation. The uterus was fixed, and lateroverted to the right ; its cavity two and one-half inches in depth. Exploratory puncture (through Douglas's fossa), with a small trocar by Dr. Mack, confirmed the existence of fluid. Three pints of a light straw-colored serum were withdrawn by aspiration, which completely emptied the cyst. The result of an analysis by Dr. Fitz, of Boston, was as follows : ' A clear, light reddish-brown, odorless, slightly alkaline fluid, sp. gr. 1020; absence of sediment ; abundance of albumen, it becoming solid by boiling; abundant chlorides and sulphates. Microscope reveals numerous oil-globules, a few round cells with large nuclei and a small amount of granular pro- toplasm ; an occasional granular corpuscle. If it be a question between ascitic or ovarian, the latter is probable.' ZSTothwithstanding this result we were disposed to consider this case one of encysted dropsy of the peritoneum following hematocele. Being now intrusted to my care she was ordered rest in bed, no treatment. Not the slightest reaction followed the operation, and in the course of three weeks she resumed her ordinary duties. " Dr. Mack was disposed to attribute much of the pain as well as the renal derange- DIAGNOSIS. 341 ment to pressure upon the nervous filaments of the tissues in the vicinity of the cyst. The description of the pain and the renal and vesical symptoms were at least sugges- tive of some interference with the functions of the ureter by pressure from the cyst. "The following letter from Dr. Byford, received since the operation, tends to con- firm the diagnosis: "' Deae Doctor : lean emphatically indorse your diagnosis and proposed treat- ment. In my own practice 1 have met with but two cases of serous accumulation after hsematocele. One was cured by a single tapping with the aspirator, the other by establishing a permanent drain from the cavity. In the last case reaccumulation took place. I then punctured with a large trocar, and passed through the canula a flexible catheter, and left it in position. The cure was effected in about three weeks.' " Diagnosis. The diagnosis of these old hsematoceles is not always easy. The history, if the patient can intelligently trace it, will often lead to a strong suspicion of the character of the tumor. The primary attack may date back several months, and sometimes as many years, and may have been distinguished by symptoms arising from the continued presence and occasional augmentation of the tumor, indicative of some form of pelvic disease. Not unfrequently, however, the commence- ment is so obscured by attendant circumstances as to evade the most diligent inquiry, when we shall be obliged to depend upon recent developments and physical examination for a diagnosis. In many cases the patient will have suffered a long time from pelvic symptoms, and be aware of the existence of a tumor. The tumor is often mistaken for growths, as ovarian or uterine tumors, and even extrauterine pregnancy. In hsematocele the tumor is situated behind and adherent to the uterus. The uterus is pressed strongly forward and upward, and generally to the right side, so that the fundus may be felt above the right ramus, itself simulating a tumor. Generally the top of the hsematocele may be recognized by pressing the hand down into the brim of the pelvis, while the lower end will be found to fill up the cul-de-sac of Douglas, and distend it very greatly. The distension is especially downward, reaching occasionally as low as the external organs. I should regard the forcible downward distension of the cul-de-sac with fluid as a very important, if not a distinctive sign of chronic hsematocele. The upper part, or fibrinous covering of the haematocele, is inelastic and does not permit of distension in that direction, while the wall of the retrouterine pouch is elastic and permits distension. An ovarian tumor, a tumor of the lateral ligament, or an extrauterine pregnancy develops upward instead of downward. While any or all of these may be felt to occupy the cul-de-sac, they do not forcibly distend it downward. Instead of displacing the uterus upward as well as forward, they displace it forward at first, and afterwards down- ward. 342 METATITHMENIA. The hardness and more globular shape of a fibroid tumor, situated in the retrouterine space, will generally enable us to distinguish it from an old haematocele. An abscess is seldom situated immediately behind the uterus, and when it is there is generally so much hardness around the presenting fluid as to make the distension irregular, aside from the usual tenderness. "When the diagnosis cannot be made in any other way the tumor may be aspirated. The fluid drawn from an old hfematocele is well described in Dr. Bixby's case. The coloring matter of the blood is always noticeable. Treatment. The proper treatment of the chronic hffimatocele consists in evacu- ating it, draining the cavity, and frequent injections of some disinfec- tant solution, — the carbolic acid or permanganate of potash. When a sufficient amount of fluid is removed for diagnostic purposes the tro- car or asj^irator needle may be taken as a guide for the incision. The incision should be made in the most prominent part of the tumor large enough to admit the finger. The index finger should be introduced through it, and be made to tear a large opening into the sac. The opening must be large enough to admit two fingers freely into the cavity. Large deposits of the fibrin of the blood will be found adher- ing to the inner wall of the sac. The removal of these coagula of fibrin is very important, for if allowed to remain they will undergo decomposition, and thus be the source of sepsis. The large opening I have recommended has the advantage of permitting the free use of the, fingers for this purpose and the efficient cleansing of the cavity by injections. When carefully performed this operation causes little or no shock, and the patient usually recovers in two or three weeks from the effects of the evacuation. It requires several months for the sac itself to be removed by absorption. Eventually, however, it disappears to such an extent as not to be recognizable by an ordinary vaginal ex- amination, and with proper care the patient speedily recovers her usual health. CHAPTER XIV. CHANGE OF LIFE— MENOPAUSE AND SENILITY. At the period when woman ceases to menstruate various changes in her system occur, which constitute what is termed ''change of life." The peculiar anatomical feature noticeable is progressive atrophy of the ovaries, uterus, and usually of all the other female organs, in- cluding the mammary glands. Dr. Tilt, in his excellent work on the Change of Life, says : " Puberty and the change of life are caused by anatomical changes, the one by ovarian evolution, the other by ovarian involution." I should say these two conditions were accompanied by, instead of caused by, the ovarian evolution and involution. The change of life is an important epoch in a woman's existence, for if not, as Dr. Tilt thinks, the cause of many diseases, it is contem- poraneous with a number of the most dangerous affections, and cer- tainly modifies very materially the course of others. When not ac- companied by disease it is normal, and usually leaves the woman, to say the least, in no worse condition than before it occurred. Generally she becomes more vigorous after it, and her prospects for life and health are increased. The change of life is gradual, requiring from one to eight, or even ten years for the processes of involution and changes in all the body to take place. The average of the menojjause is forty-five years. While it may not always be the case I think a very early or very late menopause is abnormal in other respects than time. The cases that come about very early in life are much more frequently than otherwise caused by pathological conditions. Peculiarity of organization is the only way to account for the remainder. Such instances as have fallen under my observation were without exception preceded by diseases of the uterus and probably of the ovaries. I say probably, because the ovarian affection cannot always be diagnosticated with certainty. The late menopause I have not met with as often, and I have not been so clearly convinced of the condition of the patients as in the former. In such cases as I have noticed most of the women seemed to be pecu- liarly vigorous, though sometimes I have thought the long-continued functional activity of the genital system appeared to depend upon chronic hypergemia, caused by tumors, congestion, or inflammation. Simple cessation of the menstrual return is not the change of life. When the menses cease from a failure of the general powers, the term will not api^ly. 344 CHANGE OF LIFE — MENOPAUSE AND SENILITY. The cessation of the menses does not always take place in the same way. Sometimes it occurs suddenly, with no change in the c^uantity, quality, or jDcriodicity up to the last return, and with no premonitory symptoms. At other times a change in the periodicity of the men- strual flow occurs as a premonitory symptom of its cessation, the in- tervals in some cases being irregular, in others steadily decreasing in time until complete cessation occurs. Not unfrequently the menstrual discharges grow progessively less for ten or twelve years before they completely cease. By this method the change of life becomes an accomplished fact only after a compara- tively protracted transitional ^Deriod. Sometimes a severe hemorrhage is succeeded by the menopause. Numerous other methods exist by which this important change is brought about ; those which I have mentioned are the more common ones. There are probably no reliable symptoms, not immediately connected with the cessation of the menses, to indicate 4:he approach or even the progress of the change of life if the woman is in a perfectly healthy condition. The change, when a healthy one, is so gradual that the various organs and the nervous and vascular systems have amjDle time to accommodate themselves to the difference in the functions of the sexual system. Does the change of life give origin to the diseases, or to any of them, occurring at that time ? My opinion is that it does not. I believe them to be merely coincident. Fibroid tumors of the uterus and cancer of various organs do frequently occur about the time of the menopause, but they also are often met with both before and after that period. The long list of diseases and symptoms enumerated by Dr. Tilt are only evidence that the woman was diseased before, or became so at the time, from other causes, instead of indicating the change of life as the cause of them. Yet there is little doubt that the progress of existing diseases is modified by the changes in the circulation, nutrition, and nervous energies which occur at the change of life. In different parts of the present work I have alluded to this in describing the diseases in per- sons of different ages. Women undergoing the change of life who are not the subject of disease require no special management or treatment. It is well to have them as nearly as jDOSsible cured of the inflamma- tions, congestions, and displacements which afflict them, as that will cause the j)rocess to be more easily and naturally accomplished. How- ever, I think we need not fear that the change of life will be disastrous either as a cause of disease or by injuriously modifying those already existing. As elsewhere stated, we usually expect chronic inflamma- tion and its consequences to be benefited, if not entirely cured, by senile involution of the organs of generation, and we also often find CHANGE OF LIFE MENOPAUSE AND SENILITY. 345 the fibroid degeneration and growths of the uterus arrested in their progress by the same change. In all respects, when not complicated, we may expect the menopause to be a favorable crisis in woman's life; and even when contemporaneous with diseases, it is much more likely to beneficially influence their course than cause them to be aggravated. In all my expressions on the subject I have steadily kept in mind the fact that the menopause is but an incident among the processes which go to constitute the change of life. Senility in woman, after a com- plete change of life, is a state in which she is free from the embarass- ments connected with the active sympathies of the genital organs. Her diseases are more simple and less liable to become complicated. They are no longer female in their nature but fall into the category of common diseases. Exceptions occur to this statement. We do, though rarely, find some of the diseases, such as metritis, and even ovaritis, etc., commencing in old age. When they do originate in this stage of life, as the genital organs are in a state of feeble vitality, and the gen- eral system is incapable of exerting the same recuperative force as in earlier life, we may expect them to be both more obstinate in their re- sistance to treatment and more disastrous in their course. CHAPTER XV. ACUTE INFLAMMATION OF THE UNIMPKEGNATED UTERUS. Causes. Acute inflammation, not arising from specific causes, generally affects the fibrous portion or substance of the walls of the uterus. It almost always, if not quite, pervades the whole of the organ, the fundus, body, and cervix. Exposure to cold is the most frequent cause. The cold may be applied to the general surface when the uterus is in a state of turgescence from menstrual congestion, sexual excitement, or incomplete involution after labor or abortion. The same agent acting upon a portion of the surface, as the feet and legs, under a similar condition of the organ, may give rise to the same dis- ease. It is not likely that cold, however applied, would be a sufficient cause, but for the predisposing condition I have mentioned. The ex- citement of excessive sexual indulgence may be carried so far as to cause a moderately acute inflammation of the substance of the uterus, as also blows upon the abdomen, etc. It is not a very common disease, and yet I do not think it can be regarded as an infrequent affection. Symptoms. In speaking of the symptoms of the disease, I wish the reader to bear in mind that their intensity will vary from a mildness that will scarcely confine the patient to her couch to a very severe and grave disease, almost overwhelming the nervous system, with delirium and convulsions, and calling the stomach into excruciating symjjathy with it. In considering the subject, I wish to be understood as attaching more importance to the suddenness than to the intensity of the attack in determining the nomenclature. It is somewhat owing to the exciting cause, as to the symptom which is likely to usher in the attack. If the cause is a moderate one, as excessive sexual indulgence, pain will generally begin some time before the general symptoms. If the cause is cold suddenly and extensively apiDlied to a menstruating patient, chills and rigors may precede the pain. However that may be, when the case is fairly developed there is fever, aching in the back, pain in the head and ex- tremities, flushed face, and furred tongue. In addition to these general manifestations there is local pain, indicating the organ affected. This pain may be confined almost entirely to the sacrum and the lumbar PROGjSTOSIS — DIAGNOSIS. 347 region if the inflammation is moderate, but generally there is pain in the pelvis behind the pubis, or in one or both iliac regions. Some- times the pain radiates in several directions up the abdomen, down the thighs, and around the body. The pain is usually of a dull aching, but sometimes of a sharp character. In addition to these symptoms indicating inflammation in some of the pelvic organs, the nervous system is often afiFected with hysterical symptoms, convul- sions, coma, laughing, crying, or unreasonableness of some kind. I should have mentioned among the local symptoms dysuria and diffi- cult and painful defecation. Should the peritoneal covering become involved there is swelling and greater or less tenderness of the abdo- men. Nausea and even vomiting are not infrequent symptoms. After a week or more of this kind of suff"ering the symptoms gradu- ally subside, and the patient slowly recovers her usual health ; or sometimes the subsidence of the pains is not complete, and she con- tinues to suffer with a chronic form of inflammation. The termina- tion is almost ahvays in resolution or the chronic form of the disease. Possibly, in some exceedingly rare instances, the force of inflammation is spent in some circumscribed locality, and it proceeds to suppura- tion. I have lately seen an instance of this kind where the suppura- tion was in the anterior lip of the cervix. Prognosis. ■ The termination is so frequently in resolution or a moderate form of chronic inflammation, that we may almost always expect complete or partial recovery. Death probably never results in uncomplicated cases of acute metritis, but unfortunately we occasionally^ meet with grave and even fatal peritonitis, apparently resulting from extension of the disease from the uterus. It has been my misfortune to have lately met, in consultation, with two instances of' this sort. Although the prognosis is favorable, as a general rule, so far as the recovery of the patient from the attack is concerned, it is not so favorable for the complete re-establishment of health, as the patient is likely to be affected with chronic inflammation in the body or cervix. Not un- frequently we trace chronic inflammation back to a moderate attack of the acute. Diagnosis. Inflammation of the cellular tissue beside the uterus, metatithmenia, rectitis, or cystitis, cause symptoms which may be mistaken for me- tritis. When doubt exists it may be easily and certainly solved by a digital examination. If the bladder is the seat of disease, the tender- ness complained of by pressing it between fingers in the vagina and others above the pubis will be sufficient proof; pressure may be made upon the rectum by including it between the introduced fingers and 348 ACUTE INFLAMMATION OF THE UNIMPREGNATED UTERUS. the sacrum. The inflammation at the side of the uterus, or cellulitis, causes tenderness and hardness close to the iliac bones on the side, and the hardness seems to be continuous with the bones. The greatest tenderness is therefore close to the side of the pelvis. In all these cases the uterus may be touched, provided it is not moved so as to press upon the inflamed part or organ without causing pain. If it is the seat of inflammation the tenderness will be confined to that organ, while all the rest are free from it, and may be handled freely. We should not forget that all these organs may be implicated in one great mass of acute inflammation, and all the pelvic contents be intolerably tender to the touch. In an examination to diagnosti- cate inflammation of the uterus, I need hardly say that a resort to instruments is unnecessary. Treatment. The intensity of the inflammation will govern us in the activity of treatment. If it is not attended with great pain or febrile reaction, although our remedies must be the same, there is no need of using them with the same energy. We should, however, bear in mind the great likelihood of leaving the chronic form behind, and be diligent in our medicinal and hygienic appliances when practicable, until every vestige is gone. If the attack is moderate, it may sometimes be interrupted in the beginning, by measures to induce a copious per- spiration, more particularly if caused by an exposure to cold. Even a smart attack may sometimes be relieved by a large dose of opium and a steam-bath, used within a few hours after the commencement of the symptoms. After the symptoms have become fairly established and have lasted for twenty-four hours, we must not expect to find im- mediate relief, and should begin the systematic use of antiphlogistic treatment. In the subacute form, a brisk cathartic, foot-bath, and fomentations over the uterus, should be followed by tart, antimony, muriate of ammonia, and calomel. Perfect quietude should be enjoined also, and rest at night may be insured by giving one grain of calomel, with twice the amount of opium, in a pill at bedtime. Continued for five or six days this will generally induce slight mercurial effect, when the pain and other symptoms will pretty surely subside. If they do not do so, a blister over or a little above the pubis will aid in banishing them. If the attack is severe, we ought to add to the above remedies the more immediately deiDressing. The patient may be bled from the arm until a decided impression upon the pulse is produced, or we may apply from ten to twenty leeches to the vulva and groins, as a de- pletory measure. In the country, where leeches cannot be had, scari- fication and cupping can be profitably substituted for them. Should arterial excitement be high after the depletory measure, the tinct. of ACUTE INFLAMMATION OF MUCOUS MEMBRANE OF UTERUS. 349 verat, viride in doses from four to six drops every four hours, with the ammon. mixture, will be an efficient adjunct to our remedial measures. The calomel should be withheld as soon as its specific effects are produced. I should not discharge the obligation I feel to the student in the treatment of this disease were 1 not again to caution him against an imperfect cure of it. Very often it becomes chronic, and renders the patient miserable for years. We should try to avoid this consequence. Too early a resumption of duties and active exercise should be espe- cially prevented. When practicable, a continuation of treatment and avoidance of the causes which produced the inflammation are of equal importance. As a means of perfecting the cure which the more active treatment has brought about, the sedative effect of water affords us valuable aid. The sitz-bath and vaginal injections are the modes of using it. The sitz-bath ought to be used as much as the time and patience of the patient can be made to allow. An hour is short enough time, and two hours is better, twice or thrice in twenty-four hours. The injections should be copious, and may be used in the bath and of the same water. From two to four gallons of water ought to be passed through the vagina in this way each time the bath is used, by means of the rubber syringe. Acute Inflammation of the Mucous Membrane of the Uterus. — I do not know that I have ever met with an uncomplicated case of acute in- flammation of the mucous membrane of the uterus. Cases that I have seen have been connected v/ith inflammation of the vagina, and have arisen as the effect of some poison directly applied to the mem- brane. Most of them were gonorrhoeal, but in some I have been puzzled to determine whether the poison of this affection was the cause or not. Probably this poison gets into families, where and in ^Yays it ought not, and thus deceives us. However this may be, I think one of the worst features of gonorrhoeal inflammation is the frequency with which it invades the mucous membrane of the uterus and the difficulty of completely eradicating it. It is very apt to lurk in the uterus after the acute symptoms are removed and the inflam- mation gone entirely from the vagina, and thus require treatment as chronic endometritis. CHAPTEE XVI. GENERAL CONSIDERATION ON "UTERINE DISEASE" OR HYSTEROPATHY. There is a long list of symptoms, called nervous, or sympathetic, which, although not exclusively confined to women, are more fre- quently found to manifest themselves in them. They were formerly regarded either as independent affections, or as having various sources of origin ; and although hysterical was the term usually applied to them, it was not definitely known in what manner they originated. Patient investigation has given us more definite and correct notions of them, and we have come to regard them as nearly always dei3end- ent on trouble of some kind in the sexual system. Medical men, however, are not united in the opinion that the symptoms alluded to are thus caused, but are divided into two well-defined parties with respect to uterine pathology. 1st. There are those who believe that the uterus has very little sym- pathetic influence on the system ; that the diseases of that organ are more frequently the result of diseases in other organs than of inde- pendent origin ; that the symptoms accompanying and almost always found in connection with actual lesion of the uterus do not at all de- pend upon this organ ; that these symptoms may be cured without any attention to the condition of the uterus, and, in fact, whatever cures them, almost always cures the affections of that organ. 2d. The other party holds the opinion that the sexual system of the female, in a state of disease, exercises a morbid influence over nearly the whole organization ; that this morbid influence is particularly ex- erted over the spinal and cerebral nervous systems ; and that the only sure and permanent relief is found in the cure of the disordered con- dition of the uterus. Those who adhere to the latter view may be classified under two subdivisions, one of which holds that the sympathetic influence of the uterus is only manifested when that organ is inflamed or ulcerated, and that the cure of the inflammation and ulceration relieves the symptoms. The other maintains that inflammation and ulceration are only of slight, if indeed of an}^, importance ; while the cause of all the difficulty is some sort of displacement. It will probably surprise the student when he is told that all of these diverse and various oj^inions are held by gynecologists of equal emi- nence, integrity, and opportunity for observation. There is reason for surprise in this consideration, and yet this same diversity of opinion "uterine disease" or hysteropathy. 351 exists in all departments of medicine ; for example, as to the nature and treatment of inflammation, as to the essential nature of typhoid fever and its treatment, as to the local or general origin of cancer, and the propriety of extirpation. How can this discrepancy be accounted for? It is not my purpose to answer this question at length, but merely to indicate a few obvious considerations, of which one is that the attention of medical men has been too recently directed with suf- ficient intensity to the points involved to enable them to make an induction full enough to convince by its results all the members of the profession of the correctness of any one view. This, therefore, is just the time when we meet with conservatism in the views of tem- perate and judicious investigators, as well as with the less laudable conservatism of those who have lived too long to improve. Another consideration is, that while judicious practitioners hold antagonistic opinions as to the nature of diseases, they pursue so nearly the same line of j)ractice as to lead to similar results in the treatment of them. A third consideration relates to the power of prejudice, which forms in very many minds an invincible barrier against the acquisition of truth ; and the opinions imbibed in early education are those which are maintained the most persistently, sometimes in consequence of an unwillingness to learn, and sometimes even against the I'ight of reason itself. From the pernicious influences of association and prejudice neither learned nor unlearned are exempt. CHAPTER XVII. SYMPATHETIC OR REFLEX SYMPTOMS OF UTERINE DISEASE. Dr. Scanzoni* says : " The sympathetic phenomena which very distant organs so often present during the course of uterine diseases are of the highest scientific importance." They are the more impor- tant because our attention is more frequently called to them than to their original exciting cause. The secondary or sympathetic diseases often distress patients most, and the fact of their mentioning no other troubles may, without inquiry, mislead us into the opinion that they are indej)endent affections. The general symptoms attendant upon uterine disease are primarily sympathetic and secondarily neurasthenic. The sympathetic are re- flex. An imj)ression is produced on the ganglia of that portion of the sympathetic nervous system connected with the uterus and ovaries especially. Thus propagated it is conveyed along the nerve fibrillse to the genito-spinal centre, and from this reflected to all the organs with which the genital system is in sympathetic relation. The stomach is deranged in various ways ; the bowels, the liver, and the spinal and cerebral nerve centres become affected. The derange- ments of digestion interfere with nutrition, the blood becomes poor in the materials calculated to sustain the vigor of the nerve centres ; they become ansemic, and in this way nervous exhaustion occurs and we have with the original sympathetic symptoms, or succeeding them, neurasthenia. Neurological writers, among whom are Drs. Weir Mitchell, Beard, and Professor Jewell, ascribe neurasthenia to an exhausted state of the nerve centres. If I rightly understand what they mean by this it is that the brain and spinal cord have become damaged by overaction. I do not mean by damage, structural lesion, but a condition in which the cell action is slow, labored, and painful, because the parts have been overworked, and according to this method of interpreting the symptoms they prescribe rest as one of the essential jjarts of the cure. This is so different from the way I look at the subject that I will risk a concise statement of my views. I think that the nerve centres do not become exhausted, but that the blood circulating through them does become exhausted of the ma- terial necessary to promptly renew the loss during functional action of the nerve centres. On account of the Avant of general vigor, the * Diseases of Females. SYMPATHY OF THE STOMACH. 353 heart and arteries may not transmit the blood through them in the usual quantity, but if the circulation is not deficient in quantity, the blood itself is deficient in quality. With a deficient supply of nutri- tive material their functions are performed irregularly and imperfectly, and there is neurasthenia. If my explanation of the origin of neurasthenia is correct, absolute rest is not so important to the cure as full feeding. We shall be able to study the general symptoms of uterine disease more profitably by taking them up separately as they are manifested by different organs, and without attempting absolute correctness in this respect, it will be practicable to present them in something like the order of frequency in which they occur. Sympathy of the Stomach. The stomach is apt to be disturbed as early and as frequently as any other organ by uterine disease. This is no more than we would ex- pect, considering how often and intensely it is influenced by preg- nancy, and its great readiness to complication in most affections of other parts of the system. Simple anorexia is one of the most com- mon of the sympathies of the stomach, as is also its contrary, vo- racity ; but occasional unbecoming, and even disgusting, depravity of appetite is also met with. Inappetency sometimes proceeds to the extent of loathing of food and to longing for inappropriate articles of diet. Nausea, with loathing of food and disgust at the smell of it, is another feature of stomach trouble ; also frequent vomiting when the stomach is full; an absence of discomfort when it is empty, and the vomiting is sometimes worse when there are no ingesta, and nothing is expelled but some of its secretions, which are usually acid, but sometimes bilious. Gastralgia may occur when the stomach is empty ; or during digestion, or immediately after swallowing food. The ca- pacity of the stomach to digest food of any kind is often impaired, but more frequently some particular sort of food disagrees with and embarrasses digestion ; in short, almost every form of disordered stomach may be looked for as the result of the sympathetic influence of diseases of the uterus upon that organ. The grade of functional disturbance may vary from the slightest inconvenience to that com- plete arrest of digestion which rapidly induces inanition and death. Extreme cases of indigestion, however, are not of frequent occurrence, and the disturbances are rather those of great annoyance than such as result in very serious impairment of nutrition ; and many patients who constantly complain of suflering very severely from sensitiveness connected with digestion attain to a state of apparent robust embon- point. 23 354 SYMPATHETIC OR REFLEX SYMPTOMS OF UTEEINE DISEASE. Sympnthetic Disease of the Boivels. The bowels probably sympathize in diseases of the uterus next in frequency to the stomach, and their functional derangements are mul- titudinous. ConstiiDation is very common. The bowels, in many in- stances, have apparently no natural tendency to move. I have one patient who assures me that she has often been fourteen days without any fecal discharge whatever, and that she dare not try how long she could go without it, but says that she always uses some means to pro- mote the alvine evacuations. In other cases constipation terminates with diarrhoea, and an alternation. of diarrhoea and costiveness, which lasts from two to six days, is a constant and habitual state with the patient. In cases of constipation resulting from this cause, the con- stipation seems to depend upon a want of muscular tone in the intes- tines ; peristaltic action is deficient, and the appearance of the evacu- tions is in all respects natural, and their consistence proper. In other cases the secretions are deficient, and the stools are dry, hard, and small in quantity. But constant diarrhoea and irritable bowels are also frequent accompaniments of uterine disease. The passages may be profuse, water}^, and exhausting, or profuse and fecal. A peculiar kind of discharge in cases of diarrhoea in uterine disease presents a muco-fibrinous cast of the intestines. The casts are sometimes quite tenacious and of variable length, from two to ten inches, and are often complete casts of the intestinal tube ; at other times there are shreds of false membrane of irregular shape and size. The discharge of these substances is usually attended with some dysenteric symptoms. The diarrhoea sometimes seems to be excited or aggravated by certain articles of food ; at other times one kind of ingesta seems to agree as well as another; and, again, the bowels may be quite regular, except at or near the period of menstruation. The irregularity is often en- tirely confined to that time. With or without diarrhoea there may be tumultuous gaseous commotion in the bowels ; they may be more or less distended, or without distension there may be annoj- ing borboryg- mus and motion, from the gas passing from one part of the intestines to another, inducing the opinion that pregnane}^ exists. The gaseous distension of the abdomen is sometimes so extensive and permanent as to induce the overwilling patient to believe that it is caused by ges- tation, and being frequently connected with hysterical craftiness, she may impose the same belief on a careless practitioner. Sympathetic Affection of the Liver. Closely connected with and, of course, very much influencing the condition of the alimentary canal, is the condition of the liver. Sometimes the bile is poured out in such copious quantities as to induce full and free discharges of it from the stomach by vomiting, SYMPATHETIC AFFECTIONS OF THE NERVOUS SYSTEM. 355 and to stimulate the intestines to copious bilious diarrhoea when they are not irritable, but subject to the ordinary stimulation of ingesta. This overflow of bile comes in paroxysms, and produces a sort of cholera morbus. When it occurs only once a month, it is apt to be near the time of menstruation, or it may return several times between the monthly periods. But there is often a persistent absence of secre- tion for a time, or this condition may alternate with the other; or the bile, instead of finding its way into the alimentary canal, may pass into the circulation and give the skin a jaundiced hue. When the functions of the liver are seriously disturbed, there is apt to be at one time a deficiency of bile, and at another a great redundancy. I have not seen this organ congested to any great extent, as observed by Dr. Bennett. But I have seen an enlargement of the spleen in such instances, though I have not supposed it to be the result of the influence of uterine disease. When copious effusions of bile take place somewhat suddenly, all the pain and spasmodic action observed in bilious colic are likely to present themselves. Sympathetic Affections of the Nervous System. Much more distressing if not more serious sufl"ering is experienced in the nervous system than in the digestive apparatus. Aches, pains, and complaints of evident nervous ailments are the peculiar province of uterine disease. There is hardly a disagreeable or even excruciat- ing sensation that these patients do not experience ; and too often this real suffering is mistaken by the friends for imaginary, and the patient's complaints are treated with unreasonable impatience and rudeness by persons from whom she ought to receive kindness and sympathy, because her appearance does not correspond with her mor- bid sensations, as we are apt to observe them in other examples of disease. It is remarkable, too, and a fact that often impeaches them with insincerity in their complaints, — when the uninitiated are the judges, — that these patients will pass from a state of excruciating suffering and loud complaints, under a little excitement, to one of actual enjoyment and hilarity, or conversely. The ■ transition from the excitement of private company, or a public party, gives way in a few minutes to a doleful condition of suffering and unappeasable complaints. The inconsistency of the complaints and enjoyments, the incapacities and the performances of these patients, are almost characteristic, — at least in their sudden alternation, — and are inex- plicable in any other way than by supposing that the pains in the different organs, to which they are referred, are more dependent upon the general nervous susceptibility than upon the organic disease of even trivial character. They are strictly neuralgic in their nature, and confined to the nerve-matter or tissue of the parts. A great num- 356 SYMPATHETIC OR EEFLEX SYMPTOMS OF UTEEIXE DISEASE. ber of the disagreeable sensations and pains appear more frequently in particular parts, and hence may be distinctly referred to in this description. Accompanying Manifestations of Moral and Tatellectucd Perverseness. During the spasmodic action -which, in the majority of cases, has to a critical observer the appearance of being partly voluntary, there is &]}t to be a singular perverseness of moral and intellectual mani- festations, which was on a certain occasion very graphically expressed by a clerical friend in speaking of a patient, by saying that she " seemed to be actuated by an evil spirit." In the midst of great suffering, patients not unfrequently try to bite and otherwise wound those who endeavor to restrain their violent agitation ; they attempt to throw the covering from them with the apparent object of expos- ing their person, or say some very perverse things. At other times they attempt to imitate the symiDtoms of some grave organic affection. One patient, by heaving up the lower part of the chest spasmodically at rapidly succeeding intervals, induced her friends to think that she had violent palpitations of the heart, and therefore must be the sub- ject of cardiac disease; she also imitated throbbing of the temples by spasmodic contractions of the temporal muscle. "When this throbbing of the temples was very violent, I requested her to hold her mouth open so as to relax those fibres, but she looked up and said very wicked things, and became contemptuously calm. A request to hold her breath when the palpitations were violent, induced her to act in the same way, and caused an instantaneous cessation of them. The great peculiarity in these spasms has always seemed to me to be a guarded cunning, a deceitful and perverted consciousness. To a close observer this is always easily detected. By using the foregoing epithets descrip- tive of the peculiarity of this kind of hysterical phenomena, I do not wish to be understood as saying that deceit, cunning, etc., are indica- tions of freedom from disease on the part of patients who are thus affected. I think this is not usually the case, but that they are the result of the morbid state of the mind and body. The spasmodic action of the muscles is not contemporaneous in the corresponding extremities, as in epileptiform hysteria or epilepsy, but is so irregular as to move the body in many different directions instead of giving to it frequently repeated similar motions. Syncopal Convidsions — Hystero-Epdepsy. There is a singular variety of semi-convulsions, or syncopal con- vulsions, which I have often noticed, and I do not remember to have observed in any other connection. They occur very frequently after they have once seized the patient, as often as three or even six or eight MORAL AND MENTAL DEEANGEMENT. 357 times during the twenty-four hours. They take place in the daytime or at night, during the sleeping or waking condition, and do not seem to result from any particular excitement at the time. If the patient is sitting and talking, or is engaged in work, she suddenly ceases and slowly sinks down to the floor; she turns her head to one side, almost ceases to breathe, becomes pale and trembles, sometimes very gently, sometimes violently. This state lasts only for a few seconds ; she arouses, looks about confusedly, and, although she knows she has had a fit, as her friends call it, she does not remember distinctly anything which passed during the time. As these attacks become chronic, they may be attended with very slight convulsive movements, frothing at the mouth, and sequential somnolence ; but, ordinarily, this is not the case. If the patient is attacked in the night while asleep, unless some person observes the attack, it will not be known to have occurred, the patient being unconscious of it. There is generally, however, move- ment enough to awaken anybody who may be in the same bed with the patient. In all cases of this kind I have noticed great impair- ment of memory, particularly of recent occurrences. There is not usually any severe pain in the head or spinal centres ; there is, in fact, no prominent painful circumstance apparently connected with the case. Patients having such paroxysms are generally worse at or near the time of menstruating ; but sometimes they are quite exempt from them at this time, but have them not long after the menstrual conges- tion is over. Moral and Mental Derangement. No more constant derangements, perhaps, occur than are observed in the mental and moral qualities of the patient. The patient loses the complete control which she has been in the habit of exercising over her emotions, and finds herself becoming despondent, fretful, suspicious, and unsteady in her purpose : whimsical, having desires not before experienced, indulging in thought and feelings toward her friends which in her former da3^s she did not entertain. She will often call herself a changed woman. If the source of irritation is not dis- covered and removed, she loses her strength of will entirely ; and, instead of her moral feelings being guided by her will under the in- fluence of a sound judgment, she exhibits indecision, and wavers in matters about which she heretofore had no difficulty in making decision. She finds herself giving way to peevishness to a frightful degree ; no- body can please her. In place of her usual satisfaction in the atten- tion of her friends, she finds fault with their efforts to make her com- fortable. Sourness, moroseness, jealousy, carelessness, timidity, and peculiar perverseness change her nature entirely. Sometimes one class of ideas will seize her whole faculties, and she will scarcely think or talk of anything else. She has no patience with anybody who will 358 SYMPATHETIC OR REFLEX SYMPTOilS OF UTERINE DISEASE. not listen to her, and believes everybody to be her enemy vrho cannot sympathize with her in her imaginary troubles. The different phases of mental and moral troubles under which the patient labors are al- most innumerable. As will be seen, this state of things closely borders on insanity, and there is no doubt that insanity is often the result of uterine irritation in patients who are hereditarily predisposed to it. I think I have seen cases of insanity that were excited into activity by the great nervous irritation connected with uterine disease. But in place of this steady deviation from her natural mental condition, the j^atient may generally be sane, and show an abnormal state of mind only when circumstances occur which are likely to excite her, when she loses all control and indulges in excessive anger. Some- times, in a fit of despondency or melancholy, she contemplates or even attempts suicide. Or, if her sense of wrongs weighs heavily upon her, and no means of redress shows itself, she thinks seriously of fleeing from what she fancies is the cause of them. Still another sort of paroxysm exhibits acts of a depraved and indecent nature, so disgust- ing as to shock the witnesses of them, and in her recollection of them to mortify her exceedingly. The common hysterical paroxysm of crying without a sufiicient cause, the indulgence in unbecoming and unseemly levity, rapid alternations of despondency and hope, need hardly be mentioned, from their familiarity to every observer. When, in reference to such unbecoming exhibitions, patients are kindly re- monstrated with, they will, in general, acknowledge the impropriety of them, but will end with saj'ing, " I cannot help it," which is the unanswerable and, doubtless, truthful exposition of their mental con- dition. Neglect of duty in all the relations of life is one of the phases of their mental state. Sometimes a wilful selfishness, caring for noth- ing but what they fancy will make them happy or conduce in some way to their interests, absorbs their whole mind and governs all their actions. At times there is an intelligent appreciation of the impro- priety of their actions. Cephalalgia. Cephalalgia, in some form, either partial or general, is a very com- mon attendant upon the nervous susceptibility of uterine patients. It is often general ; the whole head seems to pulsate and thrill with terrible pain, rendering the patient almost frantic with the intolerable aching. In a few hours it subsides, leaving the nervous energies pros- trate for a short time, but otherwise the patient is free from all pain. This subsidence would not be complete if the cephalalgia were any- thing but nervous pain in the head. The general cephalalgia is often, but not necessaril}^, attended by nausea and vomiting, or other sto- machic, hepatic, or intestinal disorders, and may be relieved, when that is the case, by emesis or an alterative cathartic. This is what is CEPHALALGIA. 359 commonly called sick headache. The most frequent forms of pain in the head, however, are partial, and confined to some particular part ; as hemicrania, confined to the whole of one side, or a lancinating pain in the temple, brow, or eye. All these are very common pains in uterine disease ; but persistent or frequently recurring pain in the occipital region, or on the summit of the head, is nearly pathogno- monic of uterine disease. It is almost invariably the case that a woman has chronic uterine disease if she complain of ]3ersistent pain in either of these regions. The occipital pain I have observed in this connection much oftener than the pain on the top of the head. It is, ordinarily, a dull aching, that completely unnerves the patient and renders her unfit for her duties for days together ; it is usually very persistent, in some patients being almost constantly present, but in other cases only occurring once a month, ordinarily at the menstrual period. The pain on the top of the head is described generally as a burning pain; patients complain that they have all the time a hot place on the top of their heads. This pain is probably more constant in patients that, have it than any other about the head. I have ob- served that when patients suffer greatly from pain in the head, they comjilain less of suffering which is more directly referable to the uterus than when any other symptom seems to predominate. Indeed, I have met with patients who were martyrs to these excruciating head- aches who did not complain of anything which pointed directly to the uterus as the origin of their sufferings, and yet upon examination that organ was found ulcerated and inflamed ; and when these con- ditions were cured by appropriate treatment, the headache ceased to annoy them. A remarkable instance of this kind occurred to me several years ago. The patient came to town to consult me about what she called neuralgia. The pain was located in the occiput ; it lasted one week in every four (her menstrual week), and when very severe she had hysterical convulsions. This took place at almost every recurrence of the headache. She had no backache at any time ; her menses were natural in every respect, as far as I could gather from her history, on which I placed the more reliance from the gen- eral intelligence of the patient. She could walk long distances with- out inconvenience, had no pains in the hips, groins, or legs ; in short, she made no complaint from which I could infer the origin of the nervous suffering to be in the uterus, except that the headache was sure to come on at the time of menstruation. Her uterus was ulcer- ated and hiflamed, and after appropriate treatment was cured, when the sufferings vanished, and she has since enjoyed complete immunity from them. This woman was about thirty years old and in the midst of her childbearing period, and it might hence be supposed that the uterus would exercise more sj^mpathy than at any other time of life ; but, as the following case will show, this is not the fact: Mrs. , 360 SYMPATHETIC OE KEFLEX SYMPTOMS OF UTEETNE DISEASE. forty-nine years of age, had ceased to menstruate three years before I saw her, but was subject to the most excruciating headache every six or seven days, each attack so prostrating her that she would scarcely recover from one before the next would appear. She had some back- ache and inconvenience in walking, but these symptoms scarcely attracted her attention amid the terrible sufferings caused by her head- aches. Six months' treatment addressed to the uterus alone sufficed to remove all this great trouble and render the woman comfortable and capable of her duties in life. The overwhelming influence of this terrible cephalalgia on the nervous system seems to occupy so completely the capacities of it that minor pain is unheeded, and no cognizance is taken of the sufferings of the less sensitive but inflamed and mischief-making uterus. Affections of the Spinal Cord. The spinal cord seems to partake very much of the sensitiveness of the nervous system, probably more so than the brain. Pain in some portion of the spine is almost universally present in uterine disease, but is most common in the sacral and lumbar regions. Pain is so general in those regions that it has come to be regarded as neces- sary, in the estimation of very many persons, to establish the probable existence of this affection. The pain is fixed and almost constant, but aggravated by anything that excites the uterine vascular system, as standing or walking for a long time, lifting or jumping, or sudden emotions. Fright, anxiety, or anger, as the patient says, " flies to the back " and aggravates the pain. It is especially apt to be worse during the menstrual congestion. Sometimes walking so much in- creases it as to incapacitate the subject for that kind of exercise. An expression often made use of to signify sensitiveness of the back, is " weak back." Women will say, " I have not exactly pain in my back, but it is so weak that I cannot move on account of it, or can hardly stand, or cannot arise from a stooping posture." The pain may be fixed in any part of the spine. I have a patient whose back- ache is at the junction of the dorsal and lumbar regions. In connec- tion with these pains there is often tenderness in the same region, so that pressure causes great complaint. The pain is not only increased in the part pressed upon, but it sometimes darts along the nerves around the body. Hypersesthesia. Akin to pains in various parts is hypertesthesia without inflamma- tion ; great sensitiveness of particular parts. Tenderness of the scalp is often complained of The whole surface of the head is so tender as to require great care in dressing it, and no pressure can be toler- ated without an effort. Of a similar nature is tenderness along the EXTENSION OF INFLAMMATION TO THE BLADDER AND EECTUM. 361 spine. The different spinous processes in some sections of the column cannot be touched without giving the patient great suffering. Pres- sure upon these tender vertebrje sometimes causes pain to shoot along the spinal nerves, passing out of the intervertebral foramina in the neighborhood. There is occasionally, also, general tenderness of the abdomen. Ansesthesia. Much less frequently there is ansesthesia of some particular parts. The patient complains of a want of the ordinary sensitiveness in them, or there is a feeling of numbness, which lasts for some days, and which recurs so often as to obtain the distinction of a symptom of the case. The muscular through the nervous system is, in many cases, very seriously affected. Cramps and spasmodic action are very frequent in particular cases, and they are confined almost constantly to certain limbs. They occur more frequently in the lower than in the upper extremities. Spasms. A worse state of things, however, exists when there are general spasms of the limbs and abdominal walls and hysterical convulsions. They are apparently induced by fatigue, or occur at the time of men- struation. The patient, after complaining of severe pain in the stom- ach, falls into a state of general convulsions, which lasts from thirty seconds to some hours, and subsequently sinks into a state of quietude, but not of insensibility. These attacks are usually repeated several times and then subside, leaving the patient in the possession of her usual physical condition, which is one of nervous misery. Sympathetic Pains in the Pelvic Region. Painful localities are generally found about the pelvis ; in the in- guinal or internal iliac region they are exceedingly common. Imme- diately above one of the groins a constant and fixed aching may be found, which is aggravated by all the circumstances that increase the pain in the back. Most generally there is some tenderness or soreness in the part, which is increased by pressure. The pain sometimes ex- tends to the hip and side of the pelvis. It is much more frequent in the left side, but is often confined exclusively to the right, and less frequently it is in both sides alike. In more rare instances the pain is centrally situated behind the symphysis pubis. Extension of Inflammation to the Bladder and Rectum. The patient will often say she has pain in the bladder, or pain in the rectum, and believes that these regions are affected. These 362 SYMPATHETIC OR REFLEX SYMPTOMS OP UTERINE DISEASE. pains, when complained of, are generally very ajapropriately stated to be in the bladder and rectum, and are indicative, for the most part, of an extension of inflammation to these two organs. When this is the case, pain accompanies or rather is increased by mic- turition, or may occur immediately after it. The same remarks are applicable to the alvine discharge ; during defecation the pain is increased, or then only occurs. These pains are not, strictly speak- ing, sympathetic, but occur as consequences of the extension of in- flammation, and indicate correctly its locality. In the iliac region it sometimes extends up the side as far as the mammary region, or there may be pain in this latter place not connected with the former. The pain may likewise be situated between these localities and be independent of any pain in them. Affections of the Sciatic and Anterior Crural Nerves. Pain in the course of the sciatic, obturator or anterior crural nerves is very common in uterine affections of an inflammatory nature. It is often so severe and aggravated by exertion as to incapacitate the patient for walking. Particular motions cause pain according to the nerve affected. When the sciatic is the S'^at of pain, sitting down, especially on a hard chair, increases it, so that the patient resorts to cushions for defence against pressure. Pain in the course of one or more of these nerves is often the most distressing circumstance con- nected with the case, and it is often treated as neuralgia seated in the nerves, while the cause is not even suspected. The pain may occupy the whole length of the nerve, or it may be confined to its upper or lower parts, or to an intermediate portion of variable length. The part of the limb traversed by the nerve may be tender or not ; most frequently there is no tenderness. The pain may be fixed, or darting and transitory. It may be constant or paroxysmal ; the patient may enjoy immunity for hours and days, or even weeks, or she may be a constant sufferer from them. They are apt, as other pains are, to be greater during menstrual congestion than at any other time. The pains emanating from the pelvis are not sympathetic, nor are they probably reflex ; but they are caused very likely by pressure of the uterus, or they may be produced by an extension of the inflamma- tion to the nerve-sheaths. Muscular Weakness. Extreme muscular weakness — I do not mean that which results from general debility, but of some particular set of muscles — is often present as an accompaniment of uterine disease. This is most frequent in the back and lower extremities, not often in the upper extremities. It is probably imperfect innervation of the part, or it may be some CIRCULATORY SYSTEM. 363 affection of the muscles themselves. I have been inclined to look upon it as partial paralysis, resulting from reflex irritation. More or less numbness of the parts exists in connection with the weakness of the muscles. Circulatory System. The circulation and its organs are very often deranged to a distress- ing degree. Palpitation of the heart is often troublesome, and patients are apt to think themselves the subjects of disease of the heart. We are often consulted solely with reference to this symptom, it having absorbed the attention and awakened the apprehension of the sufferer to such a degree that her other inconveniences were forgotten or over- looked. These palpitations are sometimes attended with pain in the region of the heart, which occasionally shoots up to the left shoulder and down the left arm to a greater or less distance, the distress being so great as to amount almost to angina. The palpitation is worse during nervous excitement. It occurs generally in paroxysms. We meet with instances in which it oftener occurs after lying down at night than at any other time. Sometimes it seems to be increased during digestion. The sensation of palpitation does not seem to be at all commensurate with the increased excitement of that organ, and vice versa. I have observed instances in which the patient complained of violent jDalpitation, while the pulse and heart, as far as I could judge, were not at all disturbed. In such cases we might say that the sensitiveness of the heart was increased until its ordinary motions were perceived by the patient. Indeed, the pains and increased irri- tability of the organs supplied with the great sympathetic nerve seem to result from increased susceptibility or sensitiveness instead of organic changes. There is also sometimes a sensation of throbbing, as though the blood was passing through the arteries in increased quantities, and with increased force in some j^arts of the system ; this occurs mostly about the head, sometimes in the hands and feet, and occasionally inside the head, apparently in the brain ; also about the genital organs. Great irregularity of distribution of the blood is often observable, the hands and feet being uncomfortably cold, and continu- ing in that state for twenty-four hours at a time. In connection with cold extremities, the head is apt to be hot, or warmer than natural; this heat of the head may also be present when the feet and hands are of the common temperature. The heat about the head and face is sometimes almost constantly present in certain patients, and is the source of great annoyance to them. It is apt to be caused by anything that excites the person. The heat is greatest and frequently exclusively located on the top of the head. I do not think that this sensation of heat arises from any other cause as frequently as from uterine disease, and I am sui'e it is one of the most common symptoms in such dis- 364 SYMPATHETIC OR EEFLEX SYMPTOMS OF UTERINE DISEASE. ease. There is great heat complained of in the back of the head also, in many instances, and sometimes it extends along the spine, atfecting the whole or only sections of it. Burning in the sacrum and loins is very common. Flashes of heat and flushes of color in the face and head, and even in other parts of the body, are very common and annoying occurrences. The power of nervous energy of the heart may be impaired to such an extent as to render the patient liable to faint- ness from very slight causes — anger, fear, surprise, or even the more tender emotions, overcoming the patient very readily. Re^iration. The respiratory apparatus is not so frequently or so severely affected as some of the rest of the organization, and yet we often meet with some very curious and considerable deviations from the natural con- dition of its functions. The constriction about the throat, or the feeling as if a ball rose to the throat and obstructed respiration, and the feeling as if smoke or dust were in the air which the patients breathe, are complaints we hear almost every day. All the sensa- tions, or any one of them, may be aggravated to an agonizing degree, inducing the fear that the paroxysm may be fatal, and causing the patient to suffer for some moments, and sometimes for hours, the horrible sensations of impending suffocation. The breathing may be spasmodic from painful and unnatural contractions of the respiratory muscles. There may also be pleurodynic pains during each ordinary effort of respiration. Imperfect respiration, or partial inflation of one lung, or of parts of the lungs, occasionallj^ occurs. The modifi- cation of the respiratory murmur arising from this imperfect inflation of one of the lungs I have observed on several occasions, and not without serious apprehension of the result; but in all cases where this was the only modification of physical sounds, the patients have done well, and the inflation improved as the returning nervous energy of the rest of the system was established. The respiration is not often hurried as a constant circumstance, but occurs temporarily as the effect of excitement from mental or moral emotions. In some cases, amid the tumult of nervous excitement during a paroxysm, I have seen the respiratory efforts increased to sixty in a minute ; and, occa- sionally, these nervous patients constantly have increased frequency of respiration. There are cases in which cough is a very constant symptom ; it is a peculiar, nervous cough, as a general thing, and is excited or made worse by anything that renders the patient more nervous. Sometimes it is difficult to distinguish it from the coughs which arise from insidious affections of the lungs. It is possible that the cough arising from slight lung difficulties may be aggravated by the nervousness consequent upon uterine disease. I once saw a SYMPATHY OF THE EXCRETOEY ORGANS. 365 patient affected with a peculiar nervous cough, as the effect of uterine disease, which sounded like the barking of a small dog, and the sound was made at every expiration during the waking condition of the patient, except when the mind was intensely occupied. She was an intelligent young married woman, about twenty years of age. While her whole attention was absorbed, she forgot to cough, but as soon as her attention was relaxed, she habitually produced the same sound. This had lasted when I saw her six months or more. When she was embarrassed by a conversation which related to her case, the sounds became much louder and persistent, appearing in perfect synchronism with every respiratory effort. I must further add that I did not have an opportunity to treat this patient, nor have I heard from her, so that I cannot give her subsequent history ; but the rest of the symp- toms plainly indicated uterine suffering, and an examination estab- lished the fact that she had ulceration and inflammation of the neck of the uterus. She had never borne children or miscarried. Sympathy of the Excretory Organs. The excretory organs also sympathize with the uterus, particularly the kidneys. It has been for a long time observed that female pa- tients, in a state of nervous excitement, secrete a large quantity of urine, which is usually limpid, almost odorless and insipid. These qualities are most likely dependent upon the amount of water being so much greater proportionately than the salts ; these last scarcely seem to be present at all. It is extremely dilute urine. Uterine patients are very prone to large discharge of limpid urine. This kind of alteration in the functions of the kidneys is, doubtless, indirect, and does not occur except in connection with a greatly excited condi- tion of the nervous system as the medium between the kidneys and the uterus. More considerable deviations, however, are apt to take place; the salts are likely to be increased in quantity compared to the amount of water ; or one sort of the salts may be greatly over or under the proper proportions in relation to the others. The urine may be decidedly morbid in its composition. It is probable, too, that the deviation is secondary to derangements of the stomach and liver, but, nevertheless, it is often present. The urine may be highly alkaline, or highly acid in reaction, showing the production to an unusual degree, of salts having such chemical qualities. The presence of the salts in excess, whether of the one kind or the other, is pretty sure to produce painful micturition and other disagreeable sensations, as burning and smarting in the urethra and bladder. There is no doubt, however, that the painful and disagreeable symptoms may arise as the more direct effect of inflammation of the uterus when the urine is correct in composition ; hence the examination of the urine will be 366 SYMPATHETIC OR REFLEX SYMPTOMS OP UTERINE DISEASE. necessary to determine the cause of the symptoms. But the urine is often secreted in very diminished quantities in cases of uterine disease, and that, too, without apparent general febrile excitement. Patients frequently complain of this symptom. Whether there is an increase in the excretory functions of the skin at such time I am unable to say. The skin is probably not very much affected in its excretory capacity as a general thing, but some very curious devia- tions have been observed. Mammary Bodies. More direct are the effects upon the mammary bodies. They are often highly excited by uterine disease ; this is no more than would have been expected from the close sympathetic relations between these organs. Congestion is the most common sympathetic condition. The mammge increase in size, become hot and painful as a general thing, but sometimes there is no change in their sensible or sensitive con- ditions. The appearances are natural, but the patient complains of a peculiar and painful condition, not unlike the sensations perceived during the suppurative stage of inflammation: but there is neither tenderness, nor swelling,- nor heat, nor other deviation than the un- natural sensation. Sometimes the breasts are really inflamed. The lymphatic glands in the axilla, and from the axilla to the border of the mammse, in some cases, become affected at the same time; in other instances, however, they do not partake in the sympathies of the mammse. They also become tender in some cases when the mammse do not seem to be excited. I have dwelt so long on these general symptoms, and have made so much of uterine sympathies, that I am forced to recall an expres- sion made use of in a notice of Professor Hodge's work on Diseases of Women, that " if all this is true, it is almost a pity that a woman has a womb ;" but I have fallen very far short of mentioning all the sym- pathetic evils resulting from chronic diseases of the uterus, and I only design this as an outline view of a subject that will fill itself up in painfully warm colors in the observation of those who devote them- selves to a close study of the diseases of women. While this is my conviction, I do not wish to be understood as saying that nearly all of the above symptoms will show themselves even in a majority of cases ; some of them will be prominent in some cases, others in other cases ; and in rare instances we meet with nearly all of them in some sufferer, and in nearly all chronic cases we shall find enough to move us to commiseration for the ruined health of women thus affected. I know there are thousands of my peers in the profession who do not see in the foregoing array of symptoms any indication of disease of the uterus, and when uterine diseases are obviously coexistent, they are not arranged in the order of sequency. This does not shake my MAMMARY BODIES. 367 faith in the facts I have observed for myself, nor disturb my judg- ment, formed from an observation of a very large number of cases carefully watched through all stages of progress to their termination. That all the above symptoms may occasionally be present in cases in which the uterus is healthy, I have often observed ; but that they are also j)resent as the proximate and remote effects of uterine disease, I am well satisfied. Another well-established fact, according to my judgment, is, that the direct symptoms referable to the uterus may be feebly pronounced, while some, or even a large number, of the sym- pathetic disturbances are very prominent ; and, judging by the free- dom from pain and other inconveniences in the uterine region, there are even cases in which the uterus does not seem to suffer at all. These cases are well calculated to mislead us, and to induce the opinion that the womb difficulty is of minor importance, and need not be the object of solicitude until we get rid of the more troublesome and prominent symptoms. We cannot be too careful in our consid- eration and management of this class of cases, and while we adopt judicious remedial means for the removal of the more afflictino- symptoms, we must address ourselves to the disease of the uterus however slight it may appear to be. I have seen too much good result from the observance of this direction not to dwell with emphasis upon its importance. The cure of the uterine disease will be a valu- able diagnostic measure in such cases. Not only may there be a , great difference, or want of correspondence, in the severity of the local and general symptoms, but in many cases m which the general symptoms have almost made a wreck of the health and happiness of the patient, the local inflammation and ulceration will be found upon examination to be trifling in amount and degree. The inflammation may be very slight and the patient suffer very greatly from it, either generally, or locally, or both ; or the ulceration may be extensive and the inflammation very considerable, and yet the patient hardly be sensible of any inconvenience whatever from its presence. This state- ment will be confirmed by careful observers in this field of research. This, however, will prove a stumbling-block to those who entertain the opinion that uterine disease is of small importance in the consid- eration of woman's ailments. They seem to think that there is of necessity an exact and invariable seeming correspondence between the magnitude of cause and effect, and they point to these cases and say, the symptoms were present, but a very trifling, if any, uterine disease showed itself upon examination ; or, they will say, there was great ulceration, but the patient did not suffer from its presence, at least not in proportion to the amount of local disease. I need not particu- larize instances in which other diseases are comparatively latent, or cases in which the symptoms are unduly severe compared to the 368 SYilPATHETIC OE REFLEX SYMPTOilS OF UTEEINE DISEASE. amount of actual disease, as they will suggest themselves to every intelligent practitioner. But, recurring to the sympathies of the uterus, we find that while some patients are not affected at all by pregnancy, and others favorably affected, their health being better then than at any other time, that some absolutely perish on account of the functional derangements inaugurated by pregnancy ; and, as is shown on a former page, organic diseases are not unfrequently lighted up. We shall probably always be at a loss to understand precisely this difference ; but there can be no doubt that it is more on account of constitutional differences than local ones. The concatenation of sympathetic influences may be caused by the greater susceptibility of the organs secondarily affected. In fact, the only mode of accounting for it is by supposing this in- creased susceptibility. I am convinced that this great but inexplicable diversity of sympathetic effects is as likely to result from uterine disease as from pregnancy. We must, therefore, expect a very great range of difference in the extent of sympathetic derangement from uterine disease. It is interesting to observe the rise and development of the sequences to diseases of the uterus. How far can the uterus produce a direct effect in creating this large amount of sympatlietic disorder? Are most of the symptoms produced by the direct sympa- thetic relation of the uterus to other organs, or does the diseased uterus first affect some other more influential organ detrimentally, and then this last the organism generally ? I am inclined to think, from a large observation, that the uterus has close sympathy with only a few organs, and no one probably is so powerfully affected by it as the stomach. It is the first organ affected in jDregnancy, being brought into a morbid condition in a very few weeks. The well-known, power- ful, and almost universal sympathetic influence exerted by the stomach upon other viscera is sufiicient, when it is diseased, to account for the great variety of subsequent symptoms. The stomach is the great centre from which radiate abdominal, thoracic, cerebral, and spinal disturbances almost ad infinitum; and there can be no reasonable doubt that it is an active agent in. originating the disturbances of the great vital organs. The subject of the sympathetic influence of the uterus then becomes the more interesting and important, from the fact that a very slight deviation from its ordinary condition arouses the most influential of all the organs to a state of disease, which de- presses the functional energies and increases the susceptibilities of almost all the rest of the organism. In addition to the chain of sym- pathetic susceptibilities produced by this state of the stomach, fre- quently the digestive powers of that organ are impaired or perverted, so as to supply the chyme in deficient quantities or in deteriorated quality, and in this way injuriously affect the composition of the blood, inducing anaemia or oligsemia. Imperfect nutrition will follow, as a PAIN IN THE SACRAL OR LUMBAR REGION. 369 matter of course, in the one case, and perverted nutrition in the other, so that emaciation or obesity will be ordinarily present. Another organ, probably, in direct sympathy with the uterus is the cerebellum, as it seems to me to be as frequently affected as the stomach. The mammse are, of course, in direct sympathetic relation with the uterus, and yet they are not uniformly affected in all cases when the uterus is very seriously diseased. I do not believe that we are able to say at present whether there are other organs that come directly under uterine influence. A proof of the powerful and very ready effect upon other organs, of irritation of the uterus, may be found in the fact, that very often when the patient is in a condition of comfort, so far as her general suffering is concerned, an application of nitrate of silver to a morbid os uteri will give her excruciating pain in the head, render her exceedingly despondent and irritable, and very much aggravate the symptoms with which she is affected. This I have so often observed to be the case that I cannot but regard it as one of our diagnostic means. After. such an application, the patient will generally com- plain of an aggravation of the general symptoms, whatever they may have been, and say that all the pains are made worse by the applica- tion of the caustic. When an organ has been the subject of irritation or functional derangement for a long time, in consequence of sympathy with the uterus, it may become the subject of organic disease, which may continue as an independent affection of, perhaps, a dangerous ,character ; or, if organic has not succeeded to functional disease, the power of habit, which is so frequently thus engendered, will perpetuate morbid action for an indefinite period after the cause of it has been removed. LOCAL SYMPTOMS. Pain in the Sacral or Lumbar Region. Pain in the sacrum is one of the most constant, and when persist- ent indicates, with a good deal of certainty, disease of some kind in the pelvis. The pain in this region, caused by the diseases of the uterus, is ordinarily central, being in the middle of the sacrum at its lower extremity. It is sometimes at its upper extremity, or it extends the whole length of the bone. Not unfrequently a painful spot may be found on one side, over the sacro-iliac junction. Some patients de- scribe the pain as if a bundle of nerves were pulled upon from the inside of the sacrum, and others describe it as an aching or burning pain. Accompanying the pain in the sacrum is often a sense of sore- ness upon pressure, an inability to sit with comfort, on account of the tenderness of the lower part of the sacrum. 24 370 LOCAL SYMPTOaMS. Pain in the Loins. Pain in the loins is probably not so common as that in the sacrum, but is quite as various in its nature. Very frequently there is great weakness in the loins, so great in degree sometimes as to prevent the continuance of the erect posture for any length of time. I have had a number of patients who were unable to stand long enough to dress their hair on account of a weak back. It is remarkable that patients often feel this weak back more when standing than when walking ; and they are sometimes able to walk a distance without any great inconvenience, but as soon as they stop, the weakness is apparent to a distressing degree. Inability to Walk. Ordinarily the weakness disables the patient for walking. The pain in the back is almost always increased by walking or standing, and on this account the patients avoid being on their feet, although the back is strong enough. But there are many patients who have severe disease of the uterus, who do not experience any of the inconveniences in the sacrum and loins already described ; but some of them are very generally present. Great pain in the back, closely resembling that arising fi'om a dis- eased uterus, is also caused by hemorrhoids, prolapse, or inflamma- tion of the rectum. The pain caused by diseases of the rectum, I think, is much more frequent on the left side of the sacrum and in the left nates or hip than in a central position ; in fact, I have come to regard pain, confined to the left nates and hip, as indicating, with considerable probability, rectal disease, and I always inquire into the functions of that organ when such pain is present. It differs in po- sition from the pain in the iliac region, so common as the result of uterine disease. It is situated near the sacrum, and more in the side of the pelvis than the latter. Pain in the Iliac Region. Pain in the iliac region is very common. In frequency it is next to pain in the back. The pain is commonly situated a little anterior to the sujDerior spinous process of the ilium, and below the level of it. It is not referred to the iliac bone, or fossa, but to a place a little above the groin. We often meet with it on both sides, but much more frequently on one only ■; on the left side much oftener than on the right. Dr. Dewees considered pain in the left groin, or a little above it, as almost diagnostic of prolapse of the uterus. It is certainly very fre- quently indicative of inflammation of the uterine cervix. LEUCOEEHCEA. 371 Soreness in the Iliac Region. This pain is generally accompanied with soreness upon pressure, and sometimes there is soreness upon pressure when there is no con- stant pain. Walking, standing, or riding generally increases it. A severe shock or strain from lifting will sometimes cause pain suddenly to appear in this region when it had not before been observed. Pain in the Side, above the Ilium. Instead of the pain situated as here described, there is often pain higher up in the side, or in the iliac fossa, or along the crest of the ilium, and even midway between the crest and ribs of the side. These pains are not in the ovaria, although they seem to point to the ovaria more directly than to the uterus ; and are by some regarded as a symp- tom arising from ovarian inflammation. Dr. Bennett admits that it may be a sympathetic painful condition of the ovary. It is not ma- terial whether this is true or not; it is certain that it is very frequently present in uterine disease, and is almost invariably cured by remedies addressed to the uterus instead of to the ovaria. Weight, or Bearing-down Pain, or Uterine Tenesmus. Another indication of uterine disease, of less frequent occurrence, is a sense of weight in the loins or pelvis. This sense of weight is experienced in the loins and iliac regions more frequently than else- where ; but it is often felt at the pelvis, and oftener in the perineal and anal regions. Patients express themselves as feeling a heavy weight dragging upon the back and hips, and others feel as though the insides were dropping through the vagina. Occasionally we meet with such urgent uterine tenesmus that the patient is obliged to keep the recumbent posture in order to enjoy any comfort. In such cases the patient in the erect position cannot resist a constant desire to " bear down," resembling the tenesmus of dysentery. This sensation is sometimes more distressing than any other symptom, and obliges the patient to desist from walking. Leucorrhosa. Leucorrhoea is one of the symptoms usually relied upon as an evi- dence of disease of the uterus. In the healthy condition of the uterus and vagina there ought to be no discharge ; the vaginal canal is merely moist, and no mucus should make its appearance externally. When the mucous membrane is temporarily excited, there is more than ordinary secretion ; but it ceases as soon as the cause of excite- ment passes. We should a priori expect increased vaginal discharge to be ac- 372 LOCAL SYMPTOMS. companied Trith some form of disease, especially when it continaes for more than a few days. Our knowledge of the discharge from mucous membranes lining the cavities elsewhere will afford us enough data to confirm these views. We do not expect to see a constant flow, however moderate it may be, from the male urethra when it is per- fectly healthy ; and we take gleet as an evidence of chronic urethritis, and it is generally the sequence of an acute attack of that disease. A constant discharge from the nose is an evidence also of more or less disease. It is just so with the vagina. The indications from leucor- rhoea are derived from the color or consistence of the discharge, or both. The discharge from the vagina, resulting from mere excite- ment of the vaginal crypts, is thin, glairy, and not very tenacious. It is ordinarily acid in reaction. There is no color, and but little consistence to it. When a moderate excitement of the internal mu- cous membrane of the neck of the uterus produces a discharge of mucus, sufficient to apj^ear at the orifice of the vagina, the discharge is white, not unlike milk, and when examined closely, will be found to consist of minute coagula swimming in a little clear fluid. "When the mucus flows from the mouth of the uterus it is thick, and resem- bles very closely the albumen of an egg, and is alkaline in reaction. When it passes into the vaginal canal, it meets with the acidity of the vagina and is coagulated, and the whole changed from a colorless translucency to an opaque white. The reason that the coagula are small and so numerous may j)robably be found in the fact that the mucus arrives in the vagina in such small quantities ; each coagulum represents a minute drop of mucus, changed in quality. As, how- ever, the mucous membrane of the vagina furnishes only a small quantity of acidity, when this alkaline discharge from the cervix is copious it soon neutralizes the vaginal acid, and passing through this canity unchanged, appears at the external parts possessing its charac- teristic qualities. We then hear the patient complain of a tenacious albuminous leucorrhoea; she will nearly always compare it to the white of an egg, but state that it is more tenacious. Unless the quantity is considerable, the mucus from the internal cervical mem- brane does not appear at the external orifice unchanged, but passes into this curdled condition. There is often a considerable quantity of this creamlike leucorrhoea in the whole length of the vagina, and hence it has been supposed by many that this is the vaginal mucus in its natural condition, and they have called it vaginal leucorrhoea. Amount of Leucorrhoea not always Proportioned to Extent of Disease. The abundance of this discharge is no criterion by which to judge of the amount of disease or its intensity, but it will scarcely remain colorless after the integrity of the membrane is invaded. When the BEARING DOWN NOT ALWAYS CAUSED BY DISPLACEMENTS. 373 albuminous fluid appears at the orifice of the vagina, there is per- sistent cervical disease almost of a certainty. Yellow Lencorrhcea, when there is Abrasion or Ulceration. The thick, white, or egg-like albumen will be mixed, when there is ulceration in the cervix, to a greater or less extent, with pus, so that it will be stained yellow; if the quantity of ulceration is consid- erable and its surface is producing pus, the yellow will preponderate in the color, and sometimes the whole of the production becomes yel- low. The yellow color may be in streaks through it, or intimately mixed with it, so as to stain it uniformly , or the pus may be mixed with the white, creamy secretion found in the vagina. Pus may be mixed with any of the varieties of leucorrhcea, and impart to it its tint more or less completely. Hoio is the Pain Produced f How are the local, painful symptoms produced? Is the pain in the groin or ilium caused by prolapsus, and traction on the broad or round ligaments? I think not. Pain and sensitiveness in the ilium are so frequently present — when I cannot detect any kind of displace- ment, and so generally disappear when the inflammation or conges- tion is cured— that I am convinced displacement is not necessary for their production. They are of that character of pains which range themselves in the category of the vague, yet indispensable term, sym- pathetic, or, of the not less fashionable, yet equally indefinite term, reflex; and are perhaps in the ovary. Bearing Down not always Caused by Displacements. The sense of weight or bearing down in the pelvis is one about which there would, from its nature, seem to be no doubt as to its origin being in displacement. It gives the j^atient the idea that the womb is bearing with unusual weight on unusual places, viz., the perineum, the rectum, or the bladder; and yet, in a great many in- stances, we shall fail to detect any deviation from the natural position of that organ ; and, as soon as the inflammation is cured, the symp- tom vanishes without any treatment with reference to displacement. How can we account for this symptom? I think its explanation may be found in the fact that the pelvic organs, on account of the general pelvic, vascular turgescence, are unusually sensitive and re- ceive painful impressions from contact, which in the absence of these conditions, would have no efi'ect in causing inconvenience of any kind. Moderate prolapse, retroversion, or other displacement, when unat- tended by congestion or inflammation, may exist for a long time with- out giving rise to any disagreeable sensation whatever. When the 374 LOCAL SYMPTOMS. uterus is slightly displaced, with considerable pain and sense of weight accompanying this condition, the displacement is commonly considered to be the cause of the distress. When, however, the uterus occupies a normal position, and a sense of weight and pain still exists, it is regarded by most practitioners as the result of an "irritable uterus." That the uterus is sensitive, "irritable," if the term suits better, there is no doubt; but that it is ever so without congestion or inflammation I do not believe. Severity of Suffering not Commensurate with Amount of Disease. The great error in the estimate of the importance of uterine inflam- mation is in endeavoring to measure the amount of inflammation by the severity of suffering, in assuming that because the woman suffers a great deal there must necessarily be extensive inflammation or ulceration.. I believe I have seen more nervous prostration, more keen suffering, and have heard louder complaints from a small amount of endocervicitis than from extensive and obvious external ulceration. Pelvic congestion and increased sensitiveness of the viscera contained in the pelvic cavity, caused by a small amount of persistent inflam- mation in the neck of the uterus, calls into action, in an exaggerated and intensified form, all the sympathies which are excited by the uterus in its physiologically congested condition, and its persistence wears the more upon the general organism on account of the increased sensitiveness produced from day to day by virtue of its chronicity alone. It is anticipating what I shall say in the chapter on Prognosis, to state that endocervicitis is not only more difficult to cure, but more destructive to the health and happiness of the patient than inflamma- tion and ulceration external to the os. Indeed, we often find cases of extensive ulceration very apparent through the speculum, and conse- quently entirely unmistakable to the most careless observer, which produces less inconvenience than an amount of endocervicitis so small as to escape the attention of any but an experienced gynecologist. This fact is perplexing, but the knowledge of it will cause a proper appreciation of what is apparently a trifling matter. Effects on the Functions of the Uterus. Having given the foregoing sketch of the general and local symp- toms of congestion and inflammation of the uterus, I purpose to glance at the effects produced on the functional action of that organ. The first function assumed by the uterus and the last it continues is menstruation. It becomes a matter of interest to the physician to ascertain the cause of deviations in a function so persistent, so general, and so important to the health of woman. As hyperemia is the cause of injurious and even destructive tissual changes and of func- EFFECTS OF PARTIAL CLOSUEE OF OS UTERI ON MENSTRUATION. 375 tional aberrations in the vital organs much more frequently than any other pathological condition, so I think that the functional aberra- tions of the uterus particularly depend much more frequently upon it than upon any other cause. Pain during Menstruation. Pain during menstruation is not necessarily attended by deviation from the normal monthly flow. That there are varieties of dysmen- orrhoea or painful menstruation, with unusual quantities and extra- ordinary kinds of discharge, is true ; but, in many instances, the discharge, though accompanied with pain, is right as to its character and quantity. Kind of Pain attendant upon Uterine Inflammation. The kind of pain attendant Upon uterine inflammation is, for the most part, the same in quality, but varying in intensity. It is a con- tinuous sore pain, with heat in the parts, sometimes so slight as to give the patient very little inconvenience, and it varies from this to pain of great severity. The pain is at times sufficient to cause the patient to keep her bed for several clays, and sometimes for the whole period of the menstrual flow; occasionally it amounts to agony, pros- trating her by a paroxysm which may last for hours, or even several days. Cramping Pain. Instead of this continuous sort of pain, of varying intensity and duration, there are less frequently painful throes " coming and going," like labor-pains or after-pains. This kind of pain is often mistaken for colic. They are often very severe, and may last a few hours or several claj^s. They may depend on some substance contained in the uterus, as shreds or membranes of fibrous exudation, and cease at their expulsion. But oftener no such cause can be discovered in the evacuations ; nothing can be found but fluid blood, or coagula evi- dently formed in the vagina. In other cases the os uteri internum is small, and does not readily admit the passage of the uterine sound. Effects of Partial Closure of the Os Uteri on Menstruation. Many practitioners believe that this condition of the os internum, by preventing the ready flow of the blood, causes it to accumulate until the quantity is sufficient to arouse expulsive efforts for its ex- trusion. In a large majority of cases I have had the opportunity of observing, there was no coarctation ; and in several of the worst cases I have met with, the os internum allowed the sound to pass with so much freedom that I could not distinguish its locality. It is also true 376 LOCAL, SYMPTOMS. that in many cases in which the os externum was not larger than a small pinhole, the patients menstruated without any pain whatever. By far the most frequent causes of dysmenorrhcea from obstruction I meet with are in connection with flexions of the uterus. I can easily understand that a sharp curvature in the cervix, or at the junction, will prevent the free efflux of the menstrual fluid. In such cases the pains resemble labor-pains, and are, doubtless, of the character of uterine contractions. The pain from inflammation may occur at any time during the menstrual flow, and before and after it. Not unfre- quently a paroxysm of severe pain, lasting several hours or a day, warns the patient of the approach of the discharge, and subsides sud- denly and completely, or gradually and incompletely, as soon as the discharge is fairly established. Frequently the pain continues during the whole time of menstruation, beginning shortly before or synchro- nous with the discharge, and subsiding with it, though in occasional cases it continues after it. We sometimes meet with patients who begin to menstruate without any suffering, but who have pain during the flow, or after its discontinuance. I think that a majority of patients affected with uterine disease have some pain during menstrua- tion ; but there are some who have none whatever, and pass through their period with little or no suffering. Manner of the Flow modified by Inflammation and Congestion. The manner of the flow is often modified. Instead of the continu- ous flow, commencing moderately, gradually increasing, and then as gradually declining, every manner of deviation almost may exist. With some, the discharge begins naturally, increases very rapidly, until at the end of twenty-four or thirty-six hours an average amount is lost, and then the discharge suddenly declines and ceases, or con- tinues in very moderate quantity for a time longer, and gradually or suddenly stops. With others, the flow may begin and proceed natu- rally for a day or two, cease for one or two days, and then reappear and flow freely for a sufficient time. When menstruation proceeds in this way, it is generally attended with pain. These two varieties are more frequent than any other. Duration of the Floiv. The duration of the flow may not be affected by it. The flow may continue three weeks or the whole month. This, however, is not frequent. It does not much affect the jjeriodicity of return, of men- strual congestion and effort ; but it is not unusually the case that we cannot distinguish the discharge which attends ovulation from the hemorrhage which proceeds from an ulcerated surface, as hemor- rhagic congestion is so constantly present. We often meet with MENORRHAGIA AND AMENORRHCEA. 377 patients who are so confused by the frequent irregular returns of uterine hemorrhage that they lose all reckoning as to the time for the menstrual return. Occasionally, continuous hemorrhage is present. The most frequent deviation from regularity in menstruation consists in a slight anticipation of the time of its return. Menorrhagia. Menorrhagia, or hemorrhage at the menstrual period, is not an unusual functional deviation. The hemorrhage is often very consid- erable and continues after the usual period has passed by. The flooding is usually greater while the patient is in an erect posture, and it is greatly moderated by recumbency. Occasionally, however, it is not moderated by this means. It would seem probable, a priori, that menorrhagia would be the rule with patients affected with uter- ine inflammation, but such is not the case. I am not sure that even a majority of patients have it. Menorrhagia frequent in Endo cervicitis. I have observed that menorrhagia occurs much more frequently in patients when the inflammation occupies the cavity of the neck; this also is the case with painful menstruation. All cases in which there has been either great pain or hemorrhage, or both, for they are fre- quently coexistent, have been, in my observation, cases in which endocervicitis is the principal disease. Menorrhagia is not always the result of inflammation of the uterus, though inflammation is its most frequent cause ; and in such cases it cannot be cured without first curing the inflammation. Amenorrhoea sometimes Results. Amenorrhoea is the least frequent of menstrual deviations as the effect of inflammation or congestion of the uterus ; but this inflam- mation is frequently the cause of scanty menstruation. It is curious to note the manner in which this scantiness occurs. It seems to come on after the inflammation has lasted for a considerable time, and is almost always associated with sterility. In cases I have watched for some time, the organ was atroi^hied and rendered less vascular and erectile ; probably on account of a deposition of fibrin throughout the general structures of the uterus. The scantiness is sometimes attended with irregularity, which consists in postponement or length- ened intervals. I treated one patient for endocervical metritis, in whom the uterus did not appear to be, as far as I could measure it per vaginam, more than one inch and a half in length, and corre- spondingly small in the other dimensions. This patient would men- struate sometimes only a day every month, and discharge but half an 378 LOCAL SYMPTOxMS. ounce of blood each time, and occasionally the discharge would not return for five, six, and even nine months. In early life her menses had been regular in quantity^ quality, and times, and unattended with pain. She was barren, having never conceived, as far as she was aware. She dated the beginning of her disease from vaginitis during an attack of fever, which occurred two or three months after marriage. Function of Generation affected by It. ■ The great function for which the uterus was formed, that of gen- eration, seems very frequently to be disturbed by inflammation of the neck of the uterus. Some practitioners think, because a woman bears children with frequency, the uterus cannot be much diseased. This is unquestionably a mistake. I have known many women with extensive ulceration to bear children very frequently, but there is always great liability to embarrassment of the function in such cases. Conception may be entirely prevented by inflammation, or gestation may be arrested by miscarriage, or labor may be rendered difiicult by it ; and there is no doubt that many cases of sterility depend wholly upon inflammator}' action about the neck. Sterility. Sterility is attended by different circumstances. Some women are sterile their whole lifetime ; others, after having borne children to the full period and given birth to them, become sterile for years, or for the whole of their subsequent life ; others again become pregnant soon after marriage, miscarry at an early period, and never again con- ceive. In many cases of sterility which I have had the opportunity of examining, I have found evidence of inflammation in the cervical cavity. Very often the inflammation is confined to this cavity. The history of these cases showed that congestion and inflammation had existed from the time of menstruation; these were cases in which conception had never taken place. In cases of sterility in which the women have become sterile after having once borne children, ulceration is usually situated around the os, extending upward into the cavity of the neck. This is almost certain to be the case if the woman has borne several children. When the patient has miscarried but once, there is not likely to be external inflammation to any great extent ; but if there have been several abortions, the ulceration is apt to creep out and manifest itself upon the labia uteri, and sometimes becomes very extensive. Although the foregoing statements, with reference to the position and extent of ulceration in sterility, will generally be found to correspond with the appearances, yet we must not be surprised to find pretty extensive ulceration external to the os uteri in the originally sterile j)atient ; and in those who have borne CONDITIONS OF THE UTERUS IN ABORTION. 379 children and become sterile afterward, we shall sometimes find no external ulceration. The result of my observation is, that when sterility originates in uterine inflammation, it is in that form of it known as endocervicitis. Sterility often depends on the condition and quality of the leucorrhoea. In many of these cases the secre- tions from the vagina are very abundant and intensely acid, so as to produce irritation of the external organs. Although the semen is diluted and defended from the influence of acid vaginal secretions, by mucus of alkaline reaction, yet when these vaginal secretions are abundant and possess strong chemical qualities, they may destroy the vitalizing influence of the seminal fluid, and thus prevent fructi- fication. Or the very thick, tenacious, albuminous fluid, which some- times plugs up the OS uteri and whole cervical cavity, may prevent the ingress of the spermatozoa, which, by their independent motion, according to present belief, penetrate the uterus, meet the ovum somewhere on its passage to the os uteri, and produce their fructifying influence upon it ; and thus is precluded the possibility of efi'ective insemination. Abortion. But conception may readily occur and pregnancy be complete, and after gestation has continued for a certain time abortion may take place. Abortion is a very frequent effect of inflammation and ulcera- tion of the OS and cervix uteri. The seat of inflammation or ulcera- 'tion which most frequently induces it is inside the cervical cavity. We find some patients who have aborted very frequently and never had a full-term child ; others, who have had one or more children, but who miscarry every pregnancy afterward ; and again, others who miscarry frequently and occasionally go to full term. It is not strange that miscarriages should result from this cause ; a -priori, miscarriage might be regarded as its necessary effect. Nevertheless, many patients bear children at term who labor under severe ulceration, and who are prostrated by the constitutional sympathies accompanying pregnancy. Conditions of the Uterus in Abortion. Two general conditions of the uterus exist as the efi'ect of cervical inflammation, and are probably the proximate causes of abortion, viz., congestion or arterial injection of sufficient strength to cause hemor- rhage ; and, perhaps, by means of insinuation of the clots, separation of the placenta, or irritability of such a nature occurs that contraction and expulsion follow conception ; or, perhaps increased sensitiveness of the mucous membrane may increase its excito-reflex influence so as to arouse uterine contraction, and thus cause the foetus and mem- branes to be expelled. When abortion is caused by congestion, it is apt to be ushered in by hemorrhage. The hemorrhage, after con- 380 LOCAL SYMPTOMS. tinning for a varied length of time, from a few honrs to several clays, is followed by uterine contractions. When abortion is the result of increased irritability, the first symptom is contraction, with the par- oxysmal pains attendant upon it. This continues for a time, when hemorrhage and expulsion succeed. When abortion occurs once, it is very likely to recur in every subsequent pregnancy about the same time, until the disease is cured upon which it depends. While abor- tion is very apt to recur in the congestive or hemorrhagic variety, it is generally not so exact in the time of recurrence. This variety, however, takes place more frequently at the time when the monthly congestion is present, while the other is independent of such influence. The probability is, that in the congestive variety the foetus perishes before expulsive efforts arise ; while in the other the foetus is not affected until the contractions have continued long enough to parti- ally separate the placental attachments. Whatever doubt, however, may exist in all this, there can be no question as to the injurious effect produced upon gestation by ulceration or inflammation of the cervix uteri. Mr. Whitehead, of Manchester, England, has written a book, full of information, almost solely to illustrate this consequence of uterine inflammation. Effect upon Labor. The effect which inflammation of the uterus exerts upon labor is not so apparent as upon the progress of gestation. Although I have watched patients whom I knew to be laboring under inflammation of the neck of the uterus in parturition, I have not been able to per- ceive any increase in suffering or tediousness. Even when induration and hypertrophy were both of several years' standing, no ill effects from them, so far as I could see, attended labor either at full term or prematurely. I have observed cases of abortion occurring in such patients quite as readily, and with as few trouble- some symptoms, as in one whose uterus was healthy. The general tissual changes going on in the uterus would lead us to expect this in advanced j^regnancy, but I confess to some astonishment at having seen kindl}^, rapid, and complete dilatation in abortion at the early periods. It is equally singular to see the return of the induration after the involution of the uterus is fairly completed. One would suppose that the softening accompanying pregnancy would be per- manent, and this is usually the case. I have not observed in such cases that the abortions were attended with more hemorrhage, or were more tedious or painful, than when they occur as the result of some transient cause. Effects upon the Post-partum Condition. Of its effects upon the childbed or post-partum condition, a favor- able opinion cannot be given from my observation. A good getting- EFFECTS UPON THE POST-PAETUM CONDITION. 381 up is not to be expected with much confidence in patients affected with uterine disease. The most common effect in childbed is retard- ation of the processes of involution. The congestion consequent upon labor is protracted, the uterus remains larger and more sensitive than is usual, so that instead of the organ recurring to its primitive dimen- sions and susceptibility in one month, two or more may be required. The lochia, instead of subsiding in fourteen or twenty-one days, con- tinues for weeks, or even months, after it should have subsided, and when it goes off it is apt to merge imperceptibly into leucorrhcea, which becomes persistent. Inability to walk or stand without great distress is the effect of the size and sensitiveness of the organ. • A sense of bearing down, or of weight in the pelvis, pain in the sacrum, down the sciatic nerve or in the hip, harass the patient greatly, and these symptoms pass off so slowly that she is kept in bed an unusual length of time. Acute metritis not unfrequently supervenes, or acute inflammation of the cellular tissue at the side of the uterus. Phlebitis, pyaemia, and phlegmatia dolens are more likely to arise in patients who have chronic inflammation of the cervix. On the other hand, it is a fact that these subsequent acute inflam- mations sometimes operate very favorably upon the chronic affections. Instances are not uncommon of patients being entirely cured by the effects of gestation and labor upon the tissue of the neck and its mucous membrane. We are to hope for this favorable result only ' as a remote probability, because as already stated, the condition of the parts is generally left in statu quo, or, if any difference is percep- tible, it consists in an aggravation of the disease, and the patients get up from childbed rather worse than better. CHAPTER XVIII. PATHOLOGY OF HYSTEEOPATHY. What are the pathological conditions giving rise to such numerous and diverse symptoms ? In answering this question it should be remembered that in con- sequence of the nervous and vascular connections and the one great function to which they all contribute, physiologically and patholog- ically, the pelvic viscera are a unit. From the ovaries to the perineum the genital organs are largely supplied with the same system of vessels and nerves, and are presided over by the same genito-spinal centre, and they all have for their ob- ject the same general purpose, — generation. In ovulation, menstruation, concej)tion, pregnancy, parturition, lactation, and involution they all participate, and are in a continual state of change. The rectum and bladder are continually influenced, physiologically and pathologically, by the same conditions, and in return reflect their own changes back upon the genital organs proper. All the genital organs are thus bound together as one great and complete system set ajjart for one grand purpose, — generation ; sub- ject to derangements that may begin in any one part or organ, and produce disorder in all the rest. Acting as a whole in the function of generation, this extensive and perpetually active system reacts with great energy through its spinal centre upon the whole organism. I have already in one example quoted from Dr. Tyler Smith— and similar cases are continually occurring — shown how vast and potent are the sympathetic effects produced by pregnancy upon the system at large. In a state of disease this great system is as powerful in causing morbid symptoms and changes. This view of the comprehensive nervous and vascular interde- pendence of the pelvic viscera, and their united influence upon the whole body, explains how the disease of any one of them may originate and perpetuate the general and local symptoms enumerated under the terms sympathetic nervous symptoms, hystero-neuroses, genito-uri- nary neurasthenia, etc. And we are obliged to give full scope to this idea in all our estimates of the very complex functional and organic diseases of the female organs of generation, if we would arrive at correct indications for treatment. The essential pathological conditions of the pelvic organs upon which the reflex sufferings of the general system are founded are the PATHOLOGY OF HYSTEROPATHY. 383 hyperaemia and the hypersesthesia of those organs. Without increased sensitiveness or increased vascularity of them there can be no general suffering. This proposition is proven by the testimony of the best authors and teachers everywhere. The more marked form of hypersesthesia is for the most part con- fined to the urethra, vulva, jDerineum, anus, and coccyx : vaginismus, anal fissure, urethral caruncula, coccygodynia. Sometimes there is hyperaesthesia of the vagina and vaginal cervix uteri. These will be described in their proper place. In studying the subject from a clinical point of view the practi- tioner will find disease of the ovaries or uterus the starting-point of all these sympathetic derangements more frequently than all other pelvic affections, and consequently it is very important that we should have a clear view of their pathology. While the ovaries in many respects are paramount in their influ- ence on the pelvic organs, it is to diseases of the uterus we must look for an explanation of the great majority of sympathetic ailments above described. Now what is that essential pathological condition of the uterus which causes these symptoms? One condition seems to be present more frequently than any other, and that is hypersemia. The enlarge- ment of the uterus, as well as the hyperaesthesia of that organ, gen- erally depends upon hypersemia, and the sympathetic influences of the uterus are excited through the system of nerves that accompany and control the vascular system, — the vaso-motor nervous system. Displacements, flexions, and lacerations do not produce any general disturbance except when attended with hypersemia. This statement is made in a direct or indirect manner by almost all of our best gynecologists. Dr. Emmet says :* , " A version, as has been stated, may exist for an indefinite period without causing any disturbance so long as the organ does not prolapse sufficiently to increase the ex- isting obstruction to the circulation." With reference to lacerations he says : "Sometimes the laceration heals while the woman remains in bed after labor, but if the surfaces should not heal before she gets up they will soon become the seat of exten- sive erosions, which bleed readily. As the uterus increases in size a profuse cervical leucorrhcea follows, and the appearance of a frequent show causes the patient to seek relief. She will complain of inability to stand with comfort, of a continual headache, witli pains down her limbs, sometimes irritation of the bladder, and as a rule marked nervous disturbance." * Principles and Practice of Gynecology, pp. 309, 462, 384 PATHOLOGY OF HYSTEROPATHY. And again on page 467 : "The uterus, from increased weight, and while resting on the floor of the pelvis, will, by traction on the cellular or connective tissue, obstruct the circulation sufficiently to produce not only increased congestion of the organ itself, but also of the neighboring tissue." These quotations show that Dr. Emmet believes that the effects of displacements and lacerations are to produce and keep up hypersemia, congestion of the uterus, and through this condition to cause all the local and general symptoms. The object of all his treatment preparator}^ to uniting the surfaces of a laceration of the cervix is to relieve the hyperaemia by giving free- dom to the circulation of the uterus and making local applications to the erosions. When all of this is done the symptoms subside, and the cure of the laceration renders the cure permanent, Hypersemia is not often an independent affection. It is, in fact, gen- erally the result of some antecedent etiological lesion, and may be removed by getting rid of the cause. It does, however, occasionally stand independent of an}?- other lesion, and may be cured by measures having no other object in view than the removal of the hypersemia. Now, what is this hyperemia? There are undoubtedly several forms. 1. Active hypertrophic hypereemia, as in pregnancy, the earlier conditions of subinvolution, the presence of fibrous tumors, or granu- lar degeneration of the mucous membrane. 2. Passive, venous or congestive hypersemia, as where the uterus is displaced or flexed, and the blood confined to the fundus or other portion of the organ by con- striction of the veins, or where effusions around the uterus prevent the free outward flow of the blood. 3. Inflammatory hyperjemia. These are the most common and easily-determined forms, and will serve as examples of hypersemia. All these forms may become chronic, and all of them, when of chronic duration, produce changes in the fibrous structure of the uterus. It is impossible for them to remain simple hypersemia, because the abundant supply of arterial blood in the active forms of congestion produces hj'^pertrophy of some of the tissues that enter into the struct- ure of the walls of the uterus, and in others give rise to neoplasms. In the passive and inflammatory forms of hypersemia there neces- sarily occur fibrino-plastic effusions, which, after coagulating, become organized in a low degree, causing not hypertrophy, but induration and condensation, which finally cuts off the capillary circulation. In these cases the connective tissue formed by this low organization of fibrino-plastic effusion supplants the natural structure of the uterus to a greater or less degree, and is what I understand by hyperplasia. After the uterus is thus changed in structure it is sometimes impos- sible to restore it to its natural condition. These indurated uteri un- PATHOLOGY OF HYSTEEOPATHY. 385 fortunately are not deprived of their sensitiveness ; in most cases, in fact, there is hypersesthesia, and, as a consequence, they are the source of extensive reflex mischief In the inflammatory form of hypersemia there are often circum- scribed points of induration in the cervix, in the anterior or posterior walls of the fundus, owing to the locality in which the vascularity is most protracted or intense. After the effusion and induration is established the active inflam- matory condition may subside, leaving the part in a state of indura- tion and hyperesthesia. Thus we find nodules of hardened tissue, not the seat of inflammation, but the consequence of that process. As a rule, these nodules may be removed when properly treated, especially if they exist in the cervix. The deposits thus occurring frequently distort and deform the cervix, rendering one portion more prominent than others. It should be borne in mind that these conditions do not indicate the presence of inflammation, but its effects. They give rise to the same sympathetic symptoms and suffering that are noticed in other forms of uterine disease. It is too narrow a view of the pathology of uterine disease, there- fore, to apply the term congestion to all these forms of hyperemia. To complete this very cursory statement in reference to the different forms of hyper£emia, it is necessary to trace somewhat further the changes they all may, and generally do, bring about. During the progress of all these hypersemise, the mucous membrane undergoes notable changes. One of these changes is the so-called ulceration. I use this phrase " so-called " in imitation of those who deny the exist- ence of ulceration. Now ulcer means a sore, and is defined by Dunglison to be " a so- lution of continuity in the soft parts, of longer or shorter duration." Is a solution of continuity of the epithelium an ulcer ? Abra&ioni is a term used by some writers to signify the loss of epithelium ;, but, abrasion means a solution of continuity in the ei^ithelium, and is es- sentially the same as ulceration. If it suits the reader better to call this loss of the epithelium abrasion, I have no objection to the term, but I believe it less a reformation in nomenclature than a dispute about non-essentials. I believe further that abrasion or ulceration, instead of being an incident resulting directly from laceration, is an essential effect of the impaired nutrition of the mucous membrane, brought about by the hyperffimic condition of the fibrous structure of the cervix. This is in accordance with the teachings of that eminent patholo- gist, the late Dr. E. R. Peaslee, in the lectures delivered to his classes, and published in the Medical Record for January and February, 1'876,, and most of the recent writers on gynecology. 25 386 PATHOLOGY OF HYSTEROPATHY. That ulcerations occur in the trophic forms of hypersemia, we have the assurance of the late Dr. Cazeaux, who found that a large number of pregnant uteri were ulcerated. He says :* "According to MM. Gosselin, Danyau, and Costilhes, 'these ulcerations are much less frequent than I had supposed, and are met with in hardly more than half the cases, while I have observed them in seven-eighths.' In short, therefore, tlie fungous condition of the neck, and the ulcerations, of greater or less depth, which complicate this state of the parts near the termination of pregnancy, seem to me to be the con- sequence of the active or passive congestion with which the organ is affected." So with all the active and passive congestions the integrity of the mucous surface of the cervix is affected, and it is the seat of ulceration of a greater or less depth. Now then I think we must regard abrasions, " granular and cystic degeneration," or ulcerations of the cervix, as results of some form of uterine hypergemia — trophic, congestive, or inflammatory, instead of standing as an etiological condition. While I believe the hyjoeraemia of the pelvic organs to be the more frequent form of disturbing condition, I am satisfied that there are a great many cases of pure neurosis of the genital organs. In these cases the genetic element is in the nervous system, and the manifesta- tions are morbid exaltations of the sensibility of the parts in which the suffering is the greatest. There is no congestion, no inflammation, no displacement, or other apparent deviation from the natural appear- ances of the pelvic viscera. Yet the patient has pain and sensitive- ness in one or all of them, and is the subject of the most distressing and extensive array of hystero-neuroses. In such cases, too, there may be no deviation from the normal condition except that of pain and increased sensitiveness. They are not always even dysmenor- rhoeal cases. Although not confined to multipara, they are more fre- quently found in young girls and sterile married women. In consid- ering the subject of the essential pathological conditions giving rise to uterine symptoms, we cannot, therefore, ignore the neuropathic forms of ovarian and uterine affections. They are too numerous and too obvious to escape the attention of the observing gynecologist. Mucous Inflammation. As a simple affection, that of inflammation of the mucous tissue is quite frequent. Where it coexists with inflammation of the sub- mucous substance, we have the increase of size, hardness, and irregu- larity of shape combined with the evidence of mucous disease. * Pages 456-459, fifth American from seventh French edition. ENDOCERVICITIS. 387 Seat of Mucous Inflammation. The inflammation of the mucous membrane may extend from the fundus through the cavities of the body and neck to the os, and then cover the whole of the vaginal portion of the uterus. This extent of inflammation is not very frequent, however, and when it occurs it al- most immediately succeeds parturition or abortion, or is produced by gonorrhoeal inflammation. I have seen it under these circumstances oftener than any other. It almost always causes a great deal of distress and suffering. Probably the most common extension of inflammation is to the mu- cous membrane of the cavity of the cervix and body, and a portion or the whole of the membrane covering the intralabial portion of the OS. By far the greater number of instances that have come under my observation in practice were inflammation of the membrane around the OS and inside the cavity of the cervix. I fear that this statement represents a fact that has not been generally apprehended by practi- tioners. I am disposed to believe that too many physicians have failed of success in curing their cases because they have not followed up the inflammation sufficiently in the cervix above the os, being satisfied with curing that which was visible only, and, in consequence, leaving really the most important part of the affection untouched. Cavity of the Body of the Uterus. Inflammation limited to the cavity of the body of the uterus is not common, but I am quite sure that I have met with it in several in- stances. Some of these had been treated for inflammation of the os and cervix, and cured of this, but the inflammation in the cavity of the body was left. Others had not had any treatment for uterine dis- ease, so far as I could learn. They had habitual leucorrhseal discharge of rusty-colored mucus, very much like the brickdust sputa of pneu- monia ; the OS externum was very small, and the os internum large, as was also the cavity of the body. Endocervicitis. Endocervicitis alone, or inflammation limited to the cavity of the cervix, is, on the other hand, an extremely common form of the dis- ease. Not unfrequently this form of inflammation exists without any appearance of it in the os or external to it. When inflammation of the mucous membrane of the cavity of the cervix alone exists, it has certain effects upon the shape and other properties of the neck that are apt to attract our attention. Dr. Bennett describes the os as patent and the cavity of the neck enlarged, so as to admit the finger and per- mit the opening of it by a speculum to some extent, so that we may see the inside. Now, while this is very generally the case, it certainly is not always so. This open condition of the os and cervix is more 388 PATHOLOGY OF HYSTEROPATHY. frequently met with near the menstrual periods than at any other time, and is probably always owing to the congestion of the vascular tissue of the cervix and about the os. Endocervicitis with Diminished Size. I have, undoubtedly, seen many cases of this endocervicitis, in which neither the os nor cervical cavity was in the least enlarged, and others, in which the os uteri was contracted much below its natural size. The secretions of the mucous membrane are always modified ; generally they are very much increased, and often changed in character. They may become purulent or sanguineous, owing to the grade of the inflammation and the degree of congestion. The in- flammation situated external to the os, on the end of the uterus, be- tween the labia or their external surface, is very common, but it is not often limited to this part. It is almost always combined with endo- cervicitis. Special forms of these mucous inflammations are found more fre- quently in certain sorts of patients. Endocervicitis in Virgins. Virgin patients seldom have 'inflammation external to the os uteri; their disease is endocervicitis almost always ; very rarely there is a little rim of inflammation around the os upon the end of the uterus. Endocervicitis in Aged Women. Again, in senile patients, we find the inflammation in the cavity of the- cervix. The os uteri in the aged is normally small, and simply looking at it will seldom convey a correct idea of the state of the cer- vical cavity, but the introduction of the probe in cases of endocervi- citis will give rise to very great pain. The endocervicitis of old women is extremely difficult to manage, and is always protracted. External Inflammation combined with Internal in Childbearing Women. In married, childbearing women we find the external combined with the internal uterine inflammation of the mucous membrane. They are the kind of patients in whom most frequently the enlarge- ments, indurations, axid fibro-cellular inflammations are observed. The form of disease in persons who have been married, but never have been pregnant, partakes to some extent of the character of that of the virgin and the childbearing woman. They often have external combined with internal mucous inflammation, but not often fibro-cel- lular. Now, what I mean by these statements is, that these patients are likely to have the forms of disease which I have ascribed to them, but there certainly are exceptions to all of them. CHAPTER XIX. ETIOLOGY OF UTERINE DISEASE. The genital apparatus of woman is in a constant state of predis-. position to disease. The very turgid condition of these organs for so many days in every month is one that in appearance borders so closely on the pathological thai in other organs it would be taken for one of disease, and the symptoms are equally like those caused by disease. This similarity between menstrual hypersemia and morbid conges- tion is so great that it makes it impossible to distinguish the differ- ence by sight and touch alone. The color of the menstruating uterus is greatly deepened ; the organ is larger, heavier, and less easily moved in the pelvis, and we know that it requires only a prolongation of this condition to constitute a state of disease. Another degree of nervous and vascular excitement would be morbid congestion of the uterus, and all experience shows that cold applied to the person when the organs are in this condition seldom fails to add that degree of excite- ment, or that the same thing may be brought about by standing too much or by other unusual exertion. The position of the genital organs at the lower part of the body, much below the heart, having veins without valves and of weak con- tractile powers, is another cause of exceptional hypersemia. Add to these the frequent erotic excitement to which they are sub- jected in consequence of the peculiar sexual life a woman lives, and we have another predisposing condition of great influence. By the 'peculiar sexual life of woman I mean a comparison of her life with the sexual life of other animals. Female animals do not cohabit night and day the year round, during pregnancy and nursing. The interval between the acts of sexual in- tercourse in animals is long, and comprises all the time during preg- nancy and nursing, while women observe no time of abstinence except the few days occupied by the menstrual flow, labor, and the period of lying-in. Pregnancy and parturition are strongly predisposing conditions. The long-continued and very great hypersemia of pregnancy as else- where shown causes abrasions and ulceration before labor, while the pressure of the uterus upon the bladder, rectum, etc., sometimes gives rise to permanent pelvic difficulties. Parturition is so generally recognized as a predisposing cause of disease that the greatest care is and ought to be taken to conduct pa- 390 ETIOLOGY OF UTERINE DISEASE. tients through it and the post-partum condition in order to avoid subsequent difficulties. Unusual duration of labor is to be avoided because of the damage that may arise from too long pressure by the child's head or pros- tration of the nervous system from violent exertion. But in the normal labor there are many conditions that predispose to disease. The uterus is left large, hypersemic, and in a state of degeneration, with the cervix bruised, lacerated, and denuded of its mucous mem- brane. The vagina and all of its surrounding tissues have been stretched, pressed, and bruised, and the vulva and perineum are torn and bleed- ing. While all these are conditions necessarily attendant upon a natural process, and consequently must be regarded as normal, yet they are certainly upon the verge of disease, and are predisposing conditions prolific of disease. They predispose to acute disease, as metritis, perimetritis, cystitis, vaginitis, etc., but their influence is more frequently observable in the chronic affections resulting from an incomplete recuperation from the normal accidents of labor. But abortion is another strongly predisposing as well as exciting cause to disease of the uterus. In many cases of abortion the organ is repaired of damages as well as after natural labor. This, how- ever, is an exception to the general rule. Abortion is generally fol- lowed by either acute or chronic disease, and sometimes both. The reasons for this are too obvious to require any farther consideration. Other and very grave predisposing causes may be found under the head of puberty and change of life. ■ In a state of predisposition from any of the causes above mentioned, the application of cold is often productive of congestion and chronic inflammation of the uterus and ovaries. This is often proved by the results of a cold during the congestion just preceding menstruation or at the time of the flow, and in child- bed, or for some weeks afterward. There are other causes which act in conjunction with the predis- posing conditions I have mentioned above, but are sometimes inde- pendent in their effects: the abuse of the organs by the practice of vicious habits, masturbation, excessive intercourse, etc., standing too long, working the sewing-machine, and the pursuit of other employ- ments that keep up a stasis of blood in the pelvis. School-teachers, sales-women and sewing-girls come within the influence of these causes. Still other causes are accidents, violence, gonorrhoea, etc. Gonorrhoea is a very fruitful source of chronic endocervicitis and endometritis. Dr. Emil Noeggerath,* of New York city, believes that * First volume Transactions of the American Gynecological Society. ETIOLOGY OF UTEEINE DISEASE. 391 gonorrhoea is a frequent cause of several forms of inflammation in the pelvic organs of women, as of the Fallopian tubes, cellular tissue, ovaries, and peritoneum. He finds evidence that it remains in a latent condition or form in the mucous membrane, and in consequence of the influence of some exciting cause is awakened into an acute form of disease, which probably more frequently attacks the pelvic peritoneum or cellular tissue. He thinks that gonorrhoea often per- sists in this chronic form in the male, and although apparently cured, the husband is capable of infecting his wife for years afterward. I am quite convinced that his views in this respect are not without foundation and deserve the serious consideration of the profession. If Dr. Noeggerath's teaching should be demonstrated by further obser- vation it will place gonorrhoea as a latent source of mischief on the same footing as syphilis. However this may be, I am quite sure that chronic endocervicitis, in which the glands of Naboth are the princi- pal seat, and when the cervical canal is filled with a tenacious mucus of so tough a consistency as to make it difficult to remove, is fre- quently of gonorrhoeal origin. We cannot always trace these chronic cases to an acute attack of gonorrhoea, but when we can get at the facts we will generally find that the husband has been the subject of gonorrhoea, and probably yet has gleet or the chronic form of that disease. Under the head of puberty I have pointed out many deleterious influences under which the girls of this country are placed, and which lead, primarily or secondarily, to the development of sexual disease in consequence of natural and social conditions which cannot be escaped. CHAPTER XX. DIAGNOSIS OF UTERINE DISEASE. Characteristic Signs of Inflarfimation. The signs of inflammation of the submucous tissue or substance of the neck of tiie uterus are, increase of size, tenderness, and generally hardness ; of the mucous membrane, increased color and secretion ; of ulceration, still more intense redness, purulent discharge, tenderness, and not much enlargement. The former conditions may be ascer- tained by the touch, the latter by the sight, and when they are mingled, by both combined. Open external abrasion or ulceration of the uterine cervix, after the parts are well exposed, and cleared of mucus and pus by wiping, cannot be well mistaken or overlooked ; and the practitioner must not be led to believe the case one of no impor- tance because the ulceration is not very .extensive. This raw scarlet surface is always indicative of mischief, and we should expect any amount of suffering from even a small patch of it. Diagnosis of Endocervicitis. There are cases where the appearances are not so obvious, where, in fact, all the parts exposed by the speculum and within reach of our vision have a natural appearance. No redness, rawness, or other discoloration can be detected on the neck, in the mouth of the uterus, nor on the vaginal surfaces ; they are quite healthy in appearance and reality, but there is an obvious and, in many instances, a copious secretion of tenacious mucus flowing from and lying in the os uteri ; wipe this away and all looks right. This is a case of endocervicitis. In some instances this mucus is colored with streaks of yellow by the presence of pus, or it is wholly yellow ; here there is loss of integrity in the epithelium of the cervical cavity. The mucous membrane in the cervical cavity is ulcerated. If we remember that the mucous membrane secretes only enough mucus for lubricating purposes in the natural condition, we can arrive at no other conclusion than that the membrane is in a state of hyperexcitement when its secretion is abundant or altered, or both. When we see mucus in even small, yet perceptible quantities, issuing from the anus, what is the inference ? If this is abundant, persistent, and colored yellow, however healthy the anus might appear externally, we could not believe that the rectum was in a healthy condition. Why not then positively determine that he mucous membrane is inflamed, which floods the os uteri with DIAGNOSIS OF UTEIIINE INFLAMMATION. 393 mucus or pus, or with both? If we introduce the probe into the cavity of the cervix thus abundantly secreting, the patient will nearly always complain that we touch a " sore place, a tender spot," that it hurts her in her back, etc. And very often blood will immediately follow the withdrawal of the instrument. This, however, is not inva- riably the case. Another diagnostic evidence of endocervicitis is the increase of the pain ordinarily experienced by the patient when the probe or application is introduced. The hypersecretion, or perverted secretion of the mucous mem- brane, must then be regarded as an indication of disease of that mem- brane. If we have these facts fixed in our mind, and if we act upon them, we may discover and cure disease that w^ould otherwise escape our attention and thwart our skill. But there is another obvious and common-sense sign of inflammation which has not been applied in our investigations of diseases of the uterus, viz., tenderness. Tender- ness or sensitiveness to the touch anywhere else leads us to suspect inflammation, but in the uterus it is unaccountably set down as indi- cating an irritable uterus and not an inflamed one. Diagnosis of Submucous Inflammation. I think when I touch the uterus with the finger or an instrument, and the patient shrinks from the contact and says " she is sore," or ',' it is sore," that there is inflammation there. Tenderness is not an evidence of mucous inflammation, but of submucous or fibrous in- flammation of the uterus. Complication of Mucous with Submucous Inflammation. The uterus should be examined by the same diagnostic rules that govern our investigations of disease in other organs. Some authors tell us that ulceration results from inflammation of the submucous tissue, and others that the inflammation begins in the mucous mem- brane. However this may be, I am sure that inflammation some- times exists in both these tissues at the same time. In this case we shall have tenderness and hypersecretion. At other times there is submucous without mucous inflammation; then we shall have ten- derness without hypersecretion. Again, we may have mucous with- out submucous inflammation, when hypersecretion without tenderness will indicate it. These remarks will fix the importance of these two symptoms as indicating the seat of the disease. Size of the Uterus ordinarily Increased — Exceptions. The size of the organ is one indication of the presence or absence of inflammation ; but this may vary very much under what would appear to be the same form of disease. In endocervicitis it is usual 394 DIAGNOSIS OF UTERIXE DISEASE. to find the cervical canal increased in calibre ; but this is certainly not always the case, as I have met with unmistakable instances in which this ca^'ity was decreased in size and the os uteri almost closed, it being so small as to admit only a very small probe. Where there is mucous inflammation of the cervix extending toward the cavity of the body, and more particularly where the disease extends into the cavity of the body, the whole organ is likely to be enlarged. So much enlargement sometimes takes place that the fundus may be felt con- siderably above the pubis. Neither is this always the case, however ; often there is no enlargement. The hypertrophy, or general enlarge- ment of the organ, is more frequently indicative of mucous than sub- mucous or fibrous inflammation. Atrophy as the Result of Inflammation. In fact, I think that long-continued inflammation of the substance of the body and cervix often brings about atrophy or shrinking of the uterus. Permanent increase of size or hardness of the cervix must be the result of submucous inflammation, and generally coexists with it. Almost the only disease with which chronic inflammation and ulcer- ation of the cervix uteri are likely to be confounded, is cancer in some of its stages. The many well-marked symptoms and physical condi- tions which accompany this last disease are now, however, so well understood and so thoroughly described, that the novice need not be embarrassed in his diagnosis of it. I find in Becquerel's Traite CUnique des Maladies de Uterus, pp. 320- 323, vol. i., so comj)lete and faithful a diagnostic summary between cancer and the different conditions of chronic inflammation of the cervix, that I have translated and given its substance for the conclud- ing portion of this chapter. It is subjoined : Cancer in the Scirrhous Condition, Inflammation and Ulceration. Cervix hard, unequal, nodulated ; os not Xeck less hard, developed regularly in always open, sometimes wrinkled or one of the lips; os always open, furrowed. Scirrhus of the neck often implicates the The induration of the neck never ex- vagina, tends to the vagina. Mobility of uterus complete. Hereditary influence is often traceable. No hereditary influence. Touch is painless. Touch painful. Discharge sometimes absent ; in certain Discharge constant, and characterized by cases very abundant, and consisting, for the presence of transparent mucus, the most part, of albuminous serum. muco-pus, or purulent mucus. Menstruation increased, being neither Menstruation more painful, often re- more nor less painful, and passing tarded, almost always scanty, often into the state of real hemorrhage. Absence of special anaemia when the Special anemia, as above described, vagina and body of the uterus are in- volved. Cancerous cachexia. ATEOPHY AS THE KESULT OF INFLAMMATION. 395 Cancer in the Scirrhous Condition. Inflammation and Ulceration. Progress continuous and without cessa- Often stationary for a long time. tion. The pain in cancer is very sharp, intense, Pains less severe, more dull, and percep- and lancinating, and not influenced by tibly influenced by walking and other locomotion or movements of any kind. sorts of motion. Ulcerated State. Developed at the critical period of life generally. Preceded and accompanied by hemor- rhages. Severe, sharp, lancinating pain. Development essentially in sharp irregu- larities and nodosities. Adhesions to other organs as soon as ul- ceration is formed ; immobility of the uterus. The surface only slightly soft ; subjacent tissue scirrhous. Ulceration deep, unequal, essentially ir- regular, with thick, elevated, and hard edges. Always granulations. Discharges extremely abundant, consist- ing of purulent and often sanguineous serum ; nauseous and often fetid odor. Great hemorrhage from time to time, not necessarily at menstrual period. Chronic Inflammation and Softening. Occurs earlier in life almost always. Not preceded by hemorrhage. Pain dull and profound. Enlargement regular and rounded, or regularly lobulated. Complete absence of adhesions to other organs. Entire mobility of the neck and body of the uterus. Tissue of the cervix not hard, and easily destroyed. When ulcerations exist, less deep, with tumefied edges. Granulation often accompanies the other lesions. Discharges less abundant, consisting of muco-pus alone, or accompanied with a little blood, without odor. Always hemorrhage, but often a mere pro- longation of the menstrual discharge. Cancerous Ulceration. Developed upon a hypertrophied and scirrhous surface. Ulceration deep, vast, unequal, grayish surface, with thick edges, and easily bleeding. Ulcerated surface hard, presenting numer- ous lobes and tubercles, with nodosities and great hardness. Often great loss of substance. Cervix and corpus uteri immovable, on account of adhesions. Discharges sanious, fetid, sanguinolent, and of an insupportable and character- istic odor. Cancerous cachexia always present. Simple Ulceration. Ulceration often on a healthy tissue, or presenting the soft or hard varieties or inflammatory injection. Ulceration more superficial, the edges less developed, and more regular at the bottom, not always easily made to bleed. Nothing of the sort in chronic inflamma- tion and ulceration. Ulceration is not always accompanied with loss of substance. Neck and body always movable. Discharge of muco-pus, or purulent mucus, always more or less abundant. Special ansemia. 396 DIAGNOSIS OF UTERINE DISEASE. " Professor Otto Spiegelberg, speaking of the difficulty of distingnishing between simple inflammatory induration of the cervix uteri — hyperplasia — and carcinomatous infiltration, gives the following as a certain indication of cancerous infiltration, viz. : 'A 'peculiar induration of the cervix, the disposition of its mucous membrane, and its reaxition to the dilatation of sponge tents.' He expounds each member of this rule. "The hardness of cancerous deposit, in comparison with simple induration, is well known ; but the distinction is frequently impossible to make out, even by the most cultivated touch. The two other symptoms are unequivocal, and are as follows : " ' First, the mucous membrane in cancerous growth is firmly connected with the un- derlying induration, and immovable over it, which is not the cnse in mere hyper- plastic thickening and induration ; and, second, while the latter, under the pressure of compressed sponge, in the cervical canal, becomes regularly even, though at times inconsiderably looser, softer, and thinner, the cancerous infiltration remains unalter- ably hard and rigid, and cannot be stretched.' He goes on to explain the reason for this difference between the products of the two inflammations from the locality where the cancerous inflammation originates, which is the utero-malpighii ; or, in extremely rare cases, from the glands of the cervical canal. The latter form gives rise to the al- veolar or colloid form, of which he has only seen one case. As a rule, the disease is developed from the interpapillary depressions of the epithelium. According as the growth of the epithelium into the tissues below is or is not attended by a simultaneous growth of the papillae, two forms of cancer may be distinguished, — the papillary, villous, or cauliflower excrescence, and the simple infiltrated form." — Cincinnati Clinic {from Archivfiir Gyncekologie). CHAPTER XXL GENERAL TREATMENT OF UTERINE DISEASE. Main Objects of General Treatment The main object to be gained by general treatment is to palliate the general condition of the sj^stem, to aid the local in effecting the cure^ and to remove, when practicable, the effects left after a cure of the local disease. A cure of local chronic disease, by general treatment alone, is hardly to be expected, although, in some instances, it may be indispensable to such a result. When general treatment is used as a palliative or adjunct in local diseases, it is directed to the relief of general symptoms attendant U]3on them. It will be impossible for me to notice the treatment necessary in all the symptoms which attend and add to the distress of our ]3atients in uterine diseases, but there are certain prominent and troublesome ones on which I cannot with propriety omit to dwell. I do so the more readily from the embarrass- ment which I know, from experience, fills the mind of the inexperi- enced as to the proper value to place upon general treatment and the .course to be pursued. Many of the patients laboring under chronic uterine disease come to us broken down, the subject of a multitude of symptoms resulting from inanition and depraved functions. These prostrated patients, it will be found, have passed through the primary sympathetic suffer- ing I have elsewhere described, and are in the midst of that condition we have been in the habit of calling nervous prostration, in which general treatment becomes a very important, if not an essential, means of success. This general treatment consists in the correction of the condition of the organs which were first sympathetically deranged, — the stomach and its associate organs, — introducing into the system nutritive material enough to relieve the ansemic state of the nervous centres, and conducting the patient back to her long-lost habits of activity. I have elsewhere expressed the opinion that the primary morbid condition of these organs is functional derangement, and, perhaps, always deficiency of their secretions. One of the first and most important things to be done is to correct this derangement, and the two medicines that have occurred to me to be the most efficient are mercury and nitro-muriatic acid. Mercury has always, and very deservedly, had the reputation of exciting the glands connected with the alimentary canal, viz., the salivary, gastric, duodenal, — liver and pancreas, — and those of the large intestine. Administered in small 398 GENERAL TREATMENT OF UTERINE DISEASE. doses, this excitement does not transcend the limits compatible with health ; but given in larger doses, it produces inflammatory excite- ment in all of them. We can very properly avail ourselves of this quality of mercury in such a manner as to increase the action of all these glands, and thus promote the appetite, and digestion and assimi- lation. It is, in this way, an efficient tonic, increasing the red blood- corpuscles and establishing a plastic habit so desirable in chronic diseases. To these broken-down joatients I am in the habit of admin- istering it in the form of blue mass or the bichloride ; of the former, one-third of a grain four times a day, or one grain at bedtime. When I give the bichloride, I generally dissolve it in the compound tincture of cinchona, one-sixteenth of a grain of the mercury in a tablespoonful of the tincture three times a day, after meals. These doses are too small for some patients and too large for others. When not large enough, they are not attended with any appreciable results, in which case a slight increase will be necessary. When the dose is too large it generally causes diarrhoea. When it produces this last effect, it should be withdrawn and the acid substituted, which should be given in very small doses. Dr. L. F. Warner, of Boston, wrote an article in advocacy of the use of mercury in the treatment of uterine disease for the obstetrical sec- tion of the American Medical Association. It was published in the Transactions of 1878. Dr. Warner brings forward cases to show the efficacy of this drug, and the article will repay perusal. It should be remembered, however, that medicines are but prompt- ers to nutrition, and that to reinstate the lost vigor the patient must be fed. Her anorexia should be no excuse for starvation ; food should be taken in sufficient quantities to nourish her, with as much persist- ence and regularity as she takes her medicine. If we wait for an appetite, starvation will go on ; and if we wait until digestion is com- fortable, we may often wait until inanition establishes tuberculosis, leucocythsemia or some other equally fatal disease. We ought to prescribe and particularize what, in our judgment, is necessary, and insist upon its being taken. About the only reason for withholding any article of diet indicated is the rejection of it. Diges- tion is likely to be attended with discomfort of some kind, such as fulness, cardialgia, pyrosis, etc. ; but as the blood becomes better, by virtue of its tonic influence upon the organs, the secretions in the stomach will improve, its muscular coats become stronger, bile and pancreatic secretions become normal in quantity and quality, and the digestion will be complete, easy and comfortable, and the patient will regain her strength. The articles of diet which can be tolerated will not always be the same. When I say tolerated I do not mean desired and digested with comfort, but I mean such as will not be rejected from the stomach, for NERVOUS PEOSTEATION. 399 if they are not vomited up, and do not cause diarrhoea, they will be digested, and hence be the source of nutrition. As concentrated food, and generally the most nourishing, are the different kinds of animal food ; beefsteak, roast beef, mutton chops, roast or boiled mutton, milk and eggs, butter, etc., constitute a good assortment from which to choose and prescribe. In prescribing meat in any form we will generally be met with the objection : "I do not eat meat ; I do not care for meat ; I have no appetite for it." I sometimes think, as medical men, we ought to reject the word appetite from our vocabulary. These patients usually have no appetite, and for that very reason are starved. If we do not prescribe the very articles we want them to take, the exact quantity and the time for taking them, they will generally disregard our direc- tions. We may tell them to take two ounces of beefsteak or mutton chop for breakfast, the same quantity for suj^per, four ounces for din- ner, with bread and butter, vegetables, and every such other thing as they wish, but always the meat. Then if we prescribe one pint of milk after each meal, and one at bedtime, the patient will have a good strong diet, and it will soon be apparent in her improved condition. The nurse should be responsible for the taking of this prescription, as she is for the administration of medicines. Some patients cannot chew their meat, but can swallow and digest it if it is minced finely. It will digest in this form usually very per- fectly. General Symptoms requiring Special Attention. The symptoms, the treatment of which I propose to speak of in detail, are : 1st. General nervous prostration ; 2d. Nervous excitability, exaltation of nervous excitement; 3d. Ansemia ; 4th. General plethora ; 5th. Local plethora ; 6th. Constipation ; 7th. Indigestion. These are generally more or less complicated with each other, and sometimes several of them coexist; but, ordinarily, some one assumes the most prominence, and occasions most distress, and consequently requires more of our attention than the others. Nervous Prostration. There is often great nervous prostration, and a sense of weakness, when, so far as we can judge, hsematosis and nutrition are usually well performed. The cause of this depression must be sought out in each case, as there is no uniformity in the functional deviations. Very frequently there is a deficiency of menstrual discharge, the scantiness being very obvious ; at other times it is too copious. We should inquire into the functions of all the important organs, and correct them, when disordered, as nearly as possible, by changing the habits and circumstances of the patient, and afterward, or in connec- 400 GENERAL TREATMENT OF UTERINE DISEASE. tion, address remedies to the organs themselves. The stomach, liver, bowels, skin, kidneys, and uterus should furnish their discharges in the most natural manner, and if they are not doing so, should be corrected by the most gentle means. If several of these organs are in a state of functional deviation from health, we should not expect to correct them all at one time, but alternate our attention between them ; first, with our remedies influencing one, and then another. I insist here, with reference to the plan to be pursued, that we should not address all these organs, or even a large part of them, with me- dicinal agents at one time. There is no question, I think, that com- plicated formulae often nullify themselves by containing ingredients intended for the liver, kidneys, and skin, which ought all to act about the same time. We should act upon each of these alternately, in quick succession, if we think best; but let each organ feel the full impression of its remedy before the blood and nervous energies are directed to another. In addition to this indirect way of increasing the tone of the nervous system, it is natural for us to look about for something that will act more directly. Our patient becomes so de- pressed, and suffers so much from terrible feelings of prostration, that her condition appeals to our sympathies for a more direct and imme- diate relief. If left to themselves, or the advice of injudicious friends, they almost always resort to stimulants, as whiskey, ether, chloro- form, ammonia, etc. In some cases only are these temporary reme- dies advisable, and when used, they nearly always leave the patient in a worse condition than before they were taken. They are allow- able only as necessary evils, and should be avoided when possible. These patients are usually depressed mentally, also, and much good may be done by operating upon their minds. A physician who enters the room with a cheerful countenance, and a pleasant and gentle bearing toward the patient, and who engages her in conversation, first about her case, and afterward about some favorite theme, will do more toward temporarily relieving the great nervous and mental depression than all the ether and ammonia the stomach can be made to bear. Earnest and kind assurances that her symptoms, though causing her a great deal of suffering, are not of a serious nature, and will soon subside, act generally as a good cordial to the spirit and nerves. In paroxysms of excessive nervous prostration, despondency, etc., I have seen the tonic influence of very cold air do a great deal toward relieving them. These paroxysms generally occur in close and overheated rooms, two conditions which should be removed. If it is cold weather, we should cover the patient to protect her, and let the frosty air — the colder the better — into the room, by opening all the windows and doors, and keep the room cleared of visitors. It will astonish anybody who has not observed the effect of a tem- perature near to zero on those swooning hypochondriacs. A change NERVOUS EXCITABILITY. 401 almost immediately occurs for the better. If the air is not cold, it will still do much good to give it perfectly fresh to the patients in abundance. When able, they may be taken outdoors. This treat- ment introduces the natural stimulants, oxygen and cold, into the lungs, and brings them in contact with the nerves, and is more en- livening than medicine. How long the room should be kept open and cold will depend upon the effect, but we should always, if pos- sible, make these patients sleep in open, cold rooms. This is a very important item, which it will often require ingenuity as well as authority to enforce. These patients should live outdoors as nearly as possible, and be as much as they can on their feet. Food, etc. Their food should have reference to the condition of the abdom- inal functions entirely, and be regulated by them. There is gener- ally great intestinal torpor, which should be removed if possible.* Good, cheerful company, travel, — if the patient will not employ her body and mind in domestic pursuits, — temperate and reasonable di- versions, and, above all, time and patience, are requisite remedies. The affection is obstinate and chronic, and with the most judicious management will require time, if it does not vanish as the local treat- ment advances. Nervous Excitability. Connected with it often in some manner is great nervousness, exci- tability, irritability, or exaltation of all the nervous phenomena. This nervous irritability shows itself in great mental excitability, want of sleep, unreasonable agitation, restlessness, dissatisfaction ; in short, in almost every phase of mental, muscular, or nervous excitement. There is also excitability of the different organs, with or without general nervousness, palpitation of the heart, nervous headache, local muscular contraction, etc. Successful management of these nervous and excitable patients requires a careful scrutiny into their general condition ; the ehylopoetic functions should be regulated in the most careful manner, the skin and kidneys should be attended to with great watchfulness. All that I have said as to general management in cases of nervous depression will apply to this kind of cases. As complete a revolution of the circumstances of the patient should be made as is practicable. From a life of ease, luxury, and absence of care, she should be, if possible, placed in circumstances requiring care, with muscular outdoor exercise to the greatest extent she is capable of. If we cannot place our patients in situations which their cases require, we can send them on journeys that will demand exertion, calculation, * See remarks on treatment of Constipation. 26 402 GEXERAL TREATMENT OF UTERINE DISEASE. care, and the deprivation of their usual domestic luxuries. The re- mark is frequently made that we must temper our remedies to the delicacy of the patients ; and I am afraid that this injunction is mis- construed into the necessit}^ of too great tenderness of treatment. The better rule is to make use of such means as will raise the patient from her state of delicacy to robustness. It is the delicacy of her constitu- tion that causes her to suffer so much. This can be strengthened onl}'- by proper physical, moral, and mental training. The moral and mental condition of our patients when so very excitable should be attended to. Improper reading and society should be avoided, and social and literary habits should be reduced to great plainness and simplicity. Above all things, books and society should not interfere with regular rest, exercise, and outdoor exposure. As I have said before, this last should be as great in amount as can be borne, accom- panied with active muscular exercise, as walking, and should be prac- ticed in all weathers, sufficient protection being secured by enough clothing of the right sort. With regard to the use of medicine, is is a fact, that it is an exceedingly difficult thing to find any remedy that does not produce exaggerated and in most cases disagreeable and even injurious effects. So much excitability of the nervous system nearly always modifies the effects of remedies, and we can seldom predict the operation of any of them, nor can we determine the value of any until they have been tried. When tonics can be borne, they often very much relieve and sometimes entirely cure this great nervous ex- citability. Of the mineral tonics, probably bismuth, arsenic, and zinc, agree best. Iron is frequently not tolerated in any shape by these very nervous patients. Quinine, nux vomica, cherry, and chamomile are the best vegetable tonics, but we must not be surprised if none of them are borne. Alcoholic stimulants, in general^ agree with them, and are the best cordials for temporary nervous excitement, but should be conscientiously avoided when possible, as not a few, I am sorry to say, of most estimable and intelligent women have useJ them too much, and engendered an appetite that could not be denied. Opium, and, in fact, the narcotics generally, fail to have any good effect, but on the contrary disagree with the patient. This, however, is not always the case with opium, as it acts like a charm with some. In all it should be studiously avoided as deleterious in the long run, and there is danger of creating an appetite for it. We may the more readily be persuaded to omit the use of all these medicines, as their effects are temporary, while remedies hygienic and regiminal are per- manent in their effects. The management of those cases of localized nervousness or unnatural excitability in particular organs, as palpita- tions of the heart, nervous headache, etc., is about the same as above, except that more attention to the stomach, from which they usually arise, may be necessary. ANEMIA. 403 Some forms of nervous excitement are very much benefited by the bromide of potassium. Severe nervous headache, watchfuhiess and neuralgic pains are often greatly relieved by this remedy. It should be given in full doses. For headache, from thirty to sixty grains every hour until relief is obtained. For wakefulness, the same quan- tity an hour before and at bedtime will sometimes procure a good night's rest. When given in full doses it should be dissolved in a large quantity of water, to prevent it from irritating the mucous membrane of the alimentary canal. I have sometimes succeeded in averting the return of the syncopal convulsions described under the head of general symptoms. One patient now under my care had been the subject of them for twelve months, having them several times a month. They had become so frequent and violent as to induce the fear of epilepsy, and had been treated with many remedies without material benefit. She has been taking the bromide of potas- sium for six months in doses of thirty grains three times a day, and during that time has had no convulsions. She is under treatment for endocervicitis. It remains to be seen, of course, whether this im- provement be permanent, nor can I say how much of the ameliora- tion may depend upon the treatment directed especially to the uterus. It is certain, however, that the " paroxysms," as she calls them, were improved immediately upon the commencement of the bromide treat- ment, and before I could reasonably expect benefit from the rest of the remedies. We undoubtedly have a valuable means of relief from the pains attendant upon the condition of many of these patients in the hy- drate of chloral, while it is often as prompt and positive in the relief it affords in sleeplessness and pain. So far as I am aware, it is not followed by the very disagreeable effects that result from the adminis- tration of opium and its preparations. It, too, should be dissolved in an abundance of water, to prevent it from producing local irrita- tion upon the mucous membrane of the stomach, as it often otherwise causes vomiting or decided nausea. Ansemia. Anaemia, with its disagreeable concomitants, sometimes also calls for separate treatment. It would be an unnecessary waste of time and space to enter minutely into the general treatment necessary, where ansemia is the prominent and troublesome symptom. This condition calls for the same treatment found useful under other circumstances, and, while it may not be entirely amenable to it, it will be very much benefited by the remedies indicated by the state of the blood. Iron, cod-liver oil, quinine, bitter infusions, and nutritious diet, with out- door exercise to the extent the patient can bear, are the efficient remedies. 404 GENERAL TREATMENT OF UTERINE DISEASE. Plethora. But ^ve soinetimes find general plethora instead of anaemia, a state in which there is actually an unusual amount and too rich a com- position of the blood. I need not dwell upon this general state of the system, as the treatment is simple and familiar. The great fear is that, on account of the painfulness about the hips and legs, the patient may be too much inclined to an inactive life. On no account should this class of patients be allowed their ease; they must be urged to use up their surplus blood in active exercise, and the kind of exercise, next to the cares and labor of a household, best adapted to them, is walking. Every muscle in their body must be brought into action ; every secretion must be kept free, and the mind ought to be taxed to continuous effort during the day by some useful occu- pation, while the strictest temperance, with reference to ingesta, should be their rule of living. Obesity, and the troublesome and dangerous effects of plethora, connected or unconnected with general plethora, will be thus avoided. Local Caagestions. We sometimes meet with instances of violent, dangerous, and even fatal determinations of blood to particular organs, as the consequence of the general ill-health which accompanies uterine disease, such as stupor, stertorous breathing, etc., indicating an oppressed condition of the brain, great dyspnoea, and sense of suffocation, showing congestion of the lungs. The treatment of these congestions does not differ from what would be appropriate under other circumstances of their occur- rence, and consists in revellents, alteratives, etc. The most frequent, and perhaps obstinate, of the local congestions are such as occur in the chylopoetic viscera, manifested by excessive secretion and discharges from the stomach and bowels. It is not uncommon for these patients to have suddenly recurring attacks of vomiting, cramps in the stomach and bowels, diarrhoea, and consequent great distress. Aside from the .local treatment, we shall be called upon to exert our skill against the exhausting and depressing influences of these attacks. It will almost always be found that such attacks are preceded by constipation, with scanty secretions, furred tongue, and other e"vddence of unhealthy secretions. By carefully correcting this condition we may avert these painful and exhausting occurrences. The plan recommended and so much prescribed by Abernethy will often palliate very much, \az., six or eight grains of blue mass, at night, worked off by some saline cathartic in the morning of every fourth or fifth day. If there is more permanent diarrhoea, great care should be exercised in the choice of diet; the use of warm baths should be recommended, very warm clothing, and not much medicine, as the cure will depend upon the CONSTIPATION. 405 appropriate treatment of the local disease, instead of the treatment of the general symptoms. All these symj)toms, except the diarrhoea, are apt to be moderate, and can be borne until the diseased uterus is cured ; but there are two symptoms so very annoying, and which require so much patience in the treatment, and exercise so much unfavorable influence upon the uterine disease, that I hope I shall be pardoned by the reader for dwelling upon them more at length. Constipation. I allude to constipation and indigestion, particularly the former. I have already spoken of the deleterious influence of constipation, and I think I am justified in saying that, if disregarded, it retards the cure of chronic diseases of the unimpregnated uterus more than any other sympathetic affection. And I wish to warn the practitioner to be very particular in attending to this symptom. There is proba- bly more tendency to costiveness in females than in males, chiefly owing to difference in habits. Sedentary life, confinement to close, badly ventilated rooms are among the circumstances that bring on this condition. Irregularity of meals, late hours, deficient sleep, con- centrated diet, imperfect mastication of food, all should be corrected, as any one of them alone will do harm, and all or any of these com- bined — and this is frequently the case — are very deleterious to the 'functions of the alimentary canal. But an inexcusable and very com- mon custom of most females is making the act of defecation a disa- greeable and procrastinated necessity, instead of a pleasant and punc- tual duty. The most trivial excuse — the presence of friends ; a little cold, hot, or wet weather; being among strangers; or a slightly in- convenient distance from a j)roper place — will frequently be sufficient to limit defecation to once a week; then the act is performed in a hurried manner. It is amazing to know to what lengths this negli- gence is often carried. I have known two weeks to have transpired, frequently, according to the history of patients, without any attempt to relieve the bowels. Now this should be corrected by persistent method. The habit of eating from hunger at certain hours depends upon hfelong practice, and, when once established, cannot be changed without violence to many functions, causing urgent and repeated de- mands upon the system for a resumption of it. Regular bowels come from an equally long-continued habit of going to the close-stool at particular hours of the day. Years of negligence destroy the habitual regularity with which the bowels move; hence we should not be dis- couraged if the habit be not re-established without long perseverance. A new habit cannot be formed, nor an old one altered, without long and persevering effort in the right direction. We should, therefore, encourage a patient that is in earnest in her search after health, to 406 GENERAL TREATMENT OF UTERINE DISEASE. persevere for months, years, and indeed her whole life if necessary, in going to her water-closet without fail, once every da}^, at a certain hour, as regularly as the clock points to it. This is indispensable to a correction of the bad habit of constipation. A very effective part of this regular endeavor is to cause the mind to dwell upon the neces- sity for an evacuation, and the process itself, for at least half an hour before retiring to the proper place. It is not a difficult matter, with many persons, to create a desire in this way. Let no consideration of convenience enter into this punctual effort at stool. Arrived at the proper place, the position should be an easy one; no inconvenient strain upon any muscle should be allowed, and the patient should be possessed with an entire sense of leisure to perform the act completely. The value of all these considerations, where faithfully followed, is incalculable, and very few cases can long resist them. Without them, medicine will only temporarily relieve, instead of permanently curing obstinate cases. I should caution against severe effort, or straining, as it is called; let time, patience, and gentle effort be the plan. Another matter of great importance, when an effort is made to have an evacuation, is to have the abdomen distended by ingesta. The patient should be instructed to eat plentifully of vegetable diet, such as by its bulk is calculated to produce fulness. If the patient go to the water-closet with a sense of fulness in the abdomen, success will be much more likely. Should the regular time for making an effort be soon after breakfast, which is undoubtedly the best time, and the meal has not been sufficient to produce a sense of moderate distension, a full glass of water will complete that condition. For the purpose of giving fulness and a sense of distension, various kinds of ripe fruit may be resorted to with advantage. In prescribing fruit for consti- pation, we should bear in mind that there are three indications ful- filled by it, some kinds fulfilling all, while others fulfil only a part of them. They are, first and best, distension; secondly, increase of secretion, on account of the acids; and, thirdly, increasing peristaltic action of the bowels by indigestible fibres, seeds, or rind. Ripe and mellow apples, without being divested of the rind, may be eaten in sufficient quantities to produce a sense of fulness, and this should always be at the conclusion of a meal, — breakfast, for instance; the acids will increase the intestinal secretion, and the rind quicken the peristaltic motion of the bowels by acting directly upon the mucous membrane, and through it on the muscular structure. Very acid fruits, as the lemon and orange, only produce their effect on account of the acids they contain. They are excellent as a part of the ingesta of patients whose stools are dry and hard and lumpy. Fruits con- taining an abundance of seeds, as figs, or of rind, as tamarind, etc., increase the peristaltic action without causing much secretion. By inquiring into the character of the stools, we shall have a good guide CONSTIPATIOX. 407 as to the kind or mixture of fruits to be selected. There are kinds of diet, breads particularly, that act like these last fruits, and may be used in conjunction with or independent of them. Breads in which the bran, or hull of the grain, is contained in considerable quantities are of this character. The Graham bread, as it is usually called, ordinary coarse, brown, corn bread, or wheat bread, are those mostly resorted to. When this kind of bread is used for constipation, it should be eaten at breakfast, dinner, and supper, in such quantities as the experience of the patient finds necessary. I have advised patients who could not use the coarse breads to make what may be called bran crackers. A tablespoonful of flour, one pint of wheat bran; two tablespoonfuls of white sugar, and water enough to make them all into a pasty mixture, are the ingredients. This mixture is made into cakes, small or large, as may be wished, and baked in an oven until hard. When soaked in tea, coffee, or milk, they are not unpleasant. I have known patients benefited by swallowing certain seeds, with the rind, whole. A tablespoonful of wheat grains, oats, barley, white mustard seed, etc., can all be used for this purpose, and are not more disagreeable than medicines. Another kind of diet, which may be used to produce the kind of effect here aimed at, con- sists of the various small vegetables, as celery, radishes, pepper-grass, lettuce, asparagus, cabbage, etc. These may all be taken in quantities to cause distension. In speaking of fruits, I ought to mention the berries as excellent, cheap, and easily procured, to accomplish all the objects attained by other fruits. Everything should be done by habitual effort, exercise, diet, drink, etc., before resorting to the use of medicines; because, as is well known to the patients generally, as well as to the practitioner, the more medicines taken the more will be necessary. They lose their influence, and the dose must be increased in order to produce a full effect. Notwithstanding this evil, we are often reduced to the necessity of using laxatives to overcome constipation. To a just and intelligent application of medicines in the treatment of constipation, it is indis- pensably necessary to make ourselves acquainted with the condition of the alimentary canal, with reference to its secretions and muscular powers. It will be found that there are sometimes great deficiency of secretion, and torpor or want of vitality of the muscular structure, or weakness of this tissue. The want of secretion may be in the upper portion, in which case the bilious color is wanting in the stools, or the small intestines may give out less watery material, and then the stools are less fluid, or even dry. The secretions may also be deficient in the lower portion, or colon ; in which case the fseces will be scybalous, dry, and lumpy. The muscular torpor, from want of irritability, is more frequent in the colon or rectum than in the small intestines. When 408 GENERAL TREATMENT OF UTERINE DISEASE. in the colon, there is increase in size of the lower abdomen, sense of fulness and hardness, and the fseces are expelled vdth great difficulty. If there is sufficient activity of the colon, but the rectum is torpid, large accumulations occur there, the pelvic distress is increased, and nervousness, general and local, is exceedingly annoying. Sometimes all these conditions are combined to render the case one of the most troublesome and difficult to manage. Mechanical obstruction by stricture of the rectum, formed by pressure of the uterus, may give rise to chronic constipation, which may become permanent and almost incurable ; or the uterus, by lying on the bowel, and pressing it against the sacrum, often gives rise to costiveness, that can be removed only by correcting the position of that organ. It is not sufficient to know that the patient does not have regular oiDerations from the bowels, but Ave must know why she is thus constipated : whether on account of want of secretion, and, if so, of what secretion ; whether it is at- tributable to general debility, combined with muscular weakness of the intestines, or to lack of irritability of the intestinal tube and con- sequent torpor ; and if so, whether this lack of irritability exists in the whole length of the canal, in the colon, or the rectum. We must also know whether there is obstruction from stricture in the rectum, piles, thickening in the mucous membrane, rigidity of the sphincter, or from the uterus bearing heavily upon it. To give a laxative merely because it ordinarily produces a fecal discharge, is always unphilo- sophical, and sometimes exceedingly injurious in its effects. I think it is inattention to the exact state of the alimentary canal that makes constipation so often incurable. For constipation, attended with very dry, hard stools, showing a deficiency in all the secretions from the bowels, in addition to the course of diet, including acid fraits, etc., our object should be to administer such drugs as will most effectually stimu- late to secretion. The various saline medicines are indicated. Sul- phate of magnesia is a most excellent one ; and a good way of admin- istering it is in combination with sulphuric acid. From one to two drachms, or even half an ounce, given in combination with acid enough to taste somewhat sharply, will promote secretion along the whole of the small intestines, cause a large effusion of water, which will dissolve the fasces and render their evacuation easy and sure. In the morning, some time before eating, is the best time to take it. When there is reason to believe that the portal circulation is slow, and the liver furnishing less than its usual amount of secretion, some form of mercurial should be used with the salts. If the case is chronic and the constipation obstinate, we may give from six to ten grains of blue mass in pills, at bedtime, every fourth or fifth night, and follow it with Ei^som salts in the morning. A continuance of this alterative cathartic from four to six weeks, seldom fails to cause a change in the alimentary secretions. Sometimes it is better to give these cathartics CONSTIPATIO]!^. 409 nearer, and sometimes farther apart. We must judge of this more by the susceptibility to the constitutional influence of mercury than any thing else. It is almost always the case that this very scanty state of the secretions is accompanied with an impoverished state of the blood ; hence iron in some shape will be beneficial in most cases. If there is much debility, a long course of tonics will be indispensable. It may often happen that this scanty condition of the secretions is attended with debility of the muscular fibre of the intestinal canal. When this is the case, we must add to the above treatment that which is ap- plicable to this kind of intestinal torpor, which I shall now consider. Before doing so, however, I will remark that several other salts will answer as well, and sometimes even better, than sulphate of magnesia. The kinds of tonics which are most effectual in debility of the muscular structure of the intestinal canal are such as give general strength, and it is most desirable to combine them with special tonics. The latter are rhubarb and nux vomica. These have always seemed to me to have a special tonic influence upon the intestinal tube, and, when properly given, to increase the susceptibilit}' to their own action. The rhubarb, although an alimentary tonic, induces less susceptibility to its own influence than the nux vomica. The best way to give the rhubarb is either in the root, without pulverization, or in the extract. When given alone in the root, the patient can take a little, twice a day, by chewing, and, after mixing with the saliva, swallowing it. A little 'experience will enable the patient to judge of the right quantity, which she can repeat as often as it is required. When the rhubarb is taken this way, she may also take a solution of ferri sulph. and strychnia, in water, one grain of the former to one-sixteenth of a grain of the latter. I have often succeeded in overcoming this constipation or debility by giving one grain of quin. sulph. with five grains of powdered nux vomica after each meal. Or the same amount of nux vomica, with iron by hydrogen, two grains each time, after eating. It is usual to use aloes in the constipation of uterine diseases ; but I have found very few cases with which this drug did not disagree. But there is a torpor of the intestines where general tonics cannot be borne; where, in fact, there does not seem to be any general debility, there is only a want of susceptibility to the stimuli which ordinarily arouse them to action. The secretions color the fseces properly, and give them sufficient moisture ; there seems to be no fault in their appear- ance, consistence, odor, or other character whatever. They are de- ficient only. The patient may be plethoric and florid, her general muscular strength sufficient, and her blood, so far as we can judge, good in composition. Special tonics and stimuli are indicated in such instances, and they alone should be used. Such measures should be adopted as will arouse the muscular action of the intestines. Nux 410 GENERAL TREATMENT OF UTERINE DISEASE. vomica, in five-grain doses, with the rhubarb extract or without it, or the strychnia in solution, in doses from a sixteenth to a twentieth of a grain, constitute our most valuable medicinal remedies. This is the kind of constipation that is most benefited by and is most amenable to a persevering regiminal and dietetic course of manage- ment, such as I have endeavored to give. In addition to the rhubarb and nux vomica treatment, we may get some good from external apj)liances, and manipulations of the walls of the abdomen. The most valuable, when gentl}'', perseveringly, and methodically applied, is what is understood b}' the term knead- ing. The colon is the torpid portion in most cases of this sort of constipation. The jDrocess of kneading consists in handling it so as to stimulate its fibres directl3^ One plan is to grasp it with the hand, and squeeze it from one end to the other. We should begin at the right groin, and with a knowledge of the position and direction of it, grasp it with both hands at this point, then a little higher up on the same side, and then a little higher, until we reach the right hypo- chondriac region. We should then follow it across the abdomen to the left hypochondriac region, and thence down to the left iliac. Or, we may double our hands as bakers do when kneading their dough, and standing over the patient, press with the knuckles of both hands, first in the right iliac region, and imitating the process of kneading, pass slowly from this to the right hypochondriac, thence across the abdomen and down, as before directed. If we trust this process to a non-professional attendant, we should be sure to show him how to do it, as it is important that it should be done right. When this process of kneading or squeezing the colon is first instituted, it should be practiced with the utmost gentleness, but the force and rapidity of motion may be increased until great freedom ma}' be used. It should be, resorted to a short time before retiring to the water-closet, sa}" half an hour. Some patients find an efiicient laxative in what they some- times call a water-compress, applied to the abdomen overnight. It is made b}^ doubling a naj^kin several times, so as to make a thick com- press, large enough to cover the entire abdomen anteriorly. This is saturated with water, and, after being placed upon the abdomen, covered with a roller or bandage so as to keep it in j^lace. It is thus allowed to remain from the time of going to bed until the time to rise in the morning. I think this water-compress is best adapted to cases in which there is a deficiency of secretion in the intestinal tube. A bandage, or, what is better, a roller applied tightly enough to press the wall strongly upon the contents of the abdomen, frequently stimulates them to proper action, both as it respects secretion and peristalic motion. When it is determined to use the roller or band- age for its stimulating influence, it ought to be applied upon rising in the morning, or, what is perhaps better, immediately after break- CONSTIPATION. 411 fast. This bandage should not be worn constantly, nor even many hours m the day. From the time of rising until two hours after breakfast, or from breakfast for three hours thereafter, will be long enough. The constant use of the bandage would but increase the evil — lax abdominal muscles — for which it is advised. Before leav- ing this part of the subject, I desire to say, with reference to the free use of nux vomica to overcome intestinal torpor, that in all cases we should remember its effects are cumulative, and quite a difference of susceptibility to its influence is manifested by different persons, in consequence of which the patient should be watched, and the dose graduated to the least quantity necessary in the case. Although I have given nux vomica and strychnia, for a considerable length of time to a great variety of persons, and for several weeks together, I have never seen anything more than slight inconvenience from it in the shape of nervous startings. Very rarely we meet persons who cannot take it at all; it disagrees with them as soon as they commence its use. There is another species of intestinal torpor of a very obstinate character and very distressing to the patient ; I mean a lax, torpid rectum ; so torpid as to allow the faeces to accumulate in large quan- tities, and cause great inconvenience from pressure. To such an ex- tent does this collection sometimes go as to press the posterior wall of the vagina forward and protrude it between the labia. The first 'indication in such cases is to dissolve the fecal mass and discharge it. Various kinds of injections are useful for this purpose, warm oil, warm water, etc. ; but one which I have seen do much good is com- posed of one ounce of fresh ox-gall and four ounces of warm water. This composition dissolves the fseces very readily, and the fresh bile stimulates the intestines to their expulsion. The evacuation, of course, will give only temporary relief, and there remains the most important indication, that of giving tone to the bowels, with a view of prevent- ing the accumulation in future. This is difficult, and in some in- stances of long standing quite impossible. Much good can be done in nearly all cases, however, and we do not discharge our duty if we do not try to relieve when we cannot cure. Cold water thrown into the rectum once or twice a day, in small quantities — eight ounces — is always good, without some special reason to the contrary. There are generally two indications to be fulfilled in these cases, — relaxation of the sphincters and restoration of the tonicity of the proper rectal fibres. It is a singular fact, which I think I have observed, that the sphincter muscles increase in strength with the advance of age ; this is one of the causes why the fseces are voided with more difficulty in old persons. To give tone to the rectal muscles, astringent injections have been recommended and extensively used ; but in my practice 412 GENEEAL TREATMENT OF UTEEINE DISEASE. they have been ahuost uniformly useless, many times injurious, and always disagreeable. They dry up the secretions, an evil not to be compensated for by any other effect; they do not, so far as I can judge, cause contraction of the muscular fibres, but they are very apt, if persisted in for a length of time, to cause inflammation. I have derived more benefit from tonic suppositories and injections than from any other kind of medicinal treatment. A suppository of twenty grains of extract of gentian, or five grains quin. sulph., ten grains of extract of cornus Florida, or a mucilaginous suspension of any of these introduced into the rectum every night at bedtime, and retained, if possible, until morning, are good tonics and eligible modes of using them. It will be necessary, to secure the retention and efficient contact of these tonics, to first empty the bowels Avith ox-gall and warm water, and afterward introduce them with as little irritation as possible. The quantity of mucilaginous material should not exceed two ounces. The tonic treatment of this kind must be varied, taking first one tonic and then another, in first one form and then a different one, and must be kept up for a long time to do much good. We cannot be too careful, in all our treatment, to avoid any- thing to which the rectum shows any sensitiveness. When it be- comes tender and sensitive, we should at once desist until all of this has subsided before we are justified in beginning again. It too fre- quently happens that both the physician and patient become dis- couraged, and desist before the remedies have had a fair trial. Is there anything that will relax the sphincter ani? I am not aware that any means operate with efficiency in this direction ; but I have used, in a few instances, with apparent benefit, the ointment of bella- donna, made by mixing the extract with lard. I apply it to the anus externally upon going to bed at night, and continue it, until the question against or in favor of its usefulness is fully determined. This application certainly removes the irritability of the sphincter, which causes it sometimes to resist the extrusion of the faeces. As I have before remarked, there are cases in which this relaxation cannot be cured ; we are then compelled to resort to palliatives, and we must be careful to palliate intelligently. We are to give the weak rectum artificial support, to enable it to retain, as near as may be, its ordinary size. This can be done only through the vagina. An air or sponge pessary introduced into the vagina, so as to press the rectum against the sacrum, and thus diminish its capacity, will prevent the great accumulations from taking place, and in that way prevent one source of great inconvenience. Dr. Hodge recommends the globe pessary for this condition of the rectum, which answers very well in many cases, perhaps in the majority ; but each case must be studied with reference to its own peculiarities, and the shape, size and con- sistency of the pessary adapted to it. CONSTIPATION. 413 When our object is palliation alone, there is no objection to wearing the pessary all the time, but if it is used to palliate what we believe to be a curable case, we ought to use it intermittingly, and the patient should not wear it at night, especially. It would probably be better, in a majority of the cases, to introduce it before rising in the morning, and allow it to remain until noon. One thing I think essential in the size and position of the pessary, and that is, that it does not compress the rectum below its natural capacity ; there should be room enough for an ordinary amount of fseces in it, lest it become a source of ob- struction, which it will do when larger or improperly placed. As will be noticed, I have omitted to say anything of enemata in con- stipation, from inactivity of the colon or upper portion of the alimen- tary canal. As an occasional means injections operate well ; but like other laxatives, when used for a length of time they lose their influence entirely. If we determine to use injections as an habitual laxative, by proper changes in kind and quantity, we may prolong their efficacy very much. To a person unused to them half a pint of cold water will act very well. When the bowels fail to res23ond to this quantity there ought to be an increase of two or three ounces, and then that amount used until its effects are not satisfactory, when a few ounces more should be added, and so on we may increase the amount until the quantity becomes intolerable. When this is the case we may order half a pint of water with a drachm or two of common salt, chlorate potassa, or nitrate of soda or potassa. We should increase the quan- tity of water, or strength of solution, or both, as the susceptibility of the rectum is decreased, until we cannot carry either farther. In very obstinate constipation the bowels may be emptied with much cer- tainty by injecting a large quantity of water in the knee-chest posi- tion. In this position the water will pass the sigmoid flexure of the colon into the mass of faeces, softening it, and, by its bulk, stimulate the alimentary canal to expulsive efforts. Very few cases will resist this method of administering enemata. After we have thus obtained as much good from injections as we can, it is sometimes expedient to use suppositories as laxatives. Suppositories are made of laxative medicines, or of any other material. Compound extract of colocynth or some other purgative extract may be used ; or we may enclose in some of the extracts a dose of podophyllum, or any of the purgative resinoids or alkaloids. These should be retained until absorption takes place. The common suppositories of soap, tallow, wax, sperm, stearin, etc., are of the second kind. It not unfrequently happens that the above modes of using injections and suppositories may be alter- nated very profitably, the full eff'ects of each being experienced upon their resumption after having used the other for a time. But some persons cannot use injections ; the rectum is too sensitive, and attempts 414 GENERAL, TREATMENT OF UTERINE DISEASE. to do so induce so much irritation that they must abandon them. In such cases suppositories are out of the question. This form of rectocele sometimes requires a resort to surgery. The operation is detailed elsewhere. I have elsewhere shown that the uterus, by its wrong position, some- times presses upon the rectum and obstructs the passage of the fseces. This may be effected by retroversion or prolapse. The indication, of course, is to restore the uterus to its proper place, and as we shall have occasion to speak elsewhere of these difficulties (malpositions), I do not think it necessary to more than mention them here. CHAPTER XXII. SPECIAL TREATMENT. Baths. The local treatment of inflammation of the cervix uteri is made up of several therapeutic items, varying according to the intensity, quality, and seat of disease. Of these there are, however, a few that are applicable to almost all cases ; hence their description, modes of use, etc., may be considered before going farther. Baths, injections, and some minor remedies are of this kind. Water, when applied to the surface, is purely sedative in its effects if it is of the temperature of the part on which it is used. If the bath is partial, the sedative influence is for the most part conflned or limited to the part to which the application is made. So with injections per rectum or vaginam. They soothe the parts contained in the pelvis. If the water is warmer than the part of the surface bathed, the effect is stimulant; if it is colder, by virtue of the physiological action brought into play, it is first sedative and then stimulant. The circulation and nervous influ- -ence of the vagina, for instance, when the cold water is first thrown into it, are depressed, but very soon after its evacuation, or with- drawal, the vessels become excited to increased circulation of blood, and increased heat takes place and the nerves become more sensitive. In all these respects baths and injections act alike. The injections are internal baths, by which the uterus is bathed through the vagina. But the effects of baths and injections may be modified by containing medicinal substances. They may be rendered more stimulant or more sedative, or be even made to possess other qualities by impregna- tion with medicines ; one in very common use is astringent in char- acter. Another mode of using water and applying it, either simple or impregnated with medicine, is, to wet a cloth or a sponge with it and bind it to the surface, or introduce it into the vagina. Several thicknesses of cotton cloth applied to the abdomen and impregnated with water is what is called the water compress; and often when allowed to remain in contact with the skin for several hours it pro- duces considerable excitement, and, if persisted in for days, will cause first a vesicular, next a pustular, and finally a phlegmonous eruption. The way to render it effective is, after applying the wet cloth, to cover it over with oil-silk, and then confine the whole with a bandage or roller, with a view to prevent evaporation. Sponge in- troduced into the vagina, impregnated with water holding medicine 416 SPECIAL, TEEATMENT. in solution, is a common way of affecting the uterus. I do not design giving an extended view of the effects of baths or their application and modus operandi, but so much aid is occasionally obtained by the use of them, that I cannot refrain from speaking of the application of some forms of them to diseases of the uterus. Hip-bath. The bath most applicable in inflammation of the cervix uteri and most commonly used is the sitz- or hip-bath, which is intended to allay the inflammatory irritation and pain. It is often the case that there is a great deal of suffering from pain without much inflam- matory action in the parts ; in these cases a sitz-bath will often give great relief. In many instances the efficacy of the bath may be enhanced by having the patient introduce a speculum while in the water, so that it may pass up the vagina to the neck of the uterus and thus directly affect the part diseased. In cases of medicated sitz- baths the organ may thus receive the full benefit of the saline, ano- dyne, or other medicinal impregnation. The common glass tube will do very well for this use, where we wish only to bathe the neck of the uterus ; but if we wish the fluid to come in contact with the vaginal walls and remain there for a considerable time, the wire speculum is the best. While speaking of the use of the speculum in this way, I may mention that a very efficacious mode of applying medicated washes without the bath to the cervix uteri or vaginal walls, is to have the patient lie upon her back, introduce the speculum, and then pour the fluid into it. By remaining in that position she can retain the contact of the medicated solution as long as desirable. Ice- water, ice, astringent powders, or almost any form of substance may be ap- plied and retained in contact with the os and cervix uteri with great advantage in this way. This mode of using remedies is particularly useful in bleeding fungus or vascular tumor of any kind. The sitz-bath, when a patient is suffering with the pain and heat of uterine disease, may be used as often as necessary, twice a day at least ; but three, four, or even a greater number of times will not be too often, when they are found to be soothing and useful. We may extemporize a hip- or sitz-bath, by putting water in a common wash- ing-tub; but the cheap tin vessels made for the purpose are within the command of almost all persons. There should be so much water that when the patient sits down in it, the whole pelvis will be covered. Temperature of the Bath. What should be the temperature of the bath ? The patient's sense of comfort or discomfort from its use should be our guide in thir resiDect. We should seek a temperature that is comfortable an VAGINAL, INJECTIONS, IREIGATION, DOUCHES. 417 soothing to the patient while in the water, and that leaves no sense of discomfort. The baths are intended for, and should add to, the com- fort of the patient; when they do not do this, they should at once be discontinued. As a general rule I advise my patient to take tepid water for her first baths, and then gradually use them cooler until they are cold, unless they become disagreeable in some respect; if they do so, to continue them tepid. The colder a bath is the naore good it does, provided it be comfortable. The time for taking it may be regulated by the convenience of the patient, and the necessity for it, with the view of allaying pain, heat, etc. ; probably in the majority of instances, the most advisable times for taking it are upon rising and retiring. The length of time the patient remains in the bath should also be regulated somewhat by its effects. If the patient remains too long in the water it will debilitate her, particularly if there is considerable water and the bath is frequently repeated ; on the other hand, if she does not remain long enough, she will not de- rive any benefit from it. She may try remaining in it fifteen minutes, if she does not find herself very much relieved before that time, and she ought to be governed in her use of subsequent baths in this particular by the effects- of the first few trials. While in the bath the intended temperature of the water may be kept up by adding hot water from time to time. The hip-bath is used almost wholly with reference to the local disease, but when general baths are required, it is usually for the relief of some attendant general symptom. Shower-hath. The shower-bath may be used as a roborant excitor of the circula- tion, if upon trial it can be borne, and produce a good effect. Some patients think they are very much benefited by the shower-bath, and say they cannot do without it. Sponge Bath. The sponge bath is useful in causing a tonic and soothing reaction upon the surface. Neither of these can be tolerated by very feeble patients. The cold or tepid sponge bath, administered at bedtime, not unfrequently soothes nervous irritability, and enables restless persons to sleep soundly. I have not used baths in any other form than these, but when used as I have here indicated, I have seen such pleasant results from them that I cannot refrain from recommending them. Vaginal Injections, Irrigation, Douches. The modern methods and purposes of vaginal injections differ so much from the imperfect ones used only a decade since, as to require new means as well as modes. In early gynecology we satisfied our- 27 418 SPECIAL TREATMENT. selves with the glass or hard rubber instruments, not much longer than a man's finger. Another step toward the present condition of things brought us the soft rubber tube of some length, and a bulb with which to keep up a perpetual stream. This was a laborious in- strument, and required strong muscle to use it. Next came the fountain syringe, holding a quart at first, afterwards two quarts. This was a labor-saving machine, and was an approach to luxury in the use of douches. During all this time the patient took her injections in the sitting posture. Now the fountain has grown to great dimen- sions, holding gallons, and it is indispensable that the patient assume the dorsal recumbent position, which necessitates the douche-pan and slop-bucket. Fig. 202. Vaginal Douches. At first the purpose was to medicate the vagina and cervix ; after- wards to cleanse, or medicate, or both. Now the purpose is to treat the parts to a very hot bath, with the object of stimulating the capil- laries of the mucous surfaces, causing their contraction, and restricting the flow of blood to the inflamed parts, and to influence the deeper tissues by a similar effect upon their capillaries. This amounts to a valuable alterative to the parts within reach of the effect of the heat in the water. The influence of the hot water when the patient is lying ACCIDENT IN INJECTION. 419 on her back, is complete by filling the vaginal cavity and keeping it so by furnishing a continuous supply from the fountain as long as is desirable. Injections, or more properly, douches, of hot water are applicable to a large variety of cases — chronic inflammation in the vagina and cervix, and cases of inflammatory exudation in the pelvic tissues outside the uterus. In acute cases of inflammation this hot water cannot generally be borne ; and many patients cannot tolerate it even when the conditions indicating it seem to be present, probably on account of some peculiar susceptibility. Some patients will profit by a small amount of hot water and sufi'er from the large douche. Others will be comforted and improved by the use of tepid water in large or small quantities, who cannot use the hot. The apparatus for using the douche consists of two pieces, a large reservoir of tin or rubber, and a douche-pan. The douche-pan may be made of rubber, tin, or earthen material, and resembles an ordinary bed-pan furnished with an outlet tube to carry the water into a bucket, basin, or other receptacle. These large douches are used twice a day or oftener as they may appear to be useful or not. Accident in Injection. There is one annoying, and sometimes to the patient alarming, little accident that occasionally occurs during the reception of an in- jection in the vagina. Suddenly, while injecting the fluid, she is seized with severe cramping pain in the hypogastric region, which radiates to the back and hips, down the thighs, and sometimes over the whole abdomen. She becomes sick at her stomach, is attacked with rigors, and her feet and hands often become cold. This pain continues, with exacerbations and remissions, for several minutes or hours, and when it subsides, leaves a sense of soreness, more or less considerable, corresponding with the severity of the attack. As the chilliness and rigors of the first few moments subside, there is reac- tion ; the patient becomes warm, and sometimes decidedly feverish. In all cases in which I have witnessed these symptoms the patients were using a syringe in the end of which, within the vagina, were several perforations, some on the side of the bulb at the end, and one at the very extremity. I think that one of the perforations had been accidentally placed in opposition with the external os uteri, and as the water was forced through this perforation, it entered the cavity of the cervix, and passed through into the cavity of the body of the uterus, inducing the first shock, and the pains following it were caused by the spasmodic attempts on the part of the uterus to expel it. Although I have, in a large number of instances, been called upon to witness and prescribe for these symptoms, I have not seen them proceed to dangerous extremities. I think these are cases of injection into the 420 SPECIAL TEEATMENT. womb; and, in this respect, the}^ constitute my whole observation. An opiate injection per rectum, fomentations over the pubis, and quiet, are all the remedies I have found necessary. And often the symptoms subside so soon that I have not been under the necessity of prescribing at all. We occasionally meet with patients who cannot use baths or injec- tions. In these cases it will be found, almost invariably, that this inability arises from their producing an exaggerated effect. If it is simple tepid water used for the bath or injection, its results are too sedative. The bath debilitates the patient, instead of simply sooth- ing her. I have seen a single tepid bath prostrate a patient so that she would have to lie in bed for several hours before its effects wore off. A cold bath induces chilliness and permanent coldness, and re- action is not established; the system recovers from its effects only after a number of hours, and that slowly. Hip, sitz, or general baths may produce these effects, and when they do so, should be abandoned as injurious. Other nervous symptoms, as difficulty of breathing, nausea, dysuria, etc., also occasionally seem to be the effects of baths. It is singular that some patients are so susceptible to the depressing effects of water that injections debilitate them very rapidly, and they are obliged to abandon them on this account. Cold water, as an injection, not unfrequently causes general coldness. But it is the medicated injections that most frequently produce an exag- gerated effect. Alum injections, even when the solution is weak, with some patients, produce such disagreeable and constant dryness, and sense of heat, as to make them quite intolerable. And the sensitive- ness of the vagina becomes so great that some patients are forced to cease the injections of alum wholly. The same objections apply to other astringents to a less degree, and the consequence is, that how- ever baths and injections may seem to be indicated, in the cases where idiosyncrasy renders them so objectionable, we must forego their use entirely. Should they be used in Pregnancy f Is pregnancy an objection to the use of local baths and injections? I think not with proper care. A hot bath about the hips would be objectionable ; a very cold bath that might cause much of a shock, or internal congestions, would not be advisable ; but plenty of tepid water, and even cool water, temperately used as baths, give the preg- nant woman great comfort, and cannot generally be followed by any bad effect. Injections may be used with less caution than baths. The caution which we would administer to all is, that they should not be copious. In pregnancy the patient ought not to use more than a quart at one time. The injections should always be tepid or cool ,* not very cold or very warm, lest they stimulate the muscular, vascu- INJECTIONS IN PEEGNANCY. 421 lar or nervous system of the uterus too much, and induce hemorrhage, or provoke contractions. Both of these effects, I think, I have known produced by such injections ; the cold causing contraction and expul- sion ; and the very warm hemorrhage and death of the ovum. Strong astringents should also be avoided. Much comfort may be derived from anodyne injections, when there is neuralgic suffering about the uterus or vagina, during pregnancy. Cases of superficial inflamma- tion, and even early ulceration of the vaginal portion of the cervix, may always be benefited by injections, baths, and the general treat- ment which I have heretofore detailed. In fact, most cases, if not all, where there is no idiosyncratic objection to the baths and injections, will be very much benefited by them. When, however, the disease has been of long standing, or extends between the labia of the os uteri, or into the cavity of the cervix, these will only slightly benefit it. We must then seek for something that will more profoundly influence the nutritional changes, and the vascular and nervous tissues of the parts. The introduction of anodyne, astringent and alterative ointments, pessaries and powders may be resorted to with much profit in many instances. The small instrument called the suppository syringe will enable the patient to place ointment in contact with the uterus very conveniently. Ointments made with opium, belladonna, hyoscyamus, Fig. 203. Ointment Syringe. cicuta, tannic acid, mercury, iodine — in fact, almost an}^ substance used to exert an influence locally — may be made into ointment and thus introduced. The powders of many of these articles may be deposited in the vagina in the same way. And the medicated pes- saries made by mixing the medicine intended to be used with cacao- butter, may be passed up to the os uteri through a glass speculum, either by the patient, her attendants, or the physician. In using the narcotics in the vagina, in the form of ointment or pessary, we can safely use double the quantity given by the stomach. The ointment is absorbed slowly, and consequently it requires some time to effect much by it. But the powders act much more readily. Morphia thus introduced will sometimes act with great promptitude, and the powder of tannic acid is a very efficient astringent used in this way. The absorbing power of the vaginal mucous membrane is decidedly less than that of the rectum. It takes a longer time and more of the medi- cine to affect the system through this cavity. Possibly this may be to some extent on account of the more ready escape of substances 422 LOCAL TREATMENT. from the vagina ; but I think, also, the membrane does not take up substances so quickly. From this fact injections or suppositories per rectum will often do more good in allaying pain esi3ecially than when used per vaginam. A few drops of strong solution of morphia sulph. in the rectum act very promptly. Dr. Greenhalgh and others use cotton pessaries medicated, per vaginam. The cotton is prepared by immers- ing it in a strong solution of the medicinal agent to be employed, and afterward drying before using it. Still another method of making local applications to the upper part of the vagina is to envelop the medicines in a sac of thin cotton or linen goods, and pass it up to the cervix, and let it remain there until the astringent, or whatever may be contained in it, is dissolved out, and exerts its influence upon the parts. The patient can use this kind of application without assist- ance. LOCAL TREATMENT. There are very few cases of chronic inflammation and congestion of the uterus that may not be benefited by what is known as local treat- ment. This is especially true with reference to those cases in which the intensity of the disease is sufficient to cause the loss of the epithe- lium or deeper portions of the mucous membrane, — abrasion or ulcera- tion. Local treatment is not only beneficial but indispensable to the cure of endometritis and endocervicitis. Local treatment consists in the application of certain medicines di- rectly to different parts of the uterus and vagina for the relief of the various conditions connected with the inflammation. The medicines and the methods of their application are intended: first, to relieve pain by their anodyne influence; second, to. deplete the parts of the superabundance of blood ; and, third, to change the character of the capillary circulation by restoring its natural activity. When there is much pain of whatever character the anodyne appli- cations are indicated ; and many patients will bear anodynes as local applications for the relief of pain very much better than when taken internally. Even where there is no idiosyncrasy forbidding the use of anodynes, they may affect the stomach on account of their taste, so that they cannot be borne or will not be taken. Suppositories made by impregnating cacao-butter with a quantity of the anodyne to be made fifty per cent, larger than when taken in the stomach, and repeated as frequently as required, is one method of making anodyne applications. The suppositories are made by the apothecary in a shape and of a size for the vagina, and also for the rectum. It requires a longer time for the anodyne to be absorbed by the vaginal membrane than by the stomach or rectum. When it is desired to use the suppositories in the rectum instead LOCAL TREATMENT. 423 of the vagina, it will require no more than the ordinary dose of the medicine, and the effect is obtained more promptly. It must be re- membered also that the mucous membrane of the rectum is very much more sensitive than that of the vagina. When therefore we desire to use medicines, the primary effect of which is irritation, as chloral or bromides, it will be necessary to dilute them more than for the vagina. Topical applications of anodynes may be made in various other ways, by inclosing the medicines in a sac of thin cotton cloth, gauze, or do- mestic, and placing it in the uj^per part of the vagina, or entangling it in cotton-wool and putting it near the cervix. Sometimes the medicine may be apj^lied in solution, the patient lying on her back so that the fluid may gravitate to the cervix. Half an ounce of fluid introduced through an ordinary glass or rubber syringe will generally be retained — if the patient continues the dorsal position — until it affects the nerves of the part. Applications of this kind can be made by the patient herself, or the nurse. Topical depletion in inflammation and congestion of the uterus is also a most valuable curative measure. When the uterus is very tender and sensitive to the touch, it will require but little irritation to cause intense local inflammation. We must be especially careful under such circumstances to avoid the third class of topical applica- tions. The tenderness and sensitiveness depend upon an unusual intensity of inflammation in the fibrous structure of the uterus above, which, although chronic in duration, is subacute in grade. The kind of turgidity, sensitiveness, and pain is sometimes kept up by the jDres- ence of perimetric inflammation — cellulitis — local peritonitis, cystitis, etc., and they contraindicate any stimulating applications to the uterus. It is in the conditions just described that local depletion is applicable and beneficial. Common means of local depletion are leeches and scarification. Leeches may be applied directly to the uterus through the speculum, around the anus, over the sacrum or pubic region. When we desire to apply them to the cervix, some preparation will be necessary to insure success. The vagina must be thoroughly washed by large injections of hot water to remove any offensive secretion or other contents of the vagina. The cervix may then be exposed by the speculum and sponged with sugar and milk, and it will add to the readiness with which the leeches take hold to prick the cervix until it bleeds, and then smear the surface with the blood. The leeches are first thrown into tepid water, and from it are taken out, placed in contact with the cervix, and watched until they fasten upon it. The number employed — from four to twelve — will be governed by the amount of turgescence and pain ; when the in- tensity of inflammation is very considerable, the greater number. In judging of the number necessary, we must be governed by the pain, 424 LOCAL TREATMENT. tenderness, and general condition of the patient. The pain and tenderness must be such as are caused by local hypersemia — inflam- matory or congestive — or by inflammation in the surrounding tissue, and not the pain and sensitiveness of neurotic conditions of the parts or the patient. I do not mean neuralgic pain as that term is generally understood, but hypersesthesia unattended by any hypersemia. Scarification cannot be made to take the place of leeches, but it is often followed by great improvement, and is very efficient in remov- ing congestion of the submucous tissues. It maiy be performed by any long pointed knife by which the cervix can be reached, but perhaps the more efficient instrument is Buttle's artificial leech. It is a very small spear-shaped knife mounted upon a long shank and handle (Fig. 205). With these instruments, the most dependent parts of the cervix may be pricked in several places. The bleeding may be encouraged by injections of tepid water in large quantities. Fig. 204. Knife for Scarifying the Cervix. In what time of the month is depletion the most useful ? Before the commencement of the flow, as a rule, there is the greater amount of hypersemia, and consequently is the time we might effect the most good from depletion. This is not always the case, however. There is no question that patients who have febrile excitement during the time of the antemenstrual congestion are very much benefited by local depletion at that time, but much more frequently the cases of lingering congestion will require it oftener. When the menstrual flow is deficient and the uterus is not relieved by it, many women are relieved by leeching or scarifying the cervix. The congestion which lingers after the menstrual period and causes so much suffering, is generally, although not always, the result of a very scanty flow. In either case, when we determine to deplete, it should be done as early as the close of the flow, at latest, and if the flow is scanty during the discharge. Independent of these physiological reasons for selecting these times for depletion, and notwithstanding the fact that thus used the deple- tion is generally attended with the best results, the very best rule for our guide will be found in the symptoms. In most cases there is a particular time in the month when the symptoms are the greatest in intensity ; that is the time to deplete. In some this intensity occurs before, in others during or immediately after, the flow, while in still another class of patients it is midway between the periods. Rarely there are chronic cases where the congestive or inflammatory symp- LOCAL TREATMENT. 425 toms last all the time. When there is enough general vigor, these will be improved by depletion two or three times a month. In connection with the measures for depletion, glycerin deserves to be mentioned. When placed in contact with the surface of the body, its strong affinity for water attracts the serum of the blood from the capillary bloodvessels very rapidly. This process is very much more active in the vaginal cavity, where the air is to a great extent excluded, as the whole capacity of the glycerin to take up moisture is exerted upon the membrane by which it is surrounded, and a large quantity of serum is rapidly abstracted from the diseased parts. The tumefaction and tension are at once removed and the pain relieved. When a glycerin tampon is placed in the upper part of the vagina, it requires but a few minutes to establish a copious watery discharge, that lasts until the glycerin, diluted with several times its own weight of serum, is washed out and exhausted. The relief which follows this application of glycerin is often even more marked than after depletion by leeches. Glycerin was first used as a dressing in vaginal operations by Dr. Sims, and it required but a little time for him to discover its valuable properties as a means of relieving inflammation and congestion. Used in this way I con- sider glycerin invaluable. As a lubricant or solvent for local appli- cations I believe it to be worse than useless. To dissolve medicine in it, and then apply it to the cervix, is to insure the rapid removal ,of the medicine by a current of serum poured out from the surface. For this reason absorption from a glycerin solution, applied to the vaginal surface, is simply impossible. The efficacy of glycerin appli- cations depends very much upon their preparation and the method of using them. The best quality of cotton batting is the substance most appropriate with which to make glycerin applications. There is a great differ- ence in the grades of cotton batting in the market, and we should be careful to get the best article made. It absorbs a larger quantity of glycerin, and does not wad up into such a compact mass as an in- ferior article does. In preparing the glycerin cotton for use, it should be made into a round ball, about an inch and a quarter in diameter, when loosely pressed in the hand. This may be secured by passing a strong thread around it, having the thread long enough to bring out of the vagina, so that the patient may be able to remove it ; or the cotton may be rolled into the shape of a cylinder, two inches long, and one in diameter, and secured bj^ a thread. Every piece to be used should be thoroughly saturated with the glycerin. It is not sufficient to impregnate the surface of the cotton ball with the medi- cine, but every fibre should be saturated with it. This requires some time to accomplish, and it will be well for office use to submerge the cotton in a jar of glycerin and let it lie until it becomes saturated. 426 LOCAL TREATMENT. When we use these, if they are thus saturated, they may be gently pressed until the glycerin will not flow from their surface. The speculum will be necessary to a perfect application of glycerin, and the cotton must be placed in contact with the diseased surface. One or more of these pieces may be applied according to the capacity of the vagina or the amount of congestion. Glycerin thus used may be applied every third day, and if the cotton is well saturated, allowed to remain twenty-four hours, when it should be removed. Cotton treated with glycerin in this way is not fit for a support to a displaced uterus, and too frequent use of these applications is occa- sionally followed by a sensitiveness of the mucous membrane that renders them intolerable. It is not often that we rely upon glycerin applications for a cure, or even as the principal remedy. It is more commonly used as an adjuvant or a palliative measure to follow stronger applications. When we are under the necessity of making a strong application to the cervix and vagina, to follow it immediately by glycerin prevents the severe consequences that sometimes follow. Local Alteratives. The many remedies applied to the inflamed and abraded surfaces of the cervix, while they fulfil the general indication of changing the action of the nerves and vessels of the parts to which they are applied, their special effects are not precisely the same. There is certainly a wide difference between the local effects of tannin and nitric acid, of tincture of iron and nitrate of silver. Yet we find them all, and many others, used in the same kind of cases, one or two of them re- garded as quite sufficient to cure a large majority of cases. This is the case with iodine, carbolic acid, and nitrate of silver. The prac- tice of experienced gynecologists, in the use of these local remedies, is remarkable in the fact that a very few can agree upon the same articles. To the inexperienced this is perplexing ; but it is account- able for by the consideration that anything which will excite the vasomotor nerves sufficiently to increase the sluggish capillary circu- lation,— an essential item in the process of congestion and inflamma- tion, — will induce a change in the morbid tissue to which it is applied. Astringents, stimulants, caustics, etc., have this effect, and so will the mechanical influence of friction or pressure. This consideration does not justify indifference as to the choice of local applications, for there are other differences than degrees of intensity in their action. There is, therefore, room and reason for selections, which will give quite a range in our choice. We should continually bear in mind that all irritants applied to the cervix as local applications, produce their effect upon the vasomotor nervous system primarily, and, secondarily, upon the circulatory and absorbent functions of the vascular system, LOCAL ALTERATIVES. 427 and that in consequence of the unity of the vasomotor nervous appa- ratus of the cervix and body of the uterus, any impression made upon the neck is reflected upon the body, and conversely. The reflected influence is felt not only upon the vessels, but also upon the fibrous structure of the uterus. This explains the effects of therapeutical measures applied to the cervix. There are also certain remedies which, when applied to the cervix, exert an influence through the blood. Mercury and iodine are un- questionably absorbed, and they may have a double influence upon the local disease, first, by the direct stimulating efl'ect upon the nerves of the part, and secondly, by their well-known general alterative in- fluence. I have several times seen a marked ptyalism follow a single moderate local application of the solution of pernitrate of mercury, Fig. 205. Dr. Buttle's Uterine Scarificator and Leech, very efficient and convenient for abstracting blood from the engorged cervix uteri. and it is not an uncommon thing for patients to complain of a me- tallic taste in the mouth in a very short time after an application of iodine or mercury. When thus they obviously enter the circulation, they may be expected to exert the same influence upon the effusion in the substance of the cervix and body of the uterus as if taken internally. Locally iodine, in the form of the ordinary tincture, Churchill's tincture, and other alcoholic solutions, is a very strong stimulant, and is scarcely caustic in any of these solutions. It is, therefore, in these forms, an excellent application when we desire to produce a strong but superficial effect upon the mucous membrane of the vagina, cervix, or cervical cavity, and should not be repeated often. A solution made by dissolving one part each of iodine and iodide of potassium in one part of alcohol makes a very efficacious application, made by a swab once in a week or ten days to the erosions of the cervix, connected or not connected with laceration. Applied in this way they excite the capillary circulation of the whole uterus to recuperative activity, and thus cure up the erosions and cause the absorption of the deposit in the areolar tissue. Iodine again is used in a different way and for another purpose; that is, in a non-irritating form, in which it may be absorbed and expend its influence as an alterative through the circulation. It is often dissolved in glycerin and applied on cotton to the cervix. The solution of iodine in glycerin for an apj^lication is almost, if not entirely, useles-s, so far as the iodine is concerned, for it is very soon washed out of the vagina by the serum drawn from the parts by the glycerin. 428 LOCAL, TREATMENT. The very iDest way to obtain the fullest alterative effects of iodine as a vaginal application is to impregnate cotton-wool with iodine by mixing the crystals of iodine with the cotton, and then placing them in a well-stoppered bottle in a moderately warm place, when the iodine will become volatilized and diffuse itself thoroughly and uni- formly in the cotton. This cotton may be applied through the specu- lum to the cervix, and allowed to remain there for twenty -four hours. This application may be used every fourth or fifth day. It is a very common practice to combine iodine and other medi- cines for local applications. Iodine and carbolic acid, called iodized phenol, are combined in the proportion of one part of iodine to four parts of carbolic acid. This mixture is a favorite one with Dr. Robert Battey, of Rome, Georgia. He has written an able paper,^ detail- ing its effects in endometritis. His endorsement of it, as a local appli- cation in this form of disease, is a sufficient guarantee of its useful- ness. The solution of pernitrate of mercury ^acid nitrate of mercury), be- cause of its valuable alterative influence, deserves particular notice. Unlike iodine, it is strongly caustic and can be made to destroy the parts to a great depth. In this respect, perhaps, it is about equal to nitric acid. The application of these remedies, however, can be made without destroying the tissues ; and now that we know the salutary influence of our applications does not dej^end upon " burning off the ulcer," or cauterizing the abrasion, but that their efficacy depends upon the excitation they produce upon the submucous vessels, these medicines are used very differently. The acid nitrate of mercury should be applied by the cotton swab so lightly as not to cauterize. The cotton should be dipped into the mercury solution and saturated with it, and, before being applied, pressed firmly between two wooden surfaces until it is merely moist with the solution. The cotton thus pre23ared is applied to the surface ; it coagulates the mucus on the surface merely. The application in a few hours is followed by local reaction in the capillaries immediately beneath the part, which, in a certain degree, is salutary. It is not best to use this for congestion or inflammation, attended or not with abrasion, oftener than once in two weeks or a month. The second day after the menses is the best time. Carbolic acid, in solutions of various strength, is a popular remedy for local application to the cervix uteri. The 95 per cent, solution is equal in stimulating influ- ences to that of the nitrate of silver of 20 per cent, strength. If used exclusively, or as the main article, for stimulating the inflamed cervix, it may be applied once a week. * Read at the meeting of the British Medical Association for 1879, lield at Cork, Ireland. TREATMENT OF ENDOMETRITIS. 429 Among the astringents the preparations of iron, solution of the per- sulphate and the tincture of iron are frequently used. The tincture of iron, once in five or six days, is very generally used with great benefit. The nitrate of silver, once so popular as a topical application, has fallen into disrepute, and is seldom resorted to by our best gynecolo- gists. The main objections to it are the great pain it often produces, the intensity of the submucous capillary excitement it causes, which sometimes extends to the cellular tissue ; the amount of hemorrhage it often causes, and its severe effects upon the nervous system. But the most important objection to it, perhaps, is the shrinkage and conden- sation it brings about in the cervix. After it has been used with any thoroughness for a long time the cervix, and sometimes the uterus, is diminished in size and indurated. Although hemorrhage is a common symptom immediately following the application, it is not unusual that the protracted use of it leads to suppression, more or less completely, of the menstrual flow. It must be admitted, however, that these objections apply more to what, in our present knowledge of its effects, we would consider the injudicious application of it in solid form. In solution it may be made to pro- duce an alterative influence that is difficult to effect with any other remedy. A 50 per cent, solution, applied with the swab, is not a caustic, and is not amenable to the objections just above mentioned, and intended to apply to the solid form. Whatever the application may be, it should not be repeated if fol- lowed by evidences of serious irritation, as pain, lasting for over an hour; tenderness in the iliac or hypogastric region; chilliness or febrile excitement. When an application is made from which we expect any consider- able pain or reaction, the patient should lie down and remain quiet until all sense of inconvenience has passed away. As before remarked, we may frequently secure immunity from suffering by following the application with a tampon of glycerin cotton. Treatment of Endometritis. When the disease is confined to the cervical cavity the simpler forms can be cured by the same kind of application made use of in the treatment of ordinary inflammation and abrasion of the cervix. To make these efficacious it will be necessary to remove the mucus from the cervical cavity by wiping it away with cotton, when that is practicable, and, when not, it may be removed by a syringe. With the ordinary flexible applicator, wrapped with cotton, the 430 LOCAL TREATMENT. remedy is passed into the cervical cavity up to the internal os uteri. The same precaution should be observed in other cases in which the application is made. The treatment of these simple cases is really not more difficult than when the disease is on the outer cervical mucous membrane. And as the external cervical inflammation, with erosions, coexists with the endocervical, they should both be treated at the same time, by first making the application externally, and then passing it into the cervical cavity. We sometimes meet with an obstinate yet uncomplicated form of endocervicitis, or cervical catarrh, that resists all of the usual remedies. The cervix is filled with an extremely tenacious mucus that is re- moved with great difficulty, the cavity of the cervix is enlarged, and when the mucous membrane is exposed may be seen to be very rough, granulated, and scarlet red. The granular eminences are the enlarged muciparous glands, the glands of Naboth. Dr. Sims* reports cases of this kind cured by thoroughly scraping the cervical cavity with a sharp curette, and afterwards touching the surface lightly with the actual cautery. Dr. Isaac E. Taylor, of New York, says he has re- sorted to this treatment with great success. When the inflammation extends to the cavity of the body of the uterus the treatment is more difficult of accomplishment, attended with less satisfactory results, and sometimes followed by severe symp- toms. When it is uncomplicated, and the cervical canal at both extremi- ties is patent, the treatment is generally simple and efficacious. The applications adapted to this form of disease are the same as for endo- cervicitis and are made in the same way. The applicator charged with the remedy is carried to the fundus, and by a gentle rotary movement made to touch the whole endometrium. Ordinarily these applications are not very painful. This form of endometritis, when the cervical canal is sufficiently open, may also be successfully treated by the dull-wire curette. This instrument may generally be passed with great ease, and, after it is introduced, it is gently passed over the whole surface of the cavity. This can be re- peated once a week if necessary. I could report several cases where the curette used in this way has done more good tha,n any other remedy used, and apparently com- pleted the cure. The curette in these cases is used, not for the purpose of cutting away any portion of the living membrane, nor for removing growths or granulations, but for the purpose of stimulating the circulation in the mucous membrane. * Transactions of the American Cxynecological Society, 1879. TREATMENT OP ENDOMETRITIS. 431 When endometritis is complicated, the treatment will of course be very much modified by the complicating circumstances. Stenosis from contraction is a very inconvenient complication, because it must be overcome temporarily at least before our applications can be made complete. In this form I have frequently succeeded by using the slippery-elm tent. The tent can be made to overcome the stenosis and at the same Fig. 206. Slippery-elm Tent. time exert a salutary influence by pressure upon the mucous mem- brane of the uterine cavity, and thus suffice to effect a cure. The slippery-elm tent is made about one inch and a half, or one and three-fourths long, and the sixth of an inch in diameter at the large extremity, and small enough at the other to pass through the 432 LOCAL, TREATMENT. narrowest place. Every tent should be securely fixed by threads so that it cannot be lost in the cavity, and may be easily removed. When we use them we thoroughly moisten them for two-thirds the distance from the extremity to be introduced. This moistening may be done in a moment by dipping them into water and then pinching and bending them. The part thus moistened should be soft enough to bend in any di- rection with very slight force. When the cervix is exposed we take the dry end of the tent in our dressing forceps and pass the moistened end into the uterus. The pliability of the tent enables us to pass it easily into the most tortuous canal. After having passed one, if we Fig. 207. Slippery-elm Tent introduced. are not satisfied, we may introduce one by the side of it, and then two, three, four, or a dozen, until we have dilated the canal suffi- ciently. These may be allowed to remain several hours if necessary, to cause further dilatation. But often they may be removed at once, and the cervix Avill be large enough to receive an application. I know, however, from frequent trial that no other application is neces- sary to cure many cases of endometritis. When I introduce one or two tents, in cases where stenosis com- plicates endometritis, I instruct the patient to remove the tent by TEEATMENT OF ENDOMETRITIS. 433 drawing upon the thread whenever it gives her decided pain, and to not let it remain more than twelve hom^s if it does not give her pain. This is by far the most comfortable way of dilating, and according to my observation, the most effective. The slippery elm has the ad- vantage of being inexpensive and easily procured. In ten minutes the practitioner can make a dozen Avith his pocket-knife, out of the dry bark found in any drug store. When used in this way, and for this purpose, the dilatation is very moderate, but by repeating it be- comes permanent more readily than by the use of any other means. I can say further that I have had no bad results from slippery-elm tents when used in this way, and in those exceptional cases alone where a mere touch of the probe is painful do I apprehend the pos- sibility of harm. It is the safest means to dilate the cervix now in use, and when several are introduced by the side of each other they may be made to dilate the cervical cavity in a few minutes. Fig. 208. The Uterus In a state of Anteflexion, with the Slippery-ehn Bougie introduced into it.. This tent also may be made to shield the cervix from the effects of the pressure of the more energetic dilators. If we wish to dilate the cervix largely we may pass a sea- tangle or sponge tent, and then fill the cervical cavity around it by slippery-elm tents. As the sea- tangle or sponge expands, the elm tents shield the deli- cate mucous membrane from contact with the hard tent, and when the time comes to remove it there will be no difficulty in getting it away. Complicating misplacements, especially retroversions, should be cor- rected as an indispensable item of treatment. After the correction is made the treatment will not differ in any respect from the uncompli- cated case. Flexions are more embarrassing complications than displacements, 28 434 LOCAL TREATMENT. because the point of greatest flexion is stenotic. Sometimes the ste- nosis is so great that it is difficult to pass a small sound. (Fig. 208.) The correction of the complication and the treatment of the inflam- mation may both be accomplished at the same time. These are the cases in which the slippery-elm tent will be of the greatest service. They are often attended with the dysmenorrhoea of obstruction. We can dilate and, to a certain extent, correct the flexion every time we make an application, by using one or two elm tents before introducing the application. But generally the tents, if allowed to remain in the cavity, as directed in the treatment of stenosis just described, will ex- ert a salutary effect by pressure. When the practitioner finds that a pessary can be used to advantage, it may be employed at the same time with the other treatment. When complicated by menorrhagia both diseases may generally be cured by the curette used as above directed. I have said nothing about intrauterine injections as a means of cur- ing endometritis. The subject has been very thoroughly discussed by the members of the profession, and few prominent gynecologists resort to this means in any form or at any time, except in the puerperal con- dition of the organ. For my own part, I have never injected the uterus for endometritis, and I do not hesitate to condemn it in such cases as dangerous, and yet there are those for whose opinions I have the high- est respect, who advise and employ injections, and speak of them as the most efficacious of all methods of applying medicines to the in- terior of the uterus. Professor James P. White,* of Buffalo, has invented a pipette of glass, bent to the shape of the uterus, with a bulb of india-rubber at the external end. He dips the end of the tube, which is very minute in size, into the fluid he desires to use, and then passes it through a speculum into the uterine cavity, and presses out in drops, or as much as he desires to leave there. The small quantity thus intro- duced he claims cannot, and does not, give rise to any grave symp- toms. In discussing the paper thus referred to. Dr. Munde, of New York, said : That he applies fluids to the cavity of the uterus through a very small flexible tube invented by Dr. Buttles, of New York. He thinks, cautiously done, this is a safe and efficacious way of treating the in- terior of the uterus. This method of using fluids in the cavity of the uterus can hardly be classed among injections, as the term has been heretofore understood. * Paper read before the American Gynecological Society, 1879. CHAPTER XXIII. LACEEATIONS OF THE CERVIX UTERI. The consequences of this accident are so serious, and its occurrence so frequent, that it demands a prominent place in every text^book on gynecology. While many observers had noted the presence of lacerations of the cervix uteri, their importance until lately has been underrated ; they were thought, in fact, to give rise to no appreciable effects. This view was encouraged by the fact that a proper treatment of their consequences generally resulted in a temporary and sometimes permanent removal of the symptoms. Until Dr. Emmet made his remarkable researches upon the sub- ject, laceration of the cervix j^assed for one of the forms of ulceration and was described as ulceration of the cervix uteri. Now, however, owing to the enthusiasm of the discoverer, many of his students have gone to what I consider an unjustifiable extreme in the other direc- tion, expressing their opinions that, instead of everything being called ulceration, the proper term is laceration of the cervix. To Dr. Emmet belongs the credit of first appreciating the impor- tance and appropriately treating this accident. It very seldom occurs to any man to have the opportunity of giving to the profession so complete a description of an abnormal condition, and to perfect the process of cure, so that there is left to others but little room for improvement. Yet this is the good fortune of Dr. Emmet. Causes. Laceration of the cervix occurs during labor or expulsion of the contents of the uterus in abortion. Sudden expulsion of the head in cases where the cervix is not dilated sufficiently may eventuate in its rupture. It would be foreign to my purpose at present to discuss the various causes of the rigidity which prevents the ready dilatation of the cer- vix. They certainly are numerous and of frequent occurrence. Nor do I consider it necessary to criticise the early and frequent use of the forceps practiced by the accoucheur of the present day. The time has not yet come when the facts are at hand to justify such criticism. It is in order, however, to inform the obstetrician that his patients come to the gynecologist with laceration of the cervix in great numbers. Dr. Emmet finds laceration in about 16 per cent, of the cases coming 436 L,ACEEATIONS OF THE CEEVIX UTERI. to him for treatment on account of uterine disease. Dr. Munde puts them down at about 17 per cent., Dr. Montrose A. Fallen at 40 per cent., and Dr. Goodell says one in every six of his dispensary patients has laceration of the cervix. My own observation confirms the opinion that these lacerations are of very frequent occurrence. Ob- serving the difference in virgin, as compared to the parous uteri, one must conclude that slight laceration from labor was the rule. Can extensive laceration of the cervix always be avoided ? This question brings to mind the frequency with which the perineum is torn under the management of the best practitioners, and the univer- sality with which slight laceration of that body takes place in primiparous women. The Degree, Locality, and Direction. The degree of laceration varies from the slight, a,lmost inappreciable rupture to the splitting of the cervix into and above the vaginal junc- tion. It may be confined to one side, while the other retains its integrity, or both sides may be torn, one slightly and the other largely, or both to their utmost extent. The locality of the laceration is much more frequent in a line cor- responding to the junction of the anterior and posterior halves of the cervix, but sometimes the anterior or posterior lip of the uterus is torn in the centre in the various degrees above mentioned ; in others both the anterior and posterior lips are thus lacerated. In rare in- stances we find the two lateral and the two central lesions in the same cases, making the cervix project into the vagina with four points. I have seen one case where the anterior lip was split up to the vaginal junction, and then torn across to the left side, the portion torn hang- ing down into the vagina. Dr. Emmet thinks that the anterior and posterior labia are fre- quently torn, but from the direction of the vaginal pressure they generally heal up, and consequently do not often come under our observation. It is not unlikely, as he observes, that many lateral, as well as central, lacerations close up during the term of lying in, and therefore never give rise to any inconvenience. Effects of the Laceration. If we were guided by what we know of traumatic lesions elsewhere, as well as what we find in the cervix itself, we would, a priori, infer that inflammation was an early consequence of the accident. The torn edges, much more frequently than otherwise, become covered with cicatricial tissue, the result of inflammatory exudation, and a large amount of this cicatricial deposit is occasionally found in the angle of the laceration. Sometimes this last point of deposit COMPLICATIONS. 437 presents a tough, hard node, that must be removed with great care to secure perfect results. This is not all the effects of the inflammatory action. Sometimes a fibrino-plastic exudation in the connective tissue of the two cervical flajjs takes place, and they become large, dense, and hard. The surgeon will often find the cervix indurated so greatly that it resists the instruments, especially the passage of the needles; and he will find, as a rule, the more extensive the laceration, the greater will be this particular change, showing that they are all the seat of the most intense inflammatory action, and the converse. Another effect of the laceration on the parts is, at first, an inflam- matory action in the mucous membrane of the cervical cavity. Fibrino-plastic deposits occur in the dee^Der portions of the mem- brane, which becomes turgid and redundant; its epithelium is shed, and it presents a scarlet, rough surface. Sometimes the redundancy of the membrane is so great that it rolls out and forms a mass, fun- giform in appearance. As another consequence of this fibrino-plastic exudation, the mouths of many of the ducts leading from the glands of Naboth are closed, and the mucus of the glands is confined within their cystic cavities, or the whole gland is surrounded by the exudation and becomes in- volved in the hardened mass. Thus, in different cases, we find the glands presenting the appearance of translucent blebs or shot-like granulations. Effects on the Body of the Uterus. The inflammatory process going on in the cervix, resulting from lacerations, arrests involution, and the uterus remains large and vas- cular ; in other words, in a state of subinvolution until the chronic inflammation is removed by proper treatment of the mucous mem- brane and submucous tissue, and the laceration closed by hystero- trachelorraphy. That lacerations which do not cause and maintain this uterine hypertemia are innocent of general disturbances, is admitted by Dr. Emmet, as I have shown elsewhere by quotations from his work.* Complications. Other embarrassing complications of laceration of the cervix are displacements, prolapse, and retroflexions, and lacerations of the peri- neum and vagina, and cellulitis and local peritonitis. These com- plications increase the hypersemia of the uterus, — retroflexion, by constriction of the cervix and consequent turgescence of that portion of the uterus with this ; and prolapse, by altering the direction of * Article on Subinvolution. 438 liAciERATiojsrs of the cervix uteri. the veins which carry the blood from the uterus, augmenting the previously existing hypersemia of that organ. The uterus is thereby increased in weight, fibrino-plastic changes produced in its substance, and the nutrition of the mucous membrane of its cavity disturbed in a marked degree. Symptoms. The general symptoms following laceration of the cervix are not distinctive. That lesion produces, through its effects upon the body and cervix uteri, the symptoms given in detail elsewhere, under the head of Hysteropathy, and consequently need not be repeated here. Diagnosis. This cannot be made out by subjective symptoms alone, and we must depend upon a thorough examination of the j^arts by the touch and use of instruments. By careful examination with the finger the notch in the side, when large, will be easily detected. The finger should pass along the vaginal wall to its junction with the cervix, and keeping it in the cul-de-sac, passed all around so as to encircle the neck. In most instances, as the finger passes over the side, we will rec- ognize the fact that at that point the neck does not extend below the vaginal junction. The finger will sink into a depression between the labia. When the finger is educated in the vaginal touch, the lesion will be easily recognized. The sound will generally pass deeper into the body of the uterus than it will in the normal state of that organ, because the uterus is in a state of subinvolution. When well exposed by the speculum, the cervix will generally be found covered by a muco-purulent fluid, enlarged, the labia turned out, the exposed cavity of the neck intensely red, and the surface roughened in consequence of the loss of epithelium, and an enlarge- ment of the papillae and muciparous glands. The infallible test, however, is to seize the extremities of both labia with tenacula and draw them down together, somewhat forcibly. If the cer^dx has been torn on the side, the notch will be plainly seen. If there is no laceration, the cervix will be truncated instead of bifid, and the points of the tips can be drawn down only a trifling distance below their lateral junction. Treatment. The treatment may be preventive, preparatory, and operative. The prevention of laceration of the cervix does not usually come within the province of the gynecologist. The obstetrician has charge PEEPAEATORY TEEATMENT. 439 of the patient at the time of the accident, and upon his skill will de- pend such immunity as can be secured by science. The probability is that it cannot be prevented in most instances in which it occurs, no more than laceration of the perineum can always be prevented. I can easily see how an early rupture of the membranes, a too early use of the forceps, or an ill-advised administration of ergot would favor laceration of the cervix. Now that their attention is called to the subject, obstetricians will no doubt soon be able to furnish the facts upon which may be based a judicious preventive treatment; at present it must be founded upon a rational view of the processes of labor. Preparatory Treatment. The treatment preparatory to an operation has been as fully devel- oped by Dr. Emmet as any part of the subject, and my experience corroborates the correctness of his teachings. The object of the preparatory treatment is to bring about a plastic condition of the parts to be united. This is accomplished by correct- ing any deviation from the normal state of general health by tonics, nutritious diet, exercise in the open air, promoting a soluble condition of the bowels with appropriate laxatives, etc. A robust state of the general health is an all-important part of the preparation in this as in all plastic operations. The local preparatory treatment consists, first, in placing the uterus in such position as is necessary to secure the greatest possible freedom of circulation, for the purpose of reducing the general hyperemia of that organ ; second, making use of such applications as will reduce the hypersemia of the uterus and cervix; and,- third, where there is induration from fibrino-plastic exudation in the connective tissue of the cervical flaps to as far as possible dissolve it out and bring about a normal condition of the structure. The first indication is Diet by a judicious use of pessaries of cotton, lint, and the closed-lever instrument.* The second, calls for the use of glycerin, cotton tampons, local bloodletting by puncture with Buttle's lancet-shaped knife, or other instrument which will answer the same purpose, and large hot- water injections. An employment of these means perseveringly for a sufiicient length of time will be pretty sure to effect this object. The third will generally require more time, and is of equal importance with the other two. The ap- plications for this purpose consist in remedies that will stimulate the absorbents to the removal of the indurating substance. Dr. Emmet- relies to a great extent upon Churchill's tincture of iodine for this. * See Displacement, 'AO J.ACERATIOXS OF THE CERVIX UTEEI. purpose. He applies it freely to the whole of the denuded mucous membrane about twice a week, followed by glycerin dressings. It is doubtless an excellent application. Occasional moderate dilatation by Peaslee's or Hanks's dilators, often has a beneficial effect upon the cicatrized tissues high up in the cervix, and improves the circulation. When the gland cysts are large and numerous, Emmet pricks them with the lancet-shajDed knife to void their contents and to deplete them of blood. In many cases of long standing, and where the pathological changes are greatest, the prejoaratory treatment will require to be employed for several months to secure the best results. In others of recent standing, and where the changes consist mostly of hypersemia, a few weeks will suffice. The Operation. To Dr. Dudley, of this cit}", is conceded the honor of first giving this operation an appropriate name, "trachelorraphy." Two or three days after the menses cease to flow is the best time to operate. Fig. 209. The Cervix with the Threads passed. The day before the operation it is a common practice, and I think a good one, to move the bowels pretty thoroughly by giving a laxative. THE OPERATION. 441 At the time of the operation I usually give the patient ether. This, however, is not absolutely necessary, especially in cases of moderate extent, as the operation is not very painful. The patient is placed in Sims's or Simon's position, and the vagina dilated as largely as necessary to bring the cervix into view. The Fig. 210. neck is then seized with a vulsellum forceps, and drawn down until the lips can be transfixed from before backward by a strong needle armed with a double thread. The threads are drawn through enough to form two loops, each through one of the labia, of sufficient length to pass several inches Fig. 211. Byford's Uterine Scissors. out of the vaginal orifice. With, these loops of thread the cervix can be very completely fixed, and its position varied, as the convenience of the operator may require. The loops of thread may be held up by an assistant, subject to the direction of the surgeon. A small curved tenaculum forceps may be used for holding the cervix in position, or a strong double tenaculum. 442 LACEEATIOXS OF THE CERVIX UTERI. When thus prepared the oiDerator seizes the edge of the laceration with a tenaculum, and with scissors j^ares off all the cicatricial mem- brane. The denudation should he carried up into the angle between the cervical flaps and the wedge of cicatricial deposit thoroughl}^ re- moved. In doing this care should be taken to cut off any irregularity of surface on the edge of the laceration, so that the edges of the two sides may be brought into smooth coaptation. After the denudation is perfected, and the hemorrhage ceases, the stitches may be intro- duced. Beginning an eighth of an inch from the incision on the outer surface of the flap, the needle is passed perj)endicularly through to a point that will include the same distance of the endo-cervical mem- brane. To the thread in the needle should be attached silver wire eight or ten inches long, drawn through and held by an assistant, until all of the wires are placed as in Fig. 212. Before twisting the wire the edges of the wound should be wiped clean of every small coagulum. If this precaution is not taken a clot of blood ma}^ be included between the united edges and prevent comj^lete union. The wires may then be twisted evenly, as represented in Fig. 213. Pre- pared catgut, silkworm gut, and silk thread are equally as good as the silver wire. I now always use the silk thread. After the operation the vagina should be thoroughly cleansed and the patient j)ut to bed. As the reader will see, this operation is a simple one, under favor- able circumstances, i. e., when the laceration is lateral, and does not extend above the vaginal junction. When it is stellate, or there is much loss of tissue, the ingenuity of the surgeon will be severely taxed. I am not informed as to the average number of successes in the operation of trachelorraphy, but I know that failures are not infi'e- quent, and it may be well to consider what are the reasons of failure. Among these reasons is an imperfect performance of the operation, but chief among them is imperfect jDreparation. The after-treatment is of great importance, especially for the first few da3^s. The patient must remain very quiet and avoid all causes of vascular and nervous derangements. After this time there can be more freedom of motion. It is desirable that the bowels be not moved before the end of this time, when a laxative may be given, and means taken thenceforward to keep them in a soluble condition. If we do not conclude to prevent the evacuation of the bowels, we should ad- minister diet and saline laxatives to soften the fseces. It has been usual to draw off the urine for the first four or five days, but this is not essential, as it is only necessary to avoid straining. The diet must be light, and for the most part liquid, for the first few days. The vagina should be kept clean by warm-water injections two or three times a day from the beginning to the end of the after-treat- THE OPERATION. 443 ment. I have been in the habit of removing the sutures about the tenth day, but in the majority of cases they might be taken out on the seventh or eighth clay. Fig. 212. The Mode of Passing the Sutures. Fig. 213. The Sutures Properly Placed and Twisted. CHAPTEK XXIV. OCCASIONAL UNTOAVAED EFFECTS OF UTERINE MANIPULATIONS AND OPERATIONS. For the purpose of making the student understand the necessity of great caution and gentleness in examinations and operations upon the uterus, I subjoin a summary of the researches of Dr. George J. Engle- man, of St. Louis, on the subject.* Many of the cases mentioned by Dr. Engleman occurred in the hands of the most accomplished practitioners in different parts of the world. A simple digital examination of the unimpregnated uterus, in the hands of Nelaton, was followed by fatal peritonitis. Several cases of death from peritonitis were the result of the use of the uterine sound ; some because the sound perforated the uterine tissues on account of fatty degeneration rendering them soft and j)er- meable ; others without any apparent reason. There are also cases in which untoward results followed the use of vaginal injections of warm water. A number of deaths are recorded in which peritonitis was caused by the use of sponge tents. One case is mentioned of severe perito- nitis from replacing the uterus by means of the sound. There is always more or less risk in this operation. Dr. J. M. Allen gives a case in which death was caused by the application of tincture of iodine to the cervix. Cellulitis has followed the application of various substances to the cervical and uterine canal. The danger of injections into the uterine cavity is shown by allu- sion to several cases of death in the hands of skilful gynecologists. The most trivial operations on the uterus or other organs in the pehdc cavity are sometimes followed by fatal results. Even scarification of the cervix has been the cause of fatal peritonitis. I have known of two cases of death follow incision of the cervical canal, and several others are mentioned in Dr. Engieman's pajier. Operations for lacerations of the cervix have been followed by death in several instances. The most careful removal of small polypi may be the cause of fatal peritonitis. Perineorrhaphy has, in a number of instances, been followed by * Paper read before the Missouri Jledical Society, and publislied in September No., 1880, American Practitioner. UTERINE MANIPULATIONS AND OPEEATIONS. 445 similar consequences. Stem pessaries, when incautiously used, are very dangerous instruments. It therefore appears that any kind of manipulation of the uterus or its lining membrane is, under certain inscrutable circumstances, liable to start an acute peritonitis. One of these circumstances, and per- haps the most frequent one, is the existence of an inappreciable grade of inflammation in the cellular or peritoneal structures immediately surrounding the uterus. Dr. Noeggerath * believes that latent gonorrhoea is very often the character of this lurking inflammation. It would seem that the use of sponge tents, intrauterine stem pes- saries, intrauterine injections, intrauterine applications, and cutting operations on the cervix uteri, were especially dangerous. We should exercise great care in all our manipulations of the pelvic organs, and leave no precautions known to gynecology unemployed to avoid the dangers that occasionally present themselves when we venture upon the use of sponge tents, intrauterine injections, stem pessaries, or operate upon the cervix. Antiseptic precautions are al- ways advisable. * Gynecological Transactions, 1876. . CHAPTER XXV. HYPERTROPHY OF THE CERVIX. Hypertrophy of the cervix is different from enlargement caused by fibrinous accumulation, and consists of an increase in the proper tissues of the organ. It is a real hypertrophy. Although not nearly so frequent as the enlargement from chronic inflammation, it is not of very rare occurrence. The symptoms do not differ from prolapse of the uterus sufficiently to characterize it. The patient generally ex- periences a sense of bearing-down or weight on the perineum, pain in the sacral region, leucorrhoea, sometimes menorrhagia, and the various sympathetic symptoms already sufficiently dwelt upon of uterine irri- tation. Diagnosis. Upon examination the cervix is found hypertrophiecl and enlarged. There are two general forms observed so well marked as to entitle them to special mention. The first is such as we usually find in the nulliparous, an elongation of the whole cervix, and, some but not generally very great circumferential increase of size, and without much deviation from shape. This form is seen in Fig. 214. The next variety is an elongation and enlargement of the anterior or posterior labium, as represented in Fig. 215. I am not certain, from my own observation, whether this is always a pure hypertrophy or a mixture of this process with fibrinous infiltration ; probably the latter. The only appropriate treatment is amputation, and it is generally sufficient to remove all the disagreeable symptoms resulting from it. The plan I have usually pursued in removing this growth is by icrase- ment. The chain of the ecraseur is passed around, at the place where the point marked out by the dotted line is seen in the figures, and the ratchet slowly worked until the division is complete. This operation is easily performed, and is perfectly safe when carefully done, and the parts cicatrize in a few days. An inconvenience mentioned by Dr. J. Marion Sims is encountered, in some instances, in amputating the first variety, viz., the contraction of the opening of the cervical cavity. It is an inconvenience, however, that is of no great importance generally, and may be remedied by making a small incision with a blunt-pointed bistoury immediately after the operation of amputation. Dr. Sims ELONGATION OF THE SUPEA VAGINAL CERVIX. 447 amputates the cervix with scissors. He exposes the organ with his speculum, cuts the parts squarely through at the dotted lines, and then Fig. 215. Figures showing two Varieties of Hypertropliic Elongation and Enlargement of tlae Cervix Uteri. The Dotted Lines show the Proper Place for Amputation. draws the mucous membrane together over the cut surfaces with silver sutures. (Figs. 217 and 218). This lessens the size of the cut surfaces, and the parts heal more readily. Elongation of the Supravaginal Cervix. This condition of the cervix so completely simulates procidentia of the uterus that upon a superficial examination it may be mistaken for that condition. The elongated vaginal cervix with the vagina are protruded from the external parts. The vaginal walls are everted anteriorly and posteriorly, forming in most instances cystocele and rectocele. Sometimes the protrusion is less extensive, and the cervix alone protrudes from the external parts. The diagnosis is made by introducing the sound. That instrument will enter to a much greater depth than when the uterus is prolapsed, sometimes five or six inches. 2d. By placing the patient in the knee-chest position. In this pos- ture the cervix very readily enters the pelvis and rises up to its normal position. If the sound is now introduced it will not enter the uterus to so great a depth. 3d. By introducing the finger into the rectum while the patient is standing, we can feel that the length and shape of the uterus are greatly changed from the normal. The fundus and body will be 448 HYPERTROPHY OF THE CERVIX. found in situ, and from it the attenuated and elongated supravaginal cervix can be traced downward to its attachments to the vagina. This elongation of the cervix is called tensile elongation by Dr. Matthews Duncan, and, doubtless, as Dr. Goodell* believes, is the result of hypertrophy and stretching, instead of true hypertrophy. It would seem at any rate that the elasticity of the cervical tissues was very much increased, as in the erect posture, with the slight Supravaginal ElongatioD of the Cervix. welo-ht of the relaxed vaginal walls and the bladder and rectum, the neck becomes elongated, and when the patient lies down retraction may soon follow. The vao-inal portion of the cervix in most cases is considerably hypertrophied, and in respect to length and volume is much above the usual dimensions. There are other conditions in connection with tensile elongation of the cervix that have an important bearing upon the etiology and treatment. Almost all supports in the lower part of the pelvis are in a state of great relaxation, and, instead of being reten- tive, they contribute to the aggravation of the al^normal condition of the cervix. This is especially the case with the vaginal walls, the vesical liga- ments, connective tissue, and fascia. The perineum is either anatomically deficient from laceration, or destitute of that tonicity which makes it capable of resisting the pro- * Gynecological Transactions, 1879. ELONGATION OF THE SUPRAVAGINAL CERVIX. 449 trusion of the cervix. In contrast with this the supporting apparatus in the upper part of the pelvis retains its natural, if it is not endowed with more than normal retentive power. The treatment of this form of elongated cervix will depend some- what upon the time it has lasted, the extent of the elongation, and the relaxation of the perineum. When the lesion is of recent origin, and the perineum has not been lacerated, and possesses a reasonable amount of resistance, we may- hope to succeed in restoring the shape and size of the cervix by prop- erly supporting it with a pessary. In selecting an instrument for this purpose it will not often do to choose one that has its bearings wholly upon the perineum, but one that is partially maintained in position by external means. In the hands of most practitioners, I believe Cutter's or Scott's will fulfil the purpose more certainly than any other. While both of them rest upon the perineum, they may be so adjusted that they will not bear upon it with much weight. If, however, the perineum is in a lacerated or greatly relaxed state, we must depend mainly upon surgical means, and as the result of ray own observation, I do not hesitate to indorse the practice of Goodell as set forth in the paper above referred to, viz., to amputate the vaginal cervix and operate upon the perineum afterward if necessary. I do not consider it neces- sary to remove the cervix at the vaginal attachment, but think it better to leave a margin of one-fourth of an inch. Great care is neces- sary in removing the cervix in this condition to avoid wounding the bladder or opening the peritoneal cavity. Whether the amputation is done with ' scissors, knife, galvano- cautery, or ecraseur, we should take measures to secure ourselves against this accident. The most convenient way to do this is to pass two strong steel wires through the cervix slightly below the junction of the vagina and cervix. The wire or chain of the ecraseur may be applied close up to this wire ; this will prevent any traction upon one part more than another. The scissors may be used and the cervix amputated according to the method of Sims (Figs. 217 and 218), who draws the mucous membrane over the stump and unites it with four sutures, two on each side of the cervix. Hegar similarly unites the edges of the sides, but also unites the edges of the cervical mucous membrane with the vaginal edges opposite by two or three on the ante- rior, and the same number on the posterior cervical walls in the middle portion. The patient must remain in bed several weeks to secure the best results. Simon operated by cutting a wedge from each lip (Fig. 219) and uniting the raw surfaces. This method is more applicable to cases in which the cervix is thickened as well as elongated. As there is often more or less cervical laceration, Emmet's operation for lacera- tion (removing plenty of tissue) is sometimes preferable to amputation. 29 450 HYPERTROPHY OF THE CERVIX. When the perineum has been lacerated perineorrhaph}' should be performed before the patient attempts to exercise on foot. Fig. 217. Amputation of the Ccr\i\— aftei Sims. Amputation of the Cervix — Sutures Tied. If the perineum does not need restoration, and there should be any tendency to continuance of supravaginal elongation after the opera- tion, Scott's pessary should be introduced, to supply the support that the perineum in a healthy condition would give. Fig. 219. Simon's Method of Amputating the Cervix. Success in this operation will depend very greatly upon the treat- ment and care the parts receive for some time after the patient resumes the erect posture and her usual exercise. CHAPTER XXV I. ACUTE PERIMETRITIS. I USE the term perimetritis to signify inflammation of the tissues surrounding the uterus, and include both cellulitis and local perito- nitis under this head. There is an abundance of areolar tissue in the pelvis. It is be- tween the bladder and pubis, the bladder and vagina, the vagina and rectum, but in greater amount between the sides of the vagina, uterus, and bladder, and the pelvic bones. (See p. 23, Figs. 7, 8, 9.) In a loose manner it fills up the space indicated. Within the folds of the peritoneum, the ovaria, the Fallopian tubes, and the round ligament are included with the cellular tissue. Inflammation attacks this areo- lar tissue not unfrequently on one side, and involves the tube, the ovary, ligament, and peritoneal covering ; less frequently both sides are simultaneously inflamed, and still less often that part between some of the hollow organs of the pelvis is affected, when we have a comparatively small point of disease, as, for instance, between the 'bladder and vagina, or this last and the rectum. This is perimetritis. There is a strong tendency when inflammation is lighted up in any part, to spread to the space at the side of the uterus and vagina cov- ered by the broad ligament, on one or both sides. The inflammation is apt to run its course rapidly, as is usual in areolar tissue, either to resolution or suppuration, and as this tissue is abundant, and the organs in the pelvis easily moved, the effusive products are likely to be copious. In the first stage of inflammation, serum is rapidly poured out between the folds of the peritoneum by the side of the uterus and vagina ; it pushes these organs to one side of the pelvis, and forms a prominent inflammatory tumefaction at the side of the pelvic cavity, within easy reach of the finger. This tumidity becomes harder in a short time, and forms a solid medium of connection be- tween the uterus and wall of the pelvis, indicating the change from serous to fibrinous effusion. Within a week or ten days, in very acute cases, in others from two to four, or even six weeks, the areolar tissue is broken down into copious suppuration. In some instances the suppuration does not advance beyond the stage of serous effusion. When, after lasting for an uncertain time, the symptoms begin to subside, the tumefaction disappears, and the patient soon recovers her health; while in others it is arrested after fibrinous infiltration has cemented the parts solidly together. Although the symptoms are 452 ACUTE PEEIMETEITIS. moderated from their first acuteness when this is the case, some of them, as undue sensitiveness and sense of weight, and other kinds of pelvic distress, remain for a considerable time, and the patient re- covers from the attack very slowly, if ever completely. When sup- puration takes place, if it is completely and readily evacuated, the patient very soon regains her health and strength. In some patients of broken-down or damaged constitutions, sloughing and extensive ulceration increase the damage to the organs. I once saw a syphilitic patient in whom extensive and rapidly spreading ulceration opened the rectum, vagina, bladder, and, finally, the peritoneal cavity. Sup- puration in this case was unhealthy and ichorous, smelling strongly, and produced excoriation of the parts over which it flowed. If the evacuation of the jdus is imperfect on account of opening into the rectum or bladder, and even in the vagina, the symptoms may be prolonged for months and even years. And in some cases where the evacuation of the pus and subsidence of the inflammation seemed complete, the disease recurs usually with diminished acuteness a num- ber of times. I once had a patient in whom an attack of perimetritis was contemporaneous with incipient pregnancy for four different times while under my care. In each one of these four times, the inflam- mation commenced at about the time the menstrual flow ought to have appeared after conception. Every time there was copious sup- puration, a free discharge of the pus, and, to all appearance, a com- plete recovery from the inflammation. The intervals were about two years in duration. I have seen three instances in which the recurrence of the inflammation had occurred at irregular intervals from three months to a year for over six years, another ten, and one as much as eighteen years. In this last case, the abscess was situated at the left side of the uterus, and usually after a week or ten days of acute suf- fering, it discharged about a half ounce of fetid pus, and then disap- peared, so that nothing but a slight induration at the point mentioned indicated any tendency to its recurrence. This chronic form, I think, is not very uncommon. I believe, also, that chronic induration in the spaces occupied by the pelvic areolar .tissue, caused by fibrinous infiltration, not unfrequently presents itself as the effect of acute peri- metritis, producing many distressing symptoms, and rendering the patient liable to a recurrence of acute attacks. The extent of the in- flammation and tumefaction is governed somewhat by the condition of the jDatient. If she be in the puerperal state, the inflammatory excitement is likely to be greater, the swelling more extensive, and the suffering more severe, than if this condition is not present. Preg- nancy increases the intensity of the disease beyond what it is in the unimpregnated condition; the fever runs higher, and the extent of the inflammation is greater. The same will be the case after abor- CELLULITIS. 453 tions. The mildest form of perimetritis is that which occurs in the unimpregnated female. When pus is formed, it finds its way out through several different channels. First, and most frequently, through the vagina ; the wall of the abscess nearest the vagina ulcerates through into this canal, and the pus escapes, first in small quantities, and finally freel}^, until the whole is evacuated; a number of days, and even weeks, may elapse before the discharge ceases and the cavity is filled up. The escape through the vagina is not only the most common, but this is the most favorable outlet, as the opening is generally pretty free and permanent. Second, in frequency, as the medium of discharge is the rectum ; the pus makes its way into this intestine generally at the upper end of the septum between it and the vagina. The discharge is comparatively slow and unsatisfactory, appearing with the stools in small quantities, and continuing for a length of time. The open- ing into the bowels is almost, if not invariably, valvular and tottuous, permitting the escape with difficulty. If there does not occur a second opening into the vagina, the abscess will generate pus almost as fast as discharged, and we may expect times of partial relief and exacerbation for months and even years. I am acquainted with an instance in which the patient has not been entirely free from suffering from this cause for the last six years, and a number of times has been prostrated for weeks. But few days pass without the patient observ- 'ing matter in the fecal evacuations. The pus makes its way at other times through the inguinal regions ; sometimes it points in one of the labia, or burrows through the gluteal region. It also jDerforates the uterus or bladder, and follows the channels leading from them out- wardly. When the pus finds its way into any of these hollow organs, it causes severe irritation in them and efforts at expulsion. Dysuria, dysentery, and vaginitis are generally caused by it to a moderate de- gree, but sometimes the suffering from this cause in these organs is very great. But another mode of escape from the cavity of the ab- scess is into the peritoneal sac. This misfortune is comparatively infrequent, fortunately, but invariably fatal unless relieved by lapa- rotomy. I have been unfortunate enough to be connected with two cases in which this untoward circumstance occurred. One of the patients was attacked in the puerperal state, and, after suffering for eight weeks with the inflammation of the tissues around the uterus, acute general peritonitis terminated her life in about thirty-six hours from the time it commenced. Upon examining the abdominal cavity, an opening was found near the left sacro- iliac junction, which communicated with the interior of the abscess, and several ounces of jdus was in the cavity of the peritoneum, that had made its way through this opening. The usual lesions of extensive and acute peritonitis gave evidence of the cause of death. The other 454 ACUTE PERIMETEITIS. case was in a sterile married woman, about twenty-five years of age, who had been treated three weeks for typhoid fever. Dissection revealed a large pelvic abscess, with recent rupture into the peritoneal cavity, and extensive peritoneal lesions. This overwhelming perito- neal inflammation lasted only about eighteen hours before the death of the patient. When the peritoneal symptom supervened, it was regarded as the result of the intestinal ulceration which sometimes so suddenly terminates typhoid fever. Causes. Perimetritis occurs as a sequel to abortions and labor at full term, and there is but little doubt but that these two conditions sometimes predispose to the disease. The menstrual congestion seems to do the same thing. Any circumstance that fills the pelvis with blood in active congestion may so predispose to it. Cold suddenly apj)lied to the surface or to the feet and legs may excite the already congested parts into a state of inflammation. Much exercise of the limbs in walking or standing on them for a long time, when the pelvic vessels are already distended and excited, has, on some occasions, seemed to me to awaken inflammation. The incautious use of strong caustics to the cervix uteri may give rise to it. I think I saw a case in which perimetritis was brought about by severe exercise in walking imme- diately after the use of caustic potassa. Excessive venereal indul- gence predisposes to this inflammation, if it does not produce it alone.* Symptoms. The patient is attacked suddenly, usually with pain in the pelvis, hyjDOgastrium, or iliac regions, which radiates to the sacrum, loins, and abdomen. Sometimes it passes down one extremity, or there is pain in both legs. The pain, generally at first aching and moderate, may become very severe, and darting or cramping in character. In the beginning, or after the inflammation has lasted a little while, there is pain or difficulty in urinating ; by ijressing upon the inflamed parts, the passage of faeces through the rectum is painful. The patient usually experiences a sense of weight about the perineum, and drag- ging in the loins and hips. All the pains are much aggravated by motion, or assuming and continuing in the erect posture. Pressure over the epigastric and inguinal portions of the abdomen increases the pain and suffering. At the commencement of the pain the patient is attacked with rigors of greater or less severity. The chilliness may be slight, but * See Chapter XX. for other causes. CELLULITIS. 455 often it amounts to severe shaking and trembling ; reaction propor- tionate to the intensity of the chill succeeds ; the head aches, the limbs are pained, the skin is hot and dry, and the tongue coated, and the mouth dry and parched. These symptoms may come on very suddenly, and the case be well marked in a few hours from the time they commence, or so moderately and gradually as to be several days in assuming prominence. In puerjDeral patients they occur generally several days after confinement, and seem to be induced by undue exertion or exposure. In such cases the symptoms are more intense than in the non-puerperal cases. The pulse is rapid, the nervous system much disturbed, the heat great, and often there is delirium. The high febrile excitement is attended with severe pain, extending in various directions. Tumefaction and tenderness over the lower parts of the abdomen indicate a local peritoneal inflammation in many of the more severe instances, although this is not always the case. Some of these puerperal cases so closely resemble cases of, metroperitonitis — if they are not so indeed — that the cases are re- garded as attacks of puerperal fever. So intense are the symptoms as apparently to jeopardize the life of the patient immediately by the gravity of the general pelvic and abdominal inflammation. And when the tumefaction and tenderness of the abdomen subside, the febrile reaction is moderated or becomes more paroxysmal, we find a hard tumor generally on one side dipping down into the pelvis .and extending sometimes to the ribs and across to the umbilicus; or it may be developed in the mesial portion of the abdomen and pelvis, extending upward to a greater or less degree. Tumors of this kind are tender, and may be detected in the pelvis by a vagi- nal examination. They do not always suppura^-e, but generally disappear by absorption. At other times they produce copious quan- . titles of pus. This inflammation sometimes dissects up the peritoneum over the osseous iliac, and lumbar muscles, to a great extent, dissolv- ing out the areolar tissue in a large space. The distension and ten- derness are quite frequently confined to one side, showing the point of greatest intensity of the disease, but we often find them extending entirely across, and sometimes considerably up the abdomen. These symptoms appertain to the first stage, and last for from four or five days to two weeks, and in rare cases longer, when they are gradually succeeded by those that indicate the suppurative stage. The pain be- comes less acute, and changes ordinarily to a burning character, quite as distressing, if not more so, than at first. It is worse at night, and prevents the patient from resting. The fever assumes something of a remitting type. It is more intense in the evening and night ; toward morning a moisture is observed upon the skin, the heat becomes less, and there is some amelioration in the suffering. After a little longer the paroxysms are very marked ; chilliness in the afterpart of the day 456 ACUTE PERIMETRITIS. is succeeded by a very rapid pulse and intense heat of the surface. This fever lasts for six or eight hours, and is resolved by a copious perspiration. These perspirations are accompanied with great lan- guor and depression. The patient is debilitated and much worn by the continuance of the symptoms. At length, after days of this ex- hausting, suppurative fever, the pus makes its way through the walls of the abscess, and is discharged through some of the outlets men- tioned above. If the evacuation is free, and the discharge consider- able, the relief is very great indeed, the fever subsides, the perspiration ceases, the spirits are good, the appetite becomes excellent; in fact, the change in the patient is very great and gratifying. Convalescence is now established, and in a few days all the serious and distressing symptoms vanish. If the discharge is not free, and but a small quan- tity of the matter escapes, although there is relief, it is not so complete. The patient is temporarily better, but not convalescent. The opening is not sufficient, the pus continues to increase and imperfectly dis- charge, and fluctuations in the intensity of suffering continue to inspire hope and cause depression, until a freer opening occurs in the same place, or another one allows the pus to escape more freely. This description is intended to apply to cases of considerable in- tensity in the puerperal or non-puerjDcral patient. But the degrees of intensity are very different in different instances. Sometimes the symptoms are so slight as to scarcely attract attention, until the dis- charge begins to make its appearance. At other times there is dis- tressing fever, but the local symptoms are so poorly marked that the case is misapprehended. I have known the fever to last for three or four weeks, ending in hectic, with its exhausting accompaniments, before the true nature of the case was discovered. An example of the occasional insidiousness of the non-puerperal form of this affection is exhibited in the following case : Mrs. A , aged twenty-four, married two months, has suffered for the last four years with moderate dysmenorrhoea, and occasional leu- corrhoea. Sexual intercourse has given her much pain from the first since her marriage ; after three weeks the pain in the coitus became intolerable. At this time she had severe pain in the back and pelvic region constantly, but not so severe as to prevent her being about in the attention to domestic duties and taking a short trip by rail with her husband. She had some very slight febrile reaction, with sense of chilling, for about twenty days, when the paroxysms assumed something of a hectic character, lasting from three o'clock until seven or eight p.m., terminating with copious diaphoresis. A little later a very severe pain in the hypogastric region was developed, attended with frequent efforts at urination. In about four days from the super- vention of this pain she began to pass pus in large quantities in the urine, together with marked quantities of blood. Upon making ex- CELLULITIS. 457 amination at this time the pelvis on the right side and front portion was filled by a tumefaction very tender to the touch, which had crowded the uterus back uj)on the rectum and down so that the os was in contact with the perineum. These symptoms and the exami- nation fully declared it a case of cellulitis. Diagnosis. Although the symptoms, in most cases, are severe and sufl&ciently prominent, they are not often distinctive. Several other affections resemble it in many symptoms. Hence, the only way to arrive at correct diagnosis is by physical examinations. The finger Avill be the only instrument necessary. It is cruel to use the speculum, while it affords us no aid in the vast majority of cases. I should not think it necessary to caution the reader against the use of this instrument if I had not seen it resorted to more than once, to the great torture of the patient. In making examinations for this kind of case, the patient should be so placed that we may use both hands if necessary. When one or two fingers are introduced into the vagina, they will detect un- usual tumidity in the pelvis. Sometimes this tumidity extends to the bottom of the pelvis on one side, and occasionally apparently fills up the whole lower part of the pelvic cavity ; at other times the tu- midity is circumscribed and confined to one side high up, or before the uterus. The tumefied parts are generally hard, and very tender to the touch, so that a small amount of pressure causes great suffer- ing ; the uterine neck is almost always pushed to one side, backward, upward, or downward ; the vagina is generally hot and dry, and all the parts sensitive. If we place one hand above the pelvis, while the fingers of the other are in the vagina, we will have a consciousness of a tumor between the fingers of the two hands. It is not always the case that any tumidity can be felt above the superior strait, but generally there is tumefaction in one iliac region or sometimes in both. The tumefaction may extend much above these regions, high up into the abdominal cavity, though not often. If the tumefaction is considerable, the uterus is firmly fixed in its place, but when less, this is not the case. In childbed patients we may distinguish cellulitis from i3eritonitis by digital examination per vaginam. There is not the hard tumefaction in the pelvis in the last as in the first. Tenderness and general distension of the abdomen are greater in peritonitis; the pulse is more rapid and is peculiar. These may and probably are often combined in puerperal fever, when the diagnosis is of less importance than when they are separate affections. The general peritoneal inflammation supervenes after delivery much earlier — generally on the second day — than any of the localized inflammations do. Cellulitis is more likely to attack the 458 ACUTE PERIMETRITIS. patient when or after she begins to make exertion, or is exposed to cold several days, six to ten, and even more after delivery. (See Pelvic Peritonitis, p. 460.) From acute metritis in the puerperal or non-puerperal state, it may be distinguished by examination with the finger. There is not much difference in the mode of attack and history between acute metritis and perimetritis; but by a careful survey of the jDelvic organs, we may separate the inflamed from the sound parts. In metritis the uterus is generally and symmetricalh^ enlarged, and extends lower down in the pelvis, and if touched at any point is tender ; in cellulitis this organ is not generally enlarged, and if touched an3"where in such manner as not to press it against or move it on the side where the inflammation exists, is not the subject of painful impressions. The tenderness in cellulitis is generally to one side of the uterus, close to the walls of the pelvis. If the inflammation is in the badder, we may easily ascertain this fact, by pressing this organ between the fingers in the vagina and those above the symphysis pubis. From metatithmenia it is distinguishable by the tenderness and firmness of the tumor, the febrile symptoms, and the history of the two condi- tions; cellulitis being previously inflammatory, while metatithmenia, when inflammatory at all, becomes so some time after the commence- ment of the symptoms. The blood}^ tumor may be handled without much pain, is soft and yielding, and commences at the time of menstru- ating with sharp pain likened often to severe colic, without chill and fever at the beginning ; sometimes with collapse more or less intense. Carcinoma filling up the lateral parts of the i^elvis, is sometimes mistaken for cellulitis, but more often the latter is mistaken for the former. Carcinoma is insidious in its incipiency. It has made great advance before symptoms indicate its existence, while cellulitis is heralded by inflammatory symptoms from the start. The hardness of carcinoma is greater, the tumidity more irregular and devoid of tenderness ; it is not hot as in inflammation. The discharge from carcinoma when it occurs is cadaverous in odor, thin and ichorous in character. In cellulitis the discharge is pus, and if it smells at all, the odor is faintly fecal. I have noticed this last feature in several instances of perimetritis, when the evacuation of the pus was free and copious through the vagina. The diagnosis from chronic metritis is not always easy. Wlien cellulitis is chronic, it causes many of the symptoms wliich we ob- serve to be present in chronic metritis. It will require a careful consideration of the symptoms and history of the case, with physical examination. Chronic cellulitis ordinarily results from an acute attack, that was accompnnied witli a discharge of pus more or less copious, and par- oxysms of less intensity have succeeded, growing more mild, until the CELLULITIS. 459 symptoms become obscure. Paroxysmal discharge of pus is a com- mon sj'mptom of chronic cellulitis. Upon a thorough and careful examination of the pelvic cavity, we may find some small spot, not in contact with the uterus, but by the side of it ordinarily, that is hard and tender to the touch. In chronic metritis there is not always tenderness. Prognosis. This is generally favorable. There is probably more danger in attacks during the puerperal condition, or after miscarriage, than in unimpregnated patients, although the very large majority of these cases terminate favorably. Of course I leave out of this considera- tion such instances as are attended by general peritonitis of simulta- neous origin, and constitute only a part of the whole puerperal fever. I do not think there is much difference in the fatality of uncompli- cated cases occurring under these diverse circumstances. When cellu- litis proves fatal, it is generally in one of three ways: 1st. By ex- haustion caused by excessive and long-continued febrile excitement, symptomatic of extensive inflammation. 2d. The exhausting effects of hectic fever, diarrhoea, diaphoresis, and want of nourishment. 3d. Severe complications, arising during the progress, as peritonitis, by extension of inflammation; or the more rapidly fatal form of peri- tonitis, caused by effusion of pus in its cavity. I have seen three fatal cases. Two of them resulted from rupture of the abscess, and discharge of the pus into the peritoneal cavity. One of these was puerperal, and death occurred ten weeks after confinement; the other non-puerperal, and ended in eight weeks from the attack. The one which proved fatal from exhausing hectic, without evacuation of the pus, terminated in sixty days from the commencement. A great many cases terminate in the chronic form. The cause of this sort of termination is often incomplete evacuation of the pus, and, as a consequence, imperfect obliteration of the cavity of the abscess. The pus accumulates from time to time, and fresh eruptions, attended with a greater or less exacerbation of the symptoms, every few weeks or months, occur as this result. Or the external opening, wherever it may be, does not close, and there is a constant discharge of greater or less quantity, keeping up a kind of fistulous canal, leading generally some distance to the main seat of the difficulty. Or in still another sort of cases, the pus seems to be entirely evacuated, and the cavity obliterated, and there is nothing left but a small point of indurated tissue, which is the nucleus of inflammatory action under certain circumstances, as pregnancy, unusual excitement of the sexual organs from other reasons, etc. 460 ACUTE PERIMETEITIS. Local Peritonitis. Post-mortem examinations, as shown especially byGoupel, demon- strate the fact that we may have peritonitis confined to the pelvis and its vicinity. Observing practitioners of long experience must have met with instances which, without any great difl&culty, could be classed under this head, and I have no doubt of the practicability of generally distinguishing them from those of cellulitis, with which they are most likely to be confounded. Pelvic peritonitis is seldom primary and simple. More frequently it is primary, and leads to cellulitis as a complication ; and in other cases it is secondary, and a consequence of pre-existing cellulitis, and there- fore complicated with it. Post-mortem examinations are not always conclusive as indicating a condition which had existed during the entire course of the disease; for while in the more acute stages there may have been coexisting in- fiamniation of the peritoneum and cellular tissue, the inflammatory action in the cellular tissue may have subsided, and the peritonitis alone remain to be discovered at the autopsy, and vice versa. This would mislead the pathologist who depended upon the post- mortem appearances entirely. When the peritoneum is primarily attacked, and the inflammation is confined to this membrane, it becomes injected with blood, dry, and rough, and in the motion to which the viscera are subjected during respiration, etc., the surfaces rub together and cause sharj) stabbing pain. Upon the subsidence of this stage of the inflammation, an effu- sion of serum, rich in fibrin, takes place, which gravitates to the most dependent part, and usually accumulates in the cul-de-sac behind the uterus, but does not displace the organ to any marked degree. The effused fluid soon coagulates, and the liquid portion of the serum is removed by absorption, and there is a solid mass of fibrin left in the retrouterine pouch. If the uterus happens to be retroverted at the time of the coagula- tion, it is fixed in that position during the life of the patient or until absorption liberates it. The movements of the pelvic organs — and, by the way, these organs are always in motion in unison with the respiratory movements, and as an effect of the movements of the body — sometimes modify the form of the coagulum, drawing it out into bands, which stretch from one surface to the other. After this serous efl'usion, the inflammation may subside and leave the patient comfortable, but the subject of a fixed uterus. In some cases, however, the absori:)tion is rapid, and the organ is left entirely free in a short time. Should the inflammation be more intense, the epithelium of the LOCAL PERITONITIS. • 461 membrane is loosened and falls off, leaving a pyogenic surface, from which pus is produced in greater or less quantities when there is a sero-purulent effusion confined in an irregular fibrinous capsule. If the pus is considerable in quantity an abscess is the result, which finds its way out in a manner similar to the evacuation of pus as a result of cellulitis. In the non-puerperal moderate cases of local peritonitis the serous and purulent accumulations are confined to the pelvic cavity, but in the puerperal or the more intense forms of non-puerperal inflamma- tions, these accumulations reach higher than the brim, and are often found in indurated patches in both iliac regions or over the hypo- gastrium. When these accumulations are round, or shaped like tumors, they may be mistaken for ovarian or uterine neoplasms. The Fallopian tubes are sometimes constricted by these fibrinous bands, and a portion of their cavity isolated, in which liquid accumu- lations collect, and give rise to Fallopian tumors, — hydrosalpinx. Bernutz and Goupil in some instances found the ovaries involved in the inflammation, and either destroyed by suppuration or left in a state of chronic inflammation. Causes. The puerperal condition at term, or after abortion, is a very fre- quent, if not the most frequent, cause of local peritonitis. The action of cold upon the woman, when the pelvic organs are in a state of intense congestion, just prior or at the time of menstrua- tion, is also a prolific cause. Gonorrhoeal inflammation, by making its way through the cavity of the uterus and along the Fallopian tubes out upon the peritoneum, is, by common consent, taken to be another one of the causes ; but inflammation may, by contiguity, also extend from the uterus to the peritoneal membrane. This is the case, doubtless, in the puerperal condition, after the violence dotie to the uterus by severe labor or abortion, and in non-puerperal cases where strong applications have been made to it, operations, etc. Direct violence to the retrouterine portion of the peritoneum is often done by the injudicious introduction of foreign substances by the patient herself, excessive coition, and by rude and ill-directed attempts to replace the uterus by instruments. Symptoms. Pain in the pelvis and lower abdomen is one of the most common and distressing symptoms, and this pain is generally characteristic. It is sharp, stabbing, and paroxysmal, or exacerbating. The sharp, 462 ACUTE PERIMETRITIS. stabbing, exacerbating pain is accounted for, as before said, by the friction of the two surfaces of the peritoneum, rendered dry and rough by the inflammation. In cause and character the pain resembles that of the early stages of pleuritis. While pain is one of the most constant symptoms, cases do occur in which there is very little pain, probably because early effusion, or some other condition, prevents the friction. Another consideration, which will enable us to account for the absence of pain, is the great difference in the susceptibility of different persons. However we may explain it, we know from observation that pain is sometimes almost entirely absent, and then the disease may be mistaken for some other affection. In the commencement there is a sharp febrile reaction, with its attendant phenomena, as quick pulse, headache, delirium, nervous excitement, and derangement of the secretory functions, etc. The intensity of the excitement will depend very greatly upon the suddenness of the attack and extent of the tissue affected by the in- flammation ; greater when sudden and extensive, and less when the progress of the inflammation in the first stage is slow and the parts involved are sm.all in extent. The febrile reaction is usually high at first, and very much moderated as the effusion occurs. The character of both pain and febrile reaction are greatly modified by the conditions which give rise to suppuration. As suppuration is established the sharp pain gives way to a sense of tension, weight, and heat, while the febrile movement becomes more remittent or paroxysmal. Debility, copious perspiration, and frequent chills make up the items indicative of suppuration. These symptoms are partially or completely relieved by opening the pyogenic cavity and permitting the pus to be discharged. The points where the pus flows, as in cellulitis, are the upper part of the vagina, rectum, the bladder, inguinal or femoral canal, some place in the abdominal wall, the gluteal region, or one of the greater lij)S of the vaginal orifice, and rarely the peritoneal cavity. If suppuration does not occur, and the case terminates in convales- cence without it, the symptoms gradually subside. Upon examining the lower abdominal region we will generally find tenderness upon pressure, and often more or less tumef^iction, with or without tympanitis. The uterus, if displaced, is pressed forward, but it often occupies its normal position. In the first stage there is gen- erally not much tumefaction in the pelvis felt through the vagina, but great tenderness behind and by the sides of the uterus. When the fingers are pressed well upward in the stage of effusion there is tume- faction behind the uterus, and sometimes in the iliac and hypogastric regions. LOCAL PERITOXITIS. 463 Diagnosis. When free from complications, — which, I must say, judging from my own observations, I believe to be less frequent than the converse, — I do not see why there should be any great difficulty in differen- tiating local peritonitis. The affection with which it is more likely to be confounded than any other is cellulitis. The pain in the first stage of cellulitis is more steady ; is dull or aching, instead of stabbing or lancinating : and the tenderness, although considerable, is not so great as in j)elvic peritonitis. In the second stage the pain in the two affections does not differ much, if at all. The tumefaction is not in the same locality ; in cellulitis it is by the side or in front of the uterus, while in local peritonitis it is behind that organ. If the peritonitis extends above the pelvis, which it often does, it may be in one or both iliac cavities, or extend across the lower part of the abdomen. When the effusion in peritonitis is above the pelvis in the centre percussion will elicit marked resonance, because the in- testines are contained in the mass, and this resonance will enable us to distinguish it from a tumor. The history, symptoms, and physical signs enable us to decide be- tween local peritonitis and retrouterine hsematocele. In peritonitis the history is one of inflammation, well marked in the beginning and throughout its whole progress, while that of hsematocele does not indicate inflammation in the beginning of the attack, and seldom in any of its later stages. In local peritonitis metrorrhagia is not a symptom ; in hsematocele it is. Tenderness is a permanent feature in peritonitis, while it is very slight if it is present in hsematocele. This remark applies when pressure is made above the symphysis or in the vagina. The pelvic tumors in both disorders are ordinarily retrouterine, and not dissimilar in shape ; but in the earlier periods the hsematocele is uniformly soft, while the inflammatory effusion is harder. The hsematocele displaces the uterus more than the inflam- matory product. The tumors caused by both may and often do ex- tend above the pelvic brim. The bloody tumor is generally central, and forms a somewhat level line across the lower abdomen, while the inflammatory tumor is usually irregular and hard, and is often con- fined to one iliac region. In retrouterine pregnancy the absence of acute inflammatory symp- toms, unless in exceptional cases, and the presence of the evidences o-f pregnancy, are strong differentiating circumstances, and will generally lead to definite conclusions. In extrauterine pregnancy we can watch the case for a sufficient length of time, and the growth of the tumor will do much to solve the difficulty. The pelvic tumors formed by cancer differ from those of local peri- tonitis in the facts that they have no inflammatory history, in their 464 ACUTE PERIMETRITIS. great hardness and irregularity of growth. Fibrous tumors have no inflammatory history, are more or less movable, more dense and regular in outline. The fibrous tumor is generally accompanied by metrorrhagia, while the inflammation is not often attended by that symptom. Prognosis. When peritonitis is confined to the pelvis and its vicinity it is rarely fatal. One of the dangers connected with it is the probability of its extension to the whole or greater part of the abdominal peritoneum. This is much more likely to occur in puerperal cases. The fatal ter- mination is sometimes the result of exhaustion induced by protracted suppuration and febrile excitement. Acute pelvic peritonitis has a strong tendency to become chronic by the continuance of the inflammation in a subdued form. In this condition, by exposure, over- exertion, sexual excitement, or injudi- cious treatment, it may become intensified to an acute degree. When pelvic peritonitis has resulted in collections of pus in portions where the evacuation of the fluid is imperfect, the inflammation may be protracted to an indefinite time. Fortunately, however, in the great majority of cases it passes into convalescence, which is usually slow, but complete. Before giving the treatment of local peritonitis I must again say that this disease is so frequently complicated b}^ cellulitis that its occurrence in the simple form is not common. I believe, also, that simple cellulitis is as rare as uncomplicated local peritonitis. But it is very often the case that the cellulitis is comparatively intense, while the peritonitis is not severe, when the symptoms and physical signs are those of cellulitis ; and again, the peritonitis may assume a grave form, while the cellulitis exists in a very moderate degree, when the symptoms of peritonitis will predominate. The contiguity of the tissue implicated in these two affections, and the identity of vascular and nervous supply, are facts that hardly admit of any other conclu- sion than that inflammation does not generally invade either of them and leave the other unaffected. Treatment of Perimetritis: From what I have seen and had to do with these affections, I am led to prescribe in a general way the same treatment for both of them. In the early days of an attack of peritonitis the object of treatment should be to abort the inflammation, and, when this is impracticable, to limit its extent. We can seldom accomplish the first of these objects unless we see the patient and recognize the nature of the attack in the very beginning. It is not possible to declare just how many hours or days must elapse when we are no longer justified in trjdng to arrest TEEATMENT OF PEEIMETEITIS. 465 the disease, for this will greatly depend upon the intensity, but we may always find something in the conditions to guide us. Before any con- siderable amount of effusion and tumefaction has taken place we may hope to check the progress of the inflammation, even if this is two or three days after the commencement, or, when great swelling has occurred, we may still expect to limit its extent. The symptoms indi- cating the measures necessary to interrupt the inflammation are great pain, accompanied by tumefaction. These call for an energetic anti- phlogistic treatment as the strength of the patient will bear. If she is robust, from twelve to twenty leeches on the hypogastrium should be applied at once, and after they have fallen off the hemorrhage must be encouraged by poultices or fomentations until, if possible, the hard- ness of the pulse is affected. At the same time a large dose of opium, or one of its preparations, should be administered, and repeated in such quantities as to keep the pain in complete subjection, and not merely given from time to time when the pain returns. If the patient is not robust we cannot resort to bloodletting, but we must always administer the opium in this way. As secondary measures the arterial sedatives may follow the depletion, when that is deemed advisable, or be our main reliance if we do not consider it best to deplete. Veratrum viride has gained such a reputation that it would naturally suggest itself as the most efficient of these. It may be given in doses sufficient to control the circulation, and keep it under control for the first five or six days of severe attacks. Poul- tices or fomentations to the hypogastric region should be one of the features of the treatment for the whole of the more active stages of the disease. They will often give marked relief. Large injections of very warm water, the patient lying on her back, should also be employed. An apparatus that will permit the water to run off with- out wetting the clothing will be indispensable to the proper manage- ment of the injections. This kind of treatment will sometimes check the force of the attack in a very short time by arresting or limiting the extent of the inflammation, and thus save the patient from the protracted suffering which neglect of energetic treatment is sure to entail. After the effusion has taken place, and before the period of sup- puration has arrived, alteratives, such as mercury and iodide of potas- sium, are very important remedies. The former may be given in small and frequently-repeated doses, until the slightest possible indication of its general effects are noticed, when it should be displaced by the iodide. This is the period when decided saline laxatives are useful and advisable. When the symptoms indicate the commencement of suppuration we can no longer continue all of the foregoing treatment. • 30 466 ACUTE PERIMETRITIS. The opiates may now be given when the pain requires it. Tlie regi- men and medication should be changed to quinine in liberal doses, two to four grains or more, as often as necessary, to keep up its influ- ence, and supporting food in as large quantities and such quality as the stomach and rectum will bear. Unfortunately we are often called upon to treat patients who have already passed the time when any other than the supporting and anodyne treatment would be entirely out of consideration, because many of these patients have been too greatly reduced by preceding influences to permit of any other than anodyne and s.upporting treat- ment from the beginning. These are the unfortunates who linger for weeks, and sometimes for months, in spite of anything we can do for them. During the progress of perimetritis there is a time when counter- irritation will be of great service. After the more acute symptoms have subsided, and effusion is evident, a blister applied over the iliac region, where the pain is greatest, or over the hy230gastrium, if that is the location of the most pain, will be required. The blister applied at this time will often relieve the deep-seated pain, prevent the effusion from becoming purulent, and excite the absorbents to remove it. Later in the disease tincture of iodine will go far toward accomplish- ing the same objects. A question arises at the suppurative stage of the affection which must be decided after a careful survey of the whole case, viz., should we evacuate the pus, or should this process be wholly left to nature ? As one of the disastrous terminations is a rupture in the peritoneal cavity, as nature often selects very circuitous and unsatisfactory via- ducts, as the rectum, bladder, etc., and as a consequence of this last circumstance the recovery is very much protracted, I think we should, when practicable, furnish the pus an outlet of our own choosing, and as early as can be conveniently done. Soon as evidences of suppu- ration begin to be manifested through the general symptoms, we should make as thorough an examination as we can to ascertain where the collection has occurred. If we can discover the pus, we evacuate without apprehension of damage to any of the organs. If our first examination fails to satisfy us, it should be repeated as often as every twenty-four hours until the discovery is made. When this is done, we institute one or two precautionary measures, which will almost preclude the possibility of doing harm by an intelligent penetration. The first is to completely evacuate the contents of the bladder and rectum by the catheter and an injection. We ought to be sure that the rectum is empty of fluid and gas. I knew fluid in the rectum to so far deceive a practitioner as to cause him to make preparation for TREATMENT OF PERIMETRITIS. 467 its puncture. We ought to pass the catheter into the bladder and rectum after we sit down to operate. The next precautionary measure is to introduce the exploring trocar into the tumor, and after the pus has made its appearance, open the cavity by the side of the retained canula. In this way I think there is great safety in the operation. The patient may be preiDared for the puncture by being placed on the left side before a good light, as if for operation for vesico-vaginal fistula, and anaesthetized. The part may be exposed by Sims's specu- lum. The instrument most convenient for making the incision is a tenotomy knife. The opening should be free and direct, so as to permit of a ready discharge. The opening should not be allowed to close. This may be prevented by keeping a tent in the wound until the pus ceases to be discharged. The objects of thus opening the cavity are to secure an external and safe outlet and its ready evacua- tion, and thereby attain a speedy cure and safety against peritoneal inflammation. When the chronic form consists in frequent repeti- tions of the inflammation, on account, perhaps, of its imperfect sub- sidence, much may be done by persistent counter-irritation, and among the best kind is a seton in the groin kept running for months. An issue will have equal good effect. This permanent form of counter- irritation is better, I think, than blistering or pustulation. When the opening into the intestine or bladder becomes fistulous, as it some- times does, and the discharge continues for months and even years if there is no vaginal opening, and the discharge is into the bowel or bladder, we should seek for a point in the tumor where it may be punctured, and the opening made free and direct through the vagina. If no such point can be found, we cannot, with propriety, interfere surgically. The openings are, however, often located so that we may easily reach them, as through the lower part of the abdominal walls, the labia, the gluteal region, the perineum, or vagina. If the Orifice is accessible, we may generally succeed in obliterating the suppurating cavity and fistulous canal. Preparatory to making an effort to do so, we should try to ascertain the tortuosities of the fistulous duct and the depth of the pus-cavity. In some instances the canal is so crooked that the straight probe will pass but a very short distance, and it be- comes necessary to send it in various ways ; and sometimes an elastic or elm bougie will suit better for a probe than the ordinary metallic one. Professor Simpson recommends leaving a wire in the track of the fistula until adhesive inflammation is excited. I have not tried this means, for I have been so well pleased with injections of car- bolized water that I have used them almost exclusively. I inject through a small-sized catheter. The smallest-sized elastic catheter, pushed to the bottom of the cavity, will convey the fluid in its con- centrated strength to the bottom, and thus produce the eff'ect at that 468 ■ ACUTE PERIMETEITIS. point. We ought, after introducing the catheter, to inject the cavity with tejDid soapsuds, so as completely to cleanse the internal parts of pus, and then immediately introduce the solution. Sometimes the first injection prevents the production of pus and causes adhesive inflammation. In order effectually to inaugurate the treatment, it generally becomes necessary to slit up the orifice of the fistula somewhat, as it is usually smaller than any other part of the duct. CHAPTER XXVII. CHEONIC PERIMETRITIS. Chronic perimetritis is a common form of disease. It is the cause of much suffering and is often misunderstood. Causes. By far the greater number of cases can be traced to the acute form, but there is no doubt that many others have an entirely different origin. Most practitioners of extensive observation must have seen many cases of chronic perimetritis, in the history of which no evidence could be found that the patient had ever had an acute attack. We know that the acute form is often the result of an extension of inflammation from the uterus and vagina to the broad ligament and peritoneum, and I think I have seen instances where inflammation of a, moderate grade had been propagated from the uterus and re- mained thus associated for an indefinite length of time. , This I think is the right way to account for those cases so fre- quently found complicating chronic uterine diseases, and in which the symptoms of perimetritis are completely, masked by those attend- ing the more prominent affection. It is indeed very seldom either in the acute or chronic form that it is not accompanied by inflammation of the uterus, and it is equally rare that the disease is not propagated from the uterus or vagina. In very few cases it is reasonable to suppose that the inflammation may originate in the ovaries. I do not hesitate to assert, however, that I have not seen many cases of acute or chronic perimetritis, — where their history could be clearly traced, — that were not secondary in their origin and transmitted from the uterus. Varieties. Chronic perimetritis presents quite a variety of appearances ; one form traceable directly to the acute attack is chronic abscess. After the process of suppuration has led to a discharge of pus, and the acute symptoms have subsided, the patient still suffers from ten- derness, pain, and long-continued suppuration. The pyogenic cavity is perpetuated by the imperfect discharge of pus. While the pus is being constantly discharged, the sac whence it comes is not entirely emptied, and there is enough pus generated to keep up a perpetual 470 CHROXIC PEEIMETEITLS. drain. The manner in wliicli the original opening Tras effected is almost always the cause of this imperfect evacuation of the abscess. The canal or conduit leading from the cavity is tortuous, and pene- trates the muscular fibres of the rectum or bladder diagonally, so as to form a valvular opening. The pus, after having travelled along between the different muscular layers of the walls of one of these organs, makes an opening that is closed with every contraction and opened with each relaxation of the fibres. Still another unfortunate method of perforating the intestinal tube or bladder is when the level of the sac is below the opening. In all of these ways the complete evacuation may be prevented and the discharge protracted for years. We meet with another form of perimetritis in which the abscess seems to have been cured after complete evacuation. The subsidence of the symptoms is so complete as to leave the patient in the enjoyment of fair health. After a time, of greater or less duration, sometimes a few weeks only, at others several months, the symptoms recur in a less severe degree than in the acute form, and after a duration of several days or weeks a discharge of pus is again succeeded by relief These attacks are repeated an indefinite number of times, and if the patient recovers it is after a number of months or years. The suffering is sometimes very great and followed by large dis- charges. More frequently, however, the pain is not so excruciating and the discharge of pus is small. Again, other cases are met with in which the progress of the in- flammation from the beginning is very slow, and not attended with very severe pain, but continues until quite a large amount of pus is formed, which remains in the sac, with very little tendency to ulcerate through the tissue. Whether the pus in some of these cases would ever be discharged by spontaneous processes is a matter of great un- certainty. I have seen cases where from the history I felt assured that this indolent abscess had existed for years. I saw a case in this city with Dr. T. D. Fitch, that he informed me had been in the condition it was when I saw it for three years. That he had seen it, discovered pus, and advised its evacuation, as long as that, before I was called. I have seen others equally protracted in my own practice and in consultation. Some cases are met with, the history of which includes a number of recurring acute or subacute non-suppurating attacks, weeks or months apart, that finally culminate in suppuration. Patients suf- fering from this form have an attack of fever, with pain in the pelvis, pains running down the limbs, tenderness, and perhaps very slight tumefaction of the h^'pogastric region. This passes for "inflamma- tion of the bowels." The patient more or less completely recovers from the attack, and after a time is again prostrated with similar but less pronounced symptoms, these run a course of four or six weeks SYMPTOMS AND DIAGNOSIS. 471 and the patient again recovers. This time the fever may be called typhoid or bilious fever; in a subsequent attack suppuration reveals the true character of the disease. The explanation of all these symp- toms is that the patient had several attacks of moderate perimetritis, that for want of proper physical examination were misunderstood and called by different names. But all cases do not end in suppuration. The exudate does not break down, but continues hard, and is formed in masses of greater or less size in the broad ligament, attached to the side of the uterus, or between the uterus and bladder. Or where the disease is in the peri- toneum the exudation may be above the brim of the pelvis in the iliac region. These deposits of fibrin are often mistaken for tumors. Not unfrequently a large part of one side of the pelvis is filled with a hard immovable mass of plastic effusion, and the uterus misplaced and fixed in its malposition. In other instances the accumulation is small and does not affect the position or mobility of that organ. Instead of the localized effusions here described, sometimes there is a diffuse moderate infiltration of fibrin in the cellular tissue that causes thickening of the ligament. The j^arts are less elastic than usual, the uterus less movable yet not fixed. This condition is the one most frequently present when the uterus is said to be "bound down," so that it cannot be reposited and re- tained in position without causing great suffering or awaking acute inflammation. There is also a very moderate degree of chronic inflammation — hyperffimia with sensitiveness — which invades and remains in the peri- metric tissue without causing effusion or any considerable degree of tumefaction. Whether this degree or form of disease is one introductory or pre- paratory to the more grave acute grade, or one that may last indefi- nitely, without any great variation in intensity, is not certain. It is probably the condition to which the term — so frequently used — "latent inflammation" is applied, because under certain favoring circumstances the vascular and nervous action is developed into the acute form. I have no doubt that this low degree of inflammation may exist a long time, and perhaps indefinitely, in the absence of causes exciting it to a higher grade of action. Symptoms and Diagnosis. Generally the symptoms of chronic perimetritis are not distinctive, and arrange themselves under the general head of " Uterine Symp- toms." In those cases in which pus is formed the symptoms become more marked, and we may not be at a loss to understand them ; but 472 CHRONIC PERIMETRITIS. even in some of these the symptoms are not decisive. We must, for the most part, therefore, deiDend upon physical examination. The history of those cases of frequently recurring paroxysms of pelvic inflammation, which for many months, or even 3'ears, precede sup- puration, will often indicate pretty clearly the character of the disease with which we have to deal. Yet, without an examination of the pelvic organs, even these cannot be diagnosed until they have about run their course. There is generally one element which, to one whose attention is attracted in that direction, will be found to be almost always present, viz., fever in a more or less marked degree. In all but the indolent abscess, and the slighter degree of its form, in which there is no exu- dation, this symptom will pretty uniformly present itself. Physical examination will uniformly develop sensitiveness. It will often happen that, during the examination, the tenderness will be so slight as not to elicit complaint from the patient ; but, after the mani- pulation is ended, there will be left aching and a sense of tenderness. Sometimes the reaction will be quite severe and last for hours, or even awaken an acute attach. This subsequent tenderness, however slight, is a symptom of much significance, and should teach caution in future examinations. Another important sign (yet not so important as the last) is certain positions of the uterus. When the cervix is drawn strongly to one side, and especially if it is fixed in that position, it indicates an irregularity in the length of the broad ligament. The ligament of the side toward which the traction is noticed is shortened, and, while not invariably so, the shortening is frequently owing to previous or present inflammation in the connective tissue of the ligament. If associated with tenderness this condition ought to complete the diagnosis. Bimanual examination of the sides of the pelvis will generally enable us to detect even a small amount of fibrinous deposits. They may generally be diagnosed from tumors by their tenderness, fixed- ness, and loca]it3^ In most cases they will be fixed to the i^elvic walls, especially when situated, as most of them are, in the connective tissue of the broad ligament. Sometimes, however, they are developed at the side of the uterus, and adhere firmly to it. In such cases they move with the uterus, and cannot be made to move upon that organ. These are more likely to be mistaken for subserous fibrous tumors. The history will do something toward clearing up the diagnosis. There will always be a history of inflammation. The menses are not so likely to be profuse as in the case of fibrous tumors. Each manipulation will be attended or succeeded by tenderness. When the deposit is extensive the position of the uterus is generally affected b}' it also. The indurated patches at the brim of the pelvis, left by local perito- nitis, are sometimes mistaken for tumors. We should give due weight TEEAT.MEXT. 473 to the history of inflammation, with which these are connected, and the tenderness that is developed by pressure and other manipulations. When examining them we will generally find them flat instead of globular, and not movable. But the most remarkable, and, I think, pathognomonic sign, is resonance under percussion. However exten- sive these indurated masses may be, percussion will elicit intestinal resonance over the whole space occupied by them. The resonance is clue to the fact that the effused fibrin surrounds, instead of displaces, the intestine, and in coagulating includes that tube in the indurated mass. These signs are all different from those evinced by an exami- nation of a tumor. The signs of the indolent abscess of the broad ligament are an immovable tumor, which is elastic or fluctuating, and the test is aspiration. Treatment. The treatment of these several diverse conditions must necessarily vary. The form in which sensitiveness and hyperemia are not attended with effusion will require great circumspection in the treat- ment.* One is continually tempted by local inconvenience to depend too much upon stimulating local treatment, whereas I think it is benefited less by local measures than any other form of the disease. It is, in fact, more frequently connected with, if not dependent upon, some dyscrasia (or dysthetica) than upon local conditions, and hence must be treated largely by general measures. One of the most efficacious of these measures is a judicious change of climate and habits. The object in making a change of climate and habits should be to revolu- tionize the circumstances of the patient. It is astonishing how these patients, who cannot stand upon their feet, on account of the great sensitiveness of the pelvic organs, will improve on a long journey, which, from the symptoms, would seem impracticable. A trip to, and residence in, California has done more to cure some of these patients than could have been done by medicine alone. But much good can be done by medicines, such as will improve the condition of the sys- tem. The bowels should be the subject of special care. They will more frequently than otherwise be constipated, and their secretions inferior in quality as well as scarce in quantity. The mercurials and bitter tonics, if perseveringly administered, will often correct the con- stipation, improve digestion, and act favorably on the depraved state of the general system. The sixteenth of a grain of the bichloride of mercury, with a full dose of the compound tincture of cinchona, or the tincture of Colombo, three times a day, makes an excellent mixture for such cases. The diet should be full in quantity and nourishing in quality. Exposure to the fresh air and sunshine is also indispensable to restoration. The 474 CHRONIC PERIMETRITIS. exercise should not be too much restricted, because confinement always aggravates the general condition, and moderate exercise is not harmful to the local trouble. The special treatment should consist in large injections of tepid water, and extensive but very moderate counter-irritation. The counter-irritant I rely upon most is the tincture of iodine, diluted with an equal quantity of alcohol. This liniment should be applied over the whole lower part of the abdomen, back, and hips. I believe, however, that the local treatment can often be dispensed with if judicious management of the general health is persevered in and diligently applied. In the cases in which fibrinous deposits are observed, special treat- ment is of more importance. And the first thing that I would insist upon is that pessaries and stimulating applications to the uterus should be abjured. Large hot or tepid water injections and sitz-baths will be of great service. It will sometimes be found that hot- water injections will cause discomfort, while tepid water will be followed by relief, and the effect experienced from them should guide us in our choice. Concentrated counter-irritants in the inguinal regions will also be found very beneficial. A small seton I believe to be the best form of counter-irritant, and when kept clean and shielded from the friction of the clothing it will give the patient but little inconvenience. We must not forget the soothing influence of glycerin tampons. Diligent attention to the general health is of the greatest importance also, and very small doses of mercury, laxative diet, and exposure to pure air in a mild climate will generally suffice. In the suppurative variety, which is but the advanced stage of the latter form, attention to the general health is of paramount importance. When the suppu- ration is intermitted with intervals of comparative comfort, we may generally interrupt the paroxysm by establishing and keeping up for a considerable period a discharge from the iliac or inguinal region over the seat whence the discharge emanates. I know of no one remedy that does so much good as the seton. It should be larger than in the last variety, and the local irritation kept up for several weeks or even months. When the suppuration is continuous, in addition to attending to the general health, we should try to establish a more direct outlet. When the discharge is from the rectum we may sometimes pass a bent probe through the opening and bring its point down upon the roof or side of the vagina, and make it a guide to a puncture in that direction. When we cannot improve the direction of the outlet we may sometimes destroy the pyogenic character of the cavity by injections of carbo- lized water through a flexible catheter, introduced and carried to the bottom of the cavitv. TREATMENT. 475 How to treat chronic pelvic abscess in all its phases is one of the most difficult problems in gynecological surgery. The plain proposi- tion to evacuate the pus and maintain a free opening expresses the main objects to be accomplished. The difficulty consists in selecting the best method of doing so in all cases. Of course this will vary with the differences noticed in each case. A rule which is, I think, a good guide, is to open the abscess through the nearest surface. If nearest to the vagina it should be opened into that cavity, if near the rectum, into the rectum. Sometimes the pus makes its way to the cutaneous surface and then it must be evacuated at the point it approaches. We will seldom be able to divert the pus from the course it takes in making its way out. When practicable the opening should be at the lowest pus level and when we can choose the most favorable time and locality for the evacuation, the results will be satisfactory, both as to the primary and continued evacuation. Perplexities are now frequently met with when the abscess has dis- charged spontaneously in some unsuitable place and in such a manner as to prevent a complete discharge. In cases where suppuration takes place near the vagina, and the pus finds its way into that cavity it is generally easy to correct any defective manner in the discharge by enlarging and keeping the opening patent until the cavity is ob- literated. If there is any difficulty in finding the opening, or in the manipula- tion for its enlargement, the vagina may be stretched and dilated suf- ficiently to give freedom in our operations. This will often greatly facilitate our efi"orts and thus insure the best results. For this purpose we may use Sims's or Simon's speculum, or we may employ our thumbs as for dilating the rectum. The enlargement of the opening to the abscess should be effected by stretching and tearing rather than cut- ting. Thus we will risk but little from hemorrhage. The dilatation can be done by a small bladed uterine dilator and the finger, or by Hanks' rubber dilator succeeded by the finger. After thus dilating the opening the whole interior of the cavity should be scraped by the- finger or dull wire curette, for it will generally be found that the inner surface of the chronic suppurating cavity is covered with large, irregu- lar and indolent granulations. These should be thoroughly removed. The cavity ought be washed out daily with plenty of pure warm water.. Sometimes there is a tendency in the discharging orifice to contract and close up. This may be counteracted by repeating the dilatations with the finger as often as necessary. If the suppurating cavity has discharged into the rectum, and the evacuation is unsatisfactory, and draws out a tedious and chronic course, the treatment should be the same as directed for the vagina.. The rectum must be dilated by the thumbs to the greatest extent.. When this is sufficiently done the whole rectal cavity maybe brought. 476 CHEONIC PERIMETEITIS. within reach and view by retractors and we can with great facility and safety operate within it. I have on more than one occasion reached the discharging orifice of an abscess at the brim of the pelvis. After the exposure of the discharging orifice the treatment is the same as in the vagina. In speaking of my treatment of abscess of the pelvis some of my friends have misunderstood and misinterpreted me. I have been understood as advising the use of cutting instruments in enlarging the opening. I mention this with a view to correct this impression. I have thus far only attempted the enlargement of the inadequate oj)ening already existing with instruments that would not cut, and as much as possible with the finger. This plan has been objected to through fear of hemorrhage ; but following the directions here given there is no more danger than operating through the vagina. And it will be ap- parent to any one doing this operation that if a vessel were wounded the ligation of it would be not at all difficult. The cavities of most chronic abscesses of the j)elvis are not simple and uniform in shape, but often present subdivisions with partitions and projections from their surfaces, more or less comj)letely dividing them into compartments. These should be broken down by the finger in order to permit the free flow of pus from every part. Some- times the level of the pus-cavity is lower than the orifice through which it escapes. In that case the elevated septum between the rec- tum and the suppurating cavity should be torn down by the finger to a level with the bottom of the purulent cavity. Again I can assure the reader that when this is carefully clone there is no danger from bleeding and that any severed vessels may be secured without diffi- culty. The important points in this method of evacuating the pus from a pelvic abscess through the rectum are : First, to stretch the sphincter until the whole interior of the rectum is brought to light. Second, to tear the old opening of the abscess so largely as to admit the easy in- troduction of the fingers. Third, to reduce the irregularities of the cavity by tearing them away. Fourth, to reduce the septum dividing the abscess from the rectum to a level with the bottom of the pyogenic cavity. Fifth, to scrape away by means of the finger or dull curette the granular projection from the wall of the cavity. As in the case of the evacuation from the vagina, the rectum may require dilating again, as it will also be necessary sometimes to repeat the stretching of the opening to the pus-cavity. There are undoubtedly instances very high up — partly abdominal — from which the pus cannot be evacuated according to the plan I have directed. In these laparotomy is advisable, in fact, demanded, as the only method of reaching the cavity. I am sure, however, such TREATMENT. 477 cases are rare. Mr. Tait, if I understand him rightly, and others, prefer laparotomy and drainage above the pelvis to the operation through the rectum. I have not done laparotomy for pelvic abscess except where connected with the tubes, but I have had the oppor- tunity of seeing the results of four cases, and have witnessed two oper- ations. I was strongly impressed with the difficulties and dangers of this very formidable procedure as compared to those of the operation through the rectum. In laparotomy for pelvic abscess the incision should be low down in the median line, or what in some cases is better, over the upper part of the abscess, near the line of the pelvis or Poupart's ligament if on the sides. When the abscess is exposed the edges of the incision should be stitched upon it, so that there may be room enough for the evacuation between them without danger of the pus finding its way into the peritoneal cavity. When the opening is made through which the pus escapes, the peritoneal cavity may be thoroughly washed out and a drainage-tube inserted. The wound may then be dressed anti- septically and treated as wounds in the abdominal walls for other pur- poses. The difference as to the dangers and difficulties of performance between laparotomy and the operation through the rectum are so great that I cannot recommend the former except as a last resort, and after the latter oj)eration has failed. We occasionally meet with a collection of pus at the superior strait extending into the pelvis and sometimes attaining very imperfect evacuation through the rectum. This may be incised and evacuated without opening the peritoneal cavity, and drained with very little danger. Before leaving the subject I will mention another objection urged against the operation of enlarging the opening of an abscess through the rectum, viz., the danger of the fseces making their way into the cavity and producing irritation. This objection will not be seriously entertained when it is remembered that the sphincter is rendered pow- erless to retain the contents of the rectum and that the abscess-cavity is so shaped by the operation that the fseces would not be retained. Then it should be further remembered that healthy fasces are not irritating to the inside of these cavities, and that the cavity is to be thoroughly washed out once or oftener every day. Another thing about which I wish to be a little more explicit is that of the opening of an abscess in the rectum. From considerable observation I am convinced that there is no more danger in opening an abscess through the rectum than through the vagina. The way I have lately operated is, after stretching the rectum so as to see and feel the place where the pus is located, to insert the point of a scissors with the blades closed and 478 CHRONIC PERIMETRITIS. follow with the point of Hanks' rubber dilator. The dilator may be made to cause quite an opening, but this may be enlarged by the finger or other instrument. There will be no hemorrhage if the opera- tion is done without cutting. In the case of the indolent abscess all that will generally be found necessary is to draw off the pus by the aspirator. In this variety the lining-membrane (or wall) of the cavity has ceased to produce pus, and consequently when the sac is emptied the fluid does not reaccu- mulate. I have seen several cases thus happily terminated. CHAPTER XXVII I. DISPLACEMENTS OF THE VAGINA, BLADDEK, AND RECTUM. In every displacement of the uterus the dh'ection of the axis and the calibre of different j)arts, or the whole of the vaginal canal, are changed from their normal conditions. In procidentia the vagina is in part or wholly inverted. In such cases, however, the changes are complications of the displacements of the uterus, and are described and treated as such. The more common and yet not entirely independent displacements of the vagina are knoAvn as cystocele and rectocele. Urethrocele^ Cystocele. Cystocele is a prolapse of the anterior wall of the vagina, the latter being borne down by a prolapsed bladder, or drawing down that organ with it. The prolapses of the anterior vaginal wall and bladder may also make sufficient traction upon the uterus to cause prolapse of that viscus, and thus be complicated by it without the posterior wall of the vagina being much disturbed. Sometimes the mucous membrane of the anterior or posterior wall of the vagina may prolapse through the vulva without displacing the fibrous sheath, the bladder, or the rectum. At other times the urethra alone will descend with the vaginal wall. Rectocele. When the posterior wall of the vagina protrudes externally it is generally, in nuUipars, attended with displacement of the anterior wall of the rectum, and sometimes the uterus is drawn down and displaced by traction of the wall of the vagina. In nullipars the rectum is usually but slightly displaced. Symptoms. The symptoms of cystocele are dragging sensation or weight in the vagina, with leucorrhoea and burning pain, occasioned by the inflam- mation from the exposure or friction of the mucous membrane of the vagina, and vesical suffering. In recent cases there is simply frequent desire to micturate and unsatisfactory discharge of the urine. As the case becomes chronic the incomplete discharge of urine leads to its decomposition, the precipitation of the salts contained in it, and the evolution of ammonia. 480 DISPLACEMENTS OF THE VAGIxNTA, BLADDER, AND RECTUM. The ammonia and salts irritate the mucous membrane of the blad- der to a greater or less degree, and in aggravated cases severe inflam- mation and ulceration occur, attended with discharge of mucus, blood, and fetid gases. These local results are attended by constitutional disturbances com- mensurate with their gravity. The sufferings in rectocele are usually less severe. There is weight, leucorrhoea, and unsatisfactory defecation. The muscular coat of the rectum loses its tone and permits the fseces to collect in a large mass in it, which intrudes into and fills up the vagina. When an effort is made to expel the excrement it is apt to collect in larger quantities and remains in this passive pouch until the patient presses or scoojds it out with her fingers. Diagnosis. Upon examining the vagina the anterior or posterior prolapse will be readily discovered, and may be isolated by passing the finger into the vagina. If the anterior wall is prolapsed the finger will 2:)ass be- hind the tumor, and in front of the tumor if the posterior wall is the portion affected. We may demonstrate a cystocele by introducing the catheter. The instrument, instead of passing backward and upward, will go down- ward and backward, and the point may be felt occupying the tumor. In rectocele, if we introduce the finger into the rectum, it may be turned forward toward the vagina and made to enter the tumor. If the prolapse consists of the mucous membrane alone, the finger or catheter will not pass into the tum or. (See Palpation of the Pubo- vesico-uterine Lig., p. 86, also Palpation of Vagina, p. 88, Chapter II.) Causes. Loss of substance or tone in the perineum is one of the most im- portant conditions necessary to prolapse of the vagina. (See Chapter VII.) There may be loss of substance in the anterior border of that body from rupture, or loss of firmness from subinvolution, lack of general muscular vigor, — debility, — or senile atrophy. In old women Ave not infrequently find all the genital organs in a state of abnormal relaxation from loss of fibrous tissue. Instead of normal atrophy, in which the parts are condensed, as the fibrous tissue disappears, there is no contraction, and the uterus, vagina, and perineum are reduced to their membranous structures, incapable of resisting force in any form. Subinvolution of the vagina, bladder, and rectum, on account of the vascularity and laxity attend- ant upon that condition, permit displacements, which are favored by the weight of these and other pelvic organs. RECTOCELE. 481 Eetention of the urine and faeces are also important factors in the displacements. They distend and weaken the walls of the viscera until they become incapable of resisting the pressure. Treatment. The same general principles govern the treatment of these two conditions. If the perineum be deficient, its integrity should be restored by perineorrhaphy, and this will often be sufficient to etfect a cure of either or both. When there is no loss of perineum, or the deficiency is slight, we may often cure cystocele by returning and retaining the prolapsed portion in position until the redundancy of tissue is reduced by the contraction and condensation which take place when the distending forces are removed or counteracted. The instrument which I have found most serviceable in cystocele is Zwank's pessary. (Fig. 242). The points upon which it rests are the rami of the ischium, and it presents the fiat surface of its expanded wings upward, affording an admirable lodging-place for the redundant tissue. The application of this instrument is not difficult, and when of the right size it very generally relieves the symptoms at once, especially the irritableness of the bladder. It will be necessary for the patient to wear the pessary for many months until the condensa- tion or involution is complete. Like every other pessary, this one should be removed and examined often enough to insure cleanliness and prevent damage to the vagina. If it causes ulceration it must be removed at once. . Sometimes a ring, kept in position by external support, may be made to retain the procident wall quite securely. The practitioner should rely upon the pessary in most instances of this kind as far preferable to other surgical means, except the restoration of the perineum when deficient. When a surgical operation is required, the object to be attained by it is to remove a portion of the redundant mucous membrane over the central part and draw the edges together, and thus lessen the calibre of the vagina. To the inexperienced this operation seems a formidable one, but it is not so, and when attempted the difficulties will rapidly vanish. In the natural condition, the mucous membrane of the vagina is attached to the fibrous sheath by very loose connective tissue. In cystocele the space is much greater, hence, with a tenaculum we can lift the membrane freely away from the vaginal sheath and with the scissors remove it to any extent we desire. As before remarked, the protrusion in many instances is made up of the mucous membrane alone, when the operation is easy and a complete success. 31 482 DISPLACEMENTS OF THE VAGINA, BLADDER, AND RECTUM. When the fibrous wall of the vesico-vaginal space yields, and is prolapsed with the mucous membrane, the operation is much more likely to fail, and we will at last be obliged to resort to a support. Marshall Hall was the first to remove pieces of the anterior vaginal wall, but he limited his amputations to the protruding folds. J. Ma- rion Sims denuded an oval surface extending back nearly to the os uteri and closed by transverse superficial sutures. Stoltz removes a circular piece of mucous membrane and draws it together by a silk thread passed completely around the circle in and out of the mucous membrane, about an eighth of an inch from the edge. When the urethral fossEe and anterior vaginal sulci are loosened from their facial attachments behind the pubes, and sag down along with Stoltz's Denudation for Cystocele (Mund6). the central ridge, I prefer to remove two small oval strips in the ure- thral fossse extending back along the sulci (Fig. 234). The tissue in the fossse should be removed deep enough to get to the firmer fascia so that the edges of the denudation will be held up by it. The denudation may, in case the whole vaginal septum be relaxed, be made to extend backward along the sulci and be joined under the neck of the bladder by a transverse strip, as in Fig. 235. In this way the anterior vaginal walls are drawn up into the sulci, or to the vesico-vaginal septum, and as nearly as possible reattached behind the pubes by deep stitches. Care must be taken that the strips be not too wide or the traction upon the stitches will be too great. (For particulars as to these operations, see Operations upon the anterior vaginal wall for Prolapse and Procidentia, p. 501). EECTOCELE. 483 Judging from my own observation, I should say that rectocele is hardly curable in any other way than by operation. The perineum is almost, if not always, deficient, which requires an operation for its restoration. When this is the case, the two may be cured by the same operation. (Chapter VII.) Dr. Gillette, of New York, performs an operation for condensing the mucous membrane without removing it, by passing silk ligatures between the membrane and the fibrous sheath and drawing it up over the most protuberant portion. The after-treatment is of great importance. The patient should be kept quiet in bed and have opium enough to relieve pain, and in cys- tocele the urine should be evacuated by the catheter often enough to prevent distension. In rectocele the rectal tube must be used to pre- vent the accumulation of gas, and the bowels moved by saline laxatives every other day. Salines should be used because they liquefy the stools. CHAPTEE XXIX. DISPLACEMENTS OF THE UTERUS. The uterus is normally located at or near the centre of the pelvis, extending from the pelvic brim or slightly below it, to within an inch of the coccyx. Its long axis changes its direction or inclination with the filling or emptying of the bladder and rectum, with the different positions of the body, and with the variations in abdominal pressure. In the standing posture the relatively increased direct abdominal pressure, and its own weight, carries the fundus downward over the bladder; in the dorsal decubitus the relatively increased backward or reflected pressure, and its weight, carries it slightly backward. In recumbent postures, however, the abdominal pressure has but a feeble effect upon the position of the uterus and allows it to move freely among the viscera. The action of its supports is then paramount, and is sufficient to restore and keep its axis in close relationship with the axis of the superior strait. An abnormal location of the entire organ, independent of any alter- ation of its shape or the direction of its axis, constitutes a dislocation or simple displacement; an abnormal position or direction of its axis, is called a version ; an abnormal curve of its axis, or the relation of its parts, is called a flexion. Simple displacements may take place in any direction, and may be called forward displacements, or ante-location; backward displace- ments, or retro-location ; right or left lateral displacements, dextro- and sinistro-locations ; upward, or elevation; and downward, in the direction of the axis of the superior strait, constituting descent, or lapsus. Descent of the uterine axis on the curve of the pelvic axis is called prolapse, and if beyond the pelvic outlet, protrusion or proci- dentia. (See Fig. 221). The inverted vagina, the rectum, the bladder, the small intestines, one or all, may also come outside of the pelvis with the protruded uterus. In cases occurring in childbearing M^omen, the bladder, or rectum, or both, may precede the uterus, and often act partly as a cause of the prolapse, by pulling the uterus down to or through the injured or lacerated pelvic outlet. In nullipars the uterus and inverted vagina protrude first and may or may not drag the rectum and bladder after them. Versions are forward, anteversions ; backward, retroversions; right DISPLACEMENTS OF THE UTERUS. 485 or left, dextro- and sinistro-version, according as the fundus turns in any of the directions mentioned. The altered position of the fundus is accompanied by a turning of the lower end of the cervix in the op- posite direction, upon the cervical attachments as an axis. Flexions have the same nomenclature as the versions, and are forward, backward, or lateral, according as the concavity is formed by an anterior, posterior or lateral uterine wall. Two or all of these three varieties of deviations may occur in the same case, for instance, anteflexion, retroversion and retrolocation (Fig. 225). Fig. 221. Pathological Changes in Location of the Uterus. Dislocations. normal position. The dotted lines show the In some cases it is better for the sake of accuracy to mention the parts dislocated. For example, in case of anteflexion we may have merely a forward displacement of the fundus, or of both fundus and lower end of cervix, or we may have a backward displacement of the upper end of cervix, or of the corpus with a normal location or for- ward inclination of the fundus alone, or lower end of cervix alone or of both. We may have a displacement of the cervix to the left with fundus in a normal location; or a displacement of the fundus to the right with the cervix in the normal position, yet either would be called a right lateral version (dextro- version). 486 DISPLACEMENTS OF THE UTEEUS. What Constitutes a Displacement of the Uterus. The normal variations in location and position of the whole or a part of the organ have been termed, by some, physiological displace- ments. Thus when the bladder is empty the fundus is pressed over the bladder causing the uterus to bend at or near the internal os ; when the bladder is full the fundus is pressed up so as to straighten the organ; the flexion thus produced is called a physiological flexion. The same may be said of a flexion of the cervix forward during ful- ness of the rectum. Such displacements, or, more-properly speaking, changes of accommodation in the parts, or the whole, of the uterus do not interfere with its normal motions or functions. A pathological displacement of the uterus is more or less permanent and interferes with its normal motion and healthy functions. For instance. Fig. 1 represents a normal position of the uterus when the bladder is empty, or nearly so. If, however, the uterus remain in this position during filling of the bladder and the fundus cannot, ex- cept by force and discomfort to the patient, be raised or pushed back- ward, the organ is anteverted. Or there may be a greater bend in the uterus than shown in Fig. 1, without constituting a pathological anteflexion, but when the axis cannot be straightened by the filling bladder or* variations in abdominal pressure, or when it interferes with functions, it is pathological. Sometimes, however, the fundus may be found turned into the hollow of the sacrum at one examina- tion ; at another it may be found lying low on the bladder. In such cases the normal motions are interfered with on account of the in- ability of the supports to promjDtly return it and hold it in the centre of the pelvis, and we observe anteversion and retroversion alternately. Causes of Uterine Displacements. Elevation is caused by tumors intimately or remotely connected with the uterus growing up out of the pelvis and dragging the uterus up with them, by inflammatory or other contraction of tissues at the pelvic brim, by the pressure of pelvic tumor or abscess below or beside the uterus, or by a loss of substance, or imperfect development. In the latter case the lightness of the organ, and the comparatively small surface presented to abdominal pressure above, give the uterine sup- ports greater elevating power. Of Descent or Lapse. Descent or lapse is brought about by symmetrical enlargement of the uterus — as pregnancy or other forms of congestion, hypertrophy, hyperplasia, subinvolution, small uterine tumors, etc., or by a general relaxation of the pelvic supports resulting from parturition, extreme emaciation or debility, overwork, prolonged lactation, tuberculosis, OF VEESIONS. 487 etc. Haste in getting up after abortion and labor at term affords one of the most common causes, and acts in both of the ways mentioned. Of Prolapse and Procidentia. Prolapse and procidentia are produced by the same causes as the last, but acting in a greater degree upon the sacro-uterine ligaments. Relaxation of these posterior supports and the contiguous connective tissue from tumors, fecal impaction of the upper rectum, or from rectal or peri-rectal disease, and the like (with but little change anteriorly), may cause simple prolapse, or descent of the uterus along the pelvic axis toward the perineal body. In procidentia the support- ing structures of the uterus are all relaxed, but the sacro-uterine to the greatest degree. Perineal lacerations and the accompanying drag of congested or hyperplastic vaginal and vulval tissues may also have much to do in the etiology of both of these displacements, but espe- cially the latter. Labor is the most frequent originator of this condi- tion. Of Displacements Forward, Backward, Sideways. Forward, backward and lateral dislocations are seldom the result of a heavy uterus or of a weakened system of supports, but rather of traction or shrinkage of tissue in the pelvis, or of pressure from patho- logical growths. Hematocele and contraction in the pubo-uterine peritoneum or connective tissue are the common causes of forward displacement, or ante-location. Posterior displacements are ordinarily due to contraction of peritoneal inflammatory deposits over or beside the sacro-uterine folds or rectum, to relaxation of the vesico-uterine ligaments from an over-distended bladder or habitual physical exer- cise in stooping or leaning postures. Tumors or inflammatory de- posits often press the uterus back. The lateral displacements result from the pressure of tumors, abscesses, or inflammatory masses, or' from relaxations or contractions in the broad ligaments. . Of Versions. Versions are caused chiefly by asymmetrical enlargements of the uterus, by tumors or deposits pressing or drawing the fundus or cer- vix out of place, or by misdirected or excessive abdominal pressure due to deformities, tight lacing, sedentary occupations, etc. In the majority of cases the cervix is drawn by a contraction in the tissues about it so that the abdominal pressure is brought to bear more directly against one of the walls of the uterus. Thus a contraction in the sacro-uterine ligaments draws up the lower end of the uterus so that the posterior wall is presented to the abdominal pressure, and the fundus or movable end is borne down over the bladder, while the ex- ternal OS is turned backward toward the sacrum (Fig. 53). Contrac- 488 DISPLACEMENTS OF THE UTERUS. tion in the vesico-vaginal septum pulls the cervix forward so that when the bladder fills or the patient lies on her back the abdominal pressure bears upon the anterior uterine wall and turns it into the hollow of the sacrum, and the os forward behind the pubes. Figs. 46, 47, and 56 represent retroversion in different degrees. Illustrations which represent the uterus as passing from anteversion to retroversion or from one degree to another of the same version upon the external OS as a pivot are incorrect, for the pivot is not only near the internal OS, but the pivot itself usually moves backward in anteversion and for- ward in retroversion. (Figs. 229 and 230.) Lateral versions take place according to the same principles. Contraction of the round ligaments, or peritoneum about them, may cause an anteversion without much change in the position of the inter- nal OS. Fig. 50 represents this somewhat rare form ; compare with Fig. 53. Fig. 222. Pathological Anteflexion causeu by a Sliortening of the Sacro-uterine Ligaments. Schultze. After B. S. One of the common varieties of retroversion is combined with slight lateral version, and is produced by a puerperal or non-puerperal relaxation of all the pelvic supports except at a limited area of atro- phic or cicatricial contraction at one side of the cervix. This contrac- tion holds up the cervix from the pelvic floor, but hinders the normal forward inclination of the corpus and backward inclination of the cer- OF FLEXIONS. 489 vix ; as a consequence the fundus is forced back until it finds rest upon the rectum or between the sacro-uterine folds or in one of the lateral sacral pouches. In such position the fundus finds support and the tender ligaments rest, and the uterus thus often lies in greater comfort than when replaced. Whenever absorption of such deposits and ad- hesions takes place and relaxation occurs over the area of previous contraction, the last support of the uterus is gone and it becomes pro- lapsed or protruded. Another important factor in the causation of versions are injuries of the pelvic floor and perineum, or inefficiency of the same structures from atony or debility. They act less directly than in cases of pro- lapse and procidentia, but often with none the less effect. 0/ Flexions. Flexions may be caused by the same influences already given for version, but the resistance at the cervical attachments causes the uterus Fig. 223. Anteflexion produced by Contraction in or about the Round Ligaments. to bend instead of turning on the cervical pivot, i. e., a hard uterus will twist the cervical attachments and turn over, a flabby uterus will bend. The healthy uterus will bend slightly, and then slightly twist the cervical attachments in its normal range of motion. When the bladder is empty the fundus leans over the bladder partly at the ex- 490 DISPLACEMENTS OF THE UTERUS. pense of a flexure of the uterine body and partly by a slight twisting of the lower portion of the broad ligaments. When the bladder fills the uterus is strengthened and the lower portion of the broad ligament untwisted and slightly twisted in the opposite direction. Such flexion and version are normal. But when the uterus is drawn back or the fundus held down, so that the natural forces, such as the filling of the bladder and dorsal decubitus, cannot straighten it, then the flexion becomes pathological, and, sooner or later, the organ becomes disordered in function or inter- feres with functions of other organs. After a time the concave side becomes atrophied or intractile, and the flexion permanent. Fig. 222 represents an extreme degree of anteflexion due to contraction of the sacro-uterine folds. Flexion caused by contraction about the round ligaments is usually situated more in the cervix, as in Fig. 223. The pressure of the posterior vaginal wall and contents of the rec- tum against the lower end of the cervix in the latter case bends it for- Fio. 224. Puerile Anteflexion. After B. S. Schultze. ward, and thus keeps it from being turned back toward the sacrum, as, for example. Fig. 222. When the posterior vaginal wall is short, and the sacro-uterine and round ligatnents both rigidly contracted, or naturally short, in earl}' OF FLEXIONS. 491 life, the external os and fundus may be both turned forward until the cervix and corpus lie parallel to each other, both pointing forward toward the pubes or pelvic outlet, as in Fig. 224. After the causative influences have ceased working, or after the liga- ments, by removal of the contracting deposits, or by the development of puberty or married life, have been relaxed or elongated, the flexure (on account of atrophy or intractility of the concave side) may remain, and the fundus, or whole uterus, sink toward the coccyx, and a retro- location or retroversion be found along with the anteflexion, as repre- sented in Fig. 225. When the fundus becomes pushed or pulled back of the pelvic axis, abdominal pressure helps to force the fundus back in the recto- FlG. 225. Anteflexion with Retroversion and Eetrolocation. uterine or sacral peritoneal pouches, while the traction of the sacro- uterine ligaments tends to draw back the cervix to its normal position and thus flex the uterus at or above the internal os. If the organ be unusually flabby, as it is apt to become when thus distorted, the cer- vix and corpus may be bent so as to lie against each other (Fig. 226). When the cervix is drawn forward by inflammatory contrac- tions beside and in front of it, the flexion is usually less acute in degree and is distributed over the whole uterus or is confined to the corpus. The fundus usually does not lie as low, for in consequence of the previous inflammation at the cervix the uterine tissue is firmer and does not allow of such complete flexion. 492 DISPLACEMENTS OF THE UTERUS. Contraction of peritoneal exudates is supjDosed to be one of the most frequent causes of the extreme retroflexion represented in Fig. 226, for such flexion occurs after inflammatory attacks (esiDCcially the puerperal) and is often complicated by adhesions between the fundus and posterior surfaces of the broad ligament with the rectum and pos- terior pelvic walls. I have in a few cases noted a gradual increase in the flexion due to a diminishing resistance of the cervical tissue and the increasing traction of the sacro-uterine folds. Because of this moderate degree of retroflexion that is usually found in cases of retroversion the Germans call nearly all of them retro- FlG. 226. Extreme Retroflexion. flexions or retroversio-flexions ; on account of the retroversion that is found in nearly all cases of moderate retroflexions, these latter are more often classed in this country with retroversions. Retroversion with flexion, or retroflexion with version, would not be inappropriate. Some cases of flexion are due to congenital causes, but like other congenital deformities are rare. Flexion acquired before puberty is undoubtedly much more common, and is often classed as congenital. Malnutrition, improper feeding, sedentary habits, muscular atony and the like tend to arrest the development and impair the nutrition of the uterus. A comparison of Figs. 227 and 228 will give an idea of TORSION OR TWISTING. 493 the different kind of pressure to which the uterus is subjected in a woman who stands erect and one who habitually stoops. It is just as likely that the woman who sits and sews by hand or on a machine for eight hours a day during a period of several years will suffer with some form of uterine displacement or deformity, as that she will begin to stoop in her gait or suffer with dyspepsia or derangement of other internal organs. Continual standing also tends to uterine Fig. 227. Fig. 228. Natural Position of the Body. Unnatural or Stooping Position of the Body. flexion and displacement, because the abdominal pressure is continu- ous, and without that variation and general tonic effect that goes with varied exercise. Lateral flexions are usually caused by extensive contraction of tissue from inflammation beside the uterus, with or without tumors, enlargements or abscesses in or about the ovaries and Fallopian tubes. Torsion or Twisting. Torsion or twisting of the uterus to an unnatural degree may result from pressure or traction forward or backward at one horn of the uterus, or at one side of the cervix. The most common causes are a contraction in or about one sacro-uterine and one broad ligament (Fig. 52), and along or near the course of one round ligament. A sim- ultaneous backward or forward version or flexion is also found in most cases — sometimes a lateral version. 494 DISPLACEMENTS OF THE UTERUS. Symptoms of Uterine Displacement. The particular jjlace or position of the womb may not directly give rise to any characteristic symptoms until the organ commences to press at the pelvic outlet. The coexisting displacements, distortions or pathological conditions of the surrounding structures, whether the causes or results, usually cause the great bulk of symptoms. When the uterus is much enlarged its weight causes irritation or inflammation of the tissues upon which it presses, with the symptoms belonging to such troubles. Traction upon tender tissues also cause similar symptoms. Thus retroversion by traction, and anteversion by pressure, upon a tender bladder, may cause vesical irritability ; or retroversion by pressure and anteversion by traction upon a tender rectum may cause pain in the rectum or sacrum. Pains due to displacement are apt to be localized and persistent, and increased in certain postures and by certain occupations. Ante- versions and antefiexions are nearly always accompanied by decided symptoms, especially during the menstrual congestion, because the weighted uterus is suspended or held from fixed, and usually inflamed, tissues. Retroversion and retroflexion are much less often associated with painful symptoms, because the fundus finds a resting place be- hind, and hence does not drag so heavily upon inflamed parts. Even when the twisting of the broad ligament produced by the displace- ment is primarily painful, the state of rest of the organ often favors a subsidence of the inflammation, and particularly so if the recto- vaginal promontory and posterior vaginal wall are high and firm enough to afford indirectly some support to the cervix, turned for- ward over them. Pain in one iliac region is often caused by the trac- tion of an ante verted or retro verted uterus when complicated by a contracted broad ligament. Constipation is often a result of the pressure of a retroverted organ upon the rectum, but may also be caused by the induration and contraction in the sacro-uterine liga- ments encircling the rectum in case of anteversion. Sterility is more often a symptom of anteflexion than of retroflexion or retroversion, and more often of decided retroflexion than of retro- version. Extreme lateral version or flexion are also apt to be accom- panied by sterility, due, however, to its cause. Retroversion although seldom a cause of sterilit}^ is not infrequently a cause of abortion. Protrusion may give rise to faintness, dragging sensations about the pelvis, indigestion, inability to endure continuous exertion, irritability, hysteria, local irritation and ulceration, and in some cases renders the erect position unbearable, and life a burden. The symptoms of uterine displacement are so variable and so inti- mately connected with the pelvic diseases that I do not attempt to give all that are observed, but enough to enable the student to understand DIAGNOSIS OF UTERINE DISPLACEMENTS. 495 their nature, ^nd appreciate the relation of the symptoms to the dis- placement, which in reality is itself but a symptom among the others of some pelvic disease or disorder. Diagnosis of Uterine Displacements. For a diagnosis of the positions of the uterus the reader is referred to Chapter II. It will only be necessary here to give a few facts rela- tive to the differential diagnosis. One of the first and most important points is to determine the place and position of the cervix. Antever- FlG. 229- Anteversion and Retroversion (Schematic), after B. S. Schultze, illustratiii^ i.ie Changes in Location of the Lower End of the Cervix (^). n, normal position of uterine cavity ; a, anteversion ; r, retroversion. sion of a full-sized uterus scarcely ever exists when the lower end of the cervix is two inches or less from the pubic arch ; nor retroversion when it is more than two inches. Fig. 229 illustrates the changes in position of the lower end of the cervix in anteversion and retroversion, and Fig. 230 between anteflexion and retroflexion. The uterine cavi- ties only are represented. Anteflexion with retroposition or retroversion is often mistaken for 496 DISPLACEMENTS OF THE UTERUS. ordinary retroversion because the cervix extends forward in the vaginal axis, and its posterior wall is felt as far as the finger can reach extend- ing as a flat or slightly convex surface (antero-posteriorly) towards the sacrum (Fig. 224). By placing the finger tip against the os and rais- ing the side of the finger against the inferior pubic ligament in one of the urethral notches, it will be immediately perceived by measurement that there is no room for the fundus between the cervix and the sacrum unless the uterus be flexed. If flexed backward the fundus will of course be easily reached behind the concave cervical wall. If the os point toward the pubes or vulva and be less than two inches from the pubic arch there is retroversion (Fig. 229) or retroflexion (Fig. 230) or Fig. 230. Anteflexion and Retroflexion (Schematic), after Schultze, showing the Changes in Location of the Lower End of Cervix. ?i, normal position ; a, anteflexion ; r, retroflexion. else the fundus will be reached in the bimanual examination. Should an anteflexed uterus be drawn too far back to be palpated bimanually, the tense sacro-uterine ligaments may be felt behind the cervix. An unusual length of the anterior vaginal wall, from the inferior pubic arch to the cervico-vaginal junction (over 21 inclies) is diag- nostic of the great majority of cases of anteversion (229 a) or anteflexion (230 a) — it is much greater than in retroversion and retroflexion (r). DIAGNOSIS OP UTERINE DISPLACEMENTS. 497 The ease with which the fundus can be reached bimanually is of great importance. A knowledge of the location of the fundus, the vaginal junction and the external os gives as accurate information as to the shape and position of the whole organ, even when the entire anterior or posterior surface cannot be palpated. Retrouterine tumors are liable to be mistaken for retroflexions or even retroversions. The finger should be pressed as far up the ante- rior and lateral cervical wall as possible in search of the body. If the body be not thus detected over the retrouterine mass, it should be searched for bimanually. Its absence of course would prove the sup- posed tumor to be the fundus. The probe will pass backward if it be the fundus, but upward over it if it be a retrouterine tumor. The tumors most liable to be thus mistaken are retrouterine hematocele, fibroid in posterior uterine wall, small ovarian tumor, faeces in the rec- tum, and inflammatory or malignant deposits. The diagnosis of procidentia is easy because the cervix and urethra are visible and can be probed. The uterus can also be returned and then palpated. In prolapse the cervix is found by the finger pointing almost in the direction of the vaginal axis, less than two inches from the pubic arch, and lying on or at the recto-vaginal promontory. The uterine probe passes up in the direction of the curve of the pelvic axis or nearly so. 32 CHAPTER XXX. DISPLACEMENTS OF THE UTERUS {Continued). Treatment of Uterine Displacements. — Prophylactic. A LARGE proportion of the uterine displacements and deformities are acquired before and soon after puberty, and the majority of those acquired later are from causes originating in pregnant and puerperal conditions. Much can therefore be done in the rearing of children to prevent these troubles. Fewer hours of sitting, more hours of active outdoor exercise are required. The menstruating girl should be taught to rest during menstruation. The harmful ness of retaining the urine uncomfortably long, and the necessity of a daily movement of the bowels should be impressed upon her mind. Her food should be of a healthful kind. Anaemia, debility, nervous peculiarities, etc., should receive prompt attention. Especially should the least menstrual ir- regularity be made the subject of watchful study. After a miscarriage a woman should remain in bed as long as after labor, and after both she should be carefully watched by the physician until involution is safely and completely accomplished. If she have at the time, or previously, suffered with laceration or inflammation of the pelvic tissues, she should remain in bed two or three weeks instead of the usual eight or ten days. Immediate repair of extensive lacera- tions is of prime importance. • Treatment of Simple Dislocations, Upward, Forward and Backward. The treatment of displacement of the uterus upward, forward or backward consists almost entirely in the removal of the displacing cause. Pending this it is often necessary to support the uterus in its malposition and thus relieve the tender and perhaps rigid supports from the abdominal pressure and the weight of the organ. Cotton tampons soaked in glycerine, placed under and around the cervix in the morning and removed at night, form the best kind of support. They may be introduced through the speculum in the dorsal position, and should not be made of absorbent cotton which packs too hard, but of the best quality found in the dry-goods stores. A string should be attached to each to facilitate its removal. For elevation due to inflammatory conditions of the pelvic brim, one tampon about the size and shape of the terminal phalanx of the thumb should be placed in each lateral fornix, one or two in the pos- terior fornix, a flat one under the cervix, and one or two large dry ones SIMPLE DISLOCATIONS, UPWARD, FORWARD, AND BACKWARD. 499 in front of the cervix, according as there is much space to fill. For retrolocations the tampons are placed similarly except that they are left out of the posterior fornix. In lateral displacements no tampon, or only a very small one, should be put in the lateral fornix on the side of the displacement, but a proportionatel}^ large one should be put in the other lateral fornix. They may be placed very easily by withdrawing the speculum slightly after the deeper ones have been introduced. They are of but little service while the patient is in a recumbent position, and should not be employed until the acute stage of inflam- mation has passed, and the patient leaves the bed. Nor should the pelvis be packed too full of them, for our object is not to produce con- stant upward pressure, which would be intolerable, but to place a cushion around and under the cervix upon which it may settle when the erect position is assumed, and which will thus receive all increase of abdominal pressure and render it harmless. After the pelvic inflammation has passed into the chronic stage an inflated rubber ring (Fig, 231) maybe used; that it may better accom- FlG 231 Soft Rubber Inflated Pessaries. modate itself to the parts, the air may be let partly out with a pin and the pinhole closed with melted wax. Some of those in the stores have a piece of wax on the inside through which they may be punc- tured, and then closed by pressure. Some patients can wear the cotton tampons or the soft pessary con- tinuously, others only about half of the time. When it is not con- venient to replace them every night they may be left in place for thirty -six hours, then removed by the patient, and replaced by the physician after another thirty-six hours. Strings should always be attached to them for removal by the patient at any time that they may cause discomfort. In some cases of backward dislocations of the uterus the pressure of the abdominal viscera stretches and depresses the anterior vaginal 500 DISPLACEMENTS OF THE UTERUS. wall and makes it desirable to introduce a retroversion pessary (see Treatment of retroversion) which will turn the fundus forward over the bladder, and will also press upward behind the pubes with its anterior end, such as a Hodge, Thomas, Fowler or a Schultze's sleigh pessary. In case the bladder be separated from the uterus so as to allow of an anterior vaginal enterocele, a permanent fixation forward of the fundus by shortening the round ligaments (see Alexander's operation) may become advisable. Descent or Lapse. When the uterus sinks down in the axis of the superior strait with- out losing its mobility, either the ligaments are relaxed or the uterus is too heavy. Both conditions are apt to be present. Particularly is this so after inflammatory conditions which have raised or drawn the uterus toward the pelvic walls, have been in part removed, and the congestion, hyperplasia or subinvolution persist. The uterine sup- ports, weakened partly by the inflammatory action, and partly by long inaction, allow the heavy organ to sink down against the rectum or coccyx, or thereabout, and thus become permanently overstretched and subject to perpetual irritation and congestion. The indication here is to support the uterus, and relieve the trac- tion by tampons and soft pessaries. The tampons are placed as already directed for the elevated uterus, and may be used thus until the irritation in part subsides. After the vagina will tolerate a pretty Fig. 232. Peaslee's Elastic Ring. full packing they may be introduced in Sims's position, in which the uterus is drawn away from the pelvic floor as far as its supports will comfortably allow. Some prefer, after placing two or three glj^cerine tampons about the cervix, to stuff" one large piece of dry cotton or fine wool so as to fill the vaginal cylinder. If a little boracic acid has been dusted on the cotton or wool it may remain three or four days, then be removed and replaced immediately, or in twenty-four hours. The inflated soft rubber rings. Fig. 231, or Peaslee's elastic ring pessary, Fig. 232, can be used later. Such support, especially that by the tampons soaked in glycerine, by removing the traction and irritation, often relieves both pelvic and uterine troubles, and promotes involu- tion. TO STRENGTHEN OR ELEVATE THE PELVIC ROOF SUPPORTS. 501 Later, if these means fail, the uterus may be reduced by electricity or stimulating medicines applied to the endometrium, etc. Prolapse and Procidentia. Three indications are to be considered in the treatment of this form of displacement, viz. : to diminish the weight of the uterus and the other prolapsed structures, to strengthen or elevate the pelvic roof supports, and to restore or supplement the pelvic floor and perineum. Measures for Diminishing the Weight of the Uterus. When subinvolution, hyperplasia, or morbid growths occur in con- nection with prolapse and procidentia, they must be treated before a satisfactory cure can be effected. The means employed to reduce the size of a hyperplastic or subinvoluted uterus are strong galvanic cur- rents applied to the interior of the uterus, intrauterine applications of caustic or irritants, ergot, repair of cervical lacerations, the amputation of an elongated cervix, or an excision of wedge-shaped pieces from the external os in case the cervix be elongated supra-vaginally or en- larged merely in circumference. In a few cases the whole uterus has been removed per vaginam. This, as Schroeder-!^ remarks, is not now as formidable f n operation as formerly, and can be easily executed when the uterus is prolapsed or protruded, yet cannot be considered justifiable unless malignant disease, gangrene, or other equally grave indications call for it, i. e., unless the complication, not the displacement, calls for it. Measures to Strengthen or Elevate the Pelvic Roof Supports. Operations on the Anterior Vaginal Wall. — J. Marion Sims denuded a V-shaped figure from the anterior vaginal wall with the apex near the urethra and the ends of the arms just in front and on either side of the cervix. The denuded strips forming the V are about a third of an inch wide, and when united, narrow the vagina, more particularly at the upper end. Emmet found that the cervix sometimes caught into the cavity formed under the united arms of the V and became retro verted or otherwise caused the patient discomfort. He therefore modified the denudation by converting the V into a triangle (Fig. 233). This operation was invented for the purpose of narrowing the vagina, and as such has been largely supplanted by operations on the posterior vaginal wall. But as a means of drawing together the re- laxed pelvic roof-tissues and strengthening them, it is rational and useful, and involves less mutilation than an excision of a large oval or round piece of vaginal wall. It is preferable, I think, to combine * Op. cit. 502 DISPLACEME2sTS OF THE UTEEQS. such an operation with perineorrhaphy than to remove as large a part of the posterior vaginal wall as is frequently clone in posterior colpor- rhaphy. When the parts about the urethral fossse, or lower end of the vaginal sulci, are the ones most relaxed, the excision of two narrow strips from the fossge (one on each side), diverging as they extend backward, may be indicated. (Fig. 234). These strips may be connected by a transverse strip under the neck of the bladder when there is much Fig. 233. The Sims-Emmet Denudation for Cystocele and Procidentia, ^.uterus; ii, urethra ; CCCC, denuded surface. redundancy of the anterior vaginal wall in an antero-posterior direc- tion. (Fig. 235;. The stitches of the transverse denudation take an antero-posterior direction, those of the lateral a diagonal direction, Avith reference to the vaginal axis. The object is to draw the relaxed vaginal wall up behind the pubes into the sulci and urethral fossfe. There is a peculiarity about the passing of the sutures in the ure- thral fossse and the lateral denudations that is worthy of attention. They should be passed in a direction diagonal to the long axis of the vagina and made to include the edges of the wound and a strip of the TO STRENGTHEX OR ELEVATE THE PELVIC EOOF SUPPORTS. 503 centre, as in Fig. 236. It draws, when tightened, the edges and bottom of the wound up together (237). When, however, ordinary stitches are passed, not including the bottom of the wound, the tissues are folded so that the bottom is removed as far as possible from the edges as in Fig. 238. In denudations directly under the urethra and bladder Fig. 234. Fig. 2f! I Zlrcfkra Cerrt-x Cei'Vi^ Fig. 234.— Lateral Denudation in the Urethral Fossee and Anterior Vaginal Sulci, for elevating and strengthening the Pubic End of the Vesico-vaginal Septum. Fig. 235.— Denudation for raising and strengthening the whole Vesico-vaginal Septum. in the median line, the latter are better, as they make a thicker sep- tum. In denudations in the urethral fossse and anterior vaginal sulci the former are preferable because they draw the vaginal walls up to the Connective tissue above. Recently gynecologists, especially the German, have gone back to Sims's first method of excising an oval piece of the anterior vaginal Fig. 236. Fig. 237. Fig. 238. -^ ir Fig. 236.— Stitch passed so as to catch up the Bottom of the Wound. Fig. 237.— Same, united. Fig. 238.— Suture passed and united in the usual manner. wall and drawing the edges together in the median line. Sims used superficial stitches only, and sometimes had trouble from an accumu- lation of the secretions at the bottom of the wound. This is now obviated by the employment of three or four additional deep stitches. 504 DISPLACEMENTS OF THE UTERUS. or by uniting the deeper portions by one or two rows of buried catgut sutures as recommended by Werth.* When soaked in oil of juniper for 24 hours, and then preserved in alcohol, Kiister claims that catgut will resist absorption for nine days (Schrceder, op. cit.). A continuous suture may be taken along the bottom of the wound, and then another a little higher up. Sometimes the entire mucous membrane is denuded from the Sims- Emmet triangle and united by transverse deep and superficial stitches. Cauterization. Cauterization of the vagina and cervix has been resorted to for the reduction of redundant tissue and the strengthening or hardening of the uterine supports. Holes have been burnt into the cervix with caustic and longitudinal strips of the vagina have been cooked by the actual cautery and electro-cautery. Recently John Byrne,t of Brooklyn, has employed partial and com- plete amputation of the cervix and vaginal folds, by means of the galvano-cautery, with success. In some cases in which the pelvic con- nective tissue has completely lost its tone and in part wasted away, this method will undoubtedly prove valuable in producing a cicatricial hardening of the pelvic roof tissues. Partial Closure of the Vagina. Lefort's method of denuding a median strip on both anterior and posterior vaginal walls, two centimetres wide and six centimetres long (I X 2J inches), and uniting them, has proved a useful operation. The parts may be denuded while protruded and returned as fast as they are stitched, commencing of course with the deeper portions. A small channel for the passage of the secretions is thus left on either side. Well prepared catgut may be used, as first recommended by Panas,J and thus the troublesome removal of stitches avoided. L. A. Neugebauer's method is practically the same as Lefort's, but his surfaces are a trifle smaller. By thus practically uniting the pelvic roof and pelvic floor, the uterus may be supported when the vaginal outlet and the perineum are destroyed beyond repair. Martin has known this artificial barrier to give way under the strain of heavy lifting, and allow the prolapse to occur again. * Centralbl. f. Gyn., 1879, No. 23, Schrceder-Krankh. d. Weibl. Gechlechtrory, 7th fed. t Transactions, Am. Gyn. Soc, vol. ii. X Winckel, Lehrbuch der Fraiienkrankheiten. HYSTEROPHORES OR PESSARIES. 605 Abdominal Section. P. Mueller, T. G. Thomas, H. Marion Sims, and others, have cured some desperate cases by amputating the uterus above the cervix, and attaching the stump in the peritoneal wound. Others have attached the uterus and its appendages to the abdominal walls after laparotomy for other purposes. This latter method would hardly be attempted by a special laparotomy, as there would be too much uncertainty of the attachment holding, and too little certainty of the patient recover- ing from the operation. Measures to Supplement or Restore the Pelvic Floor and Perineal Supports The pelvic floor and perineum may be supplemented or restored for the retention of a prolapsed or protruded uterus by (1) hystero- phores or pessaries, and (2) by plastic operations. Hysterophores or Pessaries. The simplest yet least efficient form of hysterophore is the ordinary perineal band, passing over the vulva and attached to an abdominal supporter or broad elastic belt. Its most useful application is in con- FlG. 239. Fitch Supporter. nection with a large vaginal tampon, introduced in the Sims position, so as to fill the replaced vagina. It may be medicated with astrin- gents and antiseptics, such as tannin, boracic acid, a mixture of tannin and iodoform, persulphate of iron. Fuller's earth, etc., and may be changed once in two or three days, or left for five or six days, i. e., as long as it remains in place and free from odor. Some patients can be taught to use them upon themselves, by first returning the protruded 606 DISPLACEMENTS OF THE UTERUS. mass, and j)ushing back the cervix toward the sacrum, or b}^ assum- ing the knee-chest position, and then stuffing the vagina full. Hackenberg, of Rochester, N. Y., precedes the tampon b}^ tannic acid. The uterus is pushed as far up as practicable by the speculum introduced in the dorsal position, thirty grains of the tannin placed around the cervix and dry cotton packed in the vagina after it. The Fig. 240. •CD'S N>er tubing will meet ; then twist the ends of the wire into a stem and slip another piece of PLASTIC OPERATIONS UPON THE PERINEUM AND PELVIC FLOOR. 509 tubing over the twisted stem. The junction of the tubes at the upper end of the stem may be consolidated by filling the uneven edges with cotton batting, winding thread around it, and then coating it with flexible collodion. Then bend the ring portion into an oval shape, with a curve on the flat, so as to enable it to reach up behind the cer- vix, and bend the stem sharply back at a point about an inch from the lower end of the ring and give it the curve of the sacrum, so that it will pass up between the nates toward the waist. A tape attached to the end of the wire will serve to fasten it to a strip of cloth tied around the waist. I have thus frequently made the Scott pessary, and have taught the patient to introduce it before rising in the morn- ing and to remove it after getting into bed at night. She must be told to be careful in getting the ring behind the cervix, i. e., to make the ring sweep around the hollow of the sacrum instead of straight up behind the pubes. In some of the instrument stores, particularly in New York, a Scott pessary is made of hard rubber in which the ring is prolonged into the vulval portion, or to a point where the stem should turn back. In case of simple prolapse or retroversion, when the vulva is not dilated, this prolongation is an evident disadvantage, as it takes up more space in the vulva, and is liable to irritate. The Priestly and Lazarevitsch pessaries in the foreign market are also stem pessaries. Plastic Operations upon the Perineum or Pelvic Floor. Fricke, of Hamburg, united the denuded labia (episiorrhaphy) for the retention of the prolapsed uterus and vagina and succeeded in ameliorating the condition of some of his cases in which he could not fit a pessary.^ Gerardin, of Metz, proposed in 1823 to denude two opposite surfaces at the lower end of the vaginal canal and unite them.t Meude proposed the formation of an artificial hymen. Dief- fenbach denuded surfaces on the lateral vaginal walls a;nd united them. Malgaigne made denudations higher up. These attempts were of course unsatisfactory because they merely converted a procidentia into a prolapse or lapse. Simon was the first to attempt to hold the uterus at its normal elevation in the pelvis by narrowing the vagina. Fig. 248 shows the original Simon denudation and the various modifications since employed for prolapse, and which have been referred to under the chapter on Perineorrhaphy. To these may be added those of FritschJ and Reamy,§ which will be under- stood by an examination of Figs. 249 and 250. * Lageveraenderungen, etc., des Uterus. Fritsch. t Lehrbuch der Frauenkrankheiten. Winckel. X Op. cit. I Medical News, April 9, 1887. 510 DISPLACEMENTS OF THE UTERUS. Hegar's is the best of the median operations. It forms an un- naturally large perineal triangle and a high, long recto- vaginal pro- FlG. 248. Outlines of Denudation for Procidentia. After Winckel. montory. Martin's is the best of the bilateral operations. None of them, however, are suited to the child-bearing woman. One of the Fio. 249. Fig. 2.'n. Denudation for Procidentia. After Fritsch. aaxus Denudation for Procidentia. After Reair.v. TREATMENT OF VEESIOXS. 511 other operations described in the chapter on Perineorrhaphy would be preferable as forming less obstruction during a subsequent labor. Choice of Methods. As the object to be accomplished in the management of prolapse and procidentia is not merely to push the parts back from the vulva, but to restore the normal condition and relationship of the pelvic, and to a certain extent the abdominal viscera, a combination of the dif- ferent procedures already recommended will usually be necessary. When the causative condition is found, that, of course, should receive the first attention. NuUiparous cases should if possible be treated without any mutila- tion of the vulva and vagina. Uterine enlargement in the subacute or progressive stage should be treated with remedies designed to re- move all congestion and inflammation, and the organ supported by vaginal tamponment or packing. Chronic subinvolution, hyperplasia or elongation of the cervix must, when present, receive separate treat- ment before the uterus can be jDcrmanently replaced. The strengthening of the supports by astringent vaginal and rectal injections, and the simultaneous or subsequent use of tampons and pessaries should also be thoroughly tried. If these be not sufficient, shortening of the round and sacro-uterine ligaments,* or both, may be employed together with the tampons or pessaries. When the patient has borne children, as is almost always the case, we should look for injuries, and results of injuries, in parturition. If we find a laceration of the pelvic floor or perineum, we must not, how- ever, think that the misplacement will necessarily be cured when that is repaired. The same attention must be given to all the factors as in treating nullipars, and all congestions, enlargements and subinvolu- tions of the genital organs reduced as far as possible, that they may not reproduce the difficult3^ The operation upon the perineum and pelvic floor may be among the last steps in the cure. Operations upon the pelvic roof structures must often precede them. When rational treatment cannot be carried out, sometimes Lefort's or Neugebauer's operation combined with an Alexander operation may be performed, and the patient rendered much more comfortable. Treatment of Versions. I. Anteversion. Anteversion, being usually symptomatic of contraction or pressure of tissues outside of the uterus, or of enlargement about the fundus or anterior wall, is relieved by the treatment of these pathological states. * See Treatment of Retroversions. 612 DISPLACEMENTS OF THE UTERUS. Vaginal Tamponment Abdominal or vaginal supports should be used as soon after the causative inflammatory or other conditions will permit, not so much for the purpose of replacing the uterus as to relieve the traction or pressure upon tender or indurated places. Hence the vaginal tampon should be preferred to the pessary, which is apt to press uncomfort- ably and constantly over limited areas. The tampons, in order to relieve the tender or rigid parts of the weight of the uterus or force of abdominal pressure, must sometimes temporarily favor or even increase the malposition. Thus if sacro-uterine ligaments be rigid or con- tracted, the tampons are placed under and in front of the cervix, so as to keep the cervix back, and up, and prevent it dragging upon them. They may thus increase the version. When, however, the fundus is pressed down by abdominal pressure so as to irritate the bladder or painfully twist the cervical attachments, then the corpus, or both corpus and cervix, should be raised to a position of comfort. When the round ligaments or their surrounding tissues are tender and con- tracted, the plugs should hold the cervix and fundus in the position in which they are thus drawn. When the weight of only a part of the uterus is at fault, the tampons must, of course, aid in supporting the weighty portion. Anteversion Pessaries. When the deposits and contractions have been removed, then the uterus will need no pessary or support for the anteversion, not only because the anteversion would then be painless and harmless, but because the anteversion will usually cease to exist. The uterus may return to a normal or, what is usual, pass to a state of lapse, prolapse, retroversion, or other malposition, and thus require a pessary or other treatment for its new position. The anteverted uterus is usually hardened and heavy, or we would have an anteflexion at the same time. The disappearance of the disease about the contracted sacro- uterine or round ligaments is apt to be followed by their relaxation, and a consequent movement either of the cervix too far downward and forward, or of the fundus too far back. A lapse or prolapse follows in the first case, while a retroversion may easily be produced in either. When, however, a pessary is used it should be used on the same principles as the tamponment, viz., to give the pelvic organs relief without reference to the malposition. When the retention of the uterus in a normal position gives greatest relief, then, and not until then, should it be so held by a pessary. In this country, Gehrung and Thomas, and in England, Hewitt have invented the most popular forms of anteversion and anteflexion pes- saries. Thomas has invented several varieties. In my own practice ANTEVERSION PESSARIES. 513 I utilize my own model of retroversion pessary (see Retroversion, Fig. 256), by bending the neck or collar a little further forward than for retroversion, as in Fig. 254. I thus can make it support the cervix, or lift the body, as much or as little as desirable by altering the size, position, and shape of the collar. When the vesico-vaginal septum is Fig. 232. Gehrung"s Pessary for Anteversion. Hewitt's Anteversion Pessary. firm, it does not reach the corpus, but pries up the fundus by the traction of the elevated septum upon the cervix in a forward direction. When the cervix is to be supported merely, a small sized one with the Fig. 253. Fig. 254. "■'"«M^7w;-^5~- Thomas's Anteversion Pessary. Byford's Pessary with tlie Neck Elevated for the Relief of Anteversion. retroversion shape may be used, Fig. 256 or 257. Thomas's elastic soft rubber modification of the Albert Smith pessary, Avith a pad for retroflexions. Fig. 270, can often be satisfactorily bent into this shape. Sims's operation of denuding a surface in front of the cervix, and another a little lower down and stitching them together, so as to shorten the anterior vaginal wall, is, it seems to me, an unscientific procedure for anteversion or anteflexion, and does not affect the parts involved in their production except to create traction upon the cervix. It can only overcome such displacement by force. Sims's method of 614 DISPLACEMENTS OF THE UTEEUS. denuding the anterior lip, and uniting it to the anterior vaginal wall farther down, is still less scientific. I formerly modified the Albert Smith retroversion pessary by elon- gating the tongue or anterior end, and bringing it out over and under the perineum, so as to prevent the instrument slipping too far into the vagina. By then making the vaginal jjortion sufhciently short, it held or pried the lower end of the cervix forward and corrected the malpo- sition. At the point where the bars passed through the vulva, they Fig. 255. "S-e-ctitzni Anteversion Pessary acting by holding the Lower End of the Cervix Forward. were made to touch each other, and thus occupy but little space. The discomfort experienced by the patient from having the cervix thus dragged forward, led me, however, to abandon such treatment. It corrected the misplacement, but often increased the irritation, which should have been subdued. II. Retroversion. The treatment for retroversion here given is equally applicable to retroversion with slight retroflexion. In the Acute and Subacute Stages. Before the uterus is replaced, acute and subacute inflammatory con- ditions should be removed. When the uterus and vagina become tolerant of cotton tampons medicated with glj^cerine, they may be used with great benefit. At first it is better to place a soft one under the cervix, in order to relieve the cervical supports of the strain, which the abdominal pressure bearing upon the exposed vesico-vaginal septum must occasion — particularly so in the standing posture. But the tampon should not be pushed back in the fornix so as to press upon tender ovaries or retrouterine tissues. In many cases the con- tinuance of localized pelvic inflammations renders all other mechanical support than this impossible for a long time. Rejilacement. After the inflammation has subsided an attemi^t may be made at replacement. This is done by pushing the cervix back, or the fundus ADHESIONS. 515 upward, or both. The most common method employed is to introduce two fingers into the vagina and push upward against the fundus through the posterior cul-de-sac with one, and backward against the cervix with the other. It is very difficult to reach far enough with the finger in the posterior fornix to get the fundus above the sacrum, hence the finger against the cervix has to do the jDrincipal work. I usually find it more efficacious to depend entirely upon leverage, and accord- ingly press the middle finger in the vaginal fornix backward under the fundus toward the lower end of the sacrum. The posterior vaginal wall is thus made to draiv the upper end of the cervix back, while the forefinger pushes back the lower end. After the cervix is well back the other hand over the abdomen should, if joossible, be caught over the fundus and be used to pull it down over the pubes, and complete the replacement. Sometimes two fingers in the rectum may be used to press up the fundus, and the thumb of the same hand in the vagina to push back the cervix. Another method of replacement, advocated by Campbell,* is to put the patient in the knee-chest position and admit air to the vagina. If the fundus is not immediately drawn up into the abdomen it may be pushed out of the hollow of the sacrum by the fingers or by any thick blunt instrument. In case the vaginal portion of the cervix is too short or soft to afford any leverage, or the uterus too flabby to be forced or pushed up, I sometimes introduce a stem probe, which is practically the same as a hard stem pessary (Fig. 269) and then am not only able to replace the uterus by leverage, but can tell by the position of the lever end of the stem just where the fundus has gone to. This method is valuable in determining the presence or extent of adhesions, and is much less severe upon some patients than the bimanual. Some gynecologists use the probe or an intrauterine repositor for the purpose of reposit- ing the fundus. Such methods are more hazardous for any but the experienced to employ, and are seldom a necessity. Adhesions. When the uterus cannot be thus replaced, or when the fundus will rise only a certain distance before encountering firm resistance, or causing the patient great pain, it is probably held by adhesions. Adhesions are of two kinds, viz: (1) direct adhesions between the peritoneal surfaces of the uterus and its appendages to their surround- ings, and (2) indirect adhesions, as cicatrices or contractions in the cellular tissue about the uterus preventing it from returning to a normal position. Both kinds may sometimes be overcome, especially if recent, by treatment directed to the absorption of the abnormal * Transactions American Gyn. Soc, vol. i. 516 DISPLACEMENTS OF THE UTERUS. tissues. In the chronic stage the first may be materially influenced and sometimes overcome by intermittent or constant traction, while the second kind are only slightly benefited thereby. The Vaginal Pack. In the subacute and chronic stages of the inflammation producing the adhesions, and after the pelvic tissues will tolerate moderate pres- sure, the retroversion is benefited by the vaginal pack or tamponment. We then no longer rely on the mere cervical support of a glycerine plug, but we pack the posterior and lateral fornices with antiseptic cotton so as to support the whole organ. The cervix is not merely pushed back and tamponed there, for that would tend to increase whatever flexion or tendency to flexion might exist, and create dis- comfort, but the fundus is pushed well up, and the posterior fornix filled with two or three dry pieces of wool or cotton (not the absor- bent). Then, if there be room, a small flat tampon saturated with glycerine or oil is placed on each side of the cervix, a larger one under it and perhaps one in front. The vaginal entrance should, however, be free of all packing or pressure. When the uterus is quite movable the packing may be more advan- tageously placed in the knee-chest position. The fundus and ovaries will then be out of the way during the packing and will settle on the pack more comfortably. The first packing should be loose and small, and should not distend the vagina, nor should subsequent ones ever be so large as to cause discomfort. Engleman"^ uses medicated cotton for the purpose of getting a medicinal effect upon the pelvic organs as well. When the fundus can be replaced by the knee-chest position the pack should be so arranged as to hold the cervix well back and thus retain the organ in as normal a position as possible. If properly placed it may remain from two to five or six days. If any tendency to irritation or ulceration due to the packing be discov- ered the cotton or wool should be lubricated and should not be re- newed for a day or two after being removed. Breaking Up of Adhesions. B. S. Schultze f recommends the breaking up of adhesions under chloroform narcosis. He introduces two fingers into the rectum and the thumb into the vagina, and after repositing the uterus sufficiently to put the band of adhesions on the stretch, breaks them slowly by hooking the rectal fingers over them. Flat adhesions are separated by the rectal finger as the placenta would be separated from the uterine * American Journal of Obsteti-ics, June, 1887. f Op. cit. MECHAISIICAL, SUPPORT. 517 wall. Flat adhesions of the uterus to the rectum are often difficult to separate because the rectum ma}^ be drawn forward with the uterus. Adhesions of the tube and ovaries to the sacrum require delicate handling and should be separated by a slowly increasing pressure. Usually they cannot, with a safe amount of pressure, be separated at one sitting, but may be tried again, provided no reaction follows the first trial. In subacute cases we may usually get the uterus free by treatment directed to the absorption of the plastic deposits. In chronic cases I have for weeks, and sometimes months, employed vaginal and bi- manual manipulation once or twice a week to break up the adhesions. By sweeping the vaginal finger-end from side to side between the ad- herent rectum and uterus, and drawing up the uterus until the pain became quite severe, I have usually succeeded in freeing the fundus so that it could be lifted up but not always forward. The difficulty is that when the patient can endure such manipulations the adhesions are too chronic to be completely sejjarated in this way. I have also partly liberated ovaries and tubes, and have, by no other treatment than this, supplemented by a glycerine tampon and the vaginal douche, caused all dysmenorrhoea and pelvic symptoms to disappear, together with the cervical ulceration and congestion. But the vast majority of cases that come to me require a long course of treatment before such manipulations can be tolerated. Recently Polk * has recommended and performed laparotomy for the purpose of breaking up the adhesions in old, obstinate cases, accompanied by great suffering, and has succeeded in relieving the symptoms. In case the uterus requires support, he follows the laparotomy by an Alexander-Adams operation. I prefer making a vaginal incision into the recto-uterine pouch, and breaking them up through that. I have done so in four cases, but have each time found it advisable to remove the diseased ovaries and tubes at the same time. In the last two cases I held the uterus in place by vaginal tampons, and thus cured the displacements. Mechanical Support. After all inflammatory reaction and obstructing adhesions or con- tractions have been removed from the pelvic tissue, the uterus has a tendency to return to its normal position. Many times, however, the sacro-uterine and round ligaments remain relaxed and weakened, and have not the power of turning the fundus forward after an evacuation of the bladder, or of preventing a backward displacement during straining in a stooping posture, as in defecation, lifting, etc. It may be reiterated here that during muscular exertion a greater strain is * American Journal of Obstetrics, June, 1881. 518 DISPLACEMENTS OF THE UTERUS. often thrown upon the uterus than its suspensory supports can bear (crowding it down against the pelvic floor), while during muscular relaxation but little power is required to return and hold it in a nor- mal position. As a consequence, much advantage will be gained by supporting the uterus until stretched ligaments have become retracted, and any chronic indurations or cicatrizations sufficiently absorbed or stretched to allow the corpus uteri to incline over the bladder without restraint. Mechanical supports or pessaries accomplish this by taking advantage of the pivot or ball-and-socket action of the cervical supports, and pry the fundus forward by turning the cervix backward. They may be divided into four classes : (1) those acting in front of the cervix by keeping it in the back part of the pelvis ; (2) those acting behind the cervix by drawing the cervix backward; (3) those combining the action of both of the above methods, and (4) those acting similarly upon the cervix within its canal. Pessaries Acting in Front of the Cervix, or Barrier Pessaries. The advantages of pessaries acting in front of the cervix are that they interfere but little with the natural uterine supports, restrict but slightly the normal motions of the uterus, and can be removed and introduced by the patient. The great disadvantage of this form of instrument is that it requires the fundus to rest without restraint in front of the sujjerior strait so as to receive the abdominal pressure upon its posterior surface. When from lateral or other traction, or retroflexion, the fundus does not re- main well forward, abdominal pressure, which at times is all-powerful, will turn the fundus back and either pry the cervix over the barrier, or else pry up the barrier out of place. A short vaginal portion of the cervix, short anterior vaginal wall, a flabby uterus, tenderness in front of the cervix, are also not uncommon conditions that limit its useful- ness. These barrier-pessaries, therefore, find their chief use after other more powerful supports have been used, and it has become desirable to partly withdraw the artificial support and allow the uterine liga- ments to assume function. They supplement but do not supplant the ligaments as do the firmer supports. They are especially useful after labor, at which time the size of the uterus affords them greater advan- tage. In case of laceration of the cervix they should especially be tried, as they both lift the cervix from the posterior vaginal wall and hold the torn lips together. On account of the possibility of a retroversion occurring while they are apparently in proper place, the patient should assume the knee- chest position two or three times in twenty-four hours and admit air to the vagina, and thus replace both uterus and pessary in case they should be displaced. BARRIER PESSARIES. 519 The simplest form of the barrier pessary is a piece of ordinary cotton loosely rolled in the shape of a spool of thread, and introduced over and behind the rectal promontory, in front of the replaced cervix. It should be changed once in twenty-four or forty-eight hours, when an antiseptic vaginal douche may be used. Having been thus used for a time it may be removed at night and another introduced in the morning. The patient may even learn to introduce it herself in the knee-chest position ; or in the knee-elbow position after having thus replaced the uterus. She can of course remove it by first attaching a string to it. Similarly a collapsed rubber ring may be introduced by the patient in the knee-elbow position after thus replacing the uterus, and then inflated. Courty's barrier pessary consists of two bars resting on the pelvic floor, joined in front where they impinge against the pubes or vaginal entrance by a cross bar, and curved up posteriorly around either side of the cervix so as to meet in front of it. The neck thus made for the Fig. 256. Fig. 257. Byford's Retroversion Pessary. Byford's Retroversion and Prolapse Pessary. cervix forms a rigid barrier to keej^ it back. Dr. T. D. Fitch of this city, without having seen Courty's instrument, invented, during an extended series of experiments, an instrument similar to it. By turning the posterior end of an Albert Smith in front of the cer- vix I devised an instrument which, although I did not know of Courty's pessary, was practically a modification of it (Fig. 256). The difference lay in the tongue shape of the anterior end, the curving of the bars to correspond to the posterior vaginal wall or (if that were relaxed) the pelvic floor, and the depression of the middle portion of the collar for the reception of the cervix. The consequent action of the pessary is elastic, for a slight rocking motion is allowed by the curved arms. Where there is danger of the pessary slipping, the arms may be separated and the tongue curved back under the pubes, as in Fig. 257. Fig. 258 shows the pessary in place. It may be introduced turned sideways or upside down, or any way in which it enters best, until the collar passes behind the pubes, and 620 DISPLACEMENTS OF THE UTERUS. then turned right side up. The patient can easily place it by intro- ducing it far enough for the collar to rest behind the pubes, and then assuming the knee-chest position and allowing it to slip into position. She can remove it by turning it partly around and giving it a little twist as she withdraws it, or by turning it upside down and rolling or prying it out. On account of the difficulty in altering the arms so as to fit the posterior vaginal wall in the hard rubber instrument, I have so far made my instruments out of the soft rubber, elastic, Thomas and Albert Smith pessaries or, when a large one was required, out of the largest size ring of cojDper wire covered with soft rubber, as found in the shops. Fig. 258. Byford's Retroversion Pessary in Place. By depressing the collar the barrier may be placed in front of the lower end of the cervix and get a powerful leverage upon the fundus ; by raising the collar the barrier holds the whole cervix back, but gets less of the leverage power. The straighter the arms the less is the rocking motion and the firmer and more rigid the barrier. During defecation it is always advisable for the patient to press the finger against the end of the pessary and prevent its coming forward, and to assume the knee-chest position afterward. I have had better success in permanently curing retroversions with TRACTION PESSARIES. 521 this pessary than with any other. Its inefficiency in many cases is in accord with its non-interference with uterine motion, for it allows the uterine ligaments to resume healthy motion. Pessaries acting behind the Cervix, or Traction Pessaries. The advantages of the pessaries acting behind the cervix are that they take a firm hold upon the posterior vaginal wall, and draw the cervix up as well as back, and thus prevent ordinary abdominal pressure from bearing ujDon the anterior uterine wall and reproducing the displacement. Contractions beside the uterus which prevent the barrier pessaries from acting efficiently, have but little effect in repro- FlG. 259. Fig. 260. The Albert Smith Retroversion Pessary. Hodge's Closed Lever Pessary. ducing the displacement when the traction pessaries are used because of the firm elevation of the cervix. Another advantage is their me- chanical simplicity, and the ease with which they can be successfully used by the general practitioner. Their disadvantages are that they are apt, by distending the vagina, to weaken the pelvic roof ; they draw the cervix higher than natural and thus interfere with the normal action of the supports ; they are apt to retrovert the uterus when removed by the patient, and they cannot be replaced by the patient. In proportion as they are modified to lessen these disadvantages they become either less efficient or more difficult of adjustment. They are, however, and will probably remain the most generally useful pessaries for retroversion. The Hodge closed lever pessary is the oldest and most efficient of the almost infinite varieties to be found in the shops. It consists of an elongated ring bent somewhat abruptly upward behind the cervix, and more gently upward in front, so as to impinge against the ante- rior vaginal wall behind the pubes. It is liable to turn in a roomy 522 DISPLACEMENTS OF THE UTEEUS. vagina and to find inefficient support against a relaxed vesico-vaginal septum. These disadvantages have been overcome in the Albert Smith pessary by narrowing the anterior end of the ring, and turning it down so as to project slightly under the pubic arch. An increase in the curve of the arms elevates the cervix, increases the anteversion, and renders the pessary mechanically more efficient. A separation of the bars diminishes the tendency to turn sideways and slip out at the vulva. As an excessive elevation of the cervix is unnatural and often harmful and unbearable, Emmet diminishes the length and abrupt- ness of the posterior upward curve. He also employs a larger bar than others. Hewitt's retroversion pessary is simply an elongated Fig. 261. Hewitt's Cradle Pessary. ring with a gentle curve on the flat. It is particularly useful when the vagina is small, but it is liable to press injuriously behind the pubes. Schultze's sleigh pessary is a modification well adapted to a relaxed vagina. (See Fig. 241.) The Scott, Thomas, Cutter, Priestly, and Lazarewitsch pessaries with external supports are also valuable when the relaxed vagina does not retain the other forms. (See Figs. 245, 246.) Hanks, Noege- rath, Schroeder, Gehrung, and others have devised other slight modi- fications. The ordinary material for such pessaries is the hard rubber. The Albert Smith pessary is made also of spring wire covered with soft rubber, and constitutes an excellent instrument for the general prac- titioner. Any form, however, may be given to the copper wire rings covered with soft rubber, and after a thorough and satisfactory trial may be reproduced by the instrument dealer, in hard rubber. Pessaries Acting both in Front and Behind the Cervix. The advantages of pessaries acting both in front and behind the cervix, are a firmer grasp of the cervix, and a dividing of the force between the traction and pressure. They are particularly applicable when the posterior vaginal wall is relaxed and voluminous, or when the cervix is lacerated. The disadvantages are an unnatural confine- PESSAEIES ACTING WITHIN THE CERVICAL CANAL. 523 ment of the cervix, difficulty of adjustment, and a tendency to injuri- ous pressure. Fritsch places a bar (which projects slightly upward) across a Hoclge pessary at about the junction of the posterior and "middle third. Studley, and T. D. Fitch, place a ring on a Hodge or Albert Smith pessary, so as to project forward from the posterior upper end and encircle the cervix. Schultze twists an elongated ring into a figure eight, the upper or cervical end of which is a little smaller than the lower. He then curves the upper ring slightly on the flat so that the concavity looks upward, and the lower so that the concavity looks downward; or gives it any special curve that the case may require. The cervix rests in the upper ring. Objection has been made to the pessary on account of its interference with copulation. I have not used it. Thomas places a semicircular bar upon the upper half of an Albert Smith pessary, and thus gets an anterior bearing upon the Fig. 262. Fig. 263. Thomas's Retroflexion Pessary. Fowler e, i'e&E,iii > . Cervix without confining it as much as those just mentioned. When the cervix is flabby or lacerated, this form is often very useful. The Fowler pessary has a circular opening for the cervix, and is otherwise thick and solid, excepting a small hole in the tongue in front. It is very much the shape of a cadet cap turned upside down, and rocks upon the posterior vaginal walls, as do the others. Pessaries Acting within the Cervical Canal. Retroversion and retroflexion pessaries acting within the cervical canal, are usually of the Albert Smith or Hodge variety, with an intrauterine stem attached to a cross bar, or resting in a cup or sup- port. The only true pessary of this kind with which I am acquainted, is one invented by H. Marion Sims.* There is no projection into the posterior fornix, but the stem is attached to the posterior end or cross bar, and moves forward and backw^ard on it as a pivot. He intro- * American Journal of Obstetrics, June, 1886. 524 DISPLACEMENTS OF THE TTEEUS. duces it in the Sims's position. When the stem is in the uterus, it carries the cervix back and tilts the fundus forward as the ring is pushed into place in the vagina. The Byrne, Thomas, and Kinlock instruments have the posterior projection of the Hodge or retraction pessaries, and are therefore a combination of both varieties. Fig. 264. H. Marion Sims's Retroversion Stem Pessarv. Those in which the stem has a hinge, or ball-and-socket motion upon the cross bar, are safer and hence preferable to those in which the stem is fixed firmly upon the cross bar. The advantages of this form of pessary are those that belong to the uterine stem (see Treatment of Flexions, and of Dysmenorrhoea), and which aid in making the cure of the replacement permanent. The disadvantages are the great danger of the use of the intra- uterine stem in general, and of the application of the force by so small a rod. Since writing the above description, I have learned* that Dr. S. J. Donaldson, of New York, had used a similar instrument about three years before Dr. Sims, but with- out his knowledge. * American Journal of Obstetrics, August, 1887. CHAPTER XXXL DISPLACEMENTS OF THE UTERUS {Continued). Operative Procedures for Retroversion. Operative measures for the relief of retroversion are (1) for the pur- pose of restoring the uterus to its natural condition, (2) of restoring the function of the uterine supports, and (3) of holding the fundus forward or the cervix backward (operations of expedience.) To Restore the Uterus to its Natural Condition. Enlargements of the uterus and cervix may be treated by the same operations as already recommended for prolapse and procidentia. To Restore the Function of the Uterine Supports. Not only are the sacro-uterine and round ligaments the ones which prevent retroversion and replace the temporarily retroverted uterus, but they are the ones always found relaxed or elongated. Therefore the shortening of these ligaments may be resorted to as a cure for the misplacement. Shortening of the Sacrouterine Ligaments. I have so far only attempted to shorten the sacrouterine ligaments in two cases, but obtained such satisfactory results in one case that I consider the subject worthy of farther study. The following is the method that was employed. With a pair of small tenaculum forceps I drew the cervix forward until I could feel the somewhat tense sacro- uterine ligaments by a finger of the other hand. An assistant then held the forceps while I introduced a stitch, by the aid of the touch, along the sacrouterine ligament so as to grasp an inch or more of it. In order to accomplish this I used a long heavy needle slightly curved from eye to point, and sharpened only about the point.^ It was grasped in Fritsch's needle holder so that the chord of the arc formed by the needle was almost parallel with the long axis of the holder (Fig. 265). Some difficulty was experienced, for the needle point had to be intro- duced into the vaginal covering of the cervix just below the attach- ment of one of the ligaments, carried up to the ligament and then backward along the ligament (as felt upon the finger) into the back * A round point requires too much force to push it through the connective tissue. I bent one the first time I tried it. 526 DISPLACEMENTS OF THE UTERUS. part of the pelvis. After carrying the point as far back as the finger can follow, the traction upon the cervix was removed and the posterior vaginal wall pushed back as far as possible, so that the needle when brought through it would include as little vaginal wall as might be. Fig. 265. Needle Mounted upon Fritsch's Needle-holder for Introducing Sutures into the Sacrouterine Ligaments. So far I have merely tied the stitch about the puckered vaginal wall that is included. Had I not done them as secondary to another operation and been fearful of interfering with the main operation, I should either have excised a fold of the vaginal wall between the entrance and exit of the needle, or should have made a vaginal in- cision along the track of the sutures, from each stitch hole a third of the way to the other into which a part of the suture would have sunk. In the first case I used silkworm gut, in the second catgut, and obtained the best results with the former. In each case there was a lacerated perineum, and relaxation of all the uterine supports, so that but for a cicatricial contraction in the left broad ligament, the cervix would have come through the vulva. In each instance I short- ened only the right sacrouterine ligament, or that upon the side opj^o- site the cicatricial contraction. A cotton tampon was placed in front of the cervix, removed each day for a vaginal douche to be given, and then another tampon introduced. In the case in which I used the silkworm gut the cervix is now held higher from the pelvic floor than normal, when the pessary (which she still wears) is removed. Although six months have elaj^sed I have not removed the pessary except temporarily because she has been obliged to carry coal up a long flight of stairs and do her wash- ing and ironing almost from the time she left the hospital, and also because the uterus is still larger than natural. In the other case, in which catgut was used, although the fundus is held forward by the shortened round ligaments, the cervix still comes forward, although not to the same extent as before. I am led to believe from my experi- ence with these cases that a shortening of both ligaments would often give satisftictory results in cases of retroversion, and in cases of pro- lapse or even procidentia would be efficacious in connection with the operation upon the round ligaments and, if necessary, the perineum. As to the dangers of this procedure, only a few drops of blood es- caped, and no reaction followed. If the point of the needle be not allowed to get far from the finger end, there is not much danger of THE ALEXANDER-ADAMS OPERATION. 527 injuring the rectum or upper intestines. Before the needle is pulled through, an assistant should introduce the finger into t\\e rectum for the purpose of making sure that the needle has not punctured it. Septic matter might also be carried to the peritoneum on the point of the needle and would constitute a danger in case antiseptic precautions were not taken. Possible dangers might arise from breaking the needle, or losing track of the point and puncturing the intestines or blood- vessels, or from carelessly operating upon a ligament surrounded by inflammation or induration. The operation could undoubtedly be more easily done by making an opening into the cul-de-sac large enough to admit one finger as a guide. The point of the needle could then be made to enter the cul- de-sac through the cervical attachment of the sacrouterine ligament and to enter the ligament again at any desirable distance back of this, and thus gather up a fold ; and after being drawn through it could be either so tied, or reintroduced into the ligament from the peritoneal side near the cervix and be brought out into the vagina near its point of entrance, and then tied. This is perfectly justifiable when the cul-de-sac is already opened for the removal per vaginam of an ovary lying under the retroverted corpus ; and perhaps by means of a special opening in extreme cases. The abdominal cavity would be almost entirely shut off by the over- lying uterus. The stitches could both be passed before lifting the 'fundus, and then tightened one immediately after the other. The cul- de-sac could then be sponged or washed out and closed or, if any ooz- ing were noticed, drained. I have performed the oj)eration upon the cadaver by way of the ab- dominal cavity with the result of producing anteversion of any degree desirable. It could be done on the living subject through a low incision that would admit one hand and two fingers of the other, and might be justifiable in cases in which the abdomen was already opened for other purposes, such as removal of the appendages, etc. Shortening the Round Ligaments, or the Alexander-Adams Operation. The Alexander-Adams operation, or shortening the round ligaments for the relief of certain cases of retroversion, is based upon true scien- tific principles, for it restores the action of the relaxed round ligaments in drawing the fundus uteri forward, and bringing the abdominal pressure to bear upon the posterior surface of the uterus. The abdomi- nal pressure then relieves the ligaments of their burden except for oc- casional short periods of time. It is, however, unscientific to depend entirely upon the operation when the sacrouterine ligaments are greatly at fault, for means should be taken to restore them also to function. When the sacrouterine ligaments are chiefly at fault they should, if 628 DISPLACEMENTS OF THE UTEEUS. possible, be shortened first, and if the round ligaments cannot then be made to renew their function they may be shortened afterward. Shortening the round ligaments was suggested by Alquie* of Mont- pellier, but was not successfully performed on the living subject until December 14, 1881, by W. Alexander of Liverpool. Jas. A. Adams of Glasgow, without a knowledge of Alexander's operations performed it in Glasgow in 1882. It has now been performed over two hundred and fifty times. Indications. The indications for the operation are a persistence of retroversion (or retroflexion) with distressing symptoms after a failure of other means. In case of prolapse it is occasionally indicated, as a secondary to other operations when the round ligaments allow the fundus to fall back toward the sacrum. Con train dications. Among the contraindications are the following : all conditions that prevent the placing of the uterus in a position of anteversion without discomfort to the patient; adhesion of thebroad ligament or Fallopian tubes to the back part of the pelvis ; acute and subacute pelvic inflam- mation, a tense state of the ro,und ligaments while the uterus is retro- verted, and an enlarged ovary and tube that are not drawn up by the replaced uterus. The Operation. The operation consists in cutting down upon the terminal ends of the round ligament at the external inguinal ring, drawing them out until they are felt to move the previously replaced uterus, cutting off their redundancy and stitching their ends into the wound. An incision from one and a half to three inches is made from the pubic spine along the upper edge of Poupart's ligament. After cut- ting through the skin and a layer of subcutaneous fat, the deep layer of the superficial fascia is encountered. In fleshy people another layer of fat is found under this about half as thick as the first. In slender women this deeper layer of fat is often very insignificant, so that we come almost directly to the coarsely striped intercolumnar fascia covering the ring. We may know the ring b}^ its tendency to bulge, and at the same time by its depressibility on pressure. The depression immediately under Poupart's ligament does not bulge, has a harder bottom, and is less definite in shape. The intercolumnar fascia should be incised in the direction of the external wound, but only from the pubic spine to the external edge of the ring. The superficial epigastric and external piibic, which are generally cut, seldom re- quire a ligature, as they are easily controlled by the Langenbeck serre-fiue (Fig. 157). * Aran, Traits des Maladies des Femmes. 1858. THE ALEXANDER- ADAMS OPERATION. 529 For the purpose of operating rapidly without the fear of cutting too deeply, I have had a pair of scissors made, bent on the side, and with an extended probe-point on the under blade. When a fascia is cut down upon, or cut through, this jDoint is slipped either over or under it, and the incision extended by one cut as far as desirable. In fleshy women a ball of fat, somewhat smoother and more delicate in appearance than that we have encountered before, will fill the field ; in slender patients, however, the round ligament will be found lying in full view near the external pillar and spreading out toward the pubic spine. It is pinkish-white and round, and frequently has the small white glistening genital branch of the genito-crural nerve lying Fig. 266. Byford's Probe-pointed Scissors for Cutting Fascia. upon it. When the field is filled with fat the ligament usually lies imbedded in it, or surmounted by it. The fat should therefore be pulled or dissected ofi" and the ligament be sought close to the inferior edge of the ring. If the mistake is made to poke down into the canal, the ligament will not be easily found, for it there resembles the ten- .dinous bands and aponeurotic edges closely and descends rapidly beneath them. When the round, pinkish, slightly mottled ligament cannot be dis- tinguished from the muscular and aponeurotic edges, there are two sensations which belong to the ligament when grasped by the forceps that may help in finding it, viz. : the ligament usually feels elastic when pulled, and it bleeds but little when loosened from its surround- ings. The aponeurotic edges may be pulled out a certain distance and then may resist suddenly, and if pulled much harder, break, while the round ligament resists pulling in a more gradual or elastic manner. Everywhere that the aponeurotic or muscular edges are separated blood oozes from the torn surface. When the ligament has been seized by the forceps at the inguinal ring, it is so intimately attached to the external (inferior) pillar by its fibres, and their connective tissue or fascial covering, that it will be necessary to thrust the scissors-point through this thinner membranous portion, connecting the ligament with the edge of the ring, in order to hook up the ring. I have had a hook constructed that is widened and flattened in the curve so as to present a surface of one-eighth of an inch to the ligament, and is sufficiently sharp on the point to penetrate the connective tissue under and about the ligament without any previous puncture. With this the ligament may be lifted and 34 530 DISPLACEMENTS OE THE UTERUS. put upon the stretch, while with a fine pair of scissors curved on the flat, we clip off the loose fibres that connect the sheath with the ingui- nal canal. We should then use the fingers in preference to the hook in pulling upon it. If, after loosening the ligament as far as we can see, it does not " peel out " or " run," we may slit up the canal for a short distance in order to continue the separation. If the ligament still cannot be made to run by moderate traction, we must dissect off its entire sheath for a short distance all around and then draw it out. After one ligament is thus separated so as to run, it should be dropped and a clean sponge laid in the wound until the other ligament is Fig. 267. ^^^^^ fe ^ ^^^^ By ford's Broad Hook. loosened. It is better, as Alexander has suggested,* to stand on the side opposite to the incision that is being made in order to be able to look deeper into the canal. The ligaments being loosened, the next step is to replace the uterus by the finger, a sound, or an intrauterine stem, and have it so held by an assistant. The ligaments are then drawn out until they are felt to move the uterus. Not infrequently the inverted sheath is drawn into view and must be peeled back out of the way. The next step is to stitch the ligament to the ring. This may be done by three medium-sized juniper catgut sutures passed from the external or internal side of the ring through the round ligament to the opposite side. When tied loosely so as not to constrict the liga- ment, they close the upper external end of the ring and incised edge of the canal, and leave room for a small drainage-tube underneath. I then cut off the superfluous portion of the ligament and attach the divided ends by a catgut suture. In my last two cases I have used silkworm catgut. Alexander t "stitches each (ligament) to both pillars of tlie ring by two sutures on each side," cuts off the ''chafed ends" and stitches the remainder " into the wound by means of the sutures that close the external incision." I then introduce a small drainage-tube into the canal under the ligament, dust a little iodoform into the external wound and sew it up with silk. One of the external sutures is passed deep enough to in- clude the ligament. A one per cent, solution of carbolic acid is then injected into the tube to more completely cleanse the deeper wound, and an antiseptic dressing of iodoform gauze, cotton smeared with a * British Gyn. Journal, Part III., November, 1885. f Op. cit. THE ALEXAJSTDEE-ADAMS OPERATION. 531 ten per cent, solution of carbolic acid in glycerine, or the equivalent, should be placed over the wound. A Hodge or Albert Smith pessary which has been previously fitted should be introduced, and, if the uterus be much flexed, a stem pessary. The drainage-tube should be taken out as soon as the discharge of bloody serum has ceased, viz. : in twentj^-four to forty hours. Its track should, however, be first washed out by another injection of the carbolic acid solution. If the dressings become saturated they may be changed before that time, and once in twenty-four hours after. Union by first intention may then be expected in patients that are not too fat or too poorly nourished. After all discharge has ceased I use a dry iodoform dressing. The stitches should be removed in five or six days and a few adhe- sive straps applied. After- Treatment. The patient should be kept in bed between two and three weeks, and should not walk until after three weeks nor perform any hard work until after six or eight weeks have elapsed. The stem pessary should be worn from two to three months, the vaginal pessary from three to twelve months, or until the sacro-uterine ligaments become contracted so as to hold the cervix back in place. Results of the Operation — Cases. 'My own experience extends to ten cases, seven performed by myself and one by my assistant. Dr. Carrie N. White, at the clinic in the Woman's Hospital. In the first case, Miss B w, aged 24, tliere was a sliglit irreducible retroflexion. Pessaries could only be tolerated for a short time before causing distress. Five years treatment, the last two by myself, had failed to put her in a condition to do the house- work for herself, mother and brother. Dysmenorrhoea, attacks of uterine colic and vesical tenesmus from once to twice a month had confined her to bed for a day or two each time, previous to the operation. The pessary was removed six weeks after the operation. Glycerin tampons worn about half of the time for a month longer, and then about two days out of the week. At first the cervix hung low, so as to reach almost to the coccyx, but the fundus remained in front of the pelvic axis. The first two or three menstrual periods were painful, but since then she has steadily improved. Dysmen- orrhcea, uterine colic and bladder symptoms are all gone. The sacro-uterine ligaments have contracted somewhat, so that both the cervix and fundus are now (over a year after the operation) normal in position, although a very slight retroflexion persists. Is now able to do her work. (Woman's Hospital.) In the second case, Mrs. K p, the results were not so satisfactory. The opera- tion was performed for the relief of severe dysmenorrhoea and backache combined with sterility that was getting worse in spite of treatment. There was a gonorrhceal salpingitis of right side with some contraction in upper part of the broad ligament. No pessary could be found that would keep the uterus in place during the performance of her household duties. She was unwilling to submit to a salpingotomy. The liga- ments were easily drawn out, but the operation was followed by an acute attack of local 532 DISPLACEMENTS OF THE UTERUS. peritonitis or peri-salpingitis, probably due to the breaking np of adhesions. Highest temperature 101° F., on fourth day. Walked across floor twenty-three days after the operation without disconafort. Menstruated seven weeks after operation with less pain than usual. Pessary removed in six weeks. About a week after, the uterus became retroverted while she was leaning over the stove, and another attack of peri-salpingitis, with excessive nausea, followed. Highest temperature, 101 1° F. Saw her next day and reintroduced a pessary. Fallopian tube felt in right sacral pouch, enlarged. Temperature normal on seventh day. Had a slighter attack at the beginning of next two menstrual periods. Substituted a Thomas for the Albert Smith pessary. She has had no acute attack since, and is now, eleven months after the operation, free from her old backache (which has not troubled her since the operation), and menstruates without pain, and is satisfied if she can remain as well as now. Slie still wears the Thomas pessary. (Woman's Hospital.) In the third case, Mrs. D , the subinvoLited uterus seemed to be held in retro- version by the weight of the enlarged right ovary and tube lying in the cul-de-sac of Douglas. The cervix appeared at the vaginal entrance whenever the pessary was left out for any length of time The operation was followed by no disagreeable symptoms. The pessary was removed after three months and left out for a few days, but was rein- troduced because the cervix came forward and the enlarged uterus literally hung upon the round ligaments. The ovary and tube could not be reached by the vaginal finger. The pessary was removed after seven months, and the uterus found slightly retroverted the next day. When replaced it remained temporarily in a normal position, showing that the ligaments, although unable to hold the heavy uterus and ovaries up during active exercise, were not relaxed as before the operation. The ovary followed the uterus. The pessary was replaced. (Private family.) The fourth case, Mrs. T , is one in which a cicatricial shortening of left broad ligament (due to a lacerated cervix with subsequent inflammation) was all that pre- vented a procidentia. The left ovary and tube were adherent to the broad ligament, tlie right ovary slightly enlarged and lying in the rectouterine peritoneal pouch. Moderate right diagonal laceration of the perineum and pelvic floor, relaxing the pel- vic outlet. Subinvolution. She had been treated by two pi'ominent gynecologists, but obtained no relief. None of us could fit a pessary that could be tolerated. It had been proposed to remove the appendages. In operating I found the left ligament enlarged to about twice the normal diameter by the increase of connective tissue, and the right one much smaller than usual. A pessary was from that time worn without discomfort, except from its tendency to protrude. Four weeks after the operation unilateral perineorrhaphy was performed. After this the uterus hung upon the broad ligament, with the cervix just behind the newly-formed recto-vaginal promontory, and before it was considered safe for her to wear a pessary the right ligament had relaxed so as to allow the right horn to swing laack a little. The left side lield. She now wears a small Hodge pessary (seven months afterward) with comfort, and feels belter than for years. The old ovarian pain, for which the appendages were to be removed, is gone. (Woman's Hospital.) The fifth case, Mrs. H — -e, was one of subinvolution and retroversion with con- traction in the left broad ligament and relaxation of all the others. There was also a rectocele due to an uncicatrized transverse perineal laceration. A Scott pessary was the only one that could be used with any benefit. I relieved the rectocele by a plastic operation, and was then able for awhile to hold the uterus in position with a Hodge pessary. But in a short time the perineum began to relax and the uterus turned backward over the pessary, no matter how much I increased tiie size. I preceded the Alexander operation by a stitch in the right sacrouterine ligament, taken with silk- worm gut. Tlie cervix was held back by vaginal tampons for the first ten days and THE ALEXANDER-ADAMS OPERATION. 533 afterwards by a much smaller sized Hodge pessary than those that had before failed to do so. All symptoms of ill health rapidly subsided, and she was doing her washing and housework in two months after the operation. She feels entirely well. The cervix remains higher in the pelvis than normal when the pessary is removed. On account of the enlargement of the uterus and the amount of hard work she is obliged to do I have not yet thought it safe to remove the pessary. It is six months since the operation was performed. (Woman's Hospital.) In the sixth case, Mrs. S , performed over five months ago, the retroversion resisted the pessary treatment for a year, and was accompanied by backache and in- ability to perform her household duties with comfort. She was anxious for relief. I was unable to make the ligaments run satisfactorily, but removed three-quarters of an inch from each, and inserted the stitches so as to draw the ligaments a little farther out. The inguinal ring was literally filled with veins and small arteries. Notwith- standing the failure to satisfactorily shorten the ligaments, the uterus was more com- pletely anteverted by the pessary than before, and now remains in a state of ante- version when the pessary is removed. The result could not have been better had I removed three inches of ligament. The pessary is still worn. (Woman's Hospital.) In the seventh case there was a contraction of the left broad ligament, and a small- ness of the vagina (although she had borne an illegitimate child a number of years before) that made all pessaries either useless or intolerable. The ligaments were only about half the normal thickness, and were made to run with difBculty. She still wears the pessary. Improvement was gradual. Two months after the operation she was not able to work as well as before. Four months after she could work better. (Woman's Hospital.) Case eight was one of extreme retroflexion, in which pessaries were useless ana could not be tolerated. No trouble was experienced in the operation, except the ad- justment of the pessaries. A hard rubber intrauterine stem to control the tendency of the uterus to double up or " recoil," and a small, well-curved Hodge pessary were finally made to hold the cervix and uterus in their proper relations with the fundus. The stem slipped out two or three times during the first three weeks, but soon lost that tendency. Two months after the operation the pessaries were removed, but as there was still a tendency to flexion and a relaxed condition of the sacrouterine liga- ments the Hodge was again introduced. (Woman's Hospital, Dr. White.) Case nine was one of extreme retroflexion of a flabby uterus. An intrauterine stem was used. She was doing her housework in two months completely relieved of all symptoms. (St. Luke's Hospital.) Case ten is too recent to be reported. (Woman's Hospital.) A study of these cases has led me to expect less of the operation, but (expecting less) to regard it as one of the most valuable of the recent additions to minor gynecology. It is applicable scientifically to only a small percentage of cases of retroversion and retroflexion, and then is often only an aid to other measures, or one among others; but as such it gives most satisfactory results. When employed as a sole remedy it frequently fails, but when employed as a step toward the cure, preceded and followed by other appropriate and no less necessary treatment, it does not disappoint. Perhaps its most strik- ing result is the comfort and benefit with which a pessary (including the intrauterine stem) can be subsequently worn. If the operation did nothing else it would still have a just claim to recognition as a scientific procedure. In view of the recurrence of the displacement 534 DISPJ.ACEMEXTS OF THE UTERUS. in ray second case I consider it safer to leave the pessary in the vagina from six to eight months. This prolonged use of the pessary is par- ticularly indicated when a contraction in or about a broad ligament prevents the uterus lying comfortably in a position of moderate ante- version. Theoretically, such a contraction would contraindicate the operation, but practically there is often nothing better to be done; and there is a better prospect of a final adjustment of the tissues than without it. Dangers and Difficulties. "When properly performed there is almost no danger connected with Alexander's operation ; when carelessly or ignorantly performed hemorrhage, peritonitis, interfascial suppuration and pyeemia are liable to result as from any operation. Pyaemia from suppuration occurring in the deeper portions of the wound has been the cause of most of the deaths. A drainage tube to the bottom of the wound and removed in twenty-four hours is no hindrance to union by first intention, and avoids the retention of the sero-sanguineous oozing that alwaj's follows during the first few hours after the operations. The difiiculties are numerous to the beginner, but rapidly vanish by a minute study of the various steps. It is better to see it per- formed before attempting it, or else to study it upon the cadaver. Raising of the Perineum or Pelvic Floor. As the perineum and pelvic floor play an important part in sustain- ing the pelvic viscera, the uterus cannot be expected to remain in Fig. 268. Curves of Posterior Vaginal and Rectal Walls after a poorly performed Perineorrhaphy, lines show the normal curves, the heavy Lines the faulty ones. Dotted proper place when they are relaxed or lacerated. Hence any course of treatment looking to a permanent cure of retroversion should not leave these parts out of consideration. But not only must the vaginal outlet be restored, but the muscles and fasciae must be drawn together OP±.KATI0N FOR HOLDING OR FIXING THE CERVIX BACKWARD. 535 SO as to form a firm and resistant as well as a high recto-vaginal pro- montory against which the cervix will find rest and the uterine liga- ments be relieved from tension during the action of strong abdominal pressure. The fibres and fascia of the levator ani under the rectum must also be raised or pulled forward to their normal place, and the lower curve of the posterior rectal wall (see Figs. 31 and 54) be restored. The shape of the denudation is determined by the location and extent of the relaxation fsee chapter on perineorrhaphy). The vaginal walls, the pelvic floor, the perineum, separately or simultaneously as a whole, or in a particular region, may be at fault, and require the operation to be chiefly within the vagina or entirely about the vulvo- vaginal entrance. Operations of Expedience. These operations fix the fundus forward or the cervix backward, and although seldom strictly scientific may be useful as substituting a lesser evil for a greater one. Abdominal Section for Fixing the Fundus Fonuard. Abdominal section for the cure of retroversion or retroflexion usually has for its object the stitching of the upper end of the uterus, the cornua, the round ligaments or their appendages to the abdominal -wall above the pubes. Koeberle was the first to perform it while operating for removal of the ovaries. Since then it has been done by Mueller, Lawson Tait, Skene Keith, Heywood Smith, William H. Byford, Hennig, Czerny, Bardenhauer, H. A. Kelly, Polk and others. It is as a ride not justifiable to open the abdominal cavity primarily for the cure of retroversion, yet, as Olshausen, Kelly, Polk and Hey- wood Smith have maintained, it does occasionally become necessary in extreme cases, after other treatment has failed. The chief criticism to be made is that a fixed anteversion or anteflexion is substituted, and that those who have opened the abdominal cavity particularly for this purpose have not always tried every other means. Olshausen* and H. A. Kellyf suspend both uterine horns, utilizing the broad ligament, round ligament and the Fallopian tube, if their function is no longer needed, and employ from two to three sutures on either side. William H. Byford depends mainly upon the round ligaments. Operation for Holding or Fixing the Cervix Bachvard. It has been attempted to cause cicatricial contraction of the pos- terior vaginal wall by cautery (Amussat), to obtain adhesive inflam- mation between the cervix and posterior fornix, and to unite these * Centralb. f. Gyn., No. 43, 1886. f Medical News, December 4, 1886. 536 DISPLACEMENTS OF THE UTERUS. tissues by denuding them and stitching them together (Lowenthal, Hunter, 0. E. Herrick). As a secondary procedure in rare cases the last mentioned one may be worth remembering. Stitching the anterior lip of the cervix and the upper end of the anterior vaginal wall to the posterior vaginal wall, while the uterus is held in moderate antever- sion, may also be of occasional use in connection with it. The vagina must of course not be occluded. The Sims-Emmet triangular opera- tion upon the anterior vaginal wall (Fig. 233) is occasionally appli- cable to retroversions. Treatment of Uterine Flexions. What has been said about the treatment of uterine versions applies also to flexions, and will be sufficient if the flexion be moderate. When it is congenital or extreme in degree and accompanied by dys- menorrhoea {q.v.), other treatment may be indicated. In the congenital variety means for normally developing the mus- cular and sexual system are of especial importance, such as massage, walking, out-door games, gymnastics, association with the opposite sex, marriage, pregnancy, etc. Dilatation by Peaslee's or Hanks' dilators, commencing with the smallest, relieves the dysmenorrhoea, stimulates the uterus and often cures the sterility. Compressed slip- pery elm tents (Fig. 96) curved to suit the shape of the uterine cavity are often preferable because of their curve, and because they can be left in place from one to several hours and thus act as a powerful stimu- lant. If the uterine substance be hard, violence must not be done to it by forcing a hard straight dilator into it. If these means be in- efficient and the uterus remain small, flexed or flabby, without any signs of inflammation, the uterine stem may be tried, partly to splint the uterus or hold it straight, but i3rincij)ally to act as a powerful stimulant. Fig. 269. Jackson's lutra-Uterine Stem. In case of acquired flexion or that coming on after puberty, or after childbirth or abortion, a stem may be necessary to hold the uterus straight that the pessary in the vagina may become effective. In the eighth and ninth cases of the Alexander operation already reported in this chapter, its use was well illustrated as necessary to render both the shortening of the ligaments and the Hodge pessary effective. The stem should not as a rule be attached to the other pessary. If the uterus be hardened the stem must have a similar although a TREATMENT OF UTERINE FLEXIONS. 537 slighter curve than the uterine cavity. If the uterus be flabby it may be straightened by the probe and a straight stem slipped in beside the probe as far as the constricted point, and pushed farther in as the probe is withdrawn. It is easier to introduce it with a Sims's speculum, or in the dorsal position without a speculum, so that it can be held in place by the finger until the vagina closes upon it. The stem should be of hard rubber or whalebone from an eighth to a sixteenth of an inch in diameter, and a quarter of an inch shorter than the uterine cavity. It should have a button-shaped or globular piece on the vaginal end to protect the vagina and keep it from passing too far into the uterus. Jackson's soft rubber stem is useful in developing the uterus, prevent- ing stenosis and favoring the occurrence of pregnancy, and is less apt to do harm in inexperienced hands. It of course has less power than the hard ones to immediately straighten the uterus, and is of less assistance to a retroversion pessary in holding the organ in its natural place and position. Anteversion and anteflexion pessaries have been variously modified for the treatment of flexions. Thomas has thickened the posterior end of the Albert Smith pessary and given the arms a sharper curve so as Fig. 270. Thomas's Bui'u Kecroflexion Pessary — Elastic. to form a high broad rest for the retroflexed body of the uterus. Fig. 270 represents the same, made of spring wire and covered with soft rubber. The retroversion pessaries acting both in front and behind the cervix (page 523) are also useful in retroflexions as they get a firmer hold on the cervix and vaginal fornices. Anteversion pessaries may be modified anteflexion so as to press farther in front of the cervix and thus by lifting the bladder i:)roduce an effect upon the upper por- tion of the uterus. In applying tampons for flexions we should avoid making use of ordinary leverage force applied to the end of the cervix, as that would only increase the flexion. In retroflexion we apply one or two tam- pons behind the cervix, and push them high uj) along its posterior surface so as to fill as near as possible the angle formed by the flexion. We then push the cervix back against the tampons (which in turn lift the fundus), and fill the vagina in front of the cervix, as recom- 538 DISPLACEMENTS OF THE UTERUS. mended by Thomas. If it be desirable to lift the whole organ we may also put a small tampon in each lateral fornix beside the cervix and a soft flattened one under the end of it. For anteflexions the tamj)ons are placed as for anteversion, except the lower or anterior ones are made a little larger in order to press up the tissues toward the part of the uterus above the curve, and also to fill the angle. CHAPTEE XXXII. DISPLACEMENTS OF THE UTERUS {Continued). Retroversion and Retroflexion of the Uterus during Pregnancy. The uterus is sometimes found retroverted or retroflexed during pregnancy. When small during the first few weeks of pregnancy, its existence is not observed because it produces no inconvenience, and it is not until it grows large enough to partly or completely fill up the pelvis that anything is known of it unless discovered by accident. If it is examined at such time, the os uteri will be found against the symphysis pubis, sometimes but little above the arch, but occasionally as high as the top of that junction. If the uterus is retroverted fully, the mouth looks upward and forward ; if retroflexion exists, the os is still at the symphysis, but its opening is directed downward and for- ward. In this last case the cervix is bent upon itself at a sharp angle, the lower extremity as before remarked looking downward and for- ward, and the uterine extremity turned backward and downward. So that the difference in these two conditions consists in the bent state of the cervix, and not in the position of the uterus. The body of this organ has its axis reversed almost completely, the fundus extremity running through the lower bone of the sacrum, while the upper ex- tremity of the axial line passes out of the abdomen above the sym- physis. The body lies in the hollow of the sacrum included in the peritoneal cul-de-sac between the vagina and the rectum. Both these canals are compressed, the rectum hard against the sacrum and the vagina up against the pelvic bone. The direction of the vagina is upward and forward instead of backward, its usual course. The finger cannot be made to sink deep into the vagina except behind the pubis ; in introducing, it turns upward and forward. The urethra runs up in close contact with the symphysis pubis, and is narrowed very mate- rially by extension and pressure, so that it very imperfectly performs the function of a viaduct from the bladder. Causes. Although pregnancy usually corrects misplacements of the uterus, such is not always the case, for this condition is sometimes a mere continuation of its unimpregnated position. It is well understood by accoucheurs also, that in the early months of pregnancy the normal position of the organ is depression, and that prolapse and retrover- sion are not unusual 'effects of recent impregnation. Under certain 540 DISPLACEMENTS OF THE UTERUS. circumstances this last deviation is not corrected by the advance of growth in the organ. Where other causes co-operate, a distended bladder may aid in causing the uterus to assume and retain this posi- tion, as may also loaded intestines pressing upon the fundus and anterior face. These causes and perhaps others operate to bring about a gradual displacement, but there are some that produce the condition suddenly. It should be remembered that it is only at a certain time that these sudden causes can produce the effect, and that is after the end of the third month and before the beginning of the fifth month. It is about this time that the uterus attains a bulk sufficient to partly or entirely fill up the pelvic cavity. If when it has attained this size, a sudden impulse is imparted to the fundus and anterior face of the organ, the fundus may be crowded so low into the hollow of the sacrum as to reverse the axis. In this state the forces acting in favor of cor- rection are feeble and may fail to bring it about. Strong abdominal pressure upon the intestines and bladder under tenesmus, falls upon the feet or breech, lifting heavy weights, and even severe sneezing and coughing, are occasionally causative. In the cases where the efficient causes are suddenly applied, the symptoms are acute and established at once. In the other cases the train of symptoms gradually make their appearance. Symptoms. When induced suddenly the patient is seized with great pain in the back, with a sense of weight upon the perineum, constipation, reten- tion of urine, tenesmus, dragging sensation in the loins, and often, though not always, sickness of stomach and vomiting. If gradually established, the pains, constipation, and retention of urine are slowly established, requiring from seven to twenty-one days or more, to ren- der them intolerable. I knew a case caused by a woman riding all day in railroad cars without urinating. There are two important symptoms, viz., retention of the urine and of the fseces ; from these result most of the distress complained of. Great distension of the bladder and the terrible suffering thereby pro- duced, is the worst. The student should bear in mind that quite fre- quently this symptom is deceptive. The urine is constantly dribbling from the meatus, and the patient thinks, and will say, she passes plenty of urine. The fact of this constant slight discharge should cause us to suspect that the bladder is distended ; it does not occur when the bladder is empty ; it is not sufficient to prevent it from being distended. Indeed, I do not now recollect any condition but overdis- tension that causes it. Retention of faces is not productive of so great trouble as the other, but is attended with more less inconvenience. Great pelvic distress, with stillicidium urinss, are almost characteristic of retroflexion or retroversion, when recent pregnancy exists. EETEOVEESION AND EETROFLEXION OF THE UTEEUS. 541 Diagnosis. This is usually not difficult. The first, a very important consid- eration, is the existence of pregnancy. Upon making vaginal examin- ation, immediately upon introducing the finger it comes in contact with a tumor. The pelvis is filled up by it in the posterior and lower part so that the finger is directed upward and forward. Very high up the vaginal cavity is quite small from pressure, at its extremity ; in contact with the pubis is the os tincse, very firmly held in its place. The tumor is round, elastic, and smooth ; not so hard as fibrous tumors, more central than ovarian, and more uniformly round than extra- uterine pregnancy. It may be ascertained in most instances, also, that the tumor is larger toward the sacrum than the symphysis. Termination. When left to itself retroversion may terminate in abortion, when the contents of the uterus will be expelled and the symptoms thus relieved ; or the bladder may be ruptured, the urine being discharged in the peritoneal cavity, causing painful death ; or the uterus may be ruptured, and its contents discharged in the cavity of the peritoneum, giving rise to fatal peritonitis ; or the foetus and its membranes may be surrounded by fibrinous material, the patient recover, and these substances remain there enveloped; or, inducing local suppurative inflammation, be discharged by exulceration. Sometimes the tenes- mus becomes so great as, by the violence of the efforts, to break through the posterior walls of the vagina and uterus, and discharge the contents through the vulva from this artificial opening. Inflam- mation sometimes arises without being initiated by any of these dis- astrous accidents, and less suddenly causes the death of the patient. I think there can be no doubt but that there are very rarely cases of spontaneous reposition, recovery, and completion of the term of ges- tation. The prognosis is unqualifiedly bad if left to nature, but equally favorable if intelligently treated at the proper time. Treatment. The main thing to be done is to replace the uterus. This can very generally be accomplished. The attempt should not be delayed, as the uterus is constantly increasing in size, and the impaction becom- ing more certainly greater, increasing the difficulties as well as dangers. To facilitate the replacement, the bladder should be emptied by the catheter when practicable, and the fseces removed from the rectum. This takes away some of the obstacles. Sometimes the urethra is so tortuous in its course, and the walls compressed so completely to- gether, that a catheter will not enter the bladder. An elastic catheter will sometimes pass the obstruction when the metallic will not; which- 642 DISPLACEMENTS OF THE UTERUS. ever we may use should be urged forward with the utmost gentleness, bearing in mind the great danger of perforating the attenuated urethra. The patient should be placed upon her knees and chest, or on the left side, with the left arm behind her, the thighs strongly flexed, and the right drawn up close to the abdomen and thrown for- ward. She should be placed on a table or the edge of a bed, so that the genital organs are easily controlled by the operator. In this posi- tion we may often succeed in replacement by the hand alone. The right hand should be well lubricated, and all the fingers be intro- duced into the vagina, so that the palmer surface is turned to the sacrum. The tumor is thus pushed up very gently and slowly, with the pulps of the fingers pressed closely upon the face of the sacrum, as high as the hand may be made to reach. There are not many cases in which the fingers will fail to carry the fundus above the promon- tory of the sacrum. When thus elevated it suddenly starts up and assumes the normal position. If, however, the fingers do not reach high enough for this purpose, a collapsed gum-elastic bag or bladder may be carried up between the fingers and the uterus, and, when elevated as much as we can reach, the bag may be inflated sufficiently to raise the uterus high enough. I have succeeded in all the cases I have tried with this method, and I think, when the impaction is not so great as to preclude dislodgment, that it will almost invariably succeed. Some surgeons recommend the introduction of the empt}'' bag into the rectum, and inflating it there, and pushing it up ; others introduce a drumstick, with the end cushioned and lubricated, into the rectum, and, pressing it against the uterus, elevating it in that way. Again, an instrument is used not unlike two drumsticks, some- what curved, attached together. The attachment confines the ends very near each other. The end of one of the branches goes into the rectum, and the other into the vagina. Thus arranged they pass up and carry before them the uterus. These expedients are very sure, but rough, and not a very safe means of arriving at the results. I think as much force in a proper direction can be applied by the fingers and elastic bag as it is judicious to employ in such cases. There are other methods of proceeding, but I do not think it neces- sary to mention any other, as these will suffice when reduction is practicable. In all these efforts to elevate the fundus we may fail, and then we may evacuate the uterus. This can generally be done by passing a bent probe through the mouth of the uterus far enough to rupture the membranes, and permit the escape of the liquor amnii. This being done, abortion will soon ensue. Puncturing the uterus with a trocar through the vaginal wall I can conscientiously only mention, for I can hardly think the operation ever commendable or necessary. The cervix is probably hardly ever so inaccessible but that some form of bent instrument can be made to enter it. CHAPTER XXXIII. DISPLACEMENTS OF THE UTERUS (Continued). Inversion of the Uterus. Inversion is the turning of the uterus inside out, with the fundus down and the cervix up, a reversion of its surfaces and ends. It is partial or complete. When partial, the fundus is depressed in all degrees, from a mere indentation to a considerable protrusion through the cervix and os uteri. The depression of the fundus, or partial in- version, passes into complete when the whole organ, fundus, body, and neck, have passed through the mouth, and hang down below it. It presents a recent and a chronic form. The recent may be regarded as extending through the first two weeks ; after which, the circum- stances and condition of the uterus and patient become what they re- main in the future, however long it lasts. The uterus, in that time, has been condensed by contraction and involution to such an extent as to make the case permanent and difficult of change, except to dimi- nution and further condensation. Inversion almost invariably occurs • anterior to or at the time of the removal of the placenta, but several hours, and, in very rare cases, several days may elapse before it is complete and discovered ; for it is quite probable that in these in- stances partial inversion or greater or less depression of the fundus had existed from the time of delivery. It is believed by different parties that there are two modes observed in the process of inversion. Sometimes the fundus is indented or depressed in the cavity of the body like the bottom of a "junk bottle," the depression rapidly or slowly increasing until it is completely down. At others, the whole of the fundus, and, more or less, the whole of the body, are firmly contracted, while the cervix remains flabby and relaxed. In this con- dition a slight amount of abdominal tenesmus will drive the con- tracted part down through the relaxed cervix ; and thus initiated, it requires but a continued action of the fibres of the organ and abdomi- nal muscles to finish the process. The causes of inversion are not always obvious, as cases have occurred under circumstances when least expected from any discoverable reasons, and inversion fails to be brought about by circumstances that are usually enumerated as sufficient. We occasionally meet with instances that have no history, and neither patient nor physician can give us a clear idea of the time or manner of the occurrence. Such a case was a subject of litigation in this city a few years since. And other cases are recorded in virgins, 544 DISPLACEMENTS OF THE UTERUS. and consequently referred to congenital origin. In a large majority, however, we may trace the history back to accouchement. The pre- disposing causes are enlargements and partial or complete passiveness of a part or the whole of the muscular fibres of the uterus. These are the conditions in confinement at full term, or abortion or prema- ture labor, also enlargement from hydatids, hydrometra, tumors, etc. When the uterus is thus enlarged and lax after a greater or less loss of its contents, traction on the cord or j^lacenta, or contained tumor, or injudicious or accidental pressure on the fundus by the hand of some person, or the action of the abdominal muscles thrusting the contents of the abdomen downward upon that part of the organ, it may be inverted. It is possible, I think, also, that powerful, irregular action of the fibres of the uterus may cause the initiation and comple- tion of the process of inversion. It is then said to be spontaneous. The weight of the placenta, or the contraction to expel a polypus, may commence inversion, and even complete it. The irregular con- tractions that result in inversion may commence before the expulsion of the child. After the liquor amnii has been discharged for a long time, the uterus contracts to suit the inequalities of the fetal surface, the globular shape of the organ being replaced by inequalities in a number of places. Much is yet to be learned on this subject. It would seem clear from statistics brought forward by Drs. West and McClintock that it is exceedingl}^ rare, if it ever occurs, under good management of labor cases. It has not been encountered in ^^atients confined in the London Maternity Charity, nor the Lying-in Hospi- tal of Dublin in 140,000 cases. The student is not to consider from this, that it is impossible for it to occur in the hands of the ablest of accoucheurs. Symptoms. Usually these are appalling in the extreme. "Without warning the patient is seized with faintness, coldness of the extremities, sense of great prostration, rapid and very feeble pulse, oppression about the heart, copious perspiration, hurried breathing, often vomiting, ring- ing in the ears, and blindness. Soon these symptoms increase, until the patient lies in a profound state of collapse, indifferent to every- thing transpiring around her, or throwing herself in every direction in paroxysms of agony inexpressible. This condition of collapse is not always the result of copious hemorrhage, but seems to be of nervous origin, a shock not unlike that caused by severe accidents, as falls, strokes, etc. But, generally mingled with this sort of im- pression, there is profound exhaustion from loss of blood. From this state of collapse the patient may very slowly rall}^ until she enters a tedious and imperfect convalescence. Or, in the cases where the ex- haustion from hemorrhage is added to the great depression of the shock, the patient may be overwhelmed, and in a hour, or very few INVERSION OF THE UTERUS. 545 hours, her saffermgs end in death. Imperfect recovery from the great effects of the first shock may enable tlie patient to live for several days, and at last, in five to ten days, die. In case the patient recovers from the first symptoms, after some weeks she may regain a fair degree of health, and retain it, or even improve, until lactation gives place to ovulation, or until this last function supervenes upon the first. The first menstrual discharge is preceded by copious mucous evacuation, and when the menses begin they are more than ordinarily profuse, and generally before they cease amount to prostrating hemorrhage. This hemorrhage is repeated monthly, more frequently, or is continu- ous, while the leucorrhoeal discharges become very profuse. Func- tional derangement of other and important organs enters the list of morbid impressions; the bowels are constipated, the heart palpitates, the stomach cannot digest with its former vigor and completeness, the head aches, the eyes become weak; the disposition of the patient changes ; the memory fails her ; she is pale, cold, and anaemic ; in short, she enters a decadence that is continuous, until, after several months, or a few years, she is exhausted and dies. Although this is the course usually pursued by cases of inversion, it must be remem- bered that there is a class of them in which the patients do not suffer even much inconvenience, and their condition is discovered only by accident during their life, or on the dissecting-table. Diagnosis. . When the symptoms present themselves so as to awaken suspicion, the diagnosis of recent cases may be made out quite clearly, by the descent of a tumor into or entirely through the vagina, and the ab- sence of the uterine globe above the symphysis pubis. The diagnosis,, after a few days or weeks have elapsed, and the case becomes chronic,, is not quite so simple and ready. The tumor is felt in the vagina,. and is more sensitive than polypus. It is easily surrounded by the fingers, and by introducing two fingers in the vagina to the upper end of the tumor, the depression formed by the junction of the vagina and uterus may generally be easily surveyed. If this is not entirely satisfactory, the sound should be introduced into the vagina before the fingers are withdrawn, and, guided by them, be made to sink as deeply into this depression as it will go without too much force.. If the uterus is inverted, the probe will not pass beyond the fingers any distance, but if the vaginal tumor be a polypus, the sound will pass up at some point some inches above the fingers into the uterine cavity. Traction often causes the depression between the inverted body and the os to disappear. A polypus, as Reamy has pointed out, may often be rotated, while the uterus cannot. The operator may test the position of the uterus in another way, by introducing the 35 546 DISPLACEMENTS OF THE UTERUS. finger high up into the rectum, so that the end may reach ahove the tumor, and retaining it there, he may pass a catheter or sound into the bladder, and approximate the two ; if the womb is in place, its thickness will be perceived interposed between the two, but if inverted, the extremity of the catheter can be brought down upon the finger, with nothing but the membranous walls of the bladder and rectum intervening. Prognosis. No more serious complication of labor can occur than inversion of the uterus. The danger is great and imminent; in a considerable majority of cases proving fatal, the patient dies within a few hours. Mr. Crosse says : " In seventy-two out of one hundred and nine fatal cases, the patient died within a few hours, eight of the remainder within a week, and six more within four weeks; another at five months, the result of an operation which had an unsuccessful issue, one died a't eight months, three at nine months, and the others at various periods of from one to twenty years." ( West.) Death in the first place, soon after delivery, seems to be the result of rapid exhaus- tion of the vital forces by the terrible shock to the nervous system and the profuse hemorrhage that often complicates it. Death in subse- quent times, however remote in the chronic form, is brought about by impairment of the vital functions by the same means, operating more slowly, but as surely. The patient dies from exhaustion in both forms. Accordingly, we find that w^hile inflammation has something to do in afi"ecting the issue in rare instances, those cases in which there is no uncommon hemorrhage or leucorrhceal discharge last longest, and sometimes do not prove fatal at all, the patient enjoying fair health for many years. I know one patient, fifty-six years of age, whose uterus was inverted sixteen years ago, and yet remains in that condition, as I have verified by examination, who is in the enjoyment of as good health as the majority of women of her time of life. Treatment. The management of recent cases will be the easier the sooner after the accident it is commenced. Its reduction is generally successfully accomplished within the first hour or two if intelligently attempted. It is more difficult as time elapses, but it should never be considered impracticable until proper and persevering eff'orts have been made. The first item for consideration and action is to dispose of an attached placenta when the uterus has not detached it before, during, or after its descent. If the placenta is wholly adherent, its attachment should in nowise be interfered with until the uterus is returned to its former position ; but if it is partially detached, it should be immediately separated by gently " i:)eeling " it off with the fingers. This instruc- INVERSION OF THE UTERUS. 547 tion has reference solely to the prevention or lessening the amount of hemorrhage. If the placenta is attached throughout, the hemorrhage will be trifling ; if partially separated, the condition most likely to be accompanied with fatal hemorrhage exists — relaxation of the uterus and partial separation of the placenta. It is well known that suffi- cient contraction of the uterus will separate the placenta, and when not contracted enough to do so, it is in too lax a state for us to desire its detachment. If the placenta is partially separated, the completion of it by the fingers, as in the case when included in the uterus, will enable and stimulate this organ to contraction, and thus to the sup- pression of the hemorrhage. I do not think the question of conve- nience of return, or the possibility of being foiled in the reduction by the continued attachment, should be entertained. The want of con- traction enough to throw off the placenta is an evidence of such pro- found inertia as to insure easy reduction of the uterus. It being decided what course to pursue with the placenta, imme- diate efforts should be made to revert. And before beginning these efforts, we should remind ourselves of some facts in the case that are apt to be lost sight of in the hurry and confusion of such an appall- ing occasion. One fact is, that immediately after the occurrence of the accident, the uterus is in the same flaccid condition in which it was incapable of resisting the action of the cause ; another is, that it soon begins to contract, becomes firm, and, consequently, more diffi- cult to affect by counter influences ; and a third, that the more the uterus is stimulated, by handling or otherwise, the sooner and more firm the contraction becomes, and, consequently, the greater difficulty in reduction. No operator has complained to us of the bulk being too great to return, but all of the resistance caused by contraction. The experi- ence of Dr. Meigs is conclusive on this point. He found that upon attempting to reduce the size of the uterus, by squeezing it to expel the blood, he caused it to contract, and it became so hard as to resist his efforts to push it up within the os ; but as soon as he pressed upon the fundus he would depress it, or rather elevate it, until, by continuing pressure, he made it ascend first into the body, and through it into the neck, and finally up to its proper place; Dr. White, of Buffalo, although he did not mention with the same dis- tinctness the effects of the two sorts of pressure, was enabled, by in- denting first and then following up the vantage, finally to push the fundus up the same way through the os and body of the uterus after he had in vain tried to reduce it by squeezing, etc. Dr. White's case was reduced in this way eight days after delivery. And I must be allowed to express the opinion, that it increases the difficulties in recent cases of inversion to try to lessen the bulk of the uterus. A 548 DISPLACEMENTS OF THE UTERUS. great bulk indicates a flabby, reducible state, and is favorable to success instead of otherwise. Do not squeeze the uterus to lessen its size in these cases. The two cases I have referred to, of Drs. White and Meigs, so in- telligently and deliberately observed, and so clearly described, furnish us with more intelligible means of arriving at correct ideas of the steps by which inversion of the uterus is reversed, than any I am able to find on record. They both concur in showing the usefulness of one hand in the vagina to steady the uterus, and direct the force applied to the fundus by the other hand, and the injurious effects of compress- ing the body of the organ. The most appropriate mode of operating in recent inversion, therefore, is to introduce the left hand into the vagina behind the uterus, while with the fingers of the right the fundus is indented, and gently, but steadily and perseveringly, reverted en- tirely above the os and cervix, until it assumes the globular shape and proper position above the symphysis. If the fingers of the right hand cannot be used to advantage, or are too weak to accomplish the desired elevation, we may use a large elastic rectum bougie, an instru- ment resorted to by Dr. White, or one by Dr. Beers, shaped like the end of a walking-cane, with a round smooth head upon a staff. The indentation and elevation may be more efficiently effected by this latter instrument, perhaps. The fact cannot be too forcibly impressed upon our minds, in un- dertaking this operation, that gentle firmness is the proper expression for the force to be employed. Perseverance, instead of violence, is both more certain, successful, and secure, in overcoming the resist- ance of muscular fibre anywhere. This is especially true with the uterus, the strongest muscle in the body. As nearly as may be, we should act in the absence of uterine contractions. During and after the time we are attempting the return of the organ, the strength of the patient must be supported by stimulants, tonics, and nutrients. Brandy will, perhaps, serve best to restore the circulation and heat ; it may be aided by the use of the aromatic spirits of ammonia and laudanum. In addition to the stimulant and supporting influence which laudanum exerts, it allays the irritable condition, so frequently present, of the stomach, the uterus, etc. After the urgency of the symptoms has passed by, the tincture of iron, quinia, beef essence, and nutritious diet generally, will be necessary to restore the im- paired condition of the vital energies. The energy with which the stimulants are to be urged during the shock must be regulated by the urgency of the danger. Large doses of brandy, laudanum, and spirits of ammonia will not only be borne, but often be called for to meet the symptoms. INVERSION OF THE UTERUS. 549 The Treatment of the Chronic Form, Is palliative and curative. The palliative is for the purpose, as far as possible, to check the drain which is so constantly exhausting the patient, to support the system as well as we can, and to use any other means suggested by the circumstances for the relief of distressing symptoms. The hemorrhage is from the mucous membrane of the uterus, its outer surface as it lies in the vagina, as also the profuse mucous dis- charge. I think much may be done to moderate, if not stop, these evacuations by astringents introduced into the vagina, so as to sur- round and lie in contact with the uterus. Pledgets of lint, saturated with the persul. of iron, passed up into the vagina, and allowed to remain on the bleeding surface of the uterus until the bleeding ceases, will be of great service. The tinct. ferri chlorid. on lint is an excellent application for the same purpose. Other astringents may be tried in the same manner. If these should fail, the vagina may be tamponed fully with cotton, dipped in astringents or not as the physician may think best. Severe paroxysms of hemorrhage should be carefully treated in this way until they terminate, it being desirable to save as much blood as possible. It is not necessary to suggest to the intelli- gent reader the necessity of rest in the horizontal position. Between these paroxysms the patient should use astringent injections of con- centrated strength, saturated solutions of alum, acetate of lead, tannin, etc., with a view to condense the mucous membrane, and render it less vascular, and in this way abate the urgency of the losses. The tinct. ferri chl., one part to four of water, twice or thrice a day, will have an efficient astringent effect upon the uterus. When the organ extends through the vulva, it is irritated by contact with the limbs and clothing, and it is very desirable to return it into the vagina, and keep it within that cavity. The gum-elastic air-pessary, supported by a T bandage, will keep it in the vagina, and may render it more easy of a radical cure, by reduction or reversion. I would urge the attendant to personal attention to this treatment, to such an extent, at least, as is necessary to have it efficiently tried. Very few patients have the intelligence to appreciate the importance of it, or to know when proper trial of it has been made. The radical treatment has for its objects either a restoration of the organ or its amputation and removal. So far as we can judge, although both operations are attended with danger, that of amputa- tion the more. . And I think it clearly the duty of the practitioner, when driven to a choice between the two, to give preference to at- tempts at restoration. We have not only greater safety as an argu- ment in favor of it, but successful restoration reinstates the patient in all her sexual capacities, while amputation, if not diastrous in 550 DISPLACEMENTS OF THE UTERUS. other respects, renders her forever sexually neuter. It is to be hoped that before long the operation of amputation will be regarded as un- justifiable, because of the certainty of restoration. Great improve- ment in our means and the mode of effecting this must be made, however, before this conclusion can be reached. There is no longer room for doubting that restoration of the inverted uterus occurs spon- taneously, I think it is proven by the case of Dr. Hatch, published in Dr. Meigs's Obstetrics. The case of Madame Beauchardat, pub- lished by Baudelocque, is also, I think, conclusive on the point of restoration. Other cases, less clearly and circumstantially reported, may be found scattered through medical literature for the last cen- tury. There are two methods, if they may be so denominated, that have been successful in reducing chronic inversion of the uterus. Two representative cases are published in the American Journal of Medical Sciences for July, 1858 ; one by Professor Wliite, of Buffalo (it was his second case), and one by Dr. Tyler Smith, of London. It will be observed, by examining the reports of these cases, that the restora- tion began by the cervix passing through the os uteri first, then the . body, and finally the fundus. This is different from what I think is the common mode of restoration in recent cases. The operation for reversion in Dr. White's second case was completed, we are led to suppose, in something more than an hour, and at one sitting. The uterus had been inverted five months. Dr. White operated by in- troducing the hand into the vagina while the patient was in a state of anaesthesia from chloroform, squeezing the uterus so as to lessen the size as much as possible, and at the same time pressing the organ upwards by means of the large rectum bougie. Success followed a somewhat protracted manipulation. The uterus was restored by the lips of the OS uteri beginning to fold outward, and the neck to pass up through this opening, next the body, and afterwards the fundus. There is nothing in this case said about the fundus being indented from beginning to end. This is no more than might be expected by considering the anatomical circumstances. The fundus and corpus uteri are firmer and more solid than the cervix, and hence less likely to yield to the same amount of force. The force applied to the fundus, when the organ is strongly pressed upward, acts more efficiently upon the cervix than any other part, from the fact that the vagina, attached all around the mouth, has not merely the effect of resisting the up- ward pressure of the uterus, but, being upon the outer surface, it ini- tiates and keeps up the funnel-shape expansion of the os necessary to permit the other parts to pass through it, as well as to draw it down over the part entering it from below. I believe that, in some respects, this is the best manner of operating for immediate restoration, yet one thing done seems to me to be super- fluous, if not mischievous, viz., the squeezing the uterus. Dr. Sims INVERSION OF THE UTERUS. 551 recommends that the uterus be supported by one hand above the pubis to prevent too great extension upon the vagina. While the uterus is being pushed up from below, the cup-shaped cavity formed by the inverted cervix may be felt if we forcibly press the fingers down into the pelvis from above over the pubis. This manipulation affords us valuable aid in forming our diagnosis, while it gives the opportunity of assisting in the reversion. The great thing to be gained is the commencement. After the neck is one-half reverted the restora- tion proceeds with more rapidity and ease than before until complete. A better instrument than the bougie used by Dr. White would be a cup on a strong handle, large enough to safely lodge the fundus of the uterus. Dr. White now uses what he calls the repositor. The figure Fig. 271. Fig. 272. White's Repohitor. shows its action with sufficient clearness to require no extended ex- planation of its use. The steps in the operation for immediate restora- tion are, first, to introduce the hand into the vagina, and, embracing the uterus with it, hold the organ steady, with the fundus and cervix nearly parallel with the axis of the superior strait; second, place the fundus of the uterus in the cup of the instrument held by the other hand, and then press gently upward, increasing the firmness of it until it is as great as the parts will bear without violence, and con- tinuing it with such force until the parts jdeld and pass up. The time required may be considerable, and it is an object to continue it for a long time, increasing the pressure so slowly as not to be per- ceived, except by comparing it at considerable intervals. The patient should be under the influence of chloroform to insensibility, and 552 DISPLACEMENTS OF THE UTERUS. placed on her back, with the limbs widely separated across the bed, and with the hips very near it ; or, what would be better, an operating table of convenient height, about two feet wide and five long. Greater facility would be afforded for attendants by such a table. The sur- geon should kneel or seat himself in front of the patient, so as to have free use of both hands and perfect command of the parts. The second mode of restoring the inverted uterus, as practiced by Dr. Tyler Smith, is to apply the force so gradually as to require several days for the comjoletion of it. The means used were, first, the frequent introduction — I think twice a day — of the hand into the vagina to squeeze the uterus ; and, second, to keep a gum-elastic air- bag distended in the vagina, which constantly pressed the fundus upward, certainly, however, with no great force. He succeeded in restoring a uterus that had been inverted for fifteen years. With proper apparatus I should very much prefer this gradual method, as requiring less violence, being less hazardous, and perhaps less painful. A sufficient number of cases have been successfully treated by this means to justify giving it a fair trial. Having succeeded in three cases in reducing with the elastic bag, I am more favorably impressed with its efficiency than Dr. White seems to be. The reduction was effected in from five to eight days, without giving the patient pain enough to interfere with her sleep, or causing her any serious incon- venience. Each day showed advances; the first, relaxation of the rigid neck ; the next, shortening of the displaced uterus ; and each day after exhibited gradual improvement until the restoration was found to be complete. I am convinced that in many, if not most, of the simple cases of chronic inversion the reposition may be accom- plished by this method, and I would certainly try it before resorting to the more hazardous and more painful plan of Dr. White. Success with the elastic bag, however, requires a careful study of each case, and a watchful adaptation of the means. The kind of instrument is of much importance. The best shape, perhaps, is quadrilateral. It should be strong enough to bear considerable pressure without mate- rially altering its shape, and furnished with a tube and very tight stopcock. The instrument should be distended with water instead of air, as there are few that will not permit air to escape in greater or less quantities. The chances of success will be increased by a firm and well-shaped perineum to support the pressure, and by its own elasticity adding to the efficiency of the instrument. When the peri- neum is deficient, we may compensate it by well-adjusted mechanical support. The more firm the tissues of the vagina the better (Fig. 273). The instrument should be introduced in an empty condition, and placed well back in the vagina, and the water forced into it until moderately distended. We must then carefully examine the relation- nhip between it and the uterus, and see that the latter is pressed up- INVERSION OF THE UTERUS. 553 ward in the direction of the axis of the superior strait. If this is not the case, we may be able to place the uterus in the right position by moving it with the finger. If this cannot be done, the bags should be emptied and changed until right. If the shape of the instrument is not properly adapted to the vagina, it should be replaced by another. By exercising due care in selecting and adjusting the instrument, we shall be able to get the force exerted in the right direction. When satisfied that the instrument is properly adjusted, we should inject water into it, and distend it as much as the patient can bear without decided pain. It will not be necessary to remove it more than once in twenty-four hours, but it ought to be examined in reference to the degree oiE" distension, and if it should continue tense, and the patient feels no more discomfort from it, we ought to inject more water until the patient experiences slight uneasiness from the pressure. Once in twenty-four hours the water may be allowed to escape, and the instru- ments be removed, the vagina cleansed, and the parts thoroughly examined. If we are producing any impression on the rigid cervix, the relaxation will be perceptible by the facility with which the uterus will move upward. The instrument should be carefully readjusted and again distended. On the second removal of the bag I think, usually, we may expect to discover decided progress in the process of restoration. I do not believe it judicious to manipulate and squeeze the uterus, with a view to lessen the blood in it, every time we remove the elastic bag, and would sedulously abstain from anything of the kind, believing that the reaction after the withdrawal of the hand would engorge the vessels of the organ. The daily removal of the in- strument, cleansing of the vagina, and readjustment must be continued until the uterus resumes its proper position, or until we find we can- not succeed by this plan. Judging from my own observation, and the cases I have seen recorded, I should expect success to follow between the fifth and the eighth days. But efforts may be continued much longer than this, if necessary. As soon as the fundus has passed into the cervix, it will spontaneously resume its proper position, because the resistance to its doing so is removed ; but if this should not occur, a rectal bougie may be placed against it and sufficient pressure exerted to rectify it completely. The pressure of this elastic bag when properly managed is just the kind desired, and the degree may be made very considerable. When the bag is of the right size and form, the uterus is pressed upward in such a manner as to place the vaginal attachments upon the stretch, and cause them to draw open the cervical cavity, and this tension is increased by the dilatation of the upper portion of the vagina in every direction. It thus acts as a dilator as well as repositor. And although the degree of pressure upward is not so great as may be made by the repositor of Dr. White, or by the hand, its steadiness of action, and 554 DISPLACEMENTS OF THE UTERUS. the great length of time it may be continued, more than compensate in the end for its lack of violent force. We all are acquainted with the efficiency of moderate but long-continued traction upon fibrous tissue, in cases of long-standing dislocation. I will here present a case which has recently come under my ob- servation : December 24:th, 1878. — Mrs. M., Irish, aged twenty-six years, was brought to me with inversion of the uterus, which had taken place at the time of her first labor, fourteen months before. I obtained a very imperfect history of the case, but so far as I could learn nothing un- usual occurred during pregnancy, and when the labor began the patient was in the enjoyment of robust health. The first and second stages of labor were normal, and together lasted six hours. During the third stage hemorrhage was alarming, and the succeeding pros- tration very great. The patient could give no intelligent account of the mode of delivering the placenta, or of the duration of the third stage. The only recollection of it was that she suffered from great pain and weakness. The accident was not discovered at the time, and when, after the lapse of some weeks, the attention of the prac- titioner was called to the unusual condition of the contents of the vagina, he said : "She must have a polypus or something else." He either was not aware of what had occurred or did not wish to have the true condition known. Astringent injections were used and stimulants and tonics given. The patient gradually rallied, and during the first year was seen by a number of physicians, and many opinions were expressed and methods of cure tried. No benefit resulting from treatment, she came under the care of Dr. White, of Bloomington, who recognized the true condition of the patient, and made a very judicious and prolonged effort to reduce the uterus by the forcible method and failed. He then advised her to visit me for further treatment. W^hen she arrived she was very ansemic and exhausted. She was constantly discharging blood and mucus, and at the time of her menses flowed profusel3^ There was great tenderness and sensitive- ness of the vagina, uterus, and lower portion of the abdomen. The pulse was weak and about one hundred to the minute. She had a poor appetite and was obstinately constipated. An examination confirmed the diagnosis of Dr. White. The vagina was very capacious, and depending from its roof was a small, very firm uterus. The involution seemed to have been carried beyond the ordinary degree. It was in a state of hyper-involution. It was com- pletely inverted. The labia could be felt forming a thin border, com- pletely surrounding the cervix, with the likeness of a fringe, the edge pointing upwards. The uterus was so firm and condensed that it resisted every effort to elevate it. It could be drawn down somewhat, INVERSION OF THE UTERUS. 555 bringing with it a pouch of the upper wall of the vagina: There was considerable sensitiveness of the iliac and hypogastric regions, but no tumefactions, induration, or other evidence of the products of inflam- mation. A mild cathartic was administered, followed by the tincture of iron and quinine, and on Christmas day the treatment for reduc- tion was commenced. An elastic bag, four inches long, and when distended three inches in diameter, with a tube attached, was selected as the main instrument. When collapsed this bag presented a quad- rilateral shape, larger in the centre and slowly tapering towards the ends. I selected a sac of this shape because it filled the vagina from the vulva to the bottom of the fornix, and when introduced one of the faces reached the fundus in such a manner that the organ would Fig. 273. Eeduclion of Inversion by the Elastic Bag. not easily slide over its sides. As the bag was slowly distended the fundus produced a depression in which it was firmly retained when the sac was filled. I introduced this bag, while empty, so that it lay on the posterior wall of the vagina, and carefully adjusted the dependent fundus so that the body was in a line with the axis of the superior strait. Water was slowly injected until the distension produced a sense of discomfort. The distension was kept up for twenty-four hours, when the water was permitted to flow away. The instrument was removed and cleansed, and again rej)laced and filled. The first time it was removed an evident softening of the cervix was noticeable, and the body could be pressed slightly into it. From day to day the softening 556 DISPLACEMENTS OF THE UTERUS. and dilatation became greater, and upon the removal of the instru- ment advance was ascertainable. Upon removing the bag, on the seventh day, I found that the uterus was in a state of complete inver- sion, and all progress seemingly lost. With the finger, however, I could easily press the fundus entirely into the dilated cervix, thus assuring myself that the work of reduction was almost complete. A more careful adjustment and careful distension of the bag were effected, and on the removal of the instrument on the eighth day it was found that the fundus had mounted to its normal position. The sound was introduced two and a half inches. This patient improved in strength and became more comfortable from the commencement of the treatment to the end. After the first three days she was up during a part of the day, and on the seventh and eighth was about her room, and, in addition to keeping her room in order, gave her child all the attention it needed. I have no doubt that she was perfectly truthful in her assertion that the treatment gave her no inconvenience except at the time and for a few moments each time after the adjustment of the instrument. There was no time when I felt the least uneasiness about the effects of the pressure, or was under the necessity of giving anodynes for the relief of pain ; nor did the presence of the instrument prevent the free and comfortable evacuation of bladder and rectum. In fact, the patient improved from the time she was placed under treatment. Notwithstanding the important improvements of Dr. J. P. White, who deserves more credit for his success and teaching in inversion than any other man, and Dr. Tyler Smith's success in the use of the gum-elastic bag, there will yet remain cases in which the uterus can- not be restored to its natural position and relations. Inversion, com- plicated with several fibrous tumors of the body or fundus, will resist ordinary methods of reduction, and, no doubt, cases in which the causes of difiiculty cannot be precisely discovered w^ill occasionally be found unmanageable. What shall be done with such ? The neces- sity for any operation that involves the life of a patient, already in great danger, should be clearly determined by the circumstances of the case and with ample counsel. If the patient's health is growing worse and her strength being exhausted by great discharges or per- sistent inflammation, relief should be attempted at all hazard. If, however, the woman is enjoying fair health, or if the symptoms that usually harass her after the accident of inversion are improving, any operative procedure beyond efforts at reduction, is not justifiable. In cases where restoration is proven to be impossible by proper, prolonged, and repeated eff'orts, or the uterus is so enlarged by morbid growths as to make it obviously useless to try reduction, and the con- ditions demand relief, amputation is the last resort. In a resume found in the American Journal of Obstetrics, August, 1868, translated INVEESION OF THE UTERUS. 557 from the German, we have fifty-eight cases reported of amputation of the inverted uterus ; eighteen terminated fatally, forty recovered. This is a large mortality, but probably the fatality will become pro- portionately less as all the conditions of the operations are improved. The methods of amputation now practiced are essentially three : 1. Ligating and allowing the ligature to remain until it cuts through. 2. Ligating to prevent hemorrhage, and then amputating below the ligature with the knife, scissors, or ecraseur. 3. Passing the ecraseur or galvano-cautery wire through the sub- stance of the cervix without ligating. The ligature, when properly applied, effectually prevents hemor- rhage, but it is very likely to cause inflammation, also a very formid- able occurrence, and one which is the frequent cause of death. Or if it remains long enough to cause sloughing, even of the amputated stump, there may arise toxaemia, resulting from the absorption of the putrid substance. The Ecraseur avoids this latter difficulty, but I should fear it would be an insecure guarantee against hemorrhage in all cases. Dr. Thomas Hay, of Philadelphia, reports, in the Medical and Surgical Reporter, December 2d, 1871, a case in which amputation was successfully performed by the ecraseur alone. Dr. McClintock, of Dublin, applied the ligature for forty-eight hours, and then removed the uterus by amputating with the 6craseur in the groove formed by the ligature. Practical demonstration is the only reliable guide in important operations; we are not supplied, however, with enough ex- amples of success by any one procedure to justify us in making a posi- tive choice between them. It will not be difficult to get access to the cervix for the purpose of applying the ligature or amputating. This may be done by drawing the organ down to the vulva with vulsellum forceps. The galvano-cautery is better than all the above methods of ampu- tation. The wire applied as an ecraseur, heated to a dull red color, and drawn slowly through the cervix, will do away with the dangers of hemorrhage, and leave no sloughing surface from which sepsis may be generated. CHAPTER XXXIV. DISEASED DEVIATIONS OF INVOLUTION OF THE UTEEUS. The uterus is very much hypertrophied by the processes of gesta- tion, so that after its contents are expelled by labor, the organ weighs from one and a half to two pounds. An atrophizing process, called involution, serves to reduce the organ to its original conditions in size and weight. Involution is a physiological change, as much so as evolution ; but not unfrequently disease invades the tissues and renders it abortive : 1. Causing it to be temporarily " delayed ; " 2. To fall short of comple- tion after it has been commenced ; or, 3. To proceed entirely beyond the limits compatible with the healthy functions of the uterus, reducing it below its usual weight and size. I mean by the term " delayed involution " to designate a condition of the uterus in which this process does not begin for a number of days — from ten to fourteen — after parturition. The contractions which immediately succeed and continue after labor, by interrupting the circulation in the substance of the uterus, initiate that process, and by the end of a fortnight it is half finished. Should these contractions be rendered inefficient, involution is at a stand, the uterus remains large, the circulation too great for safety to the patient, and sufficient to keep up the nutrition in the muscular fibres, which are still capable of a good degree of energetic action. For a number of days the uterus is felt to be as large as a child's head above the pubis, and not very firm. Causes. The most common cause of this delay is inflammation attacking the substance of the uterine walls. The inflammation may be acute, and the patient's suffering such as to demand attention, or so slight as to pass without much notice. Cases of puerperal metritis, for a week or ten days immediately succeeding delivery, not unfrequently present this enlarged condition of the organ. Another cause which probably operates to prevent involution is atony of the uterine muscular fibres. The contractions are feeble, and so inefficient as to delay for a long time, and render very slow, the early stages of involution. Too early assumption of the erect posture and undue exercise on foot, keeping the bloodvessels of the uterus distended unduly, and thus overcoming the muscular contrac- tion, are not unfrequently the causes of delayed involution. SYMPTOMS PROGNOSIS — TREATMENT. 559 Symptom,s. The symptoms of delayed involution, separate from the inflamma- tion, are not always very well marked. Weight, heat, and aching in the back are the most frequent, especially if inflammation is the cause. There is always great danger, however, of a very alarming symptom while this state of the uterus exists, and that is flooding. Where the delayed involution is dependent on atony of the muscular fibres, hem- orrhage is sure to take place if the patient exerts herself considerably. As the first indication of any seriously wrong condition of the uterus, the patient is suddenly seized with copious hemorrhage, which sub- sides under the influence of rest, cold, and astringents, but suddenly and unexpectedly recurs without adequate cause. When suspected, the diagnosis is not difficult by an examination with one finger of the right hand per vaginam, while with the left hand pressure is made above the pubis. The uterus, thus examined, is found to be as large as immediately after labor is ended. The soft, uncertain condition of the uterine globe will not always enable us to discover it by placing a hand upon the lower part of the abdomen alone, but by including the organ between the two there will be no danger of mistake. If the organ retains sufficient firmness to be easily distinguished above the pubis by the single hand, there will be but little danger of hemorrhage. The local distress will then be the only indication of the necessity of a diagnostic examination, when the greatly enlarged condition will be easily detected by the examina- tion above directed. The fingers may be easily made to enter the mouth of the organ and move the whole mass, while the hand above will easily recognize the movement, or the hand above may be made to press it down upon the fingers below. Prognosis. There is imminent danger of serious, if not fatal, hemorrhage. I have known as many as two cases of sudden fatality from flooding after the seventh day from the time of labor. It is always a serious condition, and should be watched diligently and treated efficiently. Even in cases where the delay is caused by acute inflammation great hemorrhage may take place, although not so likely as when caused by muscular atony alone. If the delay is for a very considerable length of time, the involution is pretty sure not to be completed, but the uterus remains in a state of subinvolution for an indefinite time. Very often the causes which effect delays continue to act, and finally produce subinvolution. Treatment. The treatment depends upon the causing conditions. If there is inflammation of the uterus the antiphlogistic measures necessary to 560 DISEASED DEVIATIONS OF INVOLUTION OF THE UTERUS, combat it are demanded, with counter-irritation, fomentations, etc. Should atony, unattended with inflammation, exist, ergot in large doses is demanded imperatively until ergotism is manifested. I usually give 3ss. pulv. secale corn, in infusion, every half hour until there are contractions. When this is done the effect of the drug may so subside that it will be necessary to administer it again in twelve or twenty-four hours, until all disposition to relax has passed away. When atony and the inflammatory condition coexist, which may be known by the tenderness, fever, and hemorrhage occurring to- gether, the ergot and other treatment should be combined. Hemor- rhage is not likely to come on until after the inflammation has pretty well subsided, and aids usually in removing the last of it. I subjoin two cases as representatives of the two conditions of the uterus, and the mode of treating them: Case I. This case was furnished me by Dr. S. Wickersham, of this city. He was called to see Mrs. E., an Irishwoman, aged twentj^-eight, in her fourth labor. May 7th, 1863, 4 o'clock p.m. She had been in labor, attended by a midwife, for the most of the day. At 1 o'clock A.M. of the 8th, pains had entirely ceased, from atony or exhaustion of the uterus. Constitutional symptoms began to show the necessity for relief The forceps were used, and the child was delivered. The placenta was delivered in due time without difficulty, and the uterus contracted well. Hemorrhage not more than usual. The pulse was unusually frequent at and after the time of delivery. The labor was followed in two days with puerperal fever, in which the uterus and peritoneum were both involved. Up to the 20th she had improved very much, so as to be considered by the doctor as convalescent. In the early part of the day sudden and violent hemorrhage prostrated the patient to what was at the time considered a moribund condition but by active stimulation and external warmth to her cold extremi- ties she rallied, and appeared to be slowly recovering. At 6 o'clock P.M. on the 24th, the hemorrhage returned with "terrible violence," and she was thought again to be dying. Notwithstanding the most energetic use of stimulants she could hardly rally from this last attack. On the 26th, in consultation with Dr. Wickersham, I found the patient so prostrated as to leave but little hope of her recovery. Suspecting that the uterus was in a state similar to what is found immediately after delivery, I insisted upon making an examination, which was resisted by the patient and friends. Through the kind perseverance of Dr. Wickersham I was permitted to do so. The uterus was so flaccid that I could not discover it above the pubis until after introducing the finger into the vagina and moving it about, when the fundus could be felt as high as the umbilicus, with the regular globular form. The mouth and cervix were large and flabby, and easily admitted two fingers. After this examination the indica- TREATMENT. 561 tion seemed plain. Large closes of ergot were given in addition to the stimulating and supporting treatment. Hemorrhage was very slight on the morning of the 27th. She continued to improve slowly until the 9th of June. At 5 o'clock a.m. the hemorrhage returned, and lasted until 10 o'clock a.m., but in so moderate a degree as to produce but little effect upon the patient. I was not in attendance after the first consultation, and could not trace the steps of condensa- tion, but after the 9th of June the hemorrhage did not recur. It will be seen that on the twelfth day after confinement dangerous hemorrhage took place ; that it again returned on the sixteenth day after delivery to a very alarming extent ; and that after the liberal use of ergot the hemorrhage returned but slightly. It should be noted, also, that the cessation of the hemorrhage was sudden, and probably resulted from faintness, and that it returned as soon as the arterial reaction amounted to any considerable degree. The faint- ness, doubtless, was the cause of stoppage in both attacks before ergot was given, but the hemorrhage was effectually checked by contrac- tions produced by the ergot. Case II. Mrs. E. is the mother of nine children. She is thirty- three years of age, and a German Jewess. Of robust, almost athletic make and habits, she always enjoys excellent health. In the last three confinements she has almost lost her life from loss of blood, both before and after the delivery of the placenta. I attended her in the eighth labor, the last before this one. There was nothing peculiar in it until after the child was delivered, the labor having lasted but about four hours. The pains were ordinarily vigorous and propul- sive. The liquor amnii was not evacuated until ten minutes before the head was distending the labia. After the child was expelled the uterus did not contract thoroughly. It seemed large and rather soft. This state lasted for half an hour, when a feeble contraction detached but did not expel the placenta. From this time hemorrhage became excessive. I waited for half an hour — using friction, kneading, and pressure over the uterus, with application of ice to the vulva — for- contraction of the uterus and expulsion of the placenta, but although, there were occasional pains, they were so feeble as to produce no effect upon the hemorrhage. About this time the ergot I had sent for arrived, and I gave immediately 3ss. in a little wine and water. Fearing the prostration which was rapidly coming over the patient, I introduced my hand into the uterus, grasped the placenta, and irri- tated the organ by moving the whole around in it. This brought on contractions enough to expel my hand and placenta, and deluge the bed with coagula and fluid blood. Very soon the ergot began to act, and the hemorrhage ceased. I give this description of her eighth labor to show her predisposition to inertia uterina. As the ninth labor approached, I determined I would administer the ergot as- soon 36 562 suBI^'V0LUTI0N or the uterus. as the parts were well dilated, and the head began to pass the os uteri. I was sent for at 8 o'clock p.m., June 30th, 1864, to attend her. I found the pains active and the os uteri fully dilated, and the mem- branes distending the labia. I at once gave her ergot 3ss. in infusion, making her swallow the ergot as well as the water. This was rej)eated in half an hour. By this time ergotism was fairly established. In three-quarters of an hour from the time I arrived the child was born, and in a few minutes the placenta was expelled from the uterus into the vagina whence it was removed. No hemorrhage followed. The uterus was well contracted. I considered her condition very favor- able, and at the end of another hour took my leave. Her condition for the first forty-eight hours was in no respect unusual, except that the lochial discharge was rather free. From this time I saw but little of her until the 10th of July. I returned from the country at 5 o'clock P.M., and found she had been flooding since early in the morning, not very greatly, but sufficient to begin to produce faintness. The uterus could be felt above the symphysis pubis as large as a child's head, and not very hard. I ordered cold to the jDubis, and twenty droj^s of aromatic sul. acid in some water every four hours, expecting soon to have the hemorrhage checked ; but to my surj^rise, at 8 o'clock on the 11th, the hemorrhage still continued, being but slightly moderated by the means used. I now ordered two teaspoonfuls of vin. ergoti every half hour until the hemorrhage ceased. But the nurse said that the " second dose put her in so much pain and caused such large clots of blood to come from her that she dare not give it again." The hemor- rhage ceased entirely from this time until the afternoon of the 13th, when it returned with considerable violence. The ergot was again given, and from this time forward the patient had a favorable con- valescence, and is now in the enjoyment of good health. Subinvolution of the Uterus. To understand subinvolution in its princijDal bearings it will be necessary to discuss more at length the subject of involution itself. I think that involution of menstruation plays a much more important part in the structural diseases of the uterus than we have been inclined to attribute to it. It will not be considered irrelevant, therefore, to take a glance at the subject, as involution presents itself in menstrua- tion as well as in pregnancy. In the healthy uterus, what may be called trophic changes are con- stantly going on, from the beginning of menstruation to the meno- pause. The circulation of the uterus is increased in quantity from the cessation of one menstrual crisis to the beginning of the next. During the days of the flow the afflux of blood subsides to the lowest amount. SUBINVOLUTION OF THE UTERUS. 563 From the cessation of the monthly flow there is an increase of solid tissue in the uterus until the beginning of the next menstrual flow, during which time there is involution or an elimination of solid tissue, notably the mucous membrane of the cavity. ' These processes of afflux of blood and accretion of tissue may be, and often are, prolonged, and pass into what is known as congestion of the uterus. When this round of monthly changes is interrupted by pregnancy, processes similar in character on a much larger scale are accomplished. The afflux of blood and increment of tissvie do not attain their maxi- mum until the end of gestation. The contents of the uterus are ex- pelled, and then begin the changes called involution, the object of which is the elimination of the superfluous circulation and solid tissues, until the uterus returns to its menstrual status. The prolongation or arrest of this is subinvolution. Post partum involution is no doubt initiated, if it is not completed, through the agency of muscular contractions. The large fibres which have been strong enough to expel the foetus, placenta, and membranes, continue to contract, and in doing so compress the vessels, and thus cut off at once a large quantity of the blood circulating in the uterus. As a result of this some of the fibres are deficiently supplied with nutritive elements, and undergo fatty degeneration. The granular fatty material is absorbed and the general bulk of the organ dimin- ished. Further contraction is thus rendered possible, when more fibres disappear in the same way until the process of involution is finished. The length of time required is, I think, much longer than is generally supposed, seldom in one month, often not in three months, and sometimes morbid causes prevent it from ever being accomplished. The uterus then remains more vascular and bulky than normal, or is in a state of subinvolution. In both post-menstrual and post-partum subinvolution this simple vascular condition does not continue for any great length of time. Hypersemia is often a mischievous condition, and sooner or later causes changes in the organization of the viscus in which it exists. In subinvolution there is at first hypersemia, with hypertrophy of the fibrous, vascular, and nervous tissues. These solid portions of the organ degenerate, not into a fatty substance that may be absorbed, but into fibrous tissue of a low organization. Either as the eff'ect of exudation from the capillaries, or the slow absorption of the more vitalized molecules of the muscular fibres, or both, there comes to be an undue amount of connective tissue. The transition from the more muscular and highly vitalized state of the uterus to this one of induration may be accomplished in a few months, or it may require the lapse of years. When it is complete, many of the symptoms that indicated the state of recent subinvolution are re- 564 SUBINVOLUTION OF THE UTERUS. placed by others of a different kind ; especially do the bloody dis- charges from the uterus become less than normal. Subinvolution is a term, then, which embraces different pathological conditions; or, perhaps, it would be expressing the facts better to say that several distinct pathological conditions of the uterus result from subinvolution. This last statement will apply equally to men- strual subinvolution as to the post-partum. We ought not to lose sight of the fact that all the physiological and some of the pathological changes occurring in the uterus are to a great extent coincidental with, if not the consequences of, the changes going on in the ovaries, — the organs that dominate the whole genital system. During ovulation the menstrual hypertrophy takes place ; at the time of the discharge of the ovum menstrual involution occurs. During the development of the ovum in the uterus, ovarian hyper- trophy is going on ; at the time of the expulsion of the ovum the pro- cesses of involution begin. It is quite probable that after the ovum is inclosed in the uterus and gestation established, the uterus is ijrompted by ovarian influence to the enormous physiological and anatomical changes which go for- ward in it, up to the perfection of fetal life, and afterward govern the processes of labor and involution. It is certain that the ovaries do not return to the condition in which they were, before conception, until pregnancy has terminated, nor in fact during several months of lactation. While the generative functions of the ovaries are held in abeyance by lactation, — or, if I may express it differently, while the ovaries are engaged in the reflex duties of sustaining lactation, — they do not re- turn to their former condition. According to my observation, involu- tion of the uterus, ovaries, and vagina is not complete in persons who nurse their children until the ordinary term of lactation has elapsed. Looked at in this way I think involution will present different feat- ures than when viewed from a more circumscribed standpoint. We will attach more importance to the influence of the nervous system, exerted through the ovaries. The term and process of involution extend to the changes observed in all the genital organs, the lacteal glands, the ovaries, uterus, vagina. Fallopian tubes, uterine ligaments, and perineum. How much more susceptible to the effects of morbid causes, therefore, must be all the contents of the pelvis in the hyperaemic, hypersesthetic, and hyper- trophic conditions during the time involution is going on, and how readily the affections of one pelvic organ will influence the condition of all the others. The genital organs constitute a separate and, in some respects, inde- pendent physiological system, governed by special nervous centres, all CAUSES — FREQUENCY OF ITS OCCURRENCE. 565 bound together and dominated by the ovaries, under all the physio- logical changes accompanying pregnancy, labor, and involution. Causes. Any morbid causes that prolong the processes of involution may arrest the process entirely. The character of the labor may have this effect. If it has been tedious enough to produce great nervous ex- haustion, the uterine fibres will be powerless to conduct the changes necessary to a speedy and perfect involution. If the cervix is lacerated or badly contused, the consequent inflam- matory reaction interrupts involution for a greater or less length of time, or perhaps for all time. Inflammation of the body of the uterus resulting from severe labor or exposure may do the same thing. General and special causes not dependent upon labor often act so as to bar the completion of in- volution. Some of these causes are general debility, an impoverished condition of the blood, lack of nervous energy, a want of the jjowers of endurance, cold acting through the nervous system u[)on the circu- lation of the uterus post-partum or during menstrual congestion, the excitement of anger, fevers, or the depression of fear, etc. Special causes operate through the genital nervous centres upon the uterus directly, as venereal excitement from unnatural lascivious practices, coition during or just before menstruation and within the month after labor, libidinous literature, and exciting exhibi- tions. Diseases in the surrounding organs, by keeping up nervous and vascular excitement, ulceration, fissure, and hemorrhoids of the rectum, specific vaginal inflammation, laceration of the perineum, urethral and vesical inflammation, displacements of the uterus, etc., all tend to produce this effect. Frequency of its Occurrence. Without exaggerating the importance of subinvolution, I believe it would be correct to say, that more of the chronic congestions of the uterus originate in puerperal and menstrual subinvolution as here explained than in any other one condition. By taking the puerperal and menstrual involution as a fundamental and almost constantly present condition of the pelvic organs for a basis, I think we can better explain the mode of operation of exciting- causes in producing chronic diseases than by any other hypothetical method. Certain it is, that there is no other organ in the body so prone to lesions of circulation and their consequences as the uterus, and that the reason why this is the case must reside in the anatomy and functions of the orean. 566 suBusrvoLUTiox of the uterus. It is an organ, the very nature of whose condition is one of unceas- ing fluctuation of vascularity and nervous suscej^tibility. Symptoms and Diagnosis. The general symptoms of subinvolution are in no respects distinc- tive. All the reflex symptoms sjDoken of as uterine symptoms, or symptoms of uterine disease, may exist in jDatients the subjects of this condition; neither do the local sj^mptoms guide us with certainty to a correct diagnosis. In the earlier months of subinvolution, in fact for an indefinite term, metrorrhagia is a frequent sjmiptom, and in some instances continues as long as the disease lasts. It represents what may be termed the vascular stage of subinvolution. In a great many cases of subinvolution after a certain time, which also is very indefinite, the bloody discharge from the uterus becomes less copious, and occasionally entirely ceases. The diminution of the flow indi- cates the supervention of the fibrino-plastic stage, or a condition in which the vascularity of the uterus is diminished while the solid tissue is increased. Leucorrhoea is generally present or absent under the same conditions that govern the flow of blood. Diagnosis. The diagnosis must be made up from the history and physical examinations. If the sufferings of the patient date from an abortion, or labor at full term, and in addition to the general and local symp- toms of uterine disease there is or has been for months too copious or too frequent menstrual discharges, or hemorrhages intervening be- tween the regular periods, the presumption is that there is subinvolu- tion, or at least that the symptoms were at first those of that condi- tion. One of the most constant appreciable conditions of subinvolution is the large size of the uterus. This may be ascertained by bimanual examination and the introduction of the sound. When the uterus is lifted up by the fingers in the vagina, the fundus will be more easily felt by the hand above, and the sound will pass farther beyond the normal dejDth into the cavity than when the organ is of a normal size. The shape of the uterus is generally still that of the post-partum organ. It is proportionated thicker through its antero-posterior diameter. The enlargement, therefore, is difi'erent from enlargements from other conditions. The shape is often modified by retroflexions and lacerations of the cervix. When retroflexed Avithout laceration, the fundus and body are much larger proportionate!}^ as compared with the cervix. When the cervix is badly lacerated, it is enlarged. The appearances in this resj^ect are sometimes deceptive when the labia are widely separated. PROGNOSIS TEE ATMENT. 567 When examined through the speculum the color is deeper than natural, the mouth patulous, the cervix large and often ulcerated. Generally, also, there is copious albuminoid mucus hanging from the OS uteri, sometimes of an amber color, from the admixture of pus- corpuscles. When the cervix is lacerated, the mucous membrane of the cervical cavity is exposed, and presents a papillary or fungoid appearance. These are the appearances in the vascular stage of subinvolution. After this has passed, and the fibrino-plastic change has taken place, the cervix and body will feel hard to the touch ; sometimes the indu- ration in such cases is very marked indeed. While the induration is generally uniform with respect to the cervical circle, and extends en- tirely around, at other times it is confined to one of the lips. Then the color is often not increased, and the surface is smooth and covered with cicatricial tissue instead of granulations or fungoid bodies. Prognosis. During the vascular stage of subinvolution, and while the hyper- trophied fibres of the uterus retain their muscular character, we may hope to succeed in restoring the normal condition of the organ. We must remember, however, that metrorrhagia, indicating great vascu- larity of the uterus, is no evidence that the fibres are not greatly X3hanged or replaced by non-contractile tissue, and consequently the prognosis should be guarded. The longer the time the case has lasted, the greater the probabilities are that the fibres are replaced by connective tissue. After this vascular and hypertrophic condition of the muscular fibres have passed away, and there has been extensive fibrino-plastic deposit in the walls of the uterus, the probabilities of a cure are very remote. The uterus is then hard, inelastic, its tissues permeated by few vessels, and the nerves diminished, if not entirely absent. Treatment. The preventive treatment should begin during pregnancy. Every means necessary to place the patient in good health, both generally and locally, must be resorted to, — exercise in the open air on foot,. if at all practicable, and domestic employment or jesercise of like- character. The habits of the patient should be regulated with a view to; the development of the muscles of the entire body, while her diet shcoQ-ld' be abundant in quantity and of the most nutritious quality. It is not my purpose at this time to do more than to call the attenr- tion of the obstetrician to the subject of preparing patients for the great task of passing safely through labor. During labor everything; 568 SUBINVOLUTION OF THE UTEEUS. should be conducted with the view of preserving the integrity of all the soft parts, because, as before intimated, damage to any of the parts concerned in labor is pretty sure to be followed by subinvolu- tion. The more physiological a labor is, and the more skilfully conducted, the less the tendency to subinvolution. After labor complete contraction should be brought about, and maintained, not by mechanical irritation, but, if need be, by the use of ergot and vaginal injections of hot water. These latter will stimu- late the j)elvic nerves and prompt the uterus to contraction, and by their cleansing effects promote the repair of every damage that the soft parts may have sustained. Above all things, a sufficient amount of absolute rest must be enjoined to insure recovery of the viscera. The most assiduous attention should be especially given to control all inflammations that follow labor. From the immense number of gynecological cases traceable to labor, it is to be feared that some of the modern innovations in the practice of midwifery are not improvements. More attention and care in conducting patients through cases of abortion and jjremature labor should be practiced than is usually done. Abortion is looked upon by the patients themselves as a small mat- ter, and it is very difficult to induce them to give the necessary time and care to themselves. Physicians know that it is a more disastrous process than labor at full term, and they will do service, therefore, by enforcing proper measures, whenever it is practicable, to insure good recovery from it. After the patient has passed from the hands of the accoucheur to those of the gynecologist the treatment of subinvolution will be gov- erned by the conditions in each case. Until the muscular fibres have lost their power of contraction, ergot, strychnia, quinine, and iron, with good, nutritious diet and exercise in the open air, will be the gen- eral remedies most efficacious. Ergot, given in moderate doses, perseveringly administered, is a very powerful means of supiolementing the natural contractions. It is not applicable to cases, however, where there is inflammatory excitement in the uterine substances, and should be withheld until, by alteratives, counter-irritants, and rest, that condition is removed. When this inflammatory condition is not present the ergot and tonics, judiciously administered, will co-operate well in the accomplishment of the gen- eral result. However, gynecologists do not often see these cases until the contractility of the fibres has been very much impaired, if not entirely lost. In most cases, even thus late, the ergot and tonics will have some good effect. In chronic cases the local treatment is of prime importance ; and TREATMENT. 569 the first thing to be thought of is the removal of any cause of increased vascularity that may be found associated with it. If there is lacera- tion of the cervix or perineum it should receive attention. If there is misplacement it must be corrected, so that the outgoing circulation may be as free as possible. When these conditions are corrected we may begin, a system of local treatment that will remove the congestion, and cause the absorption of the fibrino-plastic deposits. The use of glycerin tampons and hot-water injections will be found applicable and beneficial in most cases. The glycerin cotton should be applied about every second or third day, and allowed to remain in the vagina from twenty-four to forty-eight hours. It should support the uterus so as to relieve the tender or irritated pelvic tissues of all strain. During this time the capillary bloodvessels will be depleted by the loss of a part of the serous portion of the blood they contain, and ex- osmosis from the intervascular spaces will also be excited in such a manner as to empty them of their contents. This leaves the part with which the glycerin comes in contact white, shrivelled, and lessened in bulk, ^. e., depleted. This is not all the good efi"ect produced by the glycerin applied to the cervix of the uterus, for the frequent removal of the serum from the intervascular spaces, which, of course, is replaced by a fresh supply from the vessels, is a very efficient means of dissolv- ing out the fibrino-plastic material. It is, in fact, a kind of washing- out of the tissue with serum derived from the minute bloodvessels ; it acts, therefore, both as a depletent and a solvent. Large hot-water injections constitute another valuable means of overcoming hypersemia, and causing absorption of solid deposits. But there is another class of local remedies that is more serviceable than these, and that is local stimulants applied directly to the mucous membrane, such as iodine, carbolic acid, tincture of iron, acid nitrate of mercury, and many others that I might mention. In the teachings of twenty-five years ago the application of these remedies to the mu- cous membrane was supposed to exert only a very limited influence at the point to which they were applied, and we thought in applying nitrate of silver to an abraded or ulcerated surface the only effect it had was to heal up the abraded patch. Now we know that this is a very small part of the effect of these local applications. The vasomotor nerve supply of the whole uterus is so intimately connected that it may be considered a unit, and no part of it can be stimulated without aftect- ing the whole. Applications made to the cervix of sufficient strength to stimulate its circulation to greater activity affect every fibre and capillary in the organ in a similar manner. When, therefore, there is chronic engorgement of the uterus, the very best way to get rid of it is to stimulate the circulation by local applications to the cervix. This same principle may be turned to great advantage by stimulating its 570 HYPERIN VOLUTION. internal mucous membrane, and one of the best wa5's to do this is to scrape the cavity of the uterus with a dull wire curette. This instrument may be introduced in most instances without diffi- culty, and passed slowly but firmly over the whole surface. In some instances, where the mucous membrane is soft, small pieces may be brought out by the instrument, but generally this is not the case. When pieces of the mucous membrane are thus removed it would be too mechanical an explanation to say that the patient is cured be- cause the uterus has been partly or wholly divested of its diseased membrane. It is the excito-motor influence exerted on the nerves, and the consequent effect upon the whole circulation of the organ, that is the result of its use. It is not merely to the hemorrhagic condition of subinvolution, but to the hypertrophic condition also, that the curette is applicable. Dilatation with compressed sponge has often accomplished good in the same kind of cases as those to which the curette is adapted, but it is a much more hazardous measure, and should only be resorted to when the other means fail. Hyperinvolution Is the state of the organ in which the involution has proceeded to such a degree as to condense the tissues beyond their ordinary density. The condensation thus accomplished renders it less vascular and erec- tile, and the fibrous structure is paler and harder than natural. As the result of this condensation and diminution in the quantity of the circulation, the uterus as a whole is smaller and lighter than common. The degree to which hyperinvolution may be carried varies greatly ; sometimes it is so slight as to require great care to distinguish it, at another the uterus is reduced to half its ordinary weight and di- mensions. Causes. Inflammation seems here to be more concerned in the production of hyperinvolution than any other morbid process. From examina- tions during the progressive steps of morbid states of involution, I am inclined to think that in cases where inflammation of the mucous structures exists exclusively, or where inflammation of the mucous membrane preponderates, the involution is arrested, and hence we have subinvolution ; but when the inflammation is mostly confined to the submucous tissue it proceeds to hyjierin volution. Symptoms. The condensation of the tissue and reduction of the vascularity of the organ always diminish the menstrual flow ; and hence we have de- creased menstruation in a moderate degree, and obstinate amenorrhoea DIAGNOSIS. 571 in the more extreme condition. The symptoms attendant upon hyper- involution are very similar to those enumerated in the description of chronic inflammation. They are sometimes very distressing, rendering the patient thoroughly miserable for many years. The worst cases of this form of diseased involution I have met with have been traced to inflammation resulting from abortions ; but it likewise takes place as the efi'ect of inflammation after ordinary or full term parturition. Diagnosis. The diagnosis is easy with the aid of the uterine sound. This in- strument will not enter the uterus as far as it does into a healthy organ. The uterus is lighter and more easily moved, also, by the finger intro- duced into the vagina. One of the almost invariable effects of hyperinvolution is sterility. I have met with a number of cases of sterility occurring soon after marriage, on account of abortion, in the first three or four months, being followed by inflammation and hyperinvolution, the patient ever afterwards remaining sterile. The successful treatment of these cases requires a great deal of patience and well-adapted measures. If the change in the condition of the uterus is slight we may sometimes succeed by introducing a bougie of slippery-elm bark, large enough to distend the cavity of the -cervix as much as practicable, three or four days before the expected menstrual discharge. This seldom fails to increase the discharge, and if used perseveringly for several months will sometimes cure the case. The bougie should be cut out of the bark so as to be about an inch and three-quarters in length, for cases of moderate contraction, and secured by a thread before introducing it. It should be allowed to remain until the discharge begins, and then removed. If, however, it is of long standing, and the diminution in size very considerable, we will be under the necessity of using the stem-pessary recommended by Professor Simpson. It may be made of zinc and copper, in order to add the influence of galvanism. CHAPTER XXXY. CANCER OF THE UTERUS. "Those growths maybe termed cancerous which destroy the natural structure of all the tissues, which are constitutional from their very commencement, or become so in the natural process of their de- velopment, and which, when once they have infected the constitu- tion, if extirpated, invaria,bly return, and conduct the person who is affected by them to inevitable destruction." (Miller, as quoted by West.) This general definition of cancer will include all its varieties, which are usually divided into four : 1st, medullary ; 2dly, epithelial ; 3dly, colloid ; 4th]y, scirrhus. I have mentioned these varieties in the order of frequency in which they usually occur in the uterine tissues. I have not seen either a case of colloid or scirrhus in the uterus. There can be little doubt, however, that both are met with. The medullary variety is by far the most common form with w^hich this organ is affected, the epithelial being also quite common. Cancer of the uterus is of very frequent occurrence, and the deaths from it, com- pared to death from the same disease occurring elsewhere in women, predominate over all other localities. It attacks the cervical portion of the uterus more frequently than all other parts of the organ, yet it begins in every other portion, — in the fundus, body, or cavities of the body or cervix. In some rare instances it runs its course to fatal re- sults without involving all these parts. When it begins in the cervix, it usually, either gradually or suddenly, passes upward to the fundus ; or if beginning in the fundus or body, it creeps downward to the os tincse. I have seen two instances where the lower portion of the cer- vix was but slightly, if at all changed, while all the other parts of the organ were infiltrated by cancerous deposit. The material of cancer, particularly the medullary, is deposited in the tissues, supplanting them more or less perfectly. The tissue most commonly attacked by all the varieties except the epithelial is the connective tissue. The parts attacked are thickened and indurated, the thickening and induration being very irregular in shape and size. If one of the lips of the os uteri is hardened from cancerous deposit, the elevated points are sharp and angular, and the hardened parts terminate abruptly, and in a manner unlike the in- duration from any other cause. The hardening from inflammatory fibrinous deposit is more globular than angular, and less abrupt in its termination in the sound parts. If the cancerous deposit is in the CANCER OF THE UTERUS. 573 body or side, or any part of the wall, it is enlarged into an irregular shape, and there are pits and points in many places. The infiltration and induration increase for an uncertain length of time, until, perhaps, the cancerous deposit so far displaces and re- places the ordinary tissues that the nutrition of the parts is disturbed by the destruction of the bloodvessels, and sloughing takes place over a small or large space, but always over an irregular space, thus leav- ing a greater or less chasm. This is ulceration, — cancerous ulcera- tion. The absorbents do not remove the parts, and thus cause ulcera- tion, but there is sloughing and denudation by death of many minute parts, the absorbents having but little to do in the process. The sloughing causes the smell and putrilaginous character of the dis- charges. This process widens and deepens the chasm, sometimes quite rapidly, at others very slowly. In the case of the medullary variety, after induration and enlargement have advanced to a con- siderable extent in the uterus, the nutrition of the neighboring organs and tissues is disturbed, and the deposit is infiltrated into all the sur- rounding parts, — the bladder, the rectum, the areolar tissue by the side of the uterus, the peritoneum, in fact, into everything in the neighborhood. This general deposit is not limited by the coverings or divisions of the parts, but all become united, so that all the pelvic tissues become one agglomerated mass of cancer ; or, if it take one direction more than another, the bladder and uterus may be glued together, or the rectum may be bound thus to the uterus. This dis- position of the deposit very soon becomes sufficient to fix the uterus immovably in its place. After the ulcerative process has fairly begun, it advances more or less rapidly, until much of the surrounding parts is destroyed ; the bladder and uterus become one continuous cavity, and sooner or later the rectum also is laid open, and then the pelvic viscera are involved in one confused excavation, from which the putrilage of cancerous degeneration is poured out, commingled with urine, fseces, and blood. There is quite, a constant proportion between the rapidity of the destructive progress of cancer and the age of the patient. It is slower in the aged, and destroys the young patient most readily. Of three cases under observation, in which cancerous deposit began in the body or fundus of the uterus instead of the neck, two were in patients be- yond the climacteric period, one being sixty-four years of age and the other fifty-seven when the symptoms first attracted their attention. The other patient was forty-three. In this last patient, simultane- ously with the evidence of deposit in the body of the uterus, signs of it appeared in the bladder, vagina, and clitoris, the duodenum, and in the pyloric orifice of the stomach. I always look for a more rapid degeneration of the tissues invaded by cancer in comparatively young patients. 574 CANCEE OF THE UTERUS. Synijotoms. Discharges, pain, and fetor are the symptoms that usually attract our attention in cases of cancer of the uterus. When a patient com- plains of any of these, however, the case is generally an advanced one. Pain, perhaps, is the symptom first experienced, and is caused earlier than any other. Unfortunately, pain is so common to women — they suffer so often in the regions of the uterus and hips — that this symptom is not heeded by them until some other symptom makes its appearance. The pain is not generally intense nor troublesome until after the disease is recognized. Nor is it peculiar. It is described as lancinating, darting, twinging, — and very correctly, too, — but there is often no pain of this kind during the whole course of uterine cancer. The discharges in cancer are of three kinds, and the mixture of them in different proportions. They are: 1st, blood; 2d, limpid serum ; 3d, sloughs, generally minute. The first two are not offen- sive to the smell when pure or mixed together, as they often are, and they only become so by being mingled with the last, by dissolving or holding in suspension or being merely mixed with greater or less pieces of dead tissue. In the earlier stages of cancer blood or serum may be, and generally is, effused, while the latter is reserved to the open or ulcerated stage. In this open or ulcerated stage all three kinds of discharges are almost always mixed together. In women who are still menstruating, the discharge first experienced is of blood. There is, at first, an increase in the amount of menstrual discharge ; a little later, and blood is lost between the times of menstruation. The blood thus lost is derived from the same source as the menstrual blood, — the vessels of the mucous membrane of the corpus uteri. Later, when hemorrhage is so constant and attended with fetor, it is effused from eroded vessels upon the ulcerated surface. The blood in the former case is produced as the result of constant turgescence ; in the latter, on account of the disintegration of tissue. Limpid, unoffensive serum is almost always observed in the cases of old women, after the menstrual period of life has passed, and gener- ally coming from the os uteri, which may be for a long time un- changed, indicating that it comes from some distance up in the organ. In fact, if the same serum was effused from the surface of the vaginal portion of the cervix it would most likely be mixed with blood, be- cause the parts producing it would not be sufficiently protected to insure the integrity of such frail tissue. In two remarkable instances the copious discharge of this limpid serum was, for many months, the only sign of disease presented by the patients. One of my patients, sixty-one years old, had been under the necessity of wearing napkins for six or more months before calling my attention to her condition. SYMPTOMS. 575 The discharge was so copious when I saw her for the first time that I collected about two drachms from the speculum in ten minutes. When examined it was found to resemble distilled water in appear- ance, it was so clear and colorless. There was no smell nor other offensive quality to it. When examined b}^ the microscoj)e no solid substances were found, except a very few natural epithelial scales. In a very gradual manner this transparent liquid became colored with blood. It was sometimes clear and sometimes bloody for several months before becoming fetid, and only for a few weeks before the patient died was it constantly bloody and fetid. The cervix uteri in this case was not attacked at all, and the mouth and lips of the neck were natural. The body of the uterus, as high as the fundus, was enlarged more than double its natural size, indurated, and nodulated ; and, when examined after death, the walls presented the peculiar friable hardness of medullary cancer, but there was no excrescence in the cavity, as I had expected to find. Whether the. discharge is blood or serum at first, or a mixture of both, it is generally odorless ; but after a time it becomes fetid, and remains so persistently. The fetor appears, from the testimony of most observers, to be peculiar ; but I have not been able to distinguish it from the smell of putrilage of other jDroductions. When all these symptoms unite they form a case almost unmistakable. Lancinating pain, sero-sanguineous discharge, and peculiar fetor, continuing per- sistently, are almost distinctive of cancer. I cannot lay much stress on either one of these symptoms ; but of the three the most importance should be attached to the fetor. Per- sisting for weeks it should cause us to suspect a cancer. Contempo- raneous with the complete estabUshment of these symptoms we have constitutional suffering. It is not often, I think, that general suffer- ing precedes the local symptoms of cancer, and it has always seemed to me to follow as the effect of local disease. It has not been my lot to meet with the broken-down constitution sometimes said to be gen- erated by the cancerous diathesis. Cancerous antemia, causing the straw-colored translucency of the skin, considered characteristic of the malignant cachexia, is not distinguishable from the hemorrhagic anaemia occurring sometimes in persons of the same age, produced by the drain upon the blood. In the fully-developed condition of carcinoma the constitution suffers, and the collection of symptoms are such as arise from the embarrassment and failure of the functions in a long struggle with pain, loss of blood, anxiety, and inaction. Debilit}^, with indigestion, palpitation, restlessness, neuralgia, constipation at first, colliquative diarrhoea and aphthae toward the end, nightsweats, wandering of mind, unsteadiness of purpose, succeeded by delirium and apathy ; in fact, all the train of symptoms which precede dissolution when it ap- 676 CANCER OF THE UTERUS. proaches through protracted struggles, in which pain and exhausting discharges are the destroying agencies. Causes. But little can be said as to the causes of cancer of the uterus. The general opinion that it is hereditary in most cases is, doubtless, true; and yet a great many instances occur that cannot be traced to such a cause. This is no reason why they may not be hereditary, because sometimes the circumstances which permit the hereditary taint to show itself do not exist for a number of generations. And again, the taint may be so dilute as to require very favorable circumstances or co-operating causes to bring it out. If a mother dies of cancer at the age of forty-five, and impart the same morbid tendency to her daugh- ters, the laws of cell-development would bring it about at the same a,ge in the child. If, therefore, the daughter dies a year too soon of some other disease, the taint is inoperative, though present. Two or three gen- erations of cancer-bearing persons cut off by other diseases lose the his- tory of its inheritance. Or if a mother be the subject of cancer at the end of a life of active, nay, excessive, child-bearing, while her daugh- ter leads a life of celibacy, or has but a single child, the physiological life of the two is so different that we would naturally expect some modi- fication of consecutive cell-development to result. So that, although the hereditary taint is the same in the two, their pathological ages may differ, and the daughter may not have cancer until a later period, and die before that time arrives. We should, I think, allow much for influences that may modify hereditary taints, and only regard them as hereditary tendencies, to be brought out in mother and daughter under similar circumstances, and which may be postponed or pro- duced earlier in the one or the other by certain conditions. Married women are affected more frequently than the single, and the fruitful than the barren. When we consider how many more married than single women there are in civilized communities, and how few married women are sterile, we ought not to attach much importance to these facts. A much more significant fact is that a very large majority occur during the menstrual years of a woman's life. It is true that there may be nothing more than a mere coinci- dence in this fact, and that, after all, the hereditary mutations in the system during these years may bring about cancerous deposit, inde- pendently of any connection with the menstrual function. But it certainly is a coincidence, if not an etiological coincidence. As to the connection of cancer with chronic inflammation and ulceration of the uterus, much has been and may be said. I cannot lay my hand on statistics upon this subject, but I have never observed the coinci- dence of inflammation and cancer, or that cancer was a consequence of inflammation. If, however, they are occasionally connected, there DIAGNOSIS. 577 are but few at the present day who believe cancer to be the result of long-continued inflammation. Diagnosis. It would seem that the diagnosis of a disease so marked as cancer would be an easy matter, and so it is when all or even most of the peculiarities of the disease have been fully developed ; but in the very beginning there may be much obscurity. A patient complaining of nothing more than a perfectly clear, inodorous, watery discharge, seemingly in the enjoyment of good health, would hardly be regarded as a victim to one of the most surely fatal and loathsome diseases incident to the human race ; and yet it is almost invariably so when the patient is advanced beyond the epoch allotted to menstruation. The cancerous disease, as it usually occurs, advances beyond the period of doubtful symptoms in a very short time, and in the majority of cases our attendance is not requested until a scrutinizing examina- tion will enable us to decide very positively on the nature of the case. Our attention will be attracted by the unusual amount and character of discharge, pain, and smell. The following characteristics of beginning carcinoma are given by Stratz : * 1. The diseased portion has a definite and well-defined contour, and nowhere merges gradually into the healthy tissue. 2. There is always a perceptible difference in the diseased portion as a whole, and the healthy. 3. The carcinomatous tissue always has a yellowish tinge of color. 4. The malignant spots show small, hard, yellowish-white elevations, at least in places. It is not necessary to insist on the importance of an emiy diagnosis, since it is only in the early stages that we may hope to effect a per- manent cure. Summary of appearance in cases from Becquerel : " Cancerous Deposit. Cervix hard, unequal; nodulated, os not always open, sometimes wrinkled or fur- rowed. Cancer of the neck often implicates the vagina. Hereditary influence is often traceable. Touch is painless. Discharge sometimes absent, in certain cases very abundant, and consisting, for the most part, of albuminous serum. Menstruation increased, being neither more nor less painful, and passing often into the state of real hemorrhage. * Zeitsch. f. Geb. und Gyn., 1886, vol. xiii., No. 1. 37 578 CANCER OF THE UTERUS. Absence of special anaemia when the vagina and body of the uterus are involved. Cancerous cachexia. Progress continuous and without cessation. The pain in cancer is very sharp, intense, and lancinating, and not influenced by locomotion or movements of any kind." " Ulcerated State. Developed at the critical period of life generally. Preceded and accompanied by hemorrhages. Severe, sharp, lancinating pain. Development essentially in sharp irregularities and nodosities. Adhesions to other organs soon as ulceration is formed ; immobility of the uterus. The surface only slightly soft; subjacent tissue scirrhous. Ulceration deep, unequal, essentially irregular, with thick, elevated, and hard edges. Always granulations. Discharges extremely abundant, consisting of purulent and often sanguineous serum ; nauseous and often fetid odor. Great hemorrhage from time to time, not necessarily at menstrual period." " Cancerous Ulceration. Developed upon an hypertrophied and scirrhous surface. Ulceration, deep, vast, unequal, grayish surface with thick edges, and easily bleeding. Ulcerated surface hard, presenting numerous lobes and tubercles, with nodosities and great hardness. Often great loss of substance. Cervix and corpus uteri immovable on account of adhesions. Discharges sanious, fetid, sanguinolent, and of an insupportable and characteristic odor. Cancerous cachexia always present." Prognosis. The prognosis of cancer is a gloomy one. Indeed, there is no dis- ease which so uniformly terminates fatally as cancer of the uterus. Notwithstanding this fact forces itself upon our observation, there will sometimes, in the course of a large experience, occur a recovery from it spontaneously and unexpectedly. I need not enter into the dis- cussion of the causes of this fatality. Whether the disease is essen- tially a blood-disease, or whether primarily local, there are but few instances in which it is not multilocular. It exists from the begin- ning, or very soon afterwards, in more than one place. Yet again, this is not invariably the case. We very seldom meet with an in- stance in which the area of deposit is small and confined to one locality. If this locality is accessible, the case possibly is curable. I say possibly, because the pathology is treacherous. This gloomy pic- ture is in part relieved by the greatly improved palliative means we TREATMENT. 579 now possess. Very much may be clone to allay the agonizing state of body and mind under its ravages. Treatment. Both medicinal and surgical means fail to give the profession much satisfaction in the treatment of cancer of the uterus. When the disease is clearly confined to the cervical portion of the organ, amputation of that portion holds out a very faint hope of cure. It is so common for the cells constituting the main bulk of the deposit to be scattered far beyond the apparent margin of the disease, that much more frequently than otherwise an abundant crop of them is left behind to continue the work of destruction. Very rare instances of cure are reported. While, then, it is our duty to give our patient even a remote chance for recovery, we cannot hold out much hope of radical cure by re- moving the cervix. The same is true in reference to the operation for extirpating the entire uterus. The immediate danger attending the removal of the cervix need scarcely enter into our calculation of the benefits that may arise from it. This cannot be said, however, of the operation for exsecting the whole uterus. The dangers in this operation are mani- fold, while the immunity from a return can be counted upon in only a small proportion of cases. Nevertheless, the recent improvement in the statistics of vaginal hysterectomy, together with the possibility of an earlier diagnosis than formerly, are giving surgeons great encour- agement. I do not think the operation can be sustained by success until the immediate dangers are very much diminished. (For these operations see Epithelioma.) Can we reasonably hope for a cure of cancer by medicine? I think this question can be unqualifiedly answered in the negative. I fully believe that the rapidity of growth may sometimes be re- tarded, and possibly stayed for a length of time. Many medicines have enjoyed the reputation of curing cancer, and have been used with implicit faith, but I may safely say that not one does at the present time. I need not stop to inquire how such reputation could have been acquired, except to say that until within a comparatively recent date other and curable diseases were mistaken for cancer. Quite lately we have been assured of the great powers of cundurango in this direction, and for a time there were very slight reasons to hope that it was a useful if not a curative means in the treatment of cancer. It has enjoyed a place in the category of cures for cancer for a shorter time than many others. Within a few months a beam of light has fallen upon the subject 580 CAlSrCER OF THE UTERUS. which has again awakened the hope that possibly we are on the eve of finding a medicine capable of influencing this destructive cell- growth. Professor John Clay,* obstetric surgeon to the Queen's Hospital, Birmingham, has had some very fortunate experience with Chian turpentine in uterine cancer. The statement, coming from one whose professional character, so far as I know, cannot be impeached, and published in the staid old journal, the London Lancet^ must command general attention. Considering our experience in the cure of cancer the results obtained by him seem marvellous, and for fear of marring the face of his report I abstain from making my own summary, but will quote his case in full, together with some of his remarks. "A woman came to the hospital as an out-patient, aged fifty-two. She was sufier- ing from scirrhous cancer of the cervix and body of the uterus. Hemorrhage was excessive, pain of the back and abdomen agonizing, and cancerous cachexia well marked. The patient evidently had not a long time to live. The uterus was so ex- tensively destroyed by the cancerous ulceration that its cavity readily admitted three fingers. In such a case it appeared to be justifiable to attempt to relieve the suffer- ings of the patient, even if the remedy should produce unfavorable symptoms, or should prove of no avail. I therefore prescribed Chian turpentine, six grains; flowers of sulphur, four grains; to be made into two pills, to be taken every four hours. No opiates were prescribed or lotion used. No change was to be made in her diet or occupation. On the fourth day after taking the medicine the patient reported herself greatly relieved from pain, and was in better spirits, but she complained of a large amount of discharge. It was feared that she referred to a discharge of a sanguineous nature. On examination, however, the vagina was found to be filled with a dirty- white secretion, so tenacious as to be capable of being pulled out rope-like, and this although she had syringed herself three hours previously. The os was quite con- tracted and would now scarcely admit the finger, and the surrounding swelling or can- cerous infiltration of the cervix was much reduced. On the twelfth day the thick tenacious secretion had almost disappeared, and was succeeded by a somewhat copious serous fluid. The os was not so firmly contracted, but would only admit the finger. The patient's general health was improved and the medicine well tolerated. Sixth week: I ordered her a quinine mixture in conjunction with the turpentine, but sick- ness supervened, which ceased on omitting the quinine. Twelfth week : My notes are, — the parts feel ragged and uneven, and do not bleed on roughly touching them. The speculum shows several cicatricial spots. The turpentine has been taken regu- larly during the day for twelve weeks every four hours, during which time she has been almost free from pain and has had no hemorrhage; no glandular enlargement; general health improved. Walks easily to the hospital, being about a mile distant. As the patient did not come again to the hospital her address was obtained, and it was ascertained that she had left her residence. Being a widow she could not afford to keep her home, and she went to reside with her married daughter in a northern town, but left no address. The case showed that the medicine was one of great power in cancer of the uterus, and it is to be regretted that an opportunity was not offered for fully carrying out the treatment. " Another patient, aged thirty-one, suffering from cancer of the os and cervix uteri, * London Lancet, June number, 1880. TEEATMENT. 58] was treated concurrently with the one just mentioned. These parts were enlarged from carcinoma to the size of a hen's egg. The os was dilated, and the cavity of the cervix was filled with epithelial growths, which bled freely on examination. Sacral pain was very severe, and hemorrhage had been continuous for the previous six weeks. The Chian turpentine and sulphur were given as in the previous case. The patient again attended at the hospital on the seventh day after taking the medicine. She was in excellent spirits, and expressed her gratitude for the relief afforded her. The medi- cine entirely relieved her pain. She had increased white discharge. On examina- tion the OS and cervix were found to be nearly of the normal size. The os was patu- lous, and its surface was studded with flabby shot-like eminences, which did not bleed on roughly rubbing them. I said to her: 'You are better; you must continue the medicine.' She answered : ' I should think I must, for I could not do without the pills; they have eased me so very much.' She continued to improve, and on the fourth week she expressed herself as quite well. I impressed upon her the necessity of continuing the medicine, and told her to see me occasionally. She did not come to the hospital again for four months, when she brought another patient to consult me, believing that she was suffering from cancer. I reproved her for leaving off attend- ance at the hospital. She answered that she thought it unnecessary, as she had con- tinued quite well. On this visit she submitted to an examination. The os was rough and irregular, but was of nearly the normal size ; no signs of cancerous infiltration ; the periods were regular, and not profuse, and were unattended with pain ; there was slight leucorrhcea. This case was a most remarkable one. The turpentine acted upon the growth with great vigor, literally melting it away in the brief period of four or five weeks. " The third case was one of epithelial cancer of the os, cervix, and the body of the uterus, in a woman, aged fifty-two years. The vagina was not involved. The mass was larger than a cricket-ball, almost filling the vagina. The border of the os was three-quarters of an inch in thickness, forming a ring of two and a half inches in diameter, through which protruded an epithelial growth, pi-incipally proceeding from the anterior wall of the uterus, and projecting about two and a half inches into the vagina. The case was sent to the hospital for my opinion by my son, Mr. Langsford Clay, who had attended the patient but a short time. The journey to the hospital fatigued her very much, and she declared that she could not come again, and that she did not wish to remain as an in-patient, believing that she could not live many days. She had repeated hemorrhages, had much pain, and had the cancerous cachexia well pronounced. My son volunteered to attend her at home, and I agreed to see her occasionally with him. I thought it advisable, as an experiment, to vary the treat- ment somewhat, and ordered to be added to the pills one-sixth of a grain of the ammo- niated copper, as from the large mass to be acted upon I thought that an astringent should be superadded to the turpentine. The dirty-white, tenacious discharge, appeared and continued for the first five weeks, but there was no hemorrhage after the first examination. The swollen os uteri and the cervix beyond were the first to show signs of diminution ; this was noted on the fourteenth day. The tumor, however, was rough and shrunken, and did not project so much. Sixth week: The surface of the tumor was at the level of the os uteri, and seemed to consist of a mass of bloodvessels, which bled moderately after examination. This condition occasioned me some surprise, as three weeks previously the patient was ordered a lotion made with perchloride of iron, with a view to arrest hemorrhage, since from her anaemic condition it was feared that the loss of a moderate amount of blood would be followed by serious consequences. I asked her what kind of a syringe she used with the lotion. She replied, ' I thought the lotion was merely to bathe the external parts.' This, as it happened, was very satisfactory information, as it showed that the lotion had no share in the reduction of 582 CANCER OF THE UTERUS. tlie mass, which now was scarcely half the original size. She was supplied with a syringe for the purpose of applying the lotion, and after using it three days the mass of vessels had considerably shrunken, and no longer bled on manipulation ; but the surface of the growth had the touch and appearance of a gangrenous mass, but there was scarcely any fetor. The patient now complained of gastrodynia, with colicky pains in the bowels, but she had no diarrhoea or vomiting. 1 believed this to be due to the copper, and it was consequently discontinued. It also appeared to me that the turpentine might not be efficiently digested in the solid form, and that it would be better if the remedy were administered in a state of minute subdivision, as in the form of an emulsion. An ethereal solution of Chian turpentine was prepared by dissolving one ounce of the turpentine in two ounces of pure sulphuric ether (anaesthetic). The ether dissolved the turpentine instantly. This solution was given to our skilful dis- penser, Mr. Whinfield, with a request that he would prepare a pleasant mixture or emulsion from it ; and, after a few trials, he prepared one which is not unpleasant to take, according to the following formula : Solution of Chian turpentine, half an ounce ; solution of tragacanth, four ounces ; syrup, one ounce ; flowers of sulphur, forty grains ; water to sixteen ounces ; one ounce tliree times daily. This form of mixture was given to the patient, and was much liked. She has now taken the turpentine for thirteen weeks uninterruptedly. The os uteri is a little more than one inch in diame- ter, and feels like a ring of cartilage about a quarter of an inch in thickness. The tumor has nearly disappeared, and the finger can be introduced posteriorly into the uterus for more than an inch. The general health has much improved, and she is quite free from pain and looks cheerful, and is becoming stouter. No sedative what- ever has been given during the treatment. Fourteenth week: She complained of severe ' cramp-like pains' in the back and lower part of the abdomen, which she attributed to the mixture, and in consequence it was discontinued for a few days, and an opiate given, by which she was greatly relieved. The turpentine was again resumed. Nineteenth week : She is now fairly convalescent. The growth has almost disappeared, and the parts beyond the os uteri are somewhat hypertrophied, yet are almost normal to the touch. "The fourth case was that of a patient aged thirty-two years, who came to the hos- pital after having been discharged as incurable from the Women's Hospital. She was greatly depressed, and was most desirous to be cured, for the sake of her family of young children. She has had repeated floodings, and suffered greatly from pain dur- ing the past five months. Constipation very troublesome, which probably arose from the opiates she had been in the habit of taking. On examination, she was found to be suffering from epithelial cancer of the os and cervix uteri, but not involving the vagina. There was a cancerous mass of the posterior parts of the os and cervix, of the size of a goose-egg. This growth pushed the os uteri towards the pubis, almost preventing that part from being felt. The turpentine mixture was given her three times daily, and from this period a very rapid diminution of the growth took place, so that by the sixteenth day it had almost entirely disappeared. The os uteri was now in situ, admit- ting the finger readily, and there was the same condition of the vessels as that observed in the preceding case. The lotion with the perchloride of iron was used daily for a few days with excellent effect. In the ninth week the patient suffered from spasmodic pains in the back and abdomen, and as this was attributed to the medicine, it was dis- continued, and iodide of calcium, in five-grain doses, three times daily, was administered. This was taken for about a fortnight, but, not feeling so well, the patient was admitted into the hospital. The condition of the internal organs was now much the same as before the iodide of calcium was given, but there was some thickening about the cervix, which was fixed to the vagina. The rectum was excessively loaded, and required several days to effectually relieve iti The Chian turpentine was administered simply ; TREATMENT. 583 but a lotion was prescribed, containing six grains of white arsenic to one pint of water, to be used daily. Under this treatment the woman very rapidly improved, the pains entirely ceased, and the parts became much reduced in size, and more movable. The patient was now anxious to leave the hospital for her home, as she felt quite well ; but it was deemed advisable to send her to the Sanatorium instead. She is very active, cheerful, and happy, and may be pronounced convalescent. " Other cases are under treatment, both in the hospital and privately, all showing similar effects. The remedy is now being tried in cancer of other organs, and ap- parently with good results. One of the most interesting, perhaps, is a case of scirrhus of the breast, which has been under observation for some weeks. Among the other cases are cancer of the vulva, stomach and abdomen, in which very remarkable benefit has been already produced. " From the results obtained by the use of Chian turpentine, it may be confidently said that the remedy does exert a powerful action on cancer of the female generative organs in particular, and it will be of advantage to point out some of the conclusions at which I have arrived respecting the efficacy of the drug, and the manner in which it should be employed. The oil of turpentine, if it produces any effect on cancer, is inadmissible on account of the speedy production of its specific effects even when administered in small doses. The same remark applies with less force to the Venice and Strasbourg turpentines ; in my hands they have not produced the same beneficial effects on cancerous growths as the Chian turpentine has done. The maximum dose of the last-named drug which can be safely and continuously given is twenty-five grains daily. It is advisable to discontinue the remedy for a few days after ten or twelve weeks' constant administration, and then to resume it as before. The combina- tion with sulphur was given at first, and has been continued. It is doubtful whether much benefit is derived from the combination, but the effects have been so uniformly good with it, that it was thought advisable to continue its use. There is every reason to believe, from the trials made with otiier substances in combination with the turpen- tine, such as carbonate of lime, iodide of calcium, ammoniated copper, quinine, ber- berine, hydrastin, etc., that the turpentine is best administered simply, as the most marked and rapid effects have always been manifested when it has been given alone. " The turpentine appears to act upon the periphery of the growth with great vigor, causing the speedy disappearance of what is usually termed the cancerous infiltration, and thereby arresting the further development of the tumor. It produces equally efficient results on the whole mass, seemingly destroying its vitality, but more slowly. It appears to dissolve all the cancer cells, leaving the vessels to become subsequently atrophied, and the firmer structures to gradually gain a comparatively normal con- dition. " It is a most efficient anodyne, causing an entire cessation of pain in a few days, and far more effectually than any sedative that I have ever given. In the cases I have described no sedative was employed in any instance, although in some cases where great pain had existed previously to commencing the treatment, large doses had been given. Whether this arrest of pain arises from the death of the tumor, or, as my son suggests, is due to there being no longer irritation of the sentient nerves (in conse- quence of tension being withdrawn by the removal of the cells), the fact is the same. "If, after the use of the remedy for some weeks, one of these cases were examined by a stranger for the first time, he would probably conclude that it was one of com- mencing malignant disease, by reason of the irregularities of its surface. The effect of the remedy being first to remove the cellular structures, any loss of tissue produced by the invasion of the disease cannot be restored, and hence the irregular touch and appearance even after cicatrization. The arrest of the hemorrhagic discharge and the remarkable freedom from glandular affections, after a lengthened use of the turpentine 584 CAJS'CEE OF THE UTERUS. are especially important fectors in materially aiding the removal of the cachexia, and of improving the general condition of the patient. " Without being in position to affirm that the Chian turpentine is a positive cure for advanced cancer of the female generative organs, yet, however, the facts here adduced may be interpreted in this respect, two circumstances are indisputable — one, that all the patients after several months' treatment are living, and that the disease has not advanced as is usually the case, but has retrogressed — in fact, has all but disap- peared ; and it may at least be safely asserted that when the remedy is steadily used for some time it arrests the progress of the disease, and relieves the pain incidental to the morbid growth in a manner which cannot be said of any other remedy. It is probable that on an extended experience of its use and by variations of the mode of administration, it may prove an effectual cure for this intractable disorder. Patience and perseverance on the part of the patient and medical adviser are absolutely required. We know that in some diseases, as bronchocele and syphilis, a long continuance of well-known remedies is often necessary to effect a cure of the particular disorder, and that the administration of the remedies has to be varied from time to time, according to the therapeutic effects produced by the drugs. In cancer, as far as experience has at present indicated, the same alternating method may perhaps have to be employed. Whatever may be the ultimate results there can be no doubt that Chian turpentine in these disorders is a most valuable medicine. Judging by my experience it is no figura- tive expression to say that it acts as a direct poison upon the growth, probably causing its ultimate death. In advanced cancer the process of reparation is slow, but if the surrounding structures are not too much involved in the process of destruction, it will seem that a cure may be reasonably expected. It is not that the remedy has failed against the cancer, but that the vital organs are so much destroyed that their complete reconstruction and adjustment of functions are not possible, and life fails in conse- quence of their mutilated condition. Even under these circumstances, if the cancer does not recur, the efficacy of the medicine is obvious. In the early stages of cancer it may be affirmed that an undoubted cure may take place speedily, and as the con- tiguous structures are not extensively involved, but little deformity ensues ; and experi- ence justifies the expectation that under such circumstances a recurrence of the disease will not follow. " The history of the local treatment of cancer of the uterus is one of singular interest, and is highly instructive to the practical physician. The contrast between the general and local treatment is the more notable, as nothing can be more injurious to the welfare of the patient than an attempt to destroy the cancer by external agencies. The disease is not to be averted by this means, as the symptoms assume a more intense and threat- ening character, until the patient rapidly sinks. It may be observed that the internal treatment here recommended when used for a considerable period is borne by the patient with remarkable tolerance. As I have mentioned, in some of my experiments I de- termined, in order most thoroughly to test the medicine, to reply upon this alone. Recently the arsenical lotion has been superadded, and with no injurious consequences — it appears to act as a disinfectant, and it may produce some benefit by promoting the cicatrization of the tissues. Several suggestions offer themselves for inquiry as to aid- ing locally the detachment of the growth, after its vitality has been destroyed ; but this is not of much importance, as there seems to be no fear of the blood becoming affected by the absorption of the decaying tissues, the turpentine probably preventing any such calamitous occurrence. " If the practice now described should prove by future experience to be justified, then it will be incumbent upon the medical adviser to treat cancer of the generative organs at an early stage of its development, and it is reasonable to conclude that this dreaded and most fatal disease will no longer be the scourge it has hitherto proved, PALLIATION. 585 and that another benefit will have been conferred upon suffering humanity by the resources of therapeutic art." Professor Clay has recently publislied several cases in which he claims a cure by the use of this remedy. Palliation. There comes a time in the progress of cancer of the uterus that the patient is prostrated by the septic effects, caused by absorption of gan- grenous products at the surface of the degenerating mass. When this is the case we may often relieve the patient more by removing all the dead and dying tissue with a sharp curette and thermo-cautery than in any other way. To do this the vagina should be dilated with Sims's or Simon's speculum until the parts are thoroughly exposed. Then with the sharp curette we should gouge out and remove in detail all the diseased substance down to the solid tissue of the cervix, and then cauterize the whole surface with the thermo-cautery. In this way, for a time, we get rid of the hemorrhage, the fetid discharge, and often the distressing pain. After this the patient's general health will almost always be greatly improved, and she will have a happy respite from her terrible suffering. ' This operation may be repeated once or oftener, as the conditions seem to justify. One who has never tried this method of relieving the patient would very naturally be deterred from resorting to it by fear that the hem- orrhage would be dangerously profuse. A trial, however, will prove to him that this apprehension is groundless. If the curetting part of the operation is done briskly there will not generally be much hemorrhage, and the benefits resulting from it will far exceed the ill effects of the loss thus incurred. I mention this as the first and most important palliative measure to which we can resort, as the comfort of the patient will be promoted to a greater extent than by a resort to any other. Palliation of the pain, smell, and debility, is the object of the most of our treatment. For pain we use local remedies, introduced into the vagina. Opium, belladonna, cicuta, hyoscyamus, and Indian hemp, may all be used locally. The best form for their application, is that of a bolus of five grains of pul. opii. We may instruct the patient to introduce the finely powdered opium through a small glass tube, with a piston of whalebone and cotton. It is applied thus to the ulcerated part and to the walls of the vagina in the neighborhood, and very effectually acts as an anodyne. Ten grains of the extract of hyoscy- amus may be used as a bolus, or two grains of ext. belladonna j and 586 CAXCEE, OF THE UTERUS. SO on with all the anodynes. A grain of morphia may be mixed with the ext. hyoscyam. to great advantage. Medicated injections often soothe the diseased part very much also. The watery extract of opium may be thrown into the vagina by a small syringe, and allowed to remain, the patient lying on her back for a length of time. Hydrocyanic acid in solution, gtt. xx to a pint of water, passed through the vagina, has a very pleasant effect some- times. Injections of vapors of the anaesthetics are highly recom- mended, particularly by Professor Simpson. Carbonic acid gas and chloroform are those most used. The chloroform vapor may be passed through the vagina by the ordinary perpetual syringe, made by the Union Rubber Company. The chloroform should be placed in the bottom of a large bottle, while the receiving-tube of the syringe may be passed through the cork and made air-tight with wax. The other end, being inserted in the vagina, high enough to almost come in contact with the disease, the pumping may be commenced. The vapor will be caused to rise in the bottle quite rapidly under the exhausting influence of the syringe. Care should be taken not to let the tube deep enough in the bottle to come in contact with the chloroform, lest this fluid, in- stead of its vapor, pass through the instrument. The vapor thus de- livered into the vagina causes a sense of heat and glow, which very soon seems to replace the pain. When properly done, patients expe- rience great relief from this gaseous injection. The same apparatus will do to convey carbonic acid gas to the parts. The gas is gener- ated by mixing in the bottle carb. soda and tart, acid, and then pour- ing a little water upon it. Although I have never yet tried the effect of great cold to the part, I have no doubt it would be very effective in relieving the pain. It should be applied through the speculum directly to the parts diseased, and no other. A small amount of the freezing mixture, of two parts pounded ice and one part common salt, in a small muslin bag, is the means used by Professor Simpson, It is thought this cold not only relieves the pain, but that it retards the advance of the disease somewhat. The contact should be con- tinued until the parts assume a pale, bloodless appearance, when this is practicable, and may be used twice or three times in twenty-four hours. With the local remedies for pain may be mentioned the sub- cutaneous injection of morphia over the sacrum, or in the iliac region. All local remedies for pain will, after awhile, fall short of the relief demanded by our suffering patients, and we will be under the neces- sity of introducing them into the system in a more effective manner. We must resort to their internal use. I need not mention the ano- dynes to which we would resort in such cases ; they are well known to the profession. I would, however, caution the student not to use opium when any of the others will answer the purpose. Indian PALLIATION. 587 hemp will be found to do this more frequently than any of the others. They will all fail, eventually, and opium will prove the great blessing in such cases. And let me add the further caution : to commence with as small doses as will -answer the purpose ; and while we deal liberally enough with the drug to get its good effects, increase it slowly as possible, for with all our precautions in this respect we will be under the necessity of giving it enormously. The anaesthetics are too evanescent to be relied upon for main remedies, but they will render the influence of opium more prompt, and perhaps lasting. The hemorrhage of cancer will sometimes require prompt inter- ference. I think, however, that, although the bleeding is always ultimately exhausting, it is seldom immediately dangerous from its copiousness. I have generally, when the hemorrhage required in- terference, depended upon the introduction of small pieces of ice fre- quently repeated. It is often very grateful to the patient as well as hsemostatic. Dr. Simpson recommended powdered tannin introduced through the speculum and placed on the part ; but he places more dependence on a paste made of perchloride of iron and glycerin. If the bleeding should be very alarming, notwithstanding these means, the tampon would be our last resort. The ofiFensive odor emanating from the disease makes it very de- sirable to have some means of correcting it. I should remark, with reference to the plans often resorted to, that they are more or less in- jurious to the patient and attendant, viz., the burning of sugar, myrrh, etc., in the room. This should be done very sparingly. For the air, chloride of lime, and good ventilation will do better than all other expedients. We do not wish to make a stronger smell less offensive, to be sure, but we desire to remove the effluvia. Burnt sugar simply fills the room with various other less offensive gases, while we breathe with them the original cause of the trouble. Chlorine, disengaged from the chloride of lime, probably destroys the material floating in the air that offends the sense of smell. But the emanation may be lessened by the use of carbolized water as a wash and injection. Fre- quent changes of the linen and bedding of the patient are matters of cleanliness that, of course, will readily suggest themselves. Septicaemia is the condition which most commonly causes the greatest suffering and hurries the patient towards a fatal issue. Any palliative measure, therefore, which enables us to stay or modify its course, will prove a source of great relief. The absorption of the liquid products of the necrosed and sloughing tissue eliminated from the surface of the ulcer is the cause of the septic fever ; hence a most important item in the palliative treatment of cancer is to keep the surface of the ulcer as free from dead and fungous substance as pos- sible. This may and ought to be done by removing it with the sharp curette as often as necessary. When we operate for the re- 588 CANCER OF THE UTEEUS. moval of the necrosed substance and fungus, the parts should be well exposed by Sims's or Simon's retractor speculum, the vagina thor- FlG. 274. Fig. 275. il i II 111 Sharp Curette. Simon's Curette. OUghly washed out, and then freely sponged with the tincture of iron. This will enable us to see the line of demarcation bet\Yeen the sound PALLIATION. 589 and dead tissue. Then with Simon's spoon every portion of the rotten substance should be freely removed. During the operation frequent washing away of the blood will be necessary, that we may see what we are doing. When the ulceration is extensive, and making its way toward the bladder or posterior peritoneal cul-de-sac, it will require care to avoid opening one of these cavities. Although I have done this palliative operation a great many times, I have not seen an excessive loss of blood or any other serious con- sequence follow it. It is always better, however, to be prepared with means by which to check the bleeding, and probably the best is the ■ thermo-cautery. If this, or some other form of cautery, cannot be commended, and hemorrhage is sufficient to require an haemostatic, a tampon of cotton, saturated with a solution of the persulphate of iron, may be advantageously used. It is surprising how much relief this little operation generally affords. The patient w^ill often be so much improved as to indulge in the hope that she is recovering from her loathsome disease. In a greater or less time, however, the symptoms will return, and may be again relieved by the operation. When a case is advancing slowly, this process of cleansing the ulcer may be profitably and safely resorted to a number of times. We ought not to try to remove any of the tissue beneath the ulcerated surface, but confine the operation to the scraping away of the necrosed substance. This same operation is applicable to cases in which there are frequent hemorrhagic discharges. It generally checks, and some- times permanently, losses of this kind, especially if followed by the use of the actual cautery or the thermo-cautery. The history of can- cer discloses many disappointments in so called cures of this terrible malady. The more recent discoveries of this kind are jaborandi and the Chian turpentine. The former temporarily tempted the credence of the more sanguine of the profession, but after repeated trials has been condemned as utterly worthless. The Chian turpentine, which, on account of the great respectability of its early advocate, seemed to hold out a faint hope that we were on the threshold of a valuable discovery, has been found wanting also. That the progress of cancerous deposit will ever be arrested by medi- cine is a problem for the future. That true cancer of the uterus can be cured by any kind of surgical operation is yet to be proven. Can- cerous deposit in the uterus, if not the result of blood disease, is a focus from which widespread contamination emanates in every direc- tion, to an extent that surgery cannot reach. Such is the melancholy paucity of our resources in cancer of the uterus. Scarce as they are, however, they may afford the sufferer great comfort; and we should fall short of our duty if we did not in- dustriously employ them, as the best the profession can afford. CHAPTEK XXXVL EPITHELIOMA, CANCROID, EPITHELIAL CANCER OF THE UTERUS. All these terms, with many others, are applied to a fungoid devel- opment in and upon the mucous membrane of the uterus. It is essentially an excessive and modified proliferation of the epithelial cells, which destroys the. membrane upon which it grows, and sloivly penetrates adjoining structures. Its development is not by interstitial deposit, as in other varieties of cancer, but consists of superficial accumulations and soft deposits of epithelial cells, held together by very dehcate connective tissue. Fig. 276. [Epithelioma of Uterus. The shape of the deposit, or growth, varies. In some instances it is thinly spread over a large surface, while in others it grows out as a fungus from a restricted area. In the former instance the whole mucous membrane of the cavity of the uterus may be overlaid and permeated by it. from the external orifice to the fundus, and thus be converted into a flat, frialde covering of the deeper structure; while in the latter there may be fungi, of greater or less size, projecting EPITHELIOMA CANCROID. 591 from the mucous membrane of the uterine cavity ; but much more frequently they spring from one of the cervical labia, or the whole cervical circle. The substance of the membrane thus diseased is generally hyper- trophied, but not otherwise very much changed in character, until the disease has made great progress on the membrane itself. When the disease is situated in the endometrium, the body of the uterus may be enlarged for a long time, and not be attached to the other organs. When the growth occupies the external membrane of one of the cer- vical labia the submucous structure is sometimes increased so that it Fig. 277. Epithelioma of the Cervix. may project into the vagina much beyond its ordinary extent. This will give the appearance of a large fungus, while it is really the hyper- trophied lip covered with cancroid deposit. At other times the labium is not so much enlarged, while the fungus projects down sufficiently to partially or wholly fill the vagina. In all of these varieties, after a time, the more superficial parts of the growth undergo a process of necrosis and slough off. The parti- cles thus sphacelated, together with sanguineous and mucous fluids, constitute the discharges from epitheliomatous surfaces. Disintegration of this sort is generally accompanied with further 592 EPITHELIAL CANCER OF THE UTERUS. growth, so that the size of the deposit is not materially, if at all, diminished. Fig. 278. Fungus Growing from the Cervix. When the process of disintegration has fairly begun, the disease becomes developed, and gradually the role of septic symptoms super- venes, and carcinomatous dyscrasia is established. Diagnosis. The symptoms of epithelioma are the same as in other forms of can- cer. They have already been described, and I need not reproduce them here. We may differentiate epithelioma from other forms of cancer by examination with the finger and sound. In epithelioma there is an absence of the irregular hardness caused by the submucous deposit, by the presence of a soft, friable projection into the vagina, or DIAGNOSIS — PEOGNOSIS. 593 the same kind of substance occupying the whole of the cervix, not indurated, but somewhat enlarged. When this substance exists in the mouth of the uterus, we may ascertain how far it extends by passing the sound through it into the cavity. The resistance to the instrument will be slight, yet sufficient to impart that feeling of resistance caused by its passage through a yielding tissue. If the deposit is confined to the cervix the slight opposition to the advance Fig. 279. structure of Epithelioma. — From Cornil and Ranvier. of the instrument will cease before it reaches the uterine cavity. If it extends to the fundus the resistance will continue the whole depth of the organ. I can imagine, although I have not met with such a case, that a polypus in a gangrenous condition might embarrass us somewhat in making a diagnosis. The use of the microscope would clear up the difficulty in such a case. A very small piece pinched off from the mass will suffice for examination. In the disintegrated substance of the polypus we find the debris of fibrous tissue, while the cells of epithelioma would be found in the malignant growth. If a sarcoma- tous polypus should occupy the vagina the microscopic test would be equally decisive. From a decaying placenta, arrested in the os uteri, we may distin- guish the epithelioma by means of the microscope, in case any doubt should arise. Prognosis. The prognosis is not so hopeless as in the other varieties of cancer of the uterus, as it is usually localized. In the earlier stages at least it is occasionally amenable to treatment. Without treatment it is 38 694 EPITHELIAL CANCER OF THE UTERUS. equally fatal, as the morbid process is progressive to an unlimited extent. Treatment. The treatment of epithelioma of the uterus, as just intimated, is much more promising than the other cancerous affections. The curative treatment consists in removing the whole of the diseased tissue, and when this is practicable we may reasonably indulge a hope of success. Fig. 280. Dr. Paquelin's Thermo-cautery. This can generally be done when the morbid deposit is confined to the vaginal portion of the cervix, and sometimes when it extends to the fundus of the uterus. The means we possess by which this may be ac- complished are the knife, the scissors, the sharp curette, ecraseur, — wire or chain, — the galvano-cautery, and the thermo-cautery, or the actual cautery. I have performed the operation for removing epithelioma by all these different instruments separately, and by using several of them in the same operation. Dr. John Byrne, of Brooklyn, in a very interesting article pub- lished in the second volume of the Transactions of the American Gynecological Society, advocates the exclusive use of the galvano- cautery. He gives a number of cases illustrated by his method of operating, and of the success following it. The results are very encouraging, and at the time his plan was published it was regarded as TREATMENT. 595 most promising. He exposed the cervix by his speculum, and ampu- tated it with his cautery knife, heated by the battery to a temperature that made it assume a dull red color; or, surrounding the cervix, or that portion to be removed by the platinum wire, and then applying the battery so as to heat it to the same temperature. In doing the operation according to the latter method the cervix is fixed by the vulsellum, and, if movable, drawn down to a convenient distance Fig. 281. Fig. 282. Byrne's Cautery Battery, Byrne's Cautery Ecraseur. from the vulva, and the wire, while cold, placed around the cervix as high as possible not to include the utero-vaginal junction. In this position the wire is tightened while cold, and then heated. Before heating the wire the constriction should be increased slowly until the wire has fairly imbedded itself into the included tissue. Quite forcible traction, exerted by the vulsellum, should be main- tained while the wire is slowly passing through the substance of the neck. This will cause the central portion of the amputated cervix to be divided higher than the periphery, and the cavity will be conoid in shape with the apex in the centre. If the disease is not all 596 EPITHELIAL CANCEE OF THE UTERUS. removed by this operation the cautery knife may be applied, as dif- ferent parts are drawn down by hooks, until the operator is assured that all the disease is removed, or that the operation is carried as far as the integrity of the bladder and peritoneal cavity will allow. The prominent dangers in performing this operation are hemor- rhage, wounding the peritoneal cavity, and oi3ening the bladder. The first may be avoided by having the temperature of the wire low. If it is white hot it will cut the tissues, including the arteries, without closing the latter. But if of a dull red heat it will coagulate the albumen in the areolar tissue, and the blood in the arteries, some dis- FlG. 283. U ^ Byrne's Cautery Electrodes. tance from the wire. In this way the vessels will be sealed and primary hemorrhage avoided. To avoid wounding the bladder or peritoneum, I am in the habit of applying the wire with the cervix in its normal position, and making traction after the wire has been drawn tight enough to fix it firmly in its bed. If we are careful to apply the wire in this way, there is not much danger of accident. When the disease does not extend to the junction between the vagina and uterus, this is an admirable method of removing the cervix. The objections I make to the galvano-cautery are, that it requires more skill in the management of the battery than most practitioners possess ; that the burnt surface is so changed we are unable to judge whether TREATMENT. 597 at the point of separation all of the disease has been removed or not; that it is cumbersome as a portable instrument, and that it is no better in any resiDect and not so manageable as the thermo-cautery, I think also that the great heat generated in the vagina is not without objection. The advantages are that it destroys the cell growth some distance above the surface of the amputated stump, and the opera- tion is entirely bloodless. I have not employed it in my recent opera- tions. In removing the cervix for epithelioma, it will be very convenient, however, to have the galvano-cautery, or the thermo-cautery, as one of the instruments, but if we intend to thoroughly remove the disease, and especially if it extends above the vagino-uterine junction, I think we can remove it more safely with the scissors or knife, or both. If there is much of a tumor projecting into the vagina, I generally apply the ecraseur around it, and include, if possible, the whole of the vaginal neck within its grasp. I use the chain instead of the wire in the ecraseur because I find it much easier to manage. We should be very careful in the adjustment of the chain to avoid injuring the bladder or penetrating the peritoneal cavity. In thi^ part of the operation the galvano-cautery may be used in place of the ecraseur. If we use the ordinary ecraseur, there is no need of dilating the vagina with any sort of speculum ; but if we use the hot wire, then the vagina should be well dilated by Sims's speculum, Simon's retractor, or Bryne's speculum. After as much as possible of the vaginal cervix has been removed in this way, the most important part of the operation is just begun, because, in most cases we will not be sure of having removed all the diseased tissue. The surface from which the neck has been thus removed should be examined thoroughly. We can do this best by seizing it with the vulsellum or single hooks and drawing it down as low as possible, where it can be thoroughly examined. It will also insure precision to examine the portion arpputated from the cervix to ascertain whether any of the diseased tissue was cut through, or whether the cut surface is all sound or not. If we can assure ourselves in this way that the disease is all removed we have little else to do than secure our patient from hemorrhage. In my own operations I have had no trouble with any of the arteries divided. They usually spirt pretty freely for a few minutes, and then gradually cease bleeding. I do not make this statement to encourage carelessness as to hemorrhage, because, in exceptional instances the hemorrhage is dangerously profuse. Hence, as a precaution against hemorrhage, and for the purpose of destroying the cell growth deeply, we should apply the cautery at a dull red heat all over the amputated surface and be suj^plied with peroxide of iron tampons. If we find by the examination of both amputated surfaces that we have not removed all of the disease, or if we have any doubt upon the subject, we should 598 EPITHELIAL CANCER OF THE UTERUS. seize point after point of the remaining portion of the uterus and cut it off with the scissors, and thus excavate the supra-vaginal cervix and body of the uterus as high as practicable, or until we are satisfied that all the disease is removed. By the frequent examinations as we pro- ceed in this part of the operation, while the whole is held down, we can keep within the peritoneal covering of the uterus. In opera- ting in this way, we should often introduce the sound to determine the direction and depth of the uterine cavity above the excavation. The sound will serve as an excellent guide to our progress. If the vagina is roomy enough, we may sometimes have the sound held there most of the time. After we have excavated to the desired extent, we should char the surface of the artificial cavity with the thermo-cautery. Dr. H. C. P. Wilson, of Baltimore, has invented an ingenious shield, with which the cautery is surrounded, to prevent the heat from affect- ing the parts anywhere except at the point of contact. Wilson's shield is a very useful addition to Paquelin's thermo-cautery. This operation should be repeated as soon as evidence of the return of the disease is apparent. Often when the cavity of the uterus has been curetted free from the epithelial deposit, that organ contracts, and, to some extent, obliterates the cavity formed by the excavation, and the area of the disease becomes less each time. In such cases we may repeat the operation with more prospect of removing the whole of the disease than in the first ; and even the third or fourth opera- tion may thus advantageously be performed. Recent experience leads me to attach much importance to the very free use of the solution of the pernitrate of mercury. Small pellets of absorbent cotton satu- rated with that fluid are placed in contact with the scraped surface, supported by larger pieces of dry cotton. These large pieces we use in such position and in such quantities as to completely protect the sound parts, by absorbing the free acid. I am encouraged in this recommendation by the fact that epithelial cancer may occupy the mucous membrane for a long time without vitiating the substructure deeply. I prefer this before any other medicine, because it is absorbed and acts as a local alterative upon the lymphatics and the juices surround- ing the parts. Formidable as this operation really is, I have not seen it followed by untoward symptoms of any kind. In many cases I have excavated the uterus entirely above the internal os until the walls became very thin in every direction, and many others to a less extent. Opening the peritoneal cavity and bladder is one of the dangers in the progress of this operation. This can be avoided by care. Hemorrhage is probably the only other danger, and with Paquelin's thermo-cautery, or the galvano-cautery, at hand we can easily check it by touching the bleeding artery. TREATMENT. 599 The operation may be followed by dangerous shock, primary or secondary hemorrhage, metro-peritonitis, cellulitis, or septicaemia. For the treatment of all these conditions, except hemorrhage, the reader is referred to ovariotomy. Injections of carbolized water, sufficient to keep the vagina well cleansed, is all that will be found necessary to secure the patient from blood-poisoning. Ordinarily the cavity is filled up in two or three weeks, and the wounded cervix covered with a firm cicatrix. In some instances, however, the process of malignant degeneration goes on, and we are restricted to palliative measures for the rest of the patient's life. The operation of Dr. W. H. Baker, of Boston, is thus summarized by him in the eighth volume of the American Gynecological Society Trans- actions. After drawing down and fixing the cervix he disects out the supra-vaginal portion anteriorly to the level of the internal os, sepa- rating it from the bladder with scissors aided by the forefinger then proceeding posteriorly working in the same manner in the cellular tissue up to the same level. The posterior and anterior incisions are then to be united by lateral incisions which prepares the cervix for complete removal. " Having done this I cut away the cervix by means of the uterotome (or scissors) removing a cone-shaped portion from the body of the uterus. It thus becomes possible to remove from one-third to one-half of the body of the uterus without cutting into the peritoneal cavity or opening the bladder. At this point," he he says, " I applied the thermal cautery to the stump at a red heat. Applied at a red heat I think we are able to destroy the structure be- neath quite effectually. After a thorough application of the cautery the patient is put to bed and left undisturbed. We have controlled the hemorrhage, and within the space of two weeks the slough comes away and we have a clean granulating surface left." Dr. Baker cites six cases that have remained cured for five or six years. I have operated this way fifteen times, and can count five cures of from four to six years' standing. Koeberle, in the Nouv. Arch, d' Ohst. et de Gynecologic for J 886, ex- presses himself strongly against total extirpation of the uterus for cancer, saying the necessity of it is exceedingly rare. In reading his article one would think that he scarcely if at all believed in the pro- priety of total extirpation of the uterus for cancer. He says cancer of the uterus usually begins in the cervix and extends to the vagina and adjoining parts before it reaches above the level of the internal OS. Primary cancer of the body of the uterus does not often occur, and when it exists the cervix is not invaded for a long time. Just so long as the diseases in the cervix remains localized, and does not extend to the vagina, broad ligaments or the lymphatic glands which communicate with the lymphatic vessels of the uterus, so long is the 600 EPITHELIAL CANCER OF THE UTERUS. body of that organ sound, and it is absolutely useless to remove it. On the other hand, in case of primary carcinoma of the body of the uterus or of epitheliomic fungosities, etc., of the mucous membrane, the cervix being sound, it is useless to remove it. Total extirpation of the uterus, whether by laparotomy or through the vagina, being admittedly more difficult and more dangerous than the removal of either the cervix or body, hysterectomy should be re- served for those special cases where partial hysterotomy will not suffice for the removal of the entire disease. Abdominal hysterotomy — for the removal of the uterus — is applicable to those very rare cases in which the disease commences in and is confined to the body of that organ, while vaginal hysterotomy is the resort in those more fre- quent instances where the disease has commenced in and is limited to the cervical portion of the uterus. He has performed extirpation of the cervix nine times. In two the cancer returned, and in one time enough had not elapsed to decide whether it would return or not. He mentions one case of epithelioma of the uterine cavity in which he removed the uterus by abdominal section in 1875 with no recurrence to date. In 1882 he performed successively vaginal extirpation of the cervix and abdominal extirpa- tion of the body of the uterus. The patient recovered from the two operations, and has not had a return of the cancer. Koeberle's opera- tion for cancer of the cervix is essentially the same as that of Dr. Baker above described. After some observations with the more powerful caustics of potash and zinc, I would caution the inexperienced against the introduction into the vagina of agents so destructive and difficult to limit. Their action may and is likely to extend beyond desirable bounds. There can be no question as to the choice between them and the actual cautery in some form. The operator can see and control the effects of the cautery, and thus limit it to the desired extent, which cannot be said of these powerful caustics. The less severe forms of caustic, such as the solution of the pernitrate of mercury may serve an excel- lent purpose without much danger of too destructive effects. I have twice operated by removing epitbeliomatous fungus that pervaded the whole mucous lining of the uterine cavity, in which there has been no return of the disease after four years. With a sharp curette I thoroughly and carefully removed the whole of the diseased material (after having inverted the uterus in one case), and then filled up the cavity with cotton saturated with the solution of the pernitrate of mercury. One of the patients was fifty-five years of age and the other forty-three. In three other cases operated on this way the disease returned ; one within three months, one in about twelve months, and in the other the disease did not seem to be arrested. In using the solution the cotton should be divided into small pellets TREATMENT. 601 about the size of a Lima bean, saturated with mercury and afterward the free fluid pressed out between the smooth surfaces of two pine boards and dried. When we are ready to use them they should be secured by strong cotton threads so they may be easily removed. After the scraped cavity is filled with these pieces of cotton, a large tampon of surgical cotton should be passed up to the cervix and the vagina be- neath it filled with cotton tampons saturated with glycerin. The j)ernitrate does not destroy the tissues to which it is applied very deeply, but I believe it destroys the vitality of the morbid cells much beyond its boundary as a caustic. The pernitrate dressing may be allowed to remain about twenty- four hours, when everything should be removed and the parts kept clean by warm water douches twice a da.j. If extirpation of the uterus is justifiable in any form of malignant disease it is so in epitheliorha, for that disease is often entirely local- ized in the uterus, and yet occasionally so situated that we cannot remove the whole of it by any other operation. The formidable operation proposed by Freund, and practiced by him and his followers, has not been followed by a success that would encourage me to perform it under any circumstances. We may rea- sonably hope, "however, that some method of exsecting the uterus which will be less difficult of performance and less dangerous in its results may be some day invented. Indeed, a long stride in that direc- tion has already been made, and is illustrated by an oj)eration recently performed by L. C. Lane, M.D., professor of Surgery in the Medical College of the Pacific. Dr. Lane terms his operation pervaginal enu- cleation of the uterus. That term alone would mislead the reader,, for the uterus was not enucleated ; it was extirpated, and the opera- tion might very properly be called colpo-hysterectomy, or vaginal ex- tirpation of the uterus. The operation is very simple, and does not involve the necessity of extreme and protracted exposure and handling of the abdominal organs. The wounding of tissue is less extensive, and the whole operation is done in the lowest and least susceptible portion of the peritoneal cavity. After placing the patient on her side, in Sims's position, and dilating the vagina with Sims's speculum. Dr. Lane had the uterus drawn down with Pean's tenaculum forceps, and then made an incision through the posterior wall of the vagina. "The fundus was then seized by the forceps and the uterus made to revolve on its transverse axis, so that the Fallopian tubes and ovaries were brought down low in the pelvic excavation in such manner that the base of the tubes and accompanying arteries became accessible and easily ligated. " Ligation was done with a strong silken cord so passed throughi. button-holes (?) in the broad ligaments that they could not afterward slip off. This portion of the opera- 602 EPITHELIAL CANCER OF THE UTERUS. tion was completed in fifteen minutes, but the detachment of the organ from the blad- der was long and tedious, but finally successfully done without opening that viscus. Yet so thin was the remaining vesical walls that the lustre of the catheter, which served as a guide, at times could be seen. The organ being removed the pelvic ex- cavation was rinsed out with a one per cent, solution of carbolic acid, a Ndlaton flexi- ble catheter was placed in the bladder, the pelvic excavation was filled with lint, saturated with four per cent, carbolized linseed oil, and the abdomen covered with india-rubber ice-bags. A drainage-tube was so fixed alongside the carbolized lint as to allow the escape of any fluids which should be passed out from the wounded surface. "The convalescence was uninterrupted." The description of the operation is very imperfect, yet I think it will not be difficult for the reader to follow it understandingly. The steps of the operation are : 1. The dilatation of the vagina by Sims's speculum. I believe Simon's position and retractors would be better. 2. Fixing and traction of the uterus downward. 3. Incision of the posterior vaginal wall, which should be in the central line and extend from the cervix to the recto-vaginal attachment. 4. Bringing the fundus uteri down through the vaginal opening by vulsellum forceps. 5. Ligating the posterior border of the broad ligament near the cervix uteri, so as to include the Fallopian tubes, ovarian ligaments, and accompanying arteries. 6. Separation of the anterior surface of the uterus from the bladder. The first two steps of the operation need no further description than is given in the quotation. In the third step of the operation a fold in the centre of the posterior wall of the vagina should be drawn forward by the tenaculum, and incised with scissors. The incision should be perpendicular with, instead of across, the vagina, and large enough to admit the finger, by which we should be guided in com- pleting the opening from the cervix to the attachment with the rectum. What we are to avoid in making this incision is the wounding of a loop of intestine or projection of omentum, which may occupy the posterior cul-de-sac, and, while dividing low enough, not to wound the rectum. The fourth will be facilitated by traction on the cervix, which will bring the fundus downward and forward within reach of the finger, and then permit the uterus to be retroverted within reach of the forceps. Drawing the fundus forward, up well toward the pubis, will so twist and condense the posterior portion of the broad ligament as to make the fifth step easy of accomplishment. With the posterior border of the broad ligament thus brought forward we can easily pass the needle containing the ligature from the vagina backward, or from behind forward, and secure the arteries with great facility. Without some caution another danger is that of including the ureters in the ligatures. The ureters approach the neck of the uterus TEEATMENT. 603 in passing to the bladder, and at the anterior part of the cervix are within less than three lines. The ligature, therefore, should not be more than one-quarter of an inch from the cervix. The most difficult part of the operation is the separation of the uterus from the bladder. The fibrous coat of the bladder, where it is attached to the uterus, is very thin, and great care is required in sep- arating it from the uterus not to open the bladder. The direction given by Freund should be remembered. He recommends making an incision across the anterior surface of the uterus, through the peri- toneum and connective tissue. Then by means of the finger or handle of the scalpel, strip the bladder off from the uterus. When the point of vaginal attachment to the uterus is reached it may be carefully sepa- rated with the knife or scissors. The separation of the neck from the vaginal attachment and the side will be easy after the bladder is iso- lated. It seems to me that the operation of Dr. Lane would have had a better conclusion if he had closed the wound either with silk or wire sutures. The most of the large opening ought certainly to be closed in this way, and if the operation is performed under carbolized spray it would be better thus to unite the whole of it. Czerny* the reviver of vaginal hysterectomy operates similarly, ex- cept that he begins by incising the vaginal wall around the cervix, and separates the bladder from the uterus before opening the sacro- uterine pouch. The fundus is then turned back and brought out through the opening, the peritoneum then opened at the anterior uterine wall, the broad ligament ligated and the uterus cut out between them. Olshausen removes the uterus without retroverting it. He draws down the cervix, cuts through the vaginal wall all around it, and sepa- rates the bladder and rectum from the uterus with the finger. The bleeding is then completely checked, the cervix drawn down until the broad ligaments are felt to be put upon the stretch, the j)eritoneum punctured with scissors, and the opening enlarged with the fingers. An elastic ligature is then passed over the left broad ligament by means of a hook, shaped like an aneurism needle, the ligature tied, and the broad ligament severed between it and the uterus. The same is then done on the right side. Leopold (with three deaths in forty-two cases) operates similarly but ligates the broad ligament in sections, beginning below and includ- ing the peritoneal coats. Peter Mueller made the operation easier by cutting the uterus in two halves by a median longitudinal incision with blunt pointed scissors or knife. The bleeding may be controlled by compressing * Lehrbuch d. Frauenkrankheiten. F. Winckel. 604 EPITHELIAL, CANCER OF THE UTERUS. the uterine halves, while the broad ligaments are carefully tied in sec- tions. Fritsch, whose statistics are unusually favorable, incises first the lateral vaginal fornices and separates the uterus above the uterine artery. After checking all hemorrhage he unites the lateral incisions by transverse ones in front and behind, ties a rubber ligature tightly around the cervix in the incision, loosens the bladder from the uterus, and after drawing the cervix well downward and backward, pulls the fundus forward and out through the vesico-uterine opening. The broad ligament is ligated from above downward. Winckel* recommends, as a farther improvement, the cutting out of the uterus in a spiral manner. He begins his incision in the anterior vaginal fornix, carries it around the cervix and deepens it gradually as he goes around and around. Each vessel is tied as it is cut, and the uterus is pulled down as it becomes loosened. The peri- toneum is easily opened, both before and behind, when thus reached, and the broad ligaments can then be seen and tied in portions. When the tubes and ovaries can be readily drawn down they should also be removed, as they may contain germs of the disease. The vaginal edges when not closed by sutures are merely drawn together and supported by a vaginal tampon of iodoform gauze (ten per cent.). The tampon may be left in place for six or eight days, but the vulval dressings must be changed frequently on account of the sero-sanguineous discharge that occurs on the first days after the operations. Antiseptic vaginal douches are used after the tampons are removed. Pean and his followers use hemostatic forceps instead of ligatures for the control of the hemorrhage. After opening the abdominal cavity the fundus is brought down and out of the posterior or anterior opening (as may be the easier) the whole ligament clamped in a single long pair of forceps and severed between the forceps and the uterus. If one paix is not large enough, or fails to prevent bleeding, one or two more may be applied. If the fundus cannot be brought down suffi- ciently a pair may be applied to the base of each broad ligament, the cervix cut loose as high as the instrument reaches, and the fundus then turned down and the remainder of the ligaments clamped from above. Curved forceps are sometimes used for the latter purpose, for they do not require the fundus to be so completely turned out. Bleed- ing vaginal edges may also be clamped by forceps. At the end of forty-eight hours the forceps are all removed, and the antiseptic tam- pons in two or three days afterwards. After this the vagina is gently irrigated two or three times a day and antiseptic dressings applied to the vulva and vaginal entrance. * Op. cit. TREATMENT. 605 This method seems to be a decided improvement upon the others, since it enables us to operate naore quickly and therefore with less shock and less danger to the patient, and also with less danger of hemorrhage. Hemorrhage and shock are the chief immediate dan- gers, sepsis and inflammation the principal remote ones. Occasionally it may be better to use both ligatures and the hemostatic forceps ; the former for the cut vaginal edges and small bleeding surfaces, the latter for the main parts of the broad ligaments and such extensive bleeding surfaces as can be gathered into the jaws of one pair. Should we desire to amputate the body from the cervix this method of bringing the uterus out of the peritoneal cavity would give us an excellent opportunity with the minimum risk. Redner explains how the favorable results in ovariotomy led also to the removal of myoma and carcinoma of the uterus by laparotomy, and then how more recently the unfavorable results of the method of operating advocated by Freund led to a neglect of laparotomy. This change was favored also by the fact that the large number of cancers springing from the cervix uteri could only be removed imperfectly and with difficulty by this method, hence we have drifted back to the older practice of attacking the organ through the vagina. Redner himself operated several years ago in twenty-eight cases of carcinoma uteri through the vaginal wall, with almost invariable success (only three deaths, two by infection, one by hemorrhage), by supravaginal excision of the cervix. And once having gone so far it was but a step to remove the whole uterus through the vagina. The prognosis is not only considered good by Schroeder* because the mortality figure is so small, but also because the convalescence is so rapid and easy, for in the cases cited only two showed slight fever, and two others mild symptoms of collapse. As to the indications for such operative measures, Schroeder advises against interference when the cellular tissue of the pelvis is already invaded by cancer, which must be determined by careful palpation. He further calls attention to the fact that the larger the diseased uterus the greater will be the difficulties by this method, and the more appropriate will Freund's procedure become, and, at the same time, that in cases of cancer of the cervix situated low down we should be more conservative in either enucleation or supravaginal incision ; yet after all, notwithstanding all of the advantages of the new procedure, the former methods would still retain their merits, according as they might be selected in particular cases. * Paper read by Schroeder (Berlin) on "Total Extirpation of the Uterus per Vaginam " in the gynecological section of the fifty-third Versaramlnng der deutsche Naturforscher und Aertze in Danzig, in September, 1880. Keported in the Archives fiir Gynacologie Sechszehnter Band, Drittes Heft. 606 EPITHELIAL CANCER OF THE UTERUS. In Martin's three cases he found such difficulty that in only one case was the operation complete. 2d case: Impossible to sever all adhesions ; portion of diseased tissue remained behind. 3d case : Same kind of difficulty ; conclusion that firm adhesions and brittleness or friability of the uterus contraindicate the operation. Interrogated by Meyerbeer, Schroeder says he closes the vaginal opening with curved needle and silk, but recommends ligation of ligaments by wire. Baum (of Danzig) says he formerly operated successfully by supra- vaginal incision seven times, without resulting fever, that in only two cases had he failed to find a return, but in the last few months had operated per vaginam four times, two of the cases resulting in death from shock and septic peritonitis. He oj)erated after Billroth's manner, and in one case removed the ovarian tubes, but applied no sutures in order to allow better drainage of the secretions. A drain- age-tube was introduced, through which, in case of fever, the parts were washed out. Schrceder favors sutures which do not render septicaemia more liable, and insure against protrusion of intestines. Baum prefers his method, and thinks protrusion of intestine can be prevented by position. CHAPTER XXXVII. SARCOMA. Another variety of malignant disease of the uterus is sarcoma. It generally shows itself in the form of a tumor, developed at the expense of the fibrous structure of the uterus, an apparently isolated portion of which is infiltrated by an abundance of peculiar cells. While not encapsulated, like the fibrous tumors, these growths dis- place the surrounding tissue, and protrude in a submucous or sub- serous direction until they become, to a greater or less degree, pediculated. When first discovered and described these tumors were denominated recurrent fibroids, because ablation did not destroy them. Their recurrence is, doubtless, due to the fact that, while apparently isolated, the neighboring tissues are permeated by the sarcomatous cells. Instances of difluse sarcoma are also sometimes met with when all the tissues of the entire uterus are infiltrated. The cases of diffuse sarcoma with which I have met have all belonged to the small-celled variety, and the process of degeneration has spread from the uterus to the surrounding tissues, invading espe- 'cially the connective tissue of the broad ligament. Sarcoma is a less frequent disease than carcinoma or epithelioma. Symptoms. Its early clinical history is very similar to that of the fibrous tumor, and is more generally mistaken for it than any other growth. Serous leucorrhoea, metrorrhagia, and enlargement are the main ones. Its course, is usually rapid, less so, perhaps, than cancer, and more so than fibrous growths. In some cases it attains to a large size before any peculiar phenomena appear. After a time, especially if sub- miicous or polypoid, it begins to break down, the discharge becomes offensive and copious, and the disease proves fatal in much the same way as cancer. The general symptoms in the early periods of development are not marked, and they only become so after the tumor has grown large enough to interfere by pressure with the fecal and urinary excretions, or in breaking up furnish septic material in such quantities as to induce septicaemia, when all the disastrous symptoms of that formid- able fever are established. Thus diarrhoea, copious perspiration, ele- vated temperature, rapid pulse, failure of the assimilative functions, and great nervous prostration tend to a fatal issue with as much cer- tainty as any other of the malignant aff"ections. 608 SARCOMA. Diagnosis. In the commencement it is always difficult to arrive at a correct diagnosis. The symptoms are not characteristic, and until the com- mencing dissolution of the tumor are as much like those of fibrous tumor as they are like carcinoma, and when disintegration begins they thoroughly simulate cancer or epithelioma. The only sure diagnostic sign of sarcoma is afforded by the microscope. A portion of the tumor Fig. 284. Structure of Sarcoma. — From Cornil and Ranvier. should be submitted to microscopic examination, when the character- istic cell may at once be discovered (Fig. 284). Mr. Butlin* makes the following histologic distinction between sar- coma and carcinoma. He says : " I should then define carcinoma to be a tumor of epithelial origin, having generally an alveolar structure, and sarcoma a tumor of connective-tissue origin, formed gener- ally of embryonic tissues, and without alveolar structure. And, for the minor differ- ences, the cells of carcinoma generally resemble those of the epithelium from which it grows; there is little intercellular tissue ; the vessels run in the fibrous tissues, not among the cells ; and multiplications of cells is by endogenous formation. On the other hand, sarcoma is composed of round or fusiform or giant cells, and these are packed, in a more or less abundant basis ; the vessels are often mere fissures between the cells, and the cells increase in number by division. These minor characters are common, but they are not constant. One or otlier of them may be absent in a tumor of either class; or, worse, may be present in a tumor of the other class. More com- monly it is sarcoma, which simulates the appearance of carcinoma ; but, fortunately, this feigning takes place most often in textures where there can be no question of the origin, and therefore of the nature, of the tumor. The alveolar structure, found in some sarcomas, is rarely so perfect as that of most epithelial tumors ; indeed, careful study discovers that the tissue which surrounds the alveoli is generally formed of spin- dle cells. There is, in most cases, no real difficulty in assigning each tumor to its class." * Lectures on the Eelation of Sarcoma to Carcinoma, by Henry Trentham Butlin, F.R.C.S. American reprint. London Lancet, February, 188L PEOGNOSIS — TREATMENT. 609 Prognosis. The prognosis is no more favorable than that of cancer. While in many instances the tumor caused by the morbid growth seems to be quite isolated, the cells penetrate the surrounding tissue to such an extent as not to be eradicable. The contamination of the surrounding tissue does not seem to take place by absorption and transmission of the cells, or debris of the sarcomatous cells, but to be due to the insinuation of the cells into the contiguous substance surrounding the growth. It is, probably, always local in its origin and progress. This consideration, if true, would encourage us to hope that, by ablation of all the morbid sub- stance, we might arrive at a cure. Treatment. To be radical the treatment should consist of the entire removal of the growth. When the disease is confined to the uterus, I think the most rational treatment would be the removal of that organ. Hys- terectomy would seem to me to be more promising in sarcoma than in carcinoma. In addition to the general palliative treatment, detailed under the head of cancer, the removal of sloughing masses by the curette and scoop, we will often derive great benefit from the free administration of ergot. The contraction of the uterus, under the influence of ergot, will do more to clear out the softening mass from its cavity than any instrumental interference. I have in several instances removed the sarcomatous growth by ergot so thoroughly that the improvement of the patient's health led them to hope for ultimate recovery. When the growth is submucous, and of the most friable variety, I would fully expect it to be expelled b}'- ergot. It does not, however, affect the spread of the growth, and ultimate fatal result. 39 CHAPTER XXXVIII. TUMORS OF THE UTERUS. Any organized growth within the substance of the uterine walls, or depending from or connected with any of its surfaces, may be called a tumor. This definition will include polypi of all varieties and sizes, from the mere granule that renders the mucous surface irregular by its protrusion, to the growth which fills up the uterine cavity. Fibrous Tumors. Fibrous tumors of the uterus are homologous growths. They are not pure hypertrophies of certain parts of the uterine tissues. As proof of this the tumor-tissue exhibits too much of the rudimentary character of fibres of the undeveloped kind, and there is not a uni- form proportion of the different constituent elements. For instance, we find that some specimens are quite firm and resisting, while others are frail. In the firmer variety, the fibrous element is more abundant than the connective, and these ought to be denominated myomatous or muscular fibrous tumors, while the term fibroma would be better adapted to those tumors in which the fibres of the connective tissues preponderate, and the tumor is softer. The question very naturally arises : How do those tumors origi- nate? a question that cannot be satisfactorily answered. What we know about their " habits " I will lay before the reader. They occur more frequently in persons between the age of thirty-five and fifty, and are found oftener in women of African descent than in those of European or Asiatic origin. From much observation I am also per- suaded that the long continuance of great hypersemia of the uterus strongly predisposes patients to fibrous tumors. Hence, we find them connected with sterility, dysmenorrhoea and menorrhagia. I know that these conditions are often the results of fibrous degeneration, but I have had opportunity of watching many such morbid states of the uterus, which, while giving rise to other symptoms, were constantly attended with hypergemia. In some such cases after years of suffering tumors were developed. One remarkable instance is in a patient who has been under my eye for fifteen years. She is a maiden lady, now forty years of age. A few years after she commenced to menstruate, she became subject to hypersesthesia and hyperemia of the uterus. Although I saw her, and made examination of the uterus several times a year during these fifteen years, I discovered nothing which FIBEOUS TUMOES. 611 induced me to suspect fibrous growth until three years ago. Then I could easily make out a tumor, with two nuclei of development in the anterior wall of the uterus. When first noticed, the tumor was half as large as an orange. It grew to four times that size in the next twelve months. I have seen so many cases similar to this that I cannot be- lieve hyperemia and the development of the tumor to be a mere coin- cidence. We know that prolonged hypersemia is one of the necessary conditions of hypertrophy, and it is hardly possible to have hyper- trophy without hyperplasia. It would seem, indeed, to be the hyper- trophy of the vortices or foci of muscular gyrations in the undeveloped condition of the fibrous structure which leads to the formation of these tumors. All fibrous tumors of the uterus have their origin in the wall of the organ. Some arise immediately in contact with the mucous mem- FlG. 285. Origin of Fibroid Tumors. brane, then begin to intrude themselves into the cavity of the uterus as soon as they begin to grow, and become pediculated while yet small, D. Others commence their growth beneath a very thin layer of fibres, A. These are quite near the mucous membrane, but not in immediate contact with it. They very soon overcome the resistance of the thin layer of fibres, and pushing the mucous membrane before them, become pediculated later in their growth. If, however, they are deeper in the wall, but nearer the mucous than the serous surface, the larger part of their bulk encroaches gradually upon the interior of the uterus, forming broad tumors that fill the cavity. They can easily be recognized by the finger after dilating the cervical canal. 612 TUMOES OF THE UTERUS. All of these varieties are submucous tumors, but in common profes- sional language the first two are called polypi, while to the last the term submucous tumor is generally given. The term intramural is used to indicate the tumor that arises in the centre of the uterine wall, B ; a tumor which in its development displaces the surrounding tissues alike in every direction. In point of fact the exact central mural tumor is very rare, the great majority having their nidus ex- ternal or internal to the central layer. The subserous tumor varies in its relative distance from the peritoneal surface in the same manner as the submucous from the lining membrane of the uterus. Hence, some of them spring from the outer surface of the uterine wall, are suspended by a very slender pedicle, and covered only by the peri- toneum, E. Others are not so pendulous, but still are enveloped by only a very thin layer of fibres externally. If they are still more remote from the peritoneal surface, they merely show themselves as bulky protuberances on the outside of the uterus, c. One more state- ment with reference to position. They are usually developed in the wall of the body, and comparatively seldom have their origin in the cervical portion of the uterus. This statement is true of every variety. Their Nature. A dissection of these tumors enables us to discover that they are surrounded in most instances by a well-marked capsule. It ought not to be called a cyst for it has not a separate organization, and it is formed by the tissues surrounding the tumor, being compressed as they- are displaced, until the inner surface of the cavity becomes smooth. At a number of points the capsule and surface of the growth are connected by frail fibrillse and vessels. The number and magnitude of these connecting fibres and vessels vary, but it is ex- ceedingly uncommon for vessels of considerable size to enter any of these tumors, and the vascular supply is proportionately small. From these facts the logical deductions, namely, that fibrous tumors of the uterus are of slow growth, of low vitality, and not usually reproduced from their capsule, are corroborated by observation. The source of their nutrition, or their vascular supply, is diffuse, coming through many small channels at various points in their periphery, and not, as in the ovarian tumors, from one great artery. Such a supply is the cause of a somewhat definite period of vitality. It is not capable of maintaining the growth to an indefinite degree, and a disturbance of its nutrition may easily occur. Thus, after they attain a certain magnitude, they are likely to stop growing, and in many instances they degenerate into a lower form of tissue, resembling cartilage, or even to descend still lower in the scale of vitality, and be partially changed into a cretaceous deposit. Again, their low vitality subjects NATUEE OF FIBROUS TUMORS. 613 them to the process of inflammation or eremacausis. Inflammation, resulting in gangrenous disintegration, is one of the accidents that sometimes brings about their discharge and cure. At other times it occasions the death of the patient during the complicated consequences thus arising. I have witnessed both of these terminations. The fibrous tumor of the uterus is frequently multiple. The jjosition occupied by the growth is accompanied by a number of important effects. When situated in the centre of the wall — intra- mural — it grows more rapidly than when in the subserous portion of the fibrous structure, but probably not so vigorously as when nearer the mucous membrane, or when it belongs to the submucous variety. In fact, it will generally be found that the nearer the peritoneum the nucleus of origin, the more slowly will the tumor increase in size. We also find that the intramural and submucous varieties cause the uterus to grow and become vascular with much greater certainty than the subserous. Indeed, we often find very large subserous tumor^ growing from a uterus of comparatively small dimensions. The tumor may be not less than ten times the size of the organ to the fun- dus of which it is attached. If a tumor of this size were developed in the centre of the wall of the body of the uterus, the depth of the cavity would be not less than six inches. While the uterus in such cases is more than ordinarily vascular, it is not so much so as it would have been if the tumor had belonged to the intramural variety. Of course -the polypus, or submucous tumor, develops the uterus with more uniformity than the intramural variety. The uterus, in the cavity of which there is a polypus, grows with nearl}^ the same symmetry as if pregnant. It logically follows from these facts that the submucous and intra- mural varieties are the most mischievous, as the more rapidly the uterus groAvs, the more certainly will it do mischief by pressure ; and the more vascular the uterus becomes, the more hemorrhage will occur. And we find from observation that these inferences are cor- rect. Again we find that developed in certain zones of the organ their behavior and effects are different. Fibrous tumors comparatively do not often originate in the cervical portion of the organ, and when they do their growth is not very rapid, nor do they cause the uterus to become very large. In the corj)oral zone they grow most rapidly, cause the uterus to enlarge faster, and do more mischief. Lastly, in the fundus their activity of growth is less rapid, and produce less morbid changes upon the organ. In examining uteri containing fibrous tumors, which have fallen under my observation, I have noticed that the character, as well as the degree of development, has varied quite considerably. The growth of the fibrous structure of the uterus is not exactly the 614 TUMOES OF THE UTERUS. same in character and degree as in pregnancy. The fibres are cer- tainly enlarged, and they become muscular, but in very few localities do they attain to the same perfection as in pregnancy. In the subserous variety they do not anywhere attain to the per- fection of pregnancy, and are usually quite rudimentary in their character. Nor do they possess much contractile power. In the in- tramural tumors the fibres surrounding the grow^th attain much greater dimensions, and acquire great power. Seldom, if ever, how- ever, do they assume all the qualities of the fibres in the gravid uterus at term. In these cases the fibres in the opposite wall do not keep pace with those surrounding the tumor. In the submucous variety the fibres external to the tumor in the same side in which they origi- nate are largel}^ developed, while those between the tumor and mu- cous membrane attain considerable length, but are attenuated, and lack strength. This is one reason why they are pushed into the cavity of the uterus. When the tumor is polypoid, and occupies the cavity of the uterus, especially if it comes from the body near the fundus, filling up and distending the cavity of the body in every direction, it causes great uniformity of development of the fibres. The fibres all around grow more as they do in the pregnant uterus, attain great power, and usually expel the growth into the vagina. Very nearly the same statements may be made in reference to the growth of the vascular system in the diff'erent varieties of tumors. The vessels are more enlarged on the side occupied by the tumor in the intramural and subserous than on the unoccupied side. They are more generally enlarged in the intrauterine polypus. It may be further stated that a single tumor grows more rapidly, causes greater vascularity in the uterus, and brings about greater hypertrophy of the fibres of the uterus than the multinuclear form. Indeed, were numerous points of growth to commence at the same time, although great bulk may be attained, the bulk consists in the morbid deposits more than in the growth of the physiological struc- ture of the uterus. This is so markedly the case that after a certain time this kind of tumor stops growing for the want of vascular sup- ply, and becomes transformed into a dense tissue of a vitality far below that in the single tumor. It sometimes becomes a true fibroid degen- eration of the whole uterus, in which it would be hard to trace any of the anatomical elements peculiar to that organ. Sym'pto'ms. From this exposition of the growth and effects of tumors upon the surrounding structures, it will be readily inferred that the symptoms observed in connection wath fibrous tumors of the uterus are not SYMPTOMS. » 615 the same, and must vary greatly in the different varieties. The most frequent symptom is hemorrhage, either at the time of menstruation or during the intervals. In the early periods of the growth the pa- tient will observe profuseness in the menstrual flow, and some cases occur in which this is the only time when there is loss of blood, but in very many instances the losses take place at irregular intervals, and sometimes the discharge is so irregular that the patient will lose her knowledge of the time when she ought to be unwell. In quite a large proportion of cases there is no deviation from the ordinary habit of menstruation. The patient is regular. The variations of this hemorrhagic symptom conform, in general, to well-known conditions, and we may expect to find the hemorrhage more profuse the nearer the tumor is situated to the mucous mem- brane. In hemorrhagic cases we shall also find that the size of the tumor has much to do with the flow. The larger the tumor, other things being equal, the greater the hemorrhage. Large submucous tumors will, therefore, cause more profuse hemorrhage than any other sort. In estimating the value of the rule in the correspondence of these conditions, we must remember the frequent coexistence of small submucous with large subserous tumors, and that, as there are excep- tions to all rules, we may sometimes have profuse hemorrhage in sub- serous, and small losses in submucous tumors. The latter exception, however, is very rare. ' Leucorrhoea, consisting of thick, tenacious mucus, from the cer- vical cavity, is perhaps the next most frequent symptom, and it is generally governed by the same rules with respect to frequency and profuseness as metrorrhagia, being greater in quantity in submucous than subserous tumors. Watery discharges from the uterus are also a common and signifi- cant symptom. They occur more frequently just after, and appear to be supplemental to, the hemorrhages ; and I must observe with reference to them, also, that they are usually more profuse in sub- mucous tumors. It will be observed that all the discharges — hem- orrhagic, leucorrhoeal, and watery — show themselves under the same circumstances, and there is a very good reason for this, which I men- tion in passing. The cases in which the tumors are so situated as to greatly increase the vascularity of the uterus, are also the cases in which these discharges are more profuse. Dysmenorrhoea is not so commonly met with as the three symp- toms already mentioned. When it does occur it is of the obstructive variety. It is manifested by cramping pain recurring at intervals. We may account for its assuming this phase by the fact that the tumor encroaches upon the cavity of the uterus and renders it tortuous, and in some cases occludes it by forcibly pressing the sides together. The blood is accumulated above these obstructed places, and the pains 616 TFMOES OF THE UTEEUS. are caused by the efforts of the uterus to expel the blood thus im- prisoned. The subserous tumor is the only kind that may not occasionally cause dysmenorrhoea. It is probably more frequently present where there is a number of nuclei of development, some of them being sub- mucous. Among other symptoms, I wish particularly to call attention to that oi pressure. It begins very early in the progress of these growths, and is quite often noticed. The first evidence of pressure is suffering in the pelvis. When the tumor first becomes enlarged, the uterus presses upon the perineum, and this pressure causes a feeling of un- usual weight in that region. This " bearing-down sensation " may increase until, finally, the uterus and vagina may protrude through the vulva ; the womb may also fall backwards upon the rectum and produce tenesmus or other uneasiness in that organ ; and not unusu- ally hemorrhoids are thus developed with their attendant symptoms. Should anteversion occur, the bladder will suffer from the pressure in the various forms of dysuria, and even inflammation in that viscus. When the tumor is located in the posterior wall, the uterus is retro- verted ; when in the anterior, it is anteverted. When the organ is enlarged equally in all directions, it will be prolapsed. As it enlarges so as to fill up the pelvis, the pelvic veins are sometimes so pressed upon as to retard their circulation, and there may arise varicosity in the legs, anus, vulva, and surrounding parts. The nerves suffer from the pressure in such a way as often to manifest sciatica, and crural and vulvar neuralgia. When the tumor is large enough to rise out of the pelvis, it may cause pressure upon the abdominal viscera, and by its bulk, hardness, and irregular shape give rise to great inconvenience from distension of the abdominal cavity, producing more suffering than the same dis- tension from most other causes. Several important complications are likely to result from pressure, such as inflammation of the pelvic viscera, cystitis, rectitis, cellulitis, and local peritonitis. I need not stop to give the symptoms of these complications, as they are the same as when arising from other causes. The pelvic inflammation sometimes extends to the veins passing through the cavity, and gives rise to phlegmasia alba dolens. Abdominal inflammations also complicate these cases, some forms of peritonitis especially. A moderate peritoneal inflammation may result in serous effusion, and the ascites sometimes gives rise to more trouble than the tumor, being in some cases the immediate cause of the fatal result. The consideration of the effects caused by pressure exerted by these tumors leads me to the subject of their progress and development. It may be said of them, in a general way, that their growth is slow. DIAGNOSIS. 617 This is especially so as compared with most other growths. In very- many cases it requires years for them to attain a magnitude sufficient to endanger the patient's life. Indeed, some patients carry them through a long life without experiencing more than a slight incon- venience. Occasionally exceptional instances occur, however, in which the growth is rapid and very destructive. The conditions which promote their growth are now pretty well understood, especially the general proposition : that the more vascu- lar the uterus becomes from any cause the more rapid their growth. The converse of this statement becomes a necessary corollary. They grow rapidly during pregnancy. During the period of life in which the menstrual discharges occur in a normal way, the tumor grows more rapidly than after the menopause. The submucous in- crease in size with more rapidity than the subserous, and the tumor centrally located in the uterine wall generally requires for its devel- opment a period of time which may be regarded as a mean between the other two. The multiple ones advance more sloAvly than the single tumors. There is one circumstance which may add greatly to the vitality of any of these growths, and consequently cause them to grow with great energy. I allude to adhesions to the visceral or parietal peritoneum. When extensive adhesions occur, the vessel of the adherent surface penetrates the uterine tissue and greatly increases its vascularity. This is so remarkably the case in rare instances, that -the peritoneal surface of the tumor becomes reticulated with large vessels. The growths thus usually become very formidable. Occa- sionally, tumors that have grown so slowly as to seem stationery in this respect, suddenly start up, and their behavior is entirely changed. We see this in subserous tumors in a remarkable manner. It is hardly necessary for me to remind the reader that this change is generally preceded by inflammation, and that this is the cause of adhesions. When the tumors, as sometimes happens, undergo interstitial de- generation in such a manner as to cause cavities in their substance, they grow rapidly by an accumulation of fluid in these hollow spaces. This change constitutes a new variety, which is called fibro-cystic. They often become very large, grow very rapidly, and are mistaken for ovarian tumors. Some of our most expert specialists have been betrayed into their removal under this misapprehension, and have sometimes been made aware of their mistake only after a careful examination subsequent to their extirpation. Diagnosis. We learn, after much observation, that the history and symptoms, although very important items in the diagnosis, are not sufficient to establish it, hence we are obliged to resort to physical examination. 618 TUMOES OF THE UTERUS. Another observation may be made in this connection ; the greatest difficulties in forming a correct diagnosis will be experienced in tumors of each extreme in size. The medium-sized tumors may be diagnosed without much trouble. In cases of small-sized tumors we cannot always determine without much care whether the enlargement of the uterus is due to a tumor or some other cause. In such cases the depth of the uterus should be measured by the sound. While the sound is in the uterus, and that organ held in its normal posi- tion, the finger is to be passed as high as possible into the rectum, and the posterior wall thoroughly explored. If there is a tumor in that part it will be found thickened and nodulated. Should this not be the case a male catheter should be introduced into the bladder, and the anterior wall of the uterus carefully surveyed. If the symptoms are sufficiently grave to excite apprehensions, and yet leave an un- certainty, the finger may be passed into the bladder instead of the catheter ; otherwise it should not be used. To ascertain the existence of a small intrauterine or submucous growth the cervix should be dilated with sea-tangle, or compressed sponge-tent, until the finger can be passed into the cavity of the body, when there will be no difficulty in finding the tumor. None of these proceedings are justifiable, if there is tenderness or other signs of general inflammation of the uterus. It is more frequently the case that the tumor is evident, and then the object is to ascertain if it is uterine. To determine this question it is necessary to discover its attachments. This may be done placing one finger on the mouth of the uterus, and another in the rectum to move the tumor. If it is attached to the uterus they will move together. We should be careful, in making this kind of an examina- tion, to make the movements vary in direction, if possible, the tumor should be moved from the uterus, or upward, or downward. The tumor ought to carry the uterus with it when moved in any direc- tion. If the sound is passed into the uterus, and the tumor moved afterwards, the instrument, as may be seen, will very plainly indicate the movement of the organ. The cavity will also be increased in length. When a tumor is large enough to be felt above the pubis the attachment will be more easily made out by moving it with the hands pressed upon it from above, Avhile the sound is in the cavity, or the finger on the cervix. The second most important diagnostic indication is the firmness of the tumor. The fibrous tumor is usually hard and not elastic. An- other almost essential circumstance has just been alluded to, viz., the increased depth of the uterine cavity. The history of the case will generally enable us to decide, whether the tumor under examination is one caused by inflammation or not; the inflammatory tumor, more- over, is seldom movable. A htematocele is behind the uterus, is PROGNOSIS. 619 elastic, and has the shape of the cul-de-sac, instead of being glob- ular. When the tumor is large enough to fill up the abdominal cavity, and become immovable in consequence of its bulk, it is usually but not always elastic. If so, it has become fibro-cystic. We cannot always determine the relation of these tumors to the uterus by the methods I have described. Often we are unable to introduce a sound into the uterine cavity, in consequence of its tortuous direction, and the diagnosis becomes extremely difficult. These are the tumors, as I have before said, that have been mistaken for and removed as ovarian tumors. Probably the only positive way of clearing up the diagnosis, is to draw off some of the fluid with a trocar, or aspirator, and make its character the test. Dr. Washington L. Atlee, of Phila- delphia, in his admirable work on the Diagnosis of Ovarian Tumors, has furnished us with a description of the fluid derived from this kind of fibrous tumor, that is every way correct. The fluid does not run out of the canula of the trocar with the facility with which the ovarian fluid is evacuated, and often when it is received in a vessel, and becomes somewhat cool, it coagulates, and like blood separates into clot and serum. When examined by the microscope, debris of blood-corpuscles and fibrillffi of fibrin are the characteristic substances found. One other circumstance I have failed to call attention to is, that fluctuation observed upon percussion is less decided than in oTarian tumors. If the tumor is large enough to distend the abdo- men, it may be complicated with peritoneal dropsy. This condition also renders the diagnosis obscure. Tapping will generally enable us to arrive at correct conclusions. After the ascitic fluid has been re- moved, an examination of the tumor will enable us to establish its relations to the uterus, as well as determine its density and shape. The fluid in these cases should be submitted to microscopic exam- ination with a view to ascertain wdiether it came from an ovarian cyst or the peritoneal cavity. Prognosis. There are several considerations which render the general prog- nosis favorable as compared with other tumors for which they may be mistaken. They occur generally in persons who have made a near approach to the menopause, and generally they cease growing after this condi- tion is passed. They grow slowly, and may not be expected to arrive at dimensions sufficiently great to cause fatal consequences for many years, if ever. They often stop growing without any discoverable reason ; they sometimes undergo degeneration into inert masses, which remain as mere inconvenient bodies.- Nature sometimes gets rid of them by expulsion, or they may be protruded from the uterus 620 TUMORS OF THE UTERUS. into the vagina, within reach of surgical measures. Lastly, many of them disappear under judicious medical treatment, or all the threat- ening symptoms attendant upon them may be removed by such means. Almost none of these conditions obtain in ovarian tumors and very few in any others found in the same locality. These considerations will establish the conclusion that the general prognosis is favorable. The circumstances which in individual cases form an unfavorable prognosis are: the youth of the patient, as they usually grow more rapidly in young persons ; the rapid growth of the tumor ; hemor- rhagic symptoms; unfavorable complications, as peritoneal dropsy, inflammation in the pelvis or abdomen, pressure upon the pelvic organs, nerves, or vessels; inflammation of the tumor, impaction in the pelvis, uraemia, ansemia, pregnancy, ovarian tumor, etc. The fibro-cystic variety possesses several elements of danger ; its rapidity of growth being the cause of several others, as pressure, impaction, dropsy, etc. The complications of pregnancy and labor with fibrous tumors of the uterus is one of sufficient importance to demand special consid- eration, especially as we may be obliged to determine a course of action when the emergency leaves no time for research. The simjjle coexistence of a fibrous tumor with pregnancy is not sufficient reason for interference, and I am persuaded from personal observation that there are but few cases which call for any interference whatever. I do not wish to be dogmatic, but I desire to make a few definite statements of what I regard as facts. Pregnancy takes place more frequently when the tumor is situated in the central zone of the uterus and remote from the mucous membrane ; but it will not occur if the tumor belongs to the submucous variety, although it is in the middle, or even in any part of the uterus except the cervical portion of the inferior zone. I have already intimated that there are very few large tumors developed in the inferior or cervical zone compared with those that arise from the central corporeal and superior or fundal zone, and that such as these are usually developed in the submucous tissue and are generally pendulous — these do not appear to interfere very much with pregnancy. From what I can learn and have ob- served pregnancy seldom, if ever, takes place when the tumor, being of more than moderate size or situated near the mucous membrane, is located in the fundus or upper portion of the superior zone. In general the larger the tumor the less likelihood of pregnancy, and if it does occur the impossibility of normal uterine development leads to abortion. The dangers to be apprehended arise usually at the time of labor and consist: 1, In the obstruction to delivery caused by the tumor blocking up the pelvis ; 2, in the incomplete contraction after delivery PROGNOSIS. 621 failing to close up the placental vessels, and thus causing grave, if not fatal, hemorrhage. Tumors situated in the superior zone, the middle zone, or the upper portion of the inferior zone will offer little obstruc- tion, because the head will have passed them above the pelvic brim. This leaves but a limited number and those small in size that are crowded down into the pelvis b}' the side of or before the fetal head ; they are the submucous or polypoid variety situated in the cervical portion of the inferior zone. Such tumors are generally pressed en- tirely out of the vulva and permit the head to pass out after them. I may mention, in passing, that they may sometimes be detached from their base by the pressure of the head ; or, remaining intact, may be retracted within the pelvis after the labor is over. The second danger is, I think, very much overrated. The fact of the fibrous tissue of the uterus having been developed sufficiently to per- mit of the completion of gestation is an evidence that it is sufficiently powerful to contract fully, and one single case recently published by Dr. Chadwick, of Boston, in which the placenta was implanted on the uterus over the seat of the tumor, and in which hemorrhage did not prove serious after delivery, goes far to prove that great danger from this cause is not likely to occur. In no case of labor associated with a tumor which has come under my own observation has hemorrhage been a grave symptom. It is fair, I think, in the light of our present knowledge, to infer that it is seldom necessary to interrupt pregnancy when complicated with fibrous tumors of the uterus, as, in the nature of things, gestation will not continue unless there is sufficient integrity of uterine tissue to per- mit ample development. At the time of labor the indication for operative procedure will appear in the want of progress, and then the obstacles may be surmounted by turning, or forceps, if the propulsive powers of the uterus are not sufficient. Common prudence will incite to vigilance in preventing hemorrhage in these as in other complicated cases of labor. It will be observed that while I cannot ignore the im- portance of watching these cases attentively, I am far from consider- ing them as necessarily very dangerous. Another question of great importance is, what effect does pregnancy and labor have upon the tumor? In a minority of cases none whatever. The tumor remains the same after the pregnancy has terminated as before. But in the majority of cases it is far otherwise. In three instances of this nature, which have come under my own observation, the tumors have disappeared ; and the manner of their disappearance is worthy of remark. In one in- stance, occurring two years since, the tumor was located in the posterior wall of the uterus, apparently in the central portion of it, and occupied the middle zone. The pregnancy proceeded without accident, and the 622 TUMORS OF THE UTERUS. patient was delivered at term of a dead foetus, which, judging from appearance, must have been dead three days before labor came on. Moreover, according to the calculation of the mother, the first pains did not appear until two weeks after the expiration of two hundred and eighty days. The head was arrested at the superior strait and impinged upon the symphysis pubis, but was easily moved from this position. I did not see the patient until four hours after the membranes had been ruptured. At this time the presenting part did not advance, and, after consultation with the attending physician. Dr. John F. Wil- liams, of this city, it was considered best to interfere. I introduced, my hand, seized one of the feet and brought it down. There was no great difiiculty in the turning or delivery. The placenta came away in a few minutes with a very slight loss of blood. I had first seen this patient when gestation had advanced to the end of the third month. At this time I believed the tumor to be about the size of a fetal head at term. It was extremely hard, and presented two distinct nodules. At this consultation I ad^dsed non-interference. I saw her again several times during her pregnancy. She was a primipara. After the delivery of the placenta I felt curious to know what effect the pregnancy had upon the size and consistency of the tumor. In order to determine these points I introduced one hand into the uterus, and with the other manipulated above the symphysis. In this way I could fix and handle the tumor with facility. It then seemed to be about the size of the fetal head and very hard. The division between the firmly contracted uterus and the tumor was marked by a well-de- fined sulcus, traceable by the hand, above the pelvic brim. The tumor seemed harder than the contracted uterus. I had the oppor- tunity of seeing and examining this patient frequently during the year succeeding her accouchement. The tumor was decidedly less in three months, and continued to disappear. At the expiration of twelve months it was no longer jDerceptible, and the cavity of the uterus measured but two inches and a quarter. The patient now menstruates normally in every respect. The careful observation of this case convinced me that the tumor had net grown materially larger nor become softened during gesta- tion, and led me to believe that the process of absorption began and proceeded with the subsequent involution of the uterus. What effects may have been wrought upon its tissues by the contractions during labor I cannot, of course, determine ; but the gradual disappearance of the tumor and the non-appearance of inflammatory or other urgent symptoms plainly indicate that the contractions of the uterus during labor could not have produced any very violent effects upon it. It was also evident that the tumor was absorbed and slowly removed without disturbing the good health of the patient. PEOGNOSTS. 623 In the other two cases I verified the existence of fibrous tumors before pregnancy took place, and one of them I saw again after a lapse of five months, but was not present at the time of parturition of either of them, nor have I seen them subsequently. I have been assured, however, by letters from their attending physicians, that they recog- nized the tumor after labor, and that they both disappeared within a year. CHAPTER XXXIX. FIBROUS TUMOES OF THE UTERUS {Continued). Treatment. The treatment of fibrous tumors of the uterus consists largely of the means calculated to relieve such symptoms as endanger the life of the patient or materially affect her general health. When these are unavailing, resort is had to measures calculated to get rid of the tumor. Some remedies necessary to the relief of symptoms act as very powerful curative agents ; hence, while it is convenient to speak of the treatment of symptoms under one division of the subject, and the methods employed for radical cure under another, we cannot, in fact, completely separate these two branches. The reader will not be surprised, therefore, if I feel myself obliged to depart from this arbi- trary method of presenting my subject. Hemorrhage is by far the most important of the symptoms con- nected with these growths, because it is at the same time the most frequent and hazardous. It is also the symptom that leads to most suffering in consequence of depriving important organs of the blood necessary to support them in their functions. Every means, there- fore, should be made use of not only to prevent fatal losses but also to prevent even slight hemorrhage. In the outset, therefore, I would insist upon watching with great vigilance to prevent any unusual loss of blood. It will be understood by this that I advise not to tem- porize by adopting the milder and less efficient measures as being sufficient for cases not likely to prove fatal, but to treat all hemor- rhage arising from this cause with promptitude and energy. Fortu- nately in many cases we can anticipate the attacks of hemorrhage because we know when they will recur, and we are generally able to judge of their probable severity. To discharge our duty in this respect effectually, our patient should be properly provided with remedies and fully instructed how to use them. She should be made to understand that unusual hemorrhage at the menstrual period may be checked without endangering her general health. Among the remedies are dorsal recumbency with the hips elevated, cold to the hypogastric region, and cold to the dorsal spine and sacrum, which can be effected by means of a rubber pillow filled with ice water, ergot and some form of tampon. The best fluid extract of ergot in drachm doses, if the stomach will bear it, is probably the most effica- cious medicine, but the fresh drug in the form of infusion is also very TREATMENT. 625 efficient. Full doses should be given every half hour when there is much loss, until some effect is produced upon the hemorrhage, and then continued every four hours as long as necessary. Compressed sponges saturated with the solution of alum make the best tampon for the patient to make use of. These may be made and kept in readiness, so that they can be introduced as soon as they are found necessary. The patient or nurse can make them by taking a fine sponge, large enough to fill the vagina, passing a piece of strong string through the centre to aid in its removal, and then, after dipping it in the solution, well winding it with twine from one end to the other, compressing it into as small a space as possible. The twine should so compress the sponge as to make it assume an elongated form. It should then be laid aside and permitted to dry. Several sponges should be thus prepared and dried. When necessary the twine may be unwound and the sponge introduced. Its size when in the dry condition will allow of an easy passage into the vagina, where the moisture will cause it to expand, thus filling up and sealing the vagina so as to absolutely check the discharges. If the attending physician is present he may tampon the vagina with pellets of cotton secured by thread and moistened with the solution of iron, as recom- mended by J. Marion Sims and others. The inconvenience experienced from this ironized plug will be more than counterbalanced by the saving of blood. This form of tampon has the additional advantage of being antiseptic. I have allowed it to remain for three days, and upon removing it satisfied myself that there was no decomposition of the blood or the vaginal secretions. When the tampon is removed it will not be found difficult to wash out all the granular clots caused by its presence. It may be repeated as often as necessary, but usually if allowed to remain forty-eight hours the hemorrhage will not return. It may be said that for small losses this is unnecessary, but I think this is a more convenient form of tampon than any other that will answer the purpose. In dangerous cases no one will question the propriety of its employment. Another very important means of arresting hemorrhage, which can be used by the physician when necessary, is the introduction of a compressed sponge into the cervix uteri for the purpose of dilating it. This will temporarily act as a tampon and stimulate the uterine fibres to contraction. A point of much importance in the use of the tampon or sponge, is the avoidance of septicsemic poison, and I know no medicine so efficacious and handy as the preparation of iron I have mentioned. The pressure of the tumor upon the pelvic viscera is another in- convenience which calls for attention. This takes place usually at a time when the tumor has acquired a size sufficient to fill that cavity. Consequently the elevation of the tumor above the pelvis is the 40 626 FIBROUS TUMORS OF THE UTERUS. remedy. This may be done sometimes by placing the patient in the knee-elbow position and opening the vagina by two fingers, and then pressing the growth upwards. The powerful influence of atmos- pheric pressure called to our aid, by the position and opening of the vagina, is a very material auxiliary in the process of elevation. If this is not sufficient, we may pass the fingers into the rectum and elevate the tumor. I once succeeded in this operation by using an ivory- headed cane in the rectum when the fingers failed to reach high enough. Dysmenorrhoea is another symptom of fibrous tumors, and some- times a very distressing one, which we are often called upon to re- lieve. It depends, no doubt, as I have before said, on the imprison- ment of blood in the uterine cavity, in consequence of the tortuosity of the canal causing the closure of some part of it. The remedy con- sists in ^dilating these narrow places. I know of nothing so well cal- culated to eff'ect this object as the slippery elm tent. A tent of this material, long enough to reach the fundus uteri, and of sufficient size, moistened so as to render it very flexible, may be passed up through these tortuous places with great facility. If introduced as soon as the symptom begins to manifest itself, and allowed to remain an hour or two, the relief will be pretty certain. If used once a day, for four or five days before the attack, and three or four hours at a time, dys- menorrhoea may be generally avoided. When we broach the question of the permanent cure of these atfec- tions, we find that great difference of opinion exists among the mem- bers of the profession as to the value of medicines. One part, per- haps a majority, believe that no medicine has any direct effect upon them, and they ignore any means of permanent relief but surgical. There is, however, a respectable number of medical men who place great reliance upon the administration of certain medicines, and, if I am not mistaken, recent observation has added greatly to their num- ber. They do not, however, wholly agree as to the therapeutic pro- cesses that should be instituted, and consequently do not employ the same kind of medicines. Some gentlemen have more confidence in what I will term the sorbefacient process of treatment. They endeavor to institute measures that will cause the absorbents to attack and remove the neoplasm in the same way that tumefactions caused by effusions are removed. This they do by friction, pressure, and the administration of the old-fashioned sorbefacient medicines. The most popular among these are the iodides, chlorides, and bromides of mer- cury, potassium, sodium, calcium, and ammonium. Reports may be found in books and our periodical medical literature of cures by sev- eral, if not all, of these articles and their combinations. The late Dr. W. L. Atlee, whose experience has been very extensive, had great con- fidence in the action' of chloride of ammonium. He caused it to be TREATMENT. 627 administered internally, applied externally, and used as vaginal injec- tions. The iodide of potassium has long enjoyed a great reputation in causing the absorption of these and other forms of tumors. There is no professional fairness in assuming that the faith in these remedies, derived from the observation of their effects, or the promulgation of cures from the use of sorbefacient measures, are fallacious. Some of the men arrayed in favor of the opinion that cures may be effected by a patient and long-continued administration of some one of the arti- cles I have mentioned, stand high as men of honesty, accuracy of observation, and faithfulness in their records ; and for one I give full credence to their statements. Yet I must also say that I have not witnessed the good results which I unhesitatingly believe others have seen from the sorbefacient treatment alone. Others who expect much from medicinal treatment look to that class of medicines which causes contraction of the unstriped muscular fibres as the most promising. With these medicines they expect to diminish the supply of blood to the tumor, by causing contraction of the arterioles traversing their substance, and thus disturbing their nu- trition to such a degree as to stop their growth, lessen or destroy their vitality, and so render them subject to the influence of the absorbents, whereby they may be removed. Some of the more energetic of these medicines, as ergot, for instance, often affect these growths very promptly. I shall limit my remarks upon this class of medicines to what is known of the effects of ergot. As an introduction to what I have to say of ergot I submit the fol- lowing propositions : 1. When properly administered, ergot frequently very greatly ameliorates some of the troublesome and even dangerous symptoms of fibrous tumors of the uterus, e. g., hemorrhage and co- pious leucorrhoea. 2. It often arrests their growth and checks hemor- rhage. .3. In many instances it causes the absorption of the tumor, occasionally without giving the patient any inconvenience; at other times the removal of the tumor by absorption is attended by painful contractions and tendernigss of the uterus. 4. By inducing uterine contraction it causes the expulsion of the polypoid variety. 5. In the same way it causes the disruption and discharge of the submucous tumor. There are many cases on record to substantiate' every one of these propositions. From what I consider well-authenticated sources, including the cases under my own observation and in the practice of mj^ friends and neighbors, I have collected one hundred and thirty-six cases of fibroid tumors treated by ergot.- Of these, twenty-five cases were cured without giving the patient any inconvenience from painful con- tractions. In forty-six cases the tumors were diminished in size and 628 FIBROUS TUMORS OF THE UTERUS. the hemorrhage was cured. In twenty-seven others the hemorrhagic symptoms were relieved, while the size of the tumor was not affected. In eight other instances the tumors were broken to pieces and expelled piecemeal. At the risk of being tedious I will copy the summary of cases and opinions reported to me and given in my address on Obstetrics made before the American Medical Association in 1875 : Cases. It is well known that Professor Hildebrandt, in a communication to the twenty-fifth number of the Berliner Wochenschrift, as early as 1871, called the attention of the profession to the utility of ergotin in the treatment of fibrous tumors of the uterus. While administering it by hypodermic injections to moderate the hemorrhages, so often a troublesome symptom in connection with these growths, he was struck with the decided diminution in the size of the tumor. A continuation of the remedy thus administered resulted in the entire disappearance of one of them in fifteen weeks. In eight cases, all but two under- went great improvement. The great pain caused by injection ren- dered the treatment intolerable to one of these two patients. In the other the treatment was discontinued on account of ergotic intoxica- tion. In four others, the tumors were greatly diminished, and promised speedy cures, but for various reasons the treatment was not continued. One tumor of huge size, reaching above the umbilicus, totally disap- peared ; while another, extending to the ribs, and largely distending the. abdomen, was greatly reduced. The debilitating hemorrhages and leucorrhoeal discharges were promptly relieved in six of them. In the American Journal of Obstetrics for January, 1875, Dr. Hilde- brandt gives a synopsis of nineteen more cases treated by him. Two of these were cured ; and in six others the tumors were greatly dimin- ished in size, and the hemorrhages relieved. In eleven of these cases all the disagreeable symptoms were relieved, but the size of the tumor was not perceptibly affected. The last two cases reported in this series of nineteen were not benefited. Soon after Professor Hildebrandt made his first report of cases. Dr. Bengelsdorf read a paper upon the subject at a meeting of the Griefs- wald Medical Society. He alluded to four cases in which he had used the hypodermic injections of ergot. Two of these were in pa- tients after the menopause ; neither of them seemed to be influenced by the treatment. In the other two the patients were menstruating and the subjects of severe metrorrhagia. This symptom in both cases was very much mitigated, but the tumors were not materially, if at all diminished in size. Treatment was interrui3ted in one of them after the administration of sixteen injections. Dr. Bengelsdoi'f was favorably impressed by the treatment. CASES. 629 Dr. Chrobak, of Vienna, reports, in the seventh volume, second number, of the Archives fur Gyndcologie, nine cases. In the first, the tumor the size of a small apple was partially expelled from the cavity of the body into the cervical canal; the mouth of the uterus was dilated by sponge, and the protruding segment removed with the scissors. In case second, after forty -three injections, the tumor, which was situated in the posterior wall of the uterus, was not re- duced in size, but the hemorrhage was cured. The tumor in case third consisted of several nodules in the anterior wall of the uterus ; after twenty-four injections, there was no diminution in size, but the hemorrhage was cured. In case fourth the tumor was situated in the posterior wall and reached up to the umbilicus ; after three in- jections the treatment was discontinued on account of the pain and inflammation caused by them. In the fifth case the amount of hem- orrhage was reduced, but the treatment was discontinued for the same reason as in case fourth. The tumor in case sixth was large, the uterus rising above the umbilicus; after twelve injections without results, the patient could not be induced to receive further treatment. The seventh patient was fifty-seven years old, and the tumor showed a multitudinous development; the second injection, which was ad- ministered eight days after the first, caused severe symptoms of collapse, and the treatment was discontinued. The tumor in the eighth case was in the anterior wall of the uterus and reached above the umbilicus, and the monthly flow continued from eight to ten days ; seven injections were used, with diminution of the tumor and improvement in the hemorrhages ; the treatment in this case he ex- pected to continue at some future time. In the ninth case the uterus was anteverted, and the cavity measured four and three-fourths inches in length ; after twelve injections the hemorrhages ceased and the tumor diminished in size ; the uterine cavity measuring only three and one-third inches in length. Dr. Lombe Atthill records three cases in the Irish Hospital Gazette for September 1st, 1874. The first case was benefited in the diminu- tion of the flow and the improvement of health. The second case was under treatment but a very short time ; only five injections were administered, when the patient refused to permit another because of the severe inflammation following them. The third case was bene- fited, but abandoned from the same cause. Dr. J. P. White, of Buffalo, N. Y., writes me that he believes it is in this direction — the use of ergot — we must look for relief in the intramural and non-pediculated varieties of uterine fibroids. He says that in the last year and a half he has resorted to ergot in these vari- eties with marked benefit. In a few instances they have been com- pletely absorbed, and in a larger number the growth of them was arrested, the tumors were diminished in size, and the hemorrhages were 630 FIBROUS TUMORS OF THE UTERUS. suspended. He says that the number of his cases is fourteen, and that not more than one-third can be called cured, while in almost the same proportion, the growth has been stayed or diminished, and the bleeding arrested. Dr. E. W. Jenks, of Detroit, Michigan, now of Chicago, in a recent letter, says, he has used ergot during the past two years in the treat- ment of fibroid tumors of the uterus with the most gratifying results. Seventy-five per cent, of all cases thus treated were benefited, as manifested by arrest of growth and control of hemorrhage. About ten per cent, of the patients he considered cured. Dr. H. C. Howard, of Champaign, 111., sends me an account of two cases treated by him. The first case was in an unmarried woman. The tumor was one originating from a single nucleus, intramural, and as large as a pint measure. He administered hypodermic injec- tions of ergotin for some weeks, and afterward continued treatment for eight months by administering internally the fluid extract of ergot and belladonna. This case, he says, was entirely cured by his treat- ment. His second case was in the person of a married woman, forty years of age, and the mother of two children. When first seen by him she had been the subject of severe floodings for three years. He found, upon examination, a submucous fibroid as large as a quart cup. He used large quantities of ergot by vaginal injections and by the mouth for four months, at which time the tumor had entirely disappeared. Dr. A. Reeves Jackson reported to the Chicago Society of Physi- cians and Surgeons, April 13th, 1874, five cases of fibrous tumors of the uterus treated by hypodermic injections of the solution of the solid extract of ergot. The tumors in four of these cases were intra- mural; in the fifth the tumor was subperitoneal. The tumor in one was entirely cured ; in two others the tumors were greatly diminished in size. In another the tumor seemed unaffected, but the profuse hemorrhages from which the patient suffered were diminished in fre- quency and profuseness. The fifth, a subperitoneal tumor, was not benefited. Dr. Jackson reports to me three other cases. One was in a colored woman ; the uterus reached to the umbilicus ; it was entirely cured in three months. In the second the tumor reached above the umbili- cus ; this was temporarily reduced in size by the ergot, but after treatment was abandoned, it regained its former dimensions. The treatment was discontinued by the patient because of the distressing pain and contractions which occurred after eight weeks' use. The profuse uterine hemorrhage was checked, and health improved. At the same meeting of the Society of Physicians and Surgeons at which Dr. Jackson's first five cases were reported. Dr. Etheridge reported one case entirely cured. His diagnosis was confirmed by CASES. 631 Drs. Gunn and Miller, Dr. Etheridge's associate professors in Rush Medical College. Dr. Fisher also reported an intramural fibrous tumor cured in six weeks. I saw this case, and have no doubt of the correctness of Dr. Fisher's diagnosis. On the same occasion Dr. Merriman, one of my colleagues, re- ported three cases ; one, intramural, in the anterior wall, cured ; one, subperitoneal, pediculated ; the health of this patient was much im- proved, and the growth of the tumor checked ; the patient was still under treatment. The tumor in the third was intramural. At the time of reporting, the size was gradually diminishing. Dr. John Morris, of Baltimore, Md., communicates to me a case that seemed to be decidedly benefited by the ergot treatment ; but, on account of the violent uterine contractions produced by the remedy, the patient would not consent to continue the treatment. Dr. Charles E. Buckingham, of Boston, Mass., has tried hypodermic injections of ergot in the treatment of fibrous tumors of the uterus in but one case. The result was entirely negative. Dr. George Cowan, of Danville, Ky., reports a case in the person of a colored woman, unmarried, and about forty years of age. The hypo- dermic injections of ergotin were used for two weeks. At the end of this time the greatest circumference of the abdomen was reduced from thirty-six inches, which it measured before the treatment was insti- tuted, to twenty-eight and one-half inches. The patient, returning home, used the injections herself. Such frequent and painful abscesses ensued, however, that she discontinued them. During the use of the injections an obstinate constipation was removed, and her general health much improved. The abandonment of the treatment was fol- lowed by a return of the constipation, loss of flesh, great debility, and the abdomen increased in size until it measured thirty-two inches. A return to the treatment was followed by the same marked improve- ment in. the general health, and a reduction of the size of the abdomen to twenty-seven and one-fourth inches. Dr. H. W. Dean, of Rochester, N. Y., sends me an account of two cases treated by him. The first case was that of a patient forty -seven years of age, the mother of three children, the age of the youngest nineteen. She suffered from pressure upon the bladder and rectum, and was the subject of severe menorrhagia. The tumor extended two inches above the umbilicus, and occupied the lower half of the right lumbar, the whole of the right inguinal, and fully half of the corres- ponding left abdominal regions. The os uteri was a little to the left of its natural position, and sufficiently open to admit the finger half an inch. An elastic catheter was introduced into the uterine cavity between seven and a half and seven and three-fourths inches. The diagnosis was interstitial fibrous tumor of the uterus. Intrauterine injections, through the elastic catheter, of half a drachm of Squibb's 632 FIBROUS TUMOES OF THE UTERUS. fluid extract of ergot were made four times during each menstrual in- terval, from April until October, 1874. Injections into the substance of the cervix were made with the same frequency from October to the middle of December. The results were, reduction in the size of the tumor until the upper margin sank two inches below the umbilicus, and the uterine cavity measured only four and a half inches. The second case was that of a woman, forty-eight years of age, the mother of three children, the youngest of whom was sixteen. She flowed irregularly, the intervals varying from one to three weeks. The flow was profuse and attended with great pain. In the intervals there was a copious flow of serous leucorrhoea. She also suffered from pressure upon the bladder and frequent micturition. The tumor oc- cupied the right side of the abdomen, extending nearly to the umbili- cus, and to midway between the linea alba and the left ilium. The vagina could not be satisfactorily explored until the hand was intro- duced. When this was effected the finger could be easily passed into the uterus. Between the finger thus introduced and the hand on the hypogastric region, the presence of an interstitial fibrous tumor was diagnosticated. A flexible catheter was passed into the uterine cavity to the extent of eight inches. Injection into the substance of the cervix was followed in fifteen minutes by continuous uterine contrac- tions, which lasted twenty -four hours. This injection was repeated four times a month. When the amount was increased from fifteen to twenty minims, great gastric and cerebral disturbance, together with intense cutaneous engorgement and uterine pain, ensued. The injec- tions were continued from November, 1873, to the middle of the year 1874. At this time the upper margin of the tumor was but one inch above the symphysis pubis, and the cavity of the uterus measured four and a half inches. Menstruation was quite normal as to time and quantity, and attended with little pain. The pelvic organs were not subject to disagreeable pressure. Dr. W. C. Wey, of Elmira, N. Y., in a lengthy and interesting letter gives me the results of his treatment in one case. The patient was forty-seven years old. The bulk of the tumor Avas equal to both closed hands. It was reduced in six weeks about one-third, and in six months to one-half of its original size. The patient, before the treatment, was very much reduced ; her extremities had become oedematous, and ex- ercise was impossible from the effects of hemorrhage, which had become almost constant. These symptoms were relieved with great promptitude and in four months tlie menses had become normal in every respect. His treatment was continued twenty -seven months, but most of the good results, if not all, were obtained in the first six months. Dr. Edward M. Hodder, of Toronto, writes me that the number of cases in his notebook, since May, 1873, is twenty-five ; but all of these CASES. 633 reside at a distance, and therefore he saw or heard of them only oc- casionally. Nearly the whole of them were treated with ergot, but not exclusively, as he combined with it the bromide and iodide of potassium. In the majority of the cases, treatment appeared to arrest further growth, and after a time caused the tumors to diminish in size. In a few cases the tumors disappeared entirely. He gives four cases in minutiae : in one case the treatment was commenced May, 1873; tlie tumor nearly disappeared, and the patient is now six or seven months advanced in pregnancy. In the second case, the treat- ment was begun in June, 1873 ; the tumor was greatly diminished in size, the patient became pregnant, and was delivered late last autumn. In the third case the treatment was commenced in Sep- tember, 1873 ; the tumor disappeared, and the patient is now preg- nant. In the fourth case treatment was commenced in September, 1873, and the tumor is now nearly gone, and the patient feels quite well. Through the kindness of Dr. Hodder I have received the report of another case by Dr. Jukes, of St. Catherines. The tumor was discov- ered b}^ Dr. Jukes at the time of delivery after a normal pregnancy. The history of the case shows that its existence had been recognized by Dr. Hodder before the patient was married. Dr. Jukes gave the fluid extract of ergot continuously to this patient for three months, first in doses of one-half drachm, and afterwards increased the dose to one drachm, combined with the various preparations of iodine. From the beginning, the tumor slowly decreased in size, and at the end of three months had entirely disappeared. Some weeks after de- livery, lie passed the sound into the uterine cavity six inches, and the organ reached very nearly to the umbilicus. After the three months' treatment the measurement by the sound showed the organ to be very slightly above its normal size. Dr. Strange, of Aurora, Canada, says that he had on several occa- sions given ergot internally to arrest the hemorrhage attendant upon fibrous growths in the uterus, and had observed that it tended to re- tard their further growth. Dr. L. F. Warner, of Boston, has used ergot in two cases of fibrous tumors of the uterus, but could perceive no beneficial effects. Dr. J. H. Thompson, Surgeon in Chief of the Columbia Hospital for Women and Children, reports three cases treated by ergot, in all of which the tumors were reduced in size, the metrorrhagia cured, and the general health, which in all was much impaired, was entirely re- stored. In one of these cases Dr. Thompson injected the ergot into the substance of the tumor by passing this instrument through the cervical cavity, and thence penetrating the growth. No unpleasant effects followed this method of using the remedy. Dr. Russel, of Oshkosh, Wisconsin, reports one case in which the 634 FIBROUS TUMORS OF THE UTERUS. tumor, of large size, was very much reduced, and all the disagreeable symptoms were removed. During the year since the last meeting of the Association I have treated seven cases. One was not affected by the ergot, and the patient died six weeks after the commencement of the treatment. She was anfemic to a de- gree which I have seldom before seen. The remedy was administered hypodermically every day, thirty drops of Squibb's solution of the solid extract being injected each time. The second patient was the subject of a uninuclear tumor, situated in the anterior wall of the uterus, about the size of the fetal head. She had profuse hemorrhages at her menstrual periods, and copious leu- corrhoeal discharges between them, and had become very angemic. The discharge ceased and the tumor disappeared in five months from the time she first came under my care. The remedy was at first used hypodermically ; but, on account of the pain and inflammation at the punctures, I was obliged to cease this mode of administering it, and gave it internally. Teaspoonful doses of Squibb's fluid extract were given twice a day for the last three months of the time the patient was under treatment. In three other cases, in which the medicine was given internally, the tumors were very much reduced in size, but did not disappear. The hemorrhages and leucorrhoea were cured, and the j)atients restored to health. In another, the hemorrhages and leucorrhoea were rendered much less profuse, but the tumor was not reduced in size. In a colored senile patient, over sixty years of age, with a large multiple tumor, no effect was produced by the ergot. In four of my cases I was obliged to suspend the treatment several times for a few days, to give the patients a respite from the almost constant pain. Five of these complained of great heat and tenderness of the uterus after they had been under treatment about four weeks. In all, the pulse was accelerated and remained small and weak. As one of my cases presented some features of more than ordinar}'' interest, I will give it more in detail : The patient had been married twelve years, was thirtj^-seven years old, and sterile. She had been aware of the existence of the tumor for three years, but could not give a very clear history of its progressive enlargement. The uterus extended three inches above the pubes, and was a little to the right of the median line, very hard, and irregular in shape ; but I could not discover that there were subperitoneal nodules. Per vaginam, the tumor could be felt to occupy the right side and anterior wall of the uterus, and fill up two-thirds of the pelvic cavity. The cavity of the uterus measured four and a quarter inches. A polypus, jDyriform in CASES. 635 shape, quite firm in consistence, about the size of a pigeon's egg, de- pended from the mouth of the uterus, and appeared to be attached to the upper part of the posterior wall of the cervix. The diagnosis was intramural fibrous tumor of the uterus, with two nuclei of devel- opment, and a fibrous polypus. The patient was somewhat anpemio from the long continuance of profuse leucorrhoea and metrorrhagia. Without removing the polypus, I commenced treatment by giving the patient three grains of the solid extract of ergot three times a day. The next menstrual flow was not so profuse, and the leucorrhoea di- minished almost from the beginning. At the end of four months the menstruation was normal, the leucorrhoea had ceased, the tumor was reduced to half its former dimensions, and the patient's health re- stored. A continuation of the treatment two months longer causing no further reduction of the tumor, it was suspended. During the treatment, I watched with much interest the effects produced upon the polypus, examining it once in every ten or twelve days. It showed decided decrease in size at the end of the first ten days, and progres-- sively decreased until, at the expiration of four months, it was not more than one-third the size it presented when first examined. It was twisted off at this time with great ease, and its removal was followed by almost no loss of blood. The most remarkable case of which I have any knowledge was re- ported to me by Dr. G. C. Goodrich, of Minneapolis, in which absorp- tion of a large tumor took place under the administration of ergot and belladonna. I subjoin his description : "The treatment was commenced in 1870, and continued two years. The uterus filled the whole apace between the ilia, and measured in the transverse diameter twelve inches, and in the vertical nineteen inches, extended up under the ensiform cartilage and close up to the margin of the cartilages of the ribs. The treatment was followed by cramps in the uterus, which produced a wild enthusiasm in the mind of the patient, and inspired her with strong hopes of recovery. Without consulting me, she doubled the dose of medicine, which was administered internally, and as a conse- quence she was attacked with very strong uterine contractions and symptoms of me- tritis. This caused me to abandon treatment for about one month, and had it not been for the urgent determination of the patient, I would not have resumed it. She in- sisted that as this was the first medicine which had ever affected the enlarged organ,, she believed it would cure her, and promised to obey my directions if I would pro- ceed. She so promptly and rapidly improved that I doubted if it were not a coinci- dence with, rather than a consequence of, the treatment. Prompted by this doubt, I abandoned the use of the ergot and belladonna and continued alterative treatment. The patient soon assured me that she no longer felt the griping pains caiised by the remedy, and that the tumor was softer and larger than when she took the ergot pre- scription. The ergot and belladonna were again resumed, and in four months she was able to make a trip to Boston alone. While absent, she continued to take the medicine. From this time she continued rapidly convalescing, and is now in the en- joyment of fine health."* * The author's address before the American Medical Association at its meeting in 1875. 636 FIBROUS TUMORS OF THE UTERUS. I subjoin cases in which the tumors were expelled piecemeal under the administration of ergot, which came under my own observation : The first case in which this process was attained occurred in the practice of Dr. H. P. Merriman. So far as I am aware it is the first case on record. With several other medical gentlemen I had the opportunity of seeing the patient several times, fully verifying the diagnosis, and witnessing the results of the treatment. It was recorded in my address before the American Medical Asso- ciation already referred to. Dr. Merriman says : " Mrs. K., aged thirty, the mother of three children, came to me in September, 1874, in regard to a tumor in the abdomen. Examination revealed a large tumor about the size of a four and a half months' pregnancy ; it was found to be interstitial, and situ- ated on the right side and a little anterior; the sound passed six and three-fourths inches. She was at once given twenty drops of fluid extract of ergot (Squibb's) three times a day. She came a month later saying she was much better in health, but the tumor remained the same. I told her to continue the medicine, but to increase the dose to twenty-five drops and after a time to thirty. I have seen her three or four times during the past winter, and twice had to suspend treatment and give opium on account of severe pain and tenderness in the uterine region. Finally, March 23d, 1875, I stopped all use of ergot, as the patient was very weak, the pulse 110, the appe" tite poor, and a very offensive and abundant discharge was coniing from the uterus. The OS uteri was very patulous. On April 5th, I was summoned in great haste. Some- thing had just come away from the patient. I found it to be an offensive fleshy mass, evidently a disintegrated fibrous tumor. Examination showed no tumor in the abdo- men, but per vaginam the os patulous, soft, and very sensitive, and the uterus still large. A week latter the uterus had regained its normal condition." As an evidence of the complete restoration of the health of the pa- tient, Dr. Merriman informs me that she has since had a fine healthy child. The next case, which has never been published, occurred in my own practice, and I will give a brief account of it: Mrs. W., forty years of age, had been married eighteen years, and had not borne children or been pregnant. She had enjoyed good health and noticed nothing unusual in her menses until about three years before she con- sulted me on July 17th, 1875. Three years ago she began to have an increased menstrual flow, the intervals were shorter, and she be- came the subject of an acrid leucorrhoeal discharge. For the last seven or eight months the flow has been almost constant, but moder- ate. The catamenial periods had been during the time well marked by a profuse discharge every four weeks. She was quite feeble from the great loss of blood she had sustained, very nervous and dispirited. For more than a year she had been conscious of the presence of a tumor in the hypogastric region. She had at no time observed that the discharge was fetid, or indeed had any smell. By palpation, a tumor could be found extending to within about two inches of the umbilicus, and filling up the same space in the lower part of the ab- CASES. 637 domen which the uterus occupies at five months' pregnancy. It was globular, very hard, somewhat nodulated in shape, and movable. The cervix, when examined per vaginam, was ascertained to be long and pointed, and the mouth small, and not at all patulous. The probe entered the uterine cavity, passing upward and backward fully four inches, and moved with the impressions made upon the tumor above the S3'mphysis. From the history and examination it was not difficult to diagnose a fibrous tumor in the anterior wall of the uterus. I prescribed thirty drops of the fluid extract of ergot three times a day, to be taken in a wineglassful of water, and large injections of cold water twice a day. On July 19th the patient called to see me again. She informed me that the medicine had caused great pain in the tumor, resembling cramps, with a. strong desire to bear down, as though something was coming out of her. An examination revealed no change in the size of the tumor, but increased hardness and irregularity of its surface. She was directed to continue the medicine. On the 25th the patient complained that the pains were almost unendurable on account of their severity and continuousness. She said they prevented her from sleeping, or resting in any position. For the two days previous to her call on the 25th she had noticed in the discharges — which were less bloody — stringy and lumpy substances. This was different from anything she had seen before. Still there was no fetor. The tumor seemed to be somewhat less in size than upon the first examination. There were some changes in the cervix ; it was soft, and the mouth was patulous ; the finger entered it a short distance, but would not pass the inner os uteri. The cervix was still as long as before the commencement of the pains, and I thought the lower portion of the tumor seemed more elastic than at first. On the 27th the pain was so severe and persistent that I thought it advisable to diminish the doses of ergot, and directed her to take only fifteen drops three times a day. The discharge was increasing in quantity, and she gave me several pieces, one of which was as large as a cherry. It was so firm that it was difficult to break it up with the fingers, and of grayish color. There was no odor that I could dis- cover in the piece examined. Dr. W. H. Warn was kind enough to examine this specimen with the microscope. He found it composed mostly of hypertrophied con- nective-tissue fibres, with bloodvessels running parallel to them. The tumor had decidedlj^ decreased in size. On July 31st the pains, with less severity, were still continuous for the greater part of the day and night. There was a constant discharge of these small fibrous lumps. Juaging from a close examination, the tumor was not half so large as when first seen. 638 FIBROUS TUMORS OF THE UTERUS. The discharge continued without diminution until the fifteenth of August, when it became less, and the pain also decreased. At this time the upper part of the tumor could barely be felt above the sym- physis. The cervix was still long, but the mouth was less patulous, and the probe would not pass more than two and a half inches. Since the commencement of treatment the bloody discharge has not indicated a menstrual flow. In fact, the bloody discharge became progressively less, until it had entirely ceased about the middle of August. The patient's health greatly improved, and she was permitted to return to her home in the country. She wrote me on the 1st of September that she still suffered pain, and the discharge still con- tinued, but that it now had the appearance of pus, and was somewhat fetid for the first time. In October she wrote me again to say that there was no sign of the tumor; she had no pain and never enjoyed better health. She had menstruated twice since she had returned home, but the discharge at both periods was inoderate, and she had no pain. She continued the ergot up to the middle of September. Mrs. Arthur King, of Sterling, Illinois, called on me December 13th, 1875. She was thirty-five years old, married, and had never been pregnant. On the 1st of the preceding June she noticed a circumscribed hard lump two inches below and to the left of the umbilicus. She was the subject of serious uterine and sympathetic symptoms, for which she had at different times had treatment. She had profuse menorrhagia, leucorrhoea, and great sense of weight in the pelvis. Upon examination I found a hard, round, movable tumor, extend- ing up to within two inches of the umbilicus, filling up the whole of the right iliac, the hypogastric, lower half of the umbilical, and more than half of the left iliac regions. The contour of the tumor was somewhat uneven, though not dis- tinctly nodular. The cervix was long, pointed, and thrown backward and to the left. The sound entered the small uterine mouth and passed upward, backward, and to the left five and a half inches. The diagnosis was a fibrous tumor of the right anterior wall of the uterus. I prescribed thirty drops of Squibb's fluid extract of ergot to be taken three times a day. She went home, but did not commence taking the medicine until the 20th of December. On the 26th of December Dr. J. B. Crandall was called to see her, and describes her condition as follows: "The patient was in a state of great nervous prostration, and worn out by severe pain and loss of sleep. The pains commenced soon after taking tlie second dose of ergot, and were excruciatingly severe for about three hours, after which they con- tinued less severely for two days and nights. She had more or less hemorrhage from CASES. 639 the uterus after taking the ergot. Her pnlse was feeble, 110 to 120 to the minute. The skin was hot and dry, and she complained of great pain and tenderness over the uterus and lower bowels. The feet were drawn up, and the face wore a pinched and peculiar expression." Under these circumstances the doctor administered anodynes, tonics, and nourishment, to the great relief of the patient. On January 11th, 1876, the patient began to pass from the vagina small masses of fibrous substance, from the size of a chestnut to that of an English walnut. The substances thus discharged were firm and gray in color, and were exceedingly fetid. This discharge con- tinued up to the 21st of January, when the uterus was very much diminished in size, the tenderness had subsided, and the patient ap- peared comparatively comfortable. Up to that time she had taken but three doses of ergot, on the 20th of the preceding month, and the doctor ordered it to be resumed again. This time the ergot produced no pain, and after three or four days was discontinued. From the 21st of January there were no more pieces discharged, but up to February 1st a yellowish, thin, offensive fluid passed from the vagina in con- siderable quantities. On the first day of February the ergot was again ordered and continued two weeks, when, as no results ensued, it was finally dropped. Dr. Crandall states that on the 14th of February the uterus was re- duced to its normal size, and on the 26th the patient was up and about ' her work, completely cured. He remarked, in this connection, that the first three doses of ergot taken by the patient was the cause of her recovery. This case is published in the August (1875) number of the Chicago Medical Journal and Examiner^ as reported by Dr. Crandall. Mrs. L. D. M., aged forty-seven years, had a fibroid tumor in the anterior wall of the uterus, which, with the enlarged uterus, arose to within two inches of the umbilicus. She commenced taking thirty drops of the fluid extract of ergot on the 22d of Septemper, 1876, and was to increase gradually the dose with the object in view of causing the disruption and expulsion of the tumor. The ergot at first produced no perceptible effect until she had taken it ten days, when she began to experience the pain of contrac- tion. The pain became so severe and continuous that it was necessary to omit it for two or three days at a time. The patient was intelligent and understood the object and mode of action of the ergot, and when the pain entirely subsided, she courageously resumed it in the smaller doses, and increased again until the pains became intolerable. On the 13th of January, 1877, small pieces of the tumor showed them- selves in the vaginal discharges, and by the 26tli of the same month the whole of it had been discharged piecemeal. 640 FIBROUS TUMORS OF THE UTERUS, She wrote me on the 30th of January, saying : " I think I wrote one week ago to-day. At that time the tumor was passing. It continued to pass until the 26th, when, I think, the last was expelled. To-day I send you by express a portion of the last that came. I think the whole of it, including the portion I sent you, would have weighed one and a half pounds. I do not believe a quart can would hold it if the whole had been preserved. It commenced to come on Saturday, and from Saturday evening to Sunday morning there was a pint or more. After that, the stench was so disagreeable that we could not cleanse it, consequently we threw it away. Wednesday and Thursday it seemed to be in one continuous mass. I cannot better describe it than to say that it came like sausage-meat from a stuffer. I would cut off about four inches a day, that is on Wednesday and Thursday. On Friday morning the last of it came away." During, and for some days after, the expulsion she suffered slight symptoms of septiccemia, but recovered from them, and in the course of a month afterward she visited me, when I found the uterus meas- ured two inches and a half in depth. She then had some leucorrhcea, but was fast regaining her health. She is now perfectly well, and has passed in safety the menopause."^ The following case is reported to me by letter by William Fox, M.D., of Milwaukee, January 19th, 1880 : " Mrs. B., aged forty-three ; last child four years old ; did not get up well. Men- struation returned earlier than usual, and gradually became more frequent and pro- fuse, and of longer duration. Finally the abdomen began to enlarge so much that her friends believed her pregnant. But her health began to fail ; her losses became greater, and almost continuous. She was without treatment, as she believed her con- dition due to her time of life. An examination revealed a uterus as large as at the sixth month of gestation, and could be easily felt and moved through the abdominal walls. A sound entered five and a half inches, and with it in the uterus and the hand outside, a tumor could be felt in the anterior wall. The patient was put upon 30-drop doses of Squibb's extract of ergot, four times daily, and sent to consult Dr. Byford, February 3d, who confirmed the diagnosis and approved the treatment, and made a prognosis more favorable than I believed. He said, with the above treatment we would starve the growth, and possibly expel it. The period was detained a week, when it came on, February 21st, five weeks from the commencement of treatment, with a great deal of pain. The ergot was continued, the pain increasing, until, on the third day, I found the patient with a temperature of 105° ; pulse, 140, an offensive discharge, and complaining of a feeling as of some foreign body in the vagina. The vagina was full of a stinking mass, not unlike a placenta in feel, but harder. The os was quite open, and the fingers could readily pass into the uterus and describe the growth. All the gangrenous mass was taken away as fast as possible with the fingers and forceps, and the uterus carefully washed out with carbolized hot water every four hours. The ergot was discontinued because of the pain. Whiskey, quinine, and * This case, the abstract of which I have here given, was in the May 15th, 1877, number of the Archives of Clinical Surgery, N. Y. SUMMARY OF CASES CURED BY ABSORPTION. 641 milk constituted the treatment. She rapidly improved, and in less than a month was out driving, walking, and feeling well. In six weeks, menstruation returned ; came on without warning ; lasted less than three days ; the first natural period she remem- bers having had in four years. She has had three since, perfectly natural in every way. She is perfectly well." I have known ten cases in which the tumors were expelled piece- meal by ergot, with but one death. The death occurred in a patient who rode one hundred and fifty miles on a railroad train to see me, with pieces of the tumor hanging from the vagina, which she would not allow her physician to remove. When she arrived, I passed my fingers up into the contracted capsule and scooped out the remaining portion of the tumor. She was so exhausted, however, by the journey and the sepsis, that she died three days afterwards. I cannot help believing that if she had remained at home and sub- mitted to the treatment of her physician, her life need not have been sacrificed. Summary of Cases cured by Absorption. The total number of cases here cited is one hundred and one. Twenty-two of them are reported cured. In thirty-nine more the tumors were diminished in size, and the hemorrhage and other dis- agreeable symptoms removed. Nineteen of the remainder were bene- fited by the relief of the hemorrhages and leucorrhoeal discharges, while the size and other conditions of the tumors were unchanged. Out of the whole number only twenty-one cases entirely resisted the treatment. This shows results decidedly favorable in eighty of the one hundred and one cases. We may still further appreciate the favorable effects of the treat- ment by the consideration that in twenty-one cases it was suspended, which is as great a number as resisted treatment. It is also a noticeable fact that some of the cases in which the treat- ment was suspended were very much benefited by it. I have no doubt that man}^ more cases of fibrous tumors of the uterus treated by ergot might have been collected had time permitted, as I have heard of cases the history of which I could not obtain. In collating my cases, I have in no way selected or arranged them to influence inferences as to results, but I have faithfully recorded all I have received from correspondents, or found in journals, which were given sufficiently in detail to enable me to arrive at a correct idea of the treatment and its effect. 41 642 PIBEOTJS TUMOES OF THE UTEEUS. Hildebrandt I 27 Bengelsdorf [ 4 Ciirobak | 9 Atthill I 3 White j 14 Goodrich | 1 Howard | 2 Jackson i 8 Ether idge 1 Merriman 4 Fisher 1 Morris 1 Buckingham 1 Cowan 1 Dean ' 2 Wey 1 Hodder 4 Jukes 1 AVarner 2 Bvford 9 Allen 1 Thomson 3 Russell ' 1 Total 101 r- S " iC S2gS E.S c o 11 22 39 19 21 "WTiile I could add to the numlDer of cases contained in this tahle, they would not affect the deductions from it. Modes of using Ergot. Not much uniformity has been observed by the writers above quoted in the manner of using ergot. Drs. Hildebrandt, Bengelsdorf, Chrobak, Atthill, and Jackson recom- mend, and use it hypodermically. Drs. White, Jenks, and Howard administer it hypodermically, inter- nally by the stomach, and in the form of suppositories in the vagina and rectum. Some of the arguments in favor of the hypodermic injections are : 1st. It acts more rapidly and with more certainty. 2d. It does not produce the gastric disturbances sometimes caused by ergot when taken internally. 3d. It can be administered in this way when it is entirely impracticable to give it internally on account of the great exhaustion or gastric irritability of a patient. The main objections to the hypodermic method seem to be: 1st, the pain inflicted by the needle; and, 2d, the inflammation and sup- puration which ensue. Dr. Hildebrandt has met Avith but one case where the pain of the MODES OF USING ERGOT. 643 puncture was an objection to its hypodermic use. With regard to abscesses he says : " I am sure I do not exaggerate when I say that up to the present time I have myself made one thousand hypodermic injections of ergotin for various purposes, or have seen them made and observed their results in the clinical wards in charge of my assistants." And he then adds : " I have never seen an abscess fol- low the injections made by me personally, and only in three clinical cases did this occur. The chief reason why no abscesses formed among the large number of other injections is that I always injected the fluid very deep into the subcutaneous cellular tissue — perhaps even into the abdominal muscles." Dr. Atthill met with this difficulty in all three of his cases, although he also injects the fluid deep into the tissues. Dr. Chrobak was obliged to desist from treatment on this account, in four out of his- nine cases. Dr. Cowan was interrupted in his case by the formation of abscesses. Thus it will be seen that much difficulty is experienced by many in carrying out the treatment. Dr. Hildebrandt's reason does not seem to be the only one why practitioners are so troubled with this objection, since Dr. Atthill and others have also injected deeply. As far as I can judge, very few have been able, even by the most careful efforts, to achieve the same happy results in this respect as Dr. Hildebrandt. Dr. Hildebrandt, and also Dr. Atthill, select the lower part of the abdomen as the part in which to make the injections. Dr. Keating, of Philadelphia, injects just posterior to the great trochanter. Dr. Jackson selects the deltoid region, and thinks it makes but little difference where the insertion is made. Dr. White, of Buffalo, injects over the abdomen, into the cervix uteri, and into the substance of the tumor if it is accessible, and has met with no bad results. Dr. Wey used over two hundred injections in the abdominal region above the pubes in one case, and abscesses occurred in the seat of the puncture as often as once in eight operations. Dr. Dean commenced using ergot in the form of Squibb's fluid extract by injecting it into the cavity of the uterus through a flexible catheter, but now he employs the solution of Squibb's solid extract dissolved in water — one grain to five minims. Of this he injects from ten to fifteen drops into the substance of the cervix about four times a month or once a week. He thinks the effects are more prompt and energetic than when administered hypodermically. His instrument consists of a barrel the same size as the common hypodermic syringe and a tube six inches long. He has known inflammation and sup- puration to follow but once in his whole experience. 644 FIBROUS TUMORS OF THE UTERUS. Different Preparations. Believing the preparation of the medicine employed had much to do in causing the irritation thus observed, efforts have been made to find some form that would not produce the painful results thus de- scribed. Hildebrandt is now in the habit of using Dr. AVernich's formula for the watery extract of ergot, and Dr. Munde thinks it is very simi- lar to the preparation made by Dr. Squibb. Dr. Hildebrandt added pure glycerin in the proportion of about one part to four of the solu- tion, and the amount of the injection was forty minims. This con- tained a little over two grains of the extract, probably representing ten to twelve grains of the crude ergot. Most American practitioners now use Dr. Squibb's preparation above referred to, some of them by dissolving it in pure water, while others add to the water a small amount of pure glycerin. Dr. Squibb recommends a solution of this extract as follows : Dissolve two hun- dred grains of the extract in two hundred and fifty minims of water by stirring ; filter the solution through paper, and make up to three hundred minims by washing the residue on the filter with a little water. Each minim of this solution represents six grains of ergot in powder. Of this solution from ten to twenty minims are injected once daily, or once in two days. This is the only preparation I have used in hypodermic injections, and I believe it the best we can at present procure. Dr. Wey properly lays great stress on the necessity of having the solution fresh, believing that in a very short time it deteriorates, and becomes more irritating to the tissues. He says : " Ergot thus ad- ministered generally produces prompt effects." In most instances, in half an hour the patient experiences painful contractions of the uterus. The hand applied over the organ at once recognizes the in- creased hardness in the mass. These contractions increase in severity for the first two hours, and then continue with vigor for from six to ten hours, gradually becoming less until they cease entirely. Some patients suffer so much from these pains as to refuse to proceed in the treatment, while others bear them without much inconvenience. We do not always observe these painful effects even when the drug operates very beneficially. Sometimes the hemorrhages are controlled, as it were, insensibly, and the tumor slowly decreases in size without the patient experiencing any considerable discomfort. It seems highly probable, from the statements made by my correspondents, and espe- cially Dr. Wey, as well as my own o-bservations, that the benefits of the remedy are produced with more rapidity in the early part of the treatment. The preparation used internally more frequently than any other is DIFFERENT PEEPARATIOXS. 645 the fluid extract, either alone or in combination with belladonna. Each minim of Squibb 's fluid extract is equal to one grain of ergot. Some recommend that it be given in doses of thirty drops three or four times a day. Others believe that it should be given in larger doses less frequently repeated, as, for example, one drachm once or twice in twenty-four hours. It is efficacious given in either way, but probably more so in the larger and less frequent doses. This prepara- tion is so offensive, and causes so much nausea in exceptional instances, that it cannot be borne. Dr. Squibb claims that his solid extract does not offend the stomach so frequently as the fluid extract. This extract may be used in pills coated with gelatin. A pill of five grains is equal to twenty grains of the crude ergot, and may be administered twice or three times daily. From observation of the effects of the different preparations, I am satisfied that this is altogether the most efficient and agreeable for internal administration. A suppository for the rectum, which, in Dr. White's practice, acted satisfactorily, may be comjDOsed of fifteen grains of the solid extract, and enough gelatin to give it size and form. I have no doubt of the great usefulness of this method of administering ergot. I think it is also quite certain that the addition of belladonna in some cases increases the curative effects of ergot; how much, I am not quite sure. Dr. Goodrich, who reached such splendid results, gave the fluid extract of ergot and belladonna together throughout the entire treatment of his case. From what has been said it may be inferred that hyiDodermic in- jection, if the most efficacious, is also the most objectionable method of using the ergot, and that in many cases the exhibition of it in this way is rendered entirely impracticable, because intolerable, to the patients. May we not hope for great improvement still in the pharmacy of ergot ? Ergot produces many good effects besides reducing the size of the tumors and relief of hemorrhage. I have seen, and some of my correspondents mention, great functional improvement in the more important organs. Some patients are relieved by it of obstinate constipation ; the appetite is improved, and the general health restored. This remarkable salutary effect is obviously due to its action on the ganglionic nervous system. In exceptional instances ergot has very disagreeable effects. Dr. Goodrich mentions inflammation of the uterus as one, and my patients often complain of great heat and tenderness in the uterine region. Hildebrandt speaks of one case in which, after the sixth injection, the patient complained of vertigo, imperfect control of her lower extremities, and slight spasms of the flexor muscles of the forearm. Dr. Wey observed severe general nervous perturbation to follow its use in one instance. And Dr. 646 FIBROUS TUMORS OF THE UTERUS. Morris's iDatient discontinued treatment because of the terrible and tumultuous effects upon the uterus. Dr. E. P. Allen, of Athens, Pennsylvania, sends me the report of a very interesting case of fibrous tumor treated by hypodermic injec- tions of ergot, in which phlebitis supervened. A condition of one limb was produced precisely similar to j)hlegmasia alba dolens, and ran its protracted course to a favorable termination. Prior to the accident the tumor had very much decreased in size , but, after the treatment was suspended, and during the course of the phlegmasia, it rapidly increased again, and the hemorrhages which had been con- trolled returned. After trying other methods of treatment without any good results, he and his patient in despair were driven to the use of ergot again. It was tried internall}^ with some good effects, but as the remedy thus administered disagreed with the stomach, it was again injected hypodermically with rapid improvement. The injections were used on the side of the abdomen, opposite to that formerly affected with 23hlebitis. After a number of injections, signs of in- flammation of the veins Avere again observed, and the sound leg passed through all the stages of jjlilegmasia that had been observed in the first. From the intelligent observation of Dr. Wey and others, we may fairly conclude that it is not improper to continue the use of ergot during the menstrual flow. I can also add my testimony as to its entire harmlessness when given during that periodical flow. Auxiliary Treatment. With the exception of Drs. Goodrich and Howard, all the writers and correspondents quoted have depended exclusively on ergot for the removal of fibrous tumors of the uterus ; in fact, the treatment has been experimental, and had for its object the solution of the question suggested by the publication of Hildebrandt's articles on the use of ergot, viz.: Will ergot cure fibrous tumors of the uterus? The course pursued was well calculated to, and I think did, test Hildebrandt's treatment pretty thoroughly, but it is doubtful whether this exclusive- ness is the best practice. The well-known alterative and sorbefacient medicines have, in rare instances, been credited with the cure of these tumors without the aid of ergot, and it is not difficult to understand that absorption may be promoted with more certainty by the alkaline bromides and iodides, where the vitality of the tumor is first impaired by the action of ergot on its vessels and the muscular fibres surround- ing it. Dr. Goodrich seems to have held this view of the alterative treatment, as he prescribed iodide of potassium and bichloride of mercury with ergot. Dr. Howard also employed alteratives in the same way. Both of these gentlemen combined belladonna with ergot. The efficiency of this combination, as represented by their reports, justifies us in believing that the alteratives employed by them CORRECTIVE TREATMENT —MODUS OPERANDI. 647 were auxiliary in a high degree. How much may be effected by ju- dicious alterative and other auxiliary treatment will, doubtless, be determined by future observation. Corrective Treatment. By this I mean treatment that will prevent or ameliorate the dis- agreeable effects of ergot in certain exceptional instances. The dis- tressing pain caused by it may sometimes be made more tolerable by the administration of hydrate of chloral, without very materially in- fluencing its other effects. Indigestion, constipation, hydrgemia, and nervous debility may be corrected by tonics, alteratives, laxatives, and stimulants given simultaneously with ergot. In short, the general condition of the patient should be cared for in the same rational manner as if ergot was not being administered. Modus Operandi. The influence of ergot over the uterus has been a familiar fact to the profession for a long time. It is not long, however, since we were aware of its effects upon the muscular fibres entering into the forma- tion of other organs. We now know that this medicine acts upon the unstriped muscular fibre wherever found, whether in the viscera or in the vessels of the body. ' The fibres of the uterine walls, and the arteries supplying them with blood, both belong to this class ; this fact in the formation of the uterus renders it particularly susceptible to the action of ergot. The drug acts upon the uterus in a threefold manner, and causes a dimin- ished flow of blood to the morbid as well as healthy tissues in the uterine structure. 1st. The calibre of the arterial tubes is diminished by the contrac- tion of the muscular fibres which enter into their composition. 2d. The arterioles are diminished in size by compression from the con- traction of the uterine muscular fibres which surround them. 3d. These vessels are distorted and drawn in diverse directions by both the contraction and compression, and hence are rendered less fit for sanguineous conduits. Another consideration of prime importance is that, under the influ- ence of these medicines, the nutrition of fibrous tumors is interfered with, not only from diminution of blood in their tissues, but also from compression of their substance by the proper fibres of the uterus, their trophic energies are arrested, and are therefore made more susceptible to the process of disintegration and absorption. The great influence exerted by ergot over the circulation of the uterus is rendered more efficacious in the removal of fibroid tumors of that organ, because of the peculiar organization of the growths. It 648 FIBROUS TUMORS OF THE UTERUS. is now pretty well understood that this neoplasm is not very gener- ously supplied with arterial blood, and that its supply is derived from numerous minute vessels instead of one or two of larger calibre. From these circumstances it results that its vitality is very low, its circula- tion easily disturbed, and consequently its nutrition impaired. I think we are justified from observation in assuming that the action of ergot may be graded from an almost imperceptible to a very intense degree. Probably the first degree affects the vascular supply ; the second, in addition to this, causes so much contraction as to merely render the fibres tense without causing pain ; and the third prompts the uterine fibres to vigorous and painful contraction. This inference is ]3lainly deducible, I think, from the several modes by which tumors are made to disappear under its action, as well as from direct observation of the uterine fibres. I will now venture to call attention especially to the manner of ex- pulsion of the polypoid and submucous intramural varieties. It will be seen from Fig. 286 that when the uterus contracts, all the fibres Fig. 286. Fibroid Polypus. Submucous Fibroid Tumor. unite in pressing the polypus through the cervical canal, which is usually already shortened, and rendered dilataljle in consequence of its increased vascularity. The cervical canal dilates, and after more or less painful efforts the polypus is expelled entire, covered by the mucous membrane. This membrane is often in a state of gangrene, but so far as I have observed these cases, the tumor is not broken to pieces. Fig. 287 represents an intramural fibroid between the central line of the uterine wall and the mucous membrane. It is intended to MODUS OPERANDI. 649 show a tumor where a thin layer of fibres separate it from the mucous membrane, and how a thick and heavy layer is spread over its exter- nal hemisphere. Three-quarters of the thickness of the muscular wall are applied to that side of the tumor. If in this position all the fibres of the uterus vigorously contract, the fibres near the mucous mem- brane must be overcome by the heavy layer outside (at c). But the opposite wall of the uterus plays an important part by supporting the weaker layer at the fundus of the tumor, and adding its own force in overcoming the capsule (at e), where it usually gives wa3^ The posi- tion of the tumor makes its escape from the concentric action of all the fibres of the uterus impossible, and every one knows that when Fig. 288. Sub-peritoneal Fibroid Tumor. the resistance is partially overcome, the uterus is stimulated to more vigorous action, and the pains will not abate until the mass is ex- pelled. If not too large, it is driven out without undergoing great laceration, but if its size and attachments are such as to make this impracticable, it will be broken into fragments and expelled piece- meal. Allow me to supplement the above description by explaining the effect of ergot on the sub-peritoneal and central intramural tumor. In Fig. 288 we see the disposition of the fibres on the sub-peritoneal variety ; next the uterine cavity there is a thick and strong stratum of fibres, while immediately under the peritoneum the layer is very thin and comparatively weak. When the uterus is acting with vigor, 650 FIBEOUS TUMOES OF THE UTERUS. the fibres between A and B will cause those two pomts to approxi- mate each other, and the tumor will become pediculated ; but that is all, for the tumor lays outside the field of concentric action and escapes the crushing infiuence to which the submucous variety is subjected. The amount of force exerted upon it is that exercised by the weaker laj^er of fibres in a state of conquered antagonism, and the rupture of the capsule is impossible. If we take Fig. 289 as a correct representation of the fibrous tumor when situated in the central stratum of fibres, in which the antago- nism is equal at all points, it will be evident that there is no ten- dency to rupture of the capsule, and much less crushing influence exerted upon it than if it were situated slightly nearer the mucous membrane. Fig. 289. Intramural Fibroid Tumor. This variety of the tumor, therefore, yields to the influence of ergot, only as it may be " starved out " by diminution of its blood supply, and as the eff"ect of pressure, which we all know are the two conditions most favorable to absorption. Now I think we have arrived at a point in this investigation where we can draw inferences as to the forms of tumors likely to be aff'ected by ergot in different ways, as well as those that will not be afi'ected by it. We do not expect ergot to cause painful and efficient contractions in the healthy unimpregnated uterus ; its fibres are not capable of such contraction, and it is not until the fibres have become greatly developed that they are susceptible to the impressions of ergot. In cases of early abortion, its action is very unreliable, but after the fourth month of pregnancy it acts quite efficiently. In tumors of the uterus, the development of the fibrous structure MODUS OPEEANDI. 651 is sometimes so slight that it is incapable of contraction ; there may be so many nuclei of degeneration that there are not enough sound fibres left for efficient contraction. Then, where there are many small tumors developed in the uterine walls, the circulation is cut off to such a degree that they degenerate into a cartilaginoid substance, and sometimes they are infiltrated with calcareous material. In none of these cases will ergot cause any appreciable results. When, how- ever, there are but one, two, or three nuclei of morbid growths, as they increase in size the fibres undergo the development necessary to enable them to contract with great efficiency, and render them sus- ceptible to the influence of ergot. Another condition which influences the hypertrophic growth of the fibres is the situation of the tumor. Subperitoneal tumors do not cause as great growth in the fibres of their neighborhood as the intramural or submucous varieties. A single intramural tumor causes great development of the whole uterine tissues, but the development of the wall in which it is situated de- cidedly predominates. The submucous neoplasm so soon gains the uterine cavity that the development is nearly the same in the whole organ. When, therefore, we administer ergot for the cure of fibrous tumors of the uterus, the beneficial action of the drug will depend upon the degree of development of the fibres of the uterus, and the position of the tumor with reference to the serous or mucous surface. The nearer the mucous surface, the better the effects. If the tumor is very near the lining membrane, we may hope for its expulsion en masse, or by disintegration. We can often select the cases in which good results may be expected. There are four conditions which are usually reliable for this purpose. They are: smoothness of contour, hemorrhage, lengthened uterine cavity, and elasticity. A smooth, round tumor denotes, for the most part, uniform textural development, hemorrhage, a certain proximity to the mucous membrane, a lengthened cavity, great increase in the length and strength of the fibres ; and elasticity assures us of the fact that cartilaginoid or calcareous degeneration has not begun in the tumor. An uneven, nodulated tumor may be composed of many separate solid masses. These displace and prevent the growth of the fibres to such an extent as to render contractions inefficient. When hemor- rhage is not present, the tumor is probably near the serous surface, and consequently not surrounded by fibres. A short cavit.y denotes short, undeveloped fibres, while hardness is indicative of unimpress- ible induration. Although I have no experience in the use of ergot in such cases, I should expect large fibro-cystic tumors to resist its action. 652 FIBROUS TUMORS OF THE UTERUS. From this view of the subject, it will be seen that I freely admit that there is a large number of cases in which ergot cannot produce any good results in consequence of their nature. Another reason of equal moment why ergot may fail to act upon such cases as would seem to be favorable, is the worthlessness of the drug and its preparations. Dr. Squibb, of New York, a high authority, says in reference to this subject: "The molecular constitution of the active portion of the drug seems, however, in its natural condition to be loose, and, like a slow fermentation, to be undergoing slow molecular changes, so that by age its peculiar activity is slowly diminished until finally lost." And again : "The ergot in the grain, however well kept, is known to become inactive without any known change in appearance, though the sensible properties, such as odor and taste, may and probably do not change. Ergot, in powder, is known to diminish in activity much more rapidly than when in grain, and probably soon becomes inert. The tincture and wine of ergot are believed to cliange, though more slowly than the ergot in substance ; while the extracts, and so-called ergotins, are all supposed to change more rapidly." These facts, so explicitly stated by Dr. Squibb, are very sugges- tive as to the causes of the frequent failures of ergot, and need no comment. When all these causes of failure are considered, the variety of ex- perience met with in the reports upon its trial in the treatment of these tumors is not surjorising. It should not, however, be discour- aging, but should prompt us to more care in selecting the cases and securing reliable preparations of ergot. I have implicit faith in the action of ergot when all the conditions I have pointed out are present. I do not believe it to be uncertain in its action. In addition to the above conditions, I believe perseverance an in- dispensable condition to success, as it often requires several months to get the best results. In concluding, I desire to disclaim any expectation that ergot will supplant other modes of treatment. The expert surgeon will, as he always has, use his instruments to the neglect of remedies less sum- mary in their effects, and in his hands the maximum of safety will obtain ; but there are very few general practitioners who ought, or would be willing, to undertake enucleation of fibroid tumors of the uterus. I do claim, however, that the judicious gynecologist will lose fewer patients, and make more cures, by the consistent adminis- tration of this medicine than can be looked for from surgery. I am surprised that others who have written upon the subject should be so incredulous as to the effect of ergot, and the only way I can account for it is what, I think, I can see in their practice as MODUS OPERANDI. 653 related by themselves, viz., that they do not give it a fair trial. They fail to give it in large enough doses and persevere long enough in its use. The treatment of some of my successful cases extended over many months. When the pains that indicate efficient action, and always precede disruption and expulsion occur, the practitioner gen- erally becomes alarmed, gives anodynes, and withdraws the medicine, thus abandoning the case, and declaring that ergot is a dangerous remedy. If he had witnessed the same, or even severer, pains in labor, he would have encouraged them, and so he should do in ex- pelling the tumor, and the result would be a safe delivery. The tumor would be expelled and the patient relieved. Before drawing my remarks on the use of ergot to a close allow me to mention some of the queries that have arisen in my own mind, or have been propounded to me by medical men. If the ergot acts so powerfully in expelling submucous tumors, is there not danger that it may rupture the capsule of the subserous variety, thus expelling them from the uterine substance into the peritoneal cavity, and en- danger the life of the patient by causing peritonitis ? A proper con- sideration of the conditions existing in such cases will justify my answering this query in the negative. There is a great difference in the influence exerted by the uterine fibres on the two varieties of tumors. In the submucous variety the whole power of the uterine contractions is exerted toward the tumor, driving it in the direction of the OS uteri. When the tumor is subserous the contractions are from the axis of the tumor, and their effect is merely to render it pedunculated, and lessen the vascular supply going to it. The main effect, therefore, will be to check the rapidity of its growth, or to prevent its further enlargement altogether. This statement will suffi- ciently explain the effects of the medicine upon this variety of these morbid growths. Another question is, does the long-continued ad- ministration of ergot induce the gangrene of the extremities, that has been attributed to it ? And still another, does it cause inconvenience or danger by affecting seriously the nervous centres ? After having given this remedy in frequently repeated and large doses, and ob- served its effects with great care for a number of months consecu- tively, I can say that I have not noticed any such consequences. I am not prepared to assert that there is, and always will be, immunity from such effects. The worst symptoms I have witnessed are the severe and persistent pains, and the apparent inflammation of the uterus and peritoneum, where its action has been excessive. These symptoms, however, have been invariably controlled by proper treat- ment, and have in no instance proved disastrous. In other cases, when the tumor was slowly disintegrated and expelled, a moderate form of septicaemia has invariably occurred ; but this condition has not been sufficiently grave to excite alarm in my mind. 654 FIBROUS TUMORS OF THE UTERUS. A simultaneous employment of sorbefacients and the administra- tion of ergot would, doubtless, in some cases prove more efficacious than either alone. But I am free to confess that this conclusion, so far as I am concerned, is arrived at more from therapeutic inference than observation. As I am giving the results of my own observation, more than those derived from the research of others, I deem it but fair to state that I have not given this combined method of treatment an extensive trial. We should remember, in the employment of any course of treat- ment for the cure of these fibrous tumors, that reliable results are not to be obtained without the long-continued use of the remedies, and a thoughtful management of them in individual cases. And I must say, in this connection, that I believe a want of these considerations has led to much false experience. The treatment of fibrous tumors, located in other organs than the uterus, will not serve as a useful guide in the management of the uterine neoplasm. The same con- ditions do not exist elsewhere. The tumors are nowhere else sur- rounded with muscular fibres whose action can be commanded by any remedy within our knowledge. Whether the observation of the pro- fession at large will or will not at present bear me out in my earnest belief in the curability of some of these tumors by the means I am now teaching, I do not know ; but I am sure that there is so much logic in the method that it deserves a much more extensive trial than has hitherto been made of it. Treatment by Electricity. Recently the treatment of uterine myomata by electrolysis has re- ceived considerable attention. The pioneers of this method were Drs. Cutter, Kimball, and Brown. At a meeting of the American Medical Association in this city, Dr. Cutter illustrated his method of operat- ing. He uses electrodes invented especially for this purpose. They are spear-shaped and mounted upon handles, in order that they may be directed with the more certainty, and made to penetrate hard, fibrous growths without deviating from their intended course. The blades are five and one-half inches long, and are insulated to within nearly one inch of the point. Two of these electrodes are inserted through the abdominal wall into the substance of the tumor, the points being separated by a space of several inches. Through these electrodes a galvanic current is passed, the electricity being generated by eight pairs of carbon and zinc plates, excited by saturated solu- tion of potassic bichromate and sulphuric acid, one part of the former to two of the latter. The time allowed at each sitting varies from three to fifteen minutes. It was said that this operation did not pro- duce much pain, and was usually followed by a copious flow of urine. TREATMENT BY ELECTRICITY. 655 The number of operations for the individual cases varied from one to nineteen, and the intervals between them from a day to two months. In certain desperate cases this seems to me to be a valuable resource. ApostoWs Method. In 1882 Apostoli* began using electricity for these tumors in a somewhat different but apparently no less efficacious manner. In- stead of puncturing the abdominal walls, he places one pole over the abdomen and another within the uterus. When the uterus cannot be sounded he punctures the tumor either from the vagina or from the highest available point in the cervical or uterine cavity. The external electrode is made of a thin layer of wet potters' earth spread over the ab- domen so as to lie in intimate contact with the skin over a surface about twelve inches in diameter. This enables him to use a current of 100 milliamperes without harm or inconvenience to the patient. In 1887 Dr. F. H. Martin,t of Chicago, constructed an abdominal electrode of animal membrane with which he has used 300 to 400 milliamperes. The internal or active electrode is the isolated end of a platinum or gold sound, and acts upon the entire length of the uterine cavity, or upon the canal made in the substance of the tumor by a sharp-pointed electrode. He employs as strong a current as the patient can bear without discomfort, and continues it from one or two minutes to twenty, or an average of five to ten, and maintains that a mild current of longer duration does not have the same eff'ect. With these large external electrodes the strength of the current is determined by the eff'ect produced at the internal. From 100 to 150 milliamperes is the maximum intensity that can be tolerated with an ordinary internal electrode about three inches in length. When the internal electrode can be made longer or larger the intensity may be made still greater. In all cases it is, however, necessary to commence with a mild current and increase its strength gradually. The treatment is continued until the patient is relieved of all symptoms referable to the tumor, and sometimes longer. The average number of treatments is from twenty to thirty, although sometimes not half that many, sometimes many more, may be required. The removal of large tumors is not usually attempted after the symptoms are relieved, as that requires more time than the patient, and probably the physician, cares to spend in the trial. Nevertheless, some of the small ones have disappeared and many large ones have become smaller. The best time for the application is between the menstrual periods * Traitement Electrique des Turueurs Fibreuses de I'Uterus, L. Carlet. f Treatment of Fibroid Tumors by Electrolysis. Jour. Am. Med. Ass'n, April 23, 1887. 656 FIBROUS TUMORS OP THE UTERUS. and while the uterus is not bleeding, although Apostoli sometimes makes them for the purpose of checking existing hemorrhage. Modes of Action, It is difficult to determine just how electricity acts in these cases, but it jDrobably acts in several different ways. The fact that the tumors are of a low grade of vitality, and that they are surrounded by muscular tissue easily brought into action, renders them subject to an arrest of growth from comparatively slight causes. Their intimate connection with the nutritive changes of the uterus also has much to do with their growth and decay. The following are perhaps the principal kinds of action produced by the electricity : 1. The excitement of inflammation in the substance of the tumor, interfer- ing with its nutrition and producing absorption of its degenerated elements. This is probably the manner in which the applications formerly made by Cutter, Brown, Kimball, T. G. Thomas, Baker, and their followers, act. 2. The electric current is supposed, in these low forms of tumor, to have an electrolytic action^ breaking up the chemical combinations so that the acids accumulate about the positive pole and the bases about the negative, and are thus cast off and absorbed. Just how this can occur to any considerable depth in living tissue without destroying its life along the course of the current, any more than the stomach can digest itself, would, however, seem incomprehensible. 3. A chemical or caustic action is, however, more easily understood, and is one of the most important factors in Apostoli's method. His observations go to show that when the external electrode is connected with the positive pole the hemorrhage may be checked. The tissues are cauterized and hardened in much the same way as if they had been seared by the actual cautery at a low heat. In cases of subperi- toneal fibroids without hemorrhage he connects the negative pole with the uterine sound and produces sloughing and hemorrhage, and thus claims to deplete them. As the explanations are entirely theoretical, it is, I think, as reasonable to suppose that the negative pole checks the hemorrhage by simple, moderate but deep cauterization and subse- quent cicatrization, and that the positive pole diminishes the nutrition of the subperitoneal tumors by cauterizing and cicatrizing the uterine walls about their bases or pedicles. 4. Electricity also acts as a poucrful stimulant to uterine contraction, and may do so both during and after the treatment without causing pain. Such painless contraction occurs after labor, abortion or mod- erate uterine dilatation. That this contraction diminishes the vitality of the tumor there is little doubt, although it may play but a sub- TREATMENT BY ELECTRICITY. 657 ordinate part in the treatment by electricity. The cauterization also acts as a stimulant to contraction in the uterine walls. 5. A local alterative or atrophizing influence must also be attributed to this treatment. The disturbance of such a powerful electric current to the organic nerves, and to the vitality of the cell structure, must have a decided, albeit a secondary or adjuvant action. Dangers Attending its Use. The dangers of this treatment are great unless the operator is thor- oughly competent and extremely careful. However, a minute study of the technique as taught by Apostoli renders his method a perfectly safe one to emplby. But the puncture of the tumor from the abdo- men must always be attended by some danger, and also requires the use of an ansesthetic. Carelessness in the introduction or isolation of the probe, or in making the puncture per vaginam, may lead to disagreeable or serious consequences. Sudden interruptions in a powerful current would cause serious shock, as might also a sudden increase in its intensity. Severe exertions, exposure, venereal indulgence, etc., after a treatment must also be guarded against among the careless and less intelligent patients. 42 CHAPTEE XL. SURGICAL TREATMENT. Removal of Polypoid Tumors. The first thing I have to say about the operations intended for this purpose is that they should be as simple as possible, compatible with thoroughness. It is not necessary to exemplify this idea. It is self-evident, and yet often ignored. The most effectual plan of avoiding danger is to have a distinct idea of the sources whence the danger may arise, and in connection with these tumors dangers may arise (1) from laceration, contusion, or other damage to the uterus, resulting in hemorrhage or inflammation ; (2) incomplete ablation, — the remaining portion producing septicaemia; (3) shock sometimes following protracted efforts at removal. This last is a very important source of peril. These dangers will, therefore, for the most part be proportionate to the extent of manipulation and instrumental procedure and the incompleteness of the operation. The old operation of tying the neck of the tumor, and allowing it to slough away, especially when it was situated in the uterine cavity, combined all the causes of danger above enumerated except that arising from hemorrhage ; and it is a curious fact that this operation was invented for the sole purpose of avoiding hemorrhage, which is really the least dangerous of all, according to my observation. Indeed, I have never seen serious hemorrhage caused by the removal of a polypus however effected. The practice of ligating the tumor and then amputating it is to a less degree open to the same criticism. Torsion or amputation are the methods now usually employed by the best gynecological surgeons of the present day, and the first is the one I have for several years resorted to in almost every instance. Amputation may be performed by the scissors, knife, by the ecraseur, or galvano-cautery wire. All possible danger from hemorrhage will be avoided by the last means indicated ; but I may state that there is scarcely any danger of hemorrhage from the use of either of the other instruments. Torsion is performed by seizing the tumor with strong vulsellum or fenestrated forceps and twisting the tumor several times around and making moderate traction until the detachment and removal are completed. In order to amputate a polypus when the tumor is partially or wholly expelled from the uterus the tumor should be drawn down with one of the forcejDS mentioned until its EEMOVAL OF POLYPOID TUMOES. 659 attachment is brought into view, when with the scissors or the knife the neck may be divided as close to the uterine attachment as possible without cutting the substance of the uterus ; or the neck of the tumor may be surrounded by the 6craseur or galvano-cautery wire and sepa- rated by it. A tumor attached to the fundus, or high up in the body of the uterus, cannot always be drawn down and amputated in this way without causing inversion of the organ, and consequently a knife in the shape of the blunt hook in our obstetric case, with an edge upon the concavity of the curve, will be necessary. This may be in- troduced and guided as nearly as possible to the j)oint of attachment by the finger or hand. This process is very much facilitated by a piece of twine passed through a small hole in the extremity of the hook ; the twine should be long enough to hang out of the vagina and give a firm hold. When placed, the convexity of this knife should be turned towards the neck of the tumor and a sawing motion executed by the handle and twine until the tumor is cut through. The chain of an ecraseur may be carried to or near the point of attachment by means of two flexible rods with small holes in the ex- tremities. The wire is passed through the opening at the ends of the rods, and being held closely together they are introduced, carried behind the polypus, as high up as possible. One of the rods is then held in position while the other is carried around the tumor, thus en- circling it by the wire. Sometimes it will be easy to pass the wire by drawing a loop of it through the perforated ends of the rods, large enough to pass entirely around the lower end of the tumor, and as the rod ascends, the wire surrounding the polypus is carried up to the point of attachment. When well placed, the ends of the wire may be fitted to the ecraseur, and that instrument carried up to the ends of the rods. The ecraseur can then be manipulated until the tumor is separated. There is no need of removing the rods from the wire before the ecraseur is fixed, as their presence does not complicate the operation. All this explanation presupposes an open or dilatable condition of the OS uteri which does not always exist. If the mouth of the uterus is not already thus patent, it should be dilated by compressed sponges until it will admit of free access. It requires much experience and tact to perform this operation with the 6craseur, and we will find in the books and periodicals a number of instruments intended to facilitate the application of the wire to the neck of the tumor. The dangers connected with this operation are those caused by the protracted efforts to replace the chain or wire of the ecraseur, and an inability always to remove the whole tumor. The operation of torsion can be performed when the tumor wholly or partly occupies the vagina without any preparation, and is prefer- 660 SUEGICAL TREATMENT. Fig. 290 able, because the tumor is removed at the point of attachment. The reason of this is, the point of attachment is always the weakest, and yields to the force applied before any violence occurs to the other parts of the tumor or the uterine tissue. The tumor is thus com- pletely removed, and without protracted manipu- lation. No hemorrhage results for two reasons : 1, there are no large vessels entering the tumor, and the small ones are torn instead of being cut as in amputation ; 2, septicemia does not occur, for no portion of the tumor is left to slough. When the tumor is higher up, or within the cavity of the uterus, torsion is equally appropriate, and more easily executed than amputation with or without ligation. Of course if the mouth of the uterus is not open enough to permit the seizure of the polypus at a point high enough to secure a sufficiently firm hold upon it, dilation is just as necessary as in the other operations. The amount of dilation, however, will not need to be so great. In performing this operation, the operator must guide the forceps with his fingers to the part of the tumor necessary to enable him to fasten the instru- ment uj)on or near the central part of the polypus. In two instances where the tumor was too large to be firmly held by any forceps at my command, I introduced the hand inside the uterus and detached the tumors by rotating them with the hand, after- wards making traction with the forceps. I brought them into the vagina and delivered them with the obstetrical forceps. One of these weighed forty- six ounces. To perform torsion for the removal of a polypus, the surgeon, after fixing the instrument firmly in the desired position, should be careful to twist it enough to be sure of its detachment before com- mencing traction. Not less than from four to six complete revolutions should be effected. This pro- cedure will prevent the danger of lacerating the tissues of the uterus. The greatest objection urged against the opera- tion of torsion is the likelihood of lacerating the wall of the uterus at the point of attachment. If we will call to mind what was said about the rela- tive thickness of the muscular strata upon each side of the different kinds of fibrous tumors, Ave' will at once perceive Chassaignac's ]fecraseur. EEMOVAL OF POLYPOID TUMORS. 661 the groundlessness of this objection. In the pendulous variety the whole wall of the uterus is outside the point of attachment and is strong enough to resist the very few fibres that are carried down with it. Indeed, in the polypus there is almost no substantial attachment Fig. 291. Small Vulsellnm Forceps. except that formed by the investing mucous membrane. If, therefore, the torsion is performed with sufficient thoroughness before traction is begun, laceration of more than the superficial tissues surrounding Fig. 292. Medium-sized Vulsellum Forceps. the neck of the tumor is next to impossible, and consequently the operation is perfectly safe. Hemorrhage is not so likely to occur after torsion as when the tumor is amputated by the knife, or scissors, or even by the ecraseur. Fig. 293. Large Vulsellum Forceps. The danger of hemorrhage, then, is an objection that cannot with any show of reason be urged against torsion. I have never seen hemor- rhage succeed torsion. The contractions of the uterus which take place after removing the polypous growth from the cavity of the uterus, in the great majority of cases, is as effective in the prevention of hemorrhage as it is when its contents are expelled at the time of labor. I trust that it is not necessary to dilate further upon this part 662 SURGICAL, TREATMENT. of the subject. However, let me remind the reader that as hemor- rhage, although improbable, is yet possible, we should be prepared for it. After what has been said under palliative treatment about the management of this complication, it will not be necessary to enlarge upon that point. After an operation of this kind the only treatment necessary is perfect quiet a few days, cleanliness by injections, and if needful the administration of anodynes to quiet pain. When a tumor has been removed from high up in the uterus the patient should of course be carefully watched, and if symptoms of inflammation or septicaemia arise they should be treated by suitable measures. Surgical operations having the relief of hemorrhage for their primary object, but which sometimes eventuate in the cure of the tumor, have been recommended and successfully practiced. The first I shall mention, is that brought into general notice by the late J. Baker Brown, viz., incising the cervix. Mr. Brown first discovered that free incision of the cervix would check hemorrhage by doing it as a preliminary step to coring or gouging out some of the tumor. He says, in tumors of recent origin and moderate size, free incision not only checks the hemorrhage, but often arrests the growth of the tumor, and even causes its disappear- ance. Of fourteen cases thus treated, in two only was it necessary to incise or gouge the tumor. When the vagina is small he first dilates it with bougies (some prefer sponge surrounded by thin india-rubber tubing). After the preparation of the vagina is satisfactorily accomplished, he exposes the cervix by introducing Sims's speculum, seizes, fixes, and incises it freely, its whole length from within outward, with Simpson's metro- tome, the incisions being made on both sides. He then plugs the cavity thus made with lint saturated with sweet-oil (if the oil was car- bolized it would be better), to prevent hemorrhage and to exclude air. Mr. Brown lays great stress upon a thorough plugging of the cervix after the operation, and filling the vagina with cotton to sup- port the cervical plug. He allows this to remain for forty-eight hours. He insists upon making the incision in the cervix to extend within the internal os uteri. The cavity produced in the cervix by the incision should be kept dilated until the surfaces cicatrize. If then the symptoms are not relieved, he proceeds to the operation of gouging out a piece of the most dependent part of the tumor. This may be done with a knife, but he prefers pointed scissors. The object of removing a part of the tumor is to inaugurate a de- structive inflammation, which will result in the disintegration and expulsion of the tumor. Sir J. Y. Simpson introduced the cautery or caustics into the sub- ENUCLEATION. 663 stance of the tumor for the same purpose. In two instances I have caused fibrous tumors to disappear by passing cotton-wool into them. A large trocar was thrust through the cervical cavity as deep into the tumor as practicable, and after the stilet was withdrawn, several pieces of cotton secured by thread around them, were passed to the extremity of the canula into the tumor and held there by a probe, while the canula was also withdrawn. A discharge of fetid pus and serum followed moderate inflammation, and the tumor grew smaller until it disappeared. With my present experience, I would commend the administration of ergot, as soon as the tumor was affected by either of these opera- tions, with a view to aid in the expulsion of the growth. For the relief of excessive hemorrhage, Dr. Atlee passed a blunt- pointed bistoury into the cavity of the uterus, and by turning the edge of the instrument upon the tumor, cut deeply into it. The dilatation of the cervix, so generally indispensable, can be done by compressed sponge or sea-tangle tents, instead of incision. Enucleation. This term is applied to the operation of splitting the capsule and turning the tumor out of its bed. In favorable cases this operation is easily performed, but such , cases are very rare ; generally it is one of the most formidable and dangerous operations that we are called upon to perform. I say this, with reference to the operation, when it is done by the most skilful and efficient gynecologist. In the hands of the reckless, uninstructed, and inexperienced, it is still more likely to be done badly, and indeed barbarously than any other operation. The operation of enucleation should be confined to submucous tumors, or, to speak more definitely, to tumors situated between the central stratum of muscular fibre and the mucous membrane. The intrusion of such tumors into the cavity of the uterus enables us to attack them from that cavity, and the thick, strong layer of muscular fibre lying outside of the tumor, makes the operation less dangerous by protecting the peritoneal cavity from the violence which might otherwise result from the most cautious use of the instruments. When are we justified in making an attempt at enucleation? The first item in the answer to this question is, when it is evident that the patient's life will soon be sacrificed if the tumor is not in some way disposed of. The second item is, where every reasonable palliative measure has been tried without success, or where there is not time to wait for their trial, if such a condition can exist; and I may add a third, where appropriate attempts have been made and failed to break them up and expel them with ergot. Some will object. 664 SUEGHCAL TREATMENT. saying that ergot will not do this with any uniformity ; to which I would answer, that I do not believe the objectors have given it a thorough and intelligent trial. Some will further object, by saying, that the septic fever attendant upon such expulsion is more dangerous than the operation of enucleation ; to which I would answer, that my cases will not bear out the objection. I will also add, that the general practitioner will conduct a case of expulsion more successfully than he can the operation of enucleation. The first step in enucleation is thorough dilatation of the cervix, if it is not already sufficiently open. The dilatation should be sufficient to permit the fingers to pass as far up into the cavity of the uterus by the side of the tumor as they can be made to reach. If the vagina is small, it should also be prepared by stretching or dilating it. When these conditions have been obtained, the patient should be placed upon her left side with her left hand behind her, and by Sims's speculum, the cervix and tumor exposed to view. The cervix should then be seized with vulsellum forceps, drawn down as much as possi- ble, and held firmly by an assistant until the operation is completed, Fig. 294. Sims's Enueleator. varying the direction of the traction as the operator may require. The capsule may then be opened by making an incision with long curved scissors, at the junction of the tumor with the wall of the uterus the whole width of the tumor ; at the middle of the incision another should be commenced, and carried as high up over the longitudinal centre of the tumor as possible. These incisions should not penetrate the tumor to any great depth. They should simply divide the capsule, and when the capsule is not adherent, the space between it and the tumor will be easily recognized. The fingers can then be inserted between the capsule and the tumor, thus separating them as high as the operator can reach. This separa- tion should extend around the whole circumference of the growth. The fingers will not be long enough, usually, to reach over the upper end of the tumor ; the separation may be completed by Sims's enuele- ator as seen in Fig. 294. It may be passed with the concave side next to the tumor, gently to the top, and then passed around in any direc- tion until the separation is complete. While this last part of the operation is being accomplished, another vulsellum should be fastened upon the tumor as high up as possible, ENUCLEATION. 665 sixid by traction made to depress and steady it. When the tumor is thus separated from its capsule, we should make an effort to turn it upon its longitudinal axis. This will enable us to determine whether it is entirely detached or not, as well as to dislodge it from the muscular bed into which it has been moulded. If the detachment is not complete, the point of resist- ance will generally be discoverable by swaying it from one side to the other, or backward and forward, thus enabling us to apply the enucle- ator to the right place, and complete the separation. At this stage of the operation we may make more traction ; the dislodgment will be facilitated by pressure upon the fundus of the uterus by the hand of an assistant. When the tumor is not too large, it will descend as we pull upon it, and pass out through the vagina. If, however, it is so large that it cannot be made to pass through the vagina in this way, then the tumor should be split by the scissors from the bottom up- ward, as near the top as possible, without danger of wounding the fun- FiG. 295. Sims's Guarded Hook to aid in drawing the Tumor. dus of the uterus, and then (as Dr. Sims instructs us) one-half should be seized by the vulsellum and drawn down, so as to cause the tumor to undergo evolution ; the portion grasped coming down first, and by virtue of its attachment at the top, brings the other after it ; but if this cannot be done, we must cut off the part in the grasp of the vulsellum, seize another portion and treat it in the same manner, until the whole is removed by pieces. Under favorable circumstances this operation may be performed as above described ; but obstacles will sometimes be met with that will give the best operators much trouble, and render the results very unsatisfactory. The first I will mention is that presented by imperfect capsulation, or adhesion of the tumor to the walls of the uterus. Some cases occur where the tumor is not isolated by a capsule from the uterine struc- tures, but the substance seems to be continuous with them. Whether this condition depends upon original formation, or is the result of disease, which causes adhesion between the surfaces of the tumor and the capsule, I am not able to say ; but in either case it presents an insurmountable obstacle to the perfect removal of the tumor ; and, if this condition could be diagnosed beforehand, it would contraindicate the operation for enucleation. When in the performance of the operation we meet with this ob- 666 SURGICAL TEEATMENT. stacle, and can clearly ascertain its existence, I think it would be best to gouge out as much of the tumor as we could safely remove, and then commence the administration of ergot, to remove the remainder. I would do this, because cutting through the superficial layer of the tumor would be sure to disturb its vitality. The next obstacle to the removal of the tumor by enucleation is the great size to which it may attain. I have already spoken of the necessity of sometimes cutting the tumor in pieces with scissors to facilitate its removal. The wire ecraseur will often be very useful in lessening the size of the tumor. We slip the wire over a portion of the tumor and cut it off, then pull down more with the vulsellum, when that is possible, and pass the wire over another piece, and so on until it is small enough to remove. This plan, where practicable, and especially in the hands of the experienced oiDcrator, is the safest way. Dr. Thomas's serrated spoon, or a very small, crescent-shaped knife, such as is used by Dr. E. Warren Sawyer, of this city, may, by careful use, aid us in this respect. Hemorrhage constitutes a very formidable complication, in rare instances, in the operation of enucleation. I have never met with Fig. 296. Thomas's Serrated Spoon. this difficulty in the removal of these tumors by any method ; but there are too many cases on record to leave any doubt that we should be provided with the means of meeting hemorrhage of the most for- midable degree. In considering this matter in relation to the cases reported, I believe it to be the result of inertia, or want of firm contraction in the mus- cular fibre, or on account of the separation of a vessel in the uterine walls. In either case, if we continue the operation, we should follow the examjDle of Dr. Emmet in throwing ice-water freely into the cavity of the uterus. I would also resort to obstetric doses of ergot ; both of them would serve to contract the vessels of the uterus, and overcome the inertia by prompting the uterine fibres to act. If, in spite of these remedies, the hemorrhage is so copious as to make delay very dangerous^ we may inject the uterus with tincture of iodine; but I should greatly prefer immediate and complete plugging to any- thing else. If the hemorrhage has been sudden, shall we proceed with the operation ? I think not, but would assign this to the cate- gory of cases which should be treated by ergot. LAPAROTOMY. 667 What has been said of enucleation has reference more particularly to deeply-seated submucous tumors which project into the cavity, but are imbedded their whole length in the wall of the uterus. The more superficial or sessile variety of submucous tumors project so far into the cavity as to appear to be implanted upon the wall beneath the mucous membrane of the uterus. The attachment, or base, upon which it i?its, is nearly or quite the size of the tumor. This variety can be removed with much more facility. After exposing the tumor, and steadying it by traction with the vul- sellum, it may be separated from the wall, and that very neatly by the serrated spoon. This instrument should be inserted through the cap- sule, at the juncture between the tumor and the uterus, by a rotary sawing motion ; the growth severed by passing it through the capsule in any direction where the attachment exists. This is Dr. Thomas's method of removing this variety of tumors. Dr. Emmet pulls them steadily and persistently down into or toward the vagina ; this allows the upper portion of the uterus, from which the tumor is withdrawn, to contract. Further traction upon the tumor gives room for the fibres beneath the point of implication also to con- tract, until the circumference of the attachment, becoming smaller, assumes a pedunculated form, and may be severed by the ecraseur, scissors, or knife. This form of tumor may also be removed by pass- ing an ecraseur over and amputating a part of it, and then, by means of the finger or enucleator, remove the remainder. Patients who have undergone any of these operations for removal of fibrous tumors may die from shock, hemorrhage, inflammation, or septicsemia. For the treatment of shock, I will refer the reader to the subject as taught in the after-treatment of ovariotomy. I have already said sufficient upon the subject of treatment of hemorrhage as a complication in such cases. Inflammation, when it occurs, should be treated as in the after-treat- ment of ovariotomy. Septicsemia may be more effectually treated in connection with this than almost an}^ other of the great operations, as we can keep the cavity clean by hot-water injections, and disinfected by carbolic acid. For the general treatment, I will refer the reader to the after-treatment of ovariotomy. Laparotomy For the extirpation of the tumor, is another surgical resource, of which we may avail ourselves under circumstances where the employ- ment of less hazardous measures is either impracticable or unavail- ing. The extirpation of the tumor, where it is subserous and pediculated, 668 SURGICAL TREATMENT. has been performed a large number of times successfully ; and where the tumor is not adherent, there is no great difficulty in removing it in this way. The incision through the abdominal wall maybe made in the same place and in the same way as for ovariotomy, although it will be evidently necessary to make it larger. The pedicle being exposed and ligated by a double silk ligature, it will be found that the substance through and around which the liga- ture is jDassed is not so firm as the pedicle of an ovarian tumor ; hence it will be necessary to be more careful, lest it give way and cause sec- ondary hemorrhage. The ligature should not be passed through any part of the tumor, but between it and the uterine substance ; then, to get sufficient sub- stance beyond the ligature, the capsule may be divided an inch from the ligature and the tumor enucleated. When the tumor is sessile, instead of being pediculated, and the base too broad to be included in a ligature or clamp after the abdomen has been ojDened, it may be enucleated by splitting the capsule and peeling it out with the fingers. I would suggest that when enucleation has been thus performed, an opening be made from the bed of the tumor into the uterus, so that the discharge from the empty capsule may find its way out through the uterus and vagina. To secure this evacuation, we might pass a drainage tube through the opening into the vagina. "VVTiere this or some other effective ar- rangement for drainage is made, the capsule may be closed by silk sutures, and the abdominal wound treated as for ovariotomy. If the capsule should not be large, and the operation has been performed, as it always should be performed, under the antiseptic conditions, it may not be necessary to make any provisions for drainage. When a subserous tumor is situated on the posterior wall, occupy- ing the cul-de-sac behind the uterus, it may be removed by making an incision along the median line of the posterior vaginal wall and re- moving the tumor through the vagina. Dr. R. S. Sutton, of Pittsburg, has successfully removed one in this way, as also has Dr. Clifton Wing, of Boston. Of course none but the small-sized tumors can be removed by this method. The thermo-cautery, or the actual cautery, should always be in readiness to stop hemorrhage in either of these operations. Laparo-hysteredomy. The last measure I will mention, as one resorted to for the relief of patients afflicted with these tumors, is laparo-hysterectomy, or the re- moval, partially or wholly, of the uterus with the tumor. This operation resembles in many respects that of ovariotomy. LAPARO-HYSTERECTOMY. 669 Our preparation of the j)atient should be the same. The anaesthetic and the carbolic spray are used in the same way, as also in the anti- septic dressing. When we undertake the operation, we should be especially well prepared with means of arresting hemorrhage. To this end we should have in readiness the therm o-cautery, a number of hsemostatic forceps, persulphate of iron, etc., and every other arrangement should be com- plete, so that there might be no delay, as the operation is almost of necessity one of long duration under the most favorable circumstances ; and it should be remembered that everything, which may shorten the duration of the operation is of great importance, as the longer it lasts, the more depressing its effects. For fear that what I may say should encourage precipitation, I would protest against hurry, and advise de- liberation in all the steps of the operation. The incision is made in the same place and manner as in ovari- otomy ; first a small incision, say four inches long, for exploration, to ascertain the character of the tumor, its probable adhesions, and its relation to the viscera. As some viscera, especially the intestine, is more frequently found to lie across the front part of the tumor, the necessity of ascertaining any such condition is much greater than in ovariotomy. When it comes to the separation of the adhesions and the removal of the tumor, the size of the incision must be increased sufficiently to 'permit the extraction of the whole mass, instead of an effort being made to lessen the size of the tumor, as in ovariotomy. An exception may be made to this teaching, if the tumor is not en- tirely solid, but of the fibro-cystic variety. In this case, if a large cyst presents itself, we may hold the tumor close to the incision with vul- sellum forceps and evacuate the fluid through a large trocar, or an incision into the wall of the cyst. If in doing this we find there are a number of cysts, we may introduce a finger, or even the whole hand, as I once did, into the centre of the tumor, and break it up as far as possible. In this way we may sometimes very greatly lessen the size of the tumor. In this operation, as in ovariotomy, the size of the incision is of great importance ; in no case should we risk bruising or tearing the abdominal walls. In operating for fibrous tumors, we should not trust to the sound in searching for adhesions ; the hand alone should be used, and the whole surface examined before any attempt is made to dislodge the tumor. We should also remember that the adhesions, as a rule, are more vascular than in ovarian tumor, and hence, when necessary, they should be ligated twice and cut between the ligatures. When solid, the tumor may be lifted from its bed more easily by 670 SURGICAL TREATMENT. means of the vulsellum forceps than by the hands. After it is lifted out, the uterus will generally be found to be removed from the pelvis with the tumor constituting a part of the mass. If there are no more adhesions the junction between the tumor and uterus should be sought for. Sometimes the tumor is situated so low in the uterine walls that the appendages are carried high up, and may be considerably enlarged. It is then advisable to ligate the ovarian vessels laterally in the broad ligament, and the appendages near the uterus, and cut between the fimbriated extremity of the tube and the lateral ligatures. The peritoneal edges of the severed broad ligament may then be united. If the pedicle be thick, and the uterine vessels large, we may place a rubber tube tightly about the cervix, and tie the vessels above the tubing before the tumor is cut off. The bladder is usually in close proximity and must be carefully avoided. There are two methods of treating the pedicle, the extra-perito- neal and the intra-peritoneal. When treated extra-peritoneally the cervix or the uterine stump must either be inclosed in a clamp, con- stricted by rubber tubing, or ligated with heavy silk, before being cut off above. Spencer Wells was the first to treat the stump extra-peri- toneally. He transfixed it with two needles, ligated about them with a figure-of-eight ligature, and fastened it in the lower end of the wound. Pean deserves the credit of having developed this method. He passed two needles at right angles through the stump, and ligated it in halves under them by wires. If bleeding occurred afterward, the wires were tightened. On account of the liability of the wire to cut, and the ovarian vessels to slip out of the loop, Hegar* places a strong elastic ligature (rubber tubing) around the stump, cuts the tumor off, sews the peri- toneal edges of the abdominal walls to the peritoneal covering of the stump below the elastic ligature, and transfixes the stump with two needles to hold it in place. The elder Keith, who has obtained the best results (35 recoveries out of 38 cases), fixes the pedicle in the abdominal wound with a clamp or wires. The after-treatment of the pedicle treated extra-peritoneally is usu- ally tedious, for the portion above, and sometimes that a little below, the clamps or elastic ligature sloughs out and leaves a large deep ulcer to be filled with granulations. The remaining stump under- goes considerable retraction, and draws the abdominal walls down toward the pelvic cavity. Schroeder,t who was the chief representative of the intra-peritoneal method, placed a rubber ligature around the uterus and appendages * Operative Gynakologie. Hegar and Kaltenbach. t Op. cit. LAPAEO-HYSTERECTOMY. 671 below the tumor, and cut the latter off at its junction with the uterus as a piece is cut out of a melon (wedge-shaped). He then trimmed the stump, if necessary, till the peritoneal edges could be made to cover it, and disinfected the exposed cervical or uterine cavity with a ten per cent, solution of carbolic acid or the thermo-cautery. Having done this he sewed up the uterine cavity, and then the raw surfaces of the stump, with several rows of stitches, beginning at the bottom and culminating at the top with a fine row uniting the peritoneal edges. He used catgut for the uterine cavity and peritoneal edges, and silk for the rows of stitches uniting the raw surfaces where there was apt to be considerable strain ujDon them. Dr. Charles T. Parkes, of this city, ligates the stump with silk, thoroughly sears it with the thermo-cautery and drops it. He reports six cases : with two recoveries treated in this way, and four deaths with the stump treated extra-peritoneally. Among 135 cases Schroeder lost thirty per cent. This percentage in the cases of so skilful an operator would indicate that the dangers of his method are great, or that it was but imperfectly developed. The statistics of the recorded extra-peritoneal operations are far better, although the recovery is usually more tedious. There is much reason to believe that Parkes's method approaches more nearly to the ideal than any of the others. Woelfler and Hacker* stitch the stumjD (united according to Schroe- der's precepts) into the wound, so that it is extra-peritoneal but under the abdominal parietes. The dif&culties in the intra-peritoneal method are, that if the stump is not tied tight enough hemorrhage will result, if tied too tight or too extensively sloughing may occur. " Dr. Leon Labb^ communicated, at a late meeting of the Academie de Medicine, a note relative to a modification of the operation of hysterectomy as applied to fibrous tumors (exsanguinification of the tumor). " Gastrotomy applied to the treatment of fibrous tumors of the uterus is an opera- tion about which there is no longer any dispute. The note which M. Labbe com- municated to the Academy is not for the purpose of describing this operation, but simply to make known an important modification that he has introduced in the opera- tive process. "The quantity of blood contained in these enormous uterine tumors is always con- siderable; it is certain that the loss of this blood by the ablation of the tumor is a factor, the importance of which cannot be passed over, especially if we consider that the extirpation of these tumors almost always takes place in the cases of women who are in an advanced state of cachexia. Based upon the principle which had led Es- march to apply a compress bandage on limbs which were to be amputated, M. Labb^ thought the same bandage could be utilized to press back into the general circulation the blood contained in large uterine tumors, and thus practice a kind of transfusion. "The patient for whom he had occasion to apply this principle for the first time, * Schroeder, op. cit. 672 SURGICAL TREATMENT. was in a deplorable condition before the operation, and succumbed six days later to septicemia ; but M. Labb^ has been able to prove that the enormous fibroma upon which compression was first practiced was entirely exsanguined, and that about a litre of blood was by this means restored to his patient. " The theory which led M. Labb^ to apply Esmarch's compress to restore to the general circulation, at the time of their extirpation, the blood contained in such great abundance in the fibro-myomas of the uterus, is very clearly justified by the case which has been reported to the Academy. " The peculiar conformation of the tumor was such that no very particular method was employed in this case ; but if the tumor to be operated on is more regular in form we would have just reason to fear that the application of the elastic band might present some difBcuIties. In this case, to fasten the band and give it a support we should transfix the tumor near its summit by one or more metallic needles. Several of these needles may even be placed at different heights so as to give support to the compress, and to prevent its slipping. "M. Labb6 concludes : "1st. That there must be a positive advantage, in operations on large uterine fibro- myomas removed by gastrotomy, in restoring to the patient the blood which these tumors always contain in large quantity. " 2d. That this result may be employed in a complete manner by applying to the tumor Esmarch's compress, or any other compress endowed with the same elastic properties."— G'aze^ie Hebdoraadaire, 6 Aout, 1880 ; American Journal Medical Sciences, October, 1880. When the hgature is satisfactoril}^ applied we must remember also that in cutting away the tumor there is great danger of retraction of the parts included in it. The abdomen must be carefully cleansed and hemorrhage entirely checked before closing the wound. The after-treatment of these cases is more difficult than in ovari- otomy, as the shock is ordinarily much greater, and inflammation and septicaemia more likely to follow the operation. I do not believe the complete extirpation of the uterus and ovaries ^ will bear any reasonable comparison with ovariotomy, even double ovariotomy. In comparing these operations we must remember that when the uterus and both ovaries are removed, the whole genital system, with all the reflex capacities and sympathetic relations, is suddenly torn from its connections. The centric connections supplied to these organs by a complete system of nerves ; the moral, emotional, and physical energies they are continually exerting over the whole of the rest of the organism are destroyed. The importance of the relations between the genital system of woman and the rest of her body and brain is so great that it can scarcely be appreciated. These relations constitute the major part of her life. From such considerations, I can but believe that the shock of this operation is incomparably greater than in ovariotomy or double oophorectomy. When one ovary is removed, the other maintains the ovarian in- OOPHORECTOMY^ 673 fluence over the uterus and the system at large. When both are re- moved, there is still left the larger part of the genital nervous system, with its relations, although impaired, not entirely severed ; and we know, from observation, that in such cases womanhood is well pre- served. In operations of this kind, conservative surgery is of the greatest im]3ortance, and we ought never to remove the ovaries when we can preserve them. While there will continually occur cases for which this operation is the only remedy, experience will prove it to be an operation of much more gravity than ovariotomy in any of its forms. Kimball, Burnham, H. R. Storer, Thomas, and other Americans have performed this operation successfully. In Europe, Pean, Koeberle, Wells, Clay, Schroeder, and others have contributed toward perfecting hysterectomy for fibrous tumors. Oophorectomy — Battey''s Operation — Spaying. These are terms intended to designate an operation for the removal of the ovaries. To Dr. Robert Battey, of Rome, Georgia, is due the credit of first removing the ovaries for the purpose of artificially inducing the menopause. - The knowledge that the change of life generally brings relief from the intolerable and irremediable forms of oophoro-neuroses that so often perplex the practitioner, would lead to the hope that the re- moval of these bodies would produce similar cures. This operation has been before the professional public for about eleven years, and the mortalit}^ which was at first above twenty per cent, has now fallen below ten per cent. Dr. Paul F. Munde {American Journal of Obstetrics) very correctly observes that if the positive benefits of the operation were as assured as the favorable rate of mortality, the opj>osition to it would soon cease. The operation has also been repeatedly per- formed for the purpose of arresting the growth of fibrous tumors of the uterus, on account of the favorable effect the natural menopause so generally produces upon them, and in some instances with very favorable results. We should not forget, however, that menopause is not the change of life. This condition — menopause — is sometimes brought about by some of the very conditions for which Battey 's operation is performed with- out producing change of life. It is true that the ovary, if not the essential agent, is certainly necessary to the proper development of the female genital organs. After the genital apparatus is mature, it is probably the fountain of 43 674 SURGICAL TREATMENT. the excito-motor influence upon which depend the functions of the uterus and its appendages in all their relations to the generative acts. The ovaries ought not, therefore, to be classed as appendages to the uterus ; rather the latter is, in the proper sense, an appendage to the former. As an accompaniment of ovulation, which is the development and disengagement of the ovule, the trophic energies of the uterus are ex- cited in corresponding degree. The repletion and activity of its circulator}^ system corresponds to like changes transj)iring in the ovaries, and the nervous system of the uterus is acted upon by that of the ovaries, prompting glandular changes in the mucous membrane. Even the intramenstrual growth and hypertrophy of fibrous and other tissues of the uterus are but the reflex complement of the stromal h3'pertrophy of the ovaries. As the ovarian excito-motor stimulation is withdrawn from the uterus, involution simultaneously occurs in the two. It is true that the removal of the ovaries withdraws the source of the excito-motor influence from the uterus, and this generally brings about the menopause in the sense of the cessation of periodical hemorrhages; but the same operation, after the uterus has obtained maturity of organization, and especially when its tissues have become hypertrophied (vascular, nervous, and muscular), leaves a large, highly organized organ without its regulating apparatus, the subject of any morbific cause which in its nature has any aptitude for the production of uterine derangement. We see this illustrated in the case given by Dr. Trenholme, the history of which, subsequent to the operation, I give below. This, I think, is the effect produced by suddenly removing the ova- ries in large fibrous tumors of the uterus. In smaller growths, and a less vascular state of the uterus, the same conditions exist, and the same consequences will follow, only in a less noticeable degree. The senile menopause, one of the symptoms of the change of life, is the consequence of gradual changes in all of the organs concerned. This change is a degeneration of the genital organs. The tissues are not merely diminished in size, but they degenerate into those of a lower order of organization, and this same degeneration extends itself to the morbid growths of the organs. Tumors lose their vascularity, their fibres disappear, and the whole becomes a degenerate mass. It is not certain how much of this general and regular degeneration is due to the presence of the ovaries and their excito-motor energies in prompting it and in governing its nature. It is a plausible supposition, however, that as the ovarian changes and influences are so great in building up the uterus and sustaining OOPHORECTOMY. 675 its functions, it might be as efficient in its retrograde transformation, thus maldng it more complete. The removal of the ovaries in the presence of a large fibroid and hypertrophied uterus, simply takes away their governing agency before the process of degeneration has begun. We have then a highly- organized uterus and tumor, and if degeneration takes place at all, — which I very much doubt, — it is not normal in any respect, and may be the cause of morbid instead of salutary conditions. AVe then exchange one evil for another ; a greater for a lesser it may be; to the advantage of the patient somewhat, but yet not so as to make a perfect cure. Dr. E. H. Trenholme, of Montreal, reports a case* of abdominal oophorectomy for a large fibrous growth of the uterus in January, 1876. Severe uterine pains and hemorrhage were the actuating reasons for the operation. The patient, according to her own account, was very much improved for four months succeeding the operation, the uterus then (in May, 1876) suddenly commenced enlarging and gave her very great pain. The enlargement and pain were accompanied by copious hemorrhage. As the result of this attack, she was confined to her bed more or less constantly for three months. Recovering from this attack she was able to support herself a part of the time as a sales- woman, and a part of the time as a nurse, for several months. In December, 1877, she had a similar attack and of like duration. The patient has now been in this city about two years, and I have had the opportunity of seeing her in two or three of these attacks. The pain is exceedingly severe and requires the use of anodynes in considerable doses to relieve it. In April, 1878, one of these attacks commenced and kept her in bed for several weeks. And in December, 1879, another similar attack prostrated her, with pain and hemorrhage, lasting until the middle of March, 1880. During the whole continuance of this attack she was in the Woman's Hospital, of the State of Illinois, under my immediate supervision. During the early part of this last paroxysm, the uterus was enlarged until it extended two inches or more above the umbilicus, and occu- pied all of the central and lower portion of the abdomen to within two inches of the crest of the iliac bones on either side. Since the subsidence of the symptoms, the uterus and tumor have decreased about one-fourth. The tumor is now somewhat elastic, whereas during the early part of the paroxysm it was very firm. The health of the patient is so very poor and uncertain, and she so dreads the suffering she experiences during the attack, that she now begs the removal of the entire mass. She is an intelligent woman, * Obstetric Journal of Great Britain, October, 1876, p. 430. 676 SURGICAL TREATMENT. and has made herself quite conversant Avith her condition and the extreme measures sometimes resorted to for relief, and is entirely will- ing to abide the consequences of the operation. I am deterred from indulging her -\vish for the removal of the tumor by hysterectomy, by the apparent general and very firm adhesions of the front surface of the tumor to the anterior walls of the abdomen. Whether this patient's life has been prolonged by oophorectomy or not, of course no one can know. That her condition, so far as suffer- ing is concerned, has been greatly improved, I think any one witness- ing her agony and prostration during a paroxysm would believe. And while I have no doubt of the thoroughness and skill of the operation, I must say I believe it to be a partial failure. In presenting these reflections on the difference between the effect of a natural change of life and oophorectomy upon fibrous tumors of the uterus, I do not wish to be understood as opposing oophorectomy. They, however, make me hesitate to give an unconditional adhesion to the practice, even where in our present knowledge it would seem indicated. The effect of removing the ovaries for intolerable and incurable cases of oophoro-neuroses, is quite another thing ; for then we remove the cause of the disease, or rather the symptoms; because, aa they are the organic origin of the neuroses, their condition is the disease, and like amputating a limb, that is incurabl}'- diseased, to get rid of the symptoms, we cut off the ovaries for the same purpose. There is another side to this subject, however, and that is, the general condition of the patients, who are the subjects of these nervous symp- toms, in such as, in part, to account for their suffering. And we sometimes find that a radical change in the circumstances under which they live, will dispel their trouble. Instances of this kind must have fallen under the observation of most practitioners of long experience. Muscular labor, outdoor exercise, and the loss of luxuries, when brought by inexorable bad fortune, have done wonders, in the way of remov- ing oophoro-neuroses. Then the question comes up, whether we ought to spay our patient or prescribe and enforce the proper amount and kind of primitive living necessary to revolutionize her nervous functions. The former course is the easiest, and, I am sorry to say, most accept- able to some patients. The following are Dr. Battey's* conclusions as to the proper cases for oophorectomy : * "Wliat is the Field for Battel's Operation ?" A paper read before the American Gynecological Society in Cincinnati, September 1st, 1880, by Dr. Robert Battey, of Rome. Georgia. OOPHORECTOMY. 677 ' "It is not a question as to whether extirpation of the ovaries sliall be resorted to, or whether valerian or asafcetiria be given, or resort be had to any other known resources of gynecology, but the case must be narrowed down to this, as the only expedient available." The following are the classes in which he regarded the operation as justifiable : " 1st. Congenital absence of the uterus, coupled with ovulation, in which, at the men- strual epochs, there are violent vascular and nervous perturbations, that are either dangerous to life or destructive to the health and happiness of the patient. 2d. Com- plete occlusion of the utero-vaginal canal. 3d. Certain cases of menstruo-mania, abso- lutely incurable by any of the known resources of medical science or art. 4th. Ovarian epilepsy. 5th. Certain cases of chronic ovaritis. 6th. Certain cases of amenorrhoea. 7th. Ovarian hernia. 8th. Submucous or interstitial fibroids. 9th. Incurable flexion of the uterus. 10th. Csesarean section." This last, of course, means cases in which patients cannot be deliv- ered per vias naturalis. In deciding whether or not he should advise the operation, he asks himself three questions : '•1st. Is this a grave case? 2d. Is it a case incurable by any other known resources of medical and surgical art? 3d. Is it curable by the menopause?" If all are satisfactorily answered in the affirmative, he regarded the ease as a proper one for the operation known as Battey's. If either question cannot be answered satisfactorily, he regarded the case as one in which the operation is not justifiable.* While these positions are not all as definitely put as they ought to be in a matter of so great importance, one thing is made plain by them, and that is, Dr. Battey regards the operation as a last resort. We are not yet able to do more than practice Battey's operation according to the imperfect light we have upon the subject, because it is the only available means of relief we can command. By intelli- gently watching effects we will be able after awhile to arrive at defi- niteness of indications for its employment. Too much latitude is given by some and too little by others, and it will require much more observation before all shall agree upon the question — when shall we resort to this operation ? The final position of the profes- sion must come as the result of an earnest and sober estimate of col- lected facts ; sentiment should play no part in the matter. The attempt to settle this question by facetious reveries as to the value of the ovaries and supercilious flings at gynecologists, has become monotonous and contemptible. Until sufficient knowledge, derived from careful observation, is obtained to guide the practitioner defi- * American Journal of Obstetrics, October No., 1880. 678 SUEGICAL TREATMENT. nitely to unimpeachable conclusions, we must do as the members of the profession have heretofore always been obliged to do — be governed by what light we have. If we do this honestly we will be in the line of our plain duty. There are some indications for oophorectomy upon which well- informed gynecologists agree : 1st. The absence or rudimentary development of the uterus, with such severe dysmenorrhoeal symp- toms as greatly to impair the health and usefulness of the patient. 2d. Demonstrable structural lesions of the ovaries, with symptoms ot such gravity as to entail hopeless invalidism upon the subject of them. 3d. Incorrigible displacements of the ovaries, with invalidism. 4th. The presence of a solid or cavernous fibrous tumor of the uterus, attended with uncontrollable hemorrhage, or causing dangerous pres- sure. Most other indications are subjects of discussion ; while some of them are sufficient to induce some men to operate, others would hesi- tate, if they did not reject them as insufficient. Such are oophoro- mania, oophor-epilepsy and oophoralgia, nymphomania, and perhaps others. These names are according to Battey, and doubtless correct. The presence of any of the symptoms enumerated in this last series of indications is only conditionally a reason for operation. If the symptoms can be traced to ovarian irritation, cannot be cured by any other mode of treatment, and are sufficiently severe to disqualify the patient for the enjoyment of happiness and the discharge of useful duties, the indication is clearly made out. It is but fair to admit that there may be, and probably are, cases of mania and epilepsy of the type of description contemplated in this connection, that do not de- pend upon ovarian irritation. And no doubt there are cases which have their origin primarily in ovarian irritation and are perpetuated after this cause is removed, by centric conditions resulting from the powerful and frecjuently repeated reflex impressions to which the ner- vous centres have been subjected. These admissions, however, cannot exclude ovarian irritation as a frequent cause of oophoro-mania and epilepsy. Is there any essential difference between the epileptic and maniacal seizures caused by ovarian irritation, and those arising from other causes? I am not disposed to answer this question, but would sug- gest that so far as the brain is concerned, the condition is probably the same as it is in other forms of reflex mania or epilepsy. In the one case the aura arises in the ovary, and in the other some other diseased point. Operation. The operation as a laparotomy is in the main features similar to abdominal section for other purposes. It may not be unprofitable, however, to pass the different steps of the operation in review. OOPHOEECTOMY. 679 The preparation of the patient's room and other surroundings should be as thoroughly antiseptic as possible, and the strictest pre- cautions taken to avoid all risks of septic exposure from every source. The bowels should be well evacuated ten or twelve hours before the operation ; as when there is much fecal matter or gas in them the intestines will be very much in the way and prove a source of much embarrassment to the operator. To still further secure an empty con- dition of the alimentary canal the patient should entirely abstain from eating the meal before the operation. The bladder should be thor- oughly evacuated only a few minutes before the ansesthetic is given. The incision is made in the linea alba, commencing about an inch above the pubis and extending upwards two inches if there is not too thick a layer of adipose tissue. If the fat is two inches or more in depth, it may be lengthened accordingly. The strokes of the knife may be free until the skin and fat are divided down to the fascia cov- ering the tendon uniting the flat muscles of the abdomen. When this is fairly exposed it will be better for the inexperienced operator to cautiously lift up thin layers of the presenting tissues and divide them with a blunt-pointed bistoury or scissors until another adipose layer is reached. This fat is in contact with the peritoneum and clearly indicates our near approach to that membrane. Before proceeding further all hemorrhage should be arrested. When this is done we may lift the fat between the thumb and finger sufficiently to raise it and the peritoneum, to which it adheres, clear of the abdominal con- tents and make an opening in them through which a grooved director or the finger may be passed, upon which to enlarge the opening to the size of the external incision. Looking into the abdomen we will gen- erally see the om.entum covering the intestines, whose convolutions will be plainly visible through it. Sometimes the omentum does not extend so low, and then the uncovered intestines will be exposed to view. Freshly cleaning our hands we pass the two fingers of one hand through the incision down into the pelvis — over and not through the omentum — in search of the uterus, from the fundus of which we can easily trace the Fallopian tube and ovarian ligament to the ovary. When there are no morbid adhesions the ovary and tube may be raised to the opening in the abdominal walls and exposed to view. They should both be drawn up so that a double ligature can be passed beneath them and tied over either side. As much of the tube should be drawn into the ligature as we can include without forcibly stretching it. In cutting through the pedicle thus made we should be careful to remove all the ovarian stroma. This precaution is necessary because the presence of a small part of this substance may perpetuate the evils for which the operation is performed. It is not sufficient to place the ligature around the ligament and vessels of the ovaries. This, it would 8eem, does not prevent ovulation. Great care should be taken to 680 SUPtGICAL TREATMENT. ligate the pedicle so as to give room for the complete excision of the ovary and yet leave sufficient substance to avoid the danger of the ligature slipping off. In some cases, after the incision is completed, the operator will be met by adhesions of the omentum to the bladder and intestines, or by the adhesion of the convolutions of the latter to each other, to the bladder, or other organs, in such a waj^ as to bar the entrance to the cavity of the pelvis. This will require careful, gentle, and patient efforts at separation. These attempts should be made at the sides of the pelvis, in the neighborhood of the ovaries, and to such an extent only as is necessary to reach these organs first on one side and then the other. Whether this kind of obstacle exists or not, the ovary and tube may be involved in a mass of exudation which almost invests them. In the worst forms of such involvement, whether it is not better to abandon the attempt to remove, is a question of great importance, to be decided by the circumstances as met with in each case. If we decide, as we generally will, to proceed we should depend upon stretching as much as possible. Sometimes gentle and perse- vering traction between the thumb and finger will lift them out of the mass sufficiently to pass a ligature beneath them. We may greatly facilitate access to the ovaries by having an assistant press the wall down well in the side we operate upon, not n:ierely to draw the side of the incision so as to open the wound, but to depress the margin of it into the pehds toward the ovary. If it becomes necessary to tear these organs loose, the violence should be over as small an area as pos- sible, and measures taken to stop hemorrhage if any occurs. (See surface-ligation as shown in connection with Ovariotomy. ) The length of the incision in cases of great adhesion should be increased, and when we operate for the removal of the ovaries and tubes in the pres- ence of a fibroid tumor of the uterus, the incision should be longer than in other cases. The ovaries are sometimes lifted high above the pelvis by the tumor and may be found on the side of, behind, or before it. Less frequently they are found near their normal position. In ordinary cases the incision should be small and not large enough to admit the hand. Where there is plenty of room to do so, the hand is very apt to find its way into the abdominal cavity, a practice that ought to be avoided as much as possible. The most important items in this operation are gentleness and avoidance of all unnecessar}" ma- nipulation. A looker-on can give a pretty good prognosis by observing the energy and amount of manipulation practiced by the operator. The after-treatment is so like ordinary ovariotomy that it is only necessary to refer the reader to that subject. rhydcal and Psyclikal Results. I have four patients from whom I have removed both ovaries, whom I occasionally meet, and so far as I can see, and from explicit OOPHORECTOMY. 681 assurances given by them, I believe they are not unsexed in any other sense than that they are sterile, and do not menstruate. In morals, manners, appearances, affections, propensities, and voice, they remain the same. The operation of removing the ovaries per vaginam was first per- formed by Dr. Battey. After exploring the posterior and vaginal walls Dr. Battey made an incision in the central line, about one inch and a half long, and with his finger drew the ovaries through the opening, ligated them and cut them off". Since then the operation has been repeated in the same way by others. The ovaries have also been removed a number of times through the abdominal walls. The main obstacle to be met in the performance of the operation is the adhesions arising from previous or existing inflammation. Sometimes this obstacle is so great that the operation through the vaginal wall is extremely difficult, and occasionally quite impossible. In such cases laparo-oophorectomy would be the easiest operation. The incision in this operation should be made in the same place as for ovariotomy, and no larger than is necessary. Tait sometimes removes the ovaries through an opening an inch long, but probably two inches will be a more frequent incision. CHAPTER XL I. AFFECTIONS OF THE OVAEIES. Congenital Atrophy. The ovaries, like the rest of the genital organs of woman, may be imperfectly developed. It is not unusual to meet with a woman whose sexual system is developed only to a degree usually found to indicate the completion of childhood. The breasts are about the size and shape of the girl at twelve years of age. She does not menstruate, and per- haps is not endowed with the sexual desires common to the sex; and if married, fails to bear children. The uterus, if examined, is found small, as are also the clitoris, labia and nympha. In all the instances of this kind that have come under my observation, the individuals were otherwise well developed. Xot unfrequently, however, as shown by other observers, the whole person is deficient, never attaining to more than the stature of a child. Cases of the congenital atrophy of the ovaries are given in this work under the head of amenorrhoea, with the method of treating the condition. Senile atrophy of the ovaries needs no description in this place. Hypertrophy. Enlargement of the ovaries is probably occasionalh" due to an in- crease in size without other alteration of their tissues. This is hyper- trophy. It is supposed to result from prolonged congestion, causing hypernutrition of the organ. The disease is hypothetical, as it has not been demonstrated. More frequently the enlargement is caused by an increase of some of the natural tissues and by inflammatory eflfusions. This last enlarge- ment is, of course, due to clu'onic inflammations. It is not easy, if at all practicable, to diagnosticate hypertrophy of the ovaries. We can generally detect enlargement of these bodies by physical examination, but cannot in all cases determine with certainty the nature of the enlargement. Displacement. Their intimate and firm ligamentous connection with the fundus of the uterus causes them to partake of the changes in the position of that part of the organ. Thus, when the fundus rises into the ab- dominal cavity during pregnancy, the ovaries are carried up ■\^'ith it, DISPLACEMENT. 683 and in very thin persons they may sometimes be felt as small, mov- able, sensitive tumors upon the side of the uterus (see pp. 69-72). The same thing occurs in some cases when the uterus is much enlarged by a fibroid tumor. In the former condition the displace- ment is physiological, and does not ordinarily give rise to serious inconvenience, unless the organ is rendered unusually sensitive by disease. When the uterus is retroverted or retroflexed, the ovaries are displaced to a greater or less extent downward and backward, and sometimes this displacement is so great that they may be felt in the posterior cul-de-sac and constitute a very annoying complication. In fact, this condition is of more consequence than the uterine displace- ment, and is a serious barrier to the correction of the malposition of the uterus, on account of their liability to be compressed by the in- strument used to hold the uterus in place. But sometimes the ovaries fall into this position without the uterine deviation. When this is the case there are likely to be many grave symptoms, which are included in the vague and imperfectly understood term "ovarian irritation." In most cases of this nature the ovaries are the subject of some form of organic disease, and we may reasonably doubt whether the symptoms do not arise from the pre-existing disease rather than from the deviation from their normal position. There can be no doubt, however, that the displacement may greatly embarrass the circulation in them, and thus contribute still farther to their morbid . condition. In such cases, the extensive reflex nervous influence exerted through the genito-spinal centres awakens a long chain of morbid phenomena destructive of the comfort of the patient, and sometimes establishes a series of oophoro-neuroses that wrecks the patient mentally and physically. Finally, I may say that rarely these organs may make their way out through the inguinal canal, in something of the same way that the testes do in the male. As there is no scrotum, however, in which they can find lodgment, they are arrested at the upper border of the pubis, and there constitute a harassing and painful hernia. This ovarian hernia may generally be diagnosed from the omental or in- testinal hernia, from the facts, first, that these two latter seldom pass out through the inguinal ring in the female, though frequentlj^ through the femoral ring; second, that they are not particularly sensitive to the touch unless in a state of inflammation from strangulation, while the ovary is quite sensitive ; and, third, that the sensitiveness of the ovary is said to be peculiar, resembling nothing so much as the sick- ening sensation experienced upon pressing the testicle, while the sensation of omental or intestinal hernia is rather the tenderness of inflammation. Having referred to the different varieties of ovarian displacements, I desire now to confine myself to the pelvic deviations of position. 684 AFFECTIONS OF THE OVARIES. Symptoms. What are the symptoms of pelvic displacements of the ovaries? Having already referred to them, I shall be brief in their further con- sideration. They may be included under two heads, local and general. The local symptoms are not distinctive. They are pain, weight, or bear- ing-down sensation, sometimes heat in the pelvis, backache, sacral and coccygeal tenderness, and occasionally radiating neuralgia ; there are also very frequently, though not always, menstrual derangements, but these local symptoms ma}^ be i)roduced by many of the disorders incident to most of the pelvic organs. As to the general symptoms. They are quite numerous and varied. It is indeed questionable whether all of the hystero-neuroses should not be regarded as oophoro-neuroses ; that is, direct or indirect morbid emanations from the ovaries themselves. It is probably impossible for us to separate the general symptoms arising from disease of the pelvic viscera into uterine, ovarian, vaginal, and vulval, as the nerve- supply to these organs is essentially a unit, and for their nervous manifestations are subject to the same presiding centre. In them is comprised a circle of functions to the perfection ot which, soundness in all of the organs is essential. Whether the ter- rible nervous symptoms arising from certain diseases of the vulva, the vagina, or the uterus can be reflected upon the organization in any other way than through their connection with the ovaries is a ques- tion not yet solved. I think we cannot doubt, however, that to "ovarian irritation" may be attributed the whole array of reflex phe- nomena so frequently noticed in the wrecked condition of broken- down women. In the retrouterine displacements of the ovaries, these conditions are prominent features, the numerous symptoms often assuming a very aggravated form, and the suffering of the patient becoming un- endurable. The general symptoms are those of ovarian irritation, and this is to be expected, because the circulation and the innerva- tion of these organs must necessarily be very much interfered with by their malposition. The Diagnosis Of these displacements is not generally very difficult. When in the inguinal canal, an examination of the tumor, its shape and peculiar sensitiveness are both characteristic ; the only thing for which it may be mistaken is hernia of the omentum or intestine, and a tumor formed by the protrusion of either of these is more globular, less firm, and unless in a state of inflammation is not very sensitive. When in the cul-de-sac behind the uterus if not changed in shape by disease the ovary has the same outline as when naturally situated and is CAUSES EFFECTS PROGNOSIS — TREATMENT. 685 movable. We may reach it by passing one or two fingers deep into tiie vagina or rectum. Causes. In many instances this displacement is associated with retroversion or retroflexion of the uterus, and is apparently the result of the mal- position of that organ. In others, however, the ovaries fall behind the uterus, because of their enlargement and increased weight from structural disease. Possibly a relaxed condition of the fold in the broad ligament in which it is contained, may permit the ovary to settle down out of its natural position. Effects. - Are displacements of the ovaries always and necessarily accom- panied by serious local symptoms or destructive general disturb- ances? I think not. Probably every gynecologist of extensive ob- servation has noticed instances in which the ovaries could be felt in the CM/-c?g-sac, and the patient experience little if any inconvenience, from such malposition. These, judging from my own observation, are not very uncommon cases. Why should some patients suffer so much from these displacements while others experience so little inconvenience from them? In answering this, I must employ a term that is not yevy definite, and perhaps not always intelligible, " nervous susceptibility." This nervous susceptibility with some patients appears to be a part of their original construction or " make up " if you please, while with others it is an acquired condition. Nervous susceptibility and neurasthenia, if not connected as cause and effect, are at least very intimately associated, and to treat these cases successfully therefore, we must have in mind this item of ner- vous susceptibility or neurasthenia connection. Prognosis. When displacements give rise to symptoms of ovarian irritation, what is the prospect of relief? Such cases are justly regarded as very unpromising, but not neces- sarily incurable. Treatment. The treatment of the symptoms attendant, and to some extent de- pendent upon displacements of the ovaries, is sometimes followed by most satisfactory results. By treating the symptoms, I do not mean the administration of medicines for the relief of nervous headache, hysterical convulsions, sleeplessness, etc., but the removal of those conditions from the system which encourage their manifestation. 686 AFFECTIONS OF THE OVARIES. Whatever may have been the diathesis of our immediate ancestors, ■whether they were affected by diseases resulting from hypersemia or plethora or not, it is evident that we have fallen upon times when anaemia or hydrsemia among women is, to say the least, a very com- mon state of the general system. This is esjDecially the case with a large j)roportion of patients suffering from ovarian irritation, either with or without displacements of the ovaries, and the nerve centres in such people are habitually an£emic. Nervous exhaustion means imperfect nutrition or lack of trophic energy in the nerve centres. This, I have no doubt, is mainly because there is not a sufficient amount of good, rich blood circulating through them. I cannot understand how nervous exhaustion can take place when there is an unfailing supply of nutrition in these centres, but it is plain that an exhaustion of supply will render the regular working of the brain and spinal cord impossible. It is blood exhaustion, then, instead of nerve exhaustion. "What we want to do with these patients is to turn them entirely around in their habits, and lead them to the adoption of measures that will make them plenty of blood and fat. Dr. S. Weir Mitchell has taught us how to do this, and his system of managing patients of this character is admirable. It is not always practical, nor, indeed, necessary to adopt his method as a whole. This, however, does not detract from its merits. Absolute rest is necessary only in cases of extreme prostration. In most cases active exercise will be better than passive, and should always be enjoined upon the patient and attendants. The exercise in kind and quantity should be prescribed and enforced with exacting regularity, and urged by decision that will not fail. The most important part of the treatment, however, is the regulation of food, by which I mean the prescription of it in items and quantity from day to day. My routine prescription is three ounces of beefsteak for breakfast, with bread and butter, or toast, potatoes, and other vegetables, as the capacity for digestion will allow; six ounces of roast beef or mutton, bread and butter, potatoes, vegetables, etc., for dinner; for supper the same as for breakfast, and after each meal, and at bedtime, one pint of good fresh milk. The only limit I would place upon the amount of food of the kind I have indicated is the capacity of the stomach to retain it. If the food is not rejected by vomiting, or it does not irri- tate the bowels enough to cause diarrhoea, I would not allow the want of appetite nor the inconvenience that may arise during digestion to be considered as a reason for not taking it. Usually the stomach will soon become tolerant, and after a time, the enriched blood, circulating through its glandular apparatus, will engender a relish for food, and TREATMENT. 687 the patient will eat with pleasure. This intimation, that an anemic stomach necessarily digests with difficulty, is intentional, for 1 do not believe that energetic innervation is possible unless the supply of blood is sufficient to secure good digestion. With this, or some other equivalent method of feeding the patient, there should be associated some plan by which she can get plenty of fresh air, and have as much exercise as she is able to take. The ex- ercise may be passive at first, but as soon as it is possible it ought to be active. Active exercise may be begun by having the patient walk, sup- ported as much as necessary by a strong nurse, but as soon as she can walk alone the support should be withheld. Then it is not rest, but exercise, that, should be advised in these cases. Of this I am fully convinced by experiments and unmistakable proofs in my own practice. As long as nutrition can be supplied the patient will profit by ex- ercise, but if nutrition is impossible, then of course exercise is impos- sible also. Thus far I have said nothing about medicines to aid digestion or to increase nerve force, not because I have no faith in them, but because I believe them of secondary importance, mere ad- juvants instead of principals in the treatment of this condition of the system. I could cite a number of instances in Avhich this course of manage- ment averted the dangers and mutilation of the more heroic treatment of castration, by establishing a vigorous and tolerant condition of the nerve system, and thus curing ovarian irritation. These suggestions are applicable to cases other than displacements of the ovaries in which there is ovarian irritation. As to the management of the displacement. In some few cases, when the ovaries are borne down by a displaced uterus, we may oc- casionally correct the displacement so far as to greatly improve the circulation of these organs, and thus remove a great element in ova- rian distress. This, of course, is done by correcting the displacement of the uterus, by proper means of support, as a well-adjusted pessary. In the cases, however, in which the symptoms are the most grave — retroversion and retroflexion of the uterus, — the location of the ovaries in the cul-de-sac by the side of the fundus renders the satisfac- tory adjustment of the pessary almost impossible, as the instrument is pretty certain to cause pressure upon these sensitive organs, and thus become intolerable. We ought not to despair of accomplishing the object, however, until we have exhausted our ingenuity in mechan- ical appliances for this purpose. When every other measure fails either to render the condition of the patient bearable, or save her from becoming a mental and physical wreck, we still have the resource furnished us by Dr. Battey, namely, 688 AFFECTIONS OF THE OVARIES. the removal of these organs. In taking the consequences of this operation, however, we should remember that it is a dangerous one, and that, if successful, it unsexes our patient in the sense that she is at least barren for all future time. When the ovaries are displaced so as to occupy the inguinal canal, the operation for removing them is less hazardous than when in the pelvic cavity, and for that reason may be resorted to with less hesitation. Acute Ovaritis. Acute inflammation of the ovaries, in connection with local perito- nitis, or inflammation of the cellular tissue in the pelvis, is not an uncommon affection. As simple, uncomplicated disease, however, it is conceded to be of infrequent occurrence. Post-mortem examina- tions reveal the existence of inflammation of the ovaries, as a compli- cation of inflammation of the surrounding tissue, in all stages, from mere phlogistic hypera?mia to destructive suppuration. In such in- stances it is involved in the general mass of disease. This occurs after abortion, labor at full term, and even in the non-puerperal condition, as the result of cold. As ovaritis in this connection is a disease causing no separate symptoms, and recjuiringno other treatment than is necessary for the cure of the inflammation accompanying it, all that is requisite to say upon the subject will be found under the head of perimetj-itis. As the result of the infrequent occurrence of ovaritis in an uncom- plicated state, our knowdedge of it is very meagre, many experienced practitioners never having recognized it. The intense interest the profession now feels and manifests in diseases of women will soon lead to a clearer understanding of this subject. The following case is the nearest approximation to simple acute in- flammation of the ovaries ever observed by the author : "January 5th, 1872, I was called to see Mrs. S., widow, aged thirty-five years. She is the mother of three children, the youngest of whom is eight years old. She had been attacked fourteen days before with pain in the hypogastric and iliac regions; chill, nausea, headache, and great nervous excitement. Fever succeeded the chill, and the nausea was sometimes accompanied by vomiting. The pain continued, and was aggravated by the erect or sitting posture. She was attended by a homoeopathic prac- titioner, and after a few days improved until she was able to sit up a jiart of the time ; but the pail), accompanied with tenderness upon pressure in the iliac region, contin- ued in a subdued degree. Upon the 13th, about 10 p.m., after having exerted herself . too much, she had another chill, with an aggravation of the symptoms. In the morn- ing, when I was called, I found her vomiting, and unable to retain anything but cold water. She had headache, with pain and tenderness in both iliac regions. There was no tumefaction. The pulse was 110 to the minute; the tongue was coated white; the mouth dry, and other febrile symptoms usual in moderate attacks of acute inflamma- tion were present. The attack had occurred at the time the menstrual flow was subsid- ing, and was attributed to exposure after being overheated and fatigued. At the time CHRONIC OVARITIS — OVARIAN IRRITATION. 689 I saw her there was no discharge from the vagina ; the passage of the urine gave her pain of a burning character, and she suffered pain also in passing the fseces. Upon examining per vaginam with the finger I could feel both ovaries prolapsed and tender. The uterus was prolapsed somewhat ; also swollen and tender to the touch. Upon making pressure in the hypogastric region the patient complained of but little tender- ness. Downward pressure in the iliac region caused more pain, and increased the sen- sations of tenderness in the pelvis. The ovaries, as felt through the vagina, were tender, movable, and appeared to be three times their natural volume. The patient complained of increased nausea when they were touched in the examination. I found no difficulty, by using the fore and middle fingers, in examining them thoroughly and recognizing their shape and size. The diagnosis was moderate inflammation of the uterus, with more acute inflammation of the ovaries. The patient informed me that she was not aware of being the subject of chronic inflammation of the uterus, as she had not previously suffered from pelvic pain or inconvenience, indicating chronic dis- ease of any kind about the uterus or ovaries. There did not seem to be local perito- nitis or cellulitis, and but slight metritis. The bladder was irritable, and the vagina slightly tender. " Treatment. " Four grains of calomel were given, and succeeded in eight hours by a saline ca- thartic. Poultices were applied to the hypogastric region, and the patient was ordered to keep quiet in the recumbent posture. The cathartics operated well, and relieved much of the pain and suffering. One-fourth of a grain of morphia enabled her to rest with some degree of comfoi-t. When the pain returned the morphia was repeated, and thus continued when necessary for the pain. The bowels were kept soluble by the administration of a fluidounce of the saturated solution of citrate of magnesia. B7 continuing this course of treatment for six or seven days the inflammation was sub- dued, and convalescence was fairly established. In three or four weeks she was entirely well, and still remains so." Chronic Ovaritis — Ovarian Irritation. An extensive array of grave symptoms have for a long time been imputed to morbid conditions of the ovaries ; and while our informa- tion is yet meagre as to the exact nature of the pathological changes in the ovaries, and their relation to the symptoms, I think it may be said that within a few years past our knowledge in these matters has been decidedly advanced. This advancement is mainly attributable to the recent practice of removing the ovaries as a therapeutic meas- ure. The efforts to define by terms the morbid conditions of the ovaries when found diseased, so far as I know, have not resulted in anything of much value. When removed by the surgeon, statements as to their condition have been too vague to convey to the reader an accurate idea. Almost everything as to ovarian pathology has yet to be determined. In venturing to place the above heading to this section, I may be subject to criticism, and possibly correction by some one better in- formed upon the subject. It will probably be found that the reflex symptoms may be caused by more than one pathological condition of these organs. 44 690 AFFECTIONS OF THE OVAEIES. Mr. Lawson Tait in his late work on Diseases of the Ovaries has described hypersemia and chronic ovaritis. In many cases in which the nervous and other disturbances were sufficient to require oophorectomy, a common condition and one fre- quently found in my own cases, was an unusual number of cysts, doubtless from ovisacs. And judging from such examination as I could make, these cysts contained the same kind of albuminoids that are found in large ovarian cysts. I believed them to be nothing more nor less than ovisacs developed prematurely and imperfectly (imper- fectly in reference to both the contents and containing tissues), and to be the result of a hypergenetic influence in the ovaries produced by long-continued hyperemia. Dr. Goodell* thinks that sometimes the inflammation affects the stroma more than the follicles and the converse. However this may be, there is often hypertrophy of both these tissues. I say hyper- trophy because I know of no more appropriate term. It is not, how- ever, simple increase of growth in either of these tissues, because the form of nutrition in them is not normal. In the stroma the increase is inflammatory deposit, and, as before said, the fluid in the follicles while it somewhat resembles, it is not identical with their normal contents. Etiology. Without further discussing the subject of the nature of the changes in the ovaries to which the term chronic ovaritis is here applied, I think we will find reason to believe in the correctness of it in the more frequent causative conditions. Scarcely any observer will doubt that by far the greatest number of instances succeed the acute form, and are accompanied b}' unquestionable inflammatory changes in the surrounding organs and tissues. Both acute and chronic ovaritis are generally secondary ; the inflammation invades the ovaries from con- tiguous parts, as the broad ligaments, peritoneum, and especially the Fallopian tubes. It is now generally believed that gonorrhoeal in- flammation, by passing through the tubes, reaches the ovaries. Many cases arise no doubt during the progress of the continued fevers. I think also that instances of acute inflammation in the pelvis and lower abdomen, causing ovaritis, are often mistaken by careless ob- servers and reported for typhoid fever. Whether there is any con- siderable tendency to ovaritis in the eruptive or rheumatic fevers, as asserted by Mr. Tait, I do not know. Excessive and prolonged sexual excitement, the rigid discipline at some of the more strict academies and other schools, constipation, and in fact anything that causes pro- longed hypersemia of the pelvic organs, will affect the ovaries in this way. * Pepper's System of Medicine. 'SYMPTOMS. 691 Symptoms These are local, general and fanctional. Prominent among the local is pain in the region of the ovaries radiating into the back, up the sides, and down the limbs. If the disease is confined to one of the organs, the pain and suffering may be manifest on that side alone. Pain in the course of the anterior crural or sciatic nerve may be the most prominent local symptom. Not unfrequently the pelvic pain will be increased at the time of menstruation, constituting ovarian dysmenorrhoea. There is no doubt that this affection produces decided effects upon the functions of the organs of generation, causing sterility, menor- rhagia, amenorrhoea, etc. ; also the abortive development of the ovi- sacs, as shown by their arrest of growth and their immature contents, the discharge of imperfect ova, etc. I have already expressed myself as believing that the numerous cysts formed upon the ovaries are im- perfectly developed ovisacs, the imperfections consisting mainly in arrest of development in both the involucra and their contents. As there is no question of the continuous impression of the ovaries on the uterus regulating its constitutional changes and functions in health, so I believe that when morbid their impression will be vicious. Facts adduced by Mr. Tait go far towards proving that when there is chronic hyperasmia of the ovaries, there is the same condition in the uterus, and that this gives rise to menorrhagia ; also that when the inflammation has reached the stage of induration, amenorrhoea re- sults. This is but another expression of the principle that the gen- erative organs are so closely bound together by the same set of nerves and vessels that the condition of all of them is apt to be very much alike, anaemic, hypersemic, etc. The general symptoms are manifested in and through the nervous system, including the brain and spinal cord. In fact it is the kind and degree of disturbance in the nervous centres that constitutes one of the most important features in our estimate of the gravity of ovarian disease. The nervous symptoms are so varied that it is difficult to enumerate, much less describe them. I would refer the reader to the chapters on hysteropathy for a gen- eral view of the symptoms of disease of the genital organs, believing that these symptoms would fairly represent those occurring in ovarian as well as uterine disease. With reference to the nervous symptoms, mentioned in those chapters, the more grave are now almost uni- versally attributed to ovarian disease, and no doubt this is correct. Such symptoms are convulsions of varied intensity, and, mental de- rangements. When the convulsions are epileptiform they are called hystero-epilepsy, but perhaps ought to be denominated oophoro- epilepsy. As I have witnessed them in their severer forms they re- 692 AFFECTIONS OF THE OVARIES. semble epilepsy so closely that I have been unable to distmguish be- tween them, and why may they not be true epilepsy and yet be of ovarian origin? As an aura may originate in a wound, why may it not begin in a diseased ovary ? One patient of mine who had unquestionable epileptic seizures which lasted for many years was cured by having both ovaries re- moved. One ovary was included in a large ovarian tumor, and the other was found occupied by numerous small degenerate cysts. This hystero-epilepsy often results in great impairment of the mind, in fact this danger is one of the justifying conditions of oophorec- tomy. Mental derangement, however, does not always come about as a result of long-continued convulsions, but often seems to be a more direct consequence to ovarian disease. One of the tests usually applied as proof of ovarian origin is the repetition or aggravation of the attacks at the time of the menstrual period. There is generally something of a correspondence of this kind, but I think not always; for the parox- vsms may occur at regular times between the menstrual periods. Diagnosis. As the ovaries in a state of inflammation are larger and heavier than natural, they not infrequently come within reach of the finger in vaginal touch. When not enlarged or somewhat displaced, it may be very difficult for the physician to demonstrate to his satisfaction what their condition is. When they are down within reach of the finger in the vagina their shape, size and sensitiveness may be to a certain extent ascertained. The roughness and unevenness caused by cystic degeneration when present may generally be appreciated. A perfectly normal ovary ought not to be very sensitive, and hence I regard tenderness as a sign of inflammation. In very thin persons, by the bimanual examination, the ovary can often be felt when in situ. They are sometimes reached through the rectum, and when ex- actitude in diagnosis is important, two fingers or the half hand should be introduced into the rectum, when the ovaries may be brought under inspection. Another item of great importance in the diagnosis is as to whether the grave secondary symptoms, such as mental de- rangement, convulsions, etc., depend on ovarian irritation, or disease of the nervous centres themselves. A few very important considera- tions are: 1st. Is there evident ovarian disease of a serious character present? 2d. Have the nervous disorders made their appearance since the establishment of the pelvic trouble? 3d. Are the nervous symptoms aggravated at or near the menstrual period, or are they worse at some regular period during the menstrual interval? 4th. Is there an absence of hereditary tendency to diseases of the brain ? An affirmative answer to all these questions makes the probability of their dependence on disease of the ovaries quite strong. PROGNOSIS — COMPLICATIOXS — TREATMENT. 693 Prognosis. Is the prognosis of chronic ovaritis so grave as we have been in the habit of considering it ? I think not. On the contrary, I believe it is often cured, and more frequently the suffering of the patient is ameliorated until the menopause comes to her relief. The prognosis in those serious cases where the nervous centres are so severely affected that their functions are threatened with permanent disorder may be regarded as desperate ; but these are fortunately not the most common form. The prognosis is rendered desperate because the reflex effects of ovarian irritation are destroying the patient so rapidly that we cannot wait for the slow operation of a medicinal course of treatment, and hence are obliged to resort to surgical measures. There are a great many cases where the morbid conditions do not produce these symptoms and consequently do not demand such radical means of relief. In all grades of the disease the cure is slow. It is usual to consider the ansemia and nervous prostration as the direct effects of the morbid ovarian impression, but I believe that the degeneration of this structure is often the consequence of long exhausting and vitiat- ing general conditions. Complications. Chronic ovarian inflammation is nearly always accompanied with inflammation in other organs or tissues of the pelvis. The most com- mon are local peritonitis, cellulitis and salpingitis. But the uterus very frequently is also implicated. Sometimes there is displacement of the uterus and ovaries, the latter lying under the retroverted or retroflexed womb. When the erect posture causes them to be pressed upon painfully, and when they are in a position to be seriously dis- turbed during coitus, the grave nervous symptoms so frequently present stand in the relation of consequences rather than complica- tions. Treatment. The treatment will be greatly modified by the stage of the disease and intensity of the reflex symptoms. Until the functions of the nervous centres are very much disturbed, we may depend upon gen- eral and gynecological treatment with the hope of effecting a cure. When, however, there is either incipient or established insanity, epi- leptic or hystero-epileptic convulsions, and especially if the disturb- ance to the brain usually brought about by these affections is increas- ing, we must regard surgical measures as essential to a cure. Mr. Tait mentions another symptom as being equally unmanageable without surgical measures, viz., excessive and obstinate menorrhagia. Possi- bly other conditions connected with chronic ovaritis may as urgently demand oophorectomy, but I think they must be very few. In those 694 AFFECTIONS OF THE OVARIES. cases in which a multitude of derangements of minor importance exist, and in most of which nervous prostration is predominant, we may reasonably expect, if not a complete cure, very great benefit from judicious general treatment. One object greatly to be desired is improvement of the general health. In bringing this about we do not, as might be supposed, merely palliate the sufferings of the pa- tient by making her better able to bear them, but we create re- cuperative energy. An improvement in the condition of the blood and nerve force is necessary for the cure of any chronic disease. A Avoman cannot be cured of chronic ovaritis while in a state of great nervous prostration or profound ansemia, and the removal of these complications goes a long way toward the cure. The systematic feed- ing, massage, electricity, and mental rest so admirably taught and prac- ticed by Dr. Weir Mitchell, forms an excellent method of inaugurating the treatment of these cases. This followed up by travel when that can be indulged in will often be sufficient to restore the patient. When neither of these are practicable we can generally imitate the former sufficiently well to produce much the same effects upon the patient. We can prescribe the quantity and kind of food and fre- quency of taking it, the character and amount of outdoor exercise, according to her circumstances and ability to afford it. This plan is generally practicable even with people in moderate circumstances, if the physician will properly study the matter. (See General Treat- ment of Uterine Disease, from pages 397 to 415.) Another probably not less essential part of the treatment is the correction as near as possible of every abnormal condition found in all the associate organs, the uterus, vagina, tubes, etc. With the ex- ception of displacements, the remedies addressed to the diseases of all the pelvic organs affect the ovaries as well. For chronic inflamma- tion of the uterus and broad ligaments, we prescribe the hot-water douches, sitz-baths, glycerin tampons, iodine counter-irritation, etc. And these used perseveringly are precisely those from which we would expect the most good in cases of chronic ovaritis. CHAPTER XLIL AFFECTIONS OF THE OVAEIES (Continued)— OVA RIA'!^ TUMORS. Anatomy. In the ovarian tumors proper, we may trace three coats or layers of tissue forming their walls. The external is the serous or perito- neal. It is shining and smooth as this membrane is elsewhere, and seldom changed in any way, except it may be thickened and hyper- trophied. It can be traced into the peritoneal covering of the viscera and abdominal parietes, and consequently needs no elaborate descrip- tion. The internal coat or lining membrane is doubtless the mem- brana granulosa of the ovisac, very much hypertrophied. When small, something like epithelium seems to be its entire composition. As it grows and develops, the epithelial arrangement is less perfect, until, when very large, we can observe it only in patches. In many cases when thus large, this membrane has a smooth, lustrous appear- ance, but in others it is more or less thickly studded with granular projections, varying from almost imperceptible minuteness to the size of peas, or even larger. Regarding the main sac as an hypertrophied ovisac, I think these little granular sacs (for they prove to be sacs upon examination) are also of the same nature and are the origin of the numerous endogenous or supplementary growths which constitute one of the polycystic varieties. The middle coat is made up from the stroma of the ovary. Its strength depends upon quite a considerable amount of fibres, which enter into its composition. As the tumor develops, these fibres are enlarged, and apparently, if not really, increased in numbers, until they constitute the most of the thickness of the walls, and in some parts make quite a thick, dense, and tough tissue. These qualities are greater in old large sacs than in the smaller and younger ones. At the pedicle, and for some distance up the sides, they are greater than in other portions, being in these parts sometimes a quarter of an inch thick, while at the fundus or distal portion they may be thin and fragile. The whole of this coat may be very tough and thick, so as to resist great force, or it may be thin throughout, so as to be easily ruptured at almost any point. Entangled in the meshes of these fibres may be discovered, in many cases, the minute micro- scopic points so numerously scattered through the substance of the ovaria. These points are believed to be the origin of the germinal spot in the ovum by some physiologists, and around which are de- 696 OVAEIAN TUMORS. veloped the ovum, and progressively the whole ovisacs and their con- tents; and I believe that their presence in the walls of the tumors, over much, if not the whole, of their extent, accounts for the devel- opment of the minute granular internal projections above described. In a tumor recently removed from the body, by holding it up to the light, we may not unfrequently discover the peculiar huffy tinge seen in the stroma. The vessels are situated in this coat. They are numerous and some of them large, so large that great care is necessary to prevent them from bleeding when the peduncle is divided. They are developed, it is hardly necessary to say, to this great size from the minute twigs which penetrate the substance of the ovary. The shape of ovarian tumors may vary much. They may be regu- larly globular, polyglobular, angular, or irregular in almost every way. When small, the ovary may be seen as constituting a consider- able portion of the tumor. When large, the ovary may be almost- lost in the walls, or observed as a mere tubercle sticking to or im- bedded in its side. Generally but one ovary is the seat of disease, but in rare instances both are affected. Ovarian tumors divide them- selves anatomically into monocystic and polycystic, — the one having a single cystic cavity, the other several. The polycystic variety is formed by the development of several cysts adjoining or by the side of each other, and independently attached to or springing from each other on the external surface, or within the cavity of one large one. The instances of poly cysts growing by the side of each other, and being independently attached, resembles at first the monocysts. At an early stage of development they may stand free of contact one with the other, but as they grow in size, in consequence of the small surface of the ovary to which they are attached, they crowd together, so that it is not always easy to say whether they were not developed from each other. The cysts from which smaller ones grow are called pro- liferous. They are doubtless single for some time in their early development, but carrying up, as they increase in size, the proper substance of the ovary, with its rudimentary ovisacs, after awhile the inner or outer surface is bulged by the maturity of these last, which, if they do not dehisce and allow the escape of the ovum, grow into a subordinate tumor. This process is separate until there is a glomera- tion of cysts to quite a number, from four to fifty, of various sizes, from the size of a man's head down to that of a pin's head. Small ones may be so numerous as to stud a large part of the inner surface with granulated elevations. This is the most frequent variety met with in practice. When the minor sacs grow from the inner surface of a large cyst, the tumor is denominated oligocystic. There is a great difference in the sensible qualities of the contents of the cysts in different cases, and of the different cysts in the same case. In some it is very thin, in others very thick and tenacious, NATURE AND ANATOMY. 697 while the color shades from black, inky, to limpid clearness. Not unfrequentl}^ large fibroid growths are observed in the ovary at the base of a single or multiple cystic tumor. These solid fibroid or fibrous growths may be simple or benign in their nature, or malig- nant. This complication of ovarian dropsy I think is more frequent in persons advanced in years — over forty — than in younger ones. The contained fluid of the polycystic tumor is ordinarily highly albumi- nous, of high specific gravity, tenacious, and more or less colored. The fluid is sometimes so thick as not to flow through a canula. Occasionally we meet with sacs which contain blood ; more frequentl}'' serum colored with blood ; in others pus, or serum and pus. From one tumor of several cysts, I drew pus from one cyst; dark coffee- grounds sanguineo-serous fluid from another ; a beautiful straw color from another ; and lastly, from another, fluid of a delicate azure tint. After tapping, more or less alteration is observed in the fluid, each operation withdrawing fluid affected by chemical or pathological con- ditions. In the former, putridity or acridity ; in the latter, the puru- lent productions of inflammation. There are some chemical and microscopic resemblances in the fluid from almost all varieties of ovarian tumor. Albumen in some of its forms is always present. In some specimens of fluid, strong acids, or heat, cause it to assume a solid form, coagulating and adhering like the white of an egg when cooked in boiling water ; in others a small precipitate is all that is observed. Between these extremes all shades of diff"erence exist. The reaction is alkaline. Mr. Nunn says that, " As the results of many examinations (microscopic) of difierent specimens of ovarian fluid, the most constant characteristic of such fluid is its containing, in greater or less abundance, cells gorged with granules ; and, in addition, circumambient granules, having the same measurement, encompassed by the cell. The size of the gorged cells and included granules varies greatly, even in fluid from different cysts in the same ovary." This description of fluid could, with certainty, remain good of the first evacuation only, as pus and blood-globules are not unfrequently found in subsequent evacuations. The fibrous or solid variety of ovarian tumors is occasionally met with. Dr. Bogue, about ten years since, removed a solid tumor of the ovary at the Cook County Hospital, which weighed forty ounces. It was very dense and fibrous in structure. The very remarkable tumor called dermoid is so seldom met with and so little is said of them in the textbooks that I feel justified in copying somewhat at length from my article on dermoid ovarian tumors, in the third volume of the Transactions of the American Gyne- cological Society : Case I. — In the spring of 1874, the patient, a girl, eighteen years of age, noticed an enlargement in the left iliac region, which finally be- 698 OVARIAN TUMORS. came so great that in October, 1875, she was distressed from the dis- tension. At this time she was tapped and about ten quarts of fluid evacuated. The fluid was somewhat tenacious, of a clear, slightly bluish tinge, and contained the ovarian cell. The outline of the tumor could be traced quite easily after the tapping. It occupied the whole width of the abdomen between the two iliac fossse and extended upwards to within two inches of the umbilicus. It was globular and of soft consistence. After this operation the tumor filled quite rapidly, and on January 1st, 1876, the patient was as large as before the fluid was evacuated. On January 4th, ovariotomy was performed. There were no adhe- sions or other source of embarrassment to the removal of the tumor, and the patient made a good recovery. The sac was thin but firm, and presented the peculiarly pearly aspect of the ordinary ovarian tumor. When the large Wells's trocar was introduced nothing but serum flowed through the tube. Upon being opened the tumor was found to contain about half a pound of sebaceous fat. The inner surface was smooth, except a small part about the size of the palm of the hand situated at the bottom near the pedicle. Here the surface was depressed at least an inch below the level of the inner surface, and, although not sacculated, had a well-defined and pursy margin. The bottom of this depression was covered with dermic tissue, and upon it grew an abundant crop of dark-brown hair about an inch long. It was very fine, and firmly attached. Doubtless the dermic patch was the source of the fatty material found floating in the cyst which, on cooling, assumed the consistence and appearance of yellow butter. Upon closer inspection of the smooth lining of the larger part of the tumor it was found to be studded with very minute papillae, such as we sometimes see in oligocystic ovarian tumors. This specimen I regard as not a true dermoid cyst, but as a com- plex dermo-ovarian tumor, a tumor originating in a Graaffian follicle in which a tegumentary element had been inclosed. It contained no bone or teeth such as are often found in the true dermoid tumor, but did contain undoubted colloid fluid, diluted with the watery product from the sweat glands of the dermic membrane upon which the hair was implanted. Case II. — Mrs. P., aged forty-three years, the mother of one child, eighteen years old, became aware of an enlargement of the abdomen about ten months before the operation, which was performed June 28th, 1876. During that time she grew to the size of pregnancy at full term. The tumor filled the abdominal cavity and extended to the ensiform cartilage. There was no difficulty in deciding that it was monocystic and contained a thin fluid. The operation was not attended Avith difficulty in any respect. There were no adhesions, NATURE AND ANATOMY. 699 and after evacuation the sac passed through an incision only three inches long. The patient experienced considerahle depression from the shock of the operation. This, however, lasted but a few hours, no other disagreeable symptoms supervening. The recovery was rapid. The care of the case after the operation was undertaken by Dr. S. W. Green, of Marengo, Illinois. The cyst was single, thin, and uniform, except at the part opposite the pedicle, where its wall was about half an inch thick and contained a thick layer of adipose tissue. Upon the inner surface of this part was a thick tegumentary covering, upon which w^as implanted a dense mass of blonde hair, matted together, and nearly the size of an orange., The whole of the inner surface of the sac elsewhere was smooth and of a buff color. The external surface was of a pearly hue and smooth. There was no evidence of bony or dental tissue. The fluid was quite thin, of a slightly blue tinge, and floating in it in considerable masses were ten to twelve ounces of yellow sebaceous fat. The hairs, when straightened out, measured from six to fifteen inches in length. This example I regard as a simple dermoid cyst of the ovary, there being no sign of follicular papillee upon the inner surface, and the fluid not being in the least tenacious or colloid in appearance ; more- over, I was unable to find in it the ovarian cell. I think the fluid was the product of the sweat glands in the dermic structure at the bottom of the cyst. Case III. — Mrs. P., a small Jewess, thirty-one years of age, the mother of four children, the youngest being three years old, noticed about nine months before the operation — which was performed April 7th, 1875 — that the abdomen had commenced enlarging. The tumor was found to be monocystic and so completely filling the abdomen that the patient had great inconvenience from distension. The removal of this tumor, which originated in the left ovary, was easy, as no adhesion or other obstacles were encountered. The patient recovered without experiencing any untoward symptoms. The tumor was composed of a single cyst, of which the wall was thin over about three-fourths of its circumference and easily ruptured. At the bottom or pedicular portion, involving about one-fourth of the inner surface, was a dense mass of areolar tissue literally filled with pieces of bone. The greater number of these pieces were cylindrical, from half an inch to two inches in length, and varying from an eighth to a quarter of an inch in thickness. They seemed to be imbedded in loose cellular tissue, were not attached to each other, and were easily removed by the finger. Other masses of bone, made up of alveoli, were not unlike the maxillary processes, and varied in length from one to two inches, and in width from one-third to one-half inch. They resembled honeycomb, and were quite firmly attached to the cyst wail. The microscope showed their structure to be that of true bony tissue. 700 OVARIAN TUMORS. This mass was covered by a tegumentary membrane to which were attached more than a hundred imperfect incisor teeth, distributed over the whole surface, their adhesions being so slight that they could easily be scraped from the surface with the finger. These dental bodies were all about the same size, and consisted merely of the crown, but the enamel and dentine seemed perfect. They had no connection whatever with the bony tissue. Interspersed among these teeth was a dense crop of blonde hair, averaging an inch in length. The fluid, of which there was about 10 quarts, sp. gr. 1008, was clear, with a slight bluish tinge, and entirely devoid of tenacity or other colloid properties. I believed it to be perspiratory serum. There were also several ounces of yellow sebaceous fatty matter within the cyst. I should class this tumor among the true dermoid cysts of the ovary, and believe that it possessed none of the properties of the ordinary ovarian tumor. Its structure was much more complex than that of the two preceding tumors, but much less so than that to which I shall now call attention. Case IV. — Mrs. B., thirty-five years of age, the mother of four chil- dren, the last twenty months old, first noticed a tumor in the right iliac region nine years before operation. It was then about the size of her fist. It had grown steadily but slowly until June 19th, 1878, when it was extirpated. The growth did not seem to be influenced by pregnancy. She had borne three children from the time when the tumor was discovered to the time of its removal. Her health had been feeble for several years, but from the birth of her last child she had been confined to bed half of each day, and, for several weeks, all the time. The main inconvenience was from the weight and mobility of the tumor. When she Avas in the erect posture it caused dysuria and rectal tenesmus ; when lying on either side it pressed upon the subja- cent viscera and also dragged upon the upper side ; the only com- fortable position was the dorsal. The pulse and temperature were decidedly and continuously above the normal standard. She was sleepless, had a very poor appetite, and was rapidly becoming ema- ciated. The above very brief history was given me by the attending physician. Dr. J. H. Low, of Brimfield, Illinois. The appearance of the abdomen was very singular. It was con- siderably distended ; from its centre, including in fiict the whole umbilical region, arose a round projection exactly resembling a ven- tral hernia, the umbilicus occupying its apex. It measured five inches in diameter, and protruded three and a half inches above the common level. It Avas fluctuating and dull upon percussion. On each side I could easily distinguish two other, apparently larger, cysts not projecting above the surface. Percussion over these elicited no resonance, but it was easy to detect fluctuation. The tumor could be XATUEE AND ANATOMY. 701 moved pretty freely in all directions without traction upon any part of the abdominal walls. By external and internal manipulation I could trace the attachment of the mass to the right side of the pelvis and assure myself that it was not of uterine origin. It was clear that I had to deal with a tumor made up, principally at least, of three cysts, and quite certainly originating in the right ovary, but it pre- sented so many unusual symptoms and appearances, that further diagnostic measures were necessary before I would venture to remove it. After making preparations for its extirpation, the patient being fully etherized, I introduced a small trocar into the prominent cyst. A little sebaceous fat flowed through the canula, and at once made the diagnosis complete. The usual small incision exposed the pearly cyst and allowed me to evacuate the prominent sac of one quart of thin, yellow fat. The other two cysts were drawn to the opening, and their contents, of a similar character, evacuated. By this time the rubber blanket was smeared with a sticky grease, the instruments had become slippery, and my fingers were encumbered with a mass of fat which had to be removed before I could proceed with the operation. The cysts were drawn through an incision about three inches long, and a short, slender pedicle, consisting of the right ovarian ligament, part of the broad ligament, and Fallopian tube, was brought up into the wounds, ligated, cut, and dropped into the pelvic cavity. The left ovary was healthy. As nothing had been allowed to pass into the peritoneal cavity the incision was then closed. It will have been seen by this description that no adhesions or other impediment hindered or complicated the operation. It was remark- able how extremely greasy everything employed in the operation became, and I had more trouble in cleansing the instruments from the grease than is usually experienced in getting rid of the blood and mucoid fluid of the common ovarian tumor. The patient had no untoward symptoms, seeming to me more like one recovering from the exhaustion and irritation in which I had found her than from the hazardous operation for the removal of an ovarian tumor. Before describing the tumor I wish to call attention to the fact that there was no serum evacuated during the operation ; no fluid but the soft fat was observed. The tumor proved to be a remarkable specimen of the true dermoid variety, nothing in its contents seem- ing to be of ovarian origin. The cyst wall was thin, but of firm structure, and divided into three compartments of about equal dimensions. The septa were complete, and of the same consistence and density as the external wall. At the base of the tumor the sac was more dense and firm than elsewhere. The peculiar formations contained in each cyst were so nearl}'- alike that a description of the contents of one will suffice for each of the other two. On opening the cysts each was found to contain a mass of matted 702 OVARIAN TUMORS. hair, the size of a lemon, thoroughly supplied with the same fatty substance that had been evacuated from the tumor. One of these rolls of hair was red, another blonde, and the other gray. The pa- tient's hair was dark brown. Some of this hair was twenty inches long, and it was all attached to tegumentary substance closely re- sembling the scalp. The dermic structure, which was about four inches across, rested upon a very uneven layer of adipose tissue an inch thick. By the side of the dermic patch, and not covered by it, was a loose layer of areolar tissue, an inch and a half thick, contain- ing bones in a great variety of shapes, — scales, round bones an inch or more in length, alveolar nodules, etc. Upon the surface of this part of the tumor in each cyst was a half-arch of teeth the shape of one-half the superior maxilla. In one cyst the crowns of the teeth projected aboA^e the surface, while in the other two they were thinly covered by tissue so soft that it could be pinched off by the thumb and finger. The teeth were not attached to the subjacent bones, but were simply imbedded in the loose mass. The teeth in each segment very perfectly represented, respectively, an incisor and three molars, each having three well-marked fangs. One of the molars in each row strongly resembled the wisdom tooth. The perfection of their forma- tion will be recognized in the specimens which I submit for your examination. The crown with the enamel and eminences, the main body, and roots are as distinctly marked as if they had been removed from alveolar cavities. Before leaving the description of the tumors and their removal, I would call your attention to the great simplicity of the operation and the fortunate recovery of all the patients, no adhesions or other coni- plications having existed. Now what is a dermoid tumor? This name is given to a c^'st formed anywhere in the body, the internal or lining membrane of which is in ]3art or wholly tegumentary in structure. As now un- derstood, the presence of this condition alone would justify this nomenclature. The formation seems to be no less an error of struct- ure than location. Lebert, Paget, Virchow, and most other modern pathologists agree that the dermic tissue thus located is essentially the same in structure as true skin. The products are all the same, hair, sebaceous fat, and perspiratory fluid. In many of these tumors we find subcutaneous adipose tissue very perfectly formed. Less con- stantly, teeth, bone, muscular, nervous, and even brain tissues. These latter, excejit the teeth, in some instances, are found either beneath the dermic membrane or beneath the portion of the internal surface not lined by this cutaneous substance. My observation shows that the dermic tissue and its i^roducts char- acterize one variety of these formations, as in Cases II and III. These constituents are sometimes found alone, and may then be re- NATURE AXD ANATOMY. 703 garded as indicative of a more simple formation, -while the addition of bone, muscle, etc., constitute a more complex order of tumor rep- resented by Case IV. The bone and muscle, however, are never found in a tumor of this kind without the dermic membrane, its essential glands, and their products. Another thing quite apparent is that the skin and its appendages are not only constantly present, but comparatively perfect in their organization. The teeth, which are very closely associated in embryonic metamorphosis with the for- mation of the skin, stand next ; many being quite perfect in their structure. The bony, muscular, and nervous structures, although complete in their texture and formation, are never developed into complete organs. I am aware that cases have been recorded, — as, for instance, by Blumbach and Rokitansky, — that would seem to be at variance with this assertion ; but the bones in these cases lacked the completeness in structure necessary to entitle them to be classified with any of the bones in the human skeleton. When some or all of these structures, together with the products of the dermic tissue, con- stitute all the contents of the cyst, the specimen should be regarded as a simple dermic tumor, even when formed in the ovary, the fact of its having found a lodgment in that organ being an accidental rather than a necessary condition. When, however, it exists in the ovary, and with these substances there is found the colloid or mucoid fluid characteristic of the ordinary ovarian tumor, it is not merely a dermoid, but an ovarian dermoid tumor. It is a mixed neoplasm, a morbid development of the ovarian follicles in connection with the congenital dermoid. In my first case this was the character of the tumor ; and instances of this kind are recorded in the well-known books of Drs. Atlee, Peaslee, and Mr. Wells. The first variety, then, although often found in the ovary, differs in no essential particular from those found elsewhere, except in magnitude, and perhaps greater perfection of organized development. Possibly this last difference does not exist. When found in the ovar}^, either in the single or mixed form, the investing membrane seems to be the same in appearance and structure as in ordinary ovarian tumors ; and, when first exposed, it is often not easy, if at all possible, to distinguish between them until some of their contents are evacuated. To the more fluid products of the first variety of simple dermoid cysts, especially the secretion from the dermic tissue, such as the serous or perspiratory fluid, we must attribute the difference in the size of this form of tumor. The sebaceous product is also sometimes quite bulky, as seen in Case IV ; but when the sudoriparous glands are numerous and active, the amount of watery fluid is sometimes enor- mous, and consequently the tumor grows to be very large, as may be specially noted in the second case. In such instances, from causes 704 OVAEIAN TUMORS which are not appreciated, the sudoriparous glands seem suddenly to acquire great functional activity, and by pouring into the tumor a large supply of fluid make it grow with great rapidity. As there was no appreciable amount of serum in Case IV, the sac being filled with the sebaceous matter, it is easily understood why the tumor was a long time in attaining the dimensions it finally acquired. The solid contents of these tumors, as far as I can learn, do not grow to a sufficient extent to give them any great bulk, and consequently, when situated in the ovary, such a tumor, apart from its fluid contents, would hardly require extirpation. The compound variety, or ovarian dermoid, would be likely to grow to a great size in consequence of the accumulation of the colloid secre- tion, just as they would if the dermoid element did not exist. By consulting the literature of the subject, I am led to the conclusion that the dermoid and colloid contents of these compound cysts are usually contained in different co'mpartments of the tumor. This was notably the case in some of Mr. Wells's specimens. There are one or two' facts which may have some bearing upon the production and developm in inflammation of bladder, 230 j in fibrous tumor of the uterus, 624, 627, 663, 664, 666 in membranous dysmenorrhoea, 314 in menorrhagia, 302, 305, 307 in paralysis of the bladder, 225 in subinvolution, 568 mode of using, 642 modus operandi, 647 Etiology of uterine disease, 389 Excrescences, urethral, 157 Examination of tlie female pelvic organs, 53,55, 114, 138 bimanual, 57, 59. 65, 68, 74, 77, 80, 93, 94, 139, 228,472,496, 497 difficulties of, 69 instrumental, 114 manner of conducting, 138 ovaries, 69, 72 perineum, 108 position for, 56, 57 precautions necessary, 68 preliminaries, 53 through rectum, 91, 96, 104 uterus during general anaesthesia, 65 vaginal orifice, 108 vulval orifice, 110 Exsanguinification of uterine tumors, 671 Fallopian tubes, 27, 67, 68, 330, 732, 789 absence of, 789 aspiration of, 795 cancer and tubercles of, 797 catheterization of, 795 cysts of; 797 deformities of, 789 differentiation of, 81 dilatation of, 795, 796 dropsy of, 797 • extirpation of, 795, 796 felt through rectum, 95 hypertrophy and atrophy of, 749 inflammation of, 690, 693, 790, 796 obliteration of, 796 palpation of, 67, 68, 77 positions of, 68 rudimentary, 789 rupture of, 239 sounding, 116 Female pelvic organs, practical observa- tions upon tlie anatomy and physi- ology of, 17 instrumental examination of, 114 Fibroid polypus of uterus, 648 tumors, 610 Finger curette (Byford's), 134 Fistula, entero-vaginal, 275 Fistula, entero-vesical, 274 recto-vaginal, 275 urinary, 251 Fitch's sound, 114 supporter, 505 trocar, 765 Flap lacerations of perineum, 168 operations upon perineum, 206 Flattening of the perineal bodv in labor, 163 Flexions of the uterus, 489 Foetal membranes, 161, 187, 188 Folding of the perineal body in normal labor, 162 Follicular vulvitis, 152 causes of, treatment, 152 Forceps, double tenaculum, 121 Nelaton's, 766 vulsellum, 661 Foreign bodies in the bladder, 234 Freund's modified operation upon peri- neum, 208 method of passing sutures, 214 Fricke (episiorrhaphy), 509 Fritsch's needle-holder, 526 Fuller's earth, 505 Gall-bladder, 772 Galvano-cautery, 557, 594, 598, 749 Gangrenous vulvitis, 156 Gastralgia, 353 Gastro-hysterotomy, 735 Gehrnng pessary, 512 Gelsemium, 293, 412 Gentle touch, advantage of, 67 Gin, 291 Glands of Naboth, 430 Gleet, 790, 792 Glycerin, 154, 157, 243. 425, 439, 474, 499, 500, 506, 569, 587, 694, 795 and tannin, 243 carbolized, 152 Gonorrhcea, 151, 246, 349, 390, 445, 690, 789, 790, 792, 795 Goodell's dilator, 327 Goodman-Skene's self-retaining catlieter, 135 Goodman, treatment of chronic inflamma- tion of the bladder, 231 Granular cell of ovarian fluid, 720 Gray, attachment of the pyriforrais, 100 Great sacro-sciatic foramen, 100 Guarded liook, Sims's, 665 Hsematocele, chronic retrouterine, 338 peritoneal. See Metatithmenia, 330 Hanks's dilators, 132, 440 Hart and Barbour, 207, 211, 212 Heart, palpitation of, 383 Hematometra, 796. See Metatithmenia. Hemato-salpinx, 796 Hemorrhagia. See Metrorrhagia. Hemorrhage from the bladder, 225 after the cautery, 596, 597 fiom labia, 142 810 GENERAL INDEX. Hemorrhage in ovariotomy, 750, 767, 769, 777, 778, 779 Hemorrhagic diathesis, 300, 779 Hemorrhoids, 370, 616, 800 Hemostatic forceps, 604, 605 Hewitt pessary, 512 Higby's speculum, 120 Hip-bath, 228, 247, 290, 305, 311, 349, 416, 420, 474, 694, 695 Histologic distinction between sarcoma and carcinoma, 608 Hodge's closed-lever pessary, 521 Huguier's gland, abscess of, 146 Hunter's dilators, 327 Hydatids, 544 Hydrate of chloral, 403 Hydrocele, labial, 146 Hydrometra, 544, 72S Hvdro-salpinx, 791 Hymen, 108, 109, 112, 139, 176, ISO, 186, 209, 236, 240, 241, 316, 509 Hyoscyamus, 421, 585, 586, 731 Hypersemia, uterine, 383 Hyperaesthesia, 360 of the bladder and urethra, 325 Hyperinvolution, 554, 570 Hypernidation, 312 Hypertrophied labia, 147 Hypertrophy of the cervix, 446 of clitoris and nympha, 159 of Fallopian tubes, 797 of ovaries, 682 Hyrtl, arteries of the pelvis, 52 Hysterectomy for cancer, 579, 600, 606 for displacement, 501 for fibroids, 668 for sarcoma, 609 hemorrhage after, 605 sepsis after, 605 without ligatures, 604 Hysteria, 356, 361 Hystero-epilepsy, 356, 691, 692, 693 Hysterometer, 118 method of applying, 119 Hystero-neuroses, 386 Hysteropathy, 350, 441, 691 patiiology of, 382 Hysterophores, 505. See Pessaries. Hysterotomy, 549, 756 for cancer, 600, 665 for inversion, 549, 556, 557 Hystero-trachelorrhaphy. See Trache- lorrhaphy. Ice-bags, 222 Ice-bladder, 783 Ice-cap, Thornton's, 782 Immediate perineorrhaph)-, 194 Indagation, method of rectal, 91 Indigestion, 242, 398 Inflammation, acute, of the unimpregnated uterus, 346 and ulceration of the cervix, 394 chronic, of the bladder, 227 of the vulva, 150 Inflammatory form of dysmenorrhoea, 310 Infundibulo-pelvic ligament, 73 Injections, accidents in, 419 vaginal, 417 Injuries of the perineum and pelvic floor. mechanism of, 161 Instrumental examination of female pelvic organs, 114 Intramural fibroid tumors, 650 Intraperitoneal hematocele, 331 Intra-uterine pessary, Simpson's, 295 stem-pessary, Jackson's, 536 Inversion of the bladder, 235 of the uterus, 543 mortality, 545, 546 reduction by the elastic bag, 555 statistics, 546, 557 Involution of the uterus, 500 delayed, 558 diseased deviations of, 558 Iodine, 426, 427, 730, 737, 740, 741, 744 tincture of, 146, 247, 305, 33S, 427, 428, 440, 466, 474, 740 ointment of, 228, 421 Iodized phenol, 428 Iodoform, 195, 196, 198, 221, 505, 531 gauze, 198, 530 Ipecac, 311 Iron, 224, 290, 293, 309, 402, 403, 409, 625, 799 by hydrogen, 409 perchloride, 587 persulphate, 303, 429, 549, 589 Quevenne's, 293 sulphate, 409, 505 tincture of the chloride of, 154, 155, 156, 247, 306, 425, 429, 549, 589, 731 Irregular lacerations of perineum, 169 Irritable bladder and urethra, 225 Ischial spine, 99 Ischio-rectal vault or fossa, 35, 41, 42, 104, 122 Jaborandi, 589 Jackson's intra-uterine stem, 536 Jalap, 337 Jenks's sound, 114 Jewell, J. S., 49, 352 Juniper, 229 Knife for scarifying the cervix, 424 Kolpokleisis, 268 Labbfe, Dr. Leon, ex-sanguinification of tumors of uterus, 671 Labia, abscess of, 146 absence of, 149 adhesions of, 141 cancer of, 149 diseases and accidents of, 141 elephantiasis of, 148 hemorrhage from, 142 hydrocele of, 146 hypertrophy of, 147 GENEEAL IJSTDEX. 811 Labia, oederna of, 144 plalegmon of, 144 sanguineous infiltration of, 143 tnmors of, 147 varices of and vulva, 153 wounds of, 142 Lacerations of the cervix uteri, 61, 435, 569 complications, 437 degrees, localitv, and duration, 436 of the perineum and pelvic floor, 43, 113, 160 preliminary observations, 160 mechanism of, 161 of coccygeal portion, 161 of obdurato - coccygeal portion, 162 of levator coccygei, 163 of levator ani proper, 164 of levator vagiuse, 164 of constrictor cunni, 167 of vulva, 167 of trans versus perinsei and sphinc- ter ani, 168 of perineal septum, 168 of deep fascia, 168 flap variety of, 168 central, 169 irregular, 169 concealed, 170 from contusions against bony wall, 171 extending into rectum, 171 immediate efl'ects of, 171 remote effects of, 172 effects upon uterus, 172 effects upon bladder, urethra, and rectum, 173 effects upon vagina, 174 other effects, 174 symptoms of, 174 varieties of, 175 degrees of, 176 diagnosis of, 177 palpation, 180 rectal palpation, 181 inspection, 183 combined palpation and inspection, 184 degrees when extending into rectum, 184 diagnosis of lacerations of pelvic floor, 185 diagnosis of lacerations of deeper por- tions of pelvic floor, 185 metliod of diagnosis, 186 prognosis, 187 prevention, 187, 192 colpotomy, episiotomy, 189 perineal tenotomy, 190 choice of methods, 192 treatment, 193 by coaptation, 193 immediate perineorrhaphy, 194, 498 Lacerations, treatment, reasons for fsiilure, 194 contraindications, 194 the operation, 195 extending into rectum, 199 when to operate, 200 method of restoring the perineum when the rectum is not opened. See Perineorrhaphy, with lacerations of the cervix, 437 with subinvolution, 569 Laminaria tents, 128, 129, 132, 231 Langenbeck's operation, 214 serres-flne, 217 Laparo-hysterectomy, 668 Laparo-oophorectomy, 681 Laparotomy for adhesions in displace- ments of uterus, 517 extirpation of tumors of uterus, 667 Lard enema, 732 Lead acetate, 151, 229, 245, 247 Leeches, 337, 348, 423, 465 Lefort's operation for strengthening pelvic roof supports, 504, 510 Leucorrhcea, 371, 379, 388, 392, 395,438, 480, 545, 615, 628 Levator ani muscle, 101, 108 plane of, 164 Levator vaginje, plane of, 164 Lever for dilating the vagina, 126 Lewer's, Arthur, method of exposing ureters, 137 Ligaments, palpation of the ovarian, 72 the infundibulopelvic, 26, 70, 73 palpation of the I'ound, 74 interuretric, 27, 68, 89, 90, 137 of uterus, 18, 66 pubo-vesico-uterine, 18, 29, 448, 482, 487 sacro-uterine or posterior suspensorv, 18, 24, 29, 49, 68, 70, 75. 83, 86, 93, 94, 107, 160, 161, 487, 489, 492, 493, 494,496,511,512,517,524,527 broad, ligamenta lata, 18, 24, 27, 53, 69. 70,' 74, 76. 81, 82, 95, 107, 160, 172, 173, 330, 472, 490, 493, 494, 526, 690, 694, 768, 784, 789, 790, 792 round, 19, 27, 68, 74, 76, 84, 85, 172, 488, 493, 510, 512, 517, 524, 525, 534 uterine. See Ligaments of uterus. Lime, chloride, 157 Lithium, 761 Lithotomy, Sims's method, 233 Lithotrity, 233 Liver, sympathetic affections of, 354 Lobelia, 302 Local alteratives, 426 congestions, 404 peritonitis, 451, 460 symptoms of uterine disease, 369 Location of uterus, abnormal, 63, 64 normal, 17, 63 Lymphatics of the pelvis, 25, 53, 68 812 GENERAL INDEX. Lvttse, tincture of, 276 Magnesia citrate, 689 sulphate, 408, 409 Malgaigne, 509 Mammary bodies, 366 Manner of conducting an examination of pelvic organs in making a diagnosis, 138 Martin's modification of tlie bilateral opera- tion, 203 Masturbation, 390 Mayer, elastic ring pessary, 506 Mcintosh, uterine supporter, 508 Mechanical support, 517 Mechanism of laceration and injuries of the perineum and pelvic floor, 161 Median lacerations of perineum, degrees of, 182 Membranous dysmenorrhcea, 312 Menopause and senility, 343 Menorrhagia, 297, 377 from nervous influence, 296, 399 during lactation, 296 effect of mammary irritation, 296 from reflex causes, 296, 297 from fibrous polypus, 298 from inflammation, 298, 434, 472 from malignant disease, 298 from uterine displacement, 293 from tumors, 299, 472 hemorrhagic diathesis, 297 treatment, 300 palliative, 301 curative, 304 electricity in, 305 curetting in, 306 ovarian, 691, 693 in inversion of uterus, 545. See Me , trorrhagia in cancer, 574 Menstruation, 276, 278, 330 increased. See Menori'hagia. irregularities, 498 misplaced. See Metatithmenia. rest during, 448 suppressed. See Amenorrhoea. Mercurv, 153, 247, 397, 427, 474, 626, 730, 751,761 blue mass, 154, 276. 408 bichloride, 196, 293, 305, 306, 337, 398, 473, 646 cathartic, 157, 408 mild chloride, 244, 311, 348, 689 ointment, 150 pernitrate, 428, 598, 600, 601 Meso-aalpinx, 27 Metatithmenia, 330 diagnosis, 344, 458 evacuation of blood in, 337, 339 prognosis, 335 sepsis in, 333 symptoms, 336, 342 Method of rectal indagation, 91 Metritis, 347 Metrorrhagia, 296, 297, 429, 615, 624, 628, 662 in cancer, 574, 678, 587 in delayed involution, 559, 560. 562 in inversion of uterus, 544, 545, 547, 549, 554 Metrotome, Peaslee's, 323 Microscopic examination of fluid from ovarian tumors, 722 Misplaced menstruation, 330 Modified Freund's operation, 208 Molesworth's dilator, 131 Moral and mental derangement (sympa- thetic), 357 Mucous inflammation of uterus, 387 Multiparous uterus, appeai-ance of, 126 Mural salpingitis, 790 Muscles of pelvis : coccygeus, 32, 34, 35, 101, 103 constrictor cunni, bulbo-cavernosus or vulval sphincter, 40, 43,111, 161, 164,167, 180, 189, 191, 192, 200 constrictor urethra, 41 gluteal, 32, 35 internal obturator, 32, 70, 103 levator ani, 29, 32, 33, 34, 35, 42, 90, 101, 103, 104, 108, 110, 111, 162, 164, 171, 174, 181, 185, 187, 189, 195, 200, 210, 534 levator vaginae, 29, 34, 40, 42, 43, 90, 92, 103,l04, 108,110,111,112,115, 160, 161, 164, 166, 167, 168, 170, 171, 180, 183, 184, 186, 191, 192, 200, 201,204,205,211,242 psoas, 70 pvramidal, 32 pyriformis, 35, 57, 99, 101, 103, 105, 106, 108 sphincter ani, 41, 168, 172, 174, 180, 181, 182, 210, 211, 221 transversus perinsei, 35, 41, 112, 165, 166, 168, 180, 192 Muscular weakness (sympathetic), 362 Musculature of the pelvic roof, 19 Naboth glands, 430 Needle holder, Fritsch's, 526 N^laton's forceps, 766 Nelson's speculum, 120 Nerves of pelvis, 25, 53, 107, 294, 362, 616 Nervous excitability, 401 prostration, 390, 399 Neuralgia of the cervix, 798 Neurasthenia, 352, 685 Nidation and denidation, 277, 278 Noma, 156 Nott's speculum, 120 tenaculum forceps, 124 Nux vomica, 409, 410, 411, 777 Nymphn, hypertrophy of, 159 Nymphomania, 678 Oak bark, 506 Obstructive dysmenorrhea, 314 GENERAL INDEX. 813 Obturato-coccygeiis. See Levator ani. Obturator internus, 103 Occlusion of the vagina, 141 Oedema of the labia, 144 Oil, almond, 250 carbolized, 198, 775 castor, 193, 198, 221, 761 cod-liver, 247 olive, 250 Ointment of belladonna, 248, 411, 421 calamine, 156 chloroform, 154 cicuta, 421 carbolic acid, 154 hyoscvamus, 421 iodine, 228, 421 mercury, 421 nut-gall, 248 opium, 421 oxide of zinc, 154 tannin, 421 Ointment syringe, 421 Oldham, 312 Oophoralgia, 678 Oophorectomy, abdominal, 673, 681, 690, 692, 693 vagina], 681 Oophoro-electrolysis, 745 Oophoro-epilepsy, 678, 691 Oophoro-mania, 678 Oophoro-neuroses, 676, 686 Operating chair, Wilson's, 56 table, Byford's, 57 Operation, Battev's, 673 Bischoff's, 207 Bozeman's, for vesico-vaginal fistula, 271 crescent, upon perineum, 204 Emmet's crescent, 205 flap, 206 for elongation of the supravaginal cervix, 449 for retroversion, 525 for shortening round ligaments, 527 sacrouterine ligaments, 525 Langenbeck's, 214 ovarian. See Ovariotomy. Peaslee's, in obstinate dysmenorrhoea, 320 Simon's, for vesico-vaginal fistula, 264 Sims-Emmet denudation for cystocele and pi-ocidentia, 502 Sims's, for dividing straight cervix, 319 Sims's, for vesico-vaginal fistula, 255 star, upon perineum, 205 to strengthen or elevate the pelvic roof supports, 501 triangular flap, upon perineum, 206 unilateral flap, upon perineum, 209 Operation upon uncicatrized lacerations of perineum, 210 Operations, plastic, upon the perineum or pelvic floor, 509 Opium, 199, 276, 301, 336, 348, 402, 420, 421, 426, 465, 585, 587, 731, 776, 780 extract of, 151, 154 tincture of, 548 Outlines of denudation for procidentia, 510 Ovarian cell, 720 irritation, 689 ligament, palpation of, 72 tumors, 695 Ovaries, 383, 682 absence of, 289 acute inflammation of, 688, 713, 793 atrophy of, 289, 343, 682 ch]'onic inflamation of, 689, 712 conditions of, causing menorrhagia, 296 enlargemia of, 296, 298. 299, 311, 313, 379, 383,384, 385, 569, 612 hyper-involution of, 570 inflammation connected with amenor- rha?a, 291, 292 inversion of, 543 involution of, 658, 571 normal location of, 17, 63 palpation of, 63 pregnant, 63, 335, 368. See Preg- nancy. relation to bladder, 31 replacement of, 514. 515, 541, 542, 549, 557 _ subinvolution of, 562 tumors of, 610 ulceration of. See Cervix. Uva ursi, 226, 229 Vagina, 28, 31, 87, 88, 95, 139, 173, 225, 236, 448, 791 _ abscess discharging into, 452, 453 absence of, 237, 238 affections of, 236 atresia of, 237, 238 digital e version of, 113, 182, 184 examination through, 58, 67 displacement of, 479 efiects of lacerations, 160, 161, 174, 437 inflammation of, 225,378, 390, 419 occlusion of, 141 palpation of, 88 Vagina, subinvolution of, 480 tumors of, 240 Vaginal douches, 247, 41 5, 417, 694, 795 injections, 417. See Vaginal douches. accidents in, 419 orifice, examination of, 108 ovariotomy, 746 pack, 516 palpation of pelvic roof, 98 of pelvic arteries, 105 rings. See Perineal rings, sphincter. See Levator vaginfe. sulci or grooves, anterior, 29, 87, 89, 186, 482, 503 posterior, 30, 90, 109, 185, 186, 204 tamponment, 5i2 Vaginismus, 241 Vaginitis, 225, 378, 390, 453 acute, 243 chronic, 245 puerperal, 248 Varices of the labia, 143 of the vulva, 143 Vascular urethra, 158 Veratmm, 302, 349 Versions of the uterus, 487 Vesical calculus, 231 Vesicovaginal fistula, 227, 231, 249, 251, 276 Simon's operation for, 264 Sims's operation for, 255 Vesico-vaginal septum, 22, 24, 86, 92, 97, 138, 173, 227, 249, 250, 251, 275, 482, 513, 514 Viburnum, 309 Vomiting after ovariotomy, 776, 779 Voracity, 352 Vulva, condolymata of, 150 diseases of, 150 inflammation of, 150 treatment of, 151 Vulval orifice, examination of, 110 rings. See Perineal rings, sphincter. See Constrictor cunni. Vulvitis, follicular, 152 gangrenous, 156 Weak back in uterine disease, 360, 370 Wedlock, 294 Wells, Spencer, trocar, 753 White, James P., repositor, 551 Wilson, H. C. 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Pharmacopoeia. 2.50 VISITING LISTS. Lindsay and Blakiston's Regular Edition. i.oo to 3.00 Perpetual Edition. 1.25 WATER. Fox. Water, Air, Food. Frankland. Analysis of. MacDonald. " " WOMEN, DISEASES OF. Byford's Text-book. 4th Ed. • Uterus. - - - 1.25 Dillnberger. and Children. 1.50 Doran. Gynsec. Operations. 4.50 Duncan. Sterility. - 2.00 Galabin. Diseases of. - 3.00 Savage. Pelvic Organs. 12.00 Scanzoni. Sexual Organs of. 4.00 Tilt. Change of Life. - 1.25 Winckel, by Parvin. Manual of lllus. Clo.,3.00; Sh. 3.50 4.00 I.oo 2-75 FAGGE'S PRACTICE. THE PRINCIPLES AND PRACTICE OF MEDICINE. By C. HiLTON Fagge, M.D., F.R.C.P., F.R.M.C.S., Examiner in Medicine, University of Lon- don; Physician to, and Lecturer on Pathology in, Guy's Hospital; Senior Physician to Evelina Hospital for Sick Children, etc. Arranged for the press by P. H. Pye-Smith, m.d., Lect. on Medicine in Guy's Hospital, Including a section on Cutaneous Affections, by the Editor ; chapter on Cardiac Dis- eases, by Samuel Wilkes, m.d., f.r.s., with a very complete Index of Authors and one of Subjects, by Robert Edmund Carrington. Two Volumes. Royal Octavo. 1900 Pages. SOLD BY SUBSCRIPTION ONLY. Handsome Cloth, $10,00. Full Leather, Raised Boards, $12.00. One-Half Russia, $14.00. One-Half Morocco, $14.00. This work on the Practice of Medicine is based on laborious researches into the pathological and clinical records of Guy's Hospital, London, during the twenty years in which the author held office there as Medical Registrar, as Patholo- gist, and as Physician. Familiar, beyond most, if not all, of his contemporaries, with modern medical literature, a diligent reader of French and German periodi- cals. Dr. Fagge, with his remarkably retentive memory and methodical habits, was able to bring to his work of collection and criticism almost unequaled opportunities of extensive experience in the wards and dead house. The result is that which will probably be admitted to be a fuller, more original, and more elaborate text-book on medicine than has yet appeared. It is the first of import- ance emanating from Guy's Hospital, and the only two-volume work on the Practice of Medicine that has been issued for a number of years. Several subjects, such as Syphilis, that are usually omitted or but slightly spoken of in a general work of this character, receive full attention. The section on Nervous Diseases is very exhaustive, and that on Diseases of the Respiratory Organs and Larynx are equally full. The author has adopted a very simple and practical plan in the treatment of Lung Diseases, and Phthisis receives full consideration. The chapter on Cardiac Diseases, by Dr. Sam'I Wilkes, is most carefully written, and the parts devoted to Cutaneous Affections, by Dr. Pye-Smith, are excellent. PRESS NOTICES. " Those who have read Guy's Hospital Reports for the past twenty years and the many articles in the different English journals from the pen of Charles Hilton Fagge will expect a comprehensive, carefully- prepared and painstaking volume. They will not be disappointed. One cannot proceed far in the reading of this book before he is impressed with certain features of it which are very remarkable. Let him turn to almost any page at random, and he is likely to find reference made to a dozen authors ; the authors being, perhaps, of three orfour different nationalities. The author is said to have been very familiar with German, French and Italian, which, with his own English, would give him four different languages from which to cull his information. His memory must have been marvelous, and he was an original worker and thinker. * * * We close the first volume feeling that here was a master. * * * Will take and hold the very front rank among works on the practice of medicine. * * * A general and complete index to both volumes adds great value to its usefulness. One is gratified to find reference to no fewer than thirty American authors. Certainly these two volumes make a complete work on practice, whether as a book of reference or even as a text-book. It is in style worthy of a second place only to the classical work of Sir Thomas Watson." — Ne-jj York Medical Journal. " If the second volume of this treatise fulfills the promise of excellence contained in the one before us the entire work cannot fail to find favor with the profession both here and abroad." — I^eiv Vork Medical Record, notice of Vol. I. " The finest of all treatises on the healing art. It should be in every physician's library." — Cincinnati Lancet and Clinic. " A perusal of its pages shows that it is one of the most scientific and philosophical works of its kind, being, in truth, a mine of clinical and pathological facts, which are dealt with in so masterly a manner that we know not which to admire most — the patient labor and thought expended in bringing them to light, the learning and acumen that illustrate them, or the calm and judicial spirit in which they are estimated and criticised." — London Lancet. " The work is an English classic. * * * His great treatise remains a monument more enduring than fame." — Dublin Journal of Medicine. TERMS.— This work is published by subscription ; in order, however, to receive it promptly, subscrip- tions should be sent direct to the publishers, or through your regular bookseller, when the book will be shipped, carefully packed, to your address, express charges or postage prepaid. P. BLAKISTON, SON & CO., 1012 Walnut St., Philadelphia. p. BLAKISTON, SON & CO.'S jyjedical and Scientific publications. 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PREPARED ESPECPALLY FOR THE WANTS OF MEDICAL, DENTAL, AND PHARMA. CEUTICAL STUDENTS AND PRACTITIONERS. A Text-Book of Medical Chemistry. BY E. H. BARTLEY, M.D., Associate Professor of Chemistry at the Long Island College Hospital ; President of the American Society of Public Analysts ; Chief Chemist, Board of Health, of Brooklyn, N. Y., etc. Illustrated 12mo. Cloth, $2.50. This book, writteh especially for students and physicians, aims to be a text-book for the one and a work of reference for the other. It is practical and concise, dealing only with those parts of chemistry pertaining to medicine ; no time being wasted in long descriptions of substances and theories of interest only to the advanced chemi- cal student. PART I — Treats of Light, Heat and Electricity, which are described at some length, and explanations made and applied to common phenomena. In the subject of light, only so much is given as will explain the theory and use of the spectroscope. In electricity, the principal aim has been to give such information as is needed for the proper understanding, working and care of the medical battery. PART II — Theoretical Chemistry. Only such portions of the well established principles of modern chemistry as are necessary to an understanding of the subject are given. It has been deemed best to present all these elementary parts first, that the student may be better able to study any set of isolated facts. These theories are presented in a concise, clear way, in a logical order and in a manner which the author has found specially successful in an experience of over twelve years of teaching. PART III — Treats of the natural history of the elements, of their principal compounds, with their physiological action and toxicology. PART IV— Organic bodies commonly used in medicine and pharmacy. The principal organic substances derived from animal life are given a place. In the appendix will be found analyses of the principal secretions and tissues, tables of solubilities and of specific gravities, the metric system, and other useful information. Applied Medical Chemistry. Containing a description of the apparatus and methods employed in the practice of Medical Chemistry, the Chemist^ of Poisons, Physiological and Pathological Analysis, Urinary and Fecal Analysis, Sanitary Chemistry and the Examination of Medicinal Agents, Foods, etc. BY LAWRENCE WOLFF, M.D., Demonstrator of Chemistry in the Jefferson Medical College ; Member of the Philadelphia College of Pharmacy and of the Chemical Section of the Franklin Institute, etc. Octavo, Clotli, $1 50. *^^*The object oi the author of this book is to furnish the practitioner and student a reliable and simple guide for making analyses and examinations of the various medicinal agents, human excretions, secretions, etc., without elaborate apparatus or expensive processes. Practical and Analytical Chemistry. Being a complete course in Chemical Analysis, for pharmaceutical and medical students. BY HENRY TRIMBLE, Ph.G., Professor of Analytical Chemistry in the Philadelphia College of Pharmacy. Second Edition. Illustrated. 8vo. Cloth, $1.50. SUMMARY OF CONTENTS. Part I. Practical— Preparation and Properties of Gases, Preparation of Salts, etc. Part II. Section I — Bases. Group I — Potassium, Sodium, Lithium, Ammonium. Group II — Barium, Strontium, Calcium, Magnesium. Group III — Manganese, Zinc, Cobalt, Nickel. Group IV — Iron, Cerium, Chromium, Aluminium. Groujp V — Arsenic, Antimony, Tin, Gold, Platinum. Group VI — Mercury (ic), Bismuth, Copper, Cadmium. Group VII — Silver, Mercury (ous), Lead. Section II — Acids. Section III — Detection of Bases and Acids. Section IV — Some of the Reactions and Tests of Purity of the more import- ant Organic Compounds. Part III. Quantitative Chemical Analysis. Section I — Gravimetric Estimation. Section II — Volumetric Estimation. There are also a number of useful Tables. LBPPMANN'S ORGANIC AND MEDICAL CHEMISTRY. Including Urine Analysis and the Analysis of Water and Food. By Henry Leffmann, M.D., Demonstrator of Chemistry at Jefferson Medical College, Philadelphia. i2mo. Cloth, $i.oo; Interleaved for the addition of Notes, ;^i.25 P. BLAKISTON, SON & CO., ioi2 Walnut St., Philadelphia. Practical Handbooks FOR THE PHYSICIAN and MEDICAL STUDENT. VAN HARL.INGEN ON SKIN DISEASES. A Handbook of the Diag- nosis and Treatment of Skin Diseases. Py Arthur Van Harlingen, m.d., Professor of Diseases of the Skin in the Philadelphia Polyclinic ; Consulting Physician to the Philadelphia Dispensary for Skin Diseases, and Dermatologist to the Howard Hospital. With colored plates representing the appearance of various lesions. i2mo. Cloth, ^^1.75 *^*This is a complete epitome of skin diseases, arranged in alphabetical order, giving the diagnosis and treatment in a concise, practical way. Many prescriptions are given that have never been published in any text-book, and an article incorporated on Diet. The plates do not represent one or two cases, but are composed of a num- ber of figures, accurately colored, showing the appearance of various lesions, and will be found to give great aid in diagnosing. '" This new handbook is essentially a small encyclopEedia. « » * Contains a very complete summary of the present state of Dermatology. * * * We heartily commend it for its brevity, clearness and evidently careful preparation." — Philadelphia Medical Times. " The author shows a proper appreciation of the wants of the general practitioner." — /^ew York Medical Record. " It is concisely and intelligently written, and contains many of the best formulas in use for the various forms of Skin Disease." — New York Medical Times. " This is an excellent little book, in which, for ease of reference, the more common diseases of the skin are arr^ged in alphabetical order, while many good prescriptions are given, together with clear and sensible direc- tions as to their proper application." — Boston Medical and Surgical yournal. " It is just the kind of book that the general practitioner will find most convenient for reference, and we feel confident that it will be appreciated." — Southern Practitioner. BINDFLEISOH'S PATHOLOGY. The Elements of Pathology. By Prof. Edward Rindfleisch, University of Wiirzburg. Authorized translation from the first German edition, by Wm. H. Mercur, m.d. (Univ. of Pa.) Revised by James Tyson, m.d.. Professor of Pathology and Morbid Anatomy in the Univer7 sity of Pennsylvania. l2mo. Cloth, $'Z.oo Prof. Tyson, in his Preface to the American edition, says : — "A high appreciation of Prof. Rindfleisch's work on Pathological Histology, caused me to make careful examination of these ' Elements ' immediately after their publication in the original. From such an examination I became satisfied that the book would fill a niche in the wants of the student, as well as of others who may desire to familiarize themselves with general patho- logical processes, viewed from the mpst modem standpoint." BRUBN'S PHYSICAL DIAGNOSIS. Second Edition. A Pocket-book of Physical Diagnosis of the Heart and Lungs ; for the Student and Physician. By Edward T. Bruen, Demonstrator of Clinical Medicine in the University of Pennsylvania ; Lecturer on Pathology in the Women's Medical College of Phila- delphia; 2d Edition, revised, with new original illustrations. i2mo. Cloth, |S 1.50 " We consider the description of the manner and rules governing the art of perctission well given. The sub- ject is always a difficult one for beginners, and requires to be well handled in order to be properly understood." ■ — American jfournal of Medical Sciences. WOAKES ON CATARRH AND DISEASES OP THE NOSE CAUS- ING DEAFNESS. By Edward Woakes, m.d., Senior Aural Surgeon to the London Hospital for Diseases of the Throat and Chest. 29 Illustrations. i2mo. Cloth, $1.50 " Out of the large number of special works On catarrh, there is none for which we have such an unqualified good opinion. * * * The subject is clearly presented. • « • The line of treatment suggested is rational." — North Carolina Medical yournal. P. BLAKISTON, SON & CO., 1012 Walnut St., Philadelphia. THE PRACTICAL SERIES. TWO NEW VOLUMES JUST READY. *** The volumes of this series, written by well-known physicians and surgeons of large private and hospital experience, recognized authorities on the subjects of which they treat, will embrace the various branches of medicine and surgery. They are of a thoroughly practical character, calculated to meet the requirements of the practi- tioner, and will present the most recent methods and information in a compact shape and at a low price. Bound TJniformly, in a Handsome and Distinctive Cloth Binding. TREATMENT OF DISEASE IN CHILDREN. Including the Outlines of Diagnosis and the Chief Pathological Differences between Children and Adults. By Angel Money, m. d., m.r.c.p., Assistant Physician to the Hospital for Sick Children, Great Ormond St., and to the Victoria Park Chest Hospital, London. i2mo. 560 pages. Cloth, ^3.00 ON FEVERS. A Practical Treatise on Fevers, Their History, Etiology, Diag- nosis, Prognosis and Treatment. By Alexander Collie, m.d., m.r.c.p., Lond. Medical Officer Homerton Fever Hospital, and of the London Fever Hospital. With Colored Plates. Cloth, $2.50 "This volume, which forms one of the ' Practical Series' of Medical and Surgical Manuals, deserves attention from the fact that its author has been so long devoted to the subjects of which it treats. He is, therefore, in position to speak with authority as well as with complete freedom and independence. * * * * The strongest parts of the work are those which deal with diagnosis and treatment, for here Dr. Collie is thoroughly at home, and succeeds in imparting to the work its 'practical character, for which it will be highly valued.' " — London Lancet, April 23d, 1887. HANDBOOK OF DISEASES OP THE EAR. By Urban Pritchard, M.D., F.R.C.S., Professor of Aural Surgery, King's College, London, Aural Sur- geon to King's College Hospital, Senior Surgeon to the Royal Ear Hospital, etc. i2mo. Cloth, #1.50 " Exactly what is wanted at the present moment, we can recommend every practitioner to have a copy." — .London Practitioner. "A first-rate little book. * * * The man who wants a short, reliable book will buy Dr. Pritchard's." — New Orleans Medical and Surgical Journal. "Written from an eminently practical standpoint. * * * * Commended for its simplicity and directness." —Neiv York Medical Journal. "Belongs to a class that is very useful to the general practitioner." — Maryland Medical Journal. DISEASES OF THE KIDNEYS, AND URINARY DERANGE- MENTS. By C. H. Ralfe, m.a., m.d., f.r.c.p.. Assistant Physician to the London Hospital ; late Senior Physician to the Seamen's Hospital, Greenwich. i2mo. With Illustrations. 572 pages. Cloth, I2.75 " It is with keen pleasure that we recommend this really meritorious book to our readers." — New York Medical Journal. "A clear, concise and systematic account of urinary pathology and therapeutics. * * * * fhe student will find in these pages all necessary instruction imparted in a candid and not dogmatic manner, and the practi- tioner will find a ready and convenient reference book." — Boston Medical and Surgical Journal. BODILY DEFORMITIES AND THEIR TREATMENT. A Handbook of Practical Orthopgedics. By H. A. Reeves, f.r.c.s.. Senior Assistant Surgeon and Teacher of Practical Surgery at the London Hospital ; Surgeon to the Royal Orthopedic Hospital, etc. i2mo. 228 Illustrations. 460 pages. Cloth, ^2.25 " From what we have already said, it will be seen that Mr. Reeves has given us a trustworthy guide for the treatment of a very extended class of cases. * * * * If the other volumes of the Practical Series are as good as this, we shall be agreeably d\?.?c^\iamX.e:d.." —American Journal oj Medical Sciences, April, JS83. " The utility of the work now before us cannot be better recommended to the appreciation of the professional reading public than by recalling that it is the first of its kind, dealing with orthopaedics from a modern stand- point.'' — Hospital Gazette and Students' Jourtial. DENTAL SURGERY FOR GENERAL PRACTITIONERS AND STUDENTS IN MEDICINE. By Ashley W. Barrett, m.d., m.r.c.s., Eng., Surgeon-Dentist to, and Lecturer on Dental Surgery and Pathology in the Medical School of, London Hospital. i2mo. Illustrated. Cloth, ^i.oo "Replete with an abundance of practical information of unquestionable utility." — Hospital Gazette and Students' Journal. P. BLAKISTON, SON & CO., 1012 Walnut St., Philadelphia. PERIODICALS PUBLISHED BY P. BLAKISTON, SON & CO. THE POLYCLINIC. Vol. V. A Monthly Journal of Medicine and Surgery. Doubled in Size Without Increase of Price. $1.00 PER ANNUM. SAMPLE COPIES FREE. EDITORIAL STAFF. EDITOR-IN-CHIEF, HENRY LEFFMANN, M.D. Diseases of the Throat and Chest. J. Solis-Cohen, m.d., Professor of Dis- eases of the Throat and Chest in the Philadelphia Polyclinic. General Surgery, Orthopaedics, Operative and Clinical Surg-ery. Johx B. Roberts, m.d., Surg, to St. Mary's Hosp. ; Chas. B. Nancrede, m.d., Surg, to the Episcopal and to St. Christopher's Hosps. ; Lewis W. Steinbach, m.d., Wm. Barton Hopkins, m.d., Asst. Demonstrator of Surgery, Univ. of Penna., A. B. Hirsh, m.d. Diseases of the Bar. Charles H. Burnett, m.d.. Aural Surgeon to the Presby- terian Hospital. Diseases of the Mind and Nervous System. Charles K. Mills, m.d.. Lec- turer on Mental Diseases, University of Pennsylvania ; Consulting Physician Insane Department, Philadelphia Hospital. Diseases of the Skin. Arthur Van Harlingen, m.d.. Consulting Physician Dispensary for Skin Diseases ; Physician to Howard Hosp. Dermatological Dept. Diseases of the Eye. George C. Harland, m.d.. Surgeon to Wills Eye Hospi- tal and to the Eye and Ear Dept, Penna. Hosp.; Howard F. Hansell, m.d.. Physician to Southeastern Hospital and Manayunk Eye and Ear Dispensary. Genito -Urinary and Venereal Diseases. J. Henry C. Simes, m.d.. Surgeon to Episcopal Hospital. Clinical Medicine. Frederick P. Henry, m.d.. Physician to Episcopal Hospital. G3rn8ecolog'y and Obstetrics. Benj. F. Baer, m.d., late Instructor in Gynaecol- ogy, University of Pennsylvania ; Obstetrician to Maternity Hospital. Diseases of "Women and Children. Washington H. Baker, m.d., Obstet- rician to Maternity Hospital. A SPECIAL OFFER. '^° each new subscriber, who remits one dollar, in — ^M^ advance, we will send The Polyclinic for one year and a copy of the following book : Urinary and Renal Derangements and Calculous Disorders, -with Hints on Diagnosis and Treatment. By Lionel S. Beale, m.d., f.r.s., f.r.c.p., Professor of the Principles and Practice of Medicine in King's College, London ; Physician to King's College Hospital. i2mo. 356 pages. 1885. Bound in strong paper covers. The Journal of Laryngology and Rhinology. An Analytical Record of Current Literature Relating to the Throat and Nose. Edited by MORELL MACKENZIE, M.D., Lond., and R. NORRIS WOLFENDEN, M.D., Cantab. With the Co-operation of Dr. Fauvel (Paris), Dr. Joal (Paris), Prof. Massei (Naples), Prof. Guye (Amsterdam), Dr. Capart (Brussels), Dr. Hunter Mackenzie (Edinburgh), Dr. Michael (Hamburg), Dr. Ramon de la Sota y Lastra (Seville), Dr. John N. Mackenzie (Baltimore), Dr. Holger Mygind (Copenhagen), Dr. Smyly (DubUn), and Dr. Greville Macdonald (London). PUBLISHED MONTHLY. PER ANNUM, $3.00. SAMPLE NUMBERS, 25c. THE OPHTHALMIC REVI EW. A Monthly Record of Ophthalmic Science. Edited by JAMES ANDERSON, M.D. , London ; KARL GROSSMANN, Liverpool; PRIESTLEY SMITH, Birmingham, and JOHN B. STORY, M.D., Dublin. MONTHLY. SUBSCRIPTION PER ANNUM, $3.00. The Ophthalmic Review is the only Journal devoted to this special branch of medicine that is published in Great Britain, and therefore represents the advances made in that country as no other periodical can. Sample fiutnbers, 25 cents. ? QUIZ-COMPENDS ? A NEW SEKIES OF PKACTICAL MANUALS FOR THE PHYSICIAN AND STUDENT. Compiled in accordance with the latest teachings of protniftent lecturers and the most popular Text-books. They form a most complete, practical and exhaustive set of manuals, containing information nowhere else collected in such a condensed, practical shape. Thoroughly up to the times in every respect, containing many new prescriptions and formulae, and over two hundred and thirty illustrations, many of which have been drawn and engraved specially for this series. The authors have had large experience as quiz-masters and attaches of colleges, with exceptional opportunities for noting the most recent advances and methods. The arrangement of the sub- jects, illustrations, types, etc., are all of the most approved form, and the size of the books is such that they may be easily carried in the pocket. They are constantly being revised, so as to include the latest and best teachings, and can be used by students of any college of medicine, dentistry or pharmacy. Bound in Cloth, each $i.oo. Interleaved, for the Addition of Notes, $1.25. No. I. Human Anatomy. Fourth Edition, including Visceral Anatomy, formerly published separately. Over 100 Illustrations. By Samuel O. L. Potter, m.a., m.d., late A. A. Surgeon U. S. Army. Professor of Practice, Cooper Med. College, San Francisco. Nos. 2 and 3. Practice of Medicine. Second Edition. By Daniel E. Hughes, m.d.. Demonstrator of Clinical Medicine in Jefferson Med. College, Phila. In two parts. Part I. — Continued, Eruptive and Periodical Fevers, Diseases of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kidneys, etc. (including Tests for Urine), General Diseases, etc. Part II. — Diseases of the Respiratory System (including Physical Diagnosis), Circulatory System and Ner- vous System ; Diseases of the Blood, etc. *:):* These little books can be regarded as a full set of notes upon the Practice of Medicine, containing the Synonyms, Definitions, Causes, Symptoms. Prognosis, Diagnosis, Treatment, etc., of each disease, and including a number of prescriptions hitherto unpublished. No. 4. Physiology, including Embryology. Third Edition. By Albert P. Brubaker, M.D., Prof, of Physiology, Penn'a College of Dental Surgery ; Demonstrator of Physiology in Jefferson Med. College, Phila. Revised, Enlarged and Illustrated. No. 5. Obstetrics. Illustrated. Third Edition. For Physicians and Students. By Henry G. Landis, m.d.. Prof, of Obstetrics and Diseases of Woinen, in Starling Medical College, Columbus. Revised Edition. New Illustrations. No. 6. Materia Medica, Therapeutics and Prescription Writing. Fourth Revised Edition. With especial Reference to the Physiological Action of Drugs, and a complete article on Prescription Writing. Based on the Last Revision (Sixth) of the U. S. Pharma- copceia, and including many unofificinal remedies. By Samuel O. L. Potter, m.a., m.d., late A. A. Surg. U. S. Army ; Prof, of Practice, Cooper Med. College, San Francisco. 4th Edition, with Index. No. 7. Inorganic Chemistry. New Edition. By G. Mason Ward, m.d.. Demonstrator of Chemistry in Jefferson Med. College, Phila. Including Table of Elements and various Analytical Tables. New Edition. No. 8. Diseases of the Eye and Refraction, including Treatment and Surgery. By L. Webster Fox, m.d., Chief Clinical Assistant Ophthalmological Dept., Jefferson Medical College, etc., and Geo. M. Gould, a.b. 40 Illustrations. No. 9. Surgery. Illustrated. Third Edition. Including Fractures, Wounds, Disloca- tions, Sprains, Amputations and other operations; Inflammation, Suppuration, Ulcers, Syphilis, Tumors, Shock, etc. Diseases of the Spine, Ear, Bladder, Testicles, Anus, and other Surgical Diseases. By Orville Horwitz, a.m., m.d.. Demonstrator of Anatomy, Jefferson Medical College. Third Edition. Revised and Enlarged. 77 Formulae and 91 Illustrations. • No. 10. Organic Chemistry. Including Medical Chemistry, Urine Analysis, and the Analy- sis of Water and Food, etc. By Henry Leffmann, m.d., Demonstrator of Chemistry in Jefferson Med. College ; Prof, of Chemistry in Penn'a College of Dental Surgery, Phila. No. II. Pharmacy. Based upon " Remington's Text-Book of Pharmacy." By F. E. Stewart, m.d., ph.g., Quiz-Master at Philadelphia College of Pharmacy. Second Ed. Bound in Cloth, each $1.00. Interleaved, for the Addition of Notes, $1.25. Jl^^ These books are constantly revised to keep up with the latest teachings and discoveries. P. BLAKISTON, SON & CO., 1012 Walnut Street, Philadelphia. NOW READY. With Many Improvements for 1888. 37th YEAR. The Physician's Visiting List. (LINDSAY & BLAKISTON'S.) CONTENTS. Almanac FOR 1888 and 1889. I Posological Table, Meadows. Table of Signs to be used in keeping accounts. ' Disinfectants and Disinfecting. Marshall Hall's Ready Method in Asphyxia. „ ^, , , , Poisons and A.ntidotes Examination of urine. Dr. J. Daland, »(jj^rf«/Wj " Practical Examination of Urine." 5th AVeights and Measures, Dose Table, revised and rewritten for 1888, trj' Ho BART Amory H.^re, m. d., Demonstrator of Thera peutics, University of Pennsylvania. List of New Remedies for 1888, by same author. Aids to Diagnosis and Treatment of Diseases of Edition. Incompatibility, Prof. S. O. L. Potter. A New Complete Table for Calculating the Period of Utero-Gestation. Sylvester's Method for Artificial Respiration. D1AGR.A.M OF the Chest. the Eye. Dr. L. Webster Fox, Clinical Asst. Eye ^lank Leaves, suitably ruled, for Visiting List Dept. Jefferson Medical College Hospital, and G. Monthly Memoranda; Addresses of Patients and M Gould a r > others; Addresses of Is urses, their references, etc. ; Diagram S ho^hng Eruption of Milk Teeth, Dr. Accounts asked for ; Memoranda ofWants ; Obstet- Louis Starr, Prof of Diseases of Children, Univer- 1 "= jind \ accmation Engagements ; Record of Births sity Hospital, Philadelphia. ^^ Deaths ; Cash Account, etc. A NUMBER OF IMPROVEMENTS and additions have been made to the reading matter in the first part. This has been done, however, without increasing the number of pages. Great care has been taken in selecting the leather for the covers and in each detail of manufacture. SIZES AND PRICES. For 25 Patients weekly. Tucks, pockets and Pencil, $1.00 50 " " " 1.25 75 " " (( »» 1.50 100 K It " " " 2.00 50 << (< 2 Vols {Jan. to June 1 2 vols. 1 July to Dec. J " 2.50 100 t( « 2 Vols. jJT-rS^^l [July to Uec. j ■< 3.00 INTERLEAVED EDITION, For 25 Patients weekly. Interleaved, tucks and Pencil, 1.25 50 " << " 1.50 50 K <( 2 Vols. I>f-;°J^^^. [ July to Dec. i< 3.00 PERPETUAL EDITION, without Dates. B@°*C(a:« 5e commenced at ajiy time, and used until full. Similar in style, con- tents and arrangement to the regular edition. No. 1. Containing space for over 1300 names, with blank page opposite each Visiting List page. Bound in Red Leather cover, with Pocket and Pencil, $1.25 No. 2. Containing space for 2600 names, with blank page opposite each Visiting List page. Bound like No. i, with Pocket and Pencil, . . . . 1.50 These lists, without dates, are particularly useful to young physicians unable to estimate the number of patients they may have during the first years of Practice, and to physicians in localities where epidemics occur frequently. " For completeness, compactness, and simplicity of arrangement it is excelled \,y none in the market." — N. Y. Medical Record. " The book is convenient in form, not too bulky, and in every respect the very best Visiting List published. — Canada Medical and Surgical Journal. "After all the trials made, there are none superior to it." — Gaillard's Medical Journal. '.'< D , ^^'^°™-^ Standard. "Southern Clinic. '^ Regular as the seasons comes this old favorite." — Michigan Medical Ne^us. It is quite convenient for the pocket, and possesses every desirable qualit>^" — Medical Herald. '^ The most popular Visiting List extant." — Buffalo Medical and Surgical Journal. ^ rj- • "We have used it for years, and do not hesitate to pronounce it equal, if not superior, to any." — Southern CltntC.^ " This Visiting List is too well known to require either description or commendation from us." — Cincinnatt Medical News. P. BLAKISTON, SON & CO., Publishers, 1012 Walnut Street, Philadelphia. S^" Large Stock of Physicians Ledgers of Various Kinds. -@a DATE DUE - f ir»rt o ^ I ^^ciim w ] Printed in USA