G^\ 
 
A 
 
 PRACTICAL TREATISE 
 
 THE DISEASES OE WOMEN. 
 
STANDARD MEDICAL WORKS. 
 
 By Professors LANDOIS and STIRLING. 
 
 HUMAN PHYSIOLOGY (A Text-Book of) : Including 
 Histology and Microscopical Anatomy, with special reference 
 to Practical Medicine. 
 
 By Dr L. LANDOIS, of Greifswald. 
 
 Translated from the Fourth Gennan Edition, mth Annotations and Additions, 
 
 By WM. STIRLING, M.D., Sc.D., 
 Reg. Prof. Inst, of Med., University of Aberdeen. 
 
 In Two Vols. , with very Numerous Illustrations^ Royal 8vo, t 
 Handsome Cloth. 
 
 GENERAL CONTENTS. 
 
 Vol. I.— Physiology of the Blood, Circulation, Respiration, Digestion, Absorption. 
 Animal Heat, Metabohc Phenomena of the Bod}'. Price i8s. 
 
 Vol. II.— Secretion of Urine; Structure of the Skin; Physiology of the Motor 
 Apparatus ; the Voice and Speech ; General Physiology of the Nerves ; Electro-Physi- 
 ology ; the Brain ; Organs of Vision, Hearing, Smell, Taste, Touch ; Physiology ot 
 Development. 
 
 '•■ So great are the advantages offered by Prof Landois' Text-Book from the exhaus- 
 tive and eminently practical manner in which the subject is treated, that it has 
 passed through fom- large editions in the same number of years. Dr Stirling's annota- 
 tions have materially added to the value of the work. . . . Admirably adapted for the 
 practidoner. . . . with this Te.xt-Book at his command, no Student could fail in his 
 examination." — Lancet. 
 
 " One of the most practical v^^ORKS on Physiology ever written." —Britisk Medical 
 yournal. 
 
 By WM. AITKEN, M.D., F.R.S., 
 
 Professor of Pathology in the Army Medical School ; Examiner in Medicine 
 for the Military Medical Services of the Queen. 
 
 THE SCIENCE AND PRACTICE OF MEDICINE. In 
 
 2 vols., Seventh Edition, 42s, 
 
 " The Standard Text- Book in the Enghsh language. "—£^z«. Med. Journal. 
 
 OUTLINES OF THE SCIENCE AND PRACTICE OF 
 MEDICINE. Second Edition, 12s. 6d. 
 
 By a. WYNTER BLYTH, M.R.C.S., F.C.S., 
 
 Public Analyst for the County of Dei'on. 
 
 HYGIENE AND PUBLIC HEALTH (A Dictionary of). 
 
 "With Illustrations, 28s. 
 
 " A work of extreme value." — Med. Times and Gazette. 
 
 FOODS: THEIR COMPOSITION AND ANALYSIS. 
 
 1 6s. Second Edition. 
 
 " Should be in the hands of every Medical Practitioner."— T/zf Lancet. 
 
 POISONS: THEIR EFFECTS AND DETECTION. 
 
 1 6s. Second Edition. 
 
 " A sound and practical Manual of Toxicology, which cannot be too warmly recom- 
 ended. . . . Discusses substances which have been overlooked. "—0(;;«?Va/ A'ew.r. 
 
 CHARLES GRIFFIN AND COMPANY, LONDON. 
 
EROSIONS, GRANULATIONS, AND LACERATIONS 
 OF THE CERVIX UTERI. 
 
 {After Munde, Croom, and Savage), 
 
 Xo. 1. The Cervix Uteri, free from disease. 
 
 „ 2. Slight Erosion of the Cervix Uteri. 
 
 „ 3. Follicular Cervical Endometritis. 
 
 ., 4. Granular Cervix, with Laceration and Eversion. 
 
 ,, 5. Extreme Granulation of the Cervix, with Parenchyinatous thickeiiiut,'. 
 
 ,, 6. Great Bi-lateral Tearing, Granulation, and Ectropion ; the sides diawn 
 asunder liy Tenacula. 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/practicaltreatisOOthor 
 
f: 
 
 A "flu/ (/iHC 
 
 PRACTICAL TREATISE 
 
 DISEASES OF WOMEN.^ 
 
 PREPARED WITH SPECIAL REFERENCE TO 
 THE WANTS OF THE 
 
 General Practitioner and Advanced Student. 
 
 BY 
 
 JOHN THORBURN, M.D., F.R.C.P., 
 
 PROFESSOR.OF OBSTETRIC MEDICINE, THE OWENS COLLEGE AND VICTORIA UNIVERSITY, MANCHESTEK. 
 OBSTETRIC PHYSICIAN TO THE MANCHESTER ROYAL INFIRMARY, ETC., ETC. 
 
 Mitb CbromoslLitbograpb aiiD over 200 Jllustratiotis. 
 
 LONDON: 
 
 CHARLES GRIFFIN AND COMPANY 
 
 EXETER STREET, STRAND. 
 
 1885. 
 
>^ 
 
HIS COLLEAGUES 
 
 AND TO 
 
 THE STUDENTS 
 
 PAST AND PRESENT 
 OF 
 
 Jlb[c ©wens College Scbool ot /IDet)icine 
 
 AMONG WHOM HE HAS PASSED MANY OF THE 
 HAPPIEST DAYS OF HIS LIFE 
 
 THIS WORK 
 
 J S Co I^D lALLY JnSCI^BED 
 BY 
 
 Zhc autbor. 
 
ISCr 
 
 103 
 
 .IS 
 
PEEFACE. 
 
 The following work, undertaken at the request of my Publishers, 
 has l^een written with a very definite purpose. 
 
 It is intended to afford the general practitioner of medicine, or 
 the advanced student, a ^dew of the present state of gynaecological 
 knowledge and practice. 
 
 Avoiding all personal "hobbies," and, as far as possible, all 
 controversial matters, and using such judicially selective skill as I 
 (iould, without dogmatism, bring to bear upon the discussion of 
 each topic, — 1 have endeavoured to go over the whole gTound in 
 such a manner as should be most practically useful in those 
 emergencies which are daily occurring to every general practi- 
 tioner. 
 
 1 trust that a. few years spent in such practice, and followetl 
 by nearly twenty of class-room and clinical teaching, have in some 
 degree fitted me for the task. 
 
 If I have, on the whole, given such sound, practical, and fairly- 
 judicial advice as will enaljle a few of the rising generation of 
 practitioners to escape the errors and avoid the difficulties of m}- 
 own early career, I shall be more than conipensated for any laboui- 
 involved in the task. 
 
 My sincere thanks are due to Mr A. H. Young, IMJ.C.S., whose 
 facile pencil lias supplied the original illustrations ; to Mr Albau 
 Doran, for some excellent (original woodcuts from his work on 
 ovarian tumours; to Dr AVilliam Yeats and I)r Arthur liobinsou, 
 for much valualjle assistance in preparing tlie manuscript ; aud 
 to ray son, Mr William Tliorburn, M.B., B.S., for assistuig me 
 
^^J1 PEEFACE. 
 
 in passing the work through the press, and in various other 
 ways. 
 
 I have also to thank Messrs Maw, Son, & Thompson, and 
 Messrs Krohne & Sesemann of London, and Messrs Tiemann and 
 Co. of New York, for the courtesy with which they placed their 
 catalogues of instruments at my disposal. 
 
 J. THOEBUEN. 
 
 Manchester, May 1, 1885. 
 
CONTENTS. 
 
 CHAPTER I. 
 
 The Methods and Means commonly employed in Diagnosis. Manual 
 Examination, including Abdominal Palpation, Digital Examination or 
 Vaginal toucher, Bi-manual Examination, Rectal and Vesical Examina- 
 tion, &c. Insteitmental Examination, including the use of Specula, 
 Sounds, and Tents. Inspection of Mop.bid Discharges, 
 
 CHAPTER II. 
 
 Diseases of the External Genital Organs of the Female. Aphthae. 
 Herpes. Diphtheria. Lichen. Acne. Eczema. Parasites. Warts. 
 Boils. (Edema. Pruritus. Syphilis. Cancer. Lupus. Noma. Vulvitis. 
 Abscess. Cysts. Varicocele. Thrombus. Hernia. Hjalrocele. Labial 
 Tumours. Hypertrophy. Vascular Caruncles and Degenerations. 
 Fissures. Adhesions. Abnormalities of the Hymen. Coccj'godynia. 
 Ruptured Perineum, &c., ....... 36 
 
 CHAPTER III. 
 
 M KTHODS AND MeANS COMMONLY EMPLOYED IN SuRGICAL TREATMENT. 
 
 Instruments used in Local Treatment. Methods of Introducing Remedial 
 Substances. General Management of GYNiECOLOGiCAL Operations. 
 Preparation. Antiseptics. After- Treatment. ANiESTHESiA, . . 72 
 
 CHAPTER IV. 
 
 Hygienic and Medical Treatment in their Relation to Female 
 Diseases. Influence of Menstrual Periodicity. Food. Stimulants. 
 Clothing. Exercise. Bathing. Education. Chlorosis, its Nature and 
 Treatment. Neurasthenia in its various Forms, . . .96 
 
 CHAPTER V. 
 
 Diseases of the Vagina. Vaginitis, Acute and Chronic. Leucorrhcca. 
 Tumours and Growths. Foreign Bodies. Wounds, Ulceration, and 
 Fistula;. Occlusion. Prolapse, . . . . . .114 
 
CONTENTS. 
 
 CHAPTER VI. 
 
 PAUE 
 
 Congenital Malformations of the Genital Teact. Ovaries and Fallopian 
 Tubes, Uterus, Vagina, and Vulva. Hermapliroditism. Results of 
 Ati'esia, and Proceedings for its Removal, ..... 135 
 
 CHAPTER VII. 
 
 Ovulation, Menstuuation, and their Disorders. Amenorrlicea. Sup- 
 pressed Menstruation. Scanty Menstruation. Menorrhagia. Metror- 
 rhagia. Dysmenorrhcea. Vicarious Menstruation. The Menopause, . 154 
 
 CHAPTER VIII. 
 
 Diseases of the Uterus. Infantile Uterus. Stenosis of the Cervix Uteri. 
 Uterine Atrophy. Inflammation of the Uterus (Metritis), including 
 Acute and Chronic, Parenchymatous and Mucous, Corporeal and Cervical, 
 Metiitis, ......... 194 
 
 CHAPTER IX. 
 
 Diseases of the Uterus — continued. Ulcerations and Abrasions, Hyper- 
 trophy, and Lacerations of the Cervix Uteri. Chronic Hypertrophy and 
 Subinvolution of the Body or Cervix, ..... 229 
 
 CHAPTER X. 
 
 Diseases of the Uterus — continued. Fibro-myomata or Fibroid Tumours. 
 
 Uterine Polypi. Fibro-cystic Tumours, ..... 256 
 
 CHAPTER XL 
 
 Diseases of the Uterus — continued. Uterine Displacements. Theu' General 
 Mode of Causation. Prolapse of the Uterus and Vagina. Pseudo-pro- 
 lapse. Elevation of the Uterus. Forward Displacements, Anteflexion 
 and Anteversion. Backward Displacements, Retroflexion and Reti'over- 
 sion. Mobile Uterus. Lateral Displacements, .... 286 
 
 CHAPTER XII. 
 
 Diseases of the Uterus — contimied. Mechanical Supports used in the 
 Treatment of Displacements of the Uterus and Vagina. Belts, Pes- 
 saries, &c., . . . . . . . . 320 
 
 CHAPTER XIII. 
 
 Diseases of the Uterus — continued. Inversion, .... 344 
 
 CHAPTER XIV. 
 
 Diseases of the Uterus — contimied. Malignant Diseases. Cancer of the 
 
 Cervix. Cancer of the Body. Sarcoma, ..... 357 
 
CONTENTS. XI 
 
 CHAPTER XV. 
 
 I'AGK 
 
 Diseases of the Ovary. Prolapse. Neuralgia. Inilamniation, Acute 
 and Clirouic. Peri-ovaritis. Abscess. A])oplexy. Ovarian Tumours, 
 Solid and Cj-stic, ........ 380 
 
 CHAPTER XVI. 
 
 Diseases of the Ovary — continued. Ovarian Tumours. Their Size, Cover- 
 ing, Consistency, Vascular and Nervous Supply, Pedicle, Contents, 
 Progress, Accidents, and Complications. Their Symptomatology and 
 
 - Physical Signs. Their Diagnosis and DilFerentiation, . . . 404 
 
 CHAPTER XVII. 
 
 Diseases of the Ovary — continued. Ovarian Tumours. Treatment, by 
 Exploration, Tapping, Drainage, or Piemoval. Ovariotomy and Oophor- 
 ectomy. ......... 440 
 
 CHAPTER XVIII. 
 
 Diseases of the Fallopian Tubes. Congenital Abnormalities, Morbid 
 Growths, Undue Patency. Constriction. Inflammation, Acute and 
 Chronic. Abscess (Pyo-salpinx). Tubal Dropsy (Hydro-salpinx). 
 Hffimato-salpinx. Extra-Uterine Pregnancy, . . . 464 
 
 CHAPTER XIX. 
 
 Pelvic Disorders. Pelvic Inflammation, including Pelvic Peritonitis, 
 Perimetritis, or Peri-uterine Peritonitis ; and Pelvic Cellulitis, .Para- 
 metritis, or Peri-uterine Cellulitis. Pelvic Hematocele. Pelvic Abscess, . 483 
 
 CHAPTER XX. . 
 
 Dysrareunia, Vaginismus, Sterility, . ' . . . 512 
 
 CHAPTER XXI. 
 
 Some Affections of the Female Urethra, Ureters, Bladuei;, and 
 
 Rectum, ......... 526 
 
 APPENDIX. 
 
 Thr Symptoms and Signs of Pregnancy from the Point of \'ik\v of 
 
 Diagnosis and Differentiation, ..... .'>56 
 
LIST OF ILLUSTEATIONS. 
 
 The sources from which these are directly or indii-ectly derived are indicated in 
 ordinary type. The italics refer to illustrated catalogues of instruments. 
 When there is no reference, the figures have either been drawn hy Mr A. H. 
 Young, F.R.C.S., or engraved from the instructions of the author. 
 
 FIG. 
 
 1. Chad wick's Gynacological Table {Coclman &; SJmrtleff), 
 
 2. Colin's Reflecting Lamp, 
 
 3. Electric Light applied to the Tubular Specirlum, 
 
 4. Do. do. Duck-bill Speculum, 
 
 5. Diagrammatic View of Douglas's Pouch (Ranney), 
 
 6. Bi-manual Examination (Schrceder), 
 
 7. Fergusson's Tubular Speculum {Maw), 
 
 8. Speculum Forceps {ibid.), 
 
 9. Playf air's Uterine Applicator {ibid.}, 
 
 10. Barnes's Bi-valvular Speculum (iMt?.), 
 
 11. Cusco's Bi-valvular Speculum (i&ifZ.), 
 
 12. Meadows's Si^eculum {ibid.), 
 
 13. Knott's Speculum (i6zVZ.), 
 
 14. Reid's Speculum, closed, . 
 
 15. Do. do. open, . 
 
 16. Scanzoni's Speculum {Maw), 
 
 17. Sims's Duck-bill Speculum (Tie/;ia)Mi), 
 
 18. Position for the use of the Duck-bill Speculum, 
 
 19. Sims's Vaginal Repressor {Tiemann), 
 
 20. Uterine Tenacula {ibid. ), . 
 
 21. Fine Uterine Vulsellum {ibid.), . 
 
 22. Duck-bill Specukmi and Vaginal Repressor combined {Man:), 
 
 23. Emmet's Self-retaining Speculum {Tieriumn), 
 
 24. Neugebauer's Speculum {Maw), . 
 
 25. Sir J. Y. Simpson's Uterine Sound {Tiemann), 
 
 26. Sound recommended by the author, 
 
 27. Retroverted Uterus tied down by adhesions (AVinckel), 
 
 28. Jennison's Flexible Sound {C'odman & Shurtleff), 
 
 29. Sponge, Laminaria, and Tupelo Tents {Mate), 
 
 30. Expansion of Tupelo Tent (filunde), 
 
 31. Barnes's Tent Introducer {Maic), . 
 
 32. External Organs of Generation (Sappey), 
 
 33. Follicular Vulvitis (Thomas), 
 
 34. Labial Abscess {ibid.), 
 
 35. Sims's Glass Vaginal Dilator {Maio), 
 
 36. Barnes's Vaginal Dilator {Krohnc d- Sesern 
 
 PAGE 
 
 2 
 2 
 3 
 3 
 7 
 10 
 13 
 14 
 14 
 15 
 15 
 16 
 16 
 17 
 17 
 17 
 17 
 18 
 19 
 19 
 20 
 20 
 21 
 21 
 22 
 23 
 26 
 27 
 28 
 29 
 30 
 36 
 49 
 50 
 52 
 52 
 
LIST OF ILLUSTKATIONS. 
 
 xm 
 
 FIG. 
 
 37. 
 
 38. 
 39. 
 40. 
 41. 
 42. 
 43. 
 44. 
 45. 
 46. 
 47. 
 48. 
 49. 
 50. 
 51. 
 52. 
 53. 
 54. 
 55. 
 56. 
 57. 
 58. 
 59. 
 60. 
 61. 
 62. 
 63. 
 64. 
 65. 
 66. 
 67. 
 68. 
 69. 
 70. 
 71. 
 72. 
 78. 
 74. 
 75. 
 76. 
 77. 
 78. 
 79. 
 80. 
 81. 
 82. 
 83. 
 84. 
 85. 
 86. 
 87. 
 
 Elephautiasis of the Vulva (Mayer), 
 
 Ear Scoop, suitable for urethral use {Tiemann), . 
 
 Wells's jSTeedle-holder {Krohne & Sesemann), 
 
 American Needle-holder {Maw), . 
 
 Hagedorn's Needle-holder {Krohne d- Sesemann), 
 
 Straight Perineal Needle, .... 
 
 Introduction of First Suture in Perineorraphy, 
 
 Quilled Suture of Perineum (Baker Brown), 
 
 Sims's Sponge-holder {Krohne & Sesemann), 
 
 Emmet's Knife-holder {ibid.), 
 
 Bozemann's Scissors {ibid.). 
 
 Laterally Curved Needle in Handle {Tiemann), . 
 
 Tyler Smith's Tubular Needle {Arnold), . 
 
 Perineum Freshened, with Sutures introduced, . 
 
 Aspirator Needle {Maio), .... 
 
 Rasmussen's Aspirator {Krohne & Sesemann), 
 
 Growth transfixed by Needle to secure hold for Ecraseur 
 
 Chassaignac's Chain Ecraseur [Maio), 
 
 Braxton Hicks's Wire Ecraseur {Krohne & Sesemann), 
 
 Galvanic Ecraseur {ibid,. ), ... 
 
 Paquelin's Cautery (Coxeter), 
 
 Sims's Curette {Krohne & Sesemann), 
 
 Palfrey's Scarificator {Maw), 
 
 Silver Wire Twisting (Emmet), . 
 
 Higginson's Syringe {Maiv), 
 
 Yaginal Douche {Krohne & Sesemann), 
 
 Double Nozzle for Vaginal Syringe {Maiv), 
 
 Instrument for Plugging the Cervix Uteri (Chrobak), 
 
 Barness's Tampon Introducer {Maiv), 
 
 Sims's Tampon Extractor {Tiemann), 
 
 Sims's Sigmoid Catheter {Maio), . 
 
 The Skene-Goodman Self-retaining Catheter {Tiemann), 
 
 The Pelvic Viscera in Profile (Houston), . 
 
 Vertical Section of the Vagina (Hart and Barbour), 
 
 Section of the Pelvic Viscera (Ranney-Foster), 
 
 Paring Fistula by Scissors (Churchill et Leblond), 
 
 Emmet's Curved Scissors {Tiemann), 
 
 Emmet's Double Carved Scissors {ibid.), . 
 
 Fi.stula, with Wires inserted (Churchill et Leblond), 
 
 Rudimentary trace of Uterus (Schrceder), 
 
 Rudimentary Uterus {ibid.), 
 
 Uterus Unicornis (i5ic?.), . 
 
 Uterus Duplex (Thomas), . 
 
 Uterus Septus (Schrceder), 
 
 Uterus Bicornis {ibid. ), 
 
 Congenital Atresia Vaginae, 
 
 Five Diagrammatic Figures, illustrating the development of the 
 Genito-urinary Organs and Rectum (Schrceder), 
 
 ) 
 
 Marie Madeleine Lefort, a remarkable example of Pscudo-hermapliroditism 
 (Churchill et Leblond), ...... 
 
 PAGE 
 
 55 
 
 56 
 
 62 
 
 62 
 
 63 
 
 63 
 
 64 
 
 65 
 
 67 
 
 67 
 
 68 
 
 68 
 
 6b 
 
 69 
 
 73 
 
 74 
 
 74 
 
 75 
 
 75 
 
 76 
 
 77 
 
 77 
 
 78 
 
 79 
 
 80 
 
 81 
 
 82 
 
 84 
 
 85 
 
 85 
 
 93 
 
 93 
 
 114 
 
 115 
 
 115 
 
 130 
 
 131 
 
 131 
 
 132 
 
 138 
 
 138 
 
 139 
 
 139 
 
 140 
 
 140 
 
 142 
 
 143 
 
 143 
 
 143 
 
 143 
 
 143 
 
 144 
 
XIV 
 
 LIST OF ILLUSTEATIOXS. 
 
 FIG. 
 
 89. 
 
 90. 
 
 91. 
 
 92. 
 
 93. 
 
 94. 
 
 95. 
 
 96. 
 
 97. 
 
 98. 
 
 99. 
 100. 
 101. 
 102. 
 103. 
 104. 
 105. 
 106. 
 107. 
 108. 
 109. 
 110. 
 111. 
 112. 
 113. 
 114. 
 115. 
 116. 
 117. 
 118. 
 119. 
 120. 
 
 121. 
 122. 
 123. 
 124. 
 125. 
 126. 
 127. 
 128. 
 129. 
 130. 
 131. 
 
 132. 
 133. 
 134. 
 135. 
 136. 
 137. 
 138. 
 139. 
 
 Section of Pelvis of the same (Churchill et Leblond), 
 
 Hfematometra (Schrceder), 
 
 Hfematokolpos {ibid.), 
 
 Adult and Adolescent Human Ovaries. 
 
 Dysmenorrhceal Membrane (Coste), 
 
 Priestley's Uterine Dilator {2Iaw), 
 
 Sims's Uterine Dilator [Tiemann), 
 
 Tait's Uterine Dilator (Tait), 
 
 Simpson's Hysterotome {Tiemann), 
 
 Kuchenmeister's Uterine Scissors (ibid.). 
 
 Glass Intra-uterine Stem Pessarj' {Erolme cfc Sesemann), 
 
 Uterus Infantilis (Schrceder), 
 
 Formal and Infantile Uterus, 
 
 Simpson's Galvanic Stem Pessary {Krohne dc Sesemann), 
 
 Barnes's Galvanic Stem Pessary {ibid. ), 
 
 Long Conical Cervix Uteri (Churchill et Leblond), 
 
 Virgin and Parous Uterus contrasted (Sappey), . 
 
 Uterine Ointment Syringe {Tiemann), 
 
 Atthill's Intra-uterine Cannula {Moao), . 
 
 "Watch-spring Piing Pessary {Krohne & Sesemann), 
 
 Watch-spring Pessary with perforated Diaphragm, 
 
 Fissiu'ed and Granular Cervix Uteri (Schrceder), . 
 
 Ulceration of Prolapsus Uteri (Thomas), . 
 
 Pallen's Operation for Elongated Cervix, . 
 
 Stellar Laceration of the Cei-vix Uteri (Emmet), . 
 
 Unilateral Tear of the Cer\-ix Uteri {ibid.), 
 
 iDiagi'ammatic Illustration of the steps of Emmet's Operation for 
 Lacerated Cervix Uteri, ..... 
 
 Lacerated Cervix after Denudation (Emmet), ... 
 Pseudo-prolapsus Uteri. Hypertrophy of the Supra-vaginal portion o 
 
 the Cervix (Schrceder), ..... 
 
 Multiple Fibroids of the Uterus (Boivin et Duges), 
 Cavernous Uterine Fibroid (Schrceder), .... 
 Typical foiTas of Fibro-myomata, ..... 
 Cervical Fibro-myoma (Schrceder), .... 
 
 Fibroid Polypus of the Uterus (ChurchiU et Leblond), . 
 Aveling's Pol33)trite {Tiema/iin), ..... 
 Ordinary Stages of Prolapsus Uteri, .... 
 
 Prolapsus Uteri with Persistent Eeti'ofiexion (Schrceder), 
 Sims's Operation for Elytrorraphy (Thomas), 
 Emmet's Oj)eration for Elytrorraphy (I'&ic?.), 
 Pseudo -prolapsus Uteri. Hypertiophy of the Intra-vagmal portion of 
 
 the Cervix (Schrceder), ..... 
 
 Eemoval of Cancerous Cer\"ix {Hid.), .... 
 Schema of Forward Displacements of the Uterus, 
 Schema of Backward Displacements of the Uterus, 
 Bladder overlapping a Eetroflexed Utenis (Schatz), 
 Incisions in the Cervix rec[uired in Anteflexion (Sims), . 
 Eeplacement of Eetroflexed Uterus by Sound, 
 Perineal Pad, vnth Belt and Straps {Krohne & Sesemann). 
 Ball Pessary of hard material (z'izV?.), .... 
 
 PAGE 
 145 
 148 
 148 
 155 
 180 
 186 
 187 
 187 
 188 
 189 
 190 
 194 
 195 
 197 
 197 
 198 
 198 
 218 
 220 
 225 
 225 
 230 
 231 
 234 
 240 
 241 
 
 S247 
 247 
 247 
 247 
 248 
 
 253 
 257 
 258 
 259 
 277 
 280 
 283 
 292 
 293 
 295 
 296 
 
 298 
 300 
 302 
 302 
 303 
 307 
 316 
 322 
 323 
 
LIST OF ILLUSTRATIONS. 
 
 FIG. 
 
 140. Gariel's Air Pessary {Kruhne & Sesemann), 
 
 141. The Roser-Scanzoui H3'sterophor (Sclirceder), 
 
 142. Barnes's Guttajiercha Stem with Bands {Krohne <fc Sesemann) 
 
 143. Duffin's Pessary for Prolapse {Maw), 
 
 144. Whitehead's modification of Simpson's Pessary, . 
 
 145. Cutter's Pessary for Prolapse {Krohne tfc Sesemann), 
 
 146. Clay's Copper-wire Pessaries, .... 
 
 147. Zwanek's Pessary in Guttapercha {Krohne d: Sesemann), 
 
 148. Barr's modification of Zwanek's Pessary, . 
 
 149. Hewitt's Oval Lever Pessary {Maiv), 
 
 150. Galabin's Oval Lever Pessary {ibid.), . . 
 
 151. Greenhalgh's modification of Hodge's Pessary {Krohne d; Sesemann) 
 
 152. Playfair's Anteversiou Pessary, reversed (z&irf. ), . 
 
 153. Skene's Pessary for Cystocele {Tiemann), 
 
 154. Hewitt's Anteflexion Cradle, in situ (Afatu), 
 
 155. Hewitt's Cradle Pessary, vulcanite {ibid.), 
 
 156. Thomas's Anteversion Pessary, original form {Krohne cfc Sesemann) 
 
 157. Thomas's Anteversion Pessary, later form (Thomas), 
 
 158. Galabin's Anteversion Pessary {Krohne d; Sesemann), 
 
 159. Fowler's Anteversion Pessary {ibid.), 
 
 160. Cutter's Anteversion Pessary {Maw), 
 
 161. Chambers's Intra-uteriue Stem Pessary (i&zVZ.), 
 
 162. Greenhalgh's India-rubber Stem Pessary {Krohne <£• Sesemann). 
 
 163. He-ndtt's Intra-uteriue Stem, with vaginal support {Matv), 
 
 164. Wynn Williams's Intra-uterine Stem, with vaginal support {Krohne d' 
 
 Sesemann), 
 
 165. Hodge's Pessary (Hodge), ..... 
 
 166. Hodge's Pessary, in situ (Schrceder), 
 
 167. Thomas's Eetroflexion Pessary {Krohne d: Sesemann), 
 
 168. Albert Smith's modification of Hodge's Pessary {Tiemann), 
 
 169. The Open Lever Pessary {Matv), .... 
 
 170. Hodge's Pessary with Diaphragm {Krohne d; Sesemann), . 
 
 171. Cutter's Retroversion Pessary {Maw), 
 
 172. Stages and Degrees of Uterine Inversion, diagrammatic, . 
 
 173. Inversion of the Uterus (Martin), 
 
 174. Aveling's Repositor for Inverted Uterus {Mayer d: Meltzer), 
 
 175. Superficial Ulcerative Epithelioma (Schrceder), 
 
 176. Cauliflower excrescence of the Cervix (Churchill et Leblond). 
 
 177. Mushroom-like Fungus Cancer of the Cervix (Schrceder), 
 
 178. Nodular Cancer of the Cervix (iWd ), 
 
 179. Cancer of the Uterine Body (iMrf.), 
 
 180. Sarcoma of the Uterine Body (iWf?. ), 
 
 181. Myoma of the Ovary (Doran), .... 
 
 182. Dermoid Cyst of the Ovary (tizrf.), 
 
 183. Multilocular Cystoma of the Ovary (Churchill et Leblond), 
 
 184. Incipient Papilloma of Ovarian Cysts (Doran), 
 
 185. The most Characteristic Constituents of Ovarian Cystomata. 
 
 186. The Ovarian Facies (Wells), .... 
 
 187. Comparative Percussion Sounds in Ovarian Tumour and Ascites {ibid.), 
 
 188. Simple Broad-ligament Cyst (Doran), 
 
 189. Stanley's Director {3Iaw), ..... 
 
 190. Wells's Torsion Forceps (Tiemann), 
 
 191. Nekton's Tumour Forceps (iii'rf.). 
 
 I'AGE 
 
 324 
 325 
 325 
 325 
 336 
 326 
 327 
 328 
 328 
 329 
 330 
 330 
 331 
 331 
 332 
 332 
 332 
 333 
 333 
 333 
 334 
 334 
 335 
 335 
 
 336 
 338 
 340 
 340 
 341 
 341 
 342 
 342 
 345 
 352 
 355 
 358 
 358 
 359 
 359 
 371 
 375 
 390 
 398 
 401 
 402 
 408 
 41.5 
 417 
 423 
 448 
 448 
 4.')1 
 
XVI 
 
 LIST OF ILLUSTEATIONS. 
 
 riG. 
 
 192. Wells's Blunt Pedicle Needle, 
 
 193. Wells's Trocar {Tiemann), 
 
 194. Piston Trocar {ibid. ), . 
 
 195. Wells's Clamp {ihid. ), . 
 
 196. Keith's Glass Drainage Tube {Krolme & Sesemann), 
 
 197. India-rubber Drainage Tube, with. Plug, . 
 
 198. Wells's Pedicle Forceps, curved, . 
 
 199. The Left Broad Ligament, Fallopian Tube, Ovary, 
 
 (Henle), ..... 
 
 200. Tubal Dropsy (Boivin et Duges), . 
 
 201. Successive Accumulations of Lymph in Pelvic Peritonitis 
 
 202. Lateral Exudation in Pelvic Cellulitis, 
 
 203. Urethral Tubules (Skene), 
 
 204. Skene's Urethral Endoscope (Tiez/iff/wi.), . 
 
 205. Simon's Urethral Dilators [Krolme & Sesemann), . 
 
 206. Catheterisation of the L^reters (Winckel), 
 
 207. Rectum Speculum {Tiemann), 
 
 
 PAGE 
 
 
 452 
 
 
 456 
 
 
 456 
 
 
 457 
 
 
 458 
 
 
 459 
 
 
 461 
 
 and Parovarium 
 
 
 465 
 
 
 470 
 
 is, 
 
 485 
 
 
 495 
 
 
 527 
 
 
 527 
 
 
 537 
 
 
 537 
 
 
 551 
 
A MANUAL OF GYNJICOLOGY. 
 
 CHAPTER I. 
 
 /'r' 
 
 The Methods and Means commonly employed in Diagnosls. Manual Examin- 
 ation, including Abdominal Palpation, Digital Examination or Vaginal toucher 
 Bi-mauual Examination, Rectal and Vesical Examination, &c. Instrumental 
 Examination, including the use of Specula, Sounds, and Tents. Inspection 
 OF Mop.BiD Discharges. 
 
 A GREAT amount of ingenuity has at various times been displayed in the 
 invention of more or less complicated gjaigecological tables or couches. 
 Some of these are intended to facilitate the performance of operations of 
 great difficulty and importance ; others, I fear, to assist in throwing the 
 patient, at ordinary examinations, into positions which she cannot, with- 
 out such aid, assume or maintain. Dr Chadwick's Examining-table 
 (fig. 1) is one of the best known of these, and is intended by the 
 designer to serve " as a substitute for the unsightly, often ill-adapted, 
 and expensive chairs which have been used by gynaecologists for exam- 
 inations." 
 
 Much of the ordinary work of gynsecological practice must, liowcver, 
 be done at the homes of the patients, and not, as with the specialist, in 
 consulting-rooms, or " offices," or in the well furnished Avard or operating 
 theatre ; but evei-y consulting-room or surgery should be furnished with 
 a good high couch, say thirty inches in height at the very least. This 
 should have no back nor foot-board, and one end of it should slope gently 
 upwards to the extent of about a foot, and the whole surface should be 
 firmly upholstered. A movable square cushion, and a large thin coverlet 
 to throw over the patient, should also l)e at hand. The couch should 
 be placed nearly oppcjsitc to a good window light, or slioiild bo easily 
 movable. 
 
 In this climate it is always necessary to be [)rovidcd witli a reliecting 
 
 A 
 
2 VARIOUS EEFLECTING LAMPS. 
 
 lamp. Many such have been invented, one of the simplest of which is 
 
 Fig. 1.— Dr Chadwick's Table for Gyuaicological Examiuatious 
 and Operations. 
 
 shown by lig. 2. The desiderata of such a lamp are — a good concave 
 
 reflector, or a strong lens, and a flat stand. 
 A reflecting lamp may be extemporised by 
 tying a large silver spoon to a candle in 
 an ordinary flat candlestick. The inser- 
 tion of a couple of small plugs of cork 
 between the handle of the spoon and the 
 candle is an improvement, but not a neces- 
 sity, when the reflector is only wanted for 
 a short emergency. I have endeavoured 
 to procure a good lamp, electric or other- 
 wise, which could be affixed to the forehead, 
 but I find that all these, and also the 
 forehead mirrors used for the larjiagoscope, 
 are very inconvenient in gynaecology. I 
 am much indebted, however, to the follow- 
 ing suggestions of Mr Broughton, dentist, 
 of Manchester : — A small hollow pencil, 3 
 inches long by ^ inch in diameter, is fitted 
 at one extremity with a Swan incandes- 
 cent lamp, of rather less than its own cir- 
 cumference, and connected with a bichro- 
 mate battery, which stands below the usual couch. For the dentist's 
 
 Fig. 2. 
 
 -Colin's Lamp, slightly 
 modified. 
 
ELECTKIC ILLUMINATION OF SPECULA. 3 
 
 purposes this is invakiable. It perfectly lights up the moutli and 
 fauces, and unless the miniature lamp comes into actual contact with 
 tlie soft parts, it gives no sensation of heat. By a spring clip, 
 Avhich takes up no room (tig. 3, a), the illuminating pencil can be 
 retained at any part of the internal wall of a tubular sj)eculum, giving 
 perfect illumination, and allowing of the use of both hands. The 
 pencil can also be placed in the hollow of the duck-bill speculum, 
 and fixed there by a button and slit (fig. 4, b), and the firm but 
 flexible connecting wires being bent parallel with the shank, it is 
 easily held in situ by the same hand which holds the speculum. A 
 
 Figs. 3 and 4. —Application of the Electric Light to A, tlie Tubular, 
 B, the Duck-bill Speculum. 
 
 portable accumulator of electricity, which will give light for an hour, 
 can easily be carried in an outside jiocket for home practice. Mr 
 Broughton has also provided a more complex mechanism for keeping the 
 lamp cool by water iiTigatioii during long ojDerations. 
 
 In most cases some female friend accompanies the patient, or is to 
 be found at her home. She is of little \ise as an assistant, except occa- 
 sionally as a lamp holder ; but a female attendant, with more or less 
 training, at liis consulting-rooms, is invaluable to one who has mucli 
 practice in the diseases of women. 
 
ABDOMINAL PALPATION. 
 
 Manual Examination. 
 
 Under no circumstances should the use of instrumental means of 
 diagnosis ever precede a careful manual examination. The preliminary 
 information which is obtained in this way is absolutely essential to the 
 safe use of instruments, and the only guide as to their necessity ; and, 
 moreover, for diagnostic purposes, if a choice had to be made, the hand 
 is infinitely superior to any instrument, or probably to all of them com- 
 bined. As a general rule, it is advisable to commence with 
 
 Abdominal Palpation. — If the patient is in bed, she is probably lying 
 on her back, the most suitable position, and the hand is passed at first 
 lightly over the abdominal surface in search of swelling, tumour, or 
 painful localities. While the patient is engaged in conversation, the 
 fingers are then pressed more firmly downwards within the brim of the 
 pelvis. The existence and exact locality of any abnormal fulness or 
 tenderness is thus made out. Should any prominent swelling be found, it 
 is now carefully investigated by percussion, auscultation, and otherwise ; 
 or, if the patient is in the consulting-room, it is decided whether there 
 is a necessity for removing the corset, and otherwise providing for a 
 •omplete abdominal investigation. I prefer ahvays to commence a 
 more complete examination in this way by abdominal palpation, having 
 foiind that, with nervous or timid patients, it breaks the ice, as it were, 
 and leads up to an internal examination, which would otherwise be less 
 freely accorded. No deference to the natural modesty and shrinking of 
 women from such examinations should ever be neglected. Moreover, 
 this simple palpation is sometimes sufiicient in itself, and there may be 
 no necessity for going further, as, for instance, in many cases of amenor- 
 rhoea in the unmarried ; Avhile the information, positive or negative, thus 
 gained, is invaluable in enabling us to direct our future steps straight to 
 the points of the case. 
 
 Unless the symptoms point manifestly to some affection of the external 
 genitals, the next and most imjDortant step is the 
 
 Digital Examination by the Vagina, or "Toucher." — Until recently, 
 this was nearly always made, in this country, in the ordinary midwifery 
 position, the patient being turned upon her left side, with her breech as 
 near to, and her head as far from, the examiner as is conveniently 
 possible, her hip and knee joints being well flexed. Of late years, how- 
 ever, the great superiority of the position on the back, with the knees 
 moderately flexed, has been stoutly maintained by some writers, and 
 the advocates of each plan have cast not a little unnecessary contumely 
 on their opponents. The fact is, that a practitioner who has had the 
 reqiiisite experience can make out perfectly well, in either way, all that 
 
THE VAGINAL " TOUCHEi;." 5 
 
 is ordinarily required, and that in difficult or doubtful cases he will 
 often feel compelled to use each position in succession. When the 
 patient is on her back, she is more favourably placed for subsequent 
 examination with both hands, while in the other position we are more 
 ready for the use of instrumental means of examination. I am certain 
 that, for various reasons, the lateral position is less repugnant to the 
 majority of women. ^ 
 
 The student should endeavour to acquire ambidexterity, and for this 
 purpose should examine with the right or left hand iixipartially ; but, 
 contrary to the opinion of Dr Barnes and others, I am satisfied that the 
 right hand is, for ordinary purposes, the most useful to the practitioner 
 and the least uncomfortable to the patient. Nevertheless, I consider 
 that when instruments, such as the sound, tent-holder, and the like, are 
 to be introduced, the left hand furnishes the most satisfactory guide, 
 while, with most men, the right wields the instrument with greater pre- 
 cision and tact. The forefinger alone should be used, until it has been 
 ascertained that the case requires two or more, and that the parts are 
 lax enough to permit of their introduction. Vaseline impregnated with 
 carbolic acid (1 in 40), or thymol (gr. xv ad gi), forms a better lubricant 
 than oils or fats, and free lubrication must never be neglected ; it saves 
 the patient from much discomfort, and diminishes the danger to the 
 practitioner of specific infection. The finger is first placed upon the 
 perineum, and then gently hooked round its anterior border into the 
 vulva ; it is next carried slowly along the posterior vaginal wall till it 
 reaches the cervix uteri or the cul-de-sac behind it. The cervix and os 
 uteri are then carefully examined, and afterwards the upper end of the 
 vagina around them. While withdrawing the finger, the anterior 
 vaginal Avail is traced, and if any special pain has been noticed while 
 passing the Aiilva, its site is now definitely ascertained. For these ends 
 the front of the finger must be turned backw^ards, forwards, or laterally 
 as required, and to any one who has a forefinger of sufficient length, and 
 who has been accustomed to use it, it seems almost childish to discuss 
 the question which hand is preferable from this point of view ; there is 
 no difficulty with either. Hands diff"er much in size and shape, and I 
 find it therefore best to give no specific instructions as to the disposal of 
 the other fingers, further than to kce]) them folded tightly out of the 
 way as much as possible, and not to hiirt the patient with them. The 
 thumb is generally least in the way when firml}^ extended. 
 
 Let us now sec what arc the points ascertainable by a single sys- 
 
 ' Dr Paul Muude says — " The comfort of feeling that the patient is not watching 
 one's every expression and movement has liut to be experienced to be appreciated," 
 and this applies with tenfold force to clinical work, wliere several students have to 
 examine in succession. 
 
b INFOIiMATIOX OBTAINED BY THE " TOUCHEK. 
 
 tematic digital examination. In such a summaiy we must perforce 
 refer to affections not yet described, and it will be found of great service 
 to tuiTL back to it at a later stage, or to refer to it when considering any 
 special diagnosis. 
 
 1st. We note, externally, the state of the perineum, hymen, and 
 ostirmi yaginEe generally, and the pain dne to vascular groArths, vulvitis, 
 and other affections mentioned in Chapter II. ; we also perceive whether 
 any substance protiiides through the vulva or blocks the opening, such 
 as a j)rolapsed uterus, a polypus, or a malignant growth. 
 
 2nd. We mark the condition of the vagina as regards heat, moisture. 
 and tenderness, the existence of any bulging of its walls, or of any con- 
 tractions of its passage, or of foreign bodies within it. 
 
 3rd. We ascertain the presence of any feecal accumulation in the 
 rectum, or foreign body "«-ithin the rectum or bladder. 
 
 4th. We can estimate the various diameters of the bony pelvis, and 
 the existence of bony or other gTO'wths therefi'om. 
 
 5th. We learn, what no instiiunent can tell us with ceilainty, the 
 exact position and direction of the cervix uteri — its length, shape, and 
 consistence — together with any fissures, indentations, or excrescences 
 upon its sru-face. 
 
 6th. We ascertain the state of the external os uteri — its shape, 
 whether round, oval, or iiTcgaxlar — its patency to the finger, and the 
 existence of any protiiiding substance, such as fungoid excrescences, hard 
 or soft pol}-pi, a projecting ovum, or an inverted utenis. A delicate sense 
 of touch is required to ascertain the presence of small soft polypi, or of 
 the granular and velvety state of the mucous membrane, so common in 
 chi'onic inflammation of its surface. 
 
 7th. We may learn much aboiit the uteiiis as a whole. If the os, as 
 sometimes hajjpens, is widely dilated, we may explore the whole cavity 
 of the uteiiis. Or we may gain the important infonuation whether it 
 is fixed in its place, or movable when poised on the tij) of the finger, 
 or merely heavier than usual. In health, we cannot, with one hand, 
 examine the body of the utems, except to a shght extent in front ; but 
 when enlarged by pregnancy or disease it can be traced through the 
 vaginal roof, and we learn whether the expansion is unifonn or in one 
 direction only. But, when the womb is displaced, or bent upon its 
 long axis, we can reach its body or even its fundus, and, comparing 
 this with the direction of its ceiwix, make a near approach to diagnosis 
 of the exact affection. 
 
 8th. We ascertain, moreover, not least in importance, what is the 
 state of matters sim-ounding the utenis and vagina, what there is ab- 
 normal before, behind, laterally, or extending upwards towards the brim 
 of the pelvis. In fiict, so many grave and important deviations from 
 
DOUGLASS PEllITONEAL POUCH. 
 
 r 
 
 health are ascertained under this head that it seems advisable to sub- 
 classify them. 
 
 Behind the vagina we may find certain abnormalities. 
 
 (ct) The rectum may be loaded with fecal accumulation, sometimes 
 enormous in quantity ; sometimes there are only one or two hard nodules, 
 which may be mistaken for malignant growths, inflammatory exudations, 
 or a diseased and prolapsed ovarj-. On stead}- pressure through the 
 vaginal wall, fsecal masses pit and are displaceable, and if their nature is 
 still doubtful, an examination by the rectum will make it clear. The 
 rectum may also be occupied by a polypus, a mass of haemorrhoids, a 
 malignant growth, or a foreign body, differentiation being effected by 
 direct exploration of its cavity. 
 
 In the pouch of peritoneum which dips downwards behind the uterus, 
 and upper end of the vagina, 
 and in front of the rectum, 
 most of the other post-vaginal 
 abnormal substances are found. 
 This very important Douglas's 
 pouch is shown at fig. 5, and 
 is capable of great distension 
 downwards. We have here 
 occasionally 
 
 ip) A , knuckle or semi- 
 heniial protrusion of the bowel. 
 The obstetrician remembers 
 this as a possible obstruction 
 to the passage of the head, 
 though it is an infrequent 
 one. Its comparative pain- 
 lessness, its repressibility up- 
 wards in ordinary circum- 
 stances, and its pitting on 
 pressure like a fsecal mass, though found to be anterior to and not within 
 the rectum, are its chief diagnostic features, though it must be admitted 
 that it is not always easy of diagnosis except by the cxchision of other 
 conditions. 
 
 (c) The body of the uterus, gravid or non-gravid, wlicn thrown back- 
 wards — retroversion or retroflexion — is pcrlia])S the most frequent ab- 
 normal substance met with in Douglas's poucli, and is found as a firm 
 but elastic, smooth, and generally movable body. 
 
 {d) With great frequency also we have the products of inflannnatiou 
 of the peritoneum itself— firm, solid, fixed exudation of coagulated 
 lymph, wliicl) has exiided in this site, or has trickled down in its first 
 
 Fig. 5. — Diagrammatic view of Douglas's Peritoneal 
 Poucli (after Ranney). P P, Peritoneum ; R, 
 Rectum ; U, Uterus ; B, Distended Bladder ; 
 
 S, Symphysis i:)ubis. 
 
S ABNORMALITIES BEHIND THE VAGINA. 
 
 fluid state, as all fluids will, to the lowest possible level, and which may, 
 though fortunatel}' not often, return to the fluid state as abscess. 
 
 (e) Very similar in its physical characters is the exudation due to 
 the escape of blood into the peritoneal cavity (hsematocele). This also 
 tends to gravitate into this low-lying pouch, undergoes there a similar 
 hardening jDrocess, and ends similarly in absorption or puriform soften- 
 ing. Similar exudations of h-mph or of blood occur in the pelvic cellular 
 tissue, but for obvious reasons they have not the sjDecial tendency to 
 accumulate chiefly behind the vagina. They may, however, be found in 
 part, or, though very rarely, wholly in this site. See Perimetritis, Para- 
 metritis, and Heematocele (Chap. XIX.). 
 
 (/) Cancerous or tubercular deposits are found in this site, though 
 more rarely, especially as a primary aff"ection. They are, or at least the 
 former is, usually accompanied by ascites, and is often found only in 
 searching for the cause of the dropsy. 
 
 (ff) Firm, hard, and often nodulated outgrowths from the uteiais, of 
 non-malignant character (fibro-myomata), are not infrequently en- 
 countered in this site, and we may thus reach either large tumours, 
 which are perceptible above the pelvic brim, or small ones, which tend 
 by their weight to drag back the uterus towards the sacral hollow, or 
 by their presence to push it forwards or to one side. 
 
 (h) Small tumours of the ovary tend also to descend here, more or less 
 laterally, though the common cystic tumours do not generally attract 
 attention until so large that they rise above the pelvic brim, and may 
 be quite out of reach ^jer vaginam. The ovary itself, healthy or some- 
 what diseased, usually the latter, may be found here, much loAver than 
 in its normal site, giving rise by its prolapse to troublesome symptoms, 
 and the distended Fallopian tubes are also met with more frequently 
 than was, until recently, supposed to be the case. 
 
 (i) The fluid of ascites, if sufficient to render the abdomen tense, 
 may, through Douglas's pouch, press forward the upper part of the 
 vagina, but this bulging recedes on pressure Avith the finger. The 
 experienced touch recognises, however, the receding pouch, as it also 
 does that which is caused by quite recent effusion of fluid lymph or 
 blood. 
 
 (h) Lastly, that fatal though happily rare error of nature, an extra- 
 uterine fcetation, occuj)ies, in some instances, this site, being almost 
 always lateral as well as posterior. 
 
 In front of the vagina we may find — 
 
 (o) The body or fundus of the litems, when it is abnoiTaally bent 
 forwards (anteversion or anteflexion). To a slight extent Ave may trace 
 the body here in perfect health, and still more so in early pregnancy. 
 
 ih) Intra-peritoncal exudations, similar to those discoA^ered behind, 
 
ANTERIOR AND LATERAL ABNORMALITIES. 9 
 
 though very rarely extending so low dowu, owing to the non-existence of 
 so deep a peritoneal pouch. Exudations into the cellular tissue are, 
 however, not uncommon in this situation. 
 
 (c) Uterine fibroid or fibro-myomatoiis outgrowths, less comnionl}' than 
 behind. 
 
 (d) The ovary is stated to have been found displaced in this direc- 
 tion, and, as it may luidoubtedly protrude through the inguinal canal, 
 the possibility of its appearing in such a situation cannot be denied. 
 I have never met with it here, however. 
 
 (e) General enlargement of the lower segment of the uterus. 
 
 (/) Calculus, fungoid growths, &c., of the bladder, or the distended 
 organ itself. 
 
 Laterally we ma}- find — 
 
 (a) Exudation of coagulated lymph or blood, continuous with that 
 behind or in front, or confined to the lateral situation, on one or both 
 sides. When this is unilateral, the uterus is more or less pushed to the 
 opposite side. See Parametritis. 
 
 (6) The body of the uterus, either pushed laterally by exudation, t)r 
 pulled by cicatrisation, or, very rarely, bent laterally' without any 
 apparent cause of inflammatory origin. 
 
 (c) The ovary, if enlarged or hardened, and yet remaining about its 
 natural situation, may be reached almost at the level of the pelvic brim ; 
 but unless tender, or enlarged, or unduly depressed, a mere digital 
 examination wdll not easily ascertain its whereabouts. 
 
 {d) We may also discover here the presence of perityphlitic, nephritic, 
 or perinephritic abscess, or of abscess due to disease of the hiiD or sacro- 
 iliac joints or of other organs. 
 
 Bi-manual Examination. — The difiiculty of reaching the upper level 
 of the pelvic cavity by a digital examination, or of fixing the structures 
 there so as to allow of their careful investigation, suggests the necessity 
 for exerting counter-pressure by the other hand ; this again suggests the 
 simultaneous use of both hands as investigators, and this constitutes bi- 
 manual examination. By this method, while exploring the pelvic cavity 
 with one hand (say the right) from below, we not only bring within its 
 reach the organs contained, but the fingers of the other hand can be 
 slowly and gently pressed downwards from above the brim, so that, in 
 women who are not very stout, they will meet those which are in the 
 vagina, unless any normal structure or abnormal ])roduct intervene. 
 In this way a clear map of the parts at the brim of the pelvis can be 
 obtained, and the position and condition of the uterus, ovaries, Falloinan 
 tubes, or of any abnormal exudations or growths, can be made out with 
 a very near approach to absolute certainty. It is therefore imperative 
 that, in every examination for diagnostic purposes, the 1)i-niaimal 
 
10 
 
 BI-MANUAL EXAMINATION. 
 
 method should to some extent be used. In difficult cases, and with the 
 aid of anaesthesia, we thus have it in our power to realise the physical 
 condition of these pelvic viscera more completely than we can that of 
 any others in the body. In a thin w^oman it is quite possible to make a 
 fairly accurate bi-manual examination while she retains the left lateral 
 position, the left hand pressing upon the abdomen ; but if the patient 
 be stout, or the diagnosis difficult, while retaining the intra-vaginal 
 finger in place, she can easily be turned upon her back, whereby a more 
 complete control of the abdominal wall is obtained. This external 
 pressure must be slow and persistent, not losing any ground once gained. 
 To relax the muscles, the patient should be made to converse, the fingers 
 sinking a little deeper at each relaxation of the abdominal wall, and the 
 thighs must be completely flexed, though occasionally nothing but 
 anaesthetics will suffice to allow of the necessary relaxation of all parts. 
 
 The combined examination 
 ^ ^X / y (fig- 6) must be methodical, 
 
 the uterus being examined 
 with the internal finger, 
 placed first in front of the 
 cervix, then behind it, and 
 then on the os externum, 
 while the other hand clearly 
 defines its position from 
 above in each instance. 
 The condition of the ovaries 
 and other lateral structures 
 is similarly ascertained at 
 various angles, and the con- 
 tour of exudations and growths is clearly defined. This bi-manual 
 examination is inadvisable, except with very great care, during the 
 presence of acute inflammatory disease ; on the other hand, it obviates 
 the necessity for the use of the uterine sound in cases where preg- 
 nancy cannot be positively excluded, or when there are other ob- 
 jections to the use of that instrument. I would insist that the value 
 and necessity of bi-manual examination cannot easily be over-estimated, 
 for in favourable cases we may thus gain almost as clear a picture of 
 the position, size, and shape of the organs at the pelvic brim as by a 
 post-mortem inspection. However useful the lithotomy position may be 
 in certain cases of operative interference, it is seldom necessary to stib- 
 ject the patient to it for the purpose of a mere bi-manual examination, 
 and only in very exceptional cases is the introduction of the whole hand 
 into the vagina required, as in the case, for instance, of tumours which 
 cannot otherwise be ftilly explored. 
 
 Ftg. 6. — Bi-manual Examination (Schroeder). 
 
EXAMINATION BY THE UECTIM. 11 
 
 Digital examination in tlie erect position, or with the juitient upon 
 her knees and elbows, or knees and chest, is so seldom had recourse to 
 for mere diagnosis, that it need only be referred to when discussing those 
 specicxl instances in 'which it is required. But undoubtedly the various 
 degrees of prolapse may sometimes be made oiit most clearly in the 
 erect position, Avlien the end warrants the means. 
 
 Examination per Eectum— Eectal "Toucher." — In many cases, niuch 
 light may be thrown upon diagnosis by an examination of the peh'is 
 with the left forefinger passed into the rectum. The posterior surface 
 of the nterus and the contents of Douglas's pouch, as well as the liga- 
 ments surrounding it, can be thus more mimitely examined, especially if 
 the abdomen is well compressed by the other hand, and a complete recto- 
 abdominal bi-manual examination is thus performed. If the patient is on 
 her back, and the practitioner at her right side, the right hand is most 
 suitable for rectal examination, the left if she is in the left lateral position. 
 
 To estimate clearly the state of the parts between the rectum and 
 vagina, the thumb and forefinger of one hand may be passed into the 
 two cavities, or both forefingers may be used ; I prefer the latter plan 
 as a general rule. In young virgins, when an examination is impera- 
 tive, say for suspected haematocele or retroversion, the rectal should 
 at first be substituted for the vaginal toucher, and in all cases of 
 obstructed genital passages we have in this a useful alternative means of 
 diagnosis. It is also of special value in cases of intra-vaginal tumours, 
 when we' desire to ascertain their relations to the utenis above, e.g., in 
 the diagnosis of polypus from inversion of the uterus. It is well for the 
 student to learn early that the cervix uteri can be clearl}' felt through 
 the rectum, but that it appears there much larger than it does j^er 
 vaginam. I have seen rather absurd mistakes arise from forgetfulness 
 of this. I have no personal experience of Simon of Heidelberg's method 
 of introducing gradually the whole hand into the reetum during 
 ansesthesia, and then bi-manually examining the pelvis and lower 
 abdomen as high as the kidney. It can doubtless be done with satis- 
 factory diagnostic results, but at the risk of death from rupture of the 
 peritoneum in the left flank. It is occasiontdly forgotten by enthusiastic 
 clinical observers that an accurate diagnosis may bo purchased too 
 dearly, and that an approximate one may be preferable, if it is more con- 
 sistent with the recovery of the patient. Care shoidd be taken in all cases 
 of rectal examination to cleanse the fingers afterwards antiscptically, and 
 in addition to lubrication, to previously fill the space below the nail with 
 soap. If the uterus l)e drawn down by a hook or vulsellum, such as is 
 used with the duck-bill speculum, the examination of Douglas's pouch 
 and the back of the uterus j)er orctwn is much facilitated. 
 
 Examination per Vesicam. — The canal of the urethra may l)e 
 
12 VAllIOUS FOEMS OF SPECULA. 
 
 explored by the little finger without much difficulty, under anaesthetics, 
 but the introdiiction of the forefinger into the bladder is difficult, or may 
 involve previoiis dilatation by expanding or conical dilators, and though 
 necessary in certain diseases of the bladder itself, I hardly think it is 
 justified, merely for the light it may throw on the state of the anterior 
 wall of the uterus, or on pelvic exudations between the bladder and 
 vagina. But the ordinary vesical catheter or sound is of great value if 
 used in apjDosition to the finger in the rectum or vagina. We can thus 
 ascertain very clearly the presence or absence of the uterus above a 
 vaginal tumour of doubtful nature, or obtain other information which 
 the obesity of the patient prevents us from acquiring bi-manually. 
 
 Instrumental Methods of Examination. 
 
 Specula. 
 
 The use of specula of various kinds, for the purpose of inspecting the 
 vagina and cervix uteri, for the application of remedies, and for the 
 performance of operations, is now such an acknowledged necessity that, 
 previous to their introduction, gynaecology could hardly be said to have 
 commenced its career. Yet medical opinion is still somewhat divided as 
 to the kind of speculum which is most useful under varying circumstances. 
 The educated touch alone can do wonders in the way of diagnosis ; but 
 it is nearly always necessary to verify by sight the results obtained, 
 when morbid conditions of the cervix uteri or vagina exist, or when the 
 source of sanguineous, purulent, or other discharges has to be ascertained. 
 Great care must be exercised in the case of malignant disease, and the 
 presence of the hpiien, or the existence of painful affections of the vulva, 
 may entirely preclude the use of the speculum, unless with anaesthesia. 
 
 Specula are usually divided into three types — (1) The tubular or 
 original type, as far as modern practice is concerned ; (2) the valvular, 
 a modification of this ; and (3) the duck-bill or Sims's speculum, the latest 
 and best type in many respects, but somewhat unfortunately named, for 
 a duck's bill is certainly bi-valvvilar. 
 
 1. The tubular form is, as its name implies, essentially a tube, which 
 can be pushed along the vagina, and which exhibits the parts at its inner 
 extremity. It has been made of a great variety of materials, and with 
 many slight modifications in shape. Of these varieties, in my opinion, 
 all must yield to the Fergusson's speculum (fig. 7), a simple glass tube 
 coated with reflecting mercury and covered with hard black rubber. Its 
 sole drawback — its fragility — is more than compensated for in every other 
 way. The white porcelain specula common in Germany, and nearly all 
 those made of metal, arc inferior in illuminating power, and fail to repre- 
 
THE TUBULAi; SPECULUM. 13 
 
 sent with equal fidelit}' the true colour of the parts, while tlie foruier 
 are almost equally liable to c-hip, and the latter are injured by almost 
 every substance used in treatment. The so-called unbreakable glass, 
 tried for a time, was a complete failure. The size and shape of the 
 instruments are of great importance, and at least three should ahvaj's be 
 at hand. These should have a circumference of 3, 4, and 5 inches re- 
 spectively. They should measure fully six inches at their longest side, 
 and even a little addition to the length is no disadvantage, if the prac- 
 
 FlG. 7. — Fergusson's Tubular Specula. Nest of tlu'ee. 
 
 titioner does not i-equire to use them for the introduction of greatly curved 
 instruments, as he need not do. The oiiter extremity is trumpet-shaped, 
 and the other should be well bevelled off. This facilitates introduction, 
 and gives a larger field of vision with the same diameter of instriiment. 
 A fourth speculum, of the largest diameter, but not more than five inches 
 long, will occasionally be found iiseful in applying remedies. The 
 maker's name, or a little patch of white paint on the outer end, should 
 always indicate the longer side of the instrument, as this is difiicult to 
 ascertain after introduction, if once lost sight of. 
 
 There are two methods of introducing the instrument, [n the one 
 the patient is placed in the ordinary left lateral position, not for- 
 getting the necessity of approximating her breech to the operator, 
 and of removing as far as possible from him her liead and shoulders. 
 The position of the cervix uteri must first be carefully noted b}- 
 digital examination, and indeed the whole condition of matters must 
 always be previously ascertained in this manner, as far as p()ssil)k\ 
 The perineum is now gently retracted and the labia are se})arated 
 by the left forefinger or fingers, and the point of tlic well-lubricated 
 speculum is placed just within the ostium vagina;. The instrument 
 is first held so that the point, or extremity of its longer side, lies 
 against one of the labia, and it is then gently pxished along the peri- 
 neum, till the bevelled part is wholly introduced. The point is tlien 
 turned backwards, and the onward progress is continued, with the point 
 always directed well towards the hollow of the sacrum, till the summit of 
 the vagina appears to be readied. A glance through tlie instrument 
 will now generally show the cervix utej-i, which by a little management 
 
14 
 
 INTRODUCTION OF THE SPECULUM. 
 
 is made to project within. But if the cervix is not thus visible, one of 
 two things has happened, either the instrument has been pushed too far 
 1^ into the cul-de-sac behind the cervix, or 
 
 tlae point has not been kept sufficiently 
 backwards, and has got in front of the 
 cervix. In either case the remedy is 
 obvious ; the instrument is withdrawn 
 a little, and if the cervix is not then 
 seen in front of it, the point is again 
 directed as far backwards as possible, 
 and so pushed behind and beyond the 
 cervix ; a little rotatory movement as- 
 sists in this, but the direction of the 
 point must not be lost sight of If an 
 instrument of sufficient calibre has been 
 used, the difficulty requires but a little 
 easily acquired tact to overcome it, and 
 with gentleness and skill at the com- 
 mencement the largest size may often 
 be used when even the smallest w^ould 
 otherwise give pain. If the cervix be 
 distorted in any direction this will have 
 been ascertained previously, and it may 
 be necessary to hook it down into the 
 instrument with a probe or booklet. 
 Along with the speculum there must 
 always be at hand some absorbent cot- 
 ton-wool, or tenax, this latter being an 
 exceedingly useful preparation of oakum 
 with fine tar. This is required for the 
 purpose of removing secretions of pus, 
 mucus, or blood, the os uteri being 
 frequently filled with thick tenaceous 
 mucus which adheres very persistently. 
 A speculum forceps (fig. 8), and one or 
 more Playfair's probes (fig. 9), form 
 
 Fig. 8.— Speculum Fig. 9. — Playfair's therefore an essential part of the arma- 
 
 Forceps. Uterine Applica- „,entarium. The former is used to in- 
 
 tor. 
 
 troduce the wool in pledgets, which are 
 
 renewed as often as necessary ; the latter consists of a long wooden 
 
 handle, terminating in a roughened wire, which can be bent at will. 
 
 The wool is easily tAvisted around the wire so as to adhere firmly, and 
 
 thus armed, the instrument constitutes an admirable means of clearing 
 
VALVULAE SPECULA. 
 
 15 
 
 out the cervix and of applj'ing remedies within it, or to the uterine cavity 
 The speculum forcejjs has many modifications. It is well for the student 
 to learn how to use the tubular speculum, while looking carefully what 
 he is doing at every step, but after a time, no exj)osurc of the person 
 is necessary, the coverlet not being raised till the instrument is in situ, 
 and then draped round its extremity. The vaginal wall is best examined 
 during the slow and gradual withdrawal rather than during the intro- 
 duction of the instrument. 
 
 The other method of introducing the specular tube is with the patient 
 in the dorsal position. As it would be impossible to see anything other- 
 wise, she must also be brought to the end of the couch or side of the 
 bed, with her knees reared in air, and supported by an assistant in 
 lithotomy fashion, unless she is very muscular and energetic. It may 
 simply be said of this position, that it is opposed, except under strong 
 necessity, to the more than " insular " j)rejudices of our English women, 
 and of the great majority of their advisers. 
 
 2. The Valvular Specula are those wdiich, by a more or less simple 
 mechanism, are capable of being expanded at their inner extremity after 
 introduction, and in many instances of being comj)ressed before intro- 
 duction. For these it is pleaded that they are less painful, that they 
 afford a wider field 
 of view, and that 
 they are more self- 
 retaining than the 
 simple tube, while 
 they allow of a 
 freer use of the 
 
 sound and other 
 
 , ., Fig. 10. — Barnes's Bi-valvular Speciilum. 
 
 nistruments while 
 
 the uterus is in view or within reach. I doubt the greater painless- 
 ness very much, and I prefer in most instances the more brilliant view- 
 obtainable by a 
 Fergusson's spec- 
 uhxm to the pos- 
 sibly wider view- 
 obtained by a val- 
 vular one. The 
 self-retention is 
 exceedingly un- 
 stable, and the 
 sound can be better 
 used without the aid of cither, in ways about to be mentioned. A 
 valvular instrument is therefore not a necessity, though it is occasionally 
 
 Fio. 11.— disco's Bi-valviilav Speculum 
 
16 
 
 VALVULAR SPECULA. 
 
 Fig. 12.— Meaclows's Sijeciihuii. 
 
 useful, when, owing to the want of assistance, and to the resilient force of 
 the vagina, the simple tube is liable to be forced out, and the duck-bill 
 
 is not available. 
 So many instru- 
 ments of this kind 
 have been intro- 
 duced at various 
 times, and by author- 
 ities Avhom I so much 
 esteem, that it is 
 almost as difficult 
 to select one for 
 approval as it is 
 impossible to men- 
 tion all. Barnes's 
 (fig. 10) most resembles the simple tube in everything but the quality of 
 expanding. Cusco's (fig. 11) resembles more the duck-bill, with its accom- 
 panying vaginal repressor. ^ ■ 
 Meadows's quadrivalve (fig. 
 12), and Knott's trivalve 
 specula (fig. 13), have each 
 their admirers, but the most 
 useful instrument of the sort 
 with which I am acquainted 
 is one introduced by Keid 
 of Glasgow (figs. 14 and 15). 
 It is capable of some parallel 
 and external, as well as 
 merely internal, expansion, 
 and it is clean, simple, and 
 portable in the highest 
 degree. It is described and 
 figured in the Avi. Jour, of Ohstctrics for 1881, p. 276. I should perhaps 
 also mention Scanzoni's instrument (fig. 16), useful when the main object 
 is to examine the vaginal wall. 
 
 3. The third type of speculum, the Duck-bill (fig. 17), is of com- 
 paratively recent introdiiction. We owe it, and along Avith it. 
 
 Fig. 13. — Knott's Speciilnni. 
 
 greatest possible advances in gynsecology, to Dr Marion Sims. 
 
 the 
 The 
 
 J Galabin strongly insists on the advisability of Laving the blades of Cusco's and 
 other bi-valvular si^ecula of equal length. " The axis of the uterus is thereby brought 
 nearly into coincidence with that of the vagina." There are, liowever, some advan- 
 tages also in making the anterior blade to resemble the vaginal repressor used with a 
 duck-bill, rather than the movable anterior half of a tube. 
 
KEIDS, SCANZONIS, AND SIMS S SPECULA. 
 
 17 
 
 principle of action of the instiaiment is this — if a woman be placed upon 
 hex* knees and chest, or knees and elbows, so that her abdomen is under- 
 
 15. Open. 
 
 Figs. 14 and 15. — Reid's Speculum. 
 
 neath hei', but unsupported, the abdominal viscera, by their own w^eight, 
 fall away from the back and pelvis. If an instrument, or even the 
 
 Fig. 16. — Scanzoni's Speculum. 
 
 finger, be now introduced, so as to open the vulva freely, and repress the 
 perineum, air will enter the vagina, and it becomes an open cavity, its 
 anterior and posterior 
 walls separating widely, 
 and allowing inspection 
 of its contents, and free 
 manipulation of instru- 
 ments. The story of 
 his first discovery of this 
 is graphically told by 
 Sims in his Clinical 
 Notes on Uterine Surg- 
 ery. If, however, the position just mentioned were always rcciuired, 
 the use of the instrument would be very limited ; fortunately this is 
 
 Fig. 17.— Sinis'.s Duck-bill Speculum. 
 
18 
 
 THE DUCK-BILL SPECULU^L 
 
 not SO. If the patient be first placed in the ordinary left lateral posi- 
 tion, and then, if the left aim be carefully dra^vn backwards fi'om 
 beneath her, while the right leg is passed over the left one, so that the 
 right knee touches the couch, while both knees are well flexed, the 
 patient will lie as in fig. 18. Her thorax and abdomen will face towards 
 the couch, while the width of the pelvis prevents the contact of the ab- 
 domen with it, and allows of the traction by gravitation of the abdominal 
 viscera away from the back and pelvic cavity. The right trochanter 
 is further away from the operator than the left, and the posterior com- 
 missure of the vulva lies backwards and slightly upwards. This position 
 is so essential to the right use of the instrument that the student should 
 depend on no written description or diagram, but, as one of liis first and 
 
 Fig. 18.— Position for the use of tlie Duck-bill Speculum. 
 
 most important clinical experiences, should learn the necessary stej)s 
 under the eye of a competent teacher. A wrong position in using the 
 tube means clumsiness, discomfort, and delay ; in using the duck-bill it 
 means absolute failure. The instriunent, as figured above, consists 
 really of two speciila of different sizes, and attached by the intervening 
 shank ; either may be used, or others of greater or less size, and each 
 might be attached to a separate handle, but there exists a pretty 
 general consensus in favour of retaining the original pattern. One blade 
 is passed within the perineum, with precisely the same precautions 
 as the tube, the convexity backwards. The convex surface only is 
 lubricated, the concave being kept as bright as possible. The point 
 
ITS MODE OF USE. 19 
 
 must pass well into the posterior fornix vaginee. The perineum is thou 
 slowly but firmly retracted, while the point of the speculum, behind tlie 
 cervix, pushes it somewhat forwards into view, though the point is still 
 kept somewhat behind the portion in contact with the perineum. The 
 necessary amount of this manoeuvre differs in individual cases, and can be 
 learned only by experience. Under favourable circumstances the vagina 
 now opens up well to view, exposing its interior. But, generally, another 
 instrument is required to press forward the anterior vaginal wall, and 
 give a better view of the higher interior. The handle of a sound, a 
 bhmt curette, a copper spatula, or many other things would serve. 
 There are already a score of vaginal repressors with a\ithor's names 
 attached to them, but ^-^^ 
 
 most efficient. Hav- y,^^ 19.-Vagmal Repressor (Sims), 
 
 ing now obtained a 
 
 fairly clear view of the cervix, the aid of an assistant generally becomes 
 necessary. To him or to her is entrusted the speculum, placed 
 exactly as we wish. He stands directly behind the patient, and 
 must hold the instriiment steady and firm without jerking. To hold 
 the instrument by the second blade rather thaii by the shank is 
 preferable, but requires more training. The vaginal rejjressor may 
 still be held by the physician, if one hand is sufficient for what 
 I'emains to be done, if not, the assistant must lean over the patient's 
 pelvis and hold the repressor also, leaving both the practitioner's hands 
 at liberty. One other movement of the speculum is very service- 
 
 FiG. 20. — Uterine Tenacula. 
 
 able, and, indeed, in many cases is quite necessary ; instead of drawing 
 the perineum directly backwards, the blade is slightly rotated so as to 
 draw it also a little upwards, and to aid in repressing with the shank 
 the uppermost buttock. The cervix uteri can now be freely inspected, 
 but to obtain a perfect view it must be fixed and more or less drawn 
 downwards. For this purpose, cither a hook (fig. 20) or a vulselluni 
 (fig. 21) must be used. Those who practice uterine surgery to any con- 
 siderable extent will be furnished with a vai-iety of these, but it is suffi- 
 cient to say here, that a hook bent almost at right angles is the most 
 efficient for an ordinary inspection, that more curved hooks are more 
 
20 
 
 THE DUCK-BILL SPECULUM. 
 
 effective for drawing asunder the lips of the cervix when swollen, everted, 
 or torn, and that a viilsellnm ensures a more pemianent hold, when 
 
 Fig. 21.— Fine Uterine Vulsellum ; also portion of one opening outwards, to display 
 the interior of the Cervix Uteri. 
 
 considerable traction is required, and tedious operations are neces- 
 sary. 
 
 Modifications of the duck-bill are becoming almost as numerous 
 
 as valvular specula, but 
 few of them are improve- 
 ments, and still fewer 
 seem to commend them- 
 selves to the profession 
 for diagnostic pui^poses. 
 The repressor has been 
 attached to the specu- 
 lum by a hinge (fig. 22), 
 forming really a sort of 
 bivalve, and most com- 
 plicated aiTangements 
 have been attempted for 
 fixing the instmment in 
 situ, and so avoiding the 
 necessity of an assistant 
 in ordinary practice. Of 
 these, Emmet's perineal 
 retractor, as he terms it 
 (fig. 23), is the only one 
 which has made any way 
 in British practice. I 
 have occasionally found 
 it useful, and, when the vulva is not too rigid, the Avide phlange aids 
 materially in keeping back the buttock. 
 
 Neugebauer's speculum (fig. 24) is figured l)y nearly all writers. It 
 
 Fig. 22. — Duck-bill Speculum and Vaginal 
 Repressor combined. 
 
RELATIVE ADVANTAGES OF VAUIOUS SPECULA. 
 
 21 
 
 Fig. 23.- 
 
 -Emmet's Self-retaining 
 Speculum. 
 
 may be used as a duck-bill or as a sijecies of bivalve, but I fail to see 
 any superiority in it to those in ordinary use. 
 
 One feels some trepidation in venturing to advise the student or 
 general practitioner as to the relative value 
 of these types of speculum for various 
 pui-poses. It is a little puzzling to be told 
 that Fergusson's tubular speculum "has 
 probably done more to retard the advance 
 of gynaecology than any other cause " 
 (Goodell, Lessons in Gyncecology , Phila- 
 delphia, 1880), while the same author 
 elsewhere states that "it possesses the 
 great advantage of throwing more light 
 on the cervix than does any other spec- 
 ulum, and for that reason is excellent for 
 the examination and treatment of patients at their own homes." The 
 generation which, under the guidance of Simpson, Barnes, Hewitt, 
 Wells, or M'Clintock, has seen advances in the surgery of the female 
 organs, almost as striking as 
 the still more recent achieve- 
 ments of Sims, Simon, Emmet, 
 or their followers, hardly wel- 
 comes the description of it- 
 self given by Emmet as " the 
 older members of the profes- 
 sion who have become dexter- 
 ous in the use of some special 
 instrument," and who " cannot 
 be expected to change it for 
 a new one, or to appreciate 
 the necessity for doing so " 
 
 {Princ. and Pra.c. of GymecoL, 2nd ed., 1880). To adopt what is new 
 and good does not compel us to discard what is older and also good. 
 I hope to do full justice to the use of the duck-bill speculum. Many 
 of o\u' most valuable recent improvements in gjoiajcological surgery 
 were impossible without it. Many common affections of the cervix 
 can be best seen b}' its vise, and the specialist, when he can be aided 
 by a skilled male or female assistant, is irresistibly impelled to sul)- 
 stitute it more and more for every other form cif iustriiuient, even in 
 ordinary examinations ; l)ut the practitioner who is compelled to work 
 unaided, will find his wants fulfilled in a large luunbcr of cases by the 
 tubular instrument, while he is prc])ared to use tlic more modern one, 
 with such assistance as he can i)r()curc, wlienever he is satisfied that ho 
 
 Fig. 24. — Neugebauer's Speculum. 
 
22 THE UTEEINE SOUND. 
 
 cannot otherwise obtain such a view of the parts as is necessary for 
 diagnosis and treatment. He is not likely to be called on, like Dr 
 Emmet, to operate on over 400 cases of vesico-vaginal fistula, and may 
 console himself for his alleged benighted obstinacy, by the fact that 
 English midwifery practice would hardly afford so many opportunities 
 to the whole of British practitioners put together. 
 
 The Sims's speculum, with the aid of skilled assistance, and of the 
 repressor and booklets or vulsella, which are its necessary accompani- 
 ments, is undoubtedly the best instrument for obtaining a perfect view 
 of the whole cavity of the vagina, its posterior wall excepted. For most 
 plastic operations its use is imperative. But, to be efficiently used, it 
 does require such assistance as is not always to be had, and it is, in spite 
 of all contradiction, more irksome and disagreeable to the patient than 
 the tube. The greatest disadvantage of the tube, from a diagnostic 
 point of view, is that it compresses the lips of the cervix, and so may 
 conceal great mischief, but if a full-sized instrument can be used, as it 
 generally can in chronic cases, and if the danger be thoroughly kept in 
 mind, it is not impossible to separate the cervical labia sufficiently to 
 avoid error, when diagnosis is alone concerned. A Cusco's or a Reid's 
 bivalve is not open to this objection to the same extent. The important 
 point is for the student so to study the mode of using the duck-bill 
 speculum, when he has opportxmities, as never to avoid its use, merely 
 from a consciousness that he has not the reqiiisite skill. 
 
 The Uterine Sound. 
 
 It has been said of the speculum that, from a diagnostic point of view, 
 it can do little more than verify the conclusions arrived at by the highly 
 educated touch. The same may be said of the uterine sound, with an 
 equal amount of truth and error, and few of our modem instruments of 
 precision might not be dismissed in the same summary way. To Simpson 
 vmdoubtedly belongs the credit of pressing the uterine sound upon profes- 
 
 FiG. 25. — Sir J. Y. Simpson's Uterine Sound. 
 
 sional notice, although Hugiiier in France, and Kiwisch at Prague had, 
 about the same time, suggested a similar means of diagnosis. There are 
 many varieties of the instrument now in use, from the stift" German 
 silver one with deep notches and rough knobs (fig. 25), to the fine silver 
 bullet probe. The most useful material is undoubtedly silver, though 
 electro-plated copper answers almost equally well, and, other things being 
 
MODK OK USING THE .SOLND. 2:> 
 
 equal, the depth of the student's or praetitiouei's pocket should be con- 
 sidered. The instrument should be capable of being bent into any 
 desired shape with the aid of a little force, and should be easily made 
 to assume its original shape, without persistent angularity. 
 
 The sound should be neither too thick nor too thin— say No. 6 of 
 English catheter scale. The point shoidd be an olive-shaped bulb, so 
 as to indicate the passage of any obstiiiction ; but this should depend, 
 not on a thickening of the point, but on a thinning of the instrument 
 just below^ it. There should be no deep notches, and certainly no pro- 
 jections, but a slight clearly-cut nick on the convexity, 2| inches from 
 the point, should indicate the normal length of the uterus, and three or 
 four others may be added at intervals of an inch. The nail of the 
 directing finger can easily take cognisance of these, while they do not 
 materially influence the breaking or bending points. For cases of great 
 narrowing of the cervix uteri, a common silver bullet probe is used, the 
 cervix being brought within reach by booklets or tcnacula, with the 
 aid of the duck-bill specvdum. 
 
 Fig. 26 shows a sound of the most useful pattern, the handle, in 
 
 Fig. 26. — Form of Uterine Sound recommended by tlie author. 
 
 accordance with the recognised custom, being rough on the concave and 
 smooth on the convex side of the instnunent. 
 
 For the ordinary use of the sound, the speculum, in any form, is not 
 only unnecessary, but is a distinct hindrance, and this disposes of one of 
 the objections to the tubular instrument. By a digital or bi-manual 
 examination, the position and the mobility of the iiterus should be care- 
 fully made out, and the instrument should be curved a little more if 
 ther€ is a belief in, or the certainty of, the existence of uterine flexion. 
 It must be remembered, however, that such extra ciu-ving of the instru- 
 ment adds to the primary difficulty of introduction into the cervix. 
 With the patient in the same position as for digital examination, or for 
 the use of the tubular speculum, the left forefinger finds and steadies the 
 cervix uteri, or two fingers are used if there is plenty of room. The 
 right thumb and forefinger hold the sound lightly by the liandle, 
 and pass it up to the os, guided by the palmar surface of the left fore- 
 finger. The direction of the extremity of the cervix, backwards as usual, 
 or forwards in certain cases of version or flexion, indicates the direction in 
 which the point of the sound should at first be passed, and the handle will 
 always assure us how the point lies afterwards, if the gxiiding finger fail to 
 do so. Once introduced for even half an incli into the cervix, the sound 
 
24 MODE OF USING THE SOUXD. 
 
 assists in steadying it. The instrument is now gently urged onwards in 
 the direction of the cervix until it meets with some obstacle. In ordi- 
 nary cases this will be at the os internum, and it requires only a gentle 
 retraction of the handle towards the perineum, and a little tiring of 
 the obsti-uction, to overcome the difficulty. The point must now 
 be gently turned backwards, however it may have been introduced at 
 first, if it is believed that the uterus is so turned ; and in cases of sup- 
 posed flexion, either backwards or otherwise, the finger of the left hand 
 must be used to tilt up the body of the uterus, thus diminishing the 
 necessity for unduly bending the sound. In no case must any more 
 force be used than in passing the male metallic catheter, and it is far better 
 to fail, and try again and again, than to use any greater force. The 
 fewer tours de mattre the operator uses the less danger will there be 
 of producing mischief In some instances the digital examination 
 may have suggested a uterine displacement w^hich does not really 
 exist, the position of the supposed uterine body being occupied by 
 a tumour or otherwise ; and, as one object of the sound is to correct 
 error of this kind, a gentle attempt at passage must next be made in 
 other directions than that which is supposed to be the right one. No 
 •WTitten directions can confer the requisite tacttis eruditus, and the student 
 or tyro is advised not to abstain from the use of the sound in suitable 
 cases, but to be content with safe and cautious attempts, and, in case of 
 failure, to remember that bi-manual examination can, in many cases, supply 
 nearly all the requisite diagnostic infonuation. No laboured argument 
 is required to dispose of this as an objection to the use of the sound in 
 general. When the sound has passed the os internum, or the bend of a 
 flexed uterus, or any small obstacle, it glides along to the fundus, 
 unless the cavity is obstructed or twisted by morbid conditions. If 
 these are believed to exist, owing to the presence of heemoiThage or 
 increased uterine size, a good deal of " coaxing " in different directions is 
 allowable, but no force. In such cases a thin, flexible, male bougie may 
 be tried ; but for this, as for the use of the probe, in great contraction of 
 the cervix, it is better to exj)ose the parts by the duck-bill specu- 
 lum, and to use the instmment as one would probe any sinus in other 
 situations. 
 
 The use of the sound is not wdthout danger, even in skilful and cau- 
 tious hands. The most frequent source of danger lies in the induction 
 of abortion, and abortions thus induced are infinitely more likely than 
 those which are spontaneous to be followed by septicaemia or other 
 foiTUS of metria. I fear that I am not alone among those practising 
 gynaecology as the possessor of some sad confessions hereanent. This 
 danger can only be obviated by observing the golden laile — Never pass 
 the sound till you can eliminate pregnancy as a possible condition. 
 
FACTS ASCEETAIXABLE BY THE SOUND. 25 
 
 The very strictest inquiries are necessary, and in every case where there 
 can be a doubt, in the married or unmarried, pregnancy should have the 
 benefit of it. There is no doubtful case in which a little time will not 
 clear up the difficulty, and either pei-mit the use of the sound or do 
 away with the necessity for it. 
 
 Perforation of the uterus is another possible accident, and one which 
 has happened in able hands, when the uterus was softened by disease. 
 Most gynaecologists have heard of or seen cases where the sound has 
 passed a great deal further than it should have done, and the charit- 
 able explanation of a dilated Fallopian tube receiving the instru- 
 ment will rarely hold good. Fortunately, if the sound is clean and 
 a-septic, the result is seldom formidable, though none the less to be 
 deprecated. 
 
 Inflammation of the uterus or of its surroundings is occasionally pro- 
 duced by the sound, even when the manipulation is perfect. Whether 
 it is that sometimes the uterus is so sensitive that no precaution will 
 avail, or whether the sound, like the catheter, conveys septic flixids or 
 living septic germs, it must be borne in mind that this is a real danger, 
 imposing the necessity of absolute antiseptic cleanliness, and of being- 
 sure that the information to be acquired by the use of the sound is worth 
 the risk, however infrequently that may be encountered. 
 
 What, then, are the diagnostic facts ascertainable by the sound? 
 These may be conveniently given under seven heads. 
 
 1st. The patency or otherwise of the cervical canal, especially at its 
 extremities. The patency is diminished by 
 
 (a) Congenital contraction or complete atresia, or the permanently 
 infantile state of the organ, or the long conical cervix. 
 
 (b) Contraction from inflammation or other accidents. 
 (r) Small polypi or fibroid growths in the cervix. 
 
 (d) Flexion of the uterus at or close to the cervix. 
 
 (e) Spasm of the internal os, which is, however, a condition denied by 
 some authorities. 
 
 The cervix is unduly patent in many cases of chronic inflammation or 
 sub-involution, when it has been torn during labour, and, to some extent, 
 during a menstrual period. It may be widely dilated by intra-uterine 
 tumours, or less so by lipemorrhages. 
 
 2nd. The size, or at any rate the length, of the whole uterine cavity. 
 The normal length is 2^ inches, and the first nick upon the sound should 
 therefore lie close to the os externum when the point is at the fiuidus. 
 The average post-parous uterus is a trifle longer than the average nulli- 
 parous one. The chief causes of increased length arc 
 
 (a) Pregnancy, in which condition, the soiuul, of course, shovdd nut 
 be used. 
 
26 FACTS ASCERTAINABLE BY THE SOUND. 
 
 [h) Fibroid uterine tumours, which may twist as well as elongate the 
 canal. 
 
 (c) Sub-involution after delivery or abortion. 
 
 ((/) Chi'onic inflammation. 
 
 {e) Intra-uterine polypi, malignant or other growths 
 
 (/) Retained products of conception. 
 
 The lenglh of the cavity is sub-normal in 
 
 (a) Infantile development. 
 
 {h) Senile atrophy. 
 
 {c) Super-involution, not common to a high degree. 
 
 (c/) Inversion of the uteiiis. 
 
 3rd. The direction in which the uterus is lying — forwards, backwards, 
 or to one side. {See Uterine Displacement, Chap. XL) 
 
 Fig. 27. — Eetro verted Uterus tied dov.Ti by adhesions 
 (after a Pliotograpli by Winckel). 
 
 4th. The mobility of the uterus. This is diminished by 
 (a) Exudations of coagulated lymph or blood in its neighbourhood, or 
 old adhesions resulting therefrom (fig. 27). 
 
 {h) Cancerous deposits in or around the uterine body or cervix. 
 
 (c) Large tumours of the ntems or neighbouring parts. 
 
 (d) The sacral promontory or the iitero-sacral ligaments, in some cases 
 of backwards displacement. 
 
 The uterine mobility is increased by many of the causes which lead to 
 its displacement {q.v.). 
 
 5th. The relation of the utenis to neighbouring parts or abnormal 
 gi-Qwths, and its adhesion to them or the contrary. 
 
FLEXIBLE SOUNDS. 
 
 27 
 
 Gth. Tlie form and localisation of growths or substances witliin tlie 
 uterus, more or less approximately. 
 
 7th. Tenderness of the internal uterine wall when touched by the sound. 
 
 Sometimes, though rarely, the only clear evidence of endometritis is 
 obtained in this way, though, when (jncc ascertained, it is prohibitive oi' 
 the further use of the instrument. 
 
 Of the above conditions, it will be noted that the calibi-e of the cervical 
 canal can only be ascert;ained by the sound ; the length of the cavity may 
 be surmised from bi-manual measurement, but cannot be certainly arrived 
 at, owing to the varying thickness of the fundal wall. The form of intra- 
 uterine growths, and the tenderness of the intra-uterine lining, are be- 
 yond the range of bi-manual examination. The other conditions can 
 be ascertained bi-manually, in some cases more, in others less easily 
 than by the sound. The uses of the instrument as a means of treatment 
 will be referred to when speaking of the methods of replacing the dis- 
 placed litems. 
 
 I cannot conclude this notice of the sound without mentioning a very 
 ingenious American instrument, patented by Messrs Codman & Shurtleif 
 of Boston as Jennison's (fig. 28). By a skilful use of fine parallel steel 
 
 Fig. 28. — Jeunison's Flexible Uterine Sound. 
 
 rods, united at their extremities, and enclosed in an india-rul)bcr sheath, 
 every bend of the instrument which occurs at the intra-uterine end is 
 reproduced in an opposite direction at the other, and thus made visible t( • 
 the eye ; an intentional bending of the outer end produces, on tlie othei- 
 hand, an opposite bending of the intra-uterine extremity and uterus. In 
 its present form it is too mobile, but it contains the rudiments of a usel'ul 
 invention for both diagnostic and therapeutic purposes. Other flexible 
 sounds have been proposed to meet the difticultics when the uterine 
 cavity is twisted as well as elongated ; but in such cases, where it is neces- 
 sary to be precise, the elastic gum bougie, or silver probe, with tlio aid of 
 the duck-l)ill speculum, meets all wants. 
 
:28 
 
 UTERINE TEXTS. 
 
 Tents. 
 
 Another means of diagnosis, invaluable in some instances, though less 
 seldom required than the speculum or sound, is the tent. This is used 
 for the piu-pose of dilating the cer\ix uteri, and so permitting the passage 
 of the finger into the uterus to explore its cavity, or for the introduction 
 of instninients or medicaments which are otherwise unavailable. For 
 this means we are, as in so many other instances, indebted to Simpson, 
 
 although he admits, or rather 
 \/ exults, in having derived the 
 
 necessary inspiration from a 
 very remarkable source — Mr 
 John Hall of Stratford-on- 
 Avon, the son-in-law of Shake- 
 speare, who WTOte a medical 
 treatise in Latin, wherein he 
 perfectly forecasts the modem 
 sponge-tent. At his death, 
 his wife, Susannah Shake- 
 speare, sold the Latin manu- 
 script to Mr Cook of the neigh- 
 bouring town of Warwick, who 
 published an English trans- 
 lation in 1637. From this 
 Simpson got the idea — not the 
 only instance in which he 
 tiuiied to jDractical account his 
 favoiu-ite hobb}' of antiquarian 
 research. 
 
 A tent is a small pencil, 
 capable of being introduced 
 into the cervix uteri. It is 
 composed of materials which, 
 absorbing moistui'e from the 
 fluids about it, expands, and 
 so dilates the canal of the 
 cervix. Compressed sponge was the substance originally used by 
 Hall and Simpson, and this has, as yet, been only partially super- 
 seded by the Lamimiria digitata, or sea-tangle, of Dr Sloan of 
 of Ayi', or by the tupelo wood of Dr SussdorflF of New York. The sponge 
 tent is now made by machinery, and well satiu*ated with carbolic acid 
 or other antiseptic, but it should be less tapering in form than is 
 commonly the case. Fig. 29 shows the usual sponge, laminaria, and 
 
 Fig. 29. — Uterine Teuts. A, Spouge. 
 B, Laminaria. C, Tupelo. 
 
SPONGE, LAMINAItIA, AND TUrELO. 
 
 29 
 
 tupelo tents. Each kind varies somewhat in the amount of its expan- 
 sile power, but, according to my experience, there is also a great variety 
 in this respect among different specimens 
 made of the same substance. Fig. 30 
 shows the full expansion of tupelo tents of 
 good construction. All tents should be 
 perforated longitudinally, except at their 
 apex, and in the case of the vegetable tents 
 this adds to their power and rapidity of 
 expansion, and it permits of the easy in- 
 sertion of a probe or wire to guide them into 
 place. They must also be furnished with 
 a strong thread well attached to them, for 
 the purpose of removal. 
 
 Many instruments have been devised for 
 the introduction of tents. Forceps of every 
 kind are iisually a mistake; the more stead}- 
 their hold, the more liable are they to adhere 
 to the tent, and wholly or partially to with- 
 draw it again. Barnes's instnmient (fig. 31) 
 I find the most useful ; but it is better to 
 have the tubular part of metal than of softer 
 material. The tent is impaled on the wire 
 which projects beyond the tubular sheath, 
 and the whole is then used as if it were 
 a uterine sound. The tent is passed, if pos- 
 sible, nearly i;p to its full lenglh, just pro- 
 jecting beyond the os externum. Some- 
 times, however, one has to be content Avith 
 a less complete inseii:ion, to be followed up 
 afterwards by a second instnmient. While 
 the wire is withdrawn the sheath is pressed 
 
 against the tent, and so prevents its being retracted in the slightest degree. 
 All forms of tent may be introduced in the same way, but when very small 
 ones of laminaria or tupelo are required, they may necessitate the use of 
 the duck-bill specidimi to allow of the tent being carefully probed in, as it 
 were. In all cases it is well to use the largest size that can be insinuated 
 without force, in order to avoid if possible the necessity for a second 
 dilatation. The free use of antiseptics is necessary in every case. AH 
 profuse secretions should be washed away, to begin with, by injections 
 of carbolised warm water. In place of one large tent, several small 
 ones of tupelo or laminaria may be inserted with advantage side by 
 side ; the action ol)taincd seems to be more equable, but, of course, the 
 
 Fig. 30. — Expansion of Tupelo 
 Tent (after Munde). Tlie 
 larger figure shows the 
 amount of expansion ol 
 wliicli the smaller is cap- 
 able. The efiect of the con- 
 striction V)y the internal os 
 is also sho\m. 
 
so 
 
 DANGERS OF L'TEEIXE TENTS. 
 
 introduction is a little more tedions and troublesome. Several hours 
 are usually required to obtain the fuU effect, and it is most convenient, 
 and generally quite sufficient, to aUow twelve hoxu-s— from night tiU 
 
 morning, or morning till night. During 
 this time the patient must be in bed, and 
 as quiet as possible; this is a sine qua 
 lion. After introduction, a vaginal plug 
 of cotton or tenax, thoroughly soaked in 
 carbolic solution, will tend to prevent slip- 
 ping, and afford the necessary moisture 
 for expansion, if that is deficient. Imme- 
 diately on removal of the tent a free 
 vaginal antiseptic washing is imperative, 
 before any attempt at frirther examination. 
 As there is sometimes considerable pain dru-- 
 iug the process of dilatation, it is well to 
 insert a morphia suppository into the rectum, 
 or to give a subcutaneous injection of 
 moi-phia soon after the tent is introduced. 
 Tf the first tent does not expand sufficiently 
 for the object in view, it must be followed up 
 by a second or a third. Dr Goodell {op. cit., 
 p. 154) calls special attention, however, to 
 what I have long felt to be the fact — that 
 it is not usually, with due precaution, a 
 first tent, but a second, or still more a 
 third, which produces mischief. The reason 
 is obvious enough ; there is much greater 
 danger of sejrtic poisoning in dilating a cervix 
 already somewhat cracked and fissui'ed. 
 
 The dangers of the tent are real enough 
 to cause every conscientious physician to 
 weigh well the necessity before having re- 
 coui-se to them. Metritis, or inflammation 
 of the siuTounding tissues, occvu'S every 
 now and again, and is, I suppose, almost 
 invariably of septic character. But severe 
 shock, and even tetamis, have been met 
 with as a result of the mere dilatation. The 
 ■old-fashioned hand-made sponge-tents became so hombly foetid in a 
 very short time that it was wonderful how seldom they Avere followed 
 by serious results; the machine-made ones, saturated with antiseptics, 
 ai-c less objectionable. I have never met with any serious inflam- 
 
 FiG. 31.— Barnes's Teut 
 Introducer. 
 
DIFFERENT FORMS OF TENTS, THEIH RELATIVE VALUE. .'ll 
 
 matory trouble from the vise of teuts in private, though 1 have seen 
 several ver}- severe cases of ix4vic cellulitis in hospital practice, and 
 the danger niaj^, I believe, be minimised to a very great extent if 
 one can depend on the following conditions being strictly adhered 
 to : — The antiseptic washings already mentioned must he matter 
 of invariable routine — the tent itself must be thoroughly smeared 
 with carbolic glycerine or vaseline — or, as Albert Smith recommends 
 in the case of sj)onge-tents, they may be first well soaped and then 
 sprinkled with salycilic acid. If possible, one dilatation must be made 
 to suffice, and, in the event of more being necessary, it is well to 
 avoid sponge for the later ones. One further precaution consists in 
 being esjjecially chary of using tents at all when the patient has pre- 
 viously suffered from uterine or pelvic inflammations. 
 
 Every consulting phj'sician must often have met with cases where he 
 has been called, perhaps twenty or thirty miles into the country, to pro- 
 nounce upon the nature of uterine disease, which cannot be discovered 
 with certainty until the cervix is dilated and the finger introduced into 
 the uterus. He cannot wait for the process of dilatation, in this manner at 
 any rate, nor return next day without much extra trouble and expense ; it is 
 very desirable, therefore, that the practitioner in charge of the case shoiild 
 know under what circumstances dilatation is required, and arrange to have 
 it previously accomplished. I have so often seen much disappointment 
 from this source that I think it necessary to call special attention to it. 
 
 Authorities are by no means agreed as to the relative value of the 
 three forms of tent in varying circumstances. My exj^erience of the 
 tupelo tent is not yet of very long duration, but I am inclined to think 
 that it ma}^ in time be substituted for l)oth the other varieties, unless a 
 still superior material is found ; there must be very many suital^le 
 vegetable products yet imtried. The metallic tube, however, with 
 which they are freqviently perforated, is apt to protnide, and might be a 
 source of danger in introduction, but in other respects the}' seem to me 
 to possess the best qualities of both sponge and laminaria. Like the 
 latter they should always be momentarily soaked in hot water before 
 introduction ; this renders them more pliant and easy to introduce, 
 seems to cause them to be less painful, and ensures their speedily 
 commencing to dilate, thereby preventing their slipping. 
 
 The spongc-tcnt, however carefully made, lias tlie Tuidoubtcd disad- 
 vantage of being more liable to j^roduce foctor, and although foetor or 
 sapros, and sepsis, are not intei'changeable terms, the alliance between 
 them is perilously close. In expanding, the sponge becomes closely 
 associated with the surrounding tissues, interpenetrating them to a 
 certain extent, and thus giving rise to minute hoimorrhages wlicn 
 forcibly removed ; the bearing of this on septicemic risks is obvious 
 
32 INDICATIONS OF THE USE OF TENTS. 
 
 enough, but there may be some counterbalancing advantages when the 
 tents are used as a curative means. One other disadvantage of the 
 sponge-tent is its Habihty to tear when being withdrawn ; either a small 
 portion only may remain, or the thread may be detached, leaving nearly 
 the whole. Removal by forceps is easy enough in theory, but not always 
 so easy in practice, even with the aid of further dilatation. I use the 
 sponge tent therefore only when the os uteri is already pretty large, or 
 when I am desirous of aiming at absorption of cervical growths, as well as 
 at dilatation. Great antiseptic precautions are, of course, necessary, and 
 I hope ere long to be able to substitute the tupelo or other vegetable 
 form even in such cases. 
 
 The curative uses of the tent depend on the fact that its pressure 
 within the cervical canal will not infrequently cause the absorption 
 of granulations or small mucous polypi, or even fibroid growths, or 
 chronic thickening of the cervix; so that it is no vmcommon event 
 to pass a tent for the purpose of diagnosing the source of uterine 
 haemorrhage, to find little or nothing, and yet to cure the patient 
 of symptoms which may have lasted a very long time. 
 
 Other mechanical means than tents for dilating the cervix, will be 
 referred to later on, when treating of dysmenorrhoea or other affections 
 which require dilatation for curative purposes. 
 
 The diagnostic objects attained by tent dilatation are more important 
 than numerous. There are, however, several aff'ections, especially those 
 accompanied by uterine heemorrhagic discharges, with more or less en- 
 largement of the body of the uterus, which we may suspect, or even 
 diagnose with some amount of confidence, but about which we cannot 
 be absolutely sure, or which we cannot certainly differentiate from one 
 another, unless the cervix uteri will permit its to pass at least a finger 
 into the cavity of the uterus. Among these are — 
 
 1. Polypus of the uterus or within the cervical canal. 
 
 2. Fibroid growths of the same. 
 
 3. Chronic inflammatory granulations of the endometrium. 
 
 4. Cancer or sarcoma of the uterine body. 
 
 5. Retained products of conception, moles, ttc. 
 
 6. Retained non-conceptional clots or decidua. 
 
 The effect of the pressure of a tent in producing absorption, may also 
 furnish a clue to the differentiation of early cancer of the cervix from 
 chronic inflammatory thickening. My attention was first called to 
 this diagnostic means by Munde {Minor Surgical GyncBcology, p. 68), 
 and I have since been able, on more than one occasion, to satisfy myself 
 of the non-existence of malignant disease, from the fact that very con- 
 siderable absorption took place after the introduction of a tupelo tent, 
 an effect which has I'emained permanently. 
 
INSPECTION OF MORBID DISCHARGES. 3S 
 
 Inspection of Morbid Discharges. 
 
 This must be included among the general means of diagnosis, although 
 but a cursory mention of tlxe various forms of discharge met with is 
 required here. The information gathered from this source is, for the 
 most part, merely of a pi^imd facie kind, suggesting in most cases the 
 necessity for further investigation, although occasionally we may be 
 called, in the case of young patients or those who are unwilling to 
 undergo further investigation, to act upon the imperfect data thus 
 afforded. Whenever curative means are adopted merely on the ground 
 of the discharges observed, the practitioner must never forget that 
 he is acting entirely in the dark, and that he may be ignoring 
 serious or fatal diseases, during the only period at which any steps could 
 be taken for their removal. The existence of discharges may be recog- 
 nised either by the patient's own description, by inspection of the 
 genitals, or by the use of the speculum. In perfect health there is just 
 sufficient mucous discharge to lubricate the passages, preventing dry- 
 ness or discomfort, but hardly, if at all, appearing externally. This 
 discharge, apart from the menstrual period, may be increased, diminished, 
 or altered in various ways. We may have — 
 
 1st. A white, flocculent, or curdy discharge, sometimes seen with the 
 speculum in considerable quantities. This is purely vaginal, and shows 
 increased desquamation, and over-activity of the vaginal glands. 
 
 2nd. Furulent or muco-purulent discharge. This may come from the 
 Tulva, vagina, or uterus, or from abscess opening into any of these. If 
 very profuse extei-nally, it is probably from the vagina, or, especially if 
 quite purulent, from abscess. In the latter case we shall have a history 
 of pelvic or other inflammations ; in the former we yxxix.j have one of 
 gonorrhoea or acute vaginitis, or the symptoms may be chronic and of 
 gradual invasion. Acute vulvitis tells its own tale. Vaginal discharge 
 is acid in reaction, and freely mixed with, or almost composed of, the 
 tesselated epithelium of the part, while utei'ine discharge is alkaline, and 
 contains columnar epithelium ; bvit although this is repeated from 
 text-book to text-book, the physician does not rely on his microscope 
 or his test papers for information which he can acquire by the eye, 
 aided when necessary by the speculum. The marked acidity of the 
 vaginal secretion is, however, of importance, • as its influence on the 
 spermatozoa is sometimes a cause of sterility. 
 
 3rd. Clear glutinous discharge, like unVjoilcd white of egg. This is 
 seldom met with exteraally, except on the rupture of a cyst, but with the 
 speculum it may frequently be seen oozing from the cervix uteri, and is 
 
 c 
 
34 SOLID SUBSTANCES OCCASIONALLY DISCHARGED. 
 
 a sign of one stage of chronic inflammation of the uterine mucous 
 membrane, generally of its cervical part. Each of the foregoing three 
 discharges is generally described as leucorrhcea or " whites," unless pus 
 be present in very large quantities. 
 
 4th. Watery discharges are most frequently met with in cancerous dis- 
 ease, and should always excite suspicion of this, whether foetid or not ; 
 but they are also met with during pregnancy, especially in molar preg- 
 nancy, or in the presence of benign tumours, or of that rare affection 
 known as hydrometra. 
 
 5th. Foetid discharges may be caused by the want of ordinary cleanli- 
 ness, or by neglected pessaries ; but, especially if of a watery and sanguin- 
 eous character, they should always lead to an examination to ascertain the 
 presence or absence of cancer. I have never been qviite able to satisfy 
 myself as to the specific smell of cancerous discharge, and I have known a 
 case where a retained sponge tent satisfied more than one acute physi- 
 cian that cancer was present. Generally the odour of cancer is dis- 
 tinctive enough, but the retained products of conception, polypi, or in 
 fact anything which keeps back intra-uterine discharges, may give rise 
 to foetor which I at least cannot distinguish from it. 
 
 6th. Sanguineous discharge, other than menstrual, will afterwards be 
 treated of as metrorrhagia. Its occurrence from slight causes, or after 
 the menstrual age is past, should never be overlooked. It is an occa- 
 sional symptom of so many diseases that it is hardly possible to 
 attempt their enumeration now. It may occur in the most common 
 forms of chronic uterine inflammation, in slight vascular growths of the 
 vulva, and in other minor affections, and yet it is the most common, and 
 often the earliest indication of the gravest and most fatal disease. The 
 only possible deduction from this is, never to neglect a careful local 
 examination when this symptom is present. 
 
 The solid discharges which are occasionally met with are, for the most 
 part, either blood-clots or the products of conception, great care being 
 required, as every obstetrician knows, to distinguish between the 
 two. Abnormal conception may furnish either the fleshy mole or the 
 vesicles of the hydatiginous mole. In addition to these we may have 
 the unimpregnated decidvia, afterwards to be referred to when speaking 
 of dysmenorrhoea, or much more rarely, complete blood casts of the 
 uterus, which are independent of pregnancy, or polypi which have 
 become separated and are expelled by the unaided contractions of the 
 uterus, or fibroid tumours which have undergone eniicleation and expul- 
 sion, subseqvient to more or less degeneration of their structure, or casts 
 of the vaginal wall, whose microscopic character is suflicient, if such 
 evidence is required, to attest their nature. 
 
 Other means or methods not now referred to may occasionally serve 
 
OTHER DIAGNOSTIC INSTRUMENTS. 30 
 
 diagnostic purposes. The endoscope, for instance, is worthy of mention, 
 but the information derived from its present developments is meagre in 
 tlie extreme. The curette serves the purpose of obtaining substonces 
 scraped from the uterus for microscopic investigation ; but it will be 
 more appropriately described as an instrument for treatment (Chap. Ill), 
 The same remark applies to the aspirator and ej.ploring needle. 
 
36 
 
 DISEASES OF THE EXTERXAL ORGAX^S. 
 
 CHAPTER II. 
 
 Diseases of the External Genital Organs of the Female. Aphthae. Herpes. 
 Diphtheria. Lichen. Acne. Eczema. Parasites. Warts. Boils. CEdema. 
 Pruritus. Syphilis. Cancer. Lupus. ISToma. Vulvitis. Abscess. Cysts. Yari- 
 cocele. Thrombus. Hernia. Hydrocele. Labial tumours. Hypertrophy. 
 Vascular caruncles and degenerations. Fissures. Adhesions. Abnormalities 
 of the Hymen. Coccygodynia. Ruptured perineum, &c. 
 
 The diseases of the external organs of generation are deserving of more 
 
 attention than they sometimes receive 
 from students of gynsecology. I do 
 not so ranch refer to those which, like 
 cancer, compel attention by their 
 dangerous or fatal character, or to 
 those which, like iniptured perineum, 
 have a special interest for the oper- 
 ating surgeon, but to many common 
 ailments which by their chronicity 
 tend to produce much constant and 
 unbearable suffering, and thus embitter 
 the lives of not a few women. This 
 chronicity is not always due to the 
 natiu'e of the affections themselves, 
 but depends also on the fact that 
 many women have a greater reluctance 
 to seek for early advice in such cases, 
 where they know that a visual examin- 
 ation will be required, than they have 
 in the diseases of the internal organs, 
 where there is more of the unkno\vn 
 and therefore of that which is dreaded, 
 and when they hope that a mere 
 digital examination will suffice. This 
 mental condition certainly exists, 
 especially in private practice, and I 
 have known ladies driven almost to 
 the verge of insanity by simple and 
 
 curable eruptions bcl'ure they would apply for advice. Little need be 
 
 Fig. 32. — External Organs of Genera- 
 tion of the Virgin Feriude. 1, labia 
 majora ; 2, fourehette ; 3, labia 
 minora ; 4, clitoris ; 5, urethral open- 
 ing; 6, vestibule; 7, vagina; 8, hymen; 
 9, openings of ducts of glands of 
 Bartolums ; 10, mons veneris. 
 
APHTI02, HERPES, AND DIPHTHERIA. 37 
 
 said as to the methods of examination necessary in these cases. The 
 ordinary position on the side is most unsatisfactory for a minute inspec- 
 tion of the external organs. If the seat of suffering is very definitely 
 localised by the patient, we may examine in this way in the first 
 instance, but in all cases where there is the slightest difficulty or doubt 
 about the natiu-e of the disease, the patient must be examined in the 
 dorsal position and opposite to a good light. The vixlva can thvis 
 be easily exposed to view by the fingers of the left hand, while the 
 right is at liberty to search for painful points or to use remedies. I 
 have known much tedious suffering result from the neglect of this 
 precaution. A common silver probe and a good magnifying glass are 
 frequently of use to minutely localise pain or to inspect small hyper- 
 asthetic points. 
 
 Superficial Affections of the Skin or Mucous 
 Membrane. 
 
 Almost every skin affection may affect the vulva or its surroundings, 
 but it will suffice to mention those of common occurrence, or which have 
 any special characters when here met with. 
 
 Aphthse are not infrequent on the mucous surfaces of the vulva. 
 They have the same histological characters as those of the mouth, and 
 to the eye present the appearance of one or more, generally many, white 
 raised sjjots, with more or less angry redness surrounding them. They 
 cause much itching and smarting, especiall}- the latter. I have never 
 been able to identify or associate them with any particular condition of 
 system or ill health, having met with them in those who were jDerfectly 
 robust, and who had no irritating viterine or vaginal discharges. They 
 readily yield to treatment by a saturated chlorate of potash lotion, or 
 a weak solution of carbolic acid (1 in 40), or one of hyposul]ihite of 
 sodium (oi. ad gi.). 
 
 Herpes, similar in character to herpes preputialis, 1 liave seen 
 occasionally in the neighbourhood of the clitoris, and the same care is 
 required, as in the male, not rashly to mistake this for chancre. If the 
 part is kept well smeared with vaseline to prevent friction, or the contact 
 of irritating discharges, the herpes soon disappears. Herpes Zoster of 
 the groin and flank sometimes extends to the labium externum (Tait). 
 
 Diphtheritic exudation on the vulva and vagina is merely mentioned 
 here as occasionally occurring in coxuiection with the systemic disease of 
 which it is the exanthem. In the post-partum state I have occasionally 
 seen an exudation closely resembling diplitlievia, but not necessarily 
 
38 LICHEN, ACXE, AND ECZEMA. 
 
 accompanied by fever or prostration. Schi'oeder {Ziemssen's Cydoiyadia,. 
 vol. X. p. 494) speaks of this, and of a diphtheritic affection accompanying 
 wounds of the vagina. I have had no opportunity of microscopically 
 studying it ; but I think it is more allied to aphthse, and it certainly 
 yields to the same treatment. 
 
 Lichen often occurs on and around the pubes, and is best healed by 
 dusting with a fine powder of starch and boracic acid, kept free from all 
 admixtiu-e with moisture. If acute, as it frequently is, it will require 
 the same constitutional treatment as when occun-ing elsewhere. 
 
 Acne is very common on the pubes, and extends downwards on the 
 external surface of the labia, even encroaching on the mucous edges. 
 It is often very painful in this position, and simulates or runs into the 
 inflammatory condition of ti-ue frnnincle or boil. I have not found the 
 application of sulphur in powder, or as a glycerole, so useful here as it 
 undoubtedly is in acne of the face or bust. The sufferers are generally 
 out of health and require tonic regimen. I have found eucal}iDtus oil 
 and vaseline (pi. ad si.) of service externally, but probably any antiseptic 
 that was not too irritating would have the same effect in preventing 
 suppuration, and leading to absorption. 
 
 Eczema is by far the most common of the skin affections which attack 
 the external organs ; and whether it affects the mucous surface of the 
 labia or their outer surface^ or spreads to the abdomen, perineum, nates, 
 or thighs, it is usually a source of intolerable discomfort. The itching 
 it produces is sometimes suflicieut to drive the patient from society ; and 
 when by scratching, which is utterly imcontroUable, and by the drying 
 Tip of the discharges, crusts and cracks are formed, and these again are 
 rendered sodden by fresh discharge from the eczema itself, or from the 
 mucous tracts above, the condition of the patient becomes most pitiable. 
 The diagnosis, when eczema has lasted long, may present some diffi- 
 cxilty, and yet is of great importance ; but fortunately it can always be 
 arrived at by a careful inspection of the outer parts of the diseased sur- 
 face. The centre may be converted into a cracked, bleeding, and even 
 suppurating mass, but the circumference will exhibit the characteristic 
 appearances of eczema. It is, of course, not uncommon to have an 
 eczematous rash suiTOunding any affection of the vulva; but the 
 gradual shading of the outer into the inner parts, and the absence of 
 signs of syphilis or cancer, will prevent mistakes in diag-nosis. When 
 eczema occurs on the pubes, abdomen, or thighs, there are occasionally 
 the same difficulties that meet us in other regions in distinguishing it 
 from lichen or impetigo. Fortxmately, they are frequently difficulties of 
 nomenclature rather than of any more important nature. 
 
 The treatment of eczema, when developed to any extent in these 
 regions, is often most diflicult ; and the tendency to recurrence or 
 
TREATMENT OF ECZEMA PARASITES. 3^ 
 
 exacerbation is most exasperating, but patience on the part of doctot 
 and patient is ultimately followed by success. The existence of diabetes 
 as a frequent cause should not be overlooked. Above all things, con- 
 stant attention to cleanliness is required. Simple soap and water can 
 do wonders here, as in so many other affections, but the soap must be 
 of the blandest kind that can be procured. Premising that we insist on 
 at least two or three ablutions daily, and more if there is any free vaginal 
 discharge, there are innumerable local remedies recommended for eczema 
 in works on Dermatology, to which I must refer my readers. Here I 
 will mention only those which have especially commended themselves to 
 myself, or to others engaged in the practice of gynaecology. Whatever 
 applications are used, any adherent crusts must first be removed by 
 bathing, poulticing, and softening with olive oil. 
 
 Lime water applied warm will often aiford the relief which alkalies 
 generally do in eczema elsewhere. Solutions of opium, moi'phia, or 
 belladona may be added to any of the following local applications. 
 Dilute hydrocyanic acid (TTlv.-x. ad 5i.) is also highly comforting to 
 the patient. The glycerole of acetate of lead (gr. x.-xx. ad Si.) will 
 often in a very short time produce a satisfactory change in the appear- 
 ance of the rash, and should have a foremost trial ; any of the glyceroles 
 used should be carefully painted on the surface with a soft brush. 
 Zinc ointment, made with vaseline instead of lard, is another useful and 
 soothing application ; or, still better, Zinci oleat., 5i. ad vaselin. alb. Sii. 
 Oil of stavesacre (1 pt. in 8 of vaseline) has been lughly recommended, 
 but is apt to be too irritating in many cases ; it is of more use in the 
 itching of pruritus. When there is much inflammation surrounding 
 the parts, demulcent lotions, not too thick, of slippery elm or marsh 
 mallow, must prepare the way for more active remedies. 
 
 One could, of coarse, fill a page with the mere names of remedies 
 which have from time to time been lauded, but the following must 
 suffice : — Vaseline simply ; the glyceroles of the following : tar, boracic 
 acid, carbolic acid (weak) ; salicylic acid ; the oleate of lead or of zinc, 
 diluted as above ; chloral (3ss. - 3i. ad oi. glycerimc) and unguentum 
 acid, chrysophanic. 5ss. ad 5i. It need hardly be said that the same 
 attempt, as in other forms of eczema, must be made to reach any con- 
 stitutional causes by tonics, arsenic, anti-rheumatic or anti-arthritic 
 I'emedics, &c. 
 
 Parasites — tlic acarus scabici, and the various forms of lice — are not 
 infrequently met with, especially in old people. One form — the pedi- 
 culus pubis — by no means confined to the aged, makes this part its 
 especial seat, and partially buries itself beneath the cuticle. The result 
 of any of these parasites is to produce itching, and they will be referred 
 to again when speaking of pruritus. The pcdieuliis ]iiil)is is speedily 
 
40 WAETS, BOILS, CEDEMA, AIv^D PEUEITUS. 
 
 destroyed by any mercurial, 3 or 4 grs. of bichloride in the ounce of 
 water being the cleanest. 
 
 Warts. — Simple warts, independently of gonorrhoea, are occasionally 
 found on the vulva, but they are then usually an indication of great 
 want of cleanliness. The remedy lies in the use of scissors and the refoi-m 
 of the personal habits. Gonoi-rhoeal warts will yield to cleanliness and 
 an occasional touch with the concentrated solution of permanganate of 
 potash or tincture of iodine, or they must be clipped off. 
 
 Boils. — True furu.ncles are apt to occur on the external genitals. 
 As elsewhere, they not infrequently depend on the inflammation set 
 up in a hair follicle by the avulsion of its hair ; they are occasionally 
 also developed within a spot of acne, spreading from it into the connec- 
 tive tissue. Although poulticing gives relief, there is the usual danger 
 of its spreading the disease to other hair follicles or scratches. Tincture 
 of iodine applied at once seems sometimes to aiTest them, and failing 
 that, a paste of chalk and oil freely saturated with carbolic acid or 
 eucalyptus seems to prevent undiie suppuration. 
 
 (Edema of the vulva occurs in connection with dropsy of the lower 
 extremities. It is also met with during pregnancy, and, when great, 
 should alwaj^s lead to suspicion of renal disease, and an examination of 
 the urine. During the occun'ence of vulvitis or vaginitis, it is also not 
 infrequently encountered ; and I mention this here especially because 
 some authorities have looked upon oedema of the labia under these cir- 
 cumstances as affording a diagnostic point between gonorrhoeal and simple 
 inflammation. I am satisfied that it occurs more frequently in the 
 former ; but I would strongly advise that too much importance should 
 not be attached to the circumstance, especially when character or any 
 legal decision is at stake. 
 
 Pruritus. — I have included this among the affections of the vulva, — 
 not as a special skin disease, described by Willan and his followers as 
 prurigo, — but considering it to be, like pruritus ani, a mere symptom, 
 depending on a great variety of causes, though in individual cases the 
 search for the cause is sometimes completely baffled. It is met with at 
 all ages, though most frequently, in extreme degrees, in the old. All that 
 has been said with regard to the misery produced by eczema is applicable 
 to pruritus in a still greater degree ; and the two things are not in- 
 frequently met with together, as cause and effect, or as mutual effects 
 of some other affection, but they should not be confoimded. It should 
 be clearly understood that pruritus may exist, and that for years, with- 
 out the appearance of any eruption of the parts affected. I had such 
 a case in a yoimg lady in whom I tried every remedy that I could 
 <levise or hear of, for several years, without effect. It was what would 
 be termed a pure hypersesthetic neurosis. Suddenly she was attacked 
 
CAUSES OF PEURITUS, 41 
 
 with acute lichen of the chest, back, and abdomen. I treated this with 
 the simplest soothing applications and an occasional purge. At the end 
 of three weeks, it and her four or five years' tormentor were gone. In 
 popular language, it " came out." 
 
 Causes. — No one can be long in general practice without encountering 
 this troublesome affection, and the practitioner should therefore be pre- 
 pared to recognise the very various causes on which it may depend. 
 Much patient attention wall be required, and success will depend on 
 occasionally reviewing the list, to make sure that no probable factor 
 has been overlooked. Such a list should include at least the following : — 
 
 (1) Leucorrhoeal discharges from the vagina, uterus, or \'ulva. 
 
 (2) Watery discharges of cancer. 
 
 (3) Incontinence of urine, with or without fistula. 
 
 (4) Diabetes mellitus. 
 
 (5) Lithiasis, oxaluria, or other irritating conditions of the urine. 
 
 (6) Cystitis, or urinarj^ calculus. 
 
 (7) External parasites — pediculi and scabies. 
 
 (8) Ascarides or other parasites of the vagina or rectum. 
 
 (9) Stunted or broken hairs. 
 
 (10) Eczema or other local eruptions. 
 
 (11) Varicose or lymphatic enlargements of the vulva. 
 
 (12) Pregnancy. 
 
 (13) The menstrual period. 
 
 (14) Chronic metritis, polypi, or displacements of the uterus. 
 
 (15) Diathetic states — gout, rheumatism, &c. 
 
 (16) A hypersesthetic state of the nervous system. 
 
 The treatment of most of these possible causes of prurituis either 
 has been or will be separately referred to elsewhere, and can only be 
 cursorily dealt with here. 
 
 Leucorrhoeal discharge from the vulva or vagina must bo kept down 
 by frequent ablutions and injections of medicated fluids. If of an 
 inflammatory nature, these injections must be bland and tepid, other- 
 wise they must be astringent and antiseptic, as recommended for chronic 
 vaginitis. The irritation dependent on uterine discharges can be miti- 
 gated by applying a small pad of cotton-wool, moistened with the 
 glyceroles of tannin and carbolic acid, to the cervix uteri, twice or thrice 
 daily. It is removed by a thread which is tied around it before intro- 
 duction, and left hanging from the vulva, and the syringe is freely used 
 after its removal. The same applies to the discharges of uterine cancer 
 as long as they arc in moderate quantity. 
 
 Dril)bling of urine must be treated on general principles, if not due to 
 4iny rent of the bladder oi- uretlu-a. It is frc(iucnt in elderly women 
 who suffer from a lax condition <>f the vaginal wall. Local astringent 
 
42 TEEATMENT OF PRUEITUS. 
 
 lotions or pessaries, strychnine, or other nerve tonics, and careful atten- 
 tion to the wants of nature are indicated, and the catheter may be 
 temporarily required until a healthier state of the external parts is brought 
 about (see Chap. XXI.). In every case of continuous pruritus the urine 
 should be carefully examined, and sometimes a very little attention to 
 the correction of common abnormalities will be followed by good results. 
 But the state of diabetes mellitus especially produces some of the most 
 troublesome cases of pruritus, and that even in instances where the 
 urine is not materially increased in quantity. Nervoiis erythism is 
 much increased in diabetes, but it would appear to be the saccharine 
 urine which is chiefly at fault, not only by its irritating crystals, but 
 doubtless on account of some degree of fermentation. Add to this the 
 tendency to eczema which it induces, not only locally, but in other parts 
 of the body, and we have no want of causation for diabetic pruritiis. 
 Frequent tepid sjTinging and bathing are the chief resources, and, in 
 aggravated cases, tlie use of the catheter may be required if the urethra 
 is not too tender. 
 
 The possibility of the existence of external parasites, especially of the 
 pediculus pubis or vestimenti, or of the acarus scabiei, must not be for- 
 gotten. The bichloride of mercury solution will speedily destroy the 
 former source of trouble, but in some old people there is a strong ten- 
 dency to recurrent attacks. Scabies must be treated by sulphur or car- 
 bolic acid in the form of ointment. Ascarides may act by mere reflex 
 irritation conveyed to the superficial nerves, but they may pass into the 
 vagina and vulva, and thus become more direct agents. Infusion of 
 quassia, lime-water, or iron (T. ferr. perchlor., §ss. ad Oi.) injected into 
 the rectum will get rid of these. The vagina itself often harbours the 
 oidium, leptothrix, trichomonas, and various infusoria, which are doubt- 
 less highly irritating, and nearly all the specific remedies which have a 
 reputation in pruritus are antiseptics or parasiticides. Occasionally the 
 presence of stunted or broken hairs around the margin of the vulva has 
 been noted as a cause. Such cases are hardly of frequent occurrence, 
 but would, when recognised, demand the administration of aneesthetics 
 and the careful and complete epilation of all offending hairs. Eczema, 
 lichen, and other eruptions are frequently accompanied by an amount of 
 itching out of all proportion to their extent or severity, and this- 
 symptom, as pruritus, may precede or succeed this appearance. Their 
 treatment has already been referred to. 
 
 Pregnancy is frequently accompanied by very distressing pruritus, and 
 this may be due either to irritating discharge, to the swollen and varicose 
 state of the pudenda so often produced by it, or to a simple hyper- 
 asthetic state similar to that produced in other organs. Tepid bathing, 
 and syringing with one or other of the lotions given below, and atten- 
 
TEEATMENT OF I'itUEITU.S. 43 
 
 tion to the bowels, or the vise of an abdominal belt to diminish engorge- 
 ment of the pelvic viscera, are the suitable precautions. Occasionally 
 the menstrual discharge is peculiarly irritating, and gives rise to tem- 
 porary pruritus. I know of no Avay of altering this, or the similar con- 
 dition in pregnancy, by internal remedies ; tepid syringing is the only 
 resource. Chronic metritis is a frequent cause, by the irritation of its 
 discharges ; but, independently of that, it and uterine displacements, and 
 even fibroid tumours, are sometimes the causes, much as pregnancy is, 
 by their effect on the pelvic circulation, or by reflex irritation. A careful 
 examination for recognisable disease of the uterus or its appendages, and 
 corresponding treatment, must therefore precede all but the most simple 
 attempts to cure pruritus. We cannot enter here into the subject of the 
 various diathetic diseases. Gout, or those general states which are recog- 
 nised as belonging to the same class, may be suspected, as in so many 
 other neuroses and skin affections, if there is a family history pointing 
 to it, and its antidotes, medicinal, dietetic, and hydro-therapeutic, may 
 be tried. 
 
 Do what we will, however, to place the treatment of pruritus on a 
 certain basis by ascertaining its causes, we are driven sometimes, as with 
 jaundice, or dropsy, or menstrual disorders, which are but symptoms, to 
 fall back on piire empiricism. Bromides, chloral, or even opiates in- 
 ternally have their place, but the two latter should only be \ised under 
 a sense of deep responsibility. Everything that is included in the 
 widest definition of tonic treatment is generally in the right direction, 
 and a list of only a few of the local remedies that have been used 
 empirically must conclude these therapeutic suggestions. Some of these 
 will be found useful, even while attempts are being made to get at the 
 disease by removing its cause. For vaginal injections the following sub- 
 stances are recommended, and they may be combined when their chemical 
 nature will allow. The figure attached to each of the first five refers to 
 the quantity to be used per ounce :- — 
 
 Ac. carbolic, gr. x. and upwards. 
 
 Liq. plumbi acetat., 5ss. 
 
 Acid, boracic, ad sat. 
 
 Acid, hydrocyanic, dil., TTlx. 
 
 Sulplio-carbolatc of zinc, gv. x. 
 
 Tobacco I have never used, but it is reconnHonded by many — one drachm in- 
 fused in a pint of water. 
 
 Borax ad. sat., and sulphurous acid 5i- ad 5!. 
 
 Glycerine is in some cases found too irritating as a solvent for outward apidica- 
 tions ; when that is found to be the ease, olive oil must be substituted, ami 
 all the above substances may thus be applied to the itching surface fre- 
 quently during the day. 
 
 Mercurial l(;tions, such as black wash, or a ](jtiou of bichloride (if 
 
44 SYPHILIS CONDYLOMA. 
 
 mercury and hydrocyanic acid, or chloroform (1 pt. to 10 of olive oil), 
 and 01. Staphisag. ^i. ad. vas. alb. §i., may be added to our list of 
 local applications, which might be almost indefinitely extended, but 
 those substances now named are the most reliable. 
 
 Syphilis. 
 
 Few cases of primary syphilis come under the notice of the gynaecologist, 
 nd in general practice, while secondary forms of the disease are by no 
 means rare, primary affections are \incommon in the female. We will 
 therefore follow the example of most writers on gynaecology, and leave 
 those more conversant with the subject to discuss the various forms of 
 chancre, their supposed duality of type, and the like questions concerning 
 them. Even the special syphilologist sees the primary chancre much less 
 frequently in woman than in man ; it has most frequently healed before 
 the case comes under his notice. The site is rarely on the cervix uteri, 
 where it could easily be seen by the speculum. Amid the folds or rugse of 
 the vagina detection is often very difficult, and when a hard chancre occurs 
 on the vulva, it frequently resembles so much to the patient a spot of 
 acne that she waits complacently for its disappearance. The sore may 
 even be at a considerable distance from the vulva, on the mons veneris 
 or thigh — the infectious matter having reached the seat of a scratch or 
 a pimple, or a torn hair follicle. There should seldom be any great 
 difficulty in deciding on the diagnosis of a primai'y chancre when it is 
 seen. Lupus or cancer might for a time be mistaken for the small cup- 
 shaped ulcer with its hardened base, or for the more widely ulcerating 
 or phagedsenic form. But the progress is essentially different ; the soft 
 chancre is frequently multiple, whereas cancer springs usually from one 
 centre, and in case of necessity we can fall back on the test by inocula- 
 tion. A due knowledge of chancre as it occurs in the male, and a little 
 of that mother-wit which is required in all cases where there are motives 
 for concealment, should avoid error. 
 
 The possible influence of the syphilitic dj'scrasia on all chronic affec- 
 tions, especially those of a hypertrophic character, mxist ever be borne in 
 mind in every branch of practice, and especially by the gynaecologist. 
 
 Condyloma, or mucous tubercle, is a form of soft flattened warty 
 excrescence without pedicle, met with especially in Avomen of un- 
 cleanly habits. These growths are of a reddish-grey colour, varying 
 according to the amount of their vascularity. Microscopically they 
 are very similar to warts, but less firm in texture — more pajiillary, less 
 fibrous. They may exist as small separate patches, or sprout over the 
 whole vulva, and invade the surrounding skin. Opinions differ as to 
 whether they are always specific ; but setting aside one or two cases 
 
TREATMENT OF SECONDAKY AND TEUTIAKY .SVI^HILIS. 45 
 
 which might be more properly described as soft warts, I have never 
 seen one where I had any doubt as to its real syphilitic charactei*. 
 Gonorrhoea or uncleanliness will cause warts ; they will also materially 
 aggi-avate, but not alone cause condylomata. These growths are also 
 undoubtedly infectious to the male, probably a much more frequent 
 source of infection than the primary chancre, and I think I can say with 
 almost positive certainty that I have seen both w^hat is termed a hard 
 infecting and a soft non-infecting chancre derived from this source. 
 Considering the strongly infecting properties of these growths, it is 
 astonishing how rapidly curable they are in the majority of cases. Soap 
 and water, liberally and frequently used, act almost like a charm. A 
 little calomel and oxide of zinc, in equal parts, carefully applied to the 
 surface, will usually complete the cure in a very short time. 
 
 But the constitutional disease is still existent, and must be met by 
 antis}^hilitic treatment, or the affection speedily returns. I may ven- 
 ture here to express my own opinion as to the relative value of iodine and 
 merciiry in the treatment of secondary or even tertiary syphilis, as 
 we meet with it now-a-days. Commencing practice as a pupil of Syme 
 and Hughes Bennett, I Avas opposed to the use of mercury, and thought 
 that I could easily demonstrate the efficiency of a non-merciirial treat- 
 ment. The patients got well, but being for some years in a more or less 
 general practice, I was able to trace their subsequent career, and I had 
 ample evidence that the dyscrasia was left more untouched than in those 
 who were treated by mercury in small and long-continued doses. In 
 secondary, and still more in tertiary syphilis, iodide of potassium in full 
 doses will certainly often produce the most immediate and striking- 
 results, a very important matter when brain or other delicate tissues are 
 involved ; bvit permanent results are still more thoroughly attained by 
 small and long-continued doses of mercury, combined with quinine and 
 iron. 
 
 In very obstinate cases of condyloma the application of strong 
 escharotics, such as nitric acid, acid nitrate of mercury, or the actual 
 cautery, may be required, but such cases must be very rare. The true 
 condylomata are too extended in their attachments to be amenable to 
 excision by scissors, therein differing from simple warts, which have a 
 firmer basis of connective tissue, constituting more or less of a distinct 
 pedicle. 
 
 Cancer. 
 
 Cancer of the vidva almost invariably assumes the form of ei)ithelioma. 
 Other forms when met with are nearly always extensions from the parts 
 above. The clitoi'is is perhaps the most common site of commencement 
 
40 CANCER OF THE VULVA. 
 
 the disease spreading theuce to the njinphae or labia majora, but it may 
 orio-inate in any part. The first phenomenon is that of a small in'itable 
 tubercle which ulcerates in a very short time. There may be an attempt 
 at scabbing, but in spite of this the sore rapidly extends, and the thick 
 indurated edge, hanging over the angry advancing ulcer, is most diag- 
 nostic. When commencing on the inside of the labia, there is sometimes 
 at the fii-st a condition of the mucous membrane which might be mis- 
 taken for o-ranular or follicular inflammation. There is, however, an 
 indurated base underneath, and after a short time true ulceration shows 
 itself. This form usually occurs in elderly women, and I have kno^Ti it 
 treated for a considerable time as vulvitis or vaginitis. Another form, 
 consistino- of a sort of cauliflower excresence of the labium, with free 
 watery discharge, is occasionally found in old, feeble, women, and has 
 been named " oozing timiour of the labium." In all forms the inguinal 
 and pelvic glands become speedily affected. Continuous pain, hsemo- 
 rrhagic and foetid watery discharges, in time lead to the death of the 
 patient, but this is more often due to the secondary invasions elsewhere 
 and to the general cachexia thus resulting. 
 
 Treatment, to be of any use, must follow immediately and energetically 
 •on diagnosis. Excision of the whole diseased smface, whenever there is 
 the remotest chance of reaching healthy tissue, must be performed, and the 
 patient should have the benefit of any doubt that may exist on the point. 
 The knife is attended with considerable risk of hsemoiThage, which, 
 though it may he arrested by styptics and pressure, diminishes the 
 already faihng strength of the patient. Chain or ^nre ecraseiu's are too 
 clumsy, and the shai-p cutting heated platinmix wire of the galvanic 
 cautery (fig. 56) is by far the most efficient instmment. The heated knife 
 of a Paquelin's caiitery (fig. 57) is also very effective in excision of such 
 parts. The local application of bromine (1 part in 5 of spirit) or of nitrate 
 of mercury, or of salicylic acid and collodion (3i. ad §i.) may for a time 
 arrest progress and give temporary relief, but in any case where there is 
 the faintest hope of cure or of any long suspension of activity, excision by 
 the cautery knife or ecraseur is to be performed. 
 
 Lupus {Esthiomeoie). 
 
 Lupus of the external organs of generation is hardly so common 
 as the same disease affecting the face. It occurs in badly nourished 
 strmnous women, generally between the ages of twenty and thirty. 
 Without attempting here to discuss its pathology, it has always appeared 
 to me to be one of those affections whose careful study would serve to 
 throw lio-ht on the evolution of disease, so gracefully discussed by Sir 
 
LUPUS AXD Is^OMA. 47 
 
 James Paget in the first Bradshaw lecture. Its resemblance, and also its 
 dissimilarities to syphilis, scrofula, and epithelial cancer, point to a 
 possible intermediate stage in development. The majority of writers, 
 however, consider it to be only a manifestation of scrofula. Clinically we 
 have a sore which alternately ulcerates and heals, creeping around the 
 vulva, and leaving a depressed white scar to mai'k each step in its continu- 
 ■ous progress. The sores are preceded by flattish discoloured tubercles, 
 which are often very slow in ulcerating. As a rule, there is not much 
 pain. Progress, though slow, is only too sure, and large tracts are 
 covered with cicatricial contracted tissues before the disease comes to 
 an end, if it does so during the life of the patient. 
 
 As regards treatment, tonics, cod-liver oil, iodine, and arsenic appear, 
 under good hygienic conditions, to exert a somewhat favourable influ- 
 ence. They tend to induce, and may perpetuate, the cicatricial stage. 
 Though removal by galvanic cautery, or by the most powerful escharotics, 
 •often fails to aiTest progress, yet it may temporarily check the disease, 
 and give time for constitutional treatment. Of late years, most success- 
 ful results have been obtained by Volkmann, Yeats, and others, by 
 thoroughly scraping off the surface, but I have as yet had no experience 
 of this in lupus of the vulva. Should the cicatrices threaten to occlude 
 the canal, the frequent passage of a large bougie may to some extent 
 •obviate this danger. 
 
 Noma. 
 
 Under this name has been described a gangrenous condition which, as 
 Si sequel of the zymotic diseases, or of the septic or pysemic puerperal 
 affections, or as a manifestation of ejoidemic or spoi'adic erysipelas, some- 
 times attacks the external parts of generation, as it may also do the face. 
 Dr Hermann records some cases of each kind in the Ohstetrical Trans- 
 actions, vol. XXV. p. 141. It seems to be a mistake to have given the 
 this affection special name. It is simply gangrene, a sign of low vitality 
 and embolic changes. Antiseptic poultices and liberal nutrition, with 
 wine, as it may be thought desirable, are oiu- only resource. If sufficient 
 vitality can be maintained to permit of separation of the slough before 
 .a vital part is reached, the patient may be saved. 
 
 Vulvitis. 
 
 The vulva is not infrequently the seat of acute inflammation, and this 
 may either be simply catarrhal, from cold or injury, or it may ensue 
 from the spreading of va inal inflajnmation downwards, or it may be 
 
48 VULVITIS. 
 
 gonorrhceal. In each case the symptoms present so much similarity that 
 it is most difficult by these alone to diagnose between the specific and 
 non-specific cases. General redness of surface, with perhaps temporary 
 dryness, heat, tingling, itching, and smarting, speedily followed by 
 swelling and profuse muco-purulent or purulent discharge, constitute 
 the common symptoms. In the adult the acute cases are mostly 
 gonorrhceal, and there are a few points which, though separately 
 insufficient to prove anjrthing, by their combination, render the diagnosis 
 of gonorrhoea moderately certain. Great acuteness and suddenness of 
 onset, the absence of other recognisable causes, much scalding urination, 
 the presence of pus in the urethra, ascertained by forward pressure with 
 the finger, and oedema of the labia as before mentioned, are character- 
 istic of the specific form, while a more free admixture of mucus with the 
 pus points rather to the other. Additional aids to diagnosis are the 
 foetor of the discharge in the specific form ; its transmission -to the 
 male (which may, however, occur in the simple form) ; the greater 
 frequency of abscess of the vulvo-vaginal glands, and of buboes. 
 But no matter how convinced the practitioner may feel, these symp- 
 toms will never justify him in asserting that he has positive proof of 
 gonorrhoea when such a statement must be held as evidence of un- 
 chastity. As an occasional cause of acute, sub-acute, or chronic vulvitis, 
 we may also note irritating vaginal or other discharges. Nearly every 
 one of those circumstances mentioned at page 41 as among the occasional 
 causes of pruritus may also induce vulvitis. 
 
 Viilvitis is not infrequently met with in young children or even 
 infants, and here there is a necessity for still greater caution. Want of 
 cleanliness alone will suffice to produce the affection, so may injuries of 
 a perfectly innocent character, so may the presence of ascarides, 
 though Matthews Duncan throws doubt on this, and in scarlatina or 
 other zymotic diseases, rather acute vulvitis sometimes occurs. Let 
 the young practitioner beware of such cases, and remember, that 
 however circumstantial the accounts of criminal assault given by the 
 young patient herself, or, at second hand, by her friends, purulent 
 vulvitis is no proof of such assaults, and has most commonly nothing to 
 do with them. The evidence derivable from injury to the perineum, <kc., 
 is, of course, stronger. 
 
 Occasionally the inflammation of vulvitis spreads to the subjacent 
 connective tissue, giving rise to abscess or furuncles. It may also pass 
 into the ducts of the glands of Bartholinus (fig. 32), with the same result 
 as to abscess,— it may spread upwards to the bladder, giving rise to 
 cystitis, — and it may pass along the vagina to the uterus, or Fallopian 
 tubes, or peritoneum, giving rise to painful diseases of these organs, or 
 even to fatal issues, which will be subsequently referred to. 
 
FOLLICULAK VULVITIS. 
 
 49 
 
 \Mien vulvitis becomes chronic, it is often exceedingly ohstinute, and 
 ijiiiy by its continual irritation give rise to considerable hypei-trophy, 
 especially of the nymphce. 
 
 One form deserves special mention. Like the inHauimations of other 
 mucous surfaces, vulvitis may assiime sl follicular form, that is to say, the 
 mucous or submucous glands may 
 be chiefly affected (fig. 33). Such 
 cases are usually subacute ; they 
 occur not infrequently during 
 pregnancy, and they have rarely a 
 specific origin. The redness and 
 swelling or purulent contents of 
 the inflamed glands give to the 
 surface a granular appearance — 
 there is less purulent discharge, 
 and this is often mixed with or re- 
 placed by a white cheesy-looking 
 secretion from the follicles. These 
 cases tend to a chronic condition. 
 
 Diagnosis in vulvitis should 
 be free from any difliculty except 
 that of diflierentiating the specific 
 and non-specific forms. 
 
 The treatment in all cases may 
 require to be antiphlogistic at 
 first, necessitating low diet and 
 cooling purgatives, and avoidance of every kind of stimulant. In 
 the acute stage constant warm fomentation is required, and the 
 common lead and opium, or borax and hydrocyanic acid lotions, arc 
 most serviceable. I have no experience of the heroic treatment by 
 very strong solutions of nitrate of silvei-, imintcd on during this stage, 
 and I do not think I dare try it. As the acute stage subsides, the 
 applications must become more astringent. Sulphate of zinc (gr. iii.-x. 
 ad 5i-)) sulphocarbolate and chloride of zinc in the same strength, but 
 not stronger, and permanganate of potash solution gradually increased in 
 strength from 1 or 2 grs., ad §i., according to the result, arc among tin- 
 most reliable of them, but others will be mentioned when speaking of 
 vaginal inflammation. I prefer watery solutions to gh'ceroles or more 
 solid applications, but in the chronic granular or follicular form I have 
 seen much benefit accrue from wiping the diseased surface carefully 
 with cotton-wool, and then painting it with the tincture of iodine (B.P.). 
 A few applications, at intervals of one or more days, according to the 
 tenderness, will sometimes promote a ra])i<l cure in cases tliat liave been 
 
 Fig. 33.— Follicular Vulvitis (Thomas). 
 
50 
 
 VULVAE ABSCESS. 
 
 very tedious. Persulphate of iron (1 pt. to 8 of glycerine), and argent, 
 nit. (gr. X. ad aq. 5i.) are used in the same way; I prefer the iodine. 
 The larger projecting follicles may also be punctured with advantage. 
 
 Abscess. 
 
 I have already refen-ed to the occasional production of abscess of the 
 \ailva by the extension to the connective tissue of the inflammation of 
 vulvitis, gonorrhoeal or otherwise. Extension may likewise take place 
 into the ducts of the numerous small glands which open on this surface. 
 But abscess may also occui', and very frequently does, without previous 
 affection of the mucous surface. A slight blow or contusion, or the 
 septic effect of absorbed uterine or other discharges, may be the efficient 
 causes. Not iufi-equently the abscess is apparently spontaneous, but in 
 
 such cases the blocking up of a glandule 
 by its own secretion, the evulsion of a 
 hair, or some such cause, is doubtless the 
 precursor. 
 
 A common site is in one of the labia 
 majora (fig. 34), sometimes in both, and 
 the contents of these labial abscesses have 
 often the peculiar foetor observed also in 
 facial abscess. The next most common 
 site is in the duct of one of the two 
 valvo-vaginal glands (fig. 32, 9). These 
 two small structures lie at the junction 
 of the vulva and vagina ; they are com- 
 pressed backwards by the constrictor 
 vaginae, but their ducts emerge in front 
 of the hymen, hence it is the occluded 
 and inflamed ducts which chiefly figure 
 as vulvar abscess, while the glands them- 
 selves not infrequently give rise to^vaginal 
 cysts. Corresponding to Cowper's glands 
 in the male, they are sometimes named after him, also occasionally after 
 Duvernay or ]\Iorgagni, but most frequently after Bartholinus. This 
 gland or its duct is also a frequent site of chronic abscess. 
 
 After a Aoilvar abscess has burst or been opened, and has apparently 
 quite disappeared, it is apt to recur at a more or less distant period without 
 apparent cause, and this recun-ence may be so frequent as to be a source 
 of great trouble and pain. When this is the case, the wall of the abscess 
 is to be regarded as that of a suppurating cyst. True cystic growths may 
 
 Fig. 34. — Labial Abscess (Thoma.s 
 
CYSTS OF THE LABIA. 51 
 
 have been originally present, or the wall of a dilated gland or duct, or, 
 according to some, of a dilated vein, may constitute the affected surface. 
 Tlie nymphaj are more rarel}'' the seat of abscess. I have recently 
 treated a case where for over four years vulvar abscess constantly re- 
 cuiTed, driving the patient out of an excellent situation as a school- 
 mistress. Six months before I saw the case it was treated in vain by a 
 seton. No abscess was present when I saw her, but the two surfaces of 
 the right nympha, otherwise healthy-looking, could be pulled widely 
 asunder by forceps, and on cutting through the inner one a white-walled 
 cavity showed itself, quite empty, but capable of holding a large filbert. 
 This cavity was laid open from end to end and compelled to granulate 
 from the bottom, and the disease is now cured. 
 
 The treatment of vulvar abscess is that of abscess in general — warm 
 fomentation and poultices at first, and free evacuation when pus is fairly 
 made out. The labial form should always be opened on the mucous 
 side, but the possibility of a hernia in this situation must not be forgotten 
 on accovmt of its infrequency. I have no experience of antiseptic aspira- 
 tion in these abscesses. When recurrence takes place, the exact site of 
 the abscess must be very carefully made out ; it must be freely opened 
 and stuffed with lint soaked in carbolic or eucaljq^tic oil, to compel 
 granulation from the bottom. If it appears that there is a true cyst 
 wall, which can be dragged or dissected out, this is to be done. If not, 
 a small portion ma}'^ be snipped away. Abscess of the perineum is now 
 and again met with, and should be opened early, in order to avoid 
 fistulous communication. 
 
 Cysts, 
 
 Time non-pvu-ulent cysts are not infrequently met with in the labia 
 majora, and also as developments of the vulvo-vaginal gland or its ducts, 
 and occasionally they attain a considerable size. Their pathology is 
 often obscure, but there is reason to think that sometimes, instead of 
 being the result of retained glandvilar secretion, they ma}- be the sequel 
 of small haemorrhages into the cellular tissue or into a gland. True der- 
 moid cysts, containing hair or teeth, have been found here, as elsewhere. 
 The contents of ordinary vidvar cysts vary much, owing doubtless 
 to their original etiology. Clear liquid, glairy fluid, sebaceous matter, 
 altered blood, or sero-purulent fluid, are all occasionally encountered. In 
 (Hagnoi^h, if coiifoimded with chronic abscess, no harm can accrue, but 
 the occasional presence of thrombus, varicocele, hydrocele, hernia, or fatty 
 tumour of the labium, must each be kept in view. I'herc is less danger 
 of mistaking cysts of the vulvo-vaginal glands or ducts for any of these 
 than there is in tlic case of cysts of the labia, unless the former are very 
 
52 
 
 YAEICOCELE. 
 
 large, in whicli case they may assume a very similar shape and size. 
 When diagnosed, they should be freely emptied, and a portion of the 
 wall should be removed, while the cavity is filled with thin strips of lint 
 soaked in glycerole of carbolic acid, or iodine (gr. x. ad §i.), or medicated 
 with iodoform. 
 
 Varicocele. 
 
 Varicocele of the labia is sufficiently common as a result of pregnancy, 
 but may occur even in the virgin. It would seem to be occasionally 
 due to the same causes as in the male, but more often to an augmented 
 vascularity during pregnancy, or in the presence of fibroid tumoiirs or 
 other pelvic growths, together with impediment to the return of blood from 
 the same causes. The valveless condition of the left ovarian, like that of 
 the left spermatic vein, may help to account for the greater frequency of 
 varicocele on the left side. Besides the continual aching and discomfort 
 to which it gives rise, this affection is not without danger, owing to the 
 liability of the dilated veins to be ruptured by very slight traumatic 
 causes, even straining at stool. This may cause thrombus, if rupture 
 take place into the connective tissue, or dangeroiis and fatal pudendal 
 haemorrhage, if it be external. 
 
 The first point in treatment is to take off", if possible, all super-incum- 
 bent pressure, by at- 
 tention to the bowels 
 and bladder, by the 
 use of an abdominal 
 belt in pregnancy or 
 in the case of large 
 tumours, which belt 
 should lift up instead 
 of pressing down the abdominal contents ; or occasionally by raising 
 a fibroid or ovarian tumour above the pelvic brim, as will be described 
 
 when speaking of 
 uterine fibroids. 
 Some form of elas- 
 tic local pressure 
 to the whole labi- 
 um suggests itself, 
 but I have never 
 seen this satisfac- 
 torily achieved. 
 
 The radical cure by subcutaneous ligature is not open, as in the 
 case of the male, to the objection that it may destroy the vitality of 
 
 Fig. 35. — Sims's Glass Vaginal Dilator. 
 
 Fig. 36-— Barnes's Vaginal Dilator. 
 
THROMBUS, HERNIA, AND HYDROCELE. 53 
 
 the testicles. If heemorrhage should occur externally, firm pressure 
 must be at once api:)lied to the bleeding point, together with the use of 
 perchloride of iron or other styptics ; and this is much aided in the 
 way of counter pressure by the introduction of one of Marion Sims's, 
 or Barnes's vaginal dilators. If the cellular tissue is infiltrated, Avithout 
 external rupture, we have the condition known as 
 
 Thrombus. 
 
 Thrombus, or perhaps more correctly hcematoma, or blood tumour, of 
 the vulva, is most familiar to the accoucheur, but in the presence of 
 varicocele or of a weak condition of the veins, a ver}'^ small amount of 
 injury, even coitus, may suffice to produce it independently of preg- 
 nancy. The resulting tumour is sudden in its origin, and may vary in 
 size from that of an egg to a cocoa-nut ; but the full size may be only 
 gradually attained. If large, the swelling can also be felt per vaginani, 
 encroaching on the oiitlet of the pelvis. The history of previous vari- 
 cocele, or of traumatic causation, and the sudden origin and the absence 
 of inflammation, seem to distinguish this from other soft swellings of 
 this part, hernia excepted. To exclude that we must notice the absence 
 of gurgling, impulse on coughing, or resonance on percussion, and care- 
 fully ascertain the possibility of reduction. If iced water be applied 
 early, and the patient kept quiet, we may hope for an early an-est of 
 the haemorrhage and a gradual absorption of the clot. In non-puerperal 
 cases, incision should rarely, if ever, be attenuated ; but if sui3]3uration 
 has undoubtedly occurred, it may become necessary, time having been 
 given for nature to diminish the risk of septic absorption by throwing 
 out a surrounding wall of lymph. When the necessity luifortunately 
 arises, either in these or in obstetric cases, the clots must be scooped out 
 as far as possible, and there is hardly any instance in surgery where 
 more advantage is to be obtained from thorough antiseptic or asei)tic 
 treatment than in that of the cavity tlius formed. 
 
 Hernia and Hydrocele 
 
 of the labiiuii are only occasional occiun-enccs, but their very rarity makes 
 it tlie more incumbent on the practitioner to bear in mind tlie })ossil)ility 
 of at least the former, when dealing witli tiunours of tlie \)wvt. The 
 inguinal canal, or canal of Nuck, may remain so patent as to allow a 
 hei'uial ]n-otrusion of bowel, omentum, or even ovary, to pass beside tlie 
 remains of the round ligument into the labium, the analogxie of the 
 
54 HYPEETEOPHY OP THE LABIA, ETC. 
 
 scrotum. In no case, therefore, should a labial swelling be surgically 
 interfered with until the operator is satisfied that there is no inguinal 
 protrusion, or neck, and has tried the result of coughing. If the usual signs- 
 of hernia are found to be present, it can generally be easily reduced, and 
 must then be retained by a properly fitting truss. If strangulation 
 occui', the usual operation is required. It will be less complicated than 
 on the male. Now and again, as just mentioned, the ovary has been 
 met with as a hernia in the labium or inguinal canal, the reversed con- 
 dition of undescended testicle. In Pott's celebrated case it was double. 
 The sickening pain on pressure, and the solid spherical character of the 
 mass, would point to the nature of the disease. If reduction were im- 
 possible, removal would be preferable to the risks of chronic or acute 
 (jvaritis with their constitutional effects. 
 
 Hydrocele in the same site, as a labial tumour, would appear to be 
 more rare, but it is met with occasionally. Its diagnosis is of less im- 
 portance than that of hernia, but one must ascertain by taxis, in all 
 cases, whether a labial or inguinal cyst has a communication with the 
 abdominal cavity, and the treatment of a non-communicating cyst, with 
 ■clear contents, might be tried by iodine or carbolic acid injection^ 
 whether presiimably of hydrocele origin or not. 
 
 Solid Labial Tumours. 
 
 The two forms of solid benign tumour most often met with in the 
 labia, are the fatty and fibrous. Both of these have been from time to 
 time encountered, though I have never seen an example of the latter. 
 Either of them may attain a considerable size, even several pounds in 
 weight, and they generally spring from the labia majora. Kemoval by 
 the ecraseur or knife will be regulated by the size or pedunculation of the 
 growth. 
 
 Hypertrophy. 
 
 Simple hypertrophy of the nymphee, clitoris, or labia majora, occurs 
 with tolerable frequency, sometimes as a result of ^^^lvitis or other irrita- 
 tion, sometimes from causes quite obscure. The parts are most fre- 
 quently affected as placed in order above. In elderly women especially,, 
 some hypertrophy of the nymphaj is very common, and calls for great 
 care to prevent discomfort by friction. Frequent ablution, and the 
 wearing of a strip of linen smeared with vaseline or spermaceti ointment 
 between the affected parts, Avill generally suffice; but when discomfort 
 is great, removal of the whole or a portion by the galvanic ecraseur ia 
 
ELEPHANTIASIS. 
 
 55- 
 
 desirable. The tme Elepliantiaus (fig. 37) is nire in England, though 
 common in many hot climates. It differs from ordinary liypertrophy 
 chiefly in the immense size which it attains, in its tendency to become 
 nodulated, or even 
 knobby, on the surface, 
 through changes in the 
 epidermis, in its patho- 
 logical tendency to lym- 
 phatic dilatations, and 
 in its great liability to 
 recurrence. It is an- 
 other of those affections 
 which might be profit- 
 ably studied in relation 
 to the evolution of dis- 
 ease by climate, &c. 
 All authorities are, I 
 believe, agreed in re- 
 commending removal, 
 in spite of the recurrent 
 tendency. Any j)art of 
 the pudenda may be 
 affected, but the labia 
 majora most commonly. 
 
 That certain cases of h;y-pei-trophy are true tertiary syphilides there 
 can be little doubt. The difficulty lies in their differentiation from 
 others not of specific origin. I fear that for the present we can only 
 depend on the history of the patient, and the result of anti-syphilitic 
 remedies. 
 
 Fig. 37.— Elephantiasis of the Vulva (Mayer). 
 
 Vascular Caruncles and Degenerations. 
 
 What is known as a vascular tumour or caruncle is so cdinnionly met 
 with at the orifice of the urethra, that its ccnisideration might have been 
 delayed till a subsequent chapter. I believe, however, it will be most 
 satisfactorily introduced here in connection with some othei- new growtlis 
 of a similar character. Just within the urethra, and [)rotru(ling some- 
 what from it, we frequently encounter :i small crimson growth, in size 
 from a lentil to a currant or even a cheny, exc|uisit('ly jiainful to touch, 
 or on the passage of urine. It is soft, friaV)le, and more or less i)e(luncu- 
 lated, the peduncle springing fi'om the urethral wall at an eightli to a 
 quarter of an inch from its extremity. Such is the typical vascular 
 
56 YASCULAK CAKUXCLES OF THE UEETHEA, ETC. 
 
 urethral caruncle. If the patient's description of painful micturition 
 has not led to a search for it, it is betrayed on the first attempt at a 
 vaginal examination, use what care we may to avoid giving pain. But 
 it assiimes other and less common forms. It may not protrude beyond 
 the urethra at all, or it may not have any pedicle, but may encircle the 
 urethral canal with a red villous lining, requiring care to distinguish it 
 .from mere evertion of the mucous membrane. Or, it may appear quite 
 outside the urethra as one or more crimson points ; or, least common of 
 all, it may assume any of these forms, and be almost void of pain and 
 sensitiveness. An affection, practically the same in natiu-e, may be met 
 wdth elsewhere on the vulva. 
 
 These growths consist of fine loops of capillaries, with more or less, but 
 generally little, connective tissue, and, as is clinically proved, a varying 
 nerve supply. When they assume the tjq^ical form, the treatment is 
 simple enough, especially with chloroform, and in the lithotomy position. 
 Ascertaining by the gentlest use of a probe where the pedicle is, it is 
 surrovmded and cut through by a fine pair of scissors, curved on the flat. 
 The timiour maj' be raised with forceps, but is very easily torn. It is 
 generally recommended to apply a touch of nitric acid to the base in 
 order to prevent recurrence ; but recurrence will take place, nevertheless, 
 in many instances, from the immediate neighbourhood. I prefer piu-e 
 carbolic acid, which has more or less of an anodyne effect after the first 
 few moments. 
 
 When occiu'ring as small sessile growths outside the urethra, these 
 must be freely removed in the same way, but they are generally a little 
 firmer, and bear lifting up by forceps better, previous to ablation. The 
 gi'eatest difficulty is with those which sm-round the inside of the uretln-a 
 with a collar of vascular tissue. I have met with several of these, have 
 
 Fig. 38. — Ear ScooiJ. Suitable for the removal of 
 urethral fungosities. 
 
 tried various methods of treatment, and have come to the conclusion that 
 the only satisfactory plan is, under chloroform, to freely scrape the 
 urethra with a fine scoop or cxirette (fig. 38), such as is used by aurists, 
 to apply carbolic acid to the denuded surface, and to keep the patient 
 under the infliience of morphia for several hours afterwards. 
 
 I have said that similar gi-owths are to be found in other situations on 
 the vulva, and the most common of these sites is around the margin of 
 the pre-existing hymen. They may be considered as the remnants of 
 that structure, but so altered as to resemble in colour, and often in pain- 
 
ADHESIONS OF THE VfLVA. 67 
 
 fulness, the urethral growtlis. They have, however, nearly always a 
 larger amount of connective tissue, and are known as caruncuhK viyrti- 
 formes. I shall have occasion to refer to them again as one of the most 
 common causes of i)ainful connection (Dyspareunia). There is but one 
 remedy, free ablation. 
 
 Occasionally other parts of the vulva, especially the inside of the 
 labia, are the seat of a degeneration of the same kind, but which may not 
 rise above the surface at all. These have more the appearance of spots 
 of red staining on the mucous surface. These also are for the most part, 
 though not always, acutely painful. They are nearly always met with 
 in elderly woman, and tend by their recurrence in different situations to 
 make life very miserable. Strong escharotics such as nitric acid, or 
 chromic acid, or Paquelin's thermo-cautery will eradicate them for a 
 time. 
 
 Fissures. 
 
 Fissures of the vulva, similar t(j those of the anus, are not very infre 
 quent. They may follow the first attempt at sexual intercourse, or be 
 sequelfe of labour, or result from the presence of eczema or other aftec- 
 tions of the skin and mucous membrane. Their treatment is by incision 
 along their whole length, which must, of course, be accompanied by tem- 
 porary cessation of the maintal relation. 
 
 Adhesions. 
 
 In young children, the opposite surfaces (.f the labia, or, more rarely, 
 of the nymphfe, are often found to be adherent. Such adhesions are 
 usually slight, and are due to want of attention to cleanliness. They 
 will give way to the handle of a knife, or to mere stretching with the 
 fingers. If vulvitis has occurred, they may be somewhat fiiiner, and 
 require a few slight touches of the knife. After tearing of the soft 
 parts in severe labours, unless care is taken .hu-ing recovery, firm cica- 
 tricial adhesions may occur. In all cases where such tearing is known 
 to have taken place, a glass speculum, or one of Sims's glass dilators 
 (fig. 35), should be occasionally passed very carefully, after the firet week, 
 us*a pre'ventive measure. Should permanent adhesion occur, sufficient 
 to interfere with the natural functions, an;estlicsia inust be induced and 
 dilatation made with just as little nicking of thr cicatricialbands as 
 may be found necessary ; and the ground thus gained must be kcj.t up 
 by the wearing of a dilator j'or a short time daily. 
 
58 ABNOEIVIALITIES OF THE HYMEN. 
 
 Abnormalities of the Hymen. 
 
 I think it best, for reasons which will afterwards be apparent, to- 
 mention these here,rather than with the other congenital malformations;, 
 but complete closure of the hymen, with its resulting retention of the 
 menstiiial secretion, will be considered along with the occlusions of 
 the vagina or the uterus, which may j^roduce similar results (see Chap. 
 VI.). The hymen (fig. 32) varies much in form in different women; some- 
 times it constitutes a simple crescent at the back of the vaginal orifice, 
 sometimes a complete circular curtain, and sometimes it is of irregular 
 shape, or pierced with several openings. It may be so nidimentary as. 
 to be practically absent ; or, owing to accidents in early life, or to vul- 
 vitis, it may be quite absent in women who are perfectly chaste. The 
 medico-legal importance of this is self-evident. Not only are there these- 
 varieties in form, but there are equally great differences as to strength, 
 thickness, vascularity, elasticity, and innervation. I believe that, in 
 some cases, the hymen contains a fair amount of muscular tissue, and 
 that it may contract painlessly and prevent connection. Only in this 
 way can I explain one or two cases of the kind I have met with. 
 
 Undue toughness of the membrane may entirely prevent intromis- 
 sion, but it is quite a familiar fact that this is no absolute baiTier to- 
 impregnation. I was recently consulted in the case of a young unmar- 
 ried lady, who was found to be far advanced in pregnancy, although she 
 had such a complete hymen, and such a painful, spasmodic condition of 
 the parts, that a finger could not possibly be introduced without chloro- 
 form, and not easily with it. In all cases of this form of obstmction 
 sufficiently marked to require medical advice, complete removal of every 
 vestige of the hjonen by scissors is advisable at once. Anesthesia must, 
 of course, be induced, and the patient must be placed in lithotomy 
 position before a good hght. The membrane is raised by forceps and 
 carefully snipped away all roimd. If any portion is left, it is very 
 liable to become the seat of painful canxncle, to require further opera- 
 tion, or to occasion much unnecessary suffering. The hiemorrhage is 
 generally slight, but can be easily controlled, when necessary, by a 
 solid conical plvig, held in situ by a firm T-bandage. A piece of box- 
 wood, or the nozzle of a syringe of the requisite conical shape, should 
 always be used if the patient has not a good nurse, or cannot be seen 
 easily, in case of secondary bleeding. After this or any other operation 
 of the kind, the patient should wear a plug for a short time every day 
 for some weeks, which may consist of three or four inches of the largest 
 rectum bougie held m situ by tapes attached to the waist, or of the 
 special instruments introduced for the purpose by Clarion Sims or Barnes- 
 (figs 35 and 36), and to be had of various sizes. 
 
COCCYGODYMA. 59 
 
 Coccygodynia. 
 
 This name, now in cumniou use, was given by Sir J. Y. Simpson to a 
 painful condition of the parts in the neighbourhood of the coccyx, 
 characterised chiefly by severe anguish on bringing into phty any of the 
 muscles which have their insertion hereabouts. Sitting down, or, more 
 especially rising iip, but also walking, defsecation, coitus, and the like 
 actions, are thus attended by pain, but not equally in all cases. In 
 some one action, in others another, in a few all, are thus painful ; and 
 occasionally, though rarely, there is continuous pain independent of 
 motion. The pain of anal fissure or hsemorrhoids can be easily diffei-- 
 entiated and traced to its source, but symptoms midoubtedly occur cor- 
 responding closely to those of the so-called coccygodynia, and met with 
 in a few instances of pelvic cellulitis about the utero-sa<^ral ligaments. 
 The name, like so many other attempts at precise nomenclature, has, T 
 think, done, harm, having induced some to treat the affection as an 
 entity, to look for the cause, and to seek for the treatment. " Painful 
 bitting" has been suggested by Duncan, bxit he includes the pain whicli 
 is felt in the groins and elsewhere on sitting down during the occurrence 
 of peri-uterine inflammation. 
 
 The symptoms of coccygodynia often follow upon a hard labour ; they 
 occur also in the course of various uterine diseases, but some of the 
 worst and most persistent cases are encountered in the inunarried and 
 otherwise healthy. This fact, as well as the variety in the movements 
 which, in different cases, give rise to pain about the coccyx, suggests the 
 existence of more than one disease, differing perhaps completely in 
 nature, but linked by the common symptom. Success in treatment 
 will depend on the differentiation of the causes at work. The coccyx 
 and lower end of the sacrum nnist always be carefully examined per 
 rectum, in combination with external manipulation of the back ; the 
 state of the uterus and pelvic viscera must be methodically investigated, 
 and the history of previous labours must be inquired into. The origin 
 is generally traumatic and the result of delivery, though not always. 
 Prolonged horse exercise has given rise to the affection (Scanzoui), also 
 the effect of cold. 
 
 In one case there is a simple neuralgia, to be treated by anoiiyne suj)- 
 positories, morphia subcutaneous injections, and anti-neurotic regimen 
 or medicine ; by quinine, iron, arsenic, colchicum, or iodide of potassium. 
 In others there appears to be hyperjesthesia, and perhaps engorge- 
 ment, of the glandula coccygjea of Luschka, seated at the tip of the 
 coccyx ; in others there is undoubted affection of the coccygeal peri- 
 osteum, and in these two latter forms a sweep of the subcutaneous 
 tenotomy knife round the sides and ti[) of the coccyx rnay afiord imnic- 
 
60 EUPTUKED PEEINEUM. 
 
 diate relief, by taking off muscular traction or separating nerve connec- 
 tion, and this relief may or may not be permanent. Inflammation of 
 the sacro-coccygeal joint is relieved by the same procedure combined 
 with leeching. Necrosis of the coccyx requires resection of that bone, 
 and fracture with mal-union must be re-broken, and kept from uniting at 
 a sharp angle by the frequent introduction of the finger into the rectum. 
 Uterine or pelvic disease, if suspected as a cause of reflex j)ain, must be 
 treated secundem arteni. I once cured immediately an obstinate case by 
 one application of strong carbolic acid to an abraded cei'vix uteri. In 
 shoii:, coccygodjTiia is no more a special affection, to be treated in one 
 way, than would be the case with dactylodynia, if medicine had con- 
 ferred on our finger ends a uniform title for all their aches and pains. 
 
 Euptured Perineum. 
 
 The perineum may be raptured in various ways, — ^by falls, cutting 
 instruments, pitch-forks, and the like, — but practically the gynaecologist 
 has only to do with that form which is due to the effects of labour. It 
 may, I think, be said with truth that most cases of badly-torn perineimi 
 are due to faulty management — to neglect of the axis of the sacro- 
 perineal curve while guiding the head round the arch of the pubes, to 
 the wrongful administration of ergot, to the neglect of anaesthetics or 
 other means of dela3-ing expulsion while the soft parts are being slowly 
 prepared, or to graver errors in practice. But it must, on the other 
 hand, be said with equal certainty, that the accident may happen in 
 spite of all the care the most skilfid practitioner can bestow. A narrow 
 pubic arch which compels the head backwards, or a straight sacrum, or 
 some condition of the perineal tissue which renders it abnoi'mally feeble, 
 are not the fault of the obstetrician. Avoiding the support of the peri- 
 neum in the old-fashioned manner, i.e., avoiding all such pressure on it 
 as, with the counter-pressure of the head, must destroj^ its vitality, — 
 careful perineal support in the modern sense, i.e., giiiding the occiput 
 around the pubic arch with the tips of the fingers, repressing it if 
 progress seems too rapid, Avhile aff"ording only a sense of comfortable 
 support to the perineum itself — preventing any tendency of the anterior 
 vaginal waU or cervix uteri to precede the head — using plenty of lubri- 
 cants — administering aneesthetics in all cases of great rigidity, spasmodic 
 or vital — avoiding ergot — using the forceps before the tissues are dis- 
 organised, and using it at the outlet slowly, and as a guide rather than 
 a tractor, — these are the surest means of prevention. Xature indicates 
 another precaution : as the head is passing the perineimi the pain usu- 
 ally caiises the patient to cry out loudly, and, by not discouraging the 
 
NECESSITY FOR THE PRIMARY OPERATION. 61 
 
 relaxation of the abdominal muscles thus produced, we may relieve the 
 perineum. But there are cases when the utenis suddenly takes on violent 
 continuous action, as if from ergot, expelling the head without due adap- 
 tation, and others, Avhen the perineum is so muscularly resisting, or so 
 soft and clue&y, that it will not dilate, in which rupture is inevitable. 
 There is tenfold more danger in such cases than in the enormous but 
 slow and equable distention sometimes met with, and which can be com- 
 bated by the measures just refeiTed to. 
 
 Few obstetricians are not now agreed as to the advisability of imme- 
 diately operating on all cases of rupture of any extent, whether the 
 rectum is involved or not. In a very few cases of undovibtedly contracted 
 pubic arch or other pelvic deformity, if the sphincter ani is entire, there is 
 less danger in allowing the fissure to remain than in closing it, only to 
 be perhaps more deeply torn on the next occasion. No doubt a certahi 
 number of cases do Avell, if the limbs are kept close together and great 
 cleanliness is observed; but I am sure they are exceptions, as far as 
 union is concerned, although I have knowoi more than one case where 
 deep recto-vaginal tears have thus spontaneously healed. Moreover, 
 these cases of ruptured perineum are the most fruitful sources of 
 puerperal septicaemia. Their torn surfaces absorb that contagmm vivuvi 
 which, once admitted to the system, cannot be washed away like the 
 stinking fluids of decomposing placenta or clots in the uterus or vagina. 
 If the wound be well closed by metalhc sutures, and well saturated with 
 antiseptic glycerine, this danger is immensely lessened. All attempts to 
 operate after the first few hours, when the woimd is fresh, until the 
 parts have shrunk and become covered with mucous membrane, that is 
 to say, for many weeks, are generally fruitless. 
 
 When the mpture is allowed to remain, there arc always more or less 
 serious results. If the recto-vaginal septum is torn through, the life of 
 the patient is rendered perfectly miserable by the escape of fajces, or 
 perhaps only of flatus, or very watery faeces. But even if the sphincter 
 ani remain serviceable, the absence of the muscular perineum is of serious 
 consequence. Time it is that it in no way directly supports the utems, 
 and that when that organ has, from other causes, so far descended as to 
 press upon it, it is of little avail to prevent external protrusion, but the 
 absence of perineal support allows the vaginal wall to bulge out both an- 
 teriorly and posteriorly, when distended by the bladder or rectum. This 
 state of matters, a great discomfort in itself, tends to grow worse and 
 worse, and ultimately involves the descent of the uterus. Much atten- 
 tion has of late years been paid to improving the various operations for 
 the repair of the perineum. It forms no part of such a work as this to 
 attempt a criticism of these operations, and even to endeavour, m the 
 space at our disposal, to recapitulate all the improvements, more or less 
 
62 
 
 THE PRIMAEY OPERATIOIf 
 
 valuable, that have been proposed, would only tend to the confusion of 
 the reader, if not of the writer. It seems, therefore, better to describe 
 such proceedings as have commended themselves to me as an obstetric 
 physician by their simplicity, facility of execution, and proved success, 
 referring those who desire to study the surgical details more minutely 
 to suitable sources of information. The operations required are either 
 primary or secondary, and will vary in extent according to whether it is 
 merely the triangular perineal body that is torn, or whether the recto- 
 vaginal septum is also involved. 
 
 The primary oiDcration leaves little or no time for much study or con- 
 sideration ; it is a general practitioner's operation, the steps of which 
 should be familiar to all, and the means for its performance should never 
 be far to seek. A suitable needle or needles, and suitable material 
 for ligatures are the sole necessaries, and these add little to the 
 weight or bulk of the obstetric bag. For ligatures there is nothing 
 
 Fig. 39.— Wells's Needle-holder. 
 
 equal to silver wire, and a yard or tAvo of this should be cixt into pieces 
 of nearly a foot in length. No. 24 possesses the best thickness and 
 strength, combined with flexibility. Silk, hemp, or gut are all occa- 
 sionally employed, and it is a great advantage to have a few gut liga- 
 tures in addition to the Avire. As regards needles, the majority of 
 writers prefer a long curved one fixed in a handle, with the eye set in 
 
 Fig. 40. — American Needle-liolder. 
 
 the point, and of course a variety of curves, though not essential, is an 
 advantage. These needles should never have cutting edges. For silk 
 ligatures, some such curved needles are absolutely required, as they are 
 used to carry them around one side of the tear, and, after bending over 
 its vaginal edges, outwards around the other side. Many prefer to use 
 
FOR TOKX PEKINEl'M. 63 
 
 well-tempered, curved, sewing needles of various sizes, which are 
 guided first through one side and then through the other by needle- 
 holders. Several such needle-holders are in use, such as Wells's (fig. 39), 
 •or one usually known here as the American holder (fig. 40), but the 
 
 ..■■■if^' 
 
 C^iB^^' 
 
 Fig. 41. — Hageddrn's Needle-holder and Needle. 
 
 most handy that I have seen is that of Hagedorn of Magdeburg (fig. 41), 
 introduced into this country by Krohne and Sesemann. It acts much 
 more easily and simply than would be supposed at a first glance, and 
 the flat needles supplied with it are so made as to completely resist 
 fracture of their eyes when thus seized, a very frequent accident with 
 most others. If, however, silver wire be used, the operation is great!}- 
 simplified by the use of a long, straight, round needle, in a good firm 
 
 Fig. 42. — Straight Permeal Needle recommended l>y the author. (.\.) 
 
 handle, with a large well-bevelled eye near its point (fig. 42). This and 
 its suture wires will be found amply sufficient for the perfonnance of the 
 primary operation, unless in the case of great tearing of the septum. It 
 is much more satisfactory to place the patient on her back than to be 
 satisfied with the left lateral position, and she must be brought to the 
 ^dge of the bed in as good a light as possible. Anassthesia may be used 
 if she is very excitable, and if the uterus is well contracted, but owing 
 to numbness of the parts, caused by the previous perineal stretching, 
 there is usually less pain from the operation than might be expected. 
 A good nurse will contrive to hold up and separate both knees, while 
 the nates and feet rest on the edge of the bed, but a second assistant is 
 very servicable, or the hand and foot of the same side may be tied togetlier. 
 The operator, however, must depend on himself for all else but retaining 
 the patient in this position. The whole torn surface is first wiped as 
 clean as possible, and any extensive bleeding is arrested by pressure or 
 the application of a little carbolised spirit. A piece of clean sponge or 
 
64 
 
 PERIXEOKKAPHY. 
 
 linen is then pushed into the vagina, past the tear, so as to keep back 
 the lochial discharge. This must be removed after the sutures are 
 placed, and before they arc tightened. All this, like every other ob- 
 stetric proceeding, should be rendered antiseptic by the free use of carbolic 
 solution. The left forefinger of the operator is now placed within the 
 vagina, ready to receive and guide the point of the needle. This is 
 inserted on either side first, without wire, fully half an inch external to 
 the torn surface of skin and a little behind its posterior end, and is 
 pushed through the intervening muscular tissues to the extreme pos- 
 terior end of the wound in the mucous wall. A good amount of mus- 
 cular tissue is thus incKided between the rent and the track of the 
 
 Fig. 43. — Introductiun of First Suture, with Straight Needle, 
 in immediate Perineorraphy. 
 
 needle, and this is much better done by a straight than by a curved one. 
 The point should emerge as nearly as possible exactly at the torn edge 
 of the mucous membrane. If much of this is included, it will form, by 
 its inversion, when the ligature is tied, an impediment to union, and if 
 it be not caught at all, a raw surface will remain above the suture, a 
 possible source of septicsomia. The eyelet of the needle, guided and 
 guarded by the left finger, is pushed fairly through into the vagina, and 
 threaded there with one of the sections of wire. If the needle is pro- 
 perly made, and the wire is of due thickness, this is easily accomplished, 
 either by sight, or by touch alone if the patient is stout or muscular. 
 Bending back an inch of the wire, the needle is withdrawn, and so draws 
 
PEKINEOERAPHY. 
 
 65 
 
 dowai the suture ou one side. Precisely the same thing is now done on 
 the opposite side, the needle withdrawing, in its track from the vagina, 
 the other end of the wire (fig. 43). Two, three, or four other sutures are 
 similarly passed in front of this, at equal -distances, the foremost being 
 close to the apex of the perineum. The vaginal plug is then withdrawn 
 and the wound again carefully sponged with carbolic solution, cold at this 
 stage, until all bleeding ceases. The stitches must now be tightened, and 
 one pair after another gradually drawn until a finger in the vagina assures 
 tis that there is an even surface on the mucous side of the wound. Simple 
 twisting of the opposite wires is all that is necessary, and shot or other 
 clamps are, in the primary operation at any rate, a needless complica- 
 
 FiG. 44. — Quilled Suture of Perineum (Baker Browu). 
 
 tion. The line must be di-awn at that amount of tightness which ensures- 
 very slight traction on the whole wire, allowing for some subsequent 
 swelling of the parts and easy adaptation of the torn surfaces, without 
 forcible sqxieezing of the intervening parts. The wires must be taut, not 
 tight. The twisted ends arc cut off a full half inch from the surface and 
 laid flatly on the sides of the wound. If care has been taken, an inter- 
 rupted suture or two of gut, at gaping points, should be unnecessary. 
 
 The after-treatment should consist of catheterism, careful^ antiseptic 
 ablution, light nourishing food, and the other steps afterwards more 
 fully described when speaking of the management of vaginal or 
 
 i: 
 
■66 THE PEIMAEY OPEEATIOJ^T. 
 
 uterine operations in general (Chap. III.). The stitches may be allowed 
 to remain for about eight days. The patient should lie mostly on her 
 side, right and left alternately. Post-puei-peral exigencies may occa- 
 -sionally require us to depart from the usual dietetic rules. The ques- 
 tion of locking up the bowels for a considerable time, after this and 
 other operations on the perineum, is a difficult one. The immediate 
 advantage of doing so is self-apparent, but the subsequent risk from the 
 passage of large hardened masses, which forcibly distend the recently 
 united stiiictm-es, must have also occun-ed to every operator. On the 
 whole, I am inchned to agree with my colleague, Dr Cullingworth (see 
 paper in Mediad Chronicle, November 1884), that it is advisable to leave 
 matters very much in the hands of nature. 
 
 In venturing to propose this as the simplest and most satisfactory 
 method of operating primarily on the torn perineiun, I am aware that 
 many still prefer the double or quilled suture, introduced by curved 
 needles, and fastened at either side over pieces of quill, catheter, 
 or ivory. This (fig. 44) is famihar as "Baker Bro-\vn's " method. The 
 single wire is more simple, and quite as effective, and much havoc may 
 be played with the soft parts, in stout patients, by forcing needles, 
 often with shai'p edges, around the necessarily large and sweeping 
 curve. 
 
 If the tear has completely divided the perineum and gone through the 
 sphincter ani, the operation just described will yet sufl&ce, unless the 
 recto-vaginal septum is ve^'y much affected. The perineal stnictiu'es being 
 restored to their natural position, and firmly held there by the sutures, 
 the torn septtmi is thereby placed with its edges in juxtaposition. 
 But it is often desirable in such cases to apply one or more sutm-es to 
 the septum itself, though, if the rupture be very gTeat, subsequent proceed- 
 ings will probably be required. The best material for these sutures is gut, 
 which may, after insertion, be left to take care of itself. One straight 
 needle, or much better, a small curved one held in a needle-holder, is 
 armed with a gut ligature, and thus passed into the vagina, before any- 
 thing is done to the perineum. A finger of the left hand in the rectum 
 is the guide, and the sense of touch must often replace that of sight. 
 One or more sutures are thus passed through the opposite edges of the 
 torn septum, including only a small portion of its substance, and their 
 ends are tied and cut short within the vagina. The perineal operation 
 is then performed. The more elaborate proceedings recommended for 
 the secondary operation are almost always impossible in primary cases, 
 and I suspect that some of our eminent siu'geons, who recommend and 
 practice these, have had little or no experience of the Ijing-in room, 
 especially among those classes which, in England at any rate, seem to 
 furnish the great majority of such cases. 
 
THE SECOXDAEY OPEKATIOX. 
 
 67 
 
 The secondary operation is, iu one sense, little different from, the prim- 
 ary. It aims at precisely the same object, viz., the bringing together of 
 the opposite raw surfaces by suture ; but it requires to have its raw svir- 
 faces made afresh, and it is conducted under very diflFerent and more 
 favourable surroundings. A choice of time, and a choice of operator are 
 open. There is no excuse for the want of sufficient light, or of assistance, 
 or of anj-thing else that is requisite to ensure success. As in the case of 
 the primary operation, it may be necessary to repair only the perineal 
 substance, or the torn recto-vaginal septum also. The operator, under 
 the conditions of the secondary operation, has another great advantage ; 
 he may, if he think it advisable, as he often will, repair the torn recto- 
 vaginal septum first, and at a subsequent operation proceed to the repair 
 of the perineum. 
 
 At least four assistants are necessary, or at any rate useful, to perform 
 these operations with certainty and comfort. One of these takes care of 
 the ansesthetic, and two suppoi't the legs of the patient. To do this 
 satisfactorily, she is placed in lithotomy position, the hand and foot of 
 the same side being tied together. One assistant stands on each side, 
 facing the operator, and with one arm keeps the knee of the patient 
 well abducted, while with the other hands they hold open the labia, 
 taking care to keep them exactly in the same position on each side, and 
 making no irregTdar traction in any direction. Small spatuke are more 
 convenient for this purpose than the fingers. The fourth assistant is 
 prepared to assist the operator with sponges, &c., and must be careful in 
 
 Fig. 45. — Sim.s's Sponge-holder. 
 
 Fig. 46. — Emmet's Knife-holder. 
 
 doing so not to obstruct the light. To avoid this the sponge^ should be 
 small and held by forceps or special holders (fig. 45). The recto-vaginal 
 septum, if torn, is first attacked, and, as has been stated, this may often 
 suffice for one operation, where the rent is severe. The opposite edges 
 are to be freshened down to the sphincter, the operator seizing fii*st one 
 and then the other with a fine hook or forceps, and carefully cutting it 
 away. The strips should be removed from the vaginal, rather than from 
 the rectal wall. For this purpose cither a fine long-handled bistoury may 
 be used, or one capable of being set at any angle to its handle (fig. 46), as 
 introduced by Sims for operations on the cei*vix uteri ; but the majority 
 
68 
 
 VAEIOUS INSTRUMENTS. 
 
 of operators will succeed best by using scissors, curved or straight, as may 
 seem most convenient (fig. 47). Those who practise surgery of this kind 
 to any extent will find it necessary to have several pairs curved in 
 various ways. Only a thin strip is required, and its removal is a very 
 dehcate process. As far as possible it is well to remove the whole of one 
 side in one strip, and no islets must be left behind. To ensure the 
 
 Fig. 47. — Bozemann's Scissors. 
 
 apposition of raw edges at the upper angle, it is well to lengthen the 
 tear with the scissors for an eighth of an inch or thereabouts. The 
 septum operated upon is so thin that its certainty of adhesion is 
 increased by very carefully separating its two layers, or splitting it to a 
 slight extent, and this, quite independently of any relation to modifi- 
 
 FiG. 48.— Laterally Curved Needle, for fistula, &c. 
 
 cations where the slitting is made more thorough, and the vaginal and 
 rectal portions treated separately. Su.tures have now to be apphed— gut 
 when the perineal operation is performed at the same time, silver when 
 it is not. A finer wire is advisable than that used for the thick perineal 
 body. The needle for this purpose must curve laterally in relation to 
 
 Fig. 49.— Tyler Smith's Tubular Needle. 
 
 its holder, whether that be free or attached(fig. 48) ; all forms of tubular 
 instmrnent (fig. 49) are apt to get out of order, and the handled needles 
 are seldom sufficiently round and free from cutting edges. About five 
 sutures are required to the inch ; those of gut are tied in the vagina and 
 
SECONDARY PEKINEOEEAPIIY. 
 
 69 
 
 cut short ; those of silver are twisted, and cut off a full half-inch from 
 the mucous membrane, and the stumps are bent over to the right and 
 left sides alternately, to facilitate removal. 
 
 For the repair of the perineum, a freshening process is required on a 
 larger scale than would at first suggest itself. Two raw surfaces are 
 required, to represent, as nearly as possible, the torn perineal sides, 
 and as the parts have now shrunk, the freshening must extend 
 somewhat into the buttock and vagina, and beyond the new, glazed 
 mucous membrane. We form therefore such a raw surface as represented 
 at fig. 50. The dissection should commence behind, and should first 
 outline the posterior border of the new perineum, then gradually work- 
 ing forwards, a layer of the requisite size and shape is dissected ofi^ on 
 either side. If the dissection were commenced in front, the blood, trick- 
 
 FlG. 
 
 Perineum Fresliened, witli Sutures introduced. 
 
 ling backwards, would greatly obscure the subsequent progress. I have 
 seen the proposed outlines of the dissection previously mapped out with 
 a pencil of nitrate of silver, but it is better to depend on one's observa- 
 tion at the time of operation. The two sides must, however, be vivified 
 as nearly alike as is possible. Many, if not most, operators prefer to 
 denude the proposed surface by snipping with fine scissors rather than 
 by the knife. All bleeding must be stopped by pressure and torsion of 
 the most vascular points ; and continuous oozing, by cold, or by a fine 
 stream of hot water, or by the use of si)irit of wine. 
 
 A totally different plan of revivifying was proposed by Dr Jeuks of 
 Chicago in the Amerinui Journal of OhstetricK for April 1879, p. 262, 
 and has been tried with success by Emmet, Albert Smith, and others. 
 
70 SECONDARY PEEIXEOEEAPHY. 
 
 He first makes a small incision with fine scissors, about the centre 
 of the lower border of the proposed raw surface. Through this both 
 blades are insinuated, below and parallel to the mucous siuface, and 
 its separation is now performed subcutaneously by repeated snippings. 
 Discoloration of the smface clearly marks the route the scissors have 
 taken, but there is no external haemorrhage, except a few drops from the 
 opening, and the process is rapid. When the whole required surface is 
 thus separated from its attachments, and clearly indicated to the eye, 
 the flaps are cut away on each side by scissors, with perfect regularity of 
 outhne, and there is no necessity for searching for islets of mucous tissue 
 not separated. I look upon this plan as a most valuable contribution 
 to g}Ti8ecological surgery, and it can be made equally available for 
 those modifications of the operation, where the flaps of mucous mem- 
 brane are, instead of being cut away, utilised, by their apposition, to 
 increase the strength and thickness of the perineum. A probe-pointed 
 tenotomy knife can be introduced, and used in the same w-ay as the 
 scissors, but is more likely to give rise to some troublesome hsemorrhage 
 afterwards. 
 
 When the freshening is completed by the removal of the necessary 
 surface, and oozing has ceased, the sides are brought together precisely 
 as in the primary operation. The straight needle and silver Avire will in 
 most cases suf&ce equally well in the secondary operation, if care be 
 taken to place the posterior stitch quite up to the posterior angle 
 of the woimd in the vaginal mucous wall. If there is still a small 
 portion of imunited recto-vaginal septum, which has, however, been well 
 freshened, many authorities recommend the use of one posterior stitch, 
 which would certainly requu'e a long and well-ciu'ved needle for its in- 
 sertion. The course of this stitch is as follows : — Entering on one side, 
 half an inch at least external to the lower margin of the amis, it passes, 
 guided by a finger in the rectum, through the muscular tissues, into the 
 cellular tissue between rectiim and vagina, round and above the upper 
 edge of the rent, without emerging, and so downwards on the opposite 
 side. This stitch, if used at all, must be inserted before those in the 
 perineum, and it must be clamped at each extremity, rather than tied, so 
 as not to occlude the anus. 
 
 The proceeding now given is the one which seems to me to be, 
 on the whole, most capable of yielding good success, in the hands 
 of an operator endowed with a fair ordinary amount of skill. But 
 there are very many modifications, some of which are, I believe, 
 improvements, especially in the hands of the dexterous surgeons 
 by whom they are introduced ; others are, I am sm-e, unnecessary com- 
 plications. In Baker Brown's Surgical Diseases of Women, 1866, the 
 student will find the basis of these operations most carefully laid, the 
 
EMMET ON PEKINEORIIAPHY. 7 1 
 
 improvements which have since been chiefly of advantage being the 
 introduction of silver wire for ligatures, and the abandonment of the 
 double or quilled suture. A great number of the proposed alterations 
 have also for their object to avoid the removal of any part of the tissues, 
 and instead of entirely removing the dissected flaps, to utilise them 
 for the purpose of closing the rent and rendering its adhesion stronger. 
 This is accomplished by turning them upwards into the vagina and 
 uniting their raw surfaces. The coxcomb-like projection thus formed 
 soon shrinks. In Emmet's Principles and Practice of Gynmcology, 
 (1880), the student will find much recent information on perineorraphy 
 as on all surgical questions in gynaecology. In Schroeder {Ziemssen's 
 Cyclopcedia, vol. x.) he will find a short description of Langenbeck's 
 and Simon's methods. Lawson Tait's ingenious procedure for utilis- 
 ing the flaps {Obstetrical Journal, vol. vii.) I ' have known produce 
 excellent results, but it is not every tyro who will clearly understand 
 it, unless he sees it actually performed. Bantock {Rupture of Female 
 Perineum, 1878) conveys much useful information, and Goodell {Lessons 
 in Gynecology, 1880), in his racy manner, gives much sound practical 
 advice on the subject of perineal repair. No one would, I suppose, 
 undertake the management of a delicate case of this kind without care- 
 fully studying one or more such authorities. 
 
 It is characteristic, however, of the fluctuating condition of much of 
 gynaecological surgery, to find Emmet recently stating (I quote only from 
 an abstract in the American Journal of Obstetrics, vol. xvi. 1883, p. 
 1080), that "a simple laceration of the perineum, extending even to the 
 fibres of the sphincter ani, produces no inconvenience after the ]Darts 
 once have healed." Until the inutility of operations for the cure of ills, 
 believed to be due to this cause, is further proved, and the necessity for 
 other or additional oj)erations on the posterior vaginal wall is a little 
 further worked out, I must consider this matter as at least sub Judice. I 
 am, however, certain of this, that although the pelvic fascia, which is per- 
 forated by the vagina and urethra, may be probably shown to furnish the 
 chief outward support for the pelvic viscera, rather than the perineal body, 
 and although it may be the case that this fascia can only be restored to 
 action by paring and stitching together some portion of the posterior 
 vaginal wall, higher than any perineal tear, still the absence of the peri- 
 neal body does, by itself, promote vaginal prolapse, usually followed by 
 uterine descent. We shall therefore remain indebted to Ennnet and 
 others for the care they have bestowed in i)erfecting its repair. 
 
72 insteujVIents used in gynecological teeatment. 
 
 CHAPTER III. 
 
 Methods akd Meaxs commonly employed in Surgical Treatment. Instru- 
 ments used in Local Treatment. Methods of Introducing Eemedial Substances. 
 General Management of Gynecological Operations. Preparation. Anti- 
 septics. After-Treatment. Anesthesia. 
 
 In speaking of the after-treatment of the operations for torn perineum, 
 at the close of the last chapter, I referred to the present for some 
 further details. It would seem that a good deal of unnecessary repeti- 
 tion may be avoided, if, in this section, I introduce a few somewhat 
 discursive remarks on several of the means and methods employed in the 
 surgical treatment of female diseases. Many means of the kind are 
 only applicable to a small number of cases, and only intelligible when 
 these are under consideration. Others have a more general application, 
 and these I propose to mention here. 
 
 Certain Instruments nsed in Treatment. 
 
 1. Aspirators. — Both for diag-nosis and treatment, an aspirator, in some 
 form, is very commonly required. For the former purpose it may be 
 necessary to remove only an exceedingly small quantity of fluid for 
 examination, or perhaps merely to ascertain whether there is any fluid 
 to remove ; and in such cases the ordinary subcutaneous injection- 
 syringe Avill suffice. If full antiseptic precautions are employed, the 
 use of this may be said to be quite free from danger. In order to reach 
 cysts situated high in the pelvis, or in the abdomen, a much longer tubular 
 needle may be employed, furnished with a stop-cock (fig. 51). I prefer 
 to call this form of aspiration "exploration." In the case of very small 
 cysts, those of the labia or vagina, for instance, even Avhen complete 
 emptying is required, this means may also suffice ; but a larger and more 
 complicated instrament is generally necessary, the essentials of which 
 are a good-sized receiver, a strong, well-fitting exhausting syringe, 
 trocars of various sizes, or needles into which the cutting-point can be 
 withdrawn, and a connecting flexible tube, with one or more stop-cocks. 
 The instrument of Rasmussen (fig. 52) fulfils these conditions, though 
 there are several others of more elaborate make. For the diagnosis of 
 
ASPIRATORS ECRASEURS. 
 
 73 
 
 the coutents of ovarian tumovirs from ascitic fluids, or from the fluid of 
 parovarian, renal, hepatic, mesenteric, or other cysts, the aspirator is 
 frequently necessary. Cystic, or apparently cystic, tumours 
 in the pelvis, containing blood, pus, serum, or ovarian or 
 other fluids, may thus be diagnosed, but puncturing of these 
 by any but the very finest needles is very gravely to be 
 deprecated, unless the surgeon is prepared to act at once 
 upon the knowledge thus obtained. The fluid of an 
 extra-uterine foetation may also be removed by a fine aspira- 
 tor, with a view to arresting the growth of the foetus. 
 
 Ecraseurs. — The ecraseur is another instrument in fi-e- 
 quent use for the removal of tumours which can be encircled 
 by its wire or chain, especially those growths which have 
 more or less of a pedicle of attachment. It has the advan- 
 tage of performing a bloodless amputation ; it can often 
 be applied where the knife or scissors cannot reach, and, if 
 curved, it often avoids the necessity of dragging the parts 
 too forcibly downwards. On the other hand, its incision 
 is less clearly defined than that of the knife, a matter of 
 importance in malignant disease, and if there be not a well- 
 defined pedicle, it may, as it were, 
 scalp the included growth rather 
 than cut clearly through its attach- 
 ment. In some cases this can be 
 avoided by first transfixing the mass 
 with a needle just outside the bite of 
 the wire or chain (fig. 53). The fol- 
 lowing arc the chief forms : — The 
 chain-ecraseur of Chassaignac (fig. 
 54) and its modifications ; the wire 
 or wire-rope ecraseur (fig. 55), which 
 may also be curved in its shank ; and 
 the galvanic ecraseur. A smaller form 
 of wire-ecraseur is used by Emmet as 
 a tourniquet to constrict the cervix 
 uteri, and so arrest hajmorrhage dur- 
 ing the performance of operations on 
 Fig. 51.— Aspirator Needle. ,■<. , /-. ^^i o ,-i i 
 
 that organ. Growths of the vulva or 
 
 vagina, the cervix uteri itself, polj'pi or polypoid fibroids of the utcnis, 
 whether intra- or extra-uterine, are very frequently removed liy the ecras- 
 eur. The pedicle in ovariotomy is also occasionally divided in this way. 
 The chain-ecraseur has undoubtedly very great power, and is there- 
 fore applicable for the amputation of large or solid growths, when it can 
 
74 
 
 ECEASEUES, 
 
 be made to eucircle them. When they are high up in the uterus this is, 
 however, often very difl&cult, 
 owing to the too great flexi- 
 bihty of the chain. Marion 
 Sims had an ingenious appar- 
 atus for keeping the chain loop 
 open, and guiding it over a bul- 
 bous polypus, but in really 
 difficult cases I have not been 
 able to succeed with it, and the 
 same experience has occurred 
 to others. A whip-cord may be 
 passed roimd by means of such 
 an instrument as Belocq's, used 
 for plugging the posterior nares, 
 or by the old-fashioned Gooch's 
 cannulge, or by two gaim-elastic 
 male catheters, through each of 
 which the ligatui-eis passed, unit- 
 ing them loosely at their further 
 extremities, and by this cord 
 the chain may be dra-mi round 
 the pedicle or base. Even then 
 it may be very difficult after- 
 wards to fix the chain properly 
 so that the ecras- 
 eur will work. 
 The wire instru- 
 ments are rather 
 more simply con- Fig. 52. --Rasmussen's Aspirator. 
 
 structed, and the wires used vary. The best of all is a well-annealed 
 steel wire, which may be had of any 
 streng-th, and of very great pliability at 
 the same time, and there are few intra- 
 uterine growths over which it cannot 
 be manoeuvred. 
 
 The wires of many strands are useless 
 for very resisting growths, but Messrs 
 Newall & Co., of 130 Strand, London, 
 manufacture a rope for telegraphic pur- 
 poses, which was first favourably men- ^i*^- ^3.— Gro\mi transfixed by Needle, 
 tioned by Mr BarweU at the London to secure the hold of the Ecraseur. ' 
 Chnical Society. It is very strong and very flexible, superior to the 
 
ECEASEUES. 
 
 75 
 
 single wire in flexibility, but slightly inferior in strength. The ^alvanic 
 
 Fig. 54. — Chassaigiiac's Chain 
 Ecraseur. 
 
 Fig. 55.— Braxton Ilicks's Wire 
 
 Ecraseui'. 
 
76 
 
 GALVANIC ECEASEUR AND CAUTEEIES. 
 
 ecraseur (fig. 56), when its platiimm wire is heated sufl&ciently, cuts 
 
 through as cleanly as a knife. The wire 
 should, while cold, be tightened just sufficiently 
 to hold firmly, and the screw must afterwards 
 be used very slowly, so that it may burn, not 
 tear through. The least over-tension will 
 break it. It is very important to ascertain 
 before operating that the number of cells is 
 sufiicient to heat the thickness of platinum 
 wire used, and it should be remembered 
 that the heat required is much greater when 
 the wire is surrounded by moist tissues, than 
 when free in the air. The galvanic ecraseur 
 is admirably adapted for growths of the vulva 
 or cervix. It cannot be retained in its place 
 by a vulsellum or metal needle, as the electric 
 current is thus wrongly directed, but a bone 
 needle may be used for the purpose. 
 
 3. Galvanic or Thermal Cauteries are of 
 service in many other forms beside that of the 
 ecraseur. Whenever any growth can be de- 
 stroyed by the action of heat, and when there 
 are great or insuperable difiiculties in getting 
 beyond it, the variously shaped instruments 
 which are attached to Paquelin's thermo 
 cautery (fig. 57), or which may be adapted 
 to the galvanic battery, may be used for this 
 purpose, and especially the white-heated blunt 
 knife can be used bloodlessly and safely on re- 
 dundancies of the external genitals, or for open- 
 ing cysts or abscesses. Till Faure's or other 
 accumulators of electricity are placed more 
 freely at the disposal of the profession, Pa- 
 quelin's instrument will be found most useful. 
 I have not attempted to describe the detailed 
 action of either it or the galvano-ecraseur. 
 A few minutes' inspection will be more ser- 
 viceable than any instruction in their absence. 
 
 4. Curettes. — The curette is an instrument 
 of comparatively recent introduction, of un- 
 
 FiG. 56.— Galvanic Ecraseur. doubted service, but capable of being, as it 
 has been, very dangerously abused. Recamier's instiniment, introduced 
 in 1850, was a small steel loop, with a very decidedly sharp scraping 
 
CAUTEEIES CURETTES SCARIFICATORS. 
 
 77 
 
 edge, attached to a stiff handle. Since then it has been advantageously 
 modified by Thomas and others 
 (fig. 58), becoming mei-ely a blunt, 
 though not very thick, wire loop, 
 with a handle which is capable of 
 being slightly bent, while the loop 
 is rigid. Simon uses a cup-shaped 
 scoop of steel, of various shapes 
 and sizes. For diagnostic pur- 
 poses, the curette, introduced 
 through the naturally or artifici- 
 ally dilated cervix, may be em- 
 ployed to scrape small portions 
 from any sufl&ciently soft intra- 
 uterine growth, for microscopic 
 examination ; and it has been freely used by S. Moricke in his investiga- 
 tions of the menstrual mucous membrane. For the removal of chronic 
 intra-uterine, inflammatory granulations, it is also as safe and effectual, 
 in thoroughly practised hands, and none else should use it, as the 
 more powerful caustic fluids, and it is a valuable addition to our 
 means of treating retained and adherent products of abortion. For 
 
 Fig. 57. — Paqiielin's Cautery. 
 
 Fig. 58.— Sims's Curette. 
 
 the removal of intra-uterine malignant growths it is also available, 
 although, as it is impossible to hope for cure in this way, it should 
 only be used in the presence of continued wasting discharge, which 
 we hope for a time to alleviate, and there is always some danger of the 
 portions of diseased tissue thus loosened adding to the rapidity of 
 secondary systemic infiltration. Volkmann's spoon may also occasionally 
 be turned to account in uterine practice. 
 
 5. Scarificators. — Depletion of the cervix uteri is sometimes of 
 undoubted advantage. For this purpose, leeches used to be freely cm- 
 ployed, but their application is exceedingly troublesome, and many 
 accidents have followed in its wake — dangerous haemorrhages, scptictcmia, 
 hysterical complications, and escape of the animal into the uterus. 
 Their application is xmsuited, for different reasons, to the practitioner or 
 to the ordinary nurse. Some form of scarification is now, therefore, always 
 preferred, though leeches are still occasionally applied to the perineum, 
 for general engorgement of the pelvic viscera. It matters little whether 
 the scarificator is round, spear, or otherwise shaped ; any cutting instru- 
 ment, with a handle long enough to permit of its use with the speculum, 
 
78 
 
 SUTURES AND LIGATUEES. 
 
 "will suffice (fig. 59). Several radiating cuts are made, about an eighth 
 of an inch deep, which -will bleed freely, though seldom profusely. In acute 
 inflammation of the uterus, or its neighbouring parts, scarification of the 
 cervix often gives considerable rehef Among chronic 
 afl^ections, the chief indications are dysmenorrhoea, prior 
 to acute exacerbations, when these can be reasonably 
 foretold, the occasional sub-acute engorgement of fibroid 
 growths or chronic enlargements of the uterus, sup- 
 pressed menstruation with great pelvic fulness, and 
 chi'onic cervical endometritis with folhcular projections 
 from the cervix, in which case as many as possible of 
 these folhcles should be pimctured. I have no experi- 
 ence of scarifying the interior of the uterus except by 
 curette. The pain of scarification, except under condi- 
 tions of acute inflammation, is only trivial, but the 
 operation should never be performed except at home 
 and in bed. One can never be quite sure of not 
 meeting with a special hsemorrhagic tendency, or wound- 
 ing a varicose vein of the cervix. 
 
 Incision of the cervix uteri, for the purjDose of enlarg- 
 ing its canal, wiU be spoken of under the headings of 
 Dysmenorrhoea, Uterine Flexions, Fibroid Tumours, &c. 
 Dilatation of the same part by various artificial means, 
 for diag-nostic or therapeutic piu'poses, will also be then 
 discussed. 
 
 6. Sutures and Ligatures. — So many gynaecological 
 procedures, slight and of every-day occurrence, or severe 
 and within the range of the speciahst alone, involve 
 the bringing together of torn or artificially freshened 
 parts, that it wiU be well to say a few words on the 
 subject of ligatures and sutures, their material, and 
 mode of introduction and removal. As regards material, 
 owe choice is practically threefold — metal, silk, or gut. 
 
 Metal Sutures are, for the great majority of purposes, 
 the best, wherever they cannot be left for absorption or 
 other disposal by nature alone, without removal. They 
 can be made, and are in their nature absolutely a-septic. 
 They can be retained with impunity for a very long time. 
 They are, if of right material, as flexible and as strong as 
 <;an possibly be desired. An era in gynsecological surgery commenced 
 when the best foi-m of metal sutures was introduced by Marion Sims, and 
 no kind of metallic suture equals pure, or nearly pure, silver. Galvanised 
 iron wire has some advantages, chiefly on the score of expense ; but the 
 
 Fig. 59.- Palfrey 
 Scarificator. 
 
WIRE SUTURES, THEIR MANAGEMENT. 79 
 
 requisite degrees of strength, flexibility, and thickness are not in the 
 market. Silvered or electro-plated wires arc an utter snare and delusion ; 
 they break, or they hank, or they otherwise fail one at the most critical 
 periods of an operation. I advise the general practitioner, even one 
 who will never attempt any plastic operation beyond repairing a recently 
 torn perineum, to insist on his instrument-maker guaranteeing him a 
 few yards of silver wire, toughened, perhaps, by a slight alloy, but not 
 electro-plated rubbish. There are several varieties of thickness which 
 may be employed for different purposes. No. 24 is a strong though 
 flexible Avire, suited for stitching the deep perineal tissues, or for bring- 
 ing together the abdominal walls in abdominal section. No. 28 and 
 No. 30 are more suited for vesico-vaginal operations, or stitching the 
 torn cervix, but occasionally a stouter wire is preferable in this latter 
 case, Avhen the parts are indurated and the gaping is persistent. 
 
 Silk is also spun of very varying thickness, and the medium sizes are 
 still preferred by some, where the majority prefer silver. If made of silk 
 only, and well carbolised, they are certainly available for such purposes, 
 but not so safe as good wire. Some years ago I tried alternate silk and 
 silver sutures for the abdominal walls in ovariotomy, and I had, in the 
 same cases, several small purulent foci around the former and none about 
 the latter. For the pedicle in ovariotomy the strongest makes of pure 
 China silk answer admirably. 
 
 Gut Sutures, thoroughly carbolised, may be used for tying small vessels 
 within a closed wound, but torsion should nearly always sufiice for these. 
 There are few who dare trust the ovarian pedicle to them ; but either they 
 or fine silk ligatures do well for small adhesions, and are never heard of 
 more. For deep sutures about the vagina, where it would be almost 
 impossible to reach them for removal, without injuring lower and recently 
 united parts, the gut suture answers well, and in time it entirely disap- 
 pea,rs. Lister's chromic cat-gut ligature lasts a considerable time, where 
 that is desirable, and Ban- 
 tock greatly prefers the 
 so-called silk-worm gut. 
 
 Gut and silk are tied 
 in the ordinary knot, but 
 wire requires to be twisted 
 or clamped. I think there Fig. 60.— Silver Wire Twisting (Emmet), 
 
 is a strong tendency to 
 
 abandon the latter procedure in favour of the former. When the wtniiHl 
 is upon the external surface of the abdomen or ])erineuni, twisting can l)c 
 performed by the fingers alone, as well as by any instruments, — the more 
 nimble the fingers, the more is this true ; but when this has to be done 
 within the vaginal or other cavities, two instruments are useful or even 
 
80 
 
 VAGINAL INJECTIONS. 
 
 essential. One of these is a minute fork (fig. 60), through the slit in 
 which both ends are carefully placed, and shouldered together at the right 
 spot, while the twisting is performed by the other, a broad pair of forceps. 
 Removal is effected by gently lifting the twisted portion, snipping one 
 side close to it, and then drawing the twist slowly over towards the cut 
 side, while the edges of the wound are pressed with the closed scissors. 
 The operator will find many minute and valuable suggestions on the whole 
 subject of sutures in Emmet's Principles and Practice of Gynaecology. 
 
 Introduction of Eemedial Substances. 
 
 Vaginal Injections. — Vaginal injections are required either for the 
 purpose of introducing remedial fluids to the walls of the vagina, in the 
 various chronic or acute affections of that organ, for washing away hurtful 
 discharges, or for the effect to be produced upon the surrounding organs 
 and tissues. The various substances — astringent, antiseptic, soothing, 
 or alterative — employed for the first of these indications, will be men- 
 tioned in Chapter V. and elsewhere, but their efficacy is often impaired 
 or entirely destroyed by faulty methods and instruments. The classical 
 clyster-pump of Moliere's time is entirely out of date, and the little glass 
 
 Fig. 61. — Higginson's Syringe. 
 
 or pewter instruments sold in the shops are almost absolutely useless. 
 Every vaginal injection-syringe should be furnished with a slightly 
 bulbous, hard caoutchouc nozzle, some five or six inches long, and this 
 should be perforated at its sides, and not at its extremity, otherwise 
 there is a risk of performing an involuntary intra-uterine injection. If 
 well made, the lateral orifices should also perforate the tube obliquely 
 in a backwards direction. Fitted with such a nozzle, there is nothing 
 better for ordinary purposes than Higginson's syringe (fig. 61). If the 
 patient is strong, she can, in ordinary cases, use it herself, and it is very 
 easily managed by an assistant. When frequent or continuous irriga- 
 tion is required, it is better, however, to depend on simple gravitation 
 
THE VAGINAL DOUCHE. 
 
 81 
 
 or syphon action, the fluid being placed at a higher level than the patient, 
 and allowed to gravitate downwards by its own weight. Fig. 62 illus- 
 trates the principle of the vaginal douche, and it requires but little 
 inventive genius to extemporise such an one in the 
 cheapest possible fashion, while much more elaborate 
 forms of the same thing are purchasable. Brass pumps 
 and patent winding-up syphons are quite unnecessary. 
 
 The position of the patient is of great importance. 
 For simple washing, or mild astringent injections, the 
 semi-sitting posture over a hip-bath, chamber iitensil, 
 or hidet, may answer ; but it is very fatiguing, and fails 
 to allow of the full effect of any remedy. To get the 
 full advantage, the patient must lie on her back, with 
 her hips well raised, so that the fluid gravitates back- 
 wards. Some ingenuity is required to place the bed- 
 pan securely under the hips, and to guard the bed with 
 a w^aterproof sheet so that it does not become w^et or 
 soiled ; and this difficulty may sometimes be avoided 
 by attaching to the tube a double vaginal piece (fig. 63), 
 which directs the stream continuously where desired. 
 It is difiicult, however, to secure jjerfect adaptation of 
 this to the calibre of the vagina or vulva. 
 
 Hot Water Injections. — Dr T. A. Emmet has con- 
 ferred an invaluable boon by introducing into practice 
 the injection of vei'y hot water into the vagina, not 
 for its own treatment only, but for the purpose of 
 removing congestions in every part of the pelvis. 
 Already this is acknowledged on all hands as a most 
 perfect curative measure in many forms of uterine or 
 pelvic disease, though it is seldom carried out quite 
 efficiently. Explain it as we may, it is an undoubted 
 fact that very copious injections of very hot water, 
 with the pelvis well raised, do tend temporarily, and 
 often permanently, to remove that venous congestion 
 which is the most troublesome element and the greatest 
 obstacle to recovery in all utero-pelvic troubles. In all chronic enlar<i-e- 
 ments of the uterus, in all cases of chronic pelvic cellulitis, and in the 
 chronic inflammatory conditions of the cervix, with or without fissure I 
 know of no one remedy which gives so much relief. The value of these 
 injections in renovating diseased mucous surfaces, and preparing thcni for 
 operative proceedings, is also inestimable. Holding this opinion of the 
 value of hot water so employed, I may perhaps be excused if I. use Emmet's 
 words instead of my own, premising that such injections, commcncin" 
 
 V 
 
 Fig. 62.— Vaginal 
 Douche. 
 
82 HOT WATER VAGINAL INJECTIONS. 
 
 at 95° F., may be gTadually increased up to 105°, 110°, or upwards, 
 according to the patient's feelings. I have no experience of the almost 
 
 boiling injections (140° F. and up- 
 wards), which have been lately used 
 in smaU quantities, directed through 
 the speculum, and sucked up again 
 through it, so as to avoid scalding the 
 skin. Emimet says : — 
 
 T? £.0 -r^ , TVT , „ "The use of hot-water vaginal iniec- 
 
 FiG. 63.— DoTigle Nozzle for Vaginal ^. . ,, , ^ • n • ■,■■ ^ 
 
 Syringe. tions is equally benenciai m all those 
 
 conditions which constitute the vari- 
 ous forms of diseases in the female organs of generation, and which 
 are amenable to any treatment other than a surgical procedure ; and 
 equally so, whether the congestion be venous or arterial. This 
 remedy is not to be considered as a 'cure-all,' but one of the most 
 valuable adjuvants, under all circumstances, to other means. Yet 
 so beneficial is it, escept in displacements of the uteinas, that I 
 believe more can be accomplished in the treatment of the diseases 
 of women by its use, and a carefully regulated plan of general 
 treatment, than by all other means combined. The full benefit 
 can only be obtained by administering it while the patient is lying on 
 her back, and she cannot efficiently give it to herself. It is also neces- 
 sary that her hips should be elevated, and the quantity of water used 
 should not be less than half a gallon for each injection A bed- 
 pan of proper size and shape is indispensable, the one known as the 
 English bed-pan answers the purpose very well. The shovel-shaped 
 
 bed-pan does not The hollow handle may be turned to one side, 
 
 and a piece of india-rubber tubing stretched over it to allow the water 
 to pass off into a receptacle placed alongside of the bed. The vessel of 
 hot water is placed on a chair by the bedside, and the nurse passes the 
 nozzle of the syringe over the perineum into the vagina, directing it 
 along the recto-vaginal Avail until it has reached the posterior cul-de-sac. 
 The water must be thrown in, at first, very carefully, until the vagina 
 has become distended. If the nozzle is not properly introduced, the 
 stream of water may be throAni directly into the uterine canal. At the 
 completion of the injection, the vagina can be emptied by depressing 
 the perineum for a few seconds. A steady stream is never as serviceable 
 as the interrupted current from a Davidson's {Anglice Higginson's) 
 syringe. Hence it would seem as if, in addition to the heat of the 
 water, the jet from the syringe acts as a stimulus to excite the blood- 
 vessels to contraction. The temperature and quantity of water are to 
 be varied according- to circumstances. When treating the early stages 
 of inflammation, it is necessary that the temperature should be elevated 
 
VAGINAL PLUGS OK TAMPONS. 83 
 
 rapidly from that of blood-heat to 110° F., or to as high a degree as can 
 be borne by the patient, and that the injection should be often repeated. 
 For ordinary nse, a gallon of water, two or three degrees above blood- 
 heat, is generally sufficient, but the temperature must be maintained at 
 the highest point. This ' cooking process,' as it has been slightingly 
 termed, is rendered easier by the use of ivory, or some other non-conduct- 
 ing material, for the nozzle of the syringe, since the patient suffers more 
 from the heated metal surface of the ordinary nozzle coming in contact 
 with the outlet of the vagina than from any degree of heat in the water." 
 Vaginal Plugs or Tampons. — Plugging of the vagina is resorted to 
 for the purpose of controlling hsemorrhage ; but besides this, plugs of 
 various material are often introduced for the purpose of conveying 
 remedial agents intended to act on the vagina itself, the cervix uteri, or 
 surrounding parts. For the purpose of thoroughly plugging the vagina 
 for the control of uterine hsemorrhage, the speculum should always be 
 used — either the largest tubular form or the duck-bill. The upper part 
 of the vagina and the cervix being cleansed as far as possible, a small 
 piece of lint, well saturated with the glyceroles of tannin and phenol, is 
 attached to a long and strong thread, and packed well over and around 
 the cervix, the thread being allowed to hang through the speculum. 
 In many instances it is advisable previously to place a tent within the 
 cavity of the cervix itself. For the rest of the plug various substances 
 may be used, absorbent cotton-wool, strings of lamp wick, lint, car- 
 bolised tow, or tenax. I prefer the last of these when it is available. 
 It should first be well damped with carbolic solution. Portions rather 
 larger than a walnut are now introduced, one by one, by the speculum 
 forceps, holding back the string of the original pledget while they are 
 successively packed, first around the cervix, and then side by side, so as 
 tightly to fill the whole vaginal cavity. If the tubular speculuin is 
 used, it is gradually withdrawn ; but in serious cases, where every drop 
 of blood lost is of importance, and where assistance is available, there is 
 no doubt that the operation can be more satisfactorily performed by 
 means of the duck-bill. When the whole vagina is thoroughly packed 
 in this Avay, there is, vintil its removal, a perfect securit}' against ex- 
 ternal hajmorrhage. But the danger of internal bleeding into an 
 enlarged uterus, and of reflux thrcnigh the Fall()])i;ui tubes, must never 
 be forgotten. Fortunately, in most non-i)ucrj)eral cases, the introduc- 
 tion of a firm medicated plug into the cervix uteri (fig. 64),^ or a tent, 
 and its retention there for a short time by even a loose vaginal plui;- till 
 expansion occurs, is sufficient to obviate the necessity of vaginal 
 
 ^ When a small plug is drawn well into the cervix by Chroback's instruiueiit, it 
 must be retained by a probe while the instrument is withdrawn, and subsequently 
 pusheil more firmly home. 
 
84 VAEIOrS INSTEUMENTS USED FOR 
 
 plugging. No vaginal plug should ever remain beyond twenty-four 
 hours, or less if a tent has also been employed. The mass may be 
 gTadually removed by the forceps, or after a portion is removed, it may 
 be possible to slip the duck-bill blade behind the rest, but generally the 
 upper part is soft and slippery, and, by drawing at the cord of the first 
 pledget, it will come away with but slight assistance from the forceps. 
 India-iTibber vaginal dilators are not so service- 
 able as the plug in non-obstetric practice. It 
 is almost impossible to dilate them so thorough- 
 ly that blood will not ooze freely around them. 
 The introduction of vaginal tampons or plugs 
 as conveyers of local remedies is of frequent 
 \ \ necessity, especially since the valuable proper- 
 
 ' ' ties of glycerine have been understood. Its 
 
 free extraction of watery fluid from aU the 
 surrounding parts tends to render it one of 
 the best alterative remedies we possess. Next 
 /l JC^ "Xikl ^*^' ^^' alongside of, the use of hot water, no 
 
 / ^^ ^ other remedy has obtained such a hold among 
 
 all practitioners, and in all countries. Absorb- 
 ent cotton is the best substance for this purpose. 
 The size of tampon used will depend on whether 
 we wish to apply it merely to the summit of the 
 vagina or partially to fill its cavity, and will 
 also depend upon the calibre of the organ; 
 generally one about the size of a walnut is 
 required. I do not think the shape is very 
 material, though some writers lay great stress 
 upon it. A strong cord is tied round its centre, 
 long enough to hang through the vulva. Hav- 
 ing been well soaked in the material required, 
 it may be introduced either by the practitioner 
 or nurse, or patient herself, by means of Barnes's 
 FiG.64.-Instrmnent for i^strnmeut (fig. 65), which obviates squeezing 
 Plugging the Cervix ^ ° '' _□ -j tvt 
 
 Uteri (Chrobak). o^t and waste of the saturating fluid. More 
 
 rarely the speculum may be required to secure 
 complete apposition to any particular surface, but very commonly, with 
 the glycerine plug at any rate, the patient can simply push it home 
 with the vaginal nozzle of a syringe. Glycerine and the various glycer- 
 oles of astringent or antiseptic substances lend themselves most easily 
 for use by tampons, but many also use in this way emollient ointments 
 of vaseline or petrol eiim jelly, or powders sprinkled upon the surface of 
 these. Such applications of powders are apt to be irritating and diffi- 
 
VAGINAL PLUGGING. 
 
 85 
 
 ciilt of removal, and are preferably exchanged for solutions or medi- 
 
 Fig. 65. — Barnes's Tampou Introducer. 
 
 cated pessaries. Cotton, to be used as a stj^Dtic or antiseptic plug, can 
 with advantage be kept ready as a dried preparation, 
 and boracic acid, carbolic acid, thymol, iodine, iodoform, 
 salicylic acid, alum, or sulphate of iron, can all be 
 obtained thus combined with cotton-wool. 
 
 In several other ways cotton or other tampons are 
 occasionally used, but these will be referred to in their 
 appropriate context. To temporarily retain a tent or 
 intra-uterine stem pessary, to act as temporary pessaries 
 for the support of the uterus, where hai'der ones cannot 
 be borne,, to absorb the overflow of caustic solutions 
 or substances applied to the cervix uteri, and as applica- 
 tions to recent sutures or raw surfaces, all these indica- 
 tions are occasionally fulfilled by the cotton-wool or 
 tenax plug, the former material being preferable in the 
 last instance. I have not given a very extensive trial 
 to a plan recommended by Taliaferro, and highly com- 
 mended by Paul Munde, viz., the close packing of the 
 vagina for twenty-four hours at a time with dry wool, 
 cotton, or other substances. Fallen reconmicnds wet 
 clay. The object is to support and stimulate the })elvic 
 vessels, and so to get rid of the passive venous conges- 
 tion which, in chronic uterine or pelvic disorders, is the 
 main cause of back-ache, sensation of fulness, and 
 bearing down. I have certainly not tried the clay, but 
 I have tried packing with dry cotton-wool in a few such 
 cases, and the irritation produced has always seemed 
 to me to counterbalance any benefit. It is, however, a 
 resource open to us in a class of cases which are tedious Fig. 6G.— Sims-s 
 and intractable beyond endurance. I should just men- '''''''"1'°" Extractor, 
 tion a little instrument of Sims's, the tampon extractor (fig. 66), 
 
86 
 
 MEDICATED PESSAEIES OE VAGINAL SUPPOSITOKIES. 
 
 which, though by no means essential, is useful in remoYing pledgets 
 of damp wool. A few slight twists serve to entangle it in, and so to 
 break down, the mass. 
 
 Medicated Pessaries. — By these we understand the combination of 
 medicinal substances with an adhesive material which will melt some 
 time after introduction into the vagina, and allow the remedies to become 
 applied to the suiTOunding wall. The excipient most commonly used is 
 the oil of theobroma or cocoa butter, and the pessaries may be extem- 
 porised thus. Take an oimce of the cocoa butter and melt gently, 
 with or without a few drops of olive oil, according to the heat of the 
 weather, stir in carefully sufficient of the medicament for eight 
 pessaries, then pour the whole into a roll of Amting-paper which has 
 been shaped round a small niler; when cold, cut into eight portions, 
 and shape each with the fingers at one end so as to give it the form of 
 a conical bullet. Wax and lard in combination are also used, but they 
 are inferior. On the large scale, and with proper moulds, very excellent 
 pessaries are made of soluble gelatine. The mass is made by immersing 
 one ounce of gelatine in foirr ounces of water for a few seconds ; then 
 drain, and in half an hour add four oimces of glycerine to the residue. 
 Dissolve in a water-bath. Should weigh six ounces (]\Iartindale's Extra 
 Pharmacopoeia). We can combine fluid medicaments in this manner 
 only. One great advantage of pessaries is that they can be easily intro- 
 duced by the patient herself, often even by virgins. 
 
 The folloAving list of substances appUcable in this way, separately or 
 in combination, with the quantity for each pessary, is compiled from 
 Squire, ]\Iunde, and other sources : — 
 
 Antacid. 
 Sod. bicarb., gr. sv. 
 
 Alterative and Resolvent. 
 Plumb, iodid., gr. v. 
 Pot. iodid., gr. x. 
 Pot. brom., gr. s. 
 Unguent, liydrarg., gr. xx. 
 Astringent. 
 Zinci sulpho-carbolat., gr. v. ad x. 
 Acid, tannic, gr. x 
 Acid, gallic, gr. x. 
 Alum sulph., gr. xv. 
 Catechu, gr. xv. 
 Fen-o-alumen, gr. x. 
 Plumbi Acet., gr. v. ad x. 
 Matico, gi'. X. 
 Ferr. sulph. exsic, gr. x. 
 
 Deod.orant and Disinfectant. 
 Calc. carbolat., gr. xv. 
 
 Acid, carbolic, gr. ii. 
 Acid, boracic. , gr. x. 
 Thymol, gr. v. 
 
 Emollient. 
 Bismuthi oxid., gi-. xv. 
 Sod. borat., gr. xv. 
 Zinci oxid. , gr. xv. 
 
 Hcemostatic. 
 Ferr. perchlorid., gr. v. 
 Ferr. sulph., gr. xv. 
 
 Sedative. 
 Atropife sulph., gr. ^V ad -^. 
 Ext. belladonna?, gr. i. ad iii. 
 Ext. conii, gr. v. 
 Morph. hydrochlor., gr. \ ad J. 
 Ext. opii, gr. ii. 
 
 Eodra. 
 Iodoform, gr. v. 
 Chloral hyd., gr. x. ad xxx. 
 
 It is somewhat unfortunate that the term " pessary " should be used 
 
INTEA-UTEEINE MEDICATION THE CERVIX. 87 
 
 to designate both these medicated bodies and mechanical supports, and it 
 would be better to speak of vaginal "suppositories," but I have followed 
 the usual custom. 
 
 Intra-uterine Medication.— There is no part of our subject, perhaps, 
 which, more than this, requires delicate handling in a work that shall 
 convey to the student only such principles and methods of action as 
 connnend themselves by their approved safety and utility. "Within the 
 last few years the endometrium has been subjected to methods of treat- 
 ment, many of them bold, not a few of them dangerous. The estimation 
 of such of these as I consider it desirable to mention at all can only be 
 made when referring to the affections for which they are employed {see 
 especially Chap. VIII.) Dangerous diseases may warrant dangerous 
 remedies, which are highly to be deprecated under other circumstances — 
 but a few general remarks here on the subject may avoid much needless 
 repetition. 
 
 The whole interior of the cervix is often easily enough reached in 
 disease, or a veiy slight dilatation enables us to reach it, while there is 
 free egress for all superabundant applications, and sight comes to the 
 aid of touch. Almost everything that can be used in a liquid form can 
 be introduced into the cervix by the Playfair probe (fig. 9), armed thickly, 
 or tightly and thinly, with cotton, as formerly directed, but it is an un- 
 doubted improvement to have the termined wire made of incorrosible 
 aluminium. A great difficulty often lies in our way in the impossibility 
 of removing the tough mucus which coats the cervical wall. Wipe it 
 as we may, this remains adherent, or there is more to follow, and the 
 remedies cannot reach the diseased surface. The free previous use of 
 Emmet's hot-water vaginal douche is the best remedy for this state of 
 things, but if the cotton upon the probe be moistened with glycerine we 
 can generally succeed in removing all mucus without undue irritation. 
 I shall have to insist, by and by, on the importance of using the milder 
 alterative local remedies in the earlier stages of cervical disease, com- 
 bined with constitutional treatment, before the mucous surface is irre- 
 trievably ruined by the more powerful caustics ; but even when these are 
 absolutely necessary, the practitioner who knows the dangerous properties 
 of the caustics he is dealing with, and who has tactus ervditus in his 
 fingers, can do much safely with a tubular speculum and a Playfair's 
 probe properly armed, and only medicated with those agents which are 
 fluid or soluble. In hospital practice, or wherever there is intelligent 
 assistance available, the duck-bill is decidedly preferable. But some 
 additional precaution is generally advisable to ensure application of 
 these agents only to the desired surface, and to prevent their trickling 
 down to other parts. It is always a good plan, no matter how inert the 
 fluid may be, to pass up a little plug of cotton, and plant it just below the 
 
88 OPEEATIOXS COXSTITUTIOXAL PEEPAEATIOX. 
 
 cervis, so that it receives any overflow. After the apphcation has been 
 made this is removed by the forceps, the outside of the cervix and 
 the vaginal cul-de-sac are wiped dry, and a second phig moistened with 
 glycerine, and attached to a string, is planted against the end of the 
 cervix, and held there with the forceps till the speculum is removed. 
 This again is withdrawn in a few hours. Tincture of iodine, or the 
 various glyceroles, or even more corrosive solutions, are applied in 
 this way; but nitric acid, the fluid nitrate of merciu'y, bromine, 
 chromic acid, and liquefied chloride of zinc, require more careful 
 management. The whole s"arface around the cervix must be care- 
 fully packed with damp cotton, moistened with strong solution of car- 
 bonate of soda in the case of the first two, and the escharotic should 
 be applied by means of a wooden skewer, which answers better than a 
 glass point. Piu'e carbolic acid, i.e., absolute phenol with 6 to 10 per 
 cent, of water to ensure its fluidity, may be safely managed with the 
 well and tightly coated probe. Potassa fusa, and potassa c calce made 
 into a paste with alcohol, must be carefully lifted in small pieces and 
 applied to the exact spot with moderate firmness, while plugs well soaked 
 in vinegar guard all the surrounding tissues, and free injections of the 
 same fluid are subsequently used. The solid nitrate of silver requires 
 its appropriate caustic holder, which will also serve for solid sulphate of 
 zinc or copper. The application of these and other substances will, how- 
 ever, call for future remarks. 
 
 Local applications above the os externum are more serious matters in 
 every way, and for a description of the various modes of using intra- 
 uterine injections, ointments, or other media, I must refer the reader to 
 Chapter VIII. 
 
 . Qeneral Management of Gynsecologioal Operations. 
 
 It is very advisable to adopt some amount of constitutional and local 
 preparation before even very slight operations. 
 
 Constitutional Preparation. — Every kind of risk — the danger of 
 septicEemia and all that is included therein, of shock, of non-adhesion of 
 surfaces that are intended to unite, and even of hsemon'hage, — is greatly 
 diminished by previous attention to the health of the patient. By care- 
 ful regulation of the secretions of the skin, bowels, liver, and kidneys, 
 by nutritious and non-stimulating food, by the supply of pure air, and 
 by the remedying of any knowTi defect in hygiene, as long as possible 
 previously to any operation, its average mortality is largely diminished, 
 and its successful issue is ensured. The imne, if too acid, should be 
 neutralised by lithia water, and if alkaline or phosphatic by benzoic acid 
 
OPEEATIOXS LOCAL PEEPARATIOX. 89 
 
 or other usual remedies. At the time of operation also we must ensure 
 complete fi-eedom from the noxious influences derivable from any possible 
 septic, z^Tuotic, or pythogenic source. Before any operation of at all a 
 serious character is undertaken, especially if it involves the peritoneal 
 surface, or the pelvic cellular tissue, a careful examination should be 
 made to ascertain the absence of any grave constitutional affection, such 
 as phthisis or Bright's disease. It is very rarely, indeed, that during the 
 existence of these, operations are desirable or permissible. Wherever it 
 is possible, operations on the female sexual organs should be performed 
 only between two menstimal periods ; the most satisfactory time is a 
 few days after the cessation of the flow. Considering the local and 
 general hypersesthesia and hyper^emia which normally occur at these 
 periods, the precaution is an obvious one, but menstrual in-egu- 
 larities resulting from the disease requiring operation, or from the fear 
 of the operation itself, will often compel us to admit with Burns that 
 "the best laid schemes of mice and men gang aft aglee." A bright day, 
 with a moderately high barometer, should if possible be chosen for all 
 important operations, and the fewer bystanders, who may possibly have 
 septic influences about them, the better. 
 
 Local Preparation of the parts, in operations on the genital tract, is 
 no less important than previous constitutional treatment. For this 
 there is no means equal to the steady use, for some time before, of 
 Emmet's hot-water douche. Used by itself alone it relieves congestion 
 or oedema, and gives a tone and a vigour, to the whole tract, and to 
 its connective coverings, which almost compel success. The frequent 
 application of a little tinctm-e of iodine with a binash, followed by a 
 glycerine plug, to the surfaces about to be operated upon, is of great 
 service in rendering them prone to adhere, and less likely to bleed 
 unduly. It is not unkno^\'n as a clinical fact that, with these precau- 
 tions, intended operations have often been entirely forestalled by the 
 unlooked-for cicatrisation of a torn perineum or cervix uteri, or of a 
 vaginal fistula. Time spent in this way is aU gain and no loss. 
 
 Antiseptics. — I cannot refuse here to face the question of the value 
 of Listerism. Yet, considering the conflicting opinions, and still more 
 conflicting facts, which have been recently adduced for and against it — 
 with Wells and Keith, Tait and Bantock, and Thornton, to say nothing of 
 foreign authorities, uttcx'ly divided on the subject, not only among them- 
 selves, but from their own selves at other periods of their practice, it would 
 be highly unbecoming in me to speak too dogmatically. AVc must appeal 
 to the future for guidance. Yet those who have to act in the living 
 present, and to teach others how to act for the best, may not decline to 
 adopt, and to coimscl the adoption of measures based at least on care- 
 fully formed provisional hypotheses. One thing I can say dogmatically, 
 
90 ANTISEPTIC PEECAUTIONS. 
 
 and without a particle of hesitation, that no belief in, or practice of, the 
 strictest antiseptic precautions, in the way of dressings, sprays, or other- 
 wise, warrants the neglect of preventive foresight against the septic, 
 zymotic, or pythogenic influences indicated above. 
 
 Antisepticity, in the sense of absolute cleanliness — cleanliness in little 
 minutiae which, but for the germ theory, were ludicrously precise — is 
 now adopted by everyone as a rule of practice. We owe this to Lister, 
 and with it we owe a saving in human life and suffering which can 
 never be statistically recorded. There were wise surgeons in the far 
 past, notably he who invented that wonderful ointment to be applied to 
 the lethal weapon, while the wound itself was to be constantly washed 
 with spring water, and not otherwise meddled with ; but the wisest of 
 them all never persuaded the profession that to " wash and be clean " was 
 the most important, and often the most difficult triumph of their art, 
 till Lister furnished the all-powerful motive. I cannot, moreover, resist 
 the conclusion that the result of such absolute and minute cleanliness 
 as is now constantly observed in surgical proceedings, goes very far in 
 itself towards proving the germ theory of all septic mischief — the theory, 
 at any rate, or I would rather say the fact, that germs and sepsis go 
 hand and hand, and that the prevention of the one means the prevention 
 of the other. 
 
 Much careful work is being done at the present time, and a good deal 
 that is not over-careful, towards estimating the relative value of various 
 germicides or antiseptics in varying circumstances, but of none can it 
 yet be said, as of carbolic acid, that it fulfils in the simplest and safest 
 manner most of the required conditions. Thymol, boracic acid, euca- 
 lyptus, bichloride of mercury, permanganate of potash, quinine, salicylic 
 acid, chromic acid, iodoform, tar, and a host of other substances, have all 
 certain antiseptic properties, and I make free use of them all ; but I think 
 it is advisable, for the present at any rate, to look upon carbolic acid as 
 the regulation substance, although bichloride of mercury, 1 in 1000 to 
 2000 solution, is a wonderfully cheap and active agent for antiseptic in- 
 jections, especially in midwifery, and I have as yet seen no ill-effects from 
 its use. When carbolic acid is not contra-indicated, and I hardly know 
 when it is, I mingle it freely with every fluid vised for injections or ablu- 
 tions. I adopt, with it, all the now common precautions as to instru- 
 ments, sponges, and other operative armamentaria, although I never 
 allow it to prevent my choosing new sponges when they are within my 
 reach, and I believe that these precautions are equally applicable to, 
 and necessary with, every sound, catheter, speculum, or other instrument 
 in ordinary diagnostic use. I feel certain, moreover, that few, if any, of 
 the untoward results which sometimes follow the careful and skilled use 
 of the sound, the tent, or even the speculum, would occur, if one always 
 
THE ANTISEPTIC SPKAY. 
 
 91 
 
 bore in miud the danger of septic poisoning, and the ease with which it 
 might be averted. A dirty finger is more dangerous, and has, to my 
 personal knowledge, done more damage, when introduced ^Jer vaginam 
 than even a clean uterine sound pushed into the middle of the abdomen. 
 A 5% solution is advisable for all these purposes of instrumental or 
 manual purification, but it will not clean a man's nails or scour the teeth 
 of a torsion forceps. I have seen the Listerian spray, and gauze, and all 
 the rest of it, used, while the operator left a black deposit behind him 
 every time he compressed or twisted a vessel. The nail-brush, and soap 
 and water, are as essentially a part of antiseptic surgery as germicide 
 specifics. I am not sure, if I were compelled to choose between the two, 
 which I should prefer, but the choice is totally unnecessary. The dress- 
 ing of vaginal wounds or sutures with Lister's formulae of gauzes, 
 &c., is simply impracticable ; but his indications are, as far as possible, 
 fulfilled by smearing them at the time of operation, and afterwards from 
 time to time, with carbolic glycerine, 1 in 10. The vulva should, in all 
 such cases, be closed by a diaper or other dressing, soaked in the watery 
 solution and only partially dried. If abdominal incisions, as in ovari- 
 otomy, are well smeared Avith carbolic glycerine, and if a few folds of lint 
 well saturated with it are applied, the wound may be safely left for ten 
 days or more, provided that w^e are not encumbered by a drainage tube, 
 and that a layer of mackintosh overlies the dressing. I used this 
 excellent dressing with perfect success during the hottest weather of 
 this year (1884), w^hen Sir Joseph Lister found some of the more volatile 
 agents fail in his owti hands ("Address on Corrosive Sublimate as 
 a Surgical Dressing," Lancet or British Medical Journal^ October 
 25, 1884). 
 
 As to the use of the spray in abdominal operations, I own that my 
 views have become unsettled, and that my practice has been rendered 
 somewhat illogical. I have never, in my own practice, been able to con- 
 vince myself that a single bad symptom has followed the use of carbolic 
 acid in any form. I apply it freely, as a strong glycerolc, to the ovarian 
 pedicle, to the external wound, and to any intra-abdominal raw surface 
 that I can find. Much of it must find its w^ay into the abdominal cavity 
 in every case, but I have never seen even the carbolic urine — the dark 
 smoky-looking urine described by so many writers, — except in one case, 
 where, as in many scores of others, I had applied a single drop of pure 
 carbolic acid to a urethral growth. But the long-continued spray may 
 undoubtedly produce cooling of the peritoneum, which may prove 
 unduly depressing. In hospital practice, therefore, where tlie sejitic risks 
 must always be in the ascendant, I use the spray in abdominal section, 
 having it as warm as possi])le, and throwing it right across the incision ; 
 while in private practice I think that other antiseptic precautions enable 
 
92 AFTEE-TEEATMENT OF OPERATIONS. 
 
 US, as a rule, to dispense with it. I find that several of my surgical 
 colleagues have independently arrived at a similar practice. In opera- 
 tions on the vulva and vagina the spray is excessively troublesome, and 
 is advantageously replaced by a very delicate jet of hot carbolised water 
 directed occasionally upon the bleeding points. This has the additional 
 advantage of being a valuable hsemostatic. 
 
 After-Treatment of Operations.^ — This is also a matter of the 
 highest importance. Reaction must be encouraged when shock exists. 
 Hot- water bags to the limbs or trunk, and the subcutaneous injection 
 of 20 minims of ether, or the rectal administration of beef-tea and 
 brandy, may be required for this purpose ; and when the reaction has 
 fairly commenced it is aided and steadied by the administration of 
 morphia in small doses siibcutaneously. Subsequently, the diet, in 
 almost all cases, should be light and sparing, and stimulants are not 
 required except in the case of septicaemia or considerable shock. After 
 ovariotomy I think the patients do best on very nearly starvation 
 diet, a few teaspoonfuls of iced milk occasionally, for three days or 
 more ; but, of course, there are exceptional cases. Opium may be 
 freely given in nearly all cases, unless there be some special suscep- 
 tibility, which had better be ascertained previously. I was recently 
 obliged, fortunately without ultimate bad results, to keep a patient, 
 on the next day after ovariotomy, under almost constant galvanic 
 stimulation, with strong coffee, &c., from the result of two sub- 
 cutaneous injections of ;j of a grain of morphia, administered after 
 reaction had fairly taken place. But in most patients the lulling effect 
 of morphia is very valuable, together with its aid in keeping the bowels 
 at rest. In many gynaecological operations — vaginal, uterine, or ab- 
 dominal — it is desirable to keep the bowels locked for eight or ten 
 days. After repairing the torn cervix, this precaution is not necessary 
 or advisable ; on the contrary, the bowels should be relieved daily by 
 enemata or gentle laxatives. In the repair of ruptured perineum, we 
 have a choice of evils, for if the bowels are too long locked the mass may 
 become hardened to such an extent as to tear through all before it. It 
 is therefore perhaps better, as I have stated above, to leave the matter 
 to nature. For the purpose of renewing the action of the bowels, a 
 drachm of castor oil, with one of glycerine, may be given the night before. 
 If this acts spontaneously next morning, well ; but the patient should 
 avoid all straining. It is better in all cases to carefully inject two or 
 three ounces of warm olive oil into the rectum, and to encourage the 
 patient to retain it for some time. The bladder requires eqiially careful 
 attention, and it is always bettei', in all cases of abdominal section or 
 plastic operations on the vagina, to empty it artificially for the first 
 week or ten days, or even a fortnight. The dribbling of stale urine, and 
 
CATHETEEISM, 
 
 93 
 
 Fig. 67.— Sims's Sigmoid Catheter. 
 
 the fatigue or exertion involved in spontaneous evacuation, are equally 
 avoided. If I have a thoroughly reliable and well-trained nurse, who 
 can use the instrument skilfully, with the patient on her back, avoiding 
 droppings, and 
 keeping the in- 
 striunent a-septic, 
 I prefer the urine 
 to be drawn off at 
 stated intervals of 
 not longer than 
 six hours, or much 
 more often in oper- 
 ations directly 
 affecting the blad- 
 der. But when 
 
 this is not the case, a modification of Sims's sigmoid catheter (fig. 67), 
 in vulcanite or silver, may be tied into the l:)ladder for the first few days. 
 It must be so balanced as not to press on the fundus, and must be cleaned 
 frequently by the practitioner and reintroduced. The end may be 
 plugged and the plug removed for 
 urination, or, especially in vesico- 
 vaginal operations, a cup may be 
 placed so as to catch the urine as it 
 dribbles away. If the catheter be 
 made of block-tin it can be more easily 
 moulded than a vulcanite one to suit 
 
 the individual case, but is hardly so pure and clean. Skene's modifi- 
 cation of Goodman's self-retaining catheter- (fig. 68) is also a very useful 
 instrument. It is only two inches long, and has an india-rubber tube 
 attached to its outer extremity. Every metallic catheter, when not in 
 use, should lie in the carbolic solution. 
 
 Angesthesia.— I can hardly here enter into the vexed question of the 
 difterent anresthetics. Nitrous oxide, from the short diu-ation of its eff'ects, 
 is seldom available in gyntecology, except as a prelude to chloroform or 
 ether, or in cases of tapping, lancing, or other very rapid proceedings, 
 when the fear of the patient is greater than the actual suffering. Bi- 
 chloride of methylene is greatly preferred by Wells in ovariotomy, 
 chiefly on account of its slighter tendency to produce sickness and 
 retching, and very many operators follow his example. I have tried 
 it for diagnostic purposes, l)ut have not so fiir been able to attain 
 the same advantages here as from chloroform. In ovariotomy one can 
 keep up continuous insensibility to pain, while the patient seems to l)e 
 somewhat less under its general influence than is necessary when chloro- 
 
 FiG. 68.— The Skene-Goodman Self- 
 retainin? Catheter. 
 
94 ANAESTHESIA. 
 
 form is used. Recent observations have shown that this substance is 
 probably a mixture of four parts of chloroform and one of methyl 
 alcohol. A combination of alcohol, chloroform, and ether in the propor- 
 tions of one, two, and three parts is vised by many. I have, however, seen 
 it so often followed by all the baneful effects of too large a dose of 
 alcohol, that I do not like it. Ether or chloroform separately is still in 
 preponderating use in ordinary gynaecological proceedings, and the wave 
 of reaction in favour of the former, so powerful in America, has had 
 comparatively little effect in this country. In abdominal operations 
 especially, the irritating effect of ether upon the pulmonary organs 
 is much to be deprecated. Anaesthesia and the use of chloroform 
 are almost interchangeable terms in general British practice, and I 
 confess in my own. For diagnosis, ansesthesia is useful in many 
 ways. It enables examinations to be made, otherwise of a most painful 
 character — it relaxes the abdominal and other muscles, especially the 
 sphincters, and it overcomes the painful feelings of shame or modesty, espe- 
 cially in the case of necessary examinations in young girls or virgins. 
 In many cases of hyperEesthesia of the external parts it therefore becomes 
 necessary for an accurate diagnosis, in virtue of all the above-named 
 properties, and it is hardly possible without it to ascertain the normal 
 dilatability of the sphincters or to overcome their morbid spasm. When 
 delirium is present, or pain from acute inflammation, or with intractable 
 or malingering patients, it is equally useful. The diagnosis of certain 
 abdominal tvimours, especially of phantom tumours or spurious preg- 
 nancy, is rendered absolutely positive by it, and in all cases of bi-manual 
 examination, where doubt remains as to any important point, a re- 
 examination with ansesthesia will render certainty possible. In fact, 
 such an examination is almost as superior to one without ansesthesia as 
 the latter is to a digital examination with one hand only. For opera- 
 tions on the lining membrane of the uterus, such as curetting, scari- 
 fication, and even paring or stitching the cervix, it is seldom required 
 on account of pain merely, but to allay fear or overcome restlessness it 
 may become necessary. Emmet strongly warns us of the danger of 
 ether, and presumably of chloroform, in advanced cystitis or kidney 
 disease, and in such cases it should if possible be dispensed with. It has 
 been noticed that many of the accidents which have happened during 
 anaesthesia have occurred just at the moment when the first painful 
 incision was made, or an ecraseur was tightened, or a painful ovary was 
 compressed. The correct deduction from this is that the ansesthesia was 
 insufficiently complete, and allowed of reflex inhibition of the heart's 
 action from the pain still felt and conveyed by the nervous system. I 
 have twice seen apparent death thus caused in operations on uterine 
 tumours, the patient being rescued in each case by inversion of the 
 
ANAESTHESIA. 95 
 
 body. An oiDposite clanger, however, is to be g-uarded against. In 
 operations on the genital organs in young and sensitive women, con- 
 sciousness or semi-consciousness, and sensibility, return amazingly 
 quickly, and this may lead to the apparently safe exhibition of large 
 and repeated doses of the anaesthetic. At the close of the operation, 
 when all stimulus of pain ceases, the tendency to all the dangers of 
 anaesthetics is often found to develop itself suddenly. For operations on 
 the external genitals Richardson's ether spray may occasionally be of 
 use, and the newly introduced cocaine seems also to have a future as a 
 local ansesthetic in similar cases. Carbolic acid applied to a wound pro- 
 duces, after its preliminary smarting, a numbing effect. 
 
^6 HYGIENIC CONSIDERATIOXS IN GYNECOLOGY. 
 
 CHAPTER IV. 
 
 Hygienic and Medical Treatment in their Relation to Female Diseases. 
 Influence of Menstrual Periodicity. Food. Stimulants. ClotMng. Exercise. 
 Bathing. Education. Chlorosis, its Nature and Treatment. Neurasthenia 
 in its various Forms. 
 
 Having in the j)revious chapter spoken of the means employed in the 
 management of female diseases, when, whatever the causation may be, 
 the manifestations are local, and demand local treatment, it seems 
 advisable now to hasten to say something about hygienic conditions, and 
 more purely medical treatment, a timely recourse to which would often 
 prevent the necessity for the interference of surgery. 
 
 I assume, as an axiom, that the medical and hygienic treatment of 
 female diseases is, like their pathology, common to the wide field of 
 medicine. Yet there are a few points to which special attention should 
 be briefly drawn here, and the first of these is the necessity for hearing 
 in mind, ivithout unduly exaggerating, the influence on female health of 
 menstrual periodicity. 
 
 Tilt surely goes a little too far when he asserts that "the know- 
 ledge that menstiniation is a natural function does a world of mischief," 
 but there is a substratum of practical truth underljdng the remark. 
 We know that in almost all women the function is accompanied by 
 nervous and vascular phenomena, which have a real existence, and which 
 temporarily place the woman in a diff'erent physiological state from that 
 which is usual, and in one more liable to departure from health, on slight 
 provocation. "We know, also, that comparatively slight departures of this 
 kind, repeated, confirmed, and exaggerated from month to month, lay 
 the seeds of future diseases of the gravest character, of uterine displace- 
 ments, uterine catarrh, and pelvic congestions, and not infrequently of 
 more acute maladies, such as haematocele or pelvic cellulitis. In other 
 cases it is the nervous system which becomes unstrung from being 
 subjected to work while under unusual tension. This is not a mere 
 hypothesis, it is a statement of fact. There are few physicians who 
 have not seen, during an extended practice, instances of sudden death 
 from heematocele, or of bright careers of mental work and usefulness 
 cut short, never to be resumed, after a few day's hard work during a 
 menstrual period. It cannot, therefore, be too strongly insisted on, that. 
 
FOOD. 97 
 
 in the case of the young or the delicate at any rate, and to some extent 
 in all women, the period of menstruation should be a period of compara- 
 tive repose. Women have quite sufficient tact to ensure this without 
 any unnecessary parade ; and it is for those who organise their work of 
 any kind, mental or physical, to give at least a chance for the emplo}-ment 
 of such tact. Let it only he clearly borne in mind that, in ninety-nine 
 out of every liundred women, there are periodical occasions when they 
 can only work as they may do at other times, witli more or less peril to 
 their mental and liodily health. Even after menstnuition has merged 
 into pregnancy, the periodic law is, though dormant, still existent, and 
 miscaiTiage is most easily provoked at the usual epochs of menstrual 
 activity. 
 
 While, as I have said, the laws of hygiene are the same for the male 
 and for the female, they especiall}- affect the one sex or the other 
 according to many of their special suiTOimdings. 
 
 The Food Supply of our women is by no means what it ought to be, 
 the result of fashion in some cases, of poverty and unwomanly work in 
 others. Dr Thomas says that "the American woman, except in our 
 cities, is at least half stai'ved," and I fear the same remark applies to a 
 lai-ge extent to our English women also. The miserable tea diet on 
 which the women of om- artisan and agricultural labouring classes so 
 largely subsist vdW not suffice to nourish a healthy matrix, much less a 
 healthy jjroles in addition, and among the more affluent classes fashion 
 does what poverty enforces among those less well circumstanced. A 
 well-known metropolitan physician has recently been somewhat thinning 
 the number of our male patients, that is, killing or curing them, and I 
 ;un bound to say more often the latter, by his prescribed merncs; he 
 would render an equally great service if he would persuade their wives, 
 or rather their daughters, to consume some of the red meats and other 
 proscribed items. The more thorough tissue-changes which the female 
 undergoes, consequent on menstruation, demand a supply nf nutri- 
 ment which the urban male, at any rate, scarcely requires. In liis 
 address to the Obstetrical Section of the British Medical Association 
 (1883), Dr Graily Hewitt has discom-sed well and wisely on this subject, 
 and the recognition of the necessity of fuller nourishment in gynaeco- 
 logical practice forms the basis of one part of the system of treatment 
 afterwards to be mentioned as Weir ^Mitchell's. 
 
 Closely associated with the subject of food is that of Stimulants. 
 And yet I am very desirous of dissociating the two things. Tlie more 
 good noiu^shing food a patient can take, within reason, the less stimula- 
 tion he or she requires ; and yet, antithetic as it may seem, no one can 
 less safely encounter the dangers of chronic stimulation than he or she 
 who has badly nourished or overworked tissues. Woman, though 
 
98 CLOTHING AND EXERCISE. 
 
 fashion, and the instinct of self-preservation, are fortunately on her side 
 in this respect, falls more readily and irretrievably under the baneful 
 influence of alcoholic craving and chronic alcoholism than man. I can- 
 not say that a little porter, or ale, or wine may not occasionally prove as 
 useful to the female as to the male, but I believe that dietetic sub- 
 stitutes may be found, in all cases of chronic disease, which, if a little 
 more costly to the poor, or less costly to the rich, leave not on 
 the mind of the prescriber the uncomfortable reflection that he may 
 have laid the seeds of inevitable ruin to his patient. It should never, 
 however, be forgotten by the physician that it is not alcohol alone which 
 leads to alcoholic craving. Tea, coffee, tobacco, quinine, strychnine or 
 nux vomica, chloral, opium, sal volatile, and all the so-called nervine 
 tonics or sedatives of modern pharmacy, when depended on for stimula- 
 tion or sedation, lead in one and the same direction. As civilisation 
 advances, and consequent nerve tension increases, we shall have an 
 increasingly intelligent dread of their use, counterbalanced unfortun- 
 ately by an increasing supposed necessity, and by a really lessened 
 power of withstanding their baneful influences. I have long ceased to 
 recommend the use of stimulants in any form of chronic female disorder, 
 and the young practitioner who wishes to look back with pleasure upon 
 the results of his past career, will be wise to adopt this rule of practice 
 until he sees some very good reason for change. 
 
 Clothing is a siibject of extreme delicacy, and I must entirely ignore 
 its sesthetic aspects. But there are certain points of importance on 
 which all physicians are agreed, and which it must be left to the ladies 
 to reconcile with the question of outward adornment. Wool in some 
 form, however thin, should be worn next the skin, from head to foot, in 
 this climate. Everything which contracts the thorax is inadvisable on 
 general grounds, and especially tends to produce pelvic congestion and 
 other mischief Corsets with steel or whalebone appliances are as absurd 
 for a healthy woman as steel-jointed leg pieces would be for a healthy 
 man. The tying of a " dry goods store " round the waist or abdomen, 
 in the form of heavy petticoats, is highly injurious, and some modifica- 
 tion of the male system of braces is desirable. The use of high-heeled 
 shoes or boots, independently of its bad eff'ect on the feet, throws out of 
 gear the suspensory ligaments of the uterus, by altering the incline of 
 the pelvis. It would be better, I think, if medical advisers woiild keep 
 in view, and insist on, these few and simple facts, rather than attempt to 
 discuss their minute realisation. Their practical enforcement in early 
 life would obviate the necessity for many a serious surgical proceeding 
 afterwards, when the causation of the disease can be but fiiintly traced 
 to early neglect. 
 
 Proper Exercise is just as essential to the preservation of female health 
 
BATHING EDUCATION, 99 
 
 as timely rest. Female football players or gymnasts are just as much 
 an occasional possibility as female senior wranglers, though they are 
 about equally undesirable as types of the sex. But just as the really 
 well-cultured woman frequently excels her male competitors in moral 
 insj)iration, so the woman who has had free play for her muscles while a 
 girl, and in young womanhood, and who has not been injured by the 
 unwomanly work of savage or of over-civilised life, excels him, in many 
 ways, in her powers of endurance. Few, if any, men could endure 
 the sustained fatigiie daily and hourly undergone by the mother of a 
 family in poor or very moderate circumstances ; and as the necessity for 
 this will endure as long as the perpetuation of the race is carried on, on 
 its present lines, it is essential that the muscular system of women 
 should be considered in their hygienic training. In childhood the girl 
 should be allowed and encouraged to romp as much as her brothers, and 
 the more spontaneously, and the less according to anybody's " system " 
 she does so the better. As womanhood approaches, a separation of the 
 sexes becomes desirable, in order that work and play may be intermitted 
 according to the periodic necessities of the female, and the wise parent 
 or guardian will see that, while the necessary rest is obtained at the 
 period of menstruation, habits of indolence and sloth are not imported 
 into the remainder of the month. 
 
 Bathing or regular ablution of the whole su.rface is just as important 
 for the one sex as the other, but during the early years of menstrual life, 
 at any rate, periodicity must also be recognised by substituting tepid for 
 cold water, or by intermitting the use of either to some extent at the 
 periods. 
 
 Education. — This is a subject which, at the present moment, can 
 hardly be toiiched upon Avithout involving questions which are not 
 always treated with the calmness and impartiality they demand. As 
 a professor of a college and a university which are ];erhaps doing as 
 much as any in England to meet the demand for female degrees, and 
 female education leading up to those degrees, I would not for a moment 
 be supposed to join in the ignorant clamour against such education, whicli 
 is based on a desire for monoply by the male sex. The struggle for exist- 
 ence on the part of single women, and the capacity of a few of their 
 number to ignore with safety the physiological difficulties of the majority, 
 are demanding opportunities for education, and its honourable as well as 
 valuable distinctions, which cannot and ought not to be refused. 
 
 Unfortunately, however, up to tliis time, no means have been found 
 which will reconcile this with the physiological necessity for intermittent 
 work by the one sex. It becomes, therefore, the duty of every honest 
 physician to make no secret of the mischief wliich nnist inevitably 
 accrue, not only to many of our young women, but to our whole popu- 
 
100 A3IEEICAN EXPERIENCES OF 
 
 latiou, if the distinction of sex be disregarded. Co-education of the sexes, 
 i.e., either education absolutely together, or education on precisely the 
 same lines, is already -n'orking mischief in this country, ^\-hich would 
 utterly astonish that large band of distinguished American physicians 
 ■who are almost piteously holding out their hands to their own people, 
 and demanding a recom'se to what they consider the European sj-stem. 
 Dr Edward Clarke {Sex in Education, Boston, 1882) speaking of co-educa- 
 tion says : — " Neither is it asserted that all the female graduates of our 
 schools and colleges are pathological specimens. But it is asserted that 
 the number of those graduates who have been disabled to a greater or 
 less degree by these causes is so great as to excite the gravest 
 alarm, and to demand the serious attention of the co m munity. If these 
 causes should continue for the next half century, and increase in the 
 same ratio as they have for the last fifty years, it requires no prophet 
 to foretell that the ^Ives who are to be mothers in our repubhc must be 
 drawn from t ->,s-Atlantic homes. The sons of the New World will 
 have to re-act, on a magnificent scale, the old story of imwived Eome and 
 the Sabines." There is hardly an American physician who has specially 
 treated the diseases of women who does not corroborate these words. 
 Dr GaiUard Thomas {Diseases of Women, 1880, p. 44) says : — " Unfortu- 
 nately the restless, energetic, and ambitious spirit which actuates the 
 people of the United States, has prompted a plan of education which by 
 its severity creates a vast disproportion between these two systems (the 
 nervous and muscular), and its efi'ects are more especially exerted upon 
 the female sex, in which the tendency to such loss of balance is much 
 more marked than in the male. The results are, rapid development of 
 brain and nervous system, precocious talent, refined and cultivated taste, 
 and a fascinating vivacity on the one hand ; a morbid impressibility, 
 great feebleness of muscular system, and marked tendency to disease in 
 the generative organs on the other. But the mere existence of this 
 fact is not the most melancholy feature of the case ; it is far more pain- 
 ful to see mothers listening to it, admitting its truth, and yet calmly 
 and dispassionately choosing to make the trial, as we see them doing 
 constantly." 
 
 Dr Emmet {op. cit, p. 20) says : — "I hold that it is not practicable to 
 educate a girl by the same methods foimd best for the boy, without 
 entailing serious consequences, for the ovaries will always be aiTested in 
 their gi'o-n-th if the brain is forced. Even when the coiu'se of study is 
 comparatively moderate, functional distiu-bances are of too frequent 
 
 occun-ence to admit a doubt as to the cause I not only endorse 
 
 Dr Clarke's views as far as he has gone, but my o\w\ experience leads me 
 to believe that the evil is even more serious than he has represented. 
 To enable her to reach the highest physical development, the 
 
FEMALE EDUCATION. 101 
 
 young girl in the better classes of society should pass the year before 
 puberty, and some two years afterwards, free from all exciting influences. 
 
 Her dress, diet, and habits of life should be carefully looked 
 
 after as if she were a child — her mind should be occupied by a very 
 
 moderate amount of study there should be no night studying 
 
 under any circumstances. After the menstinial function has become 
 permanent, normal in character, and free from pain, she can begin to 
 increase the number of her studies, but afterwards, at the time of 
 the molimen, she should observe the same rule of rest, mental and 
 physical." 
 
 Dr Goodell {op. cit, p. 420) says: — " From the age of eight to that of 
 sixteen our daughters spend most of their time within the unwholesome 
 air of the recitation room, or in poring over their books when they should 
 be at play. As a result, the chief skill of the milliner seems to be 
 directed towards concealing the lack of organs needful alike to beauty 
 and to maternity, and the girl of to-day becomes the barren wife or the 
 invalid mother of to-mori'ow. Surely a civilisation that stunts, deforms, 
 and enfeebles, must be unsound." 
 
 Such is the Cassandra-like tone of every modern American physician. 
 Our own highest authorities, and therefore generally those who have 
 attained a somewhat mature age, say much less on tlie topic, for 
 obvious reasons, but the importance of the subject must justify me for 
 inserting a quotation from a recent English writer. jMr Lawson Tait 
 (Diseases of the Ovaries, 1883) says : — " There has grown up a desire to 
 educate women in exactly the same way and to the same extent as men. 
 It would be easy for me to show, were any charge of obstructiveness or 
 want of liberality to be made against me, that throughout my public 
 life I have ever been in the front rank of those who advocate perfect 
 freedom of every kind of instruction for every one who may desire it ; 
 and I have been particularly strong in the expression of m}- views that 
 there should be restriction of neither class nor sex. But it is useless to 
 disguise the fact that, inasmuch as women have functions to fulfil which 
 men are free from, it is not to be expected that women can, with safety, 
 do the work of men, and at the same time properly fulfil their own 
 
 special functions as women This is no place to air political 
 
 crotchets, but I own myself an advanced advocate of women's rights ; at 
 the same time I cannot help seeing the mischief women will do to them- 
 selves and to the race generally if they avail themselves too fully of 
 
 these rights when conceded To leave only the inferior women 
 
 to perpetuate the species will do more to deteriorate the Inunan race 
 than all the individual victories at Girton will ilo to l)enefit it. This 
 overtraining of young women is wholly unnecessary in the interests of 
 Imman progress, and it is mischievous alike to thcuiselves and U* 
 
102 PHYSIOLOGICAL DIFFICULTIES IX FE:\IALE EDUCATIOX. 
 
 humanity Those who advocate the equal treatment of the sexes 
 
 must bear in mind that great culture in a man does not unfit him 
 for paternity, but, on the contrary T\-ill help him in the struggle for 
 existence to maintain a family. For women, on the contrary, excep- 
 tional cultm-e will infallibly have the tendency to remove the fittest 
 individuals, those most likely to add to the production of children of 
 high-class brain power, from out of the ranks of motherhood.'"'' 
 
 This is hardly the place to discuss this question further, however, but I 
 will merely endeavour to give as soimd advice as I can on the subject to 
 the 3'oimg practitioner who may be consulted as to the education of a girl 
 say from twelve to twenty years of age, and I may also refer him. to a 
 lecture on the subject published by me in pamphlet form (Cornish, 
 Manchester, 1884). If asked what he thinks of the "higher education " 
 of woman he would be light in saying that there is no field of education 
 tabooed to her by natm'e, that the wider, and above all the more 
 thorough, her education is, the better woman will she become, provided 
 ALWAYS, as the lawyers say, that the conventional period of gh'lhood is 
 prolonged sufficiently, and that she is educated where there is sufficiently 
 inteUigent oversight to acknowledge the fact that, during a portion of 
 every month, rest and relaxation from, severe work or study are required. 
 If he is told that her success or maintenance dm'ing life depends on 
 her working -pari -po.s.su, or along with young men of the same age, it 
 will be his duty to say that the Chinese cram system of the day is 
 playing havoc with oui' young men, in spite of theii* cricket, football, 
 and other antidotes, and in spite of the fact that they are not handi- 
 capped by the household duties which fall to the lot of all our middle 
 class girls. It will also be his duty to say that work of this kind, 
 carried on " week in, week out," will probably, in a large number of cases, 
 entail either the unsexing of the girl or the exaggeration of all the weak- 
 nesses incident to her sex. In oiu' complex civilised life, dangerous 
 occupations must be followed by some ■. the risks involved, and the 
 remuneration held out, must not, however, be concealed. To persuade 
 the Enghsh universities to formulate degrees, and plan coiTCsponding work 
 for women — degrees which -^dll be fitted to acknowledge those types of 
 culture in which women excel, and work which will allow for their physio- 
 logical position as the futiu'e healthy mothers of oui- race, — this must 
 be the work of women themselves. There are better materials for this 
 purpose in England than elsewhere, and I have not the slightest doubt 
 that the common sense of oiu- people will solve the diflicu.lties involved. 
 Mistakes are inevitable at the commencement of all great movements. 
 
 I leave those remarks on the hygiene of women, which are called for 
 by the special conditions of child-bearing, to the obstetrician. It will, 
 however, be well to say a few words now on two diseased conditions which, 
 
CHLOROSIS. 103 
 
 though not by any means confined to the female sex, are much more fre- 
 quently met with in its members. I allude to the condition of ansemia 
 or chlorosis, and to that of nervous exaltation, depression, or excitability, 
 ^Yhich I have included under the one term " neurasthenia." 
 
 Chlorosis. 
 
 Chlorosis, chloro-anDemia, or, popidarly, green-sickness, is but a form of 
 anaemia, of diathetic rather than depletive character, though it is often 
 apparently aggravated or even commenced by losses of blood. It is not 
 the same as pernicious anaemia, for, under proper treatment, its tendency 
 to death is rare, and its curability is common. Its diathetic origin is 
 rendered probable from its frequent accompaniment by nerve disorders, 
 and by its frequent yielding to treatment adapted to disease of the 
 nervous system, when ferruginous remedies have failed to produce effects 
 such as are usual in ordinary anaemia. It is most common about the age 
 of puberty, though it is by no means absolutely confined to that period ; 
 nor is the greenish tinge which often accompanies the pallor of the 
 affection, and which has given to it its name (;)(Xwpo9, green), confined 
 to that time of life, or even absolutely to the female sex. I am aware 
 that many distinguished authorities, especially of the French school, 
 draw a much wider distinction betAveen anaemia and chlorosis than I 
 have now done. I could not hope to define these differences, however, 
 without an amount of logomachy, or contention about mere verbal dis- 
 tinctions, which is foreign to the scope of our present work. 
 
 The blood-changes found in chlorosis are — diminution in the total 
 quantity of blood, deficiency in both red and white corpuscles, and 
 diminution in the total as well as relative amount of hasmoglobin, to a 
 greater degree than in ordinary anaemia. Deficiency in the albuminous 
 constituents is not so marked or so frequent as in ordinary anaemia, and 
 the fatty and saline constituents are also foxind in almost normal propor- 
 tion. The fat of the body is sometimes considerably diminished, but 
 very often, and these are the most troiiblesomc cases, it is in excess. 
 Anatomical changes in the tissues, especially the lieart and aorta, may 
 be slight, or may 1)C as considerable, as in the worst forms of anaMiiia. 
 Virchow held that the essential pathological condition was a hy]Kii)lasia 
 of the heart and great vessels, — a theory manifestly inconsistent with 
 the ra])id recovery often observed. For these anatomical or pathological 
 details the student may considt the ai'ticles on "Anaemia," "Chlorosis," 
 and " Blood Changes " in Quain's Dictionary of Medicine, or Bcciuercl's 
 Maladies de V Uterus, vol. ii. 
 
 Synijnoms. — The affection usually comes on insidiously, but is some- 
 times very sudden in its onset. The most striking symptoms are the 
 
104 CHLOEOSIS, ITS CAUSATION 
 
 change in colour and complexion, and the pallid mncous membranes ; 
 but these are speedily accompanied by breathlessness, palpitation, 
 dyspepsia, and great debility, and sometimes by serous effusion into the 
 cellular tissue. This last symptom, and even optic neuritis, may occur 
 without any albuminuria ; the urine is generally abundant, pale, and of 
 low specific gravity. A certain amount of cardiac hypertrophy is often 
 present, and loud spaneemic murmurs are rarely absent. The whole of 
 the symptoms bear a striking resemblance to many of those met Avith in 
 Bright's disease, many organic cardiac affections, gastric ulcer, and chronic 
 tubercular peritonitis ; and before we can be certain of our diagnosis, these 
 must in every case be eliminated by the' most careful inquiry and inves- 
 tigation. Menstrual disorder in some shape is rarely if ever absent, but 
 it may take the form of total suppression, of diminution and irregularity, 
 or of passive monorrhagia or nervous dymenorrhoea (see Chap. VII.). 
 Leucorrhoea is an almost constant concomitant. It is surprising how 
 difficult it often is to ascertain whether these conditions were antecedent 
 to the chlorosis, and possibly causative, or succeeded to it, and were 
 therefore possibly its effects. This chlorotic condition may continue 
 unaltered through a comparatively long life, or it may yield to suitable 
 treatment. There is a constant tendency to return, how^ever, which 
 diminishes as full maturity is reached. Neuralgia and neurasthenia, or 
 nerve weakness, in every form, including hysteria, are frequent accom- 
 paniments of chlorosis, and yield to the same treatment ; but it cannot 
 be denied that they may severally exist quite independently of one 
 another. 
 
 Causation. — Our present knowledge of the patholog}'^ of chlorosis or 
 of ordinary ansemia is so imperfect that it must render us cautious in 
 dogmatically assigning their efiicient causes. The age of commencing, 
 or only partially-established, puberty, is undoubtedly a common, though 
 not a necessary predisposing element. The affection is very frequently 
 hereditary, and is said to occur most frequently in towns, but one often 
 encounters well-marked cases among country girls. In many instances 
 we have no other known causes to guide us in treatment. There is 
 sufficient evidence to show that whatever tends to deprave the nutrition 
 of the body, in the way of deficient food, exercise, air, and light, or what- 
 ever tends to lower the nervous tone, in the way of mental anxiety, loss 
 of rest, over-exertion, — especially mental, abnormal sexual excitement, 
 or the various troiibles which the adolescent girl experiences at home, at 
 school, or in society, may cause or promote the tendency to this affec- 
 tion. Their removal will at any rate materially aid in its cure, and 
 their continuous existence Avill generally be found incompatible with this. 
 
 Treatment. — The treatment of chlorosis sho\ild, in the first instance, 
 be attempted by prescribing the ordinary remedies for ansemia, espe- 
 
AND TREATMENT. 105 
 
 cially iron in its most assimilable forms, combined with attention to even- 
 hygienic error which can be ascertained and con-ectcd, under the social 
 conditions of the patient. In a certain number of cases a rapid cure is 
 attainable by this means alone. We know not positively why arsenic oi- 
 the salts of manganese succeed in many cases where iron fails, but this is 
 so often the case in chlorosis, and the patients have so often tried the ferru- 
 ginous treatment in vain before I am consulted, that I have got into the 
 habit of prescribing one or both of these drugs from the first, in almost 
 every case ; and the rapid improvement Avliich has often followed has, I be- 
 lieve, brought to me more kudos than any medication of a less empirical or 
 more scientific character which I have pursued. The arsenic may either 
 be prescribed as Fowler's solution, 3, gradually increased to 5 or 6, drops, 
 in water, after a meal ; or as arsenite of iron, gr. -^ to gr. ^, throe 
 times daily. The manganese should be given separately as the prepared 
 black oxide, 10 to 20 grains in honey or syrup. The connection of 
 chlorosis with diseases of the uterus must be carefully weighed. In tlie 
 great majority of cases, local disease, such as catarrh of the uterus or 
 vagina, or disordered menstiiiation, is the result, not the cause of the 
 chlorotic state ; but a vicious circle of causation may ensue, the catarrhal 
 discharge, or over-abundant mensti-uation, becoming in its turn a source 
 of weakness or impoverished blood. Moreover, when chlorosis occurs 
 during married life, long subsequent to the full establishment of pubert}-, 
 the haemorrhages or discharges, or perhaps even the nervous irritations 
 caused > by chronic endometritis, or ovarian diseases, niptured cervix, oi- 
 even ruptured jDerineum, may be the primary causes of the chlorosis, 
 and their remedy, secundum artem, may prove the only efl&cient means of 
 its cure. To the nature and treatment of such diseased conditions the 
 remainder of this work will be mainly devoted. The form of acute 
 chlorosis which occasionally folloAvs the puerperal state is sometimes in- 
 dependent of severe losses of blood ; and unless there are strong evidences 
 of chronic metritis, or even when those are present, it nuist be considered 
 as allied to, and demanding the same general treatment as the ordi- 
 nary form which is met with during the first estal)lishment of men- 
 struation. The sun treatment of disease, that is, constant exposure in a 
 semi-nude condition to the rays of tlie sun (Heliothorapy), oarricd on at 
 Weldes and some other parts of southern Europe, has been found l)onetioial 
 in some otherwise intractal)lc cases. In many instances a tolerably rajjid 
 cure of the condition is obtainable by a modification of AVeir Mitchell's 
 treatment. That is to say, the treatment, which 1 shall mention more 
 fully by and by, may be employed, with tlie omission t»f the isolation 
 and removal from home of tlie patient, wliicli add so mucli to its diffi- 
 culty and expense, but whicli are indispeiisalilo wlicn it is carried out for 
 the cure of more strictly nervous affections. 
 
106 NEURASTHEXIA. 
 
 Neurasthenia. 
 
 I use this term here to express, as far as possible in one word, a very 
 great variety of nervous phenomena which are certainly not confined to 
 the female sex, but which are met with in that sex much more fre- 
 quently and with more prominence than in the other. The condition is 
 closely allied to, and in very many instances quite indistinguishable from 
 that other vast group of symptoms which is usually designated by the 
 term hysteria. Indeed, it is very doubtful whether even the typical 
 paroxysm of hysteria, the globus hystericus, &c., are not mere manifesta- 
 tions of neurasthenia. Nor is the more chronic and continuous state 
 of matters described as neurasthenia to be placed altogether in opposition 
 to the more fitful and evanescent state of hysteria, for in each we may 
 have cases of great evanescence of symptoms, and in each a more or less 
 continuous state of nervous affection. The condition known as hystero- 
 epilepsy, of which the student will find a most excellent description by 
 Dr Mills in the American Journal of Medirxd Science, October, 1881, 
 comes within the same category, and perhaps also some cases of epilepsy. 
 At any rate, the remarks as to the treatment of one will apply equally 
 to all, except in such cases as can be traced to a definite organic basis or 
 anatomical lesion. The remarkable uniformity of symptoms observed 
 by Charcot in hystero-epilepsy has hardly been met with in England, 
 and I think is not likely to be until some experimenter can establish a 
 vast clinique where full play can be given to the mimetic tendencies, or 
 liability to be influenced by imitation, or association, or suggestions of 
 ideas or actions, which is prevalent in all neurasthenic or hysterical 
 patients. 
 
 Symptoms. — A state of great general debility is common to nearly all 
 cases of neurasthenia, but this may show itself much more prominently 
 in one or another direction. Inability for physical exertion of any 
 kind, constant tiredness, may or may not be accompanied by inability 
 for mental exertion, or what is very common, there may be paroxysmal 
 exacerbations of the one form of exhaustion or the other, or certain sets 
 of muscles, or certain kinds of brain work may be peculiarly affected. 
 The loss of power of taking walking-exercise is the most common and 
 early symptom, and local cramp, or utter general exhaustion, foUow on 
 attempts to enforce its practice. Feebleness of circulation is shown by 
 cold extremities and cardiac disturbance. Sleeplessness is a common 
 and distressing symptom. Morbid sensations, such as neuralgia of every 
 kind, spinal tenderness at certain points, formication more rarely, and 
 the like hypersesthesise, are seldom absent. The patient becomes in- 
 tensely hjqDOchondriacal, exaggerates every symptom, and on the slightest 
 
ITS FORMS AND CArSATIOX. 107 
 
 suggestion can be made to experience, imagine, or invent — it is often hard 
 to say which — other sj'mptoms. The want of exercise leads to dyspepsia, 
 constipation, and simihxr disorders. Then follow in rapid train, in typical 
 cases, the dreary round of hj^sterical inventions of any or evexy imaginable 
 form of paralysis or spasm, tetany and epileptiform attacks included. 
 Loss of appetite is usual, and may be carried to the extent of voluntary 
 starvation. All the common symptoms of uterine or ovarian disease 
 may be copied in perfection, or may be merely the exaggeration of a 
 slight actual basis of fact. Emaciation, to an extreme extent generally, 
 follows as a natural consequence, or if the patient retains a certain 
 amount of fat it is accompanied by chlorosis or antemia. The emotional 
 conditions commonly called hysterical may be present, or the patient 
 may be simply sluggish, or, what is perhaps worst of all, most amiably 
 and even religiously submissive to the aches and pains, or paralyses and 
 spasms, she is called on to endure. Slight degrees of this neurasthenic 
 condition are very common in the female sex, but with a resolute will, 
 the absence of injudicious pampering, and a little kindly but firm 
 medical advice, they speedily pass away. The same remark applies to 
 over-worked or self-indulgent males. A distinguishing feature in all 
 these cases is that there is never any real loss of mobility or sensation — 
 all the reflex phenomena of health, the " myotatic " contractions of 
 Gowers, are easily elicited, and there is no change in the normal electric 
 reactions. Recovery even in slight cases is usually slow, and relapses ai-e 
 common. 
 
 It is hardly necessary to speculate here as to the essential pathology 
 of these cases, but everything seems to point to what we, in our ignorance, 
 must term functional disease of the spinal and other nerve centres, as a 
 leading factor. Ansemia of the brain or cord, with perhaps occasional 
 hj^ersemic ebbs and flows, must doubtless produce changes in their 
 nutrition too minute for the anatomist to recognise, and to these we 
 must look for an explanation of most of the leading symptoms. 
 
 Causation. — The period of puberty or adolescence is by far the most 
 common time for the development of these sj'^mptoms, and one comes 
 therefore to the conclusion that the mental and bodily changes then 
 going on, are at any rate predisposing agents. Not a few cases, how- 
 ever, are met with in middle age, or at the climacteric i^eriod, while in 
 old age they are exceedingly rare. Another strong predisposing element, 
 one which I have seldom seen entirch' absent, is the existence of a heredi- 
 tary neurotic constitution, as evidenced l)y the occurrence of neuroses 
 in other members of the family. A more immediately exciting causation 
 is found in over-exertion, or prolonged emotion, or in circiunstanccs 
 violently affecting the passions. Although minor degrees of neuras- 
 thenia may have previoiisly existed, the occurrence of the more striking 
 
108 NEUEASTHEXIA. 
 
 phenomena is almost always preceded by one of those causes. Physical 
 over-fatigaie is comparatively seldom the cause in the female sex unless 
 combined with anxiety or care, as in long-continued nursing. Mental 
 over-exertion, especially if experienced during the menstrual periods, is, on 
 the other hand, a too common factor. That sexual excitement, whether 
 suppressed or unduly fostered, is occasionally a cause is absolutely 
 certain. The reticence of the sex on such subjects renders it impossible 
 to say how often this is the case. That the nervous and vascular 
 general and local changes accompanying ovulation and menstruation are 
 often strongly causative may be safely assumed, but I would earnestly 
 caution the young practitioner against assuming too freely that there is 
 always a corresponding or accompanying erotic tendency. Mal-nutrition, 
 in nearly every case, plays a part in the causation sooner or later, 
 whether it is due to insufficiency, or improper character, or faults- 
 digestion of the food ; and almost any departure from strict hygienic 
 laws tends in the same direction. There is nothing which produces such 
 baneful effects in this affection, whether as a primary cause or a fertile 
 aggravation of the symptoms, as the injudicious sympathy of friends or 
 relations, or even medical advisers. Let a young girl, or a young man 
 either, fall into the hands of a fond mother or other relative, who makes 
 it the biisiness of her life to minister to every little want, to magnify 
 every little ache or pain, or to call them into existence by her inquiries 
 and suggestions, and the patient may safely be pronounced a hopeless 
 invahd till he or she is rescued from such unfortunate sim-oundings. 
 One cannot cure these ministering angels, as the patient is apt to consider 
 them, of their mischievous, though well meant practices. 
 
 The most important question with regard to causation remains for 
 consideration. How far is uterine, or ovarian, or pelvic disease to be 
 considered as a predominant cause of this neurasthenic state ? Few- 
 cases continue long without some manifestations of apj)arent uterine dis- 
 ease, and there are not many in which, after a time at any rate, physical 
 signs of uterine versions or flexions, of chronic metritis or vaginal 
 catarrh, or of other gynic disorders, are not encountered. By the time 
 the patient has run the gauntlet of several physicians, and has reached 
 the gyn£ecologist, this is almost sure to be the case, and the attention of 
 her friends and herself will probably have become riveted upon these 
 symptoms. Now, that real uterine or pelvic disease may be the starting- 
 point, I have no manner of doubt. Its symptoms and signs may have 
 been present long before there were other symptoms of general neuras- 
 thenia, the continued reflex irritation of the spinal and sympathetic 
 nervous system, and the impoverishment of blood thus brought aboxit 
 may be the main etiological factor, and the cure of the local affection 
 may produce a speedy improvement, easily followed i;p to complete 
 
NEURASTHENIA. 109 
 
 recovery by simple hj'ji'ieuic means. All this lann l)c, and occasionally 
 is, the case. It is the duty of the shrewd physician to put together the 
 history of the various symptoms without bias, and to make sure that he 
 can speedily alleviate the local malady, before he attempts to treat the 
 case from this direction. But for the most part, and especially in the 
 instance of young or unmarried women, the relations of cause and effect 
 are precisely the reverse. It is the anemic or neurasthenic condition 
 which gives rise to local pelvic congestions, to cataiThal discharges from 
 uterus or vagina, to consequent displacements of the uterus even, and to 
 the multiplicity of ovarian, uterine, or pelvic aches and pains. I cannot 
 better illustrate this than by a quotation from Dr Goodell {op. dt., p. 398). 
 "Take, for instance, this too common picture from life. A girl Avho 
 entered puberty in blooming health, and without an ache, is over-tasked 
 and over-taxed at school, and her health begins to fail. She loses her 
 appetite and grows pale and weak. She has cold feet, blue finger nails, 
 and complains of an infra-mammary pain. Headache, and back-ache, and 
 spine-ache, and an oppressive sense of exhaustion distress her. Her 
 catamenia, hitherto without suffering, now begin to annoy her more and 
 more, until they become extremely painful, and at these times dark 
 circles appear under her eyes. Her linen is stained by an exhaiisting 
 leucorrhoea, and bladder troubles soon set in. She is wearied beyond 
 measure by the slightest mental or physical exertion ; a grasshopper is a 
 burden to her, and she finally becomes hysterical. Now, very unfor- 
 tunately, the idea attached to this group of symptoms is that the repro- 
 ductive organs are at fault, and that the unit of resistance lies in the 
 Avomb. A moral rapj is therefore committed by a digital or a speculum 
 examination, and two lesions will be found. Firstly, as a matter of 
 course, a vaginal anteflexion, and, secondly, an endometritis. These 
 are at once seized upon as the prime factors, and she is accordingly sub- 
 jected to a painful, an unnerving, and a humiliating local treatment. 
 Unimproved, she drags herself from one consulting room to another, 
 until finally, in despair, she settles down to a sof;x in a darkened room, 
 and lapses into hopeless invalidism." 
 
 I wish I could continue the quotation, but what I have already given 
 should be engraven on the memory of the young practitioner before he 
 enters further on the study of the local disorders of women. Not a few 
 of the cases in which it is the fashion now-a-days to excise the ovaries 
 are of this class, and might be cured, at any rate in their earlier stages, 
 by hygienic means. 
 
 Diagnosis. — Neurasthenia, in ordinary cases, is easily recognised by 
 the symptoms given above, and especially by the fact tliat the nmnerous 
 subjective phenomena are found, on careful examination, to lie unaccom- 
 panied by ol)jective signs. It is chiefly with tubes, or myelitis, or 
 
 \ 
 \ 
 \ 
 
110 TREATMENT OF NEUEASTHENIA, 
 
 sclerosis of the cord, or other organic spinal or cerebral affections that it 
 may be confounded, Avhen pseudo-paralytic, or spasmodic, or conviilsive 
 phenomena become developed in its course. I have known very clear- 
 headed physicians deceived in this way, and if I have rarely, though 
 not without exception, been so myself, in the case of females, it is due 
 solely to the fact that where doubt existed, I have ever placed reliance 
 on the age, sex, and surroundings of the patient, on the occurrence of 
 uterine phenomena, and on the other points which have rendered the 
 diagnosis of neurasthenia probable, even when they conflicted with much 
 of the evidence derivable from modern methods of investigating nervous 
 and muscular lesions. 
 
 Treatment. — The treatment of neurasthenia mainly consists in remov- 
 ing its causes when they can be ascertained. Rest is an important 
 element in all cases, rest from brain work, from wearing anxieties, and 
 from physical exercises beyond the strength of the patient. It is, how- 
 ever, occasionally a most difficult task to determine when a certain 
 amount of enforced exercise is likely to be more serviceable than ab- 
 solute rest. I cannot on this point do better than quote from Dr Weir 
 Mitchell {Fat and Blood, Lippincott & Co., 1884, third edition) : — 
 " Sometimes the question is easy to settle. If you find a woman who 
 is in good state as to colour and flesh, and who is always able to do 
 what it pleases her to do, and who is tired by what does not please her, 
 that is a woman to order out of bed and to control with a firm and 
 steady will. That is a woman who is to be made to walk, with no 
 regard to her aches, and to be made to persist until exertion ceases to 
 
 give rise to the mimicry of fatigue There are still other 
 
 cases in which the same mischievous tendencies to repose, to endless 
 tire, to hysterical symptoms, and to emotional displays, have grown out of 
 defects of nutrition so distinct that no man ought to think for these 
 of mere exertion as a sole means of cure. The time comes for that, but 
 it should not come until entire rest has been used, with other means, to 
 
 fit them for making use of their muscles But between these 
 
 two classes lies the larger number of such cases, giving us every kind of 
 real and imagined symptoms, and dreadfully well fitted to puzzle the 
 most competent physician. As a rule, no harm is done by rest, even in 
 such people as give no doubts about whether it is or is not well for them 
 to exert themselves I do not think it easy to make a mis- 
 take in this matter unless the woman takes with morbid delight to the 
 system of enforced rest, and unless the doctor is a person of feeble will, 
 
 and the man who resolves to send a nei'vous woman to bed 
 
 must be quite sure that she will obey him when the time comes for her 
 to get up again." The degree of mental work permissible must be 
 decided in each case on almost priecisely similar principles. Of course 
 
WEIE MITCHELLS SYSTEM. HI 
 
 the period of rest must bo utilised to the fullest extent in improvino- the 
 nutrition of the patent. 
 
 The utmost attention must be paid to securing a plentiful supply of 
 wholesome food, such as the stomach will digest, and iron, arsenic, or 
 manganese have here their fitting place. The moderate and judicious 
 use of hydrotherapy suits some cases remarkably well, but early 
 hours, plentiful and regular meals, and very mild amusement, form a 
 part of this treatment. I have already said enough as to the place 
 which special uterine medication occupies in the treatment of these 
 cases. 
 
 In very many, separation from unwholesome influences and sur- 
 roundings, with the hygienic regimen which will suggest itself to 
 every physician who understands the true nature of the case, will 
 suffice for a cure, if sufficiently prolonged. But in aggravated cases, 
 nothing has been suggested of more value than the combination 
 of several indications in one routine system proposed b}^ Dr "Weir 
 Mitchell. 
 
 It is almost impossible, in the few sentences at my command, to 
 convey the full drift of this combination, in one systematic course of 
 treatment, of these separate remedial factors — absolute mental and 
 bodily rest, systematic and successful rapid nutrition of the tissues, 
 utilisation of the large quantities of food given for nutritive purposes, 
 and prevention of its otherwise deleterious consequences, by systematic 
 rubbing and electricity, together with perfect seclusion of the i^atient from 
 all influences but those of her medical adviser and trained attendants. 
 Every practitioner who has an extreme case in charge should carefully 
 study Dr Mitchell's book for himself, and decide how far the circiim- 
 stances of the patient permit of the adoption of its recommendations. 
 The absolute rest is necessary for a time, varying in different indi- 
 viduals, to reduce the frequeney of cardiac action, to calm the nervous 
 system, and avoid all tissue changes in excess of what are absolutely 
 required. The feeding is conducted mainly by administering gradually 
 increased quantities of skimmed milk, with the addition, from time to 
 time, of other articles of diet, until enormous quantities of food are con- 
 sumed with avidity. The patient gains fat and blood, and increases in 
 weight, in an incredibly short space of time, while the accumulation of 
 waste products in the system, and injury to digestion, are prevented by 
 daily massac/e, or scientific kneading of the whole surface, and to some 
 extent by the application of the Faradic ciirrent to the muscles. The 
 necessary seclusion can only be secured by removal to an establishment 
 where every detail ordered will be rigorously enforced. I could add 
 several to the list of apparcntl}' almost miraculous cures, related by 
 Mitchell and others, of seemingly lK)})clessly paralytic invalids, or of those 
 
112 DIFFICULTIES IX THE WAY OF 
 
 in whom muscular, and nervous, and mental power were at the lowest 
 possible ebb.^ 
 
 There are, however, several drawbacks which have to be somehow 
 overcome, or they will prove prohibitive of the whole system of treat- 
 ment to large nimibers of suitable cases. Having so strongly recom- 
 mended a perusal of Dr Mitchell's original work, I think it is more pro- 
 fitable to mention these drawbacks than to dilate further on its details. 
 
 The expense necessarily entailed by separate board and lodging, with 
 skilled attendance, and massage, and proper medical siipervision, is great, 
 and the six or seven weeks which are necessary, to set the patient 
 fairly on her legs again involve an outlay of from £40 to £60 at least. 
 It is doubtless well spent money for those who have got it, and true 
 economy in the long run. Fortunately these cases are much less 
 conmion in a severe form among the poor, a proof of how predominating 
 is the influence of mental over physical causation, and of the deleterious 
 influence of luxurious coddling and pampering. But they do occur, and 
 occasionally bring ruin to a poor and worthy family, every farthing 
 beyond what is imperatively required otherwise going to comfort the 
 helpless and exacting member. It would be an interesting fact to 
 determine how many chronic invalids are found in our workhouses who 
 might have been saved by a few weeks' proper treatment, or who might 
 yet be saved, and what would be the comparative cost to the community 
 of curing or permanently housing them. Another great difficulty lies in 
 olitaining the consent of the friends or of the patient to the necessary 
 separation. A little tact will almost always persuade the latter, but the 
 former can hardly be made to see that their fond care and attention 
 are the most deleterious influences surrounding the case. They fight 
 for modifications of the seclusion, which would render it totally ineffec- 
 tual, and only the gradual increase in the symptoms at last overcomes 
 their scruples. Time and familiarity with effective cures thus brought 
 about will tend to diminish this difficulty. Another difficulty, not an 
 imao-inary one, lies in the fact that the treatment is almost necessarily 
 removed from the hands of the ordinary practitioner to a stranger. The 
 patient and her friends feel this, if they have confidence in a long-tried 
 friend and adviser, and it is only human nature to suppose that he 
 may occasionally resent it himself. Yet in many cases the patient has 
 ^ot beyond his power of efficient control, by too long sympathetic associ- 
 ation, and a change is absolutely required. It is hardly the fault of the 
 doctor, for in many instances a mere exchange of advisers between two 
 cases would do all that was necessary. This obstacle will be difficult to 
 overcome in the country, but I have found no difficulty in arranging for 
 
 1 Dr Playfair of London and Di* Little of Benrhydding were among the' first to adopt 
 this treatment fully in England. 
 
WEIK MITCHELLS TREATMENT. 113 
 
 the necessary treatment in Manchester, at Mrs Allsop's excellent nursing 
 home, under my own supervision, or that of any other practitioner, and 
 l)robably most large cities will afford similar opportunities. Before 
 undertaking the systematic treatment of such a case, previously 
 under his own care, the practitioner should, however, feel very sure 
 indeed that he holds the reins firmly, and that the steed has never 
 got the bit between her teeth, as far as his driving is concerned. If 
 he is in en-or here, a lamentable failure will result, and the plan of treat- 
 ment, and the practitioner himself, will be greatly discredited. One 
 thing is absolutely necessary, if medical men are to be expected, at 
 their own temporary loss, and with much risk of offending and alienating 
 the fi-iends of the patient, to urge this system of treatment in suitable 
 cases, there must be no quackery at the establishments selected. The 
 patient goes there on the advice and responsibility of her own medical 
 adviser, who deserves therefore the credit of success, or at any rate should 
 fairly divide it with the temporary executor. I am sorry to say that 
 this has not always been the case, and that I have known very great 
 self-exaltation claimed, and widely admitted, in favom- of the directing 
 phj'sician, and at the expense of the physician to whose skill in diagnosis, 
 thorough appreciation of the treatment, and unselfish zeal in insisting on 
 its adoption, the patient owed her delivery from social death. 
 
 My colleagTie, Dr Ross, has two admirable chapters on cerebral and 
 spinal neurasthenia, as observed chiefly in the male subject (Diseases 
 of the Nervous System). At first glance there would appear to 
 exist a much greater difTerence between the sj-mptoms observed in 
 the male and the female, than is evident on further study. Paresis is 
 more common in the female, numbness and pain in the male. The 
 change of life is perhaps the more common factor in the male, and 
 puberty in the female, bvit with many exceptions. In the middle aged 
 man we are not so apt to attribute his varied repertorium of symptoms 
 to fanc}-, caprice, or even untruthfulness, as in the hysterical girl — a 
 fact which should make us more lenient in our judgment of the latter. 
 On the other hand, we have just sufl&cient cases, in the young adolescent 
 male, of utter temporary abandonment to the highest degrees of distorted 
 will and moral nature, of false paralysis, and of con\iilsive tetany, to 
 show us the intrinsic similarity of the affection in both sexes, modified 
 liy the special surroundings of each. Dr Ross and I have recently 
 treated together a most remarkable case of the kind in a young man, and 
 we both, I think, were much impressed with the idea that it is a fortunate 
 circumstance, as fiir as treatment is concenied, that these cases of great 
 neurasthenia in the young do occur so much less frequently in the male. 
 I am pleased to note that so competent an authority attaches an im- 
 ])ortance to the "Weir Mitchell treatment, precisely coiTcsponding to Avliat 
 I have above cx])ressed. ii 
 
114 
 
 DISEASES OF THE VAGINA. 
 
 CHAPTER V. 
 
 Diseases of the Vagina. — -Vaginitis, Acute and Clironic. Leucorrhoea. Tumours 
 and Growths, Foreign Bodies. Wounds, Ulceration, and Mstulte. Occlusion. 
 Prolapse. 
 
 After the digression of the two preceding chapters, the diseases of the 
 vagina follow next in natural order to those of the vulva. In many 
 instances their pathological characters and their treatment are so similar 
 as to require little more than recapitulation, and in not a few cases the 
 maladies of the one region are sim|)le extensions by contiguity from the 
 other. In acute inflammatory affections of the vagina the introduc- 
 tion of the speculum can hardly be borne, and certainly the smallest 
 sized tubular instrument is often the best for ascertaining the general 
 state of the walls and their secretions ; but Avhen small areas of dis- 
 ease, such as fistulse, have 
 to be searched for, and still 
 more when they have to be 
 operated upon, the duck- 
 bill becomes indispensable, 
 and such an instrument as 
 that of Scanzoni (fig. 16) 
 may be of service. A 
 duck-bill speculum with a 
 long, wide fenestra in its 
 blade is also serviceable 
 for examining or operating 
 on small fistulse or ex- 
 crescences of the posterior 
 vaginal wall. 
 
 There are two ways of 
 describing the vagina. According to the one, it is a musculo-mem- 
 branous tube, more or less cylindrical in form, though compressed, 
 and extending from the vulva obliquely through the pelvis, till it 
 embraces the cervix uteri. This idea is ty^Dically showai in Houston's 
 well-known and often-copied diagram (fig. 69), and in the more recent 
 and carefully-executed drawings of Sappcy. According to the other, 
 " the vagina is a mere slit in the pelvic floor, although it is often 
 erroneously described as a tube or cavity." This is shown in Hart's 
 
 Fig 69. —The Pelvic Viscera in Profile (Houston). 
 
IS THE VAGINA A TUBE OK AN INTEitSrACE ? 
 
 115 
 
 druwiug (fig. 70), aud it is, anatomically speaking, tlic more correct esti- 
 mate of what we find in the healthy virgin female. It is very desirable 
 that the student of gyneecology should not fail to realise this fact. At the 
 same time the vagina is, embryologically, a part of the genital tube or 
 canal, and, in its physiological aspects, in copulation, parturition, and even 
 menstruation, it plays the part of a tube ; and in describing its ailments 
 or their treatment, it is almost impossible to use language which does 
 
 Fig. 70. — Vertical Section of the Vagina Fxc;. 71. —Section of Pelvis 
 
 (Hart), u., urethra; ■;;., vagina; (Rannej'-Foster). 
 
 a.l., anterior lip of cervix; p.l., 
 posterior lip ; o.u., os uteri exter- 
 num ; -p-i perineal body. 
 
 not fall in with this conception. S^^ecula, even the duck-bill, dilators, 
 and many other instruments, are all made and used with this conception 
 in view ; and I see no harm in it, if one does not forget the one form of 
 truth, while acting upon the other. lianney's diagram (fig. 71), modified 
 from Foster, shows very clearly the true relation of the canal to sur- 
 rounding parts. 
 
 Acute Vaginitis, 
 
 Acute inflammation of the vagina — vaginitis, colpitis, or elythritis — is, 
 like acute vulvitis, very frequently the result of gonorrhoea, but it may 
 also arise from other causes, and there is the same difficulty in differen- 
 tiating between the specific and non-specific forms. The suddenness of 
 the attack, its acuteness, the urethral and vulvar involvement, the labial 
 oedema, are all characteristic of the gonorrhceal form, but they arc never 
 absolutely conclusive. True gonon-hcual vaginitis may afi'ect only the 
 
116 ACUTE VAGINITIS. 
 
 lower part of the vagina, but there are cases also where it affects only the 
 npper part. Even the occurrence of apparently gonorrhoea! infection of 
 the male is not certain proof of gonorrhoea in the female, for purulent 
 discharges of a non-specific character in the female may produce in the 
 male an affection hardly to be distinguished from gonorrhoea, except 
 perhaps by its milder character and amenability to treatment. 
 
 Cmises. — Any traumatic injury, surgical operations, too strong injec- 
 tions, or medicated pessaries ; irritating uterine discharges, diabetic uxine ; 
 cold, especially during a menstrual period, or after delivery or miscar- 
 riage ; the exanthematous fevers ; badly-fitting uterine supports, or their 
 too prolonged retention, have each occasionally figured as exciting causes 
 of acute non-specific vaginitis. 
 
 The symptoms are those of mucous inflammations generally — heavy, 
 dull, aching pain, or smarting — with tenesmus, " bearing down," spasm of 
 the sphincters of the vulva, anus, or bladder, frequently accompanied, at 
 the outset, by sharp fever, the parts being acutely painful to touch. The 
 mucous membrane is at first red and velvety, perhaps bleeding easily on 
 touch ; the secretion is primarily diminished, bu.t soon becomes increased, 
 the whole affected surface being covered with pus or muco-pus. This 
 secretion is acid, and sometimes very offensive. The squamous epithe- 
 lium is shed in large quantities and washed away with the discharge, so 
 that ra\^mess occurs, and adhesions may take place between opposite 
 surfaces, or between the cervix uteri and vaginal w^all. In old people 
 these attacks, by their frequent subacute occurrence, tend to cause con- 
 traction of the vagina. 
 
 The acute form may end in resolution in a few days, or a week or two, 
 or it may subside into the chronic fonn, giving rise to endless trouble. 
 There is the same danger as in vulvitis of extension to the bladder, 
 to the inguinal glands in the form of bubo, or to the uterus, Fallopian 
 tubes, or ovaries. Such extensions may give rise to inflammation of 
 these organs, with subsequent abscess or strictures, and consequent 
 sterility, peritonitis, or death. This last result, fortunately rare, 
 may occur from the extension of very subacute or even chronic forms. 
 We have also, in vaginitis, a granular form of the disease, due to the 
 affection mainly of the small vaginal papillae ; indeed, some measure of 
 this is usually seen at the commencement, and, much more rarely, there 
 occur minute pustules, as if the affection involved a glandular rather 
 than a papillary element. Gangrenous cases are also reported, where 
 the vaginal sheath, including the muscular tissue, has come awa}' as a 
 sloughing cast, recovei-y depending on how far the parts below are 
 affected. These casts must not be mistaken for mere epithelial exfolia- 
 tions, which, in a more or less complete form, are frequently thrown off" 
 when there is but little local inflammation or constitutional disturbance. 
 
TREATMENT OF VAGINITIS. 117 
 
 True diphtheria, of zymotic origin, is sometimes met with, as on the vulva ; 
 and Schroeder, and others, describe a croupous contlitiou dependent on 
 local in'itants, such as urinary fistulee. What I have seen under tliesc 
 circumstances Avas a mixture of epithelium, pus, and urinary salts. 
 Matthews Duncan mentions a rare form of vaginitis, v. emphyseviatoga, 
 where the surface of the vagina is covered with minute air vesicles ; 
 other writers have described them as present in the cellular tissue 
 beneath, but one would in that case expect more extensive spreading of 
 the emphysema. 
 
 In children, there is the same necessity for remembering the danger 
 of false accusations as in the case of vidvitis, but vaginitis is rare in 
 children, while \ailvitis is common, and in the adult, vulvitis, apart 
 from vaginitis, is comparatively rare. 
 
 The treatment, when the affection is in its acute stage, should be by 
 complete rest, combined with cooling aperients, antiphlogistic regimen, 
 and avoidance of stimulants. The best local application at first is the 
 injection of warm water, either medicated with laudanum and borax, or 
 acetate of lead, or used alone. The Avater should be as warm as it can 
 be quite agreeably borne. But there is a certain amount of danger in 
 all injections during vaginitis, owing to the possibilit}- of tlicir washing 
 the secretions into the uterus, and for this reason they should be gi^^en 
 slowly, and it should be seen that there is free exit at the vulva. A 
 rectal suppository of morph. acet. (gr. \ ad. 5) and cxt. belladon. (gr. ii.). 
 night and morning, gives great relief. Varioiis demulcents, — slippery 
 elm, marsh-mallow, &c., may be substituted for the above watery injec- 
 tions. As the more acute stage subsides, more stimulating applications 
 become desirable, such as boracic acid, salicylic acid (R acid, salicylic. 
 3SS., sod. bicax'b 3iii., aqua 5iv., after effervescence ceases, filter, and add 
 a pint of water), or carbolic acid (1 in 60, to 1 in 20). Nitrate of silver 
 (gr. XV. ad. §1.) is not infrequently applied to the surface with a brush, 
 through the speculum, but my experience of it at this stage is unfavour- 
 able. A further stage of stibsidence being reached, the numerous class 
 of astringents comes into use, and these must be relied on more and 
 more as the disease tends to the chronic form. Alum is the most popular 
 of these (oi.-5ii. ad. Oi.), but it is apt to cause very disagreeable curd- 
 ling of the secretions. The boracic and salicylic acid injections arc still 
 useful, and sulphate of copper (gr. xx.), acetate of lead (3i.), acetate of 
 zinc (gr. xx.), sulpho-carbolate of zinc (gr. xxx.), and sulphate of zinc 
 (gr. xxx. to the pint), are all of value in turn, for they nnist be frc(piently 
 changed, rather than increased too nuich in strength. The list <>f 
 astringent or antiseptic substances wliich it lias occurred to various 
 authorities to use is of indefinite length. Sims's vaginal glass dilator 
 (fig. 3.5) has been recommended to be worn, in oi-der to keep asunder the 
 
118 CHEOXIC TAGIXITIS. 
 
 inflamed siu-faces. I have found it badly borne in cases -svliere it was 
 most required, and woidd reserve it for the most ckronic forms, when 
 there is danger of adhesions. Ermnet's plan of filling the vagina 
 with hot water, while the hips are raised, though invaluable, as we 
 have seen, in certain uterine and pelvic affections, is dangerous in 
 vaginitis, its object being to thi-ow the fluid backwards, and fully dis- 
 tend the vagina, which might favour extension of the disease. "\Mien 
 all febrile symptoms have abated, Edis's plan of injecting through a 
 sj)eculum the giycerole of carbolic acid, 1 in 4, or P. B. strengih, often 
 produces a very good effect, especially in the j^ersisteut granular foiin. 
 It requires a little care, and should be retained for a few hoLU's by a tam- 
 pon soaked in oil, and then gently spinged away. Otherwise, I do not like 
 the use of medicated jjlugs for vaginitis. They are apt to be imtating 
 and offensive. The internal remedies — copaiba, cubebs, and sandal wood 
 oil — are just as effective or ineffective in the non-specific as in the specific 
 forms. In the more chi'onic cases the patience of jDhysician and patient 
 is sorely tried, but the frequent change of these astringent and other 
 local remedies must be continued. I will only add to the number the 
 solution of j)ermanganate of potash (gT. |-, and upwards, to the ounce), 
 and a soothing mistm-e of bismuth in glycerine (gr. xx.-sxx. ad. i.), 
 to be apphed with a biaish. 
 
 Acute vaginitis has been considered, so far, mainly as a local affec- 
 tion; but undoubtedly many cases, though less freqiiently than with the 
 chronic form, depend entirely on constitutional states which demand our 
 first attention. Among these we may reckon the cases occurring diiring 
 the exanthematous fevers, or in the depressed constitutional state due to 
 chronic alcoholism, struma, tuberculosis, diabetes, tfec. Xo local treat- 
 ment avails mxich while these conditions are unchanged, and their com- 
 plete or partial removal often acts as a charm on the local affection. 
 
 Chronic Vaginitis (Vaginal Catarrh, or Vaginal 
 Leucorrhcea) . 
 
 Chronic vaginitis, as a mere stage of the acute form, need not further 
 detain us. But it is, for practical purposes, advisable to speak of that 
 condition of chronic purulent or muco-purulent discharge which is often 
 a sequel of acute vaginitis, but more often commences with little or no 
 febrile disturbance, and creeps on imperceptibly. Clinically we can 
 make no distinction l)ctween chronic vaginitis, vaginal catun-h, and 
 vaginal leucorrhooa. 
 
 The causes, as witli all other catarrhal affections, arc innumerable. 
 Constitutionally, we have damp, or hot, or very cold climates, anaemia, 
 
VAGINAL LEUCORRHCEA. 119 
 
 struma, gout, chronic alcoholism, mental or bodily over-work, and the 
 thousand-and-one other causes which depress the vital powers. Locally, 
 we have want of cleanliness, local irritation from frequent coitus, abuse 
 of pessaries, tampons, or other local applications, extensions from the 
 uterus or vulva, uterine displacements, and pelvic diseases. In fact, 
 everything that debilitates the system, or irritates the vagina, or con- 
 gests the pelvis, may show itself by the presence of vaginal leucorrhoea. 
 It may last for weeks, or months, or a life-time,- with occasional exacer- 
 bations or remissions, but that which follows as a sequel to gonorrhoea is 
 especially intractable. In 1873, Dr Noeggerath published a remarkable 
 paper,! in Avhich he showed, to his own satisfaction, that it was hardly 
 possible for a woman in New York to escape infection from gleet after 
 marriage, and that it was almost equally certain that, once infected, she 
 must sooner or later become the subject of incurable chronic uterine, 
 ovarian, or pelvic disease. At the annual meeting of the British Medical 
 Association in 1876, I read a short paper,- in w^hich I endeavoured to 
 disprove the existence of this very alarming state of matters as regards 
 the community here; but the baneful effects of chronic gleet in the male, 
 transmitted to the female after marriage, are nevertheless serious and 
 frequent enough. 
 
 Symptoms. — Every patient who suffers from vaginal catarrh or leucor- 
 rhoea suffers sooner or later from back-ache, pelvic discomforts, and 
 symptoms of anaemia or general weakness; but these symptoms, even 
 when combined with the characteristic flow, can never be considered as 
 pathognomonic of this affection alone. They may for a time be relied on 
 in the young, but if not speedily subdued, should lead to local examina- 
 tion. I have elsewhere (p. 33) mentioned the characters which differen- 
 tiate uterine from vaginal leucorrhoeal discharges. 
 
 The purulent secretion in vaginal catarrh is mixed in various pro- 
 portions with the vaginal mucus and tesselated epithelium, and is nearly 
 always acid, the action of the acid \\\)Qi\\ the spermatozoa being a not 
 infrequent cause of sterility. This partly accounts for the well-known 
 infecundity of prostitutes, although that is also partly due to more 
 serious changes in the ovaries and Fallopian tubes, the result of gonor- 
 rhoeal extension. 
 
 Treatment. — I have already iiiib'catcd fully eiidugli the means of local 
 treatment b}' astringent or antiseptic aj)])lications. Jjut the remedy of 
 constitutional causes at work must, in tlic chronic form, chiefly demand 
 attention, and in man}' instances, in very young girls, ft)r instance, to the 
 total exclusion of local measures. 1 shoidd ntjt, however, omit tt) mention 
 t])at alkaline injections may be occasionally sul)stitutcd for astringents 
 
 ^ Die, Latentc Gonorrlwi im JFciblichen GesrhlechL Bonn. 
 •- Brit. Med. Jour., 1S77, vol. i. p. 259. 
 
120 CANCER OF THE YACrlXA. 
 
 with great advantage, either as weak solutions of the alkaline carbonates. 
 or as mineral waters used at their place of origin. 
 
 The over-grown or over-worked yonng school-girl is as much a victim 
 to chi'onic vaginal leucorrhoea as the too-frequently parturient woman, 
 and there is often a vicious circle of causation. Ansemia, or debility in 
 some form, causes leucorrhoea, and leucoiThoea adds to anaemia or de- 
 bility, and there can be little doubt as to which end of the chain should 
 be cut. Local apjjlications must give place, until it is found impossible 
 to do without them, to iron, strychnia, cod-liver oil, phosphates, and atten- 
 tion to the action of the bowels and skin. But even these will do little, 
 without good, plain, nourishing food at regular hoiu's, early retirement to 
 bed, out-door exercise, avoidance of mental or physical stimulants, and 
 carefully-considered changes of climate for those who can afford them. 
 It should be remembered by every mother, that, in the case of her grow- 
 ing daughters, leucorrhoea may lay the seeds of many futiu'e troubles de- 
 pendent on pelvic relaxation ; and, still more important, that it means in 
 every case something wrong with the hygienic condition, which may or 
 may not be capable of removal. The conditions of food, air, sleep, exercise, 
 and clothing, must be referred to her medical adviser, and his advice must 
 be followed as closely as possible. If of the poorer classes, she must see 
 what can be done to alleviate her daixghter's hours and conditions of 
 work ; if of the middle class, she must not allow her, except under 
 dire necessity, to emulate the system of cram which is sapping the 
 health of oiu- young men who aim at professional life in this country. 
 When the profession of teaching, as now conducted, lies before a young- 
 woman, I feel powerless to advise ; we must look at it as we do at other 
 unhealthy occupations which are to be followed for the good of the com- 
 munity, and mitigate its dangers as we can. But iu all other cases, the 
 highest possible education of woman is only attainable by the prolonga- 
 tion of the period of girlhood, and is irretrievably injured by ignoring 
 the physical necessities for rest and relaxation which the period of 
 adolescence in woman demands. 
 
 Tumours or Morbid Growths, 
 
 Caxcer. 
 
 Cancer of the vagina is not often met with as a primary affection. It is 
 more frequently an extension from the vulva or the utenis. Epi- 
 thelioma is undoubtedly the most common form, although infiltration 
 downwards of other forms is encountered. The original site is, however, 
 sometimes in the vagina itself, the disease assuming the soft papilloma- 
 tous form ; but it is necessary to remember that in the vaginal wall, as 
 
(•VSTS. 121 
 
 on the cervix uteri, red papillomatous growths are sometimes, though 
 rarely, seeu, which to the eye may seem lualignaut, but which do not 
 appear to have any histological characters of malignancy, and which do 
 not retiim after removal. Sarcoma must be excessively rare, except as 
 an extension from the uterus. 
 
 Symptoms. — Pain, haemorrhage, and foetid discharge, characterise 
 vaginal cancer, as they do cancer in other parts of the genital tract. 
 Nothing but inspection, however, can make its existence certain. 
 
 The same remarks as to treatment apply here as in the case of cancer of 
 the vulva (p. 46). If there is any possibility of getting beyond the bound- 
 aries of the disease with safety, immediate removal by cautery, knife, 
 ecraseur, or escharotics, is desirable. If large bleeding excrescences exist, 
 they may be scraped off, and their site treated with one of the strong 
 escharotics, with the hope of temporarily alleviating symptoms ; and 
 such relief often lasts much longer than might be expected. When the 
 disease goes on continuously, especially that form which consists of infil- 
 tration from above, and the patient survives long enough, perforation of 
 the septa between the vagina and bladder or rectum sooner or later takes 
 place, and fistulous openings are formed, which are, of course, not amen- 
 able to surgical repair. There can hardly be imagined any form of more 
 utter misery than that which is thus caused, and if ever " euthanasia " 
 were allowable, it would be in such cases. OiDium and skilled nursing 
 are our only resources. In some cases of malignant rectal fistula, left 
 lumbar colotomy has been performed with considerable temporary relief. 
 
 Cysts. 
 
 Cysts of the vagina, like those of the vulva, have various origins. In 
 some instances they may commence as small extravasations or thrombi ; 
 in others they are due to the occlusion of noruuil ducts, and retention t)f 
 their contents, which are more or less changed. 
 
 The presence of follicles in the vagina is denied by some, while 
 most WTiters unhesitatingly speak of them as soi;rces of cystic growths. 
 The canals of Gartner, also, or rudiments of the original Wolffian 
 bodies, are mentioned as not infreqi;ently the origin of cysts ; Imt inas- 
 much as these rudimentary structiu-es are rarely to be found at all in 
 any other form, this would appear to be at least problematical. The 
 glands of Bartolinus, when their ducts are occluded, may enlarge up- 
 wards, and so appear as vaginal rather than vulvar cj'sts. Occasionally, 
 cysts are developed on the surface of the lower part of the vagina, vary- 
 ing much in strength and thickness of wall, and these may become so 
 pedunculated as to be described as hollow vaginal polypi. 
 
 Symptoms. — Small vaginal c\'sts may be discovered by accident only ; 
 but when they acquire notable size, they give rise to considerable 
 
122 SOLID TUMOUES. 
 
 irritation and vaginal cataiTh, and occasionally to heemorrliages. They 
 may completely block up the passage, so as to prevent or impede urina- 
 tion, coitus, or delivery. Mistakes, and very important ones, have been 
 made in the way of diagnosis. These have arisen from forgetfulness that 
 any part of the vaginal Avail itself may bulge forth, and that the soft 
 tumour thus j^roduced contains, not a cyst, but a hernial sac of bladder or 
 rectum, or even, though rarely, of Douglas's peritoneal pouch, with some 
 of the softer contents which we have noted (p. 7) as sometimes occupy- 
 ing it. All such hernial protrusions of the vagina — cystocele, rectocele, 
 enterocele, (fee. — can, with a little care, be easily replaced, though they 
 may speedily return ; and there is no true fluctuation to be obtained in 
 them. Such mistakes in diagnosis must imply carelessness rather than 
 want of knowledge. 
 
 As regards treatment, puncture, and removal of the contents by aspira- 
 tor, is nearly ahvays the first resource. Refilling may not take place, but 
 it usually does, so that it is advisable, if the boimdaries of the cyst can be 
 made out, to remove a small portion of the wall, and by iodine or car- 
 bolic injections to j)revent refilling, and promote healing with as little 
 suppuration as j^ossible. In deeply seated cysts, the aspirator should 
 always be tried first. Complete removal of the cyst wall by dissection 
 is seldom possible, unless it is small and superfcial. 
 
 Solid Tumours. 
 
 These are much more rare in the vaginal wall than cystic growths, but 
 fibroids (fibro-myomata), similar to those of the uteinis, and even solid 
 sarcomata, have been described. The extirpation of such growths, unless 
 small or pedunculated, would be a formidable matter, and would require 
 special study in each individual case. I have only met, five years ago, 
 with one exaniple, which I believed to be a fibroid, nearly as large as a 
 hen's egg, in the posterior wall. It certainly was very hard, it was -not in 
 Douglas's pouch, nor in the rectum, and it had no connection with the 
 uterus. I let it alone, and I feel siu'e that if it had given subsequent 
 trouble I should have heard of it. 
 
 Tubercular Deposits. 
 
 These may just be mentioned as occurring, very rarely, in the vaginal 
 wall, in conjunction with similar deposits elsewhere; and, once for all, I may 
 say that I make no pretence, in a work of this kind, to mention every rare 
 pathological curiosity, which a diligent search amongst authorities could 
 unearth. There is such a thing as perspective, applicable to the relation 
 of clinical facts, otherwise the well-known plan of the writer on Chinese 
 metaphysics might be adopted, — look iip the names of all the organs of 
 
FOKETOX BODIES, 123 
 
 the body, then the titles of every form of nco-plasm, add the two ingi-e- 
 dients, and the description \vo\ild be complete. 
 
 Foreign Bodies. 
 
 At one time 1 frequently had ditticulty in removing pessaries from the 
 vagina, and this was due to the common use of hard wooden balls or 
 ovals for the pm-pose of supporting the uterus. The strings attached 
 to them rotted away, the balls jjerhaps gave rise to no immediate discom- 
 fort, and in elderly women might remain for many years. Sooner or later, 
 however, ulceration, or great irritation, and vaginitis, came on, especially 
 if the pessaries were crusted with urinary salts. Deep vilceratiou some- 
 times invaded the bladder or rectum, but this accident is quite as likely 
 to occur from the neglect of a much more scientific instrument, the 
 Hodge pessary. No one should ever introduce one of these, or indeed 
 any kind of pessary, ^vithout warning the patient that every now and 
 again, or on the occurrence of any unusual discomfort, the instrument 
 should be seen to by a competent practitioner. For the extrac- 
 tion of these balls, which happily I now rarely see, a small, straight 
 midwifery forceps was often necessary, — there was no other way 
 of seizing the rotatory substance. Sometimes, from long-continued 
 vaginitis, the canal below them had contracted very much, and great 
 care was required in extraction. Other bodies have been found, from 
 time to time, introduced into the vagina, either maliciously or by the 
 patient herself. A very long list of such articles might be culled from 
 the medical journals, varying from pewter pots {Lancet, 1848, i. 313) to 
 pins. Poisoning, also, has been attempted, and executed, through this 
 channel ; but this hardly conies within our domain. No special rules 
 can be laid down for the removal of such miscellaneous articles. An- 
 aesthesia will often be required for the diagnosis of their shape and 
 relations, and if projecting parts oppose themselves to extraction, they 
 must either be broken by bone forceps and removed separately, or tlie 
 whole must l^e turned into a more fa^•ourable position. Tact, patience, 
 gentleness, and common sense are much needed, especially wlicn the 
 ofTending body is of glass or crockery. 
 
 Wounds, Ulcerations, and Fistulae. 
 
 Wounds. 
 
 Wounds of the vagina, not due to labour or to some operative pro- 
 ceeding, are by no means common, yet they sometimes occur as the 
 result of accident or wilful injiu-y. Thus the pitchfork in the hayficld, 
 
124 WOUNDS •ULCEEATIOXS FISTUL^E. 
 
 the goring of a bull, sitting upon cracked pottery, the breaking of a 
 glass syringe, "wilful stabbing or kicking, rude attempts at criminal 
 abortion, or even a sudden fall, have all been knoA^Ti to produce iTipture 
 of the vagina. If the rent is considerable, the danger from hsemon-hage 
 is great, and, indeed, very small wounds of the lower part may give rise 
 to speedily fatal results. If the instrument penetrates beyond the walls, 
 we have the further danger of ruptured or prolapsed intestine. The 
 treatment of such Avounds requires the use of ordinary surgical means. 
 The edges are to be brought together while fresh, and united by the in- 
 struments and means which are applicable to the treatment of fistulse. 
 In case of haemorrhage, pressure may be made on the lower parts of tbe 
 vagina by the solid plug of Sims's glass dilator, but not, of course, if there 
 is danger of internal bleeding. Great care must be taken to look for and 
 examine any protrusion, and to return it if uninjured ; but if serious rup- 
 ture of bowel has taken place, or if there is reason to think this highly 
 probable, the sm'geon should not hesitate to open the abdominal cavity, 
 and, with all antiseptic care, to search for the rupture, and repair it by 
 gut sutures, while carefully removing from the peritoneum every vestige of 
 escaped feecal matter. There is a great futiu-e for abdominal surgery on 
 the hues so admirably portrayed by Marion Sims in a series of articles in 
 the Brit. Med. Jour, for 1881, vol. ii. The great fear is that "fools may 
 rush whei-e angels fear to tread," and bring into discredit, for a time, 
 what promises to confer so much benefit on mankind. 
 
 Ulceratioxs. 
 
 Ulceration of the vagina, from cancer or other causes, has been already 
 casually referred to. When the disease is inevitably progTessive, there 
 is, of course, nothing to be done in the way of repair ; when such is not 
 the case, as in ulcerations after delivery, openings occur into the sur- 
 rounding hollow viscera, and the whole matter will be best considered 
 under the heading Fistulse. 
 
 Fistula. 
 
 Causes. — These may result from clean wounds, such as have been 
 mentioned above, — rarely so, however, if they have been under skilful 
 treatment from the first. Malignant fistulee may be dismissed at once as 
 beyond the reach of art. Abscess in the pelvic cellular tissues may, by 
 burrowing in two directions, connect the vagina with the bladder, the 
 rectum, or the perineum; and the same may be said of those extravasations 
 of blood already described as thrombi, or afterwards to be spoken of 
 as pelvic hsematocele, but only in the event of their suppurating. 
 The idceration produced hj a pessary or other long-retained foreign 
 
VAGINAL FISTUL.E. 125 
 
 body in the vagina ma}' lay open the rectum or bladder. Syphilitic 
 sores may also perforate the vaginal wall, but it is iisually the urethra 
 that is thus entered. Ulcerative perforation of the vagina may alsc) 
 occur from without, as from the presence of a hair-pin, or a calculus, in 
 the bladder ; and foreign bodies in the rectum, even hardened faeces, may 
 produce the same result. Chronic vesical ulceration, without any foreign 
 irritant, has been traced in some instances as a cause of vesico-vaginal 
 fistulae {Lancet, 1870, ii. 738). Artificial fistvila has also been advocated 
 and performed by Bozemann, Emmet, and others, for the cure of some 
 vesical affections (.see Chap. XXL). Sloughing of the vagina, with sub- 
 sequent fistula, in the course of eruptive fevers, has also occurred ; and, 
 as we shall see shortly, congenital malformations may also cause 
 communications between the various pelvic viscera, which, if they do not 
 produce one great common cloaca, may be so limited in area as to be 
 regarded and treated as fistulte. 
 
 But all these causes put together, except the malignant ulcerations, do 
 not create a tithe of the number of the fistulee which are due to misfortime 
 or mismanagement in the process of labour. In some instances the par- 
 turient canal gives way, and at once produces a communication of viscera. 
 Such is the case when the perineum yields, and with it a portion of the recto- 
 vaginal septum, although strictly speaking this can hardly be said to 
 produce a fistula till the perineum has healed. ]\Iore rarel}', — fortunately 
 much more rarely, — the upper part of the vagina gives way, either by 
 itself, or following the line of a ruptiu-e in the cervix uteri. But the great 
 majority of vaginal fistulse, of puerperal origin, are not immediately pro- 
 duced, but are due to subsequent sloughing fi-om severe or long-continued 
 labour without skilled help. That the forceps, or still more readily, 
 craniotomy instruments, may, in skilful hands, produce rupture, I am not 
 prepared to deny, but in the great majority of cases it is the delay in 
 using these instniments, or the using strong traction after the head has 
 been allowed to become thoroughly impacted, which is answerable for the 
 result. Fortunately, we are almost all now agreed on this point, but it 
 was not always so. "What unskilled use or neglect of obstetric instniments 
 may do, Emmet and other extensive operators on vesico-vaginal fistula- 
 have taught us. The sloughs produced by prolonged pressure may come 
 away in a day or two, or they may be delayed for a fortnight, or even 
 more, but usiually the mischief is apparent in three or foiir days. The 
 part of the ])arturient canal aftectcd by the pressure, and consequent 
 sloughing, is influenced in various ways, but it is usually that portion 
 which happens to lie between the licad and the pubic symphysis 
 at the time of gi-eatest or longest pressure. Thus the part in rear 
 of the bladder is most frequently affected, but the urethra may be 
 dragged up into this situation, or the anterior lip of the cervix uteri may 
 
126 
 
 CAUSES OF VAGINAL FISTULA. 
 
 be pushed down and caught there. The comparative shortness and 
 inflexibility of the anterior vaginal wall is also not without its influence 
 in determining the seat of rupture. The varying situations of fistulfe, 
 anterior to the vagina, are thus accounted for, but recto-vaginal fistulse 
 are more commonly due to direct rupture than to sloughing. 
 
 It may be well to shoAv at a glance the various causes of vaginal 
 fistulse— 
 
 1. Incised or piuictured wounds. 
 
 2. Cancerous ulceration. 
 -3. Pelvic suppuration. 
 
 4. Syphilitic ulceration. 
 
 5. Pessaries or other foreign bodies 
 
 in the vagina. 
 
 6. Vesical calculi. 
 
 7. Foreign bodies in the rectum. 
 
 8. Foreign bodies in the bladder. 
 
 9. Chronic vesical ulceration. 
 
 10. Sloughing during fever. 
 
 11. Congenital malformation. 
 
 12. Direct tearing in labour. 
 
 13. Slouo-hing after labour. 
 
 It is not necessary to dwell on the symptoms prodviced by these fistulse. 
 The symptom is the escape per vaginam of urine, faeces, or flatus. This 
 may vary in extent, according to the magnitude and position of the 
 fistula. In recto-vaginal fistulse the faeces may continually escape, 
 except when constipation exists in the very highest degree, or this may 
 only occur during diarrhoea, or nothing except flatus may pass. In anterior 
 fistulse the escape of urine is a more constant symptom, even when the aper- 
 ture is small. Especially will this be the case if it is situated just behind 
 the urethra. But there may be some power of retention, as for instance 
 when a portion of the urethra only is involved, and not the bladder, or 
 where the aperture in the bladder is so situated as to be above water mark, 
 either in standing up or in lying down, when the bladder is only partially 
 full. More rarely, the opposite wall of the bladder may bulge through 
 the opening in such a way as to form a sort of plug, until more complete 
 filling of the organ separates its walls. The patient's life is always a 
 miserable one ; and to add to the above-named symptoms, which cause 
 infinite discomfort, there is always some accompanying vaginitis and 
 vulvitis, and the external parts become inflamed and ulcerated, or covered 
 with eczema, and subject to pruritus. The removal of these secondary 
 symptoms, previous to operation, affords no mean element of success in 
 the operation itself. 
 
 Diagnosis of the exact condition is often more difficult than might 
 be imagined. I have come across more than one supposed urinary fistula 
 which has proved to be nothing more than incontinence, and Avhich has 
 yielded to the use of strychnia and the constant galvanic current. The 
 finder will generally detect and gxiide iis to a fistula of any size ; but in 
 the case of small openings, single or multiple, the most careful and pro- 
 lono-ed, perhaps repeated, examination may be necessary. The tubular 
 and duck-bill specula may i^e used in turn ; but no matter which of these 
 
VARIETIES OF FISTUL^E. 127 
 
 first shows the opening, the latter will be recj^uircd to bring it fully into 
 view, and within reach. A wide but short tubular speculum, or a duck- 
 bill, with a fenestra an inch wide in its walls, are either of them very 
 serviceable in detecting rectal fistulse, and in inserting su.tures in them. 
 The duck-bill is hardly impaired for its other uses by this fenestra. 
 In small vesi co-vaginal fistulse, or when there is reason to think that 
 the posterior opening is uterine rather than, or in addition to, a vaginal 
 one, the injection of fresh milk into the bladder, while the vagina is 
 exposed, is an excellent aid to diagnosis. The white oozing fluid is at 
 once apparent to the eye. 
 
 There is hardly any department of surgery in which such great im- 
 provements have been made of late years as in the operative treatment 
 of these affections ; and for this improvement, although many great 
 writers, English, continental, and American, have contributed a share, 
 we are mainly indebted to Marion Sims, who, by the introduction of his 
 speculum and of silver sutures, alone made all the rest possible. 
 Emmet, while giving full credit to his distinguished countryman for 
 these improvements, points out that in mere priority he was forestalled 
 in both ; such was also the case with the introducer of the sound and 
 the tent, and this gives point to Emmet's remark, that "ideas and 
 general principles may be new, but mechanical procedures seldom are." 
 Although I shall have little or nothing to say here of the surgical treat- 
 ment of the more rare forms of fistulae, and will chiefly confine myself 
 to mentioning the principles which guide us in the treatment of the 
 common forms, but which are applicable, with special modifications, to 
 all, yet it may be advisable to place in a tabular form the varieties 
 which such fistulse may assume. The names of the fistvilse are in them- 
 selves sufficiently descriptive of the organs communicating : — 
 
 1. Vesico-vagiual. 
 
 2. Vesico-uterine. 
 
 3. Vesico-utero-vagiiial. 
 
 4. Urethro-vaginal. 
 
 5. Uretero-vaginal. 
 
 6. Uretero-rectal. 
 
 7. Vesico-rectal. 
 
 8. Recto-vaginal. 
 
 9. Entero-vaginal. 
 
 10. Recto-labial. 
 
 11. Perineo-vagiiial. 
 
 12. Pcritoiu'o- vaginal. 
 
 Of these it will be observed that several (2, G, 7, and 10) arc not fistukc 
 of the vagina at all ; but their mode of origin, of diagnosis, and of treat- 
 ment is so closely allied, that it seems better to include them in one 
 table. Some of these fistula) are also so rare, or their treatment is so 
 exceptional, that they may be at once dismissed. These will include the 
 fistula) into the ureters, the recto-vesical fistulsc, where the vagina has 
 escaped injury, the involvement of the intestine rather than the rectum, 
 and the recto-labial fistula, a mere accidental vai-icty of the recto-vaginal 
 ("), G, 7, 9, 10). The peritoneo-vaginal (12) is a form of fistula which, 
 
128 VAEIETIES OF FISTUL.E. • 
 
 a priori, one would hardly consider as permanently consistent with life. 
 I had, however, at one time, the opportunity of carefully examining a 
 case recorded by Mr Walter Whitehead (^rjY. Med. Jour., Oct. 1872), and 
 referred to by Barnes (Diseases of Women, p. 461), where no trace of 
 uterus could be found in a multiparous Avoman (it was supposed to have 
 undergone complete super-involution), and where the sound could be passed, 
 and was often passed, through a small orifice at the top of the vagina, and 
 could with ease be moved about in any direction, and for any distance, and 
 felt in close contact with the abdominal walls. Finally, the perineo- 
 vaginal fistula (11) maybe eliminated, as differing from the others in not 
 connecting two canals or internal viscera. In its nature it is similar to 
 fistula in ano, and I have seen them coexistent, and apparently without 
 intercommunication. Nothing but the greater vascularity and com- 
 plexity of the parts about the vulva, and the fact that spontaneous 
 healing can be more readily trusted to, prevents the adoption of similar 
 treatment as in fistula in ano. I will merely indicate here the lines 
 of treatment in a case of ordinary vesico-vaginal fistula, referring also 
 to the occasional involvement of the uterus or urethra, and adding 
 anything which may be required to elucidate the treatment of recto- 
 vaginal fistulse (1, 2, 3, 4, 8). 
 
 Supposing, then, that a moderate-sized rent is discovered between the 
 vagina and bladder, Avhat are the probabilities of spontaneous cure, or 
 cure without operation? Not very great, certainly, but not entirelj- 
 hopeless. At any rate, the same measures are required for the comfort 
 of the patient as those which give the best chance of spontaneous cure. 
 A small sigmoid catheter (fig. 67), or a Skene-Goodman catheter (fig. 68), 
 should be introduced and retained in the bladder. The vagina must be 
 frequently s}Tinged Avith warm Avater containing 1 in 40 of carbolic acid, 
 and the patient must be kept as quiet as possible AA'hile recovery from 
 jDarturition is going on. As that period passes by, the injection may be 
 used hotter and hotter, and the other means are emjDloyed which are 
 required as preparatory to operating in chronic cases (see Chap. III.). 
 Spontaneous cure may occur in this AA^ay, though it rarely does with acci- 
 dental fistulse. As an aid to cicatrisation, the actual cautery is noAv 
 almost entirely out of date. Very small rectal fistulte may heal under 
 its influence, though stitching is probably better, even in these ; but 
 A^esical fistulse, eveia mere pin-hole apertures, Avould probably heal spon- 
 taneously, under careful general management as aa'cII as AA'ith the use of 
 the cautery. 
 
 There is a tolerably smart contest between some German authorities — 
 Simon, for instance — and those of the school of Marion Sims and 
 Emmet, as to the A'alue of the metallic suture, of careful preparatory 
 treatment, and as to other and less important points, and it is not for those 
 
PREPARATIOX FOR OPERATIOXS ON FISTULA. 129 
 
 who ajiproach gynsecology froui the medical rather than tlie surgical 
 side to decide judicially between such eminent disputants, but the 
 humbler function, analogous in some -wayn to that of the jury, is open to 
 us, and on the two points mentioned, the great value of silver wire, and 
 the necessity of very careful prej)aration of the patient, I feel compelled 
 to find an affirmative verdict. In following very closely the lines laid 
 down by Emmet for closing these fistulse, I am only doing what others 
 liave done, not always with similar acknowledgment. 
 
 The preparation of the patient, then, for operation furnishes an 
 element of success which should never be lost sight of. As a result of 
 the abnormal direction of the urinary flow there very speedily forms 
 a deposit of phosphatic sediment around the fistula and encrusting the 
 vaginal w^all. Hence w-e have concurrent vaginitis, the combined dis- 
 charges causing eczema of the external parts, together with abrasions 
 and ulceration of the vaginal wall, vulva, and thighs. This condi- 
 tion must be removed, if it has been allowed to occur. With a soft 
 sponge all deposits miist be wiped away, at one or more sittings. All 
 raw surfaces should then have applied to them a weak solution of nitrate 
 of silver. For several days the vagina is frequently syi-inged with water, 
 as warm as the patient can comfortably bear it, and the addition of 
 carbolic acid (1 in 40) is advisable. The external parts must be kept free 
 from irritation by the application of vaseline. The urine, generally 
 alkaline, must be restored to its normal acidity, for which purpose 
 Emmet recommends the following formula : — R Ac. Benzoic. 3ii, Sod. 
 Bor. 3iii, Aq. gxii. St. gss. ter die, ex aquae cyatho. This plan of treat- 
 ment must be continued for days, or weeks, until the parts have acquired 
 their natural appearance, an occasional touch of nitrate of silver or 
 tincture of iodine being given to excoriations which are obstinate. There 
 is no doubt that success is often obtainable hj skilful surgeons without 
 these precautions, and it will be infinitely better if, by attention to the 
 patient from the first, they are hardly required. But under this treat- 
 ment spontaneous healing does occasionally occur, as it does in spite of 
 the surgeon, in the case of clean artificial fistula; made for the cure or 
 relief of bladder disease ; and few who have seen a vesico-vaginal fistula 
 in its neglected state, and compared it with one thus attended to, can 
 doubt that the chances of spontaneous healing or operative success are 
 both greatly improved. 
 
 Another preliminary, not always, but often, required, is the division of 
 cicatricial bands which prevent the edges of the fistula from being easily 
 approximated and united without imduc strain. Such bands, if slight, 
 may be snipped with scissors at the time of operation, but if strong or 
 extensive this should be done as a preliminary operation. The resulting 
 haemorrhage must be stayed ])y hemostatic astringents and the pressure 
 
130 ' THE OPEEATION FOE 
 
 of one of Sims's dilating plugs, and a week or ten days is allowed to 
 elapse, during which frequent carbolic syringing and the occasional 
 introduction of the glass plug should be employed. 
 
 For the operation, three assistants at least are required, one to take 
 charge of the anaesthetic, another of the duck-bill speculum, and a third 
 of the other instruments, sponges, &c. This latter must be trained to 
 keep his fingers out of the way and himself out of the light. The patient 
 having had the bowels well cleared, and a dose of opium administered, is 
 anaesthetised, and placed in the lateral prone position. The duck-bill 
 speculum is introduced, and the fistula brought as well as possible into 
 view. The genu-pectoral position is rarely necessary. The lower border 
 of the fistula is then seized with a tenaculum, or a long finely-toothed 
 forceps, and a strip of vaginal mucous membrane, one-fourth to one-sixth 
 of an inch wide, is carefully removed all round the orifice, leaving the 
 vesical mucous membrane intact, but paring close 
 up to it. This freshening should extend well 
 beyond the angles of the wound, in order to pro- 
 vide against the possibility of a small fistula 
 remaining at those points. When the septum 
 is very thin it may be difiicult to obtain a sufii- 
 cient raw surface, and it may be necessary very 
 carefully to split the layers between the vagina 
 and bladder, making the non-mucous surface ot 
 each to play a part in the new cicatrix. Those 
 who have been privileged to see Marion Sims 
 operate with the small razor-like knives, capable 
 of being set at any angle in a long handle 
 (fig. 46), would be tempted to under-estimate 
 Fig. 72. -Paring Fistula by the difficulty of using such an instrument with 
 Scissors (Churchill et pq-xxj- i ^ ■■,. . 
 
 Lebloud). sutlicient steadniess and skill, bxit m ordmary 
 
 hands the use of sharj) scissors is preferable 
 (fig. 72). A variety of scissors curved in various ways would form 
 part of the armamentarium of a specialist operating on any large 
 scale, but figs. 73 and 74 show two of Emmet's favourite forms. It will 
 depend on the skill of the operator, and the accessibility and size of the 
 fistula, whether sufiicient membrane can be removed in one long strip, or 
 whether fresh hold will have to be taken and the paring done at several 
 strokes. If the vesical mucous membrane has been cut it is apt to 
 bleed freely. This may be checked by seizing the bleeding edge with 
 a torsion forceps which is allowed to hang for a short time, the delay 
 being otherwise not disadvantageous. If that fails, a ligature of gut 
 may be passed through the vaginal wall into the bladder and out 
 again at a very short distance from the raw edge, so as to encircle the 
 
VESICO-VAGINAL FISTULA. 
 
 131 
 
 bleeding vessel. Such ligatures must uever be placed far, say not more 
 than half an inch, from the middle line, or they may involve the ureter. 
 In the case of a large opening they could never be free from this danger. 
 The wound being now pared, its edges must be united so that the 
 raw surfaces will be in accurate contact. Pure silver wire is certainly 
 the best for this purpose. For their introduction most men could, I 
 think, easily manipulate laterally curved needles with fixed handles (fig. 
 48), and with their edges rubbed down so as to make them as nearly 
 round as possible. Tubular needles (fig. 49) with a lateral or double curve 
 are apt to fail, from the wire refusing to pass. Emmet, however, and 
 others prefer to use short, round needles, from one-half to three-quarters 
 of an inch in length, slightly curved at the point, which are introduced 
 
 Fig. 73. — Emmet's Curved Scissort 
 
 Fig. 74. — Emmet's Double Curved Scissors. 
 
 by means of a needle-holder, carrying with them a loop of silk. This loop 
 is used to draw back through both sides of the fistixla the end of a silver 
 wire hooked round it. The space between the stitches should be about 
 one-sixth of an inch (fig. 75). All the necessary stitches having been 
 placed, and a little time being given to allow oozing to cease, which cessa- 
 tion may be accelerated by the application of a little pure spirit, tlie 
 bladder should be washed out with a gentle stream of warm water, directed 
 through a catheter, and allowed to escape at the wound, and the edges 
 must now be approximated. Simple twisting of the wire is sufficient 
 (fig. 60). The twisted ends are then cut oft' about half an inch from the 
 wound, and bent over laterally to alternate sides. A small self-retaining 
 catheter is introduced, and the same precautions as to aft-er-trcatment 
 
132 
 
 OPERATIONS FOR VESICO-UTERINE, 
 
 must be observed as in all other operations of this kind — very light 
 nutritious food, and opium to lock the bowels for a very few days, 
 and to keep the patient at rest. The stitches should remain for eight 
 or ten days, and should be removed with the greatest possible gentleness, 
 the catheter being used for some time subsequently. 
 
 When the vesico-vaginal tear implicates also the cervix uteri, any 
 operation for its closure becomes still more difficult and complicated, but 
 must be conducted on the same lines. It not unfrequently happens, 
 however, in such cases, that partial spontaneous reparation takes place, 
 
 leaving two separate fistulse, 
 one into the vagina, the 
 other into the uterus, or 
 perhaps one only into the 
 cervix uteri. This can only 
 be reached by freely dividing 
 the cervix up to the fistula, 
 so as to reproduce, to a cer- 
 tain extent, the original tear 
 through it. 
 
 When the urethra is the 
 part involved in a vaginal 
 fistvila, the facility of repair- 
 ing it is greater than in the 
 case of the bladder, so far as 
 getting at it is concerned, 
 but the intervening tissue 
 to work upon is excessively 
 thin. It is therefore recom- 
 mended, after freshening the 
 edges on the vaginal side, to 
 relieve the tension by a 
 longitudinal incision, paral- 
 lel to the borders of the 
 repaired fistula. The fistula 
 is kept well in view during operation by retaining a full sized gum- 
 elastic catheter in the urethra. I am inclined to recommend, in this 
 case, though from little personal experience, the use of fine gut sutures, 
 which may be left for a longer period than wire ones, or indefinitely. 
 
 Recto-vaginal fistulfe have been already referred to in connection with 
 the subject of torn perineum. As a result of this accident, with sub- 
 sequent union of the perineal tear, and also as an occasional result of 
 abscess or syphilitic ulceration, they come as frequently imder the notice 
 of the general medical practitioner as vesical fistulse, although in some 
 
 Fig. 75.— Fistula with Wires inserted (after 
 Churcliill et Leblond). 
 
VESICO-URETHRAL, AND VESICO-KKCTAL FLSTUL.^. 133 
 
 respects they are more difficult of repair. This is owing to the greater 
 difficvilty of bringing them steadily into view. With the finger in the 
 rectum there is no difficulty in protruding the torn septum into the vaginal 
 space, but to insert a duck-bill speculum with its convexity to the pubes, 
 though it is generally looked upon as our only resource, is certainly not 
 in accordance with the principles upon which the use of that instnxment 
 is based. By this means, and having the labia further held open by 
 spatulse, while the patient lies on her back in the lithotomy position, 
 the fistula is exposed. A fenestrated speculum, through the fenestra 
 in which "the fistula can be got at, is sometimes of service, and it is 
 worth while to have one specially cut for the operation. When the 
 patient has been anaesthetised, a large bougie can be easily passed into 
 the rectum, previously well emptied by injections, and this serves to 
 keep the fistula prominent. The mode of paring the edges and of insert- 
 ing the sutures varies little from that followed in relation to vesico- 
 vaginal fistulse, but the bevelling of the edges, the wider part of the tear 
 being vaginal, is often already very great before any paring is done. In 
 cases where there is difficulty in obtaining a sufficient raw surface, the 
 septum may be carefully split, the vaginal layers stitched together with 
 wire sutures, and the rectal ones with pure gut, which is left to disappear 
 of itself. The rectal stitches should be first inserted. Dr Goodell recom- 
 mends {o}). cit., p. 68) a more complicated process, " a shallow cut is 
 made round the vaginal mouth of the fist\ila, about half an inch away 
 from it, and the mucous membrane dissected up to its rim in a frill. 
 This is next inverted and pushed into the rectum through the opening, 
 which is now closed by rectal and vaginal stitches — the former uniting 
 the raw surfaces of the frill, the latter the raw strip around the vaginal 
 rim of the fistula." In order to insert these rectal sutures it is necessary 
 to previously stretch and paralyse the rectum, and then to introduce a 
 duck-bill speculum within it. 
 
 Occlusion of the Vagina. 
 
 Occlusion of the vagina may be congenital, and this state, together 
 with its occasional consequences, will be described in Chap. VI., along 
 with other malformations. Much more rarely it may result from 
 injuries, or from sloughing after labour or otherwise. If complete, 
 and if it occurs before the menopause, there will of course be reten- 
 tion of the menstrual fluids, and operative proceedings will be re- 
 ipiired similar to those for congenital retention. If only partial, it may 
 still act as an inipcdinient to connection, and demand remedy. In all 
 s\icli cases, the maxim is to do as much as ])()ssib]e l)y dilatation, and as 
 
134 ACCIDENTAL AND ARTIFICIAL OCCLUSION. 
 
 little by cutting. If anaesthesia is used, the parts yield readily and 
 betray the points of greatest tension. These should be carefully snipped 
 with scissors, and the glass dilator used for the pui-pose both of disten- 
 sion and of arresting haemorrhage. In this way it is astonishing how 
 little cutting of the surface enables the vagina to unfold to its former 
 calibre. 
 
 Artificial occlusion of the vagina is recommended in the case of 
 large or incurable fistulee, and its adoption will, of course, depend, to a 
 very great degree, on the presence or absence of menstruation, and on 
 the marital relations. ]\Ienstn.iation is, however, no absolute barrier, as 
 in such cases the fluids will find their way by the rectum or bladder. 
 The former would be the more satisfactory outlet, owing to the danger of 
 cystitis and accumulation of clots in the bladder ; but I have recently 
 had under notice a case (fig. 82) where the vagina is congenitally absent, 
 the much retroverted uterus opens directly into the bladder, and men- 
 strual life has, so far, about five years, been unattended with any diffi- 
 culty, except for one or two jjeriods after my first diagnosing the case by 
 passing the uterine sound j'jer urethram. 
 
 As a matter of fact, now-a-days, vaginal rents very seldom indeed de- 
 mand total occlusion of the canal ; and, with the modem improvements in 
 operating on fistulse it should be but a last and rare resource. The surfaces 
 chosen for freshening and attachment will vary, of coui'se, according to 
 the exigencies of the case and the amount of sound tissue remaining ; 
 but, as a rule, it will be foimd better to unite the anterior and posterior 
 walls than the lateral ones. Paring and iniiting of the vulvar surfaces 
 would, a priori, appear to be a comparatively easy matter, but it has 
 been found practically to be almost impossible to avoid some fistulous 
 opening in the neighbourhood of the urethra, which destroys the effect 
 of the whole operation. 
 
 Prolapse of the Vagina. 
 
 This has already been mentioned in connection with torn perineum. 
 It seldom exists to any great extent quite independently of that, but may 
 do so. Its causes, its symptomatology, and its treatment are so inti- 
 mately associated with those of the same affection of the uterus, that it 
 will avoid much repetition if we consider them together (see Chap. XI.). 
 
CONGENITAL MALFORMATIONS. 135 
 
 CHAPTER VI. 
 
 €oxGENiTAL MALFORMATIONS OF THE Genital Tract. Ovaries and Fallopiau 
 Tubes, Uterus, Vagina, and Vulva. Hermaphroditism. Results of Atresia, 
 and Proceedings for its Removal. 
 
 It seems advisable to mention in one place the congenital malforma- 
 tions which are met with in the various portions of the genital tract. 
 Many of these abnormalities are, of course, quite incurable, and bear 
 solely on the question of viability, or of marriage or sterility, but others 
 -are of great practical importance, leading to the retention of the pro- 
 ducts of menstruation, and thus causing painful and dangerous affections 
 which are fortunately within the reach of ai't. 
 
 The Uterine Appendages. 
 
 Under this heading we include the ovaries and Fallopian tubes, 
 although from another, and perhaps more strictly scientific point of 
 view, the uterus, vagina, and Fallopian tubes might rather be con- 
 sidered as the appendages, or at least the diicts, of the ovaries. Malfor- 
 mations of the latter organs, as a rule, exist only in connection witli 
 malformations of the uterus, but they may exist separately, and are 
 doubtless sometimes the hidden and obscure causes of menstrual and 
 ■other diseases. When the uterus is absent, or practically absent, being- 
 found only in the most rudimentary form, it is rare to have the ovaries 
 present, yet cases are recorded where, in the absence of any recognisable 
 uterus or vagina, there occurred an undoubted menstrual molimen, and 
 the pathological theatre shows that in such cases one or both ovaries 
 may exist in a less rudimentary form than the uterus. The occuirencc 
 «of a monthly molimen imder such circumstances would therefore 
 warrant us in l)elieving in their existence, although we were unaV)lc U> 
 detect them by physical examination, but in tlie absence of an increasing 
 tumour, caused by the accumulation of the monthly secretion, whicli 
 would imply the presence of a uterus of some size, or if there were no 
 signs of intra-pelvic haemorrhage, it would hardly warrant us in any 
 attempt at surgical interference. I can imagine, liowever, thoiigh I 
 have never seen, such an amount of ovarian troiiblc, with complete 
 
136 CONGENITAL DEFECTS IN THE OVAEIES, 
 
 absence of vagina and utems, as might warrant an attempt to seek for 
 and remove by abdominal section the now redundant and harmful 
 glands. Peaslee operated in a case of this kind, but with fatal result. 
 Independently of absent utems, one or even both ovaries may be ab- 
 sent from foetal disease. Klob and Rokitansky have attributed this in 
 some instances to twisting of the ovarian attachments, whereby the 
 ovary was slowly strangled, atrophied, and completely obliterated. This 
 is somewhat analogous to what occurs occasionally to the mature ovary 
 when the subject of cystic enlargements. In the dissecting-room, a 
 supplementary ovary has also been occasionally found, originating in a 
 mere accidental fissiparous division of that of one side during early 
 development. If the operation of oophorectomy assumes as prominent 
 a position as it at present threatens to do, such abnormal structiires 
 may yet be encountered in the living subject. 
 
 Hernia of the ovary through the canal of Nuck, the representative of 
 the inguinal canal, and appearing either at the external ring, or in the 
 labium, has already been mentioned, and if not a congenital phen- 
 omenon, the condition of parts which allows of it is so. Its first re- 
 cognition may be due to an attack of ovaritis, and this is apt to become 
 chronic, or recurrent to such an extent as to necessitate the removal 
 of the organ, reduction being then seldom possible, and after a time 
 hardly advisable. Most commonly, however, an operation has been 
 undertaken for hernial obstmction, and the ovarian contents have 
 only then been discovered. Tait gives a fuU summary of such cases 
 as he has been able to trace {Diseases of the Ovaries, 1883). A 
 distinct swelling of such hernial ovaries is noted at the menstrual 
 periods. Hernia of the ovary elsewhere has been described, but chiefly 
 as a post-mortein phenomenon. Prolapse of the ovary into Douglas's 
 pouch will be afterwards noticed (Chap. XV.), and it is usually an 
 acquired and not a congenital condition. The position of the ovary in 
 hermaphroditism or pseudo-hermaphroditism may be very various. The 
 ovary, though existent, may also be an-ested in any stage of its develop- 
 ment, either with or without a similar arrest in the uteiiis, but most 
 commonly this arrest coexists with what will be described as infantile 
 uterus (Chap. VIIL). The combination of these two arrests in develop- 
 ment is a fertile source of menstrual derangement and difficulty, and 
 may lead to nervous affections — hysteria, epilepsy, and hystero-epilepsy. 
 It was for this condition, and to cause by its local irritation a tendency 
 to fuller development of all the organs, that Simpson introduced tlie 
 galvanic stem pessary into the uterus. 
 
 Of the congenital defects of the Fallopian tubes little is accurately 
 known, although a fuller knowledge of them would be of the greatest 
 value, seeing that the investigations of Lawson Tait have rendered it 
 
FALLOPIAISr TUBES, AND UTEKUS. 137 
 
 probable that these ducts play a more important part in phj-siology and 
 pathology thau has formerly been assigned to them {Brit. Med. Jour., 
 vol. i., 1881). In his recently published work on diseases of the 
 ovaries he intermingles his remarks on the congenital and acquired 
 abnormalities of these tubes, so as to make it a little difficult to ascer- 
 tain what ftxcts he has personally obtained, or culled from other sources, 
 on the subject of the former. But I gather that congenital tubal 
 abnormalities sometimes do, and sometimes do not, coincide with similar 
 developmental conditions of the ovary, and that a not uncommon defect 
 lies in the relative position of the ovaries and tubes (fig. 78); sterility, 
 and I would suppose tendency to htematocele, therefrom resulting. I 
 cannot ascertain whether he considers that the occlusion of these tubes 
 at both ends, and their consequent distention into cysts, is often a de- 
 velopmental defect, or one nearly always dependent on inflammatory 
 adhesions. Probably it is too miich to ask from any present observer. 
 Closure of these canals at either end is not uncommon from gonorrhoeal 
 or other inflammatory extensions, leading to accumulation of their con- 
 tents, abscess, or hsematocele (Chap. XVIII.). 
 
 The Uterus. 
 
 The key to nearly all the congenital derangements of the uterus and 
 vagina lies in the fact that they are formed in early foetal life by the 
 coalescence of the two Mllllerian ducts. Most of the recognised malfor- 
 mations ai'e thei'efore traceable to insufficient, or excessive, or unequal 
 union of the two sides, or to imperfect development of either half or 
 of both. The uterine portion unites later than the vaginal, and the 
 Fallopian portion remains permanently ununited. In the following 
 brief account of these malformations it is their practical bearing upon the 
 health and comfort of the patient which is held in view, rather than the 
 anatomical interest of the matter. 
 
 Absent Uterus. — Clinically speaking, this is not extremely uncom- 
 mon ; that is to say, a condition of matters exists in which no uterus 
 can be discovered by examination of the living subject. In the dissect- 
 ing-room, however, some trace of the organ can generally be found in 
 such cases (figs. 76 and 77). Menstruation is, t)f course, absent, altlK)ugh 
 we have seen that some moliuicn may be })rcsent, dei)cudent on tlic more 
 or less perfect state of the ovaries and Fallopian tubes. The vagina 
 also is often absent, or exists only as an imperfect canal. Every ex- 
 ternal ajjpearancc of womanlujod may be present, but the finger in the 
 I'ectum, aided by abdominal })rcssure, or by the presence of a sound in 
 the bladder, detects nothing like the usual uterine body. A very small 
 
138 
 
 ABSENT UTEEUS UTERUS UNICORNIS. 
 
 Fig. 76. — Rudimentary Trace of 
 Uterus (Schroeder). u, uteru.s. 
 
 hardish substance may sometimes be felt centrally, or at either side, but 
 practically it may be set aside as only possibly denoting some rudimen- 
 tary stage of uterine development, of no clinical importance. The traces 
 
 which are discovered on dissection are 
 found on the posterior surface of the 
 bladder, there being but one pouch of 
 peritoneum between the bladder and the 
 rectum, as in the male (fig. 76). These 
 traces may consist of either a simple 
 transverse band or bow, representing the 
 two conjoined halves of the body, with- 
 out cervix ; or there may be a small 
 substance, hollow or solid, somewhat 
 resembling the uterus in shape, and with 
 or without separate horns (fig. 77). 
 Uterus TJnicornis, or one-sided uterus 
 (fig. 78), depends on the arrest of development of one of the two 
 Miillerian ducts. This condition is compatible with perfect menstrua- 
 tion, and even pregnancy. It is difficvilt and often impossible to diag- 
 nose it during life ; 
 but it may be sur- 
 mised if we meet with 
 certain conditions, 
 
 VIZ., a narrow vagma 
 (unilateral in develop- 
 ment), a small cervix, 
 and a uterus which is 
 shown by sound and 
 bi-manual examina- 
 tion to be unusu- 
 ally bent to one side, 
 having a somewhat sharply-pointed fundus, and sometimes an unusual 
 length. All other causes of uterine elongation or lateral displacement 
 must be capable of elimination ; and, considering the rarity of the affec- 
 tion, and the many sources of error, the diagnosis must be held subject 
 to revision. How many errors would be avoided if the practitioner 
 would acquire a habit of mentally noting, and carefully remembering, 
 which of his diagnoses were merely provisional ! The undeveloped half 
 may consist of a mere band of fibro-myomatous tissue, or may contain a 
 small cavity, or an elongated tube, opening within the more developed 
 one at any point, or with no outward opening at all. If pregnancy 
 occur in the fully developed side, all may go well ; if in the undeveloped 
 one, early abortion may fortunately occur, or towards the middle of 
 
 Fig. 77. — Rudimentary Uterus (Schrceder). a, uterus ; h 
 uterine horns ; c, round ligaments ; d. Fallopian tubes 
 e, ovaries. 
 
UTERUS DUPLEX. 
 
 139 
 
 pregnancy rupture may take place, with all the phenomena and gene- 
 rally fatal results of a so-called interstitial extra-uterine pregnancy, or a 
 premature and a perfect foetus being born together, or near the same time, 
 may add to the recorded but doubtful cases of super-fcetation. While these 
 pages Avere going through press, I have met with an interesting case of a 
 
 Fig. 78. — Uterus Unicornis (Scliroeder). LH, left uteriue horn ; Lo, left ovary ; LT, 
 left Fallopian tube ; LLr, left round ligament. RH, Eo, RT, and RLr represent 
 the corresponding structures on the right side. The relative positions of the ovaries 
 and tubes are abnormal. 
 
 ladj' attacked since marriage with membranous dysmenorrhoea. She 
 herself (the wife of a medical student) observed that one horn of the 
 decidua was always much longer than the other, and this led me to 
 clearly make out the signs of u.terus unicornis in a minor degree. 
 
 Uterus Duplex, double uterus, or Hysteros Didelphys, are the terms 
 applied in the case where both 
 Miillerian tubes have become fully 
 developed, forming two almost 
 separate uteri, with little co- 
 alescence (fig. 79). It is of exces- 
 sively rare occurrence, except in 
 the case of non-viable foetal mon- 
 .strosities ; but of late years 
 instances have been fou.nd even 
 in women who have borne chil- 
 dren. They arc often accompanied 
 l)y a double vagina. A typical 
 case of the kind is well reported 
 
 by my colleague, Dr Cullingworth {Brit. Med. Jour., 1882, vol. ii. p. 387). 
 There is no reason why, in such a case, pregnancy might not occur in 
 cither section, or even in both, and that simultaneously. Menstruation 
 occurs, not at two different periods, but as in the normal condition. 
 The diagnosis, attention once called to it, would be simple if the vagina* 
 were at all jierfcct. 
 
 Uterus Duplt'x (Thomas). 
 
140 
 
 UTEEUS SEPTUS UTERUS BICORNIS. 
 
 Fig. 80. — Uterus Septus (Schroeder- 
 Kussmaul). 
 
 Uterus Septus and Uterus Bicornis constitute two varieties of imper- 
 fect coalescence of the two primordial constituents of the organ. In the 
 former (fig. 80) the uterus is divided by a septum, which extends down- 
 wards from the fundus in various degrees, but externally the organ may 
 
 show little or no sign of malformation ;. 
 in the latter (fig. 81) there is a separation 
 apparent on the outside of the organ, 
 and varying in extent from a mere sulcus 
 at the fundus, which evidences its bi- 
 lateral origin, to a division which practi- 
 cally creates two uteri with a common 
 cervix or os externum. Combinations of 
 these two forms may also exist, the 
 slightly two-horned uterus having also 
 a septum dividing the common cavity. 
 Pathological museums probably show but 
 a small portion of the possible or actual 
 varieties. A single or double vagina 
 may coexist with either of these malfor- 
 mations ; the more complete the double 
 character of the uterus, the greater the probability of vaginal division. 
 
 Although there may be no arrest of development in the sense now 
 treated of,— that is to say, in the lateral symmetry or central union,— 
 there may be an arrest of developmental growth. Thus, even in the 
 
 adult, the uterus 
 may retain the- 
 type which it 
 has normally 
 
 assumed in the 
 infant, or, reach- 
 ing the type of 
 the young virgin, 
 it may retain that, 
 while the size may 
 remain consider- 
 ably under the 
 normal. These 
 
 two abnormalities, — the infantile uterus and the so-called congenital 
 atrophy of the uterus, — are, together with the same condition of the 
 ovary, of great practical importance, but they will be more fittingly 
 described and discussed, when their resulting consequences are under 
 consideration (see Chap. VIII. ). 
 
 Fig. 81. — Uterus Bicornis (Schroeder). 
 
ABSENT, UNILATEIiAL, AND DOUBLE VAGINA. 141 
 
 The Vagina. 
 
 The vagina, as ^ye have ah-eacly noted, is also affected by the want 
 of due fusion between its lateral halves of origin, and arrest of de- 
 velopment may occur in either half, or both. In the one case we have 
 wholly or partially double vagina, in the other it is narrowed or obliter- 
 ated. Using, as far as possible, the same classification as for the uterus, 
 we have 
 
 Absent Vagina. — Clinically speaking, this refers to cases where we 
 have nothing to show that any canal exists between the bladder and 
 rectum. Rudimentary structures, discernible only 2yost mortem, may be 
 left out of account. This absence may occur either Avith a fully de- 
 veloped uterus and appendages, or with a more or less corresponding 
 want of development in them. But the absence may be partial 
 confined to a portion of the vaginal canal only, and the undeveloped 
 portion may form a barrier between the uterus and the vulva of very 
 varying extent, from a mere intervening diaphragm to complete oblitera- 
 tion. In all such cases, if the uterine and ovarian functions are active, 
 we have a condition which will demand surgical interference, as we shall 
 just now see. 
 
 Vagina Unilateralis. — ^This condition certainly exists, looked at from a 
 developmental point of view, especially in connection with the uteriis 
 unicornis, but as the vagina in this state, owing to the distensibilitj'^ of 
 its walls, usually fulfils all its normal functions, it is more interesting 
 moi-phologically than practically. 
 
 Vagina Septa, or complete Vagina Duplex, may coexist with the 
 uterus septus, bicornis, or duplex, — the septum being only partial, and 
 chiefly affecting the lower end of the vagina ; or, the two lateral organs 
 may be perfect, communicating with their individual cervices and closed 
 by perfect hymens. But double vagina may also coexist with a single 
 normal uterus, one side being in all probability somewhat rudimentary. 
 With double uterus and vagina, one vagina may terminate normally in 
 the vulva, with perfect hymen, and the other may be occluded, so as to 
 ■escape notice until distended witli menstrual fluid (unilateral liajmato- 
 kolpos). 
 
 The vagina may be abnormally narrow or short, witliout evidence of 
 any other developmental abnormality. In the former case, artificial 
 dilatation may be required sixbsequent to marriage ; in the latter, thei e 
 is danger of uterine inflammation following connection, unless timely 
 warning can be giyen by the ph3'sician. 
 
 Finally, the vagina, perfect otherwise, may be occluded by a complete 
 condition of the hymen, that structure, nearly always unduly thickened 
 
142 
 
 AUTHOES CASE OF UEO-GENITAL DEFOEMITY. 
 
 under the circumstances, having no orifice for the escape of uterine 
 discharge. 
 
 In double vagina, the one half is frequently rather in front of the 
 other, and this is attributable to the fact that the left Mtillerian duct 
 lies somewhat in front of the right. But in certain more rare uterine 
 malformations there are traces of an antero-posterior defect in develop- 
 ment, as well as of a lateral one. About two years ago I Avas consulted 
 by a young woman of about twenty-three years of age on account of 
 some vague discomforts, which led to a vaginal examination. Menstnia- 
 
 tion was said to 
 be perfectly regu- 
 lar ; but, to my 
 astonishment, I 
 found complete 
 absence of the va- 
 gina. It speedily 
 became clear 
 that menstrua- 
 tion could only 
 occur throiighthe 
 urethra, though 
 there had never 
 been any vesical 
 discomfort, nor 
 suspicion of a 
 wrong channel. 
 I had only a 
 uterine sound 
 at hand, but I 
 passed it into the 
 bladder, while I 
 explored the rec- 
 t\im with the left 
 
 forefinger in search of a uterus above the atresic vagina. In this way 
 the sound undoubtedly passed into a clearly-definable retroverted uterus^ 
 which I could move freely ^jer rectum. There were some clots after this, 
 and more irritation of the bladder than ever before. She declined to 
 allow of a digital examination of the bladder per uretliram, and I 
 have since lost sight of her. In this case (fig. 82), where the cervix 
 or lower portion of the uterus opened into the bladder, it may have 
 resembled, morphologically, the sinus pocularis of the male. And 
 we have a reminder or survival of a former state of development, 
 permanent in birds, where Miiller's tubes open into a common uro- 
 
 FiG. 82. — Congenital Atrcesia Vaginse, Uterus opening 
 into tlie Bladder (Author's case). 
 
DEFORMITIES OF THE VULVA. 
 
 14:$ 
 
 genital canal ; and where, at a still earlier stage, this common duct opens, 
 along with the rectum, into a general cloaca. The English student will 
 find a clear account of the above-mentioned congenital abnormalities of 
 the uterus in Schrceder {Ziemssen's Cyclopedia, vol. x.), who, however, 
 together with nearly all subsequent writers, is mainly indebted to the 
 classic work of Kassmaul (Wurzburg, 1859). 
 
 The Vulva. 
 
 In malformations of the vulva the antero-posterior failure in develop- 
 ment is still more frequently apparent. 
 
 Absent Vulva is found in those cases where no external opening has 
 occurred, and where, therefore, the bladder, genital canal, and rectum 
 have no outlet, common or separate (fig. 83). Such foetuses are non- 
 viable, and generally monstrous in other respects. In other cases 
 (fig. 84) the external opening is present, but the perineal septum has 
 
 '>^ ^J 
 
 Fig. 83. 
 
 Fig. 84. 
 
 Fig. 85. 
 
 W^ 
 
 Fig. 86. 
 
 Fig. 87. 
 
 Five Diagrammatic Figures, after Schrceder, illustrating stages in the development of the 
 Genito-urinary Organs and Rectum, referred to in the present text. ALL, the 
 allantois ; M, MuUer's canal ; R, rectum ; A, depression corresponding to future anus ; 
 CI, general cloaca ; C, clitoris ; B, bladder ; U, urethra ; V, vagina ; S, sinus uro- 
 genitalis. 
 
 not descended between the rectum and genito-urinary tract. In arrest 
 of development at a still later stage, both anus and perineum may be 
 found, l)ut the separation of urethra and vagina may occur high up in 
 the pelvis (fig. 85), both organs communicating with the vulva by a 
 single passage. If the clitoris be large (fig. 86), we have here a sort 
 of female hypospadias. Or the developmental narrowing of the urethra 
 may be entirely arrested, and the bladder and vagina may open into the 
 vestibule together (fig. 87). 
 
144 
 
 HEEMAPHEODITISM. 
 
 Lateral deficiencies or redundancies may exist in any part of the 
 vulva, but not so as to allow of their classification in the same manner 
 as those of the vagina or uterus. The most frequent types of malfor- 
 mation are those which give to the external organs of one sex more or 
 less of the appearance of those of the other, giving rise to what is termed 
 
 Hermaphroditism. 
 
 By this term was originally meant the union of both sexes — of Hermes 
 and Aphrodite — in one individual. This condition of things was, previous 
 to the opening up of modern gynaecological studies, not unnaturally 
 supposed to exist with moderate frequency. Cases of true hermaphro- 
 ditism — that is, cases 
 where a real testicle, 
 ' capable of secreting 
 spermatozoa, and a 
 real ovary, capable of 
 secreting ova, have 
 been found to exist in 
 the same individual 
 (for this is the only 
 true definition of a bi- 
 sexual human being), 
 are indeed few and far 
 between ; so much so, 
 that a little scepticism 
 may be considered 
 pardonable even as 
 to those which are 
 best authenticated, 
 although no antece- 
 dent impossibility can 
 be pleaded. For an 
 analysis of such cases, 
 and for a most mas- 
 terly discussion of 
 the whole subject, the 
 reader is referred to the second volume of Sir James Simpson's collected 
 works. Personally, I must plead guilty to being still a sceptic. 
 
 On the other hand, cases where the congenital modifications of the 
 external organs, in shape and relation, are so great as to render it ex- 
 tremely difiicult, if not impossible, to distinguish the sex, are by no means 
 
 Fig. 88. 
 
 -Marie Madeleine Lefort, au uudoubted female 
 (after Clim-cliill et Leblond). 
 
FALSE HEKMAPHRODITISM. 
 
 145 
 
 uncommon ; and such a case of false liermaphroditum may at any time 
 occur to the practitioner, when he may be called on, under great diffi- 
 culties, to determine the sex of an infant. Let him not do so off-hand, or 
 without careful consideration, and more than one inspection. All such 
 cases must be recognised as dependent on arrests or redundancies in the 
 development of individual parts, or on incomplete or abnormal union of 
 lateral pai-ts. Thus, a large clitoris, with completely adherent labia, 
 will give a male aspect to a female ; a very small penis, and a scrotum 
 only partly closed in, will give a female appearance to a male. The 
 closure or non-closure of the central raphe is the most frequent source of 
 temporary or permanent mistakes, the complete closure being the male 
 characteristic. The 
 
 male organs may resem- 
 ble the female in the 
 smallness of the penis, 
 especially if it be hypo- 
 spadic ; and hypospa- 
 dias, if extensive, in- 
 volves to some degree 
 a separation between 
 the lateral halves of 
 the urethra and scro- 
 tum, or even perineum, 
 thus giving rise to an 
 appearance closely re- 
 sembling the vulva. If 
 the testicles have not 
 descended, an arrest in 
 the developmental pro- 
 cess likely enough to 
 be coexistent, we lose 
 another clue to the real sex ; but even if they are apparently present, 
 the possibility of labial hernia of the ovaries must not be forgotten. 
 The female organs will resemble the male when the clitoris and its 
 prepuce are unusually large, and when adhesion has taken place be- 
 tween the opposite labia. Hernial ovaries would make siich a case 
 peculiarly difficult to decide ; and the difficulty would culminate if the 
 rare condition of the urethra, passing along the clitoris and opening at 
 or near its point, also existed. In all difficult cases, a search per rectum 
 for the uterus would solve this doubt, if it were not that absent or unde- 
 veloped uterus may further complicate the matter. Its evident pre- 
 sence is positive, its absence is only negative, evidence of the sex. A 
 very short time may suffice to render more pi-ominent tlie characteristic 
 
 Fig. 
 
 -Section of Pelvis of M. M. Lefort (after Churchill 
 et Leblond). o, ovary ; u, uterus. 
 
146 ATEESIA OF THE GENITAL CANAL. 
 
 sexual organs of the individual ; and at puberty the general physical 
 development, and the form which sexual desire may assume may assist. 
 The former must not, however, be too much depended upon, as the accom- 
 panying illustrations will show (figs. 88, 89). The occurrence of men- 
 strual or seminal discharges, the latter microscopically examined, is of 
 much higher value. If the judgment as to the sex must be suspended, and 
 as its doubtful nature cannot be publicly recognised, it is decidedly advis- 
 able to bring up the child as a male. This will involve less difficulty in 
 after-life, in case of mistake, than will the opposite course. 
 
 Atresia, or Occlusion of the Genital Canal. 
 
 So far, I have said little or nothing of the practical inconveniences 
 which accompany any form of malformation that occludes the genital 
 passage at any part of its course. Occlusion of the vulva or vagina will, 
 of course, offer an impediment to marriage, and will, as well as the occlu- 
 sion of the uterus, prevent the escape of the products of menstruation. 
 Closure of the vulva by slight acquired adhesions has already been men- 
 tioned (p. 57), and need not occupy us any further; and such external 
 closure as is due to considerable congenital abnormality of the external 
 organs, as in so-called hermaphroditism, may also be left out of considera- 
 tion. It is either irremediable, or forms part of a still further closure 
 involving the vagina, which may or may not be amenable to treatment. 
 
 An imperforate hymen is a not uncommon cause of congenital occki- 
 sion, and it generally leads, at an early period of the menstrual life, to a 
 medical investigation. If accumulation of menstrual secretion has taken 
 place above it, it may be found bulging outwards to a considerable 
 extent ; and the same bulging will probably be found when a mere band 
 of vaginal tissue exists just behind the hymen. It rarely bursts, and 
 thus performs a natural cure ; for when the hymen is complete, it is 
 nearly always also hypertrophied. The vagina may, as we have seen, 
 be congenitally occluded in its whole length, being practically absent, or 
 the occlusion may involve any portion of it. Congenital uterine occlu- 
 sion is less common than vaginal, but may involve either the os ex- 
 ternum alone, or the whole or separate portions of the cervix. Various 
 injuries may give rise to narrowing or stenosis of the vagina and uterus, 
 but this is seldom so complete as to lead to absolute occlusion. The same 
 consequences and symptoms will, however, then arise as from congenital 
 occlusion, and the treatment is conducted on the same principles. 
 
 In congenital atresia of any portion of the tract, the first suspicion 
 of anything being wrong usually occurs at the period of puberty, say 
 from twelve to fifteen years of age. The patient begins to show 
 
HiEMATOKOLPOS AND H^MATOMETKA. 147 
 
 signs of menstruation, in the form of back-ache and general malaise; 
 and this is generally accompanied by severe colicky pains and some 
 abdominal tenderness, without the least appearance of any external 
 sanguineous discharge. These symptoms subside in a few days, but 
 are repeated with greater severity at more or less regular monthly 
 intervals. They, by and by, begin to be accompanied by a sense 
 of pressure on the bladder and rectum, which never entirely dis- 
 appears. Sometimes there is distinct fever during the monthly 
 paroxysms, leading to a suspicion of, or actually caused by, local inflam- 
 mations. The general health fails, and the patient falls into a state 
 of hectic, with or without anaemia. Medical advice is now sought, if 
 not previously. In some cases the symptoms are not so characteristic. 
 In one, where I had lately to make an artificial vagina, the patient, 
 a girl under twelve years of age, had had no periodic symptoms, but an 
 almost constant agonising colic for nearly eighteen months ; there 
 were no external manifestations of puberty, but an examination of 
 the' abdomen revealed a large globular uterine tumour, easily reached 
 through the rectum. In another case, the symptoms, although present 
 for several years, were so slight, that it was only after marriage that 
 the state of matters was investigated. Sooner or later, if the uterine 
 and ovarian functions continue, the distention caused by their products 
 leads to a tense but fluctuating tumour, the site of which will depend on 
 the seat of obstruction. If the hymen alone, or only the lower part of 
 the vagina be aff'ected, the tumour will, of course, be vaginal (hsemato- 
 kolpos), will press much on the pelvic viscera, leading to constipation 
 and dysuria, and will be felt bulging towards the vulva or almost occlud- 
 ing the rectum. It is only after a considerable time that, the vagina 
 being incapable of further distention, the uterus begins to dilate also, the 
 two cavities being ultimately thrown into one, pretty much as in the 
 second stage of labour. In occlusion of the upper vagina or cervix 
 uteri, the uterine distention alone exists, and gives rise to a smooth 
 globular tumour (fig. 90) in the hypogastrium (hsematometra), often much 
 inclined towards the right side. Great distention of the vagina alone 
 may also be felt above the pubes, and a careful examination may in this 
 case detect the hard undilated uterus at its summit (fig. 91). If the 
 facts and history of the case be strictly inquired into and borne in 
 mind, and a careful examination made, these tumours can hardly be 
 mistaken for pregnancy or ovarian cystic tumour, except in the case of 
 occlusion of the uterus alone, in later life, and from accidental causes. 
 Much of the menstrual fluid in these accumulations is doubtless directly 
 absorbed, or its more liquid parts may exude through the uterine walls 
 under the inevitable pressure, to be then absorbed by the peritoneum ; 
 the remainder constitutes a dark, treacly-looking fluid, of varying density. 
 
148 
 
 IMPEKFOEATE HYMEN. 
 
 and contains altered blood-cells, mucus, and occasionally some choles- 
 terine. As the uterus continues to distend, danger arises, either from its 
 bursting, or from bursting of the Fallopian tubes, which, later, par- 
 take in the dilatation, or from escape of blood into the peritoneum through 
 their fimbriated extremities. There is strong reason also to believe that 
 blood may accumulate in the tubes to a dangerous extent, independently 
 of any reflux from the uterus. It may therefore be laid down as a general 
 rule that, when this condition of dilated uterus or vagina is discovered, 
 the sooner operative measures for its relief are resorted to the better. 
 
 Unfortunately, the escape of the fluid externally thus induced is apt 
 to be followed by sudden uterine or Fallopian contraction, which may 
 precipitate the accidents just mentioned ; but this danger has to be 
 encountered, and the longer we wait the more imminent it becomes, 
 
 Fig. 90. — Hsematometra. Uterus 
 distended with blood (Schroeder). 
 
 Fig. 91. — Hsematokolpos. Vagina 
 distended with blood (Schroeder). 
 
 especially as the Fallopian tubes are apt to contract adhesions which 
 render this tearing more probable. To the risk which may thus follow 
 the liberation of the retained fluid, there must be added another, viz., 
 the danger of septic changes in what remains, as soon as the external 
 air is admitted. These two classes of danger point somewhat in oppo- 
 site directions as regards treatment, ^ — to avoid the one, the slowest 
 possible exit should be given ; to avoid the other, the sooner the whole 
 can be evacuated and the passages rendered a-septic the better. There 
 is no use in attempting to ignore either horn of the dilemma, in the face 
 of all past experience. 
 
 Treatment. — Supposing that the hymen alone is the cause of obstruction, 
 there are two modes of treatment open to us. First, we may make a free 
 incision into the obstruction, and dilate it at once with the fingers or with 
 
TREATMENT OF GENITAL ATRESIA. 149 
 
 a rectum bougie ; then, when free escape has taken place, we wash out the 
 vaginal or utero- vaginal cavity with copious antiseptic injections. These 
 injections must be frequently repeated, and in the intervals the patient 
 must wear as large a size as possible of Sims's or Barnes's dilator. This 
 serves to prevent fresh adhesion, if it does not also to some extent prevent 
 the admission of septic germs. Secondly, we may let off the fluid much 
 more slowly, and with complete antiseptic precautions from the begin- 
 ning. This can sometimes be done by syphon action. A trocar and 
 cannula, the latter furnished with a long india-rubber tube, are inserted 
 through the centre of the hymen ; the tube, first filled with carbolised 
 water, is allowed to hang down into a basin of the same, and the contents 
 of the abnoi'mal cavity thus gradually drain away. When they have 
 ceased to flow, as a momentary lifting of the tube from the basin will 
 ascertain, the cannula is withdrawn, and the orifice in the hymen is 
 closed by a serre-fine or two, or by a suture, or by collodion, if it can be 
 made to adhere. Next day the free incision may be made, and the case 
 treated by antiseptic injections. Very slow aspiration must be substi- 
 tuted for the syphon action if the fluid is too thick to run without it. 
 
 These two plans should, in my opinion, be used eclectically. If the 
 case is seen early during menstrual life, and when the absence of a supra- 
 pubic tumour renders it probable that there is little or no uterine dis- 
 tention, or distention and adhesion of the Fallopian tubes, the former 
 plan, by free incision, may be used, and in opposite circumstances the 
 latter. In a doubtful case, the latter — by antiseptic drainage — should 
 be preferred. When the fluid will not flow through a moderate-sized 
 cannula without strong aspiration, incision must be proceeded with at 
 once. Small bands of vaginal adhesion, just within the hymen, and felt 
 to be mere membranous obstacles, are to be treated in the same way. 
 
 More extensive occlusions of the vaginal canal require careful consider- 
 ation before proceeding to their treatment. Their extent must be made out 
 as thoroughly as possible by careful rectal examination, in combination 
 with supra-pubic digital pressure, and also with a sound in the bladder. 
 In this way the presence of the uterus must be distinctly ascertained. 
 We should be quite clear as to the existence of some menstrual molimen, 
 and of some vaginal or uterine distention. It is doubtful how far one 
 would be justified in risking an operation for the mere purpose of holloAv- 
 ing out a vaginal canal, when everything points to the absence of the 
 utero-ovarian structures and functions. The object of the operation is 
 twofold — to make a permanent vagina, sufficient to permit of marriage, 
 and to allow of the immediate and permanent escape of the menstrual 
 discharge. The latter is the primary and more important one, being 
 essential to the life and health of the patient, and it may sometimes be 
 achieved when the former is impossible ; but it must not be attempted 
 
150 OPEEATIOXS FOE THE 
 
 by apparently easier methods, such as tapping the utenis ;:>er recUira, 
 when a vaginal approach is at all possible. 
 
 The process of making an artificial vagina, or of opening up any large 
 occluded portion, is simple enough on paper, but not always so simple 
 in execution. The external opening is made with the scalpel. It can 
 only be made large enough by a transverse cut, which must cross at a 
 short distance in front of the anus. If there is a slight vaginal cul-de- 
 sac, it will serve as our guide, and the incision will cross it. The skin 
 or semi-mucous tissue being thoroughly divided in this way, and torsion 
 of any bleeding point having been made, the rest is all done without 
 cutting instruments, except in cases of traumatic occlusion. In these, 
 any very prominent bands of cicatricial adhesion must be divided by 
 slight snipping with blunt-pointed scissors during the progress of 
 dilatation. 
 
 The patient being anaesthetised and placed in lithotomy position, a 
 catheter is placed in the bladder and held up against the pubes by an 
 assistant. The left forefinger of the operator is introduced into the 
 rectum and retained there as a permanent guide, while the right is 
 used, after the incision is made, as the vaginal dilator. Taking care to re- 
 tain a distinct septum between the advancing finger and the rectum behind 
 and bladder in front, we slowly tear through the connective tissue, work- 
 ing freely from side to side, so as to insure sufficient space, but always 
 pushing onwards. The handle of a scalpel may give a little occasional 
 assistance ; but if so, we must be sm'e that its edges are not too sharp, 
 and that they are only used horizontally. Gradually a passage is thus 
 opened to the uterus, or we open into the dilated upper end of the vagina, 
 and can feel that we are in a cavity filled with fluid. In this case the 
 finger is withdrawn ; and while the treacly fluid is flowing, the largest 
 possible rectum bougie is inserted, until the finger in the rectum shows 
 that it has reached the cavity, when it is withdrawn again. There is 
 not much choice now between slow and quick evacuation. The greatest 
 danger lies in the absorption of the exuding fluid by the raw surfaces 
 thus made, after air has been admitted. A double catheter is passed 
 into the cul-de-sac as far as it will go without force, then very slightly 
 withdrawn, and the cavity is well washed out. More careful search is 
 now made for the os and cervix uteri, which may be either widely dilated 
 or almost normal. The case is then treated on the same principles as 
 when a hymeneal occlusion is concerned ; but very frequent insertion of 
 the vaginal dilator for weeks or months is required to insure complete 
 vaginal patency. 
 
 It may happen, however, that we may reach the globular uterus, and 
 yet no escape of fluid occur. The uterus itself is occluded. If the 
 situation of the os uteri is apparent, we are advised to pierce it with 
 
RELIEF OF VAGINAL ATRESIA. 151 
 
 trocar or scalpel. A silver catheter of small size seems to me a more fit- 
 ting instrument. But, as in a case already referred to (p. 1 47), the globular 
 uterus may apparently be there, but no trace of os or cervix to be found. 
 In such a case the surface must be first scraped with the end of a direc- 
 tor, to ascertain that there is no intervening membrane. There was one 
 in the case alluded to, and the finger passed thi'ough into a distinct extra- 
 utei'ine space, the rudiment of the vagina, but still no perceptible os or 
 cervix was to be found. There is no remedy under such circumstances 
 but to make one. This was done, also with the end of the director, and 
 the finger was forced after it. The gush of retained menses followed its 
 removal. The uterus was now washed out, and a male lithotomy tube 
 was inserted into it and retained by tapes, being removed daily, cleaned, 
 and returned. This patient now menstruated freely, although with some 
 dysmenorrhoea ; but I have vainly endeavoured to have her brought to 
 town again for a more careful examination of the state of the parts. If 
 the vaginal canal has been freely opened and the uterus well discovered, 
 and if the symptoms are not urgent, then it would be well to wait 
 some time before proceeding to the treatment of the uterine atresia. 
 This would diminish the risk of septicaemia, and enable us to act slowly, 
 as recommended below. But on no account should the delay be per- 
 mitted if the symptoms of distention are severe, either at the menstrual 
 period or during the intervals. If kept well dilated for some months, the 
 artificial vagina acqiiires a mucous lining, and serves all the purpose of a 
 natural one, even to the extent of enduring the dilatation of child-birth. 
 
 I can imagine, although I have never seen, a case where the uterine 
 distention may be so great, and the rectal septum so thin, as to make it 
 advisable to perforate -per rectum before attempting the vaginal dissec- 
 tion. 
 
 Congenital occlusion of the uterus alone is not common, and unless 
 the whole organ is badly developed it is generally confined to the os 
 externum. But acquired occlusion may follow after pregnancy compli- 
 cated with inflammatory sequelae, or after the abuse of strong local appli- 
 cations to, incision of, and other operations upon the cervix. But even 
 long-continued catarrhal inflammation of the cervix may lead to occlu- 
 sion, especially after the menopause, and in such cases it may give rise 
 to little indication of its existence. However the occlusion is produced, 
 if it is during the period of menstrual life, accumulation of inspissated 
 menstrual discharge within the uterus {hri'viatometra) is the result, and 
 the Fallopian tubes are apt to share in this distention (Jucmatosalpynx). 
 The uterine walls may be either hypertrophied or very much thinned. 
 Occlusion may occur after impregnation has taken place ; in which case, 
 owing to the gradual uterine distention, all trace of os or cervix may 
 ■disappear, giving rise to a very awkward c<)m])licati(Mi of labour. It also 
 
152 VAEIOUS EESULTS OF ATEESIA 
 
 occasionally happens that, menstruation having ceased, the occluded uterus, 
 continues to secrete a quantity of mucous fluid, more or less watery, which 
 distends the organ, giving rise to the same physical signs as hsematometra 
 {hydrometra) ; and in still rarer cases this fluid is or becomes purulent 
 ipyometra), or decomposes, giving rise to the presence of gases {physo- 
 metra). In the diagnosis of all these tumours resulting from occlusion of 
 the uterus, the first important point is to eliminate pregnancy. In con- 
 genital cases this presents little or no difiiculty, except when there is 
 intentional fraud, and untruthful information on the part of the patient. 
 In the case of very old or very young patients there can also be little 
 doubt; but during the child-bearing age, and Avhen the occlusion is 
 not congenital, it may be essential to wait for the evidence afforded 
 by the rate of growth, although a ver^^ careful consideration of the signs 
 of pregnancy {see Appendix) will generally render this unnecessary after 
 the earlier weeks. The non-fluctuating and hard character of solid or 
 malignant uterine or other growths, and of the solidified exudations of 
 pelvic inflammation or hsematocele, should serve to eliminate them, and 
 an examination by the sound will serve to show the non-patency of the 
 uterine canal ; or, if it overcome this, will give exit to the distending 
 fluids. The danger of mistaking an ovarian cyst is in this way avoided. 
 In physometra the clear percussion note over the tumour is very 
 characteristic, although I have met with the same sign in the case of 
 ovarian cysts, when decomposition and gaseous accumulation had taken 
 place. 
 
 The higher the point of occlusion of the utero-vaginal canal, the more 
 apt are Fallopian complications to occur ; it is therefore important, in un- 
 complicated hsematometra or extensive hydrometra, to promote slow 
 evacuation when possible. If the cervix be present, it must of course be 
 the point of entry ; if not, the speculum may show a depression cone- 
 sponding to the os externum ; failing this, the uterus should be pierced 
 towards its posterior part. In all these cases a long curved trocar and 
 cannula, furnished with an india-rubber tube and allowed to act syphon- 
 wise, as previously directed, should be used. The uterus must not be 
 forcibly compressed, but a comfortable abdominal bandage is permissible. 
 If the stricture be very slight, a catheter may be used instead of the trocar 
 and cannula. Washing out of the uterus vmder these circiimstances is in- 
 advisable, unless sudden rigors or high temperature point to the occur- 
 rence of septic poisoning, in which case a double catheter must be used, 
 to make sure of free egress for the fluid, and the injection must be slow 
 and devoid of force. The opening now made must be kept patent by the 
 frequent passage of a good sized bougie, increasing the size gradually up 
 to No. 1 2 at least. This is preferable to the iise of tents, or of a stem 
 pessary. 
 
01'' THE GENITAL CANAL. 153 
 
 In the presence of uterus bicoriiis or other uterine malformations, along 
 with double vagina, cases are recorded of occlusion and vaginal distention 
 on one side only (lateral hsematometra or liEeniatokolpos), and some of 
 double affection (Schroeder, op. cit, p. 59). In the event of double occlu- 
 sion, the symptoms are similar to those met with in the more common or 
 single form ; but the second tiimour, a first having been successfully 
 treated, or the sole tumour when there exists one patent vagina and 
 uterus, must be carefully differentiated from prolapse of the vaginal wall 
 or from vaginal cysts. The former can only be mistaken through want 
 of careful examination and of attempts at reposition ; the latter may re- 
 quire exploratory puncture for diagnosis. Thrombus of the vagina, or 
 pelvic abscess, or heematocele, have each a clear distinguishing history of 
 their own to guide us in diagnosis. The treatment of hsematometra of 
 a rudimentary uterine horn [see Uterus Unicornis) by abdominal inci- 
 sion belongs to the surgery of the, perhaps, not very distant future. 
 For the diagnosis and treatment of mere narrowing, without complete 
 atresia (stenosis) of the cervical canal, the reader is referred to Chapter 
 VIII. 
 
154 OVULATION, 
 
 CHAPTER VII. 
 
 Ovulation, Menstruation, and their Disorders. Amenorrhcea. Suppressed 
 Menstruation. Scanty Menstruation. Menorrhagia. Metrorrhagia. Dysmen- 
 orrhcea. Vicarious Menstruation. The Menopause. 
 
 From a strictly scientific point of view, the consideration of the so-called 
 "functional" disorders of menstruation should be delayed until we have 
 discussed those uterine or ovarian diseases of which they are for the 
 most part mere symptoms and evidences. But there are certain practical 
 advantages to be derived from an opposite course ; and my experience as 
 a lecturer has taught me that it is preferable to speak first of the dis- 
 orders and difiiculties connected with the function of menstruation, 
 taking every care to avoid the serious error of allowing symptoms of 
 disorder — amenorrhcea, dysmenorrhoea, and the like — to be considered as 
 separate diseases, apart from their often numerous causes. 
 
 The uterus. Fallopian tubes, and ovaries are all more or less concerned 
 in the function of menstruation, and this function is most intimately, 
 although perhaps not inseparably, connected with the function of the 
 ovaries alone — ovulation. 
 
 Ovulation. 
 
 By ovulation we understand the production and expulsion of an ovum 
 or ova by the ovaries, there being still every reason to believe that such 
 expulsion obeys, as menstruation does, a very distinct law of periodicity. 
 Within the stroma of the ovary there are found, from the earliest period 
 of extra-uterine life, microscopic appearances, which indicate the presence 
 of enormous numbers of small follicles, the earliest stage of the Graafian 
 vesicles. Henle estimated these as amounting to 70,000 in one ovary 
 which he carefully examined ; and it would appear from the researches 
 of Bischoff, Fowlis, and others, that at birth the ovaries contain nearly 
 all the ova which are to be expelled in after life, although new ones may 
 be formed for a year or two subsequent to birth. As the time of puberty 
 approaches, some of the Graafian vesicles become more apparent, especi- 
 ally near the surface, and finally one of these bursts and discharges its 
 ovum on to the peritoneal surface. At every subsequent monthly 
 
ITS NATL'ltE AND PHENOMENA. 155 
 
 period this occurs, and at each, the ovum is received iuto the fimbriated 
 trumpet-shaped end of the Fallopian tube, and is so conveyed to the 
 uterus. This is reached after several days, and if no impregnation takes 
 place, the ovum disappears along with the uterine and vaginal secretions. 
 The cicatrix left in the ovary undergoes the changes which give rise to 
 the corpus luteum, true or false, and finally leaves but a faint puckering. 
 The combination of such puckevings during months and years of sexual 
 life gives rise to the altered appearance of the adult ovary as com- 
 pared with that of the adolescent girl (fig. 92). This is the generally 
 recognised course of matters in ovulation, but there is hardly a single 
 point in it which is not considered as still sub juclice by the physiologists ; 
 indeed, it would be well if some of their number, who are not very 
 sparing in their criticisms of the inexactitudes and discrepancies of 
 practical medicine, would furnish us with a little more exact certainty 
 about a function and a phenomenon deserving of their fullest considera- 
 tion. Strong doubts are thrown by some upon the question of periodicity 
 as affecting ovulation. No one can jet tell us beyond dispute whether 
 
 1..'=*^' 
 
 Fig. 92. — Human Ovary. A, from an Adolescent ; B, from 
 an Adult (Young). 
 
 impregnation affects the recently discharged ovum, or that which follows a 
 month later. The exact process by which the Fallopian tube grasps the 
 ovary, and attracts the ovum to the uterus, is still not clearly defined. All 
 that we can say is, that vascular erection of the fimbriae occurs at the 
 right time, and that capillary attraction towards the uterus seems to aid 
 the action of the cilia of the tubes. The relation in which ovulation 
 and menstruation stand to one another lies also in the debatable land. 
 That ovulation may exist without menstruation is absolutely certain, for 
 pregnancy has often been observed before any sign of menstruation had 
 occurred, and daily happens in women who are not menstruating, owing 
 to the fact of lactation going on. The converse is also true, although its 
 occurrence may be less common. When both ovaries have been removed, 
 menstniation has gone on for several periods with fair regularity. This 
 may, however, and I think with justice, be fairly attributed to the 
 lingering effect of the acquired habit of periodic engorgement, for, as a 
 i-ule, removal of the ovaries involves speedy cessation of all the symptoms. 
 In women who continue to menstruate many years after the apparent 
 
156 DISORDERS OF OVULATION. 
 
 cessation of coiiceptional power, and who are not the subjects of disease^ 
 we very probably have this habit continued after the generally supposed 
 periodic stimulus of ovulation has ceased. There is reason to believe, 
 also, that in certain cases of sterility, and of dysmenorrhoea, these are 
 due to arrested, or, as Farre termed it, "disappointed ovulation," from 
 thickening of the ovarian coverings. These pathological causes of dis- 
 sociated ovulation and menstruation need, however, in no way invalidate 
 the law that the occurrence and persistence of menstruation are in the 
 first place due to, and mainly kept up by, ovarian stimulation. No 
 ovariotomist has, so far as I am aware, ever discovered a case where a 
 woman who has never menstruated previous to operation, has done so 
 after the removal of both ovaries. When the Fallopian tubes are 
 occluded by adhesions, ovular expulsion is incomplete, and small and 
 repeated attacks of hsematocele are sometimes undoubtedly due to this 
 cause. Extra-uterine foetation is another result of incompleted ovular 
 expulsion. In considering the subject also of dysmenorrhoea (difficult or 
 painful menstruation), we shall not forget to notice that in some instances 
 it is the ovulation, rather than the menstrual phenomena, w4th which we 
 have chiefly to do. It is not necessary here to attempt to trace the role 
 which the ovum or its surrounding vesicle plays in the formation of 
 certain ovarian tumours. 
 
 After this brief mention of ovulation as a separate function, and of its 
 disorders, I shall take the liberty of considering it, as we are compelled 
 clinically to do, as only a stage in the series of menstrual phenomena. 
 
 Menstruation. 
 
 The ordinary features of menstruation are well enough known, but, 
 with regard to its intimate natvire, physiology leaves us nearly as 
 much in the dark as it does with respect to that of ovulation. That the 
 periodic secretion comes from the uterus, at least mainly, is beyond a 
 doubt, but how, or by what changes in the organ it is accompanied, is still 
 a matter open to discussion. The existence of engorgement of the uterus, 
 including its mucous membrane, may be taken as admitted on all hands, 
 as also may the fact that whatever important changes occur in the mucous 
 membrane are confined to the body of the uterus. This membrane 
 becomes swollen and hypertrophied to a considerable extent at each 
 period. At one time the blood oozing from this source was looked upon 
 as a secretion, then (as by Coste) as a transudation without any breach 
 in the capillary tubes, then (as by Farre) as an escape through certain 
 permanent vascular orifices. Pouchet adopted the view that a consider- 
 able depth of the mucous membrane itself is shed. Tyler Smith and 
 
MENSTRUATION. 157 
 
 Handfield Jones demonstrated that, in many instances at least, almost 
 all trace of the membrane disappeared from the uterine body during 
 menstruation, blood oozing from the subjacent tissues ; and John 
 Williams has so thoroughly worked out and illustrated this view, that 1 
 believe it is now generally adopted by gynaecologists as a basis for patho- 
 logical views or thei-apeutic action. But there seems to be no finality in 
 such matters. Kundrat has all along maintained, and still maintains, that 
 only the superficial layer is shed, owing to its undergoing fatty degenera- 
 tion. More recently, Leopold, after careful examination in the dead 
 subject, denies the existence of any fatty degeneration, while Moricke, 
 scraping the uterus of living subjects with the curette, leads us back to 
 where we began, and finds that no portion of the mucous membrane dis- 
 appears at all. No wonder that Thomas expresses concerning this 
 discussion what is felt by a good many other gynaecologists, when he 
 says — " I prefer to avoid it." The difficulties of the whole subject, and 
 the absence of any real solution of most of them, are very thoroughly 
 and recently detailed by Leopold (Archiv fur Gynakologie, xxi. 3). 
 Using such slight powers of deciding in the matter as I possess, I am 
 inclined to accept Williams's views {Ohst. Jour., vol. ii.), based on 
 those of Tyler Smith, as being not far from the truth, and as furnish- 
 ing at any rate the best working hypothesis. I accept also in the same 
 way the general principle of ovarian excitation as a stimulant to menstru- 
 ation. The cause of the periodicity of menstruation, or, if it is pre- 
 ferred,' of ovulation, or of the general condition which accompanies 
 these, is to me as yet an unsolved mystery. 
 
 The periodic menstrual discharge is a phenomenon which is liable to 
 very serious departures from its normal standard, such departures being 
 often due to general, often to local, disease, and, not infrequently, in their 
 turn, the cause of other general or local diseases. Tait has, I think, 
 fairly proved that ovulation undergoes similar irregularities, from which, 
 however, he draws deductions not yet by any means generally received. 
 Departing from my general plan, I think it will be well to add a few 
 more words as to the phenomena observed in health. At every returning 
 monthly period there is an increase in the nervous and vascular tension 
 of the whole system, the former being shown by an increased liability to 
 all forms of explosive nerve disease, and the latter, not only by the 
 feelings of the patient, but by actual sphygmographic tracings of the 
 pulse. Barnes and Fancourt Barnes have shown that this vascular 
 tension begins to rise some three days before the occurrence of discharge, 
 and subsides in about three days from its first flow. Dr Mary Jacobi had 
 previously described the regular sphygmographic wave, and Stephen- 
 son of Aberdeen also publishes some suggestive observations on the sub- 
 ject, although not quite coinciding with Barnes as to the relation of the 
 
158 MENSTEUATION, 
 
 discliarge to the height of the pulse tension. A striking example of 
 the general tension occurring at the menstrual periods is met with in 
 periodic fulness of the thyroid gland. I have seen one or two instances 
 in young girls where the appearance of exophthalmic goitre was present, 
 but disappeared on the complete commencement of menstruation. 
 The common symptom of swelling and uneasiness of the breasts shows 
 not only this general vascular tension, but also the special sympathy of 
 these organs with the uterus. The pelvic engorgement existing in all 
 cases doubtless corresponds in time with this heightened systemic 
 vascular tension, and the uterus can be felt per vaginam to be heavier 
 and more swollen than usual, while even the cervix is more puffy and 
 patulous. The Fallopian tubes participate in this engorgement, and their 
 extremities cling to the ovary. Lawson Tait states that this occurs at 
 the menstrual period, and that it does not occur during the inter-men- 
 strual period, whether there is a ripe vesicle or not. These functional 
 changes in the tubes are quite sufficient, I think, to show that "they 
 are most markedly under the same periodic influence as that which pro- 
 duces the menstrual flow," but surely not " that they are themselves its 
 cause." 
 
 The menstrual fluid consists of red blood mixed with varying quan- 
 tities of acid vaginal mucus, and it is the presence of this mucus which 
 prevents coagulation. Coagula are an indication, therefore, of an 
 abnormal amount of sanguineous discharge, beyond what the vaginal 
 mucus can keep fluid, or of some cause of retention of the flow. In 
 most women there is a slight odour special to this discharge, and in 
 some it is, during the whole of life, marked and offensive. I think I 
 have seen this somewhat diminished by the administration of ergotine 
 (Bonjeans's extract, gr. ii. ter die, in pill). This probably acts by pre- 
 venting retention in the uterus, but should not be used without due 
 consideration. In the commencement and at the close of menstrual life, 
 the mucou.s may predominate over the sanguineous element, and in deli- 
 cate young girls, or where menstruation is temporarily in abeyance, or 
 towards the menopause, it may solely represent the flow ; but it must 
 not be confounded with ordinary leucorrhcea. The duration of the flow 
 varies much, say from two to six or seven days, within the limits of 
 health. The quantity also varies much, say from two or three to eight 
 or ten ounces, but this is difficult to ascertain. If, in a woman of 
 cleanly habits, only one or two napkins suffice for twenty-four hours, the 
 quantity is certainly scanty, while if six or more are required it may be 
 considered over-abundant. From thirteen to fifteen is the average age 
 for commencement in this country, but there are great variations here 
 also. Hot climates, luxurious habits, and precocious experiences tend to 
 promote earlier appearance, but it may occur in the absence of any of 
 
ITS NORMAL PHENOMENA. 159 
 
 these. Exceptionally early menstruation, and even pregnancy as early 
 as from ten to eleven are recorded. Kussmaul mentions a fcase of im- 
 pregnation occurring at eight years. A discharge of blood in very young- 
 infants has not infrequently been met with. I have seen two instances 
 where this occurred slightly two or three times, with fair periodicity, and 
 then disappeared ; and I believe it has occurred persistently ft-om the 
 age of one year. The time of cessation (menopause) varies also within 
 wide limits. Forty-five is usually considered to be about the mean time, 
 but many healthy women cease ten or more years before this, and others 
 continue with perfect regularity till fifty-one or fifty-two. The periodicity 
 of the discharge, while generally observing the law which imposes a 
 lunar month or twenty-eight days, also varies within certain limits. I 
 can vouch for the fact that some women can, for long periods, reckon 
 the recurrence of the discharge by the calendar month and not the 
 lunar, and this where an entry is regularly made in the almanac. It is 
 probably an instance of mental expectancy influencing a physiological 
 function. When the whole period, from the commencement of one dis- 
 charge to the commencement of the next, falls much below the twenty- 
 eight days, morbid conditions are certainly approached, but, in the 
 absence of any deterioration in health, disease cannot be asserted to be 
 present. Attempts have been made to formulate certain types of 
 periodicity, such as the twenty-one day type, but not, I think, with 
 much success. I can only recognise frequent variations, and do not see 
 what is to be gained by collecting a percentage of twenty-seven day cases 
 and calling it a type. We might do the same, equally fruitlessly, with 
 types of gestation. 
 
 We have already noted the occurrence of a certain amount of systemic 
 disturbance, as shown by nervous and vascular tension, and this must 
 be considered as part of the physiological state ; hence there are few 
 women who are not somewhat unwell, and do not understand the 
 euphemistic term of "being unwell." Some malaise is experienced from 
 distention of the pelvic vessels and of those of the sympathetic mammoe, 
 or of the nerve centres, rendering the woman, for the time, less capable 
 of sustained mental or physical exertion. These symptoms, lassitude, 
 back-ache, irritability, headache, &c., vary much in degree, up to the 
 point of rendering the ordinary duties of life a burden, and requiring 
 temporary but absolute repose of body and mind. Those few women 
 who are entirely exempt from them, and who endeavour by their example 
 to set the fashion to their sex in the way of disregard of such frailties, 
 in educational or other pursuits, may be fitly compared to those men, 
 mostly of a past or passing generation, who are able to impose an eqiially 
 fallacious standard of alcoholic toleration on tlae male sex. 
 
 There is a stage, although a very indefinable one, at which the severity 
 
160 DISOEDEKS OF MENSTRUATION. 
 
 of these symptoms, or changes in the character, or amount, or frequency 
 of the discharge, must be held as bringing the case within the domain, 
 and as requiring the title of disease. And here arises a difficulty involving 
 some sacrifice of scientific propriety to clinical necessity. Nearly all the 
 phenomena which we must describe as disorders of menstruation are 
 mere symptoms of something lying behind, of systemic diseases, or of 
 local affections yet unmentioned. The description of a mere symptom as 
 a disease is highly unscientific, yet in no department of medicine can 
 this be entirely avoided. We no longer have separate treatises on the 
 jaundice, or cough, or paralysis, but we still, and that with propriety, 
 may have them on phthisis, or Bright's disease, or diabetes. We treat 
 them to a certain extent as diseases, and speak of their causes and 
 remedies as we must do of those of menstrual disorders, endeavouring, 
 the while, to bear ever in mind that the nearer we can approach to the 
 behind-lying causes of the apparent phenomena, the more scientific and 
 the more successful will our treatment become. 
 
 Disorders of Menstruation. 
 
 The menstrual function, or at any rate its ordinary manifestations, 
 may be absent, deficient, excessive, or accompanied by abnormal symp- 
 toms ; and these four natural divisions of the subject may be further 
 subdivided to some useful extent. Thus we must say something about 
 the following — 
 
 1. Amenon-hoea, or entirely absent menstruation. 
 
 2. Arrested, or suppressed menstruation. 
 .3. Scanty menstruation. 
 
 4. Menorrhagia, or excessive menstruation. 
 
 5. Metrorrhagia, or irregular uterine haemorrhage. ^ 
 
 6. Dysmenorrhcea, or painful or difficult menstruation. 
 
 7. Vicarious menstruation. 
 
 Amenorrhoea. 
 
 Absence of menstruation, as a symptom of closure of the genital canal, 
 at any point, has already been referred to (Chap. VI.). Under these 
 circumstances the phenomena of periodic vascular and nervous tension, 
 with more or less of the discomfort commonly accompanying them 
 (menstrual molimen), are met with at or about the usual age. These, 
 instead of being followed by the normal discharge, pass away from time 
 
 1 This is not necessarily a disorder of menstruation at all, but while treating of 
 menstrual disorders mainly as symptomatic, it is convenient to notice it here. 
 
AMENOERHCEA. 161 
 
 to time, vuitil they begin to give place to the symptoms of iiitra-pelvic 
 pressure or abdominal pain and distention already described. There is 
 already a presumption in favour of some mechanical obstruction, by the 
 time that the patient is brought for advice. If there is no doubt as to 
 the existence of molimen, there can be no doiibt also of the necessity for 
 some kind of physical examination. At first the abdomen is carefully 
 palpated to see if there is any perceptible tumour. The discovery of 
 this would compel immediate recourse to further and internal examina- 
 tion, no matter how young the patient, but in the absence of any such 
 swelling it is permissible, if the symptoms are not at all urgent, to wait 
 for a short time, and try the effect of treatment such as is recommended 
 when little or no molimen is present. This failing to produce any 
 I'esult, an examination per rectum is to be proposed. By this means we 
 can at once ascertain the presence of any accumulation of menstrual 
 secretion, and can then proceed, if necessaiy, to the further examination 
 by the vagina. The use of anaesthesia is very desirable, permitting as it 
 does, without pain, a thorough bi-manual examination of the pelvis. 
 The occurrence of atresia being established, it must be treated on the 
 lines laid down in the previous chapter. 
 
 But in the great majority of cases of amenorrhcea, there is no well- 
 defined, if any, molimen, and nothing to lead to the supposition that 
 there is secretion taking place and mechanically retained. The patient 
 has simply arrived at, or passed, the normal age for menstruation, and for 
 that reason alone, or because she is out of health, a fact always attri- 
 buted by the patient's friends to the amenorrhcea, she is brought for 
 advice. Here an examination must be the exception instead of the rule. 
 If marriage is contemplated, or if the patient is old enough to have 
 acquired the right to ask for accurate information, then it is of course 
 demanded, but otherwise, it must be borne in mind that the cause of 
 such retarded flow is usually constitutional, and that no young girl should, 
 while this is still probable, be subjected to an examination of the kind re- 
 quired for a complete diagnosis. If, by means of examination, we detect 
 a complete atresia, but without distinct molimen, and with no sign of 
 retention, I have already strongly coimselled non-intcrfercncc. Nothing 
 but an approaching marriage and the determination to proceed with it, 
 after all has been explained, would justify the attempt to make a vagina in 
 the absence of all evidence of uterine or ovarian functional existence ; I 
 should personally object very strongly to operate even under these circum- 
 stances. But in complete amcnoiThoea, examination may detect, not 
 atresia, but imperfect development of the uterus, — the infantile uterus, 
 to be afterwards described (Chap. VIII.), — with its usual accompani- 
 ment of undeveloped ovaries. In such a case, also, I would advise that 
 nothing should be done, surgically at least. Menstruation, if established 
 
162 TEEATMENT OF AMENOEEHGEA. 
 
 under such circumstances, will be fitful, painful, and productive of far 
 more mischief than amenorrhoea. If, however, after a time, nature 
 attempts to carry on the function, and that fitfully, painfully, and 
 scantily, we shall be justified in using such means to assist in the pro- 
 cess as are described when speaking of the infantile uterus or of dys- 
 menorrhoea. In the absence of an examination, or in the event of our 
 finding no mechanical obstruction, or the absence, or rudimentary condi- 
 tion of organs, constitutional treatment must be tried, and will nearly 
 always succeed. The utmost endeavour must be made to promote the 
 mens sana in corpore sano. Early hours, nutritive food, a full but not 
 excessive amount of sleep, thoroughly ventilated homes, or workshops, or 
 school-rooms, avoidance of over-work or over-education, out-door exercise 
 in some form, warm woollen under-clothing and hosiery, daily bathing in 
 water as cold as can be comfortably borne, and when this is followed by 
 good reaction, careful attention to the bowels, without purgation if pos- 
 sible — these, combined with the judicious use of cod-liver oil, iron, man- 
 ganese, arsenic, strychnine, or quinine, constitute the true promoters of 
 menstruation, or emmenagogues, in simple amenorrhoea. It is well when 
 mothers can be persuaded to avail themselves of these alone in the case 
 of their young daughters. There are certain drugs which have the repu- 
 tation of a specific action on the menstrual secretion, but I prefer to re- 
 serve the mention of these imtil we speak of their more fitting sphere of 
 action in arrested or deficient menstruation. The departures from general 
 health which most frequently account for late or absent menstruation 
 will also be more fully mentioned there. The appearance of molimen 
 must be watched for, and its advent shoiild be the signal for the use of 
 a warm or even hot hip bath, or of an injection of warm water into the 
 rectum at bed-time, for a few days, or until the flow appears. 
 
 Arrested Menstruation {Supjjressio Mensium). 
 
 Here the flow has been established to some extent, or for a consider- 
 able time, but its regular occurrence is interrupted, and that some- 
 times suddenly, at other times gradually, from some cause, often obscure, 
 sometimes apparent enough. 
 
 These causes may be classified as follows : — 
 
 1. Constitutional delicacy. 
 
 2. Diseases of, or leading to, mal-nutrition — phthisis, Bright's disease, 
 <kc. 
 
 3. Ansemia or chlorosis, constitutional or acquired — from haemorrhoids, 
 miscarriages, &c. 
 
 4. Over-work and over-education. 
 
THE CAUSES OF ARRESTED MENSTRUATION, H)3 
 
 5. Change of climate, especially from heat to cold. 
 
 6. Mental causes — fright, anxiety, home sickness, &c. 
 
 7. Acute diseases — fevers, pneumonia, pelvic inflammations, <tc. 
 
 8. Cold. 
 
 9. Supei'-involution of the uteiais. 
 
 10. Acquired uterine or vaginal atresia. 
 
 11. Ovarian diseases, cystic degenerations, &c. 
 
 12. Pregnancy and lactation. 
 
 13. The menopause. 
 
 This list could easily be extended, but there are few causes of arrested 
 menstz'uation which are not included in one or other of its items. It 
 will afterwards be seen that many of the same causes, the first half of 
 them especially, give rise, in certain circumstances, not always very 
 easily differentiated, to the opposite condition of menorrhagia. 
 
 The same constitutional delicacy which leads to retarded menstrua- 
 tion or amenorrhoea, will often lead to its temporary arrest, especially 
 during the first few years of menstrual life, and it will require the same 
 constitutional treatment, while it equally contra-indicates local interfer- 
 ence or specific drugs. 
 
 The advent of more defined and serious aff"ections, such as Bright's 
 disease and phthisis, is so often heralded, and more often followed 
 by gradual or almost sudden suppression, that the apparently cause- 
 less occurrence of menstrual cessation should, in the absence of preg- 
 nancy, lead to careful and repeated examination of the more important 
 viscera or of their functions. The opposite condition of over-men- 
 struation is no less common under these cii-cumstances, and is of 
 even graver import, from its exhaiisting tendency. Under no circum- 
 stances should menstruation be forced while there is even a suspicion of 
 the existence of such affections. 
 
 Ansemia in all its forms is productive of the same opposite results, and 
 demands the same cautionary remark. The restoration of healthy blood 
 by judicious nutriment and ferruginous tonics is called for, whether the 
 ansemia is primary, or due to any form of haemorrhage, or to pre- 
 vious menorrhagia or leucon-hcea. The action of manganese (mang. ox. 
 praicip., gr. x) in such cases, with or without iron, is not mythical. 1 
 doubt whether the opposite condition of plethora ever produces men- 
 orrhagia or suppression except as a condition secondary to more definite 
 local congestive affections, but where it is met with, and in the absoice 
 of other indications, free saline purgation can do no harm. 
 
 Over-physical work, especially in the case of sempstresses, sliop 
 assistants, and young " general servants," and over-mental work, espe- 
 cially in schools, is a fertile source of menstrual disorder, including siip- 
 pression, — the remedy is often more obvious than attainable. I have no 
 
164 THE CAUSES OF 
 
 experience of agricultural or mining workers, but I believe the former 
 are less liable to be thus affected than their urban sisters. 
 
 Change of climate, when great, has a marked effect on menstniation. 
 English women in India suffer, with few exceptions, from exhausting 
 menorrhagia or leucorrhoea, and some women are so sensitive in this 
 respect that a change from town to country, fi-om the seaside to inland 
 situations, or the hke, will produce marked and immediate effects. Such 
 cases, whether of increased or diminished flow, are idiosyncratic and obey 
 no general law, and if the change of residence is inevitable, we can but 
 attempt to modify its action by counteracting changes in the general 
 hygiene. 
 
 Mental conditions are a fimitful cause of suppressed menstiiiation. 
 Fear, or sudden joy, may cause this to be sudden, and wearing anxiety 
 may cause it gradually. Nostalgia, or home-sickness, in the case of 
 school girls or young domestic servants, though it has very often to 
 bear the blame which is due to injudicious education or over-work at 
 the periods, may act in this way ; and the dread of pregnancy in the 
 unmarried, or the expectation and hope of it in the recently married, 
 may bring about a symptom which serves to obscure the real diagnosis. 
 A similar suppressive effect is often seen during acute diseases, — 
 during the zymotic affections or inflammations of the important viscera 
 or their coverings. The suppression thus acutely induced may continue 
 long after the mental or febrile conditions just mentioned have passed 
 away. At the time of acute suppression, if the patient is otherwise in a 
 fit state, the hip or hot-water bath, or hot rectal injections, or hot vaginal 
 injections (105°), or hot applications to the extremities, may restore the 
 flow. If the suppression continues, the case will by and by be suited 
 for the use of specific remedies, so far as these are of any value. 
 
 Cold, in the foi-m of wet feet, sudden chills, continued exposure, damp 
 or insufiicient day or night clothing, or otherwise, may prove suppressive 
 during the course of the flow, and, like other sudden suppressions, may 
 give rise to very serious symptoms. Pelvic congestions or inflammations, 
 and similar affections of other viscera, are not infi-equently due to this, 
 and a great variety of anomalous nervous symptoms sometimes follow 
 in its wake. What is tnie of cold in its other medical aspects is ti-ue 
 here also, — it may be the exciting and sole cause of disease ; but unless 
 very severe, it requires also some predisposing cause. This may con- 
 sist of diminished tone from pre-existing and long-continued causes, of 
 temporary depression from over-fatigue, or of reaction from mental or 
 bodily stimulation. The immediate or subsequent treatment of sup- 
 pression from cold is similar to that necessitated by the two previous 
 causes. 
 
 Super-involution of the uterus after pregnancy and deliver}', in the 
 
AEKESTED MENSTKUATION, 165 
 
 course of middle life (see Chap. VIII.) is not a very common occurrence, 
 and when it does happen it is most probably accompanied by similar 
 changes in the ovaries. It is a matter for very careful consideration 
 whether a woman in whom this has occurred should be treated as one 
 in whom the menopause has prematurely arrived, or as one who has 
 temporarily returned to the pre-menstrual period. The presence of 
 molimen would largely determine the question in favour of the latter 
 view, and, of course, the age of the patient also ; but under ordinary 
 circumstances, bej'^ond careful attention to the general hygiene, it is 
 advisable to leave the decision to nature. 
 
 As regards atresia of the vaginal canal or cervix uteri, produced by 
 traumatic or inflammatory affection, there is nothing to be added to 
 what has been already said under the heading of " Congenital Atresia," or 
 may be incidentally said when treating of disease of the cervix uteri. It 
 will be seen that I have not thought it necessary to tabulate separately 
 the causes of suppressed menstruation and of merely suppressed 
 menstrual flow. 
 
 Cystic or other degenerative affections of the ovaries, whatever be our 
 theory as to the mutual relations of ovulation and menstruation, tend to 
 diminish or arrest the latter phenomenon. These organs, however, being- 
 double, the most extensive disease of one side may coexist with free 
 menstruation. When both ovaries are affected to the extent of destruc- 
 tion of the normal tissues, arrested menstruation follows sooner or later, 
 and the temporary' exceptions are easily accounted for on the principle 
 of periodic habit. The existence of such exceptions, however, and the 
 impossibility of telling how far either or both ovaries are affected, 
 render this symptom of wholly or partially arrested menstruation of 
 less value than it would otherwise be in the differentiation between 
 ovarian and uterine or other tumours. 
 
 All the previously named causes of arrested menstruation may be con- 
 sidered as pathological ; but we must constantly bear in mind the possi- 
 bility of physiological arrestdue to Pregnancy, Lactation, orthe Menopause. 
 One of the most frequent and difficult problems the physician is called 
 upon to solve lies in the differentiation of the arrest due to pregnancy from 
 that due to other causes ; and it cannot be too strongly impressed on the 
 young practitioner, that mistakes on this point are too often fraught with 
 disaster to his patient and disgrace to himself. I have elsewhere appended 
 the signs and symptoms of pregnancy in a separate form (Apj^endix) 
 for the purpose of reference, when speaking of the diagnosis of several 
 diseases. The only way to avoid such fatal mistakes as I have alluded 
 to, in early pregnancy, is to resist the temptation to a positive and im- 
 mediate diagnosis, or to any active treatment, or to intra-uterine ex- 
 amination, until time has been given to rcconsidci- and recompare the 
 
166 THE TKEATMENT OF 
 
 symptoms and signs, and to allow of watching whether the developments 
 of pregnancy follow in their due time and order. No matter who the 
 patient may he, pregnancy must be regarded as possible ; and this possi- 
 bility must influence all action, or rather must compel inaction until all 
 doubt is solved. With the married, the patient should be made to share 
 in the belief of this possibility ; with the unmarried we must be reticent, 
 but none the less cautious. In the latter case physical signs must alone 
 be depended on, and in all cases, little weight must be attached to mere 
 sympathetic disturbances, there being not a single symptom of the kind 
 which may not occur independently of pregnancy. The not infrequent 
 occurrence of anomalies in menstiiiation during pregnancy must also 
 be carefully borne in mind. 
 
 As a rule, menstruation is absent for several months during lactation ; 
 but there are very many exceptions, and ovulation and impregnation, or 
 ovulation alone, may certainly occur at a very early period after delivery. 
 
 The very early occurrence of the menopause may lead to difl&culties 
 in diagnosis ; but the fact reqiiires to be borne in mind that it may 
 occur at the age of thirty, or even less, and that independently of any 
 disease, or of super-involution or other local affection. This early cessa- 
 tion is often sudden, more often gradual, and unaccompanied by much 
 sign of systemic disturbance. 
 
 Treatment. — ^^So far, it will be observed that, in considering the causa- 
 tion of arrested menstruation, the appropriate treatment has almost 
 followed as a natural sequence, and that I have said little or nothing 
 of specific treatment, medical or surgical. When either amenorrhoea 
 or suppressed menstmation is not due to atresia, or is not accompanied 
 by severe pain, mechanical treatment is seldom advisable. The use 
 of an intra-uterine stem pessary for the purpose of exciting by its pre- 
 sence such an amount of physiological attention — to coin an expression 
 — to the uterus and ovaries, as will lead to further development, is 
 rarely to be recommended. Such instruments have their use, as we 
 shall see shortly, but not in painless amenon-hcea in the virgin. In 
 the married woman, when she is very desirous of offspring, they may be 
 very cautiously tried, but not unless she is under very careful super- 
 vision, and with all the precautions afterwards to be enforced. It is 
 very easy, by lighting iip inflammatory mischief, to make the remedy 
 infinitely worse than the disease. The same observations apply to 
 attempts to excite menstruation by rapidly dilating the cervix with 
 one of the dilators afterwards to be mentioned, and thus affording a 
 local stimulant. The painful and ineffective menstruation thus some- 
 times set up is a poor substitute for mere painless absence of the 
 phenomenon. The application of electricity in such cases is less objec- 
 tionable ; but it is only fair to the patient to remember that its use 
 
AKKESTED MENSTliUATION. 167 
 
 must be long continued, and that its success is very problematical. The 
 constant current is the preferable form. In young girls the electrodes 
 may be applied firmly over each ovarian region, and one of them occa- 
 sionally and alternately to the spine. In the married, or when electricity 
 is used for other affections than absent or scanty menstruation, an elec- 
 trode in the form of a sound, insulated by shellac or otherwise, except at a 
 couple of inches from the point, must be introduced into the uterus itself. 
 If such introduction produces little or no irritation, the plan may be fairly 
 tried for several weeks, but otherwise it must be abandoned. In all cases, 
 the length of time required, and the great possibility of failure, must be 
 explained to the patient by the conscientious practitioner. Neglect of 
 this rule, in more than one form of uterine treatment, has brought much 
 opprobrium, not always undesei-ved, on gjnisecological practice. The 
 external application only is not quite open to the same remark, as it can 
 after a time be entrusted to the patient and her fi'iends. The applica- 
 tion should be almost daily, and but a small number of cells should be 
 used — not more than twenty — -for some ten minutes at a time. I may 
 qualify what I have said above by stating that I have once, and only 
 once, seen this treatment of a small uterus followed by healthy menstru- 
 ation and several natural pregnancies. 
 
 The so-called emmenagogue drugs should never be used where there 
 is the faintest suspicion of pregnancy, nor where exhausting diseases, such 
 as phthisis, are presumed to lie at the root of the evil. I do not of 
 course refer to general tonic remedies, or mild aperients, or the like, 
 which can only be considered as emmenagogues in an indirect sense. 
 
 The list of emmenagogues, ancient and modem, is a very formidable 
 one, and I can only refer to a few which have some claim to authori- 
 tative recommendation, or of whose action I have some personal 
 experience. 
 
 1. Aloes. — Sharply purgative doses occasionally, and smaller but regular doses in 
 
 habitual constipation and sluggishness. An ounce of the decoction in a warm 
 rectal injection at the expected period, where such injections are recommended 
 above. 
 
 2. Myrrh. — 3 to 10 grains, generally given with aloes. Action doubtful. 
 
 3. Ergot. — 3 grains of Bonjean's ergotin in pill, or 20 minims of the ext. ergot. 
 
 liquid., or 1 to 4 teaspoonfuls of Tauret's syrup of ergotinine, ter die. Beware 
 of pregnancy. 
 
 4. Permanganate of Potash. — 2 grains in pill ter die (Ringer, Lancet, vol. i., 1883, 
 
 p. 7). Safe, and I think occasionally useful, ft. Pot. permang. ; kaolin, a. a. 
 
 gr. ii. ; vaselin., q.s. 
 i). Savin. — 01. sabinse, TTl x., in mucilage, 
 tj. Rue. — 01. rut;e, TTl x., in mucilage. 
 
 7. Caniharides. — Tinct. canthar. TTl v. ad xx. Dangerous. 
 
 8. Turjientinc.—Ol. terebinth. Trt x., in mucilage. 
 
 The last four are apt to be severely irritating to all the mucous surfaces, and 
 apart from this, their specific action is more than doubtful. 
 
168 TREATMENT OF AEEESTED MENSTRUATION. 
 
 9. Aconite— Tinct. aconit. , Ttl iiv. te?- die. Avoid its dangerous alkaloids. 
 
 10. Belladonna. — Tinct. belladon., rtl v., or ext. belladon., gr. J to \. 
 
 Both the above are of use in sudden suppression with pain, spasmodic or 
 congestive, but they are not otherwise emmenagogues. 
 
 11. Bromine.— T!]\& bromides in full doses are of use when suppressed menstruation 
 is conij)licated with pain or strong molimen. 
 
 12. Ainol. — 3 to 6 minims in perles or capsules. I think, though I say so with 
 reserve, that I have seen something like a specific action from this remedy 
 in suppression, never in amenorrhcEa. 
 
 Besides the above, I have not thought it worth while to discuss the 
 emmenagogue properties of guaiacum, mentha pulejium, galbanum, 
 achillsea millefolium, muriate of ammonia, artemisia, crocus, pulsatilla, 
 sauguinaria, taraxacum, and a host of others. Their use and application 
 is now chiefly relegated to domestic pharmacy or to the so-called eclectic 
 physicians, whose chief characteristic is the careful selection of every 
 kind of fashionable -opathy, or -ism, or popular fallacy, to the exclusion 
 of rational and scientific practice. The use of the natural mineral waters, 
 in combination with their more or less healthy surroundings, must not, 
 however, be ignored as valuable curative means, to those who can afford 
 to give them a sufficiently long trial. Harrogate, Gilsland, Strath- 
 peffer, and Moffat in Britain, and Schw^albach and Spa on the Continent, 
 may be instanced as acting indirectly as emmenagogues. The hot- 
 water springs of Wiesbaden, Tarasp, and Aix-les-Bains are valuable as 
 baths, and Kreuznach in Gennany, and Woodhall in England, have 
 valuable properties when amenorrhoea is due to the effects of strumous 
 or syphilitic cachexia, or to pelvic disease with chronic exudations. The 
 last of these springs might be made a valuable addition to our national 
 health resorts. In sudden suppression, accompanied at the time, or 
 followed at a subsequent period, by much pelvic engorgement and 
 febrile symptoms, a few leeches applied to the perineum, or better 
 still, in suitable cases, a free scarification of the cervix, Avill greatly 
 relieve symptoms, and is sometimes followed by the return of the 
 natural flow. 
 
 Scanty Menstruation. 
 
 This, which is sometimes called "spamenorrhoea," apart from its fre- 
 quent concomitant dysmenorrhoea, need occupy little of our time. If we 
 eliminate pregnancy and lactation as physiological, and atresia as a patho- 
 logical cause of arrested menstruation, every one of the causes of that 
 condition may occasionally act partially, and produce scanty instead of 
 completely arrested flow. This may show itself either in a notable 
 diminution of the amount of the discharge, or by substituting the 
 mucous for much of the sanguineous element, or by prolonging the 
 
MENOERHAGIA AND METRORRHAGIA. 169 
 
 intervals. In ■whichever way scanty menstruation shows itself, apart 
 from menstrual pain, it is amenable or unamenable to the same 
 treatment as amenorrhoea or suppressed menstruation from the same 
 causes. 
 
 Menorrhagia and Metrorrhagia. 
 
 By the former of these terms we understand either undue frequency 
 or undue quantity of the menstrual discharge, periodicity being main- 
 tained, however, with fair regularity — by the latter we mean the occur- 
 rence of sanguineous discharges, not only at the regular periods but also 
 at irregular intervals between them. The distinction is a very important 
 one, and might be held to forbid our treating of the two conditions 
 together, or of the latter at all as a disorder of menstruation. Practical 
 considerations, however, make it desirable to do so. We find that quite 
 as much as, or even more than is the case with amenorrhoea, these 
 symiDtoms are frequently capable of being traced to some uterine or 
 ovarian affection. Especially is this the case where they occur during 
 middle or elderly life. 
 
 At the first commencement of menstruation, and towards its close, it 
 is not u.ncommon to have the secretion increased in amount or frequency, 
 and this sometimes alternates with the opposite conditions of arrested 
 or scanty menstruation. 
 
 We may look upon such cases as, in a sense, functional disorders, and 
 the same thing may happen, though less rarely, at other periods of life, 
 but even here, though careful investigation may fail to discover any 
 local lesions, the increased flow must still be considered as symptomatic 
 of some constitutional state lying behind it. 
 
 Causation. — Referring to the causes of arrested menstruation wliicli 
 have been mentioned (p. 162), we find that several of them may with 
 equal propriety be enumerated as leading to menorrhagia, though com- 
 paratively seldom to metrorrhagia. We may have 
 
 1. Constitutional delicacy. 
 
 2. Diseases of, or caused by, mal-nutrition, Bright's disease es])ecially. 
 
 3. Anaemia, including scurvy and the luemorrhagic diathesis. 
 
 4. Over-work or over-education. 
 
 5. Climatic changes. 
 
 6. Mental disturbances. 
 
 7. Acute diseases, rarely. 
 
 8. Plethora or full habit of body. 
 
 9. Cardiac affections, especially with hypertrophy or dilatation. 
 
 10. Hepatic, or other visceral disease, even mere constipation, leading 
 to venous (jl)struction, especial!}' when a sequel of chronic alcoholism. 
 
170 CAUSES OF MENOKEHAGIA. 
 
 It is not difficult to understand how all the foregoing causes, which 
 lead to changes in the blood of a more or less deteriorating character, or 
 to excess of the nerve tension observed in normal menstruation, or to 
 variations in the general or local circulation, should produce opposite 
 effects. But it is often very difficult to say why, in any individual case, 
 the one result should follow rather than the other — menorrhagia or 
 deficient menstruation. The cause being recognised, however, or strongly 
 suspected, and the absence of local organic causes being as far as possible 
 ascertained, the treatment, medicinal or hygienic, follows the same lines 
 in either case. 
 
 In the vast majority of cases of decided menorrhagia in women who 
 have reached the middle period of sexual life, we have some local cause 
 which demands investigation and treatment. This is, above all, the 
 case where metrorrhagia is present even in a slight degree. No such 
 case should, therefore, ever be allowed to continue long without our 
 insisting on a svifficient local examination. 
 
 To enumerate the occasional causes of menorrhagia, most of which 
 may also occasionally give rise to metrorrhagia, will be to tabulate 
 many of the diseases upon the study of which we are just entering. It 
 is therefore impossible to do more than merely tabulate them here, 
 reserving all discussion as to their modus operandi and their treatment. 
 In addition to the causes named above, we may have 
 
 11. Chronic inflammation of the uterus with hypertrophy. 
 
 12. Sub-involution of the uterus. 
 
 13. Fibroid growths (fibro-myomata) of the uterus. 
 
 1 4. Polypi of the uterus. 
 
 15. Malignant disease of the uterus. 
 
 16. Endometritis with chronic granulations. 
 
 1 7. Inversion of the uterus. 
 
 18. Displacements of the uterus. 
 
 19. Granulations and lacerations of the cervix. 
 
 20. Retained products of conception or menstruation. 
 
 21. Congestive affections of the ovaries, Fallopian tubes, or pelvis 
 generally. 
 
 In addition, again, to these, we must bear in mind that diseases of the 
 vulva or vagina, which cause occasional hsemorrhage, may give rise to the 
 suspicion of menorrhagia or metrorrhagia, until an investigation takes 
 jjlace. It is always an important point, when menorrhagia is present, to 
 decide whether an immediate local examination is required. In the case 
 of the young, the symptom may fairly be considered for a lengthened 
 period as of constitutional origin ; about the time of the menopause, in 
 the unmarried, this is also permissible for a short time, but only in the 
 event of the patient being under regular observation. In all other cases 
 
TREATMENT OF MENORRHAGIA. 171 
 
 an examination is desirable, and the responsibility for delay in this 
 respect should at any rate devolve on the patient. 
 
 It seems unnecessary to say more here about the diagnosis of men- 
 orrhagia ; the fact is self-apparent, the cause must be differentiated, if 
 necessary, by every means at the disposal of the physician. 
 
 The treatment might almost be summarised in a similar manner. The 
 mere loss of blood must be combated by diet as generous as the patient 
 can assimilate, and by the usual blood restoratives ; but where the cause 
 remains doubtful, or where its removal must be a work of time, measures 
 may be required to arrest, or at any rate to diminish, the flow. Such 
 remedies may be divided into those which are local and those which 
 act through the general system. As local remedies, we employ — 
 
 1. Cold. — This may be applied in the form of ice, or ice-cold Avater 
 applied to the vulva, or injected into the vagina. Great caution is 
 necessary in using this means in cases which merely approximate to 
 increase of function. Coolness of diet, clothing, &c., are allowable 
 enough, but the application of extreme cold should be reserved for those 
 cases Avhich are genuine haemorrhages. 
 
 2. Heat. — A very decided effect upon severe hsemorrhage is often pro- 
 duced by the application of heat to the spine, by means of Chapman's 
 india-rubber bags. Apart from obstetric practice, and in the absence of 
 dysmenorrhoea, I have no experience of the internal use of hot water as 
 an anti-hsemorrhagic means, pure and simple, but I should not hesitate 
 to try it, according to Emmet's method, in cases where the other means 
 failed. In many cases, as will be seen, it is available as the most satis- 
 factory treatment of the local cause, especially in all cases of pelvic 
 engorgement. 
 
 3. Plugging the Vagina. — There is no doubt that by a firm vaginal 
 plug, by packing the vagina through the speculum, any form of uterine 
 haemorrhage may be arrested for the time being, provided that the 
 uterine cavity is not sufficiently dilatable to allow of dangerous concealed 
 hsemorrhage. But there are such manifest objections to this plan, in 
 most of the affections which lead to monorrhagia, that it should V)c 
 reserved for extreme cases, in which any step is permissible which will 
 obviate the tendency to immediate death. A small sponge or pledget 
 soaked in the gljceroles of carbolic acid, tannic acid, sulphate of iron, 
 or iodine, and carefully placed against tlie cervix, will often proAc 
 effectual, but in most cases where any form of plug is desirable it is 
 better to adopt the plan of 
 
 4. Plugging the Cervix Uteri- Tliis is most easily effected by a sponge 
 or tupelo tent, large enough to till the cervix, and introduced in the 
 iisual way. It must be retained in [)osition for a short time, till expan- 
 sion has fairly conuuenced, by a small tampon or by a vaginal dilator. 
 
172 THE TREATMENT 
 
 In malignant disease of the cervix, this means is, of course, seldom admis- 
 sible, or where it is known that considerable dilatation of the uterine 
 cavity exists, but in other cases it serves the immediate purpose well ; 
 and, moreover, it not infrequently brings about a permanent cure, by the 
 absorption of cervical growths or non-malignant excrescences, and it is, 
 in many instances, the first step in the way of thorough diagnosis. 
 
 5. Local Astringents. — It is difficult to see how local astringents 
 applied only to the vagina can serve any purpose in the case of intra- 
 uterine disease, but in the form of injections, very carefully administered, 
 or medicated plugs, or even pessaries, they are of service where cervical 
 ulceration or malignant fungosities forbid other steps. 
 
 6. Scarification of the Cervix. — This will sometimes cause the cessa- 
 tion of long-continued metrorrhagia, or even menorrhagia. Its modus 
 operandi is somewhat obscure, but it will again be referred to in speak- 
 ing of the haemorrhages from fibroid tumours. It is, however, also 
 occasionally serviceable in cases complicated with uterine congestion, and 
 with granular non-malignant fungosities of the cervix. 
 
 Local measures applicable to the interior of the uterus can only be 
 considered when treating of intra-viterine disease. 
 
 The above local remedies are for the most part only stop-gaps, for 
 immediate use in severe hEemorrhage, and must never be allowed to 
 interfere with the more permanent treatment directed against the 
 causation of the disease. 
 
 Among the internal remedies used, more or less empirically, in menor- 
 rhagia and metrorrhagia, I need only refer to the following, premising that 
 all those remedies which tend to promote a healthy blood pabulum may 
 be considered as rational and indirectly curative in nearly every case. 
 
 1. Ordinary Astringents. — These include acetate of lead, gallic acid, 
 the mineral acids, catechu, krameria, et id genus omne. As subsidiary 
 agents they may occasionally do good in chronic haemorrhages, but I 
 confess I have little faith in any of them. A useful precaution is to 
 avoid spoiling the patient's digestive powers by them. 
 
 2. Ergot. — This is an infinitely more valuable agent in every way, 
 acting as an astringent, not in the ordinary undefined sense, but by 
 producing tension of the whole uterine muscular tissue. That it has a 
 similar action on the muscles of the sraall vessels has been abundantly 
 proved of late years, and this has led to its general adoption as a 
 haemostatic in other than gynaecological practice. It renders the whole 
 uterus firm and less spongy — it acts as a compressor of every vessel in 
 its walls, and throughout its whole area — it tends to expel clots — and is 
 thus a valuable corrective agent in all atonic uterine states. A sense of 
 " grasping " in the lower abdomen is often an indication of its action. Its 
 effect upon uterine growths will be further referred to, and it is especially 
 
OF MENOKEHAGIA. l73 
 
 useful in cases of menorrhagia caused by, or accompanying, sub-involution. 
 If it is desirable to obtain rapid action, 1 to 3 grains of Bonj can's ergotine, 
 or of sclerotic acid, may be injected into the fleshy part of the buttock. 
 This will dissolve in twice or thrice its own bulk of water, and the 
 addition of a little chloral hydrate will preserve the solution for a time 
 from decomposing and becoming inert. A. R. Simpson's formula is— 
 ergotinse, 3ii. ; aqiise, 5vi. ; chlor. hyd., 3ss., twelve minims containing about 
 
 3 grains of ergotine. I am strongly in hope that we shall find a more 
 certain and reliable agent than ergotine in the ergotinine, or supposed 
 active principle of ergot, introduced by M. Tanret of Paris. My own 
 recent experience is too slight to speak positively, but it is very encourag- 
 ing. There is a solution of gr. -^^ to 20 minims, 3 to 10 to be used for 
 subcutaneous injection, and a syrup of —-^ to the drachm ; dose, 1 to 
 
 4 drachms. 
 
 3. Quinine. — This drug will sometimes act as an oxytocic in obstetric 
 practice when ergot has failed, and one or two grains, or five in cases of 
 severity, administered thrice daily in hsemorrhage from sub-invohition, 
 have frequently appeared to me to act as a powerful haemostatic and 
 counteractor of menorrhagia. 
 
 4. Iodide of Potassium. — This remedy will also sometimes be found to 
 produce in a few days decided diminution in chronic menorrhagia or 
 metrorrhagia. It acts no doubt as an absorbent of something, though it 
 may often be difficult to say of what. Its trial would therefore be 
 chiefly demanded where such action might fairly be supposed to be 
 required on account of the known or supposed cause of the aff"ection. 
 
 5. Digitalis, Aconite, and Veratruni viride, and probably also Conval- 
 iaria, have, by their action on vascular or cardiac tension, an undoubted 
 controlling power upon the circulation, and, through this, over some forms 
 of haemorrhage. The two former, at any rate, are indicated when uterine 
 flow seems to be due to systemic disturbance rather than to local disease. 
 
 6. Ipecacuanha. — This drug in full doses will sometimes cut short a 
 post-jyartum hsemorrhage, though recourse is seldom had to it in the 
 presence of more certain remedies. I once gave it with immediate good 
 effect in an incontrollable metrorrhagia from an intra-uterine polypus, 
 and might possibly feci called on to do so again. I liave no experience 
 of it in minute doses. 
 
 7. The Bromides. — These would seem to be of use in cases Avherc over- 
 frequent menstruation appears to depend on ovarian irritation or con- 
 gestion. I admit, however, the possibility of much fallacy here. 
 
 8. Cannabis Indica. — This has been much lauded as a specific anti- 
 menorrhagic. As a matter of theory one would expect it to act chiefly, 
 if at all, in similar cases to those benefited hy the bromides. I liave 
 often prescribed the tincture and cxti'act where menorrhagia and dys- 
 
174 DYSMENOEKHQEA. 
 
 meuoiTlioea coexisted, and have thought I have seen benefit in the 
 diminution of both symptoms together, but have never been able to be 
 sure that the hsemoiThage was specially or alone affected. 
 
 10. Iron is, according to many writers, contra-indicated in menorrhagia 
 as tending to increase the symptoms. I cannot say that I have observed 
 this effect myself; and, when auEemia is a consequence or a cause, it may, 
 I think, safely be used in small and digestible doses. 
 
 In all cases of menorrhagia, perfect rest and recumbency at the time 
 of attack, with the absence of all excitants, are an essential of success- 
 ful treatment. Metron-hagia, as a symptom of uterine disease, will be 
 further and frequently refen-ed to. I should just mention also that in a 
 few cases of both affections, of extreme gravity, transfusion has apparently 
 saved Hfe by affording the blood pabulum and cardiac stimulus which were 
 effectual in prolonging it until means could be adopted to an-est the 
 cause of discharge. 
 
 Dysmenorrhoea. 
 
 Painful menstruation is a symptom of such frequent occurrence that 
 one would expect its pathology to have been clearly worked out and its 
 treatment to be correspondingly rational and scientific, and generally 
 agreed upon. Such, however, is by no means the case, and I know of no 
 department of gynsecology in which I find it harder to follow out my 
 desire of giving to the reader only such facts or opinions as are based on 
 general experience, and as furnish a sure basis for practice. True it is 
 that every writer gives us a long list of causes, but whenever a discussion 
 arises at any of o\ir obstetrical societies, as for instance on the excellent 
 paper of Dr Williams {Ohst. Trans., vol. xxiv.), it becomes manifest that 
 the most discordant views exist amoiag the very highest authorities, and on 
 uhnost every point. To discuss these opinions, or to pit authority against 
 authority, is foreign, nay antagonistic, to my proposed objects. I cannot 
 but think that many of the discrepancies are more verbal than real, and 
 that some are even the result of the temper rather than of the judgment 
 of the speakers. Two courses are open, either to follow the teaching of 
 some one authority, or, regardless of criticism, to express merely the 
 views which have commended themselves to myself. The latter plan 
 seems to be the least objectionable. 
 
 Slight dysmenorrhoea may be said to be almost a normal condition, 
 dependent on the vascular and nervous disturbances accompanying the 
 regular function. An abnormal amount of this is often accompanied 
 by long continuance, by scantiness, or by over-abundance of the dis- 
 charge, or by alterations in its character. None of these are essential 
 to painful menstruation, though they may often afford a clue to its 
 
ITS CAUSES. 175 
 
 source. In many, perhaps most cases, dysmenon-hceal pain is clearly 
 uterine, extending like the pain of labour to the back, or loins, or hypo- 
 gastrium ; in others it is chiefly or entirely felt in the vicinity of the 
 ovaries, and is accompanied by tenderness on pressure there. Some 
 disputants say that this latter is merely ovarian pain accompanying men- 
 struation, and not dysmenon-hoea, — a distinction whose only difference 
 seems to consist in its opposition to the classification of other disputants. 
 Dysmenorrhoeal pain is sometimes spasmodic, intermitting, and expulsive, 
 like the pain of an abortion ; more often it is continuous. Often it 
 precedes the discharge for a few hours, or a day or two, and ceases on its 
 full establishment ; less often it continues or comes on during the dis- 
 charge. Sometimes there is accompanying menorrhagia, with or without 
 clots ; at other times the discharge is scanty throughout the period. In 
 some cases (a distinct group) the pain culminates up to, and is evidently 
 due to, the expulsion of the whole or portions of the mucous lining of the 
 uterus. All these varieties in pain may be traced, theoi'etically at least, 
 and often practically, to varieties in the causation of dysmenorrhoea. 
 Priestley was the first to point out a remarkable class of cases where dys- 
 menorrhoeal pain occurs, not only at the period, but also exactly midway 
 between two periods. A physiological factor not yet explained, but 
 which may have a pregnant meaning, is doubtless involved. The severity 
 of the pain is in some cases intolerable, giving rise for hours or days to 
 intense agony and depression of mind, and accompanied by sympathetic 
 vomiting, semi-consciousness, or epileptiform attacks. I have never seen 
 a case of death ensuing, but sometimes I have gravely apprehended it. 
 
 Causes. — It will be found convenient to divide and subdivide the 
 causes of dysmenorrhoea, including in the catalogue some which may be 
 open to discussion. We will notice — 
 
 (A.) Causes which are of a general rather than a local character. 
 
 1. The neuralgic habit or neurotic constitution. 
 
 2. The gouty and rheumatic diathesis. 
 
 3. Mental depression, sudden or continiied. 
 
 4. The syphilitic cachexia. 
 
 (B) Causes due to, or producing, local congestions or inflammation. 
 
 1. Chronic metritis. 
 
 2. Abdominal or visceral congestions. 
 
 3. Pelvic congestions and chronic inflammatory affections. 
 
 4. Utei'ine tumours. 
 
 5. Uterine displacements or flexions. 
 
 6. Sudden or severe cold. 
 
 (C.) Causes due to obstiniction in the passages. 
 
 1. Atresia of the cervix uteri, vagina, or vulva, or imperforate 
 hymen. 
 
176 CAUSATION OF DYSMENORRHCEA. 
 
 2. Stenosis of the same parts of the genital tract. 
 
 3. Infantile uterus. 
 
 4. Uterine flexions. 
 
 5. Polypi, or tumours of the uterus or cervix uteri. 
 
 6. Pelvic exudations or adhesions, distorting or pressing on the 
 
 uterus. 
 (D.) Membranous, decidual, or heemorrhagic substances, whose ex- 
 pulsion is causative. 
 
 1. Uterine exfoliation. 
 
 2. Early abortions. 
 
 3. Diphtheria. 
 
 4. Clots from any source of stagnation or obstruction. 
 (E.) Ovarian or Fallopian causes. 
 
 1. Ovarian hypersesthesia or inflammation. 
 
 2. Ovarian tumours, adhesions, or displacements. 
 
 3. Fallopian constrictions, adhesions, or inflammations. 
 
 In most of the above cases we have uterine spasm, playing, no doubt, 
 an important role in the production of pain, generally caused by the 
 effort to overcome obstruction or expel abnormal discharges, but some- 
 times independent of either. It is not confined to one class of cases, and 
 cannot well constitute a class of itself Formidable as is the list of 
 causes now assigned, I believe it is still incomplete, and that dysmenor- 
 rhoea can, as little as the other menstrual deviations, be studied apart 
 from its aspect of a mere symptom of something behind, either con- 
 stitutional or local. 
 
 (A.) The General or Constitutional Causes have of late been too 
 little recognised. Careful investigations by Hermann, Vedeler, and others 
 have shown that at any rate many of the uterine local affections named 
 above may be present without dysmenorrhoea, and that dysmenorrhoea 
 may very frequently exist in their absence. This should lead us to beware 
 of attaching too mu.ch importance to mere mechanical explanations ; but, 
 even in the estimation of these writers themselves, it should by no 
 means lead to equally irrational ignoring of them {see disciission on 
 this subject between Dr Graily Hewitt and Dr Hermann, in the 
 Lancet from June 7, 1884, to February 14, 1885, and apparently not yet 
 concluded). 
 
 The term "neuralgic habit " or " neurotic constitution " may not be a 
 very scientific one, but I know of no better to express what has a clinical 
 existence. Whether as a product of chloro-anaemia or of luxurious 
 habits, or of unknown factors, the neuralgic and hypersesthetic habit 
 undoubtedly exists ; and, apart from observed facts, all presumption 
 would lie in favour of the uterus or its annexes being frequently 
 affected. Why should a highly neurotic patient never have neuralgia 
 
DYSMENOEEHGEA, NEUEALGIC A^B CONGESTIVE. l77 
 
 in the organs liable, above all others, to constant changes in all tlieir 
 tissues 1 Why should this not be specially induced at the time when 
 such changes are most in action 1 And why should neuralgia, an affec- 
 tion, one of whose characteristics is a strong tendency to periodicity, not 
 affect those organs wliich are so essentially periodic in their function ? 
 The onus probandi lies with those who deny the probability or actual 
 occurrence of purely neuralgic dysmenorrhoea. The pain in this form is 
 more or less continuous, or at any rate not necessarily synchronous with 
 any stage of the flow. It may exist previously or subsequently to the 
 discharge, or be coexistent with it, and in some cases will yield like magic 
 to anti-neuralgic remedies. In the purely neuralgic form there are no 
 inflammatory symptoms, and no clots or membranous discharge. Neur- 
 algia is fi-equent in other organs, especially the breasts. 
 
 Gout and other diathetic affections must rank as causes of neuralgic 
 dysmenorrhoea until their connection with neuralgia is disproved in other 
 departments of medicine. 
 
 The same may be said of mental disturbance, and also of cold, though 
 we may fairly admit that these, especially the latter, more often act 
 through the medium of hypersemia or local congestion. 
 
 I have so frequently seen dysmenorrhoea associated with the syphilitic 
 cachexia, that I have placed it in this class of general rather than local 
 causes, although I am not prepared to maintain that local tissue- 
 changes, undiscoverable clinically, might not be found by the pathologist 
 in all siich cases. 
 
 (B.) Congestion or Inflammation. — Pain is a general characteristic 
 of congestion or inflammation in almost every organ, and especially when 
 that organ is functionally active. The utems is no exception. No one, 
 I think, disputes this source of dysmenorrhoea. If the cause be sudden 
 and acute, the resulting dysmenorrhoea will also be so ; but it may bring 
 about a habitual recurrence, either with or withoiit the persistence of 
 chronic inflammation. 
 
 Chronic uterine inflammation, especially endometritis, fulfils all the 
 cotiditions of a dysmenorrhoeal as well as of a menorrhagic cause, although 
 the patulous cervix may often diminish or even annul the tendency to 
 dysmenorrhoea. Painful menstruation may also be, in some cases, 
 lessened by the free menorrhagic discharge, wliilc in other cases it is 
 aggravated by the retention of menorrhagic clots. 
 
 Abdominal, especially hepatic disease, has already been mentioned as 
 a cause of menoiThagia, and one link in that causation is passive con- 
 gestion of the whole pelvic contents. Uterine tumovirs have a similar 
 tendency, and are thus sometimes productive of dysmenorrhoea, apart 
 from their obstructive action within the uterus. We shall have more to 
 say just now on the question of uterine flexions. 
 
178 OBSTRUCTIVE DYSMENOREHCEA. 
 
 Sudden or severe cold may produce dysmenorrhoea as suddenly as it 
 produces suppression ; the two things are often simultaneous, and the 
 local congestion thus induced may often continue for an indefinite period, 
 if the continuance of dysmenorrhoea may be considered as evidence of this. 
 
 Plethora is such an undefinable condition, that I prefer not to discuss 
 its action, further than to state that plethoric women often sufier from 
 dysmenorrhoea, which diminishes or disappears when the plethoric con- 
 dition is reduced. 
 
 (C.) Obstruction. — Complete closure of the cervix uteri, vagina, or 
 other parts of the genital canal, whether congenital or acquired, is, of 
 course, a cause of painful attempts at menstmation. No one denies this. 
 Probably every one will also admit that in such cases the pain is due to 
 the uterine muscular efforts to overcome an absolute obstruction. No one 
 would surely refuse to admit, however, that here the case may more 
 fairly be considered as one of obstruction, than as one of muscular 
 spasm, which is only secondary. 
 
 In stenosis, however, there is an orifice of outlet, though this is at 
 some points abnormally small. A too minute orifice in the hymen has 
 been noticed as a cause of dysmenorrhoea, which was cured immediately 
 by incision (Watts, Am. Jour, of Obst, 1882, p. 269). This is a rare 
 occurrence, however, and may be variously explained. I am not aware 
 that dysmenorrhoea from vaginal stenosis, apart from other presumptive 
 causes, has been recorded ; but, if uterine stenosis be admitted as a 
 cause, one could hardly dispute the possibility of vaginal. It is chiefly 
 with contracted cervix, however, that we have to do, though there are 
 many who will not admit that this is ever a cause of dysmenorrhoea. 
 A priori one might expect that the passage of a given amount of fluid 
 through a contracted passage might produce distention of the contracted 
 portion and consequent resistance and pain, even if the fluid did not 
 become inspissated during the temporary retardation of its flow. 
 Dr Matthews Duncan, and my colleague Professor A. Gamgee, showed 
 by experiment, some years ago (Jour, of Anat. and Fhys., Nov. 1870), 
 that blood will flow through a glass capillary tube. Capillary glass 
 tubes, however, cannot evidence pain. Many cases have also been 
 clinically noted where a painless menstrual flow occurred through an 
 exceedingly contracted os uteri. I have seen this myself. From this 
 fact, the deduction is made by many eminent gynsecologists that ob- 
 structive dysmenorrhoea is a myth. On the other hand, it is impossible 
 that any one familiar with female diseases can have failed to recognise 
 many cases where stenosis of the cervix uteri, or partial blocking of its 
 passage by tumours, or by flexion of its walls, Avas regularly accom- 
 panied by severe dysmenorrhoea, and where the pain disappeared imme- 
 diately on the removal of these conditions. Obstructive dysmenorrhoea 
 
MEMBKANOUS DYSMENOKKHCEA. 179 
 
 8eem3 to me to be a clinical fact, explain its occasional absence under 
 very similar circumstances how we may. In one case it may be the 
 resistance of a sensitive and contracting canal, in another the additional 
 expulsive effort required, and in another the inspissated, because re- 
 tarded, flow, which is the main factor in the production of pain ; in all it 
 is the obstruction which is primarily at fault. Stenosis of the cervix and 
 infantile utei"us are more fully discussed in the next chapter, together 
 with their treatment. 
 
 Uterine gro\vths act not only by causing hypersemia of the organ 
 itself and of the surrounding pelvic tissues, but also by blocking the 
 cervical canal, and pelvic disease may also act as a cause of dysmen- 
 orrhoea in this twofold manner. 
 
 The question of uterine flexion as a cause of dysmenorrhoea is a very 
 knotty one, if we are to judge by the extent of its literature. A flexed 
 uterus is apt to become an engorged one. The bending of its walls 
 interferes with the circulation, and both fundus and cervix are apt to 
 become swollen thereby. It is very common to observe distinct and 
 chronic engorgement of that portion of the cervix which lies towards 
 the concavity of the flexion. If the bend occur in the cervix itself, 
 there is contraction of the canal at that point, and the removal of this 
 by the sound does undoubtedly often afford temporary and sometimes 
 pennanent relief, experto crede. The retardation of the flow thus 
 caused tends to cause intra-uterine coagulation, hence an aggravation 
 of the pain. The passage of small clots thus induced has been watched 
 through the speculum, and its accompanying accession of pain has 
 been demonstrated. To say that, because sometimes pain does not 
 coexist with the passage of fluid through a contracted cervix or flexed 
 uterine canal, therefore it is never so produced, would be to pursue a line 
 of argument which would iipset many other true deductions from the 
 phenomena observed in the living subject. Bemutz has observed large 
 uterine casts passing without pain, but this does not militate against the 
 certain knowledge we possess as to 
 
 (D.) Membranous, Decidual, or Haemorrhagic Causation. On the 
 contrary, we are here on comparatively safe and indisputable ground. 
 No one doubts that the expulsion of a firm clot of blood, or of an early 
 abortion, or of a more or less complete exfoliation of the uterine mucous 
 lining — of the unimpregnated and undisintegrated decidua — gives rise, as 
 a rule, to pain, and no one is, apparently, very much inclined to analyse 
 the relative share in the production of this pain borne by uterine S])asm 
 or cervical resistance to dilatation. 
 
 T have no experience of that rare affection, true uterine diphtheria, 
 lint of early abortion every practitioner has some. Clotted menstrual 
 discharge is nearly always accompanied by pain, unless the clots are of 
 
180 
 
 MEMBRANOUS DYSMENOEEHffiA. 
 
 extra-uterine origin, or unless, as in many cases of chronic metritis, we 
 have also a very patent cervical canal. 
 
 The not very common affection of the periodical discharge of a com- 
 plete uterine cast (membranoiis dys'inenorr}u£a of most writers) demands 
 a few further remarks. According to the views of menstruation enunci- 
 ated by Williams and others, the whole, or a large amount of the 
 mucous lining of the body of the uterus is cast off at every period. In 
 health this is accompanied by fine disintegration, giving rise to no 
 pain or visible phenomena. Under certain as yet obscure conditions, 
 however, disintegration of the mucous coat does not take place, 
 though expulsion does. It is expelled as a more or less complete 
 cast, of triangular shape (fig. 93), showing, when perfect, the orifices 
 of the OS externum and Fallopian tubes. Its internal surface is 
 
 smooth and pierced 
 with the openings of 
 the uterine glands, 
 its external surface, 
 when floated in water, 
 is shaggy and villous. 
 "Why this occurs in 
 only a small percent- 
 age of women, and 
 not in others, is an 
 open question. In- 
 flammation has pro- 
 bably nothing to do 
 with it, and certainly 
 conception has not. 
 We may hide oui* 
 ignorance by saying 
 it is due to malnutri- 
 
 FiG. 93. — Dysmenorrhceal Membrane (Coste). 
 
 tion. However that may be, we may have a cast, often a very perfect 
 one, thrown off and expelled by uterine contraction, and by the blood 
 which accumulates behind it, at every period. Once established, the habit 
 of exfoliation en masse is apt to continue for years, or during the whole 
 of sexual life, giving rise to successive attacks of dysmenorrhoea, which 
 generally increase in severity and baffle the skill of the ablest practi- 
 tioners. 
 
 In all the cases of dysmenon-hoea refen-ed to under this section, the 
 pain usually ceases when the offending body is expelled. It should be 
 mentioned here, moreover, that occasionally, though rarely, a substance 
 may be expelled which bears the shape of the uterus, and resembles 
 pretty closely an early abortion. On minute examination, however, it is 
 
OVAEIAN OK FALLOPIAN DYSMENOKKHCEA. 181 
 
 found to contain no trace of decidual structure, nothing but more or less 
 decolorised fibrin. It may even have a hollow interior. The utmost 
 caution is necessary, for obvious reasons, to bear in mind the possibility 
 of such a fibrinous polypus, as it is sometimes termed, independently of 
 impregnation or sexual congress, otherwise a diagnosis disastrous to the 
 I'eputation of patient or doctor may ensue.^ 
 
 (E.) Ovarian or Fallopian Causation. — Some authors would eliminate 
 the ovary as a cause of dysmenorrhoea, but misunderstanding on this 
 point would appear to be rather as to nomenclature than otherwise. 
 Matthews Duncan says {Clinical Lectures, 2nd ed., p. 129): — "In the 
 same way she is said to have ovarian dysmenorrhoea if she has pain in 
 one or other ovary during the monthly period. But this is not dys- 
 menon-hcea proper." But, proper or not proper, it is so frequent a form, 
 and the functions of the ovary and the uterus are so allied, that it seems 
 advisable to retain it in any attempted classification. Others have 
 objected to the term because it seems to sanction the theory of a regu- 
 lating ovarian force in menstruation, beyond what is capable of proof. 
 All that is asserted, however, is the clinical fact that many women suffer 
 from acute or sub-acute pain in the ovary at every menstrual period, 
 and very frequently at that period only. This usually precedes the 
 flow, occurring at the time when the vascular and nervous tension are 
 rising to their acme. Under such circumstances the ovary is frequently 
 the subject of some abnormal condition — chronic inflammation, cystic 
 degeneration, prolapse, &c., which can be ascertained by bi-manual 
 examination, but in other cases the dysmenorrhoeal pain is the only 
 ascertainable fact. The pain may radiate into the abdomen or lower 
 limbs, and there often accompanies it a marked tendency to hysteria and 
 other neurotic affections. True epilepsy, or the train of symptoms 
 described of late years as hystero-epilepsy, are also met with. 
 
 The whole subject of the part played in menstruation by the Fallopian 
 tubes is at the present time suhjudice. That they do play a more import- 
 ant part than was formerly supposed, may certainly be taken as proved, 
 but how far that part is primary, and how far secondary, to uterine or 
 ovarian stimulation is quite uncertain. They do become intensely 
 engorged, and they are subject to disorders which must often render such 
 engorgement unusually painful, and they are thus probably to be 
 credited with some of the extra-utei-ine phenomena under considera- 
 tion. 
 
 1 See papers by Haddon, Edin. Med. Jour., Jan. 1872, p. 611 ; Cullingworth, 
 Ohsld. Jour., vol. vii., 1879, p. 438; Duncan, Obstet. Jour., vol. viii. , 1880, 
 p. 129 ; and Rae, Lancet, vol. i., 1881, p. 314. 
 
182 THE TREATMENT 
 
 Treatment of Dysmenorrhcea. 
 
 We have next to consider the bearing of the above complex but neces- 
 sary classification on the subject of treatment. AVhether the disordered 
 function exists from the commencement of menstruation and lasts in- 
 definitely, or whether it arises at some subsequent period, and is 
 temporary in its duration, the true principle of treatment must always 
 be to regard it as a symptom of some one, or of a combination of more 
 than one, of the constitutional states or local affections above men- 
 tioned. I would rather omit all mention of the treatment of so painful 
 and common an affection, than mislead the student by drawing off his 
 attention from the necessity of always endeavouring to imderstand the 
 causation and the rational treatment which depends thereon. The 
 weneral bodily conditions demand special study, and particularly in prim- 
 ary dysmenorrhcea, in young subjects, at a time when we are apt to be 
 dazzled by so many recent surgical triumphs. I need not further refer 
 to the measures required by the neurotic constitution or neuralgic habit, 
 by gout, rheumatism, or syphilis, or by abdominal or thoracic diseases 
 leading to congestion of the pelvis. They should be fully tested before 
 having recourse to manipulations which we would fain avoid. Even 
 when palliation or empirical treatment is absolutely called for, it should 
 be only an incentive to the further search for causation, and for treat- 
 ment founded on a surer basis. The treatment of chronic metritis, of 
 infantile uterus, of uterine displacements, of uterine pol}7)i and timiours, 
 and of stenosis and atresia of the genital organs, is discussed elsewhere, 
 as also that of those pelvic affections which, in various Avays, carry pain- 
 ful menstruation in their train. 
 
 Membranous dysmenorrhosa might be considered as a disease per st, 
 although, unfortunately, its treatment is almost as obscure as its pathology. 
 Fruitless attempts have been made by means of alterative medicines — 
 iodine, arsenic, mercury, g-uaiacum, cod-liver oil, and the like — to change 
 the nutritive conditions which are siipposed to involve the expulsion 
 en masse instead of the disintegration of the uterine mucous membrane. 
 All sorts of powerful local remedies — nitrate of silver, nitric acid, bromine, 
 and so forth — have been applied to the interior of the iiterus, in the hope 
 that they would in some way modify its tissue changes. I have never 
 seen any satisfactory proof of success in either way, though so eminent 
 an authority as Dewees speaks very certainly as to the favourable action 
 of guaiacum, and all that I have to recommend in this affection is to 
 adopt general means, just about to be mentioned, for relieving present 
 pain, and for giving a free egress for the uterine cast, by means of dilata- 
 tion of the cervix. 
 
OF DYSxMENORRIIOEA. 183 
 
 For the relief of the main symptom, dysmeuorrhoeal pain, we have an 
 abundance of remedies, more or less effectual. 
 
 1. Opium in its various forms is perhaps the most effective. It must 
 be used sometimes, but should always be prescribed in disguise. The 
 terrible opium habit is a wretched substitute for any painful affection, 
 even where the symptom of pain is constant, and the disease is neces- 
 sarily fatal. 
 
 2. Alcohol is perhaps the most popular remedy, and its use in dys- 
 menorrhcea, and in alleviating the nervous depression of pregnancy, is an 
 almost certain means, in neurotic subjects, of creating habitual female 
 drunkards. I can trace scores of cases, from my own knowledge, to this 
 soiu'ce alone. To be of service it must be given in sedative, that is in 
 large and increasing, doses, and for several years I have forbidden it« use 
 under these circumstances, in large or in small quantities, in disguised or 
 undisguised forms. 
 
 3. Certain other Sedative or Antispasinodic Remedies are occasionally 
 of use, but the action of every one of them is liable to be uncertain. 
 Henbane and conium are of this class. Cannabis Indica has a more 
 extended reputation, and not quite undeservedly. In doses of 15 
 minims of the tincture, or 1 grain of the extract, or 4 or 5 grs. of the 
 tannate, it frequently produces in a very short time a marked ameliora- 
 tion of the pain, even in obstructive cases, but I fear the preparations 
 are apt to vary much in strength or purity. Chloral, as in other cases 
 of severe pain, succeeds best when exhibited with a more distinct anodyne. 
 The bromides, given freely for some days previous to the period, serve to 
 mitigate the neuralgic or ovarian types. Valerian, camphor, sumbul, 
 <fec., have all their advocates, and a perle of apiol at night seems to afford 
 some relief in slight cases. I have seen also much relief, lasting for 
 some hours, from the inhalation of 3 or 4 minims of nitrite of amyl. 
 
 4. Aj^erients. — A good smart aperient, just previous to the period, will, 
 more often than might be supposed, produce complete exemption fronj 
 pain, in moderately severe cases of the congestive t}'pe. 
 
 .5. Rest during the period, and for a day or two previous, is of un 
 doubted service. Nature herself points this out to those who will attend 
 to her suggestions. Special postures, as on the back, abdomen, or side, 
 may be indicated by our views of the causation, but still more often 
 by the experience of the patient herself, directed or elicited by the 
 physician. 
 
 6. Hot Water, in various ways of application, is one of our most 
 valuable resources, and is unaccompanied by any danger except that of 
 scalding the patient. Hot pediluvia or hip baths will relieve many, 
 chiefly in the congestive forms. Hot-water bags applied to the spine 
 will relieve others, chiefly where there is much apparent spasm or colic : 
 
184 LOCAL TEEATMENT 
 
 and hotTwater injections into the vagina, after Emmet's method, have- 
 several times afforded very great relief, in my hands. 
 
 How, next, can we surgically promote the free flow of the menstinaal 
 products in a dysmenorrhoeal patient, or do away with the function alto- 
 gether 1 and under what circumstances are these safe or advisable pro- 
 ceedings ? There are at least four available methods of local treatment : — 
 1. Local depletion. 2. Dilatation of the cervix. 3. Enlargement or 
 alteration of its form by incisions. 4. Excision of the ovaries and Fal- 
 lopian tubes. These methods diff'er widely, of course, in their relative 
 importance and gravity, and in their action as mere palliatives or as 
 radical cures. 
 
 1. Local Blood-letting, previous to or during the attack, will some- 
 times afford relief, during that period at any rate, and may there- 
 fore sometimes be employed. The congestive forms, or those due to 
 obstruction by uterine tumours, are the most likely to be benefited in 
 this way, and the remedy must not be used indiscriminately. Leeching 
 is a cumbrous method of attaining the result, and scarification (see 
 p. 78) is preferable. No one would, I hoj)e, dream of employing the scari- 
 ficator as a habitual antecedent to menstruation in its chronic dj-smenor- 
 rhoeal form ; but in special exacerbations, or when the pain is due to 
 acute and temporary congestion, it is a valuable means of relieving pain. 
 
 2. Dilatation of the cervix ranks as a method both of temporary relief 
 and of permanent cure, and may not infrequently be required as a means 
 of diagnosis, and this seems to be a fitting place to mention the various 
 methods which are adopted for the purpose. We can thus indicate the 
 relative value of each for our present purpose, and we may save repetition 
 in the future. 
 
 (a) Uterine tents, of sponge, laminaria, and tupelo, have already been 
 described (p. 28), and their mode of introduction, diagnostic uses, and 
 dangers need not again be referred to. Their action is comparatively 
 slow, and they tend occasionally to increase already existing congestion 
 of the uterus. They are more apt also to be followed by inflammatory 
 accidents during or near to the menstrual period than at other times. 
 Their prolonged retention adds to the general irritability and explosi- 
 bility of the nervous system, and they introduce the element of obstruc- 
 tion, with consequent opposing spasm, when that element is otherwise 
 absent. As diagnostic aids, their value, between the periods, is some- 
 times great. When intra-uterine growths are suspected, indeed in most 
 cases where dysmenorrhoea or metrorrhagia are accompanied by enlarged 
 uterus, their employment becomes a necessity, for the purpose of ascer- 
 taining the real pathological state involved. Used in this way, they 
 may prove curative. An obstructive growth in the cervix, or intra- 
 cervical granulations from old metritis, will sometimes yield at once to 
 
OF DYSMENOERHGEA. 185 
 
 the absorbent processes set up by the pressure of a tent. In cervical 
 stenosis also, whether original or acquired, a fine laminaria tent is often 
 the most effective means of commencing the process of dilatation, which 
 may be completed by the sound or other dilators, or by incision. As 
 an immediate method, to set free — say, a dysmenorrhoeal membrane, 
 other dilators are preferable. 
 
 (6) The Hound and its Modifications. — The introduction of an ordinary 
 uterine sound, when that is possible, just previous to menstruation, will 
 occasionally bring about complete absence of pain at the ensuing period, 
 and, however we may exj)lain it, this happens chiefly in those cases accom- 
 panied by uterine flexion, especially anteflexion. It may, and often does, 
 fail, but is not to be neglected as an occasionally useful resource. When 
 used in this way, resistance may be met with either at the os externvmi 
 or OS internum, and it is frequently necessary to tire that of the latter 
 by keeping the point steadily held against it, without actually pushing- 
 forwards. By this means alone, used once only before two or three suc- 
 cessive periods, I have cured at least a dozen obstinate cases of dys- 
 menorrhoea, probably when the obstruction was mainly or wholly 
 spasmodic, or — dare I say so? — when it was due to anteflexion. But the 
 sound, or its modifications, is useful in other ways, although one eminent 
 gyneecologist (Tait) says of it that "probably we should have lost 
 nothing if it had never been invented." By using various sizes it may 
 be made the means of either tolerably rapid dilatation shortly before 
 menstruation, or of more gradual dilatation of a more permanent char- 
 acter. Matthews Duncan, and following him Godson {Oh&t. Trans., 
 vol. xxiii. j3. 277), though they are unwilling to admit the existence of 
 obstructive dysmenorrhcea, have strongly inculcated, and successfully 
 practised, a proceeding which is highly acceptable to those who do. It 
 is not necessary to have separate instriiments for the purpose. When an 
 ordinary uterine sound can be passed, the male urethral bougie, with 
 moderately short curve, like that of Brodie's or Lister's catheters, Avill 
 serve the purpose for further dilatation. A very slight nick at 2^ inches 
 from their extremity, on the convex side, does not impair their use as 
 bougies, and serves to indicate how far they have been introdiiced into the 
 uterus. When the object is to proc\ire relief by giving free exit to a 
 dysmeuorrhffial cast, it is allowable to proceed with some rapidity. 
 Thus, in a recent case of membranous dysmenorrhcea, I introduced an 
 ordinary sound, followed by a No. 6 bougie, on the morning of the 
 second day before the expected flow, and in the evening I passed Nos. 7 
 and 8 without pain or difiiculty. Next day I passed Nos. 9 and 10 
 in the morning, and Nos. 11 and 12 in the evening, retaining each foi- 
 about a minute. Menstruation supervened in forty-eight houra after- 
 wards witl\ very sliglit pain, the cast appearing as \isiu\l. At tlic next 
 
186 
 
 DILATATION OF THE CERVIX UTERI 
 
 Fig. 94.— Priestley's 
 Uterine Dilator. 
 
 period I passed Nos. 10 and 12 easily, after the com- 
 mencement of the discharge, with a similarly favourable 
 result. During the next two periods there was no cast 
 and very little pain, but I have lost sight of the patient, 
 owing to her leaving Manchester at that time. This 
 practice, when available, is free from many of the dis- 
 advantages of dilatation by tent, but it must not be 
 supposed that such rapid dilatation is often possible 
 in this way without much pain and some risk. When, 
 in such a case, the resistance, and consequent pain, 
 are greater, one must either be content with a modified 
 result, commencing much earlier before the next period, 
 or one must have recourse to some of the other methods 
 of rapid dilatation. For the more permanent cure of 
 obstructive dysmenorrhoea the dilatation must be con- 
 ducted during the intervals, allowing at least two days 
 to intervene between successive attempts. I have 
 never felt justified in producing the amount of pain 
 which is admitted as almost a necessity by Dtmcan. 
 If there is any very decided pain at all I withdraw the 
 instrument at once, and do no more at that sitting ; 
 if the introduction of one number is nearly painless, 
 I keep it in for a minute or two and then pass the 
 larger one. The progress varies very much in diffierent 
 cases, but is safe and almost certain. If there is the 
 slightest rise in temperature, the treatment is inter- 
 mitted and free injections of hot water are used. 
 Acting on these cautious principles it will be necessary 
 to admit now and again that the plan is unsuitable, 
 and to have recourse to other methods. But I feel 
 certain that, with these precautions, we are exempt 
 from the great dangers which Sims and others have 
 attributed to this plan. I can as confidently recom- 
 mend it in suitable cases as I would deprecate its use 
 in cases atteiaded by much local congestion, by sub- 
 acute uterine or pelvic inflammation, or by manifest 
 ovarian tenderness. In cases also where the litems is 
 undeveloped, dilatation in this way must be very slow 
 and gradual, and we must be prepared to readily 
 acknowledge failure, for the time being. A return to 
 it some months later has in my hands proved most 
 successful in two such cases — comparatively free men- 
 struation following, and being followed by pregnancy. 
 
IN DYSMENOERHCEA. 
 
 u: 
 
 I may, however, state here, by the way, that though sterihty usually, 
 or very often, accompanies chronic dysmenorrhcea, it has been thought 
 advisable to speak of it and its treatment separately elsewhere (Cha]). 
 XX.). 
 
 (c) Other Dilators.— M.-A\\j instruments have been devised for the pur- 
 pose of more or less forcibly and rapidly dilating the cervix uteri. 
 Priestley's (fig. 94) is one of the simplest and safest of these. Tt con- 
 
 ||yiiiiiiiiiiiiiiiiiiiiiiiiiiiii»^?i5^j 
 
 Fig. 95. — Sims's Uterine Dilator. 
 
 sists of a sound split through a portion of its length, which split poition 
 is capable of being opened by screw movement to a given extent, Avhich 
 is registered at the screw. When time is a great object, it may be used 
 to expedite or replace dilatation by bougies, but when time pennits 1 
 prefer the latter. Its use is more painful than that of the sound or 
 bougie, used as above recommended, though wdth care and patience it 
 may be made to resemble it very closely in action. Other much more 
 complicated expanding dilators 
 have been introduced by Marion 
 Sims, Atlee, Ellinger, Schultze, 
 and others, which have two or 
 more branches, that open with 
 a certain amount of parallelism. 
 Sims's instrument (fig. 95) may 
 suffice to show one of these. 
 Writing as I do mainly for non- 
 specialists, I hesitate, however, 
 to recommend costly and com- 
 plicated instruments, which re- 
 quire much tact in their man- 
 agement, and whose superiority in actual practice is by no means 
 certain. 
 
 Dilatation may also be made by hard rubber cones, somewhat similai- 
 to those of Simon for the urctlira. Mr Lawson Tait introduces these, 
 and holds them in situ by a solid stem (fig. 96), and this, again, is 
 attached to the waist by elastic cords, so that pressure is constant and 
 unifonu. When dilatation is required for diagnostic purposes, it may 
 tlius be induced with considerable rapidity, but the size of the smallest 
 
 Fig. 96.— Tait's Uterine Dilator. 
 
188 HYSTEROTOMY 
 
 cone is such as to forbid their use in most cases of dysmenorrhcea, except 
 as a means of providing escape for a membranous cast, and here I would 
 rather use them by manual pressure, and with anaesthesia. 
 
 3. Incision of the Cervix. — This plan of treating dysmenorrhcea and 
 sterility was mainly brought into notice by Sir J. Y. Simpson, who intro- 
 duced a special instrument, the hysterotome (fig. 97), for the purpose. 
 Unfortunately, the operation w^as comparatively easy, and the occasional 
 results were so striking that it was greatly abused ; and one does not 
 require to be very aged to remember the time when slitting the cervix 
 uteri threatened to become as universal a practice as was causticing 
 uterine ulcers, or as stitching up the slit cervix now thi'eatens to be 
 in some quarters. The much greater difficulty of the last-named 
 process will, however, probably seiTe as a check. Slitting up the 
 cervix uteri is perfoi-med for two distinct objects, which should be 
 clearly kept apart, though the means employed in each case are much 
 the same. The one object is simply to enlarge the cervical canal, 
 especially its external orifice ; wdth this we have to do here. The other 
 is to alter the axis of the cervical canal, in relation to the canal of the 
 
 Fig. 97.— Sir J. Y. Simpson's Hysterotome. 
 
 body of the uterus, by slitting the former backAvards in certain cases of 
 anteflexion of the uterus, whether this anteflexion is a cause of dysmen- 
 orrhcea or not, but in relation to existing sterility. Simpson's hystero- 
 tome was a bistouri cache, fine enough to be introduced into an under- 
 sized cervix, and capable of being extruded from its sheath by the spring- 
 handle, to any extent, previously determined by a screw. It was passed 
 into the cervix till it nearly reached the os internum, turned with its 
 cutting edge to one side, and withdrawn, while firm pressure was made 
 on the handles during extraction. There ensued a lateral incision, 
 small at first, but cutting right through into the vagina at the os 
 externum. The same process was repeated on the opposite side. Several 
 ingenious instruments have since been invented by leading gyneecoiogists, 
 which provide for the making of both incisions at once, and of an equal 
 depth. I need not describe these, because I believe that one incision 
 directly backwards will serve all the purpose of the double lateral cuts, 
 while it is less likely to cause severe haemorrhage, or pelvic cellulitis, 
 or undue gaping (ectropion) of the enlarged os externum. The invention 
 of new hysterotomes seems to be getting out of date. 
 
 The incision may also be made by a sharp probe-pointed bistoury, or 
 
IN DYSMEXORRHGEA. 189 
 
 by Emmet's movable knives (fig. 46) used with the duck-bill speculum, 
 or by scissors adapted for the purpose (fig. 98). The latter plan shows 
 most clearly the amount of incision made, the point at which the hooked 
 external blade grasps the cei-vix externally being clear to the eye. 
 Whichever plan is used, it is always most satisfactorily carried out with 
 the cervix well exposed to view, and steadied with a booklet. Unless 
 the largest tubular speculum, or a good expanding one, such as Reid's, 
 can be used easily, the duck-bill is required, so that it may be absol- 
 utely seen that the incision does not extend higher externally than the 
 point of reflexion of the vagina from the cervix. The haemorrhage which 
 follows such a single backwards incision is seldom great, often singularly 
 slight, and can be arrested by a temporary tampon soaked in iodised 
 glycerine, perchloride of iron, or other haemostatic, and pressed firmly 
 against the part, but occasionally, and still more if the lateral incisions 
 have been made, it may be considerable, and has proved fatal. If there 
 
 Fig. 98. — Kuchenmeister's Uterine Scissors. 
 
 is any doubt, the vagina must be plugged before the speculum is 
 removed (p. 83). The operation is never in any form absolutely free 
 from danger of septic or inflammatory mischief, and the patient should 
 be operated on at home, and carefully tended in bed for at least ten 
 days, with daily or more frequent antiseptic vaginal injections. T<> 
 prevent adhesion of the cut surface, the tip of the finger, well carbolised 
 and lubricated, should be passed as far as possible into the wound, every 
 second day for a week or more, and a sound should be passed intf) the 
 uterus once or twice previous to the next period. 
 
 What are the comparative merits of dilatation or incision ? F refer, 
 of course, only to their bearing on cervical narrowing Avith d^'smen- 
 orrhoea. Dilatation I believe to be safer, if conducted with the jire- 
 cautions mentioned above. Only in comparatively rare cases, and 
 to the skilful specialist, would I recommend incision of the os internum. 
 I would therefore advise the use of dilatation first, in most cases where 
 
190 
 
 OOPHOEECTOMY IN DYSMENOREHCEA. 
 
 one of the two courses is indicated. But dilatation is in some cases 
 more painful, more tedious, and more liable to failure by relapse. When 
 therefore dilatation by sound is unusually painful or diflficult, when the 
 effect of one sitting is more than once not apparent at the next, or when 
 the relief obtained by dilatation at one menstrual period is totally lost 
 at the next, I would recommend that incision should be used. The 
 circumstances of patients, especially those in hospitals, must always 
 form an element in such calculations ; a patient with abundant leisure 
 and a comfortable home may often, regret it as we may, be treated in a 
 different manner from one who must choose between a flying visit to 
 a dispensary in the midst of work, or a stay of two or three weeks 
 in the wards. The physician must weigh these points, the patient 
 cannot. 
 
 However the cervix may have been mechanically enlarged, it should 
 occasionally be explored with a full-sized bougie for 
 some months, or, if the uterus is evidently not very 
 irritable, a glass intra-uterine pessary (fig. 99) may 
 be worn in the interval between the periods. 
 
 It is very difficult to convey to the reader the fre- 
 quency or infrequency with which such processes are 
 required. The student is too apt to leave college with 
 the idea that ovariotomy, amputation at the hip joint, 
 removal of the tongue or larynx, and the like opera- 
 tions will frequently come across his path to do 
 or to recommend, though he speedily undergoes dis- 
 illusion. To such I would say, dysmenorrhcea is a 
 symptom, a very common symptom, of constitutional 
 states or common female affections. Constriction of 
 the cervix is only one among many, but it is one ; you must therefore 
 avoid the common error of considering it as almost the sole cause, and 
 you must equally be prepared to treat it surgically when you can 
 clearly diagnose its existence. 
 
 4. Removal of the Ovaries and Fallopian Tubes. — Eemoval of the 
 ovaries, with or without the Fallopian tubes, is now freely recommended 
 for certain forms of dysmenorrhcea, since Battey brought the opera- 
 tion into prominent notice in 1872. The consideration of oophorectomy, 
 normal ovariotomy, spaying, or whatever the disputants may finally 
 choose to term it, will be best undertaken when the ovary itself 
 is under consideration. Here I need only say that the result of the 
 cases I have seen, or of the many of which I have heard and 
 read, has been to convince me that, for nervous affections, hysteria, 
 epilepsy, hystero-epilepsy, &c., supposed to depend on ovarian or men- 
 strual derangement, it is at best a very doubtful remedy and one involv- 
 
 FiG. 99.— Glass In- 
 tra-Uterine Stem 
 Pessary. 
 
VICAEIOUS MENSTEUATION. 191 
 
 ing a grave responsibility which I should rarely be prepared to undertake. 
 On the other hand, in the presence of continued dysmenorrhoeal pain, 
 with undeveloped sexual organs, or with distinct evidence of ovarian or 
 Fallopian induration, enlargements, or displacements, which had resisted 
 the known methods of treatment, I dare not refuse to a woman the relief 
 from suffering which is clearly held out by many successful cases of 
 i-emoval of the uterine appendages under these circumstances. 
 
 The treatment of metrorrhagia as a symptom of certain local uterine 
 organic diseases, and apart from any special relation to menstruation, 
 will be further referred to under the headings of Uterine Tumours, 
 Cancer, &c. 
 
 Vicarious Menstruation. 
 
 Instances of complete vicarious menstruation — that is, of continu- 
 ously periodic discharges of blood from other parts of the body 
 than the uteinis, and entirely replacing the normal discharge — are 
 very rare, mere lusus naturae. Yet they have been sufficiently often 
 recorded to show that nature does thus sometimes relieve its periodic 
 vascular tension through other channels, chiefly through mucous 
 surfaces. Less clearly marked cases of haemoptysis, ha;matemesis, 
 epistaxis, and the like, independent of ascertainable disease of the 
 organs from which they proceed, and accompanying scanty or absent 
 uxenstruation, are not uncommon. The difficidty lies in determining 
 when such hsemorrhages are in any sense vicarious, and when not. In 
 spite of the known general systemic tension at the menstrual periods, it 
 is difficult to avoid the suspicion that there must be some local weak- 
 ness which determines the source of haemorrhage. A sound practical 
 rule is, that whenever a case of supposed vicarious menstruation has 
 been met with, it is wise not to lose sight of the organ from which it 
 pi'oceeded for a considerable time. In the temporary absence of physical 
 signs of disease of that organ the most skilful practitioner may be mis- 
 led, without this precaution. When menstruation in the natural way 
 can be safely promoted, it forms the proper treatment of such a case, 
 and I am not aware that anything more can be said on the matter. 
 
 After having taken so much pains to impi-ess upon the student the 
 necessity of regarding menstrual disorders as merely symptomatic, 1 
 should perhaps apologise for devoting so much relative space to their 
 discussion. The only excuse is this, that he who, in a large general 
 l)ractice, ftiithfully studies the causation of these symptoms, and so 
 treats them rationally, will relieve far more human suffering than the 
 most distinguished operator or discoverer can do, apart from his influence 
 <)i\ the practice of others. 
 
192 THE MENOPAUSE. 
 
 The literature of the physiology of meustiiiation is so scattered, that 
 I cannot refer the English student to any better introduction to it than 
 Williams's ]Daper in the Obstetrical Journal, vol. ii. Its disorders are 
 also discussed in every test-book, but can only be fully studied by one 
 who will take the trouble to consult the various medical periodicals of 
 the last decade. 
 
 The Menopause. 
 
 Towards the close of menstrual life — the menopause — the female sys- 
 tem becomes liable, as at its commencement, to many functional dis- 
 orders ; and, as this is also the most frequent period of origin of many 
 organic diseases, especially of cancer, it is very important that they 
 should be known and recog-nised. Cessation may be sudden or gradual, 
 or with several intermittent threatenings. It may be absolutely with- 
 out general symptoms, or it may give rise to many. The key to most 
 of them lies in abnoimal disturbances of circulation and innervation. 
 Painful and otherwise causeless flushings of the head and face, often 
 accompanied by headache, giddiness, or disorders of the special senses, 
 are most frequent. Attacks of menonliagia often occur, but nothing- 
 can be more dangerous to the patient or to the reputation of the practi- 
 tioner than to adopt without examination the popular formula of 
 '' change of life " as their cause. I am afraid to guess how many cases 
 of polypus I have seen allowed to bleed the patient almost to death from 
 such inadvertence. Every form of neurasthenia, neuralgia, hysteria, 
 convulsive disease, melancholia, or other mental affections, is rife at this 
 time. Dyspepsia is constantly met with in its protean forms. Vicarious 
 hsemoiThage is now, if ever, a reality ; and that odd mimetic affection, 
 spurious pregnancy, has to be suspected. While there is a tendency for 
 non-malignant growths, especially uterine fibroids, to become stationary 
 or to be absorbed, there is an opposite tendency in all forms of malignant 
 disease. 
 
 The woman who has arrived at this period should be as carefully 
 guarded against noxious influences as the young adolescent girl. Her 
 diet and regimen should be carefully attended to, the too free use of 
 alcohol especially being forbidden. Gout, or the tendency to lithiasis, 
 are apt to develop themselves, and must be giiarded against. The 
 bowels must be regularly attended to, and in most cases occasional free 
 purgation is acknowledged by the patient to relieve her symptoms. 
 The uterine haemorrhages, so frequent in some degi-ee, must be carefully 
 diff"erentiated from those of organic disease, and are best controlled by 
 the free use of ergot. The various nervous s^onptoms demand cai-eful 
 regulation of the occupations and amusements of the sufferer, and kindly 
 
THE MENOPAUSE. 193 
 
 care at this time is the surest j)relude to a green, prolonged, and viseful 
 old age. Too many a woman of forty-five to fifty years of age has her 
 futui-e usefulness and happiness destroyed by sacrificing herself at this 
 time to the whims and exigencies of her growing family ; and society 
 loses incalculably' in all its social and philanthropic aspects when it 
 loses the services of a hale, experienced woman, who has passed safely 
 through the climacteric period. I have little or nothing to say 
 in the way of dnig treatment of this period, further than that the 
 bromides as a non-narcotic sedative, aperients as a species of derivative 
 or temporary substitute for other evacuations, and ergot as a controller of 
 haemorrhage, have now their special value, while the various tonics — 
 iron, strychnia, quinine, <fec. — may require to be exhibited and watched 
 as to how far they are found to agree or disagree with the varying 
 abnormal vascular and nei^vous tension. 
 
194 INFANTILE UTEEUS. 
 
 CHAPTER VIII. 
 
 Dr.sEASEs OF THE Uterits. Infantile Uterus. Stenosis of the Cervix Uteri. Uterine 
 Atrophy. Inflammation of the Uterus (Metritis), including Acute and Chronic, 
 Parenchymatous and Mucous, Corporeal and Cervical, Metritis. 
 
 Infantile Uterus. 
 
 The congenital malformations of the uterus have been already men- 
 tioned in Chapter VI., together with those forms of atresia which de- 
 pend on such malfoi-mations. I stated there that, independently of any 
 imperfect lateral closure or other malformation of the genital tract, we 
 may have in the adult a form of utervis which, at an early period of 
 life, wou.ld be considered as almost normally developed, but which has 
 suffered from an arrest of growth and development, so as to render it 
 unfit to fulfil the functions of adult sexual life. For practical reasons I 
 deferred the consideration of this until the present 
 chapter, although I had occasion to refer to it when 
 speaking of menstrual disorders. Schroeder describes 
 both what he terms the uterus foetalis ml infantilis 
 and the congenital atrophy of the uterus. In the for- 
 mer case the uterus is normally formed at the time of 
 birth, but retains the infantile form in adult life. In 
 this (fig. 100) the proportion of body and cervix are 
 different from what we find in the normal adult, the 
 body constituting only about a fourth or a third of 
 I'" [a. 100.— Uterus the entire length, while its walls are thin and scantily 
 infautihs (Schrce- g^dowed with muscular fibre, the cervix approaching 
 more nearly to the adult form and size. Bu^t the whole 
 uterus is of diminished length (say 1| to 2 inches), and the vaginal 
 projection of the cervix is small compared with that in the adult. 
 There is generally coexistent a retarded development or growth of 
 the vagina and ovaries, and the signs of puberty are late or in- 
 ciomplete. The other form, that of congenital atrophy, is character- 
 ised by a much more normally proportioned uterus, but it is small 
 in every way; the fundus and cervix participating more equally in 
 this quality. It is, in fact, much more an example of diminished 
 local nutrition, met with in the chlorotic, tubercular, or scrofulous, 
 
ITS CLINICAL PHENOMENA. 195 
 
 but occasionally found in otherwise well-developed women, while the 
 previously mentioned form is rather a freak in local development 
 and growth. Clinically, I prefer to class both these forms together 
 as infantile uterus, — an affection by no means uncommon, but often 
 unrecognised as to its pathology, — though the treatment of its dis- 
 tressing results — amenorrhoea, dysmenorrhoea, uterine anteflexion, 
 ovarian irritation, and a host of nervous symptoms — is often the op- 
 probrium of gynaecology. An examination, rendered necessary by any 
 of these conditions, reveals the small nipple-like intra-vaginal cervix, 
 which is the most characteristic feature in these cases. Along with 
 this we nearly always find an excessive degree of anteflexion of the 
 fundus, the small round ball of which is felt distinctly in front, while the 
 little cervix points more or less forwards (fig. 101). If the sound can 
 be insinuated at all, it passes 
 to considerably less than 
 the normal extent, and ex- 
 treme caution is necessary 
 to avoid perforation of the 
 thin fundal wall. I am 
 sure that in actual practice 
 this description is more 
 accurate than that which 
 is gained by adhering too 
 closely to the strictly ana- ^ ^ 
 
 tomical descriptions of Fig. 101.— Normal (A) and Infantile (B) Uterus, as met 
 Schrceder and others. De- ^i*^ clinically. The proportionately long Supra- 
 
 vaginal Cervix and the Anteflexion of the latter 
 velopment and growth do are frequently less pronounced, 
 
 take place, and somewhat 
 
 modify the organ in the direction of that of the adult, with a result more 
 or less closely corresponding to that now described. 
 
 Symptoms. — Except in those comparatively few and fortmiate cases 
 where ovarian action remains completely dormant, owing to the still 
 more undeveloped state of the ovaries, and where the woman remains 
 practically a-sexual during life, the possessor of an infantile uterus is 
 generally the victim of endless suffering. In the less typical cases, mar- 
 riage may afford relief if followed by pregnancy ; but in the majority 
 marriage is unfruitful, and the stimulus of connection only produces 
 congestion and increased difficulty in the performance of menstruation. 
 This function, often late in commencement, is from the beginning irre- 
 gular and painful, the dysmenorrhoea increasing instead of diminishing. 
 Fortunately menstruation often ceases early in life, but the patient is not 
 infrequently too disabled, mentally and bodily, by previous suffering, to 
 enjoy the respite from local pain which then ensues. 
 
196 THE DIAGNOSIS AND TREATMENT 
 
 The diagnosis of the condition is all-important. For want of it many 
 Tinfortunate women are constantly condemned to suffer from fruitless 
 attempts at curing individual symptoms, without regard to the condi- 
 tion as a whole ; yet diagnosis is by no means difficult. The amenor- 
 rhoea or scanty menstruation, and, above all, the dysmenorrhoea, which 
 are the most marked symptoms, lead to investigation. The small nipple- 
 like cervix sets us at once on the track. Bi-manual esamination reveals 
 the small, and far more than normally anteflexed, fundus, and the sound 
 reveals either an almost impassable canal, or a uterus decidedly shorter 
 than the normal 2^ inches. Every one of these conditions must, how- 
 ever, be made out, for I have not unfrequently found the small nipple- 
 like cervix and some decided anteflexion combined with normal length 
 and development of the uterus otherwise, — a condition of matters much 
 more amenable to treatment, and likely to improve in course of time. 
 
 Treatment. — What can be done for such cases in the way of treat- 
 ment ? When raenstruation, and consequently dysmenorrhoea, are absent, 
 the most masterly inactivity is the wisest coui'se to pursue. Never 
 mind an anteflexed viterus or a contracted os under such circiimstances. 
 You may, by diligent irritation of the organs, induce attempts at men- 
 struation, and the patient will have many years' suffering in consequence. 
 But when futile or painful attempts at menstruation are already present, 
 and increasing in severity, something must, if possible, be done. If a 
 moderate-sized sound can be introduced, and the uterus is found to be 
 nearly normal in length, marriage, if contemplated, may be permitted 
 or even advised. But, meanwhile, how can the narrowed cervical canal, 
 or the uterus, feebly developed as a whole, or the concomitant ovarian 
 tenderness, or the general sympathetic nervous states, ranging from 
 slight hysteria to insanity or epilepsy, be best counteracted? To 
 treat the flexion by pessaries in the vagina only is entirely useless. 
 To drug the patient with narcotics and stimulants, except as an occa- 
 sional stop-gap, most religiously watched, is to add the miseries of 
 drunkenness to those already existing. Some improvement occasionally 
 follows the treatment of coexisting chlorosis, or other constitutional mor- 
 bid conditions, by suitable means, but as a rule the suffering is so great 
 as to demand local treatment. The cervical canal must be opened up 
 by probe, tent, soimd, or backward incision, as directed in the last 
 chapter, and this alone will sometimes suflfice to diminish the dys- 
 menorrhoea, while time, or the stimulus thus given, may improve the 
 nutrition and groAvth of the uterus and render the relief permanent. 
 If the progress of events shows no tendency to uterine or pelvic in- 
 flammatory attacks, a freedom evidenced by the absence of fixed local 
 pain or of exudation, and by steadiness of the temperature, an intra- 
 uterine stem pessary may be introduced, partly for the purpose of 
 
OF INFANTILE UTERUS. 
 
 197 
 
 keeping the canal open, and partly to act as a gentle but constant 
 stimulus to local growth and nutrition. Such intra-uterine stem pes- 
 saries are fully described hereafter, with their mode of introduction, and 
 the precautions to be observed (Chapter XII.). But for this particular 
 purpose the copper and zinc stem of Simpson (fig. 102) or of Barnes (fig. 
 103) is specially useful. Its slow gal- 
 vanic effect meets the requirements 
 of the case, but it must never be long 
 enough to touch the fundus uteri, and 
 it must be withdrawn at the men- 
 strual period, and on the slightest 
 evidence of local inflammation. Much 
 has been A\Titten on the treatment 
 of this affection, but beyond the 
 temporary relief of dysmenorrhoeal 
 
 pain, the opening up of the cervix, and pjQ_ 102.— Simp- Fig. 103.— Barnes's 
 the stimidation and straightening son's Galvanic 
 of the organ by stem pessaries, used 
 with the utmost precaution, and care- 
 fully watched, I know of no other available means of treatment 
 but one. The exceptional means referred to is the removal of the 
 ovaries, and the putting a stop thereby to the sexual life of the patient. 
 For an appreciation of how far this is permissible, or safe, or effectual, 
 I must again refer my reader to the chapter treating of oophorectomy 
 (Chapter XVIL). 
 
 Intra - uterine 
 Stem. 
 
 Galvanic Intra- 
 iiterLae Stem. 
 
 Stenosis of the Cervix Uteri. 
 
 Much as I shall have to insist on the essential diff'erences which exist, 
 anatomically, physiologically, and pathologically, between the cervix and 
 body of the uterus, clinical necessities sometimes compel us to overlook 
 them in an orderly description of uterine diseases. From the considera- 
 tion of the whole organ as insufficiently developed, we turn to that of 
 the cervix alone as abnormally contracted. By stenosis we understand 
 contraction ; by atresia, obstmction of a canal. Atresia has already 
 been spoken of as it occurs congenitally or otherwise in various parts of 
 the genital tract. Stenosis or contraction of the cervical canal is met 
 with as a cause of dysmenorrhoea and sterility. In the one case it causes 
 painful outlet of menstrual products, in the other difficult or impossible 
 inlet of the fei-tilising semen. As we shall afterwards see, it may also 
 give rise to, or aggravate, endometritis, by causing retention of the 
 uterine secretions. 
 
198 
 
 STENOSIS OF THE CEEVIX UTEEI. 
 
 Fig. 104— The Long Coni- 
 cal Cervix Uteri. 
 
 Nature and Causation. — Cervical stenosis may arise from traimiatic 
 causes, or from inherent or congenital malformation, or from catarrhal 
 inflammation of the canal, and owe attention is called to it either by per- 
 sistent dysmenorrhoea or by unfruitfal marriage. Among the traumatic 
 causes the abuse of strong caustics is undoubtedly very common, but 
 gonori'hoeal catarrh, or severe labour, with laceration and subsequent cica- 
 trisation, may eventuate in the same result, and 
 amputation of the cervix for hypertrophic en- 
 largement, if not carefully watched, is apt to 
 cause contraction of its canal. Congenital sten- 
 osis of the canal occurs in connection with the 
 infantile state of uterus which has just been 
 described, and causes, by its obstructive tend- 
 ency, the chief morbid symptoms in that affec- 
 tion. But a state of the cervix very different 
 from that met with in infantile uterus is some- 
 times found, equally stenotic and equally ob- 
 structive ; this is the long conical cervix which 
 is frequently found to exist in obstinate dysmenorrhoea. In this con- 
 dition, not necessarily or even frequently accompanied by infantile 
 fundus, the cervix is longer than normal, its intra-vaginal part may mea- 
 sure even as much as two inches ; it is always conical in shape, and finn 
 
 in consistence, and the 
 OS is felt to be but a small 
 round pin-hole (fig. 104), 
 very different from that 
 which is found in either 
 the virgin or the parous 
 normal uterus (fig. 105). 
 In this affection the sten- 
 osis is usually confined to 
 the external os, and the 
 rest of the canal may even 
 be dilated, so that it may 
 contain a considerable 
 quantity of viscid irritat- 
 ing mucus, which is sometimes seen to escape with a gush after 
 partial dilatation of the os externum. The usual symptoms of obstruc- 
 tive dysmenon-hoea are nearly always present. Stenosis at the 
 internal os is a much-disputed phenomenon. True organic constric- 
 tion is certainly rare, if it happens at all, but a certain amount of 
 •spasmodic resistance undoubtedly encounters the sound not infre- 
 quently, and may also retard the passage of clots, and the results 
 
 Fig. 105. — The Virgin and the Parous Utenis contrasted 
 (after Sappey). A, the Virgin ; B, the Parous. 
 
ATROPHY OF THE UTERUS. 199 
 
 of treatment lead me to think that it is sometimes not wholly sjjas- 
 modic. 
 
 Obstruction of the canal by the doubling over of a flexed uterus is not 
 true stenosis, and will be considered as a phenomenon of uterine flexion. 
 A little careful manipulation with the sound, combined with elevation of 
 the flexed fundus by the gaiiding finger through the vagina, shows that 
 organic stricture of the passage is absent. 
 
 The treatment of stenosis of the cervix, if uncomplicated by other 
 uterine disease, is capable of tolerably clear definition. The manage- 
 ment of infantile uterus has been already described, dilatation or in- 
 cision of the contracted cervix forming a part of it. The long conical 
 cervix usually requires enlargement of its external orifice only. This 
 contracts and recontracts after dilatation by tent or sound, and is best 
 divided at once by the hysterotome, if the nature and localisation of 
 the stricture are clear. The bilateral incision is permissible here on 
 account of the limited amount of the cervix which requires incision. 
 There is comparatively little risk of interfering with the uterine vessels 
 or the pelvic cellular tissue. For the methods of dividing the cervix 
 {see preceding Chapter). In the case of a very great elongation of the 
 cervix only, it must be treated, as we shall recommend in speaking of 
 hypertrophy, by amputation of a portion of it (see Chap. IX.). 
 
 Uterine Atrophy. 
 
 When speaking of infantile uterus we have referred to one condition 
 which is by some writers described as an atrophy, although clinically 
 we have held it as rather an arrest of growth. True atrophy may 
 however exist, — a shrinking from the normal size to which the organ 
 has at one time attained. The leading synii:)toin is the complete, or 
 almost complete, disappearance of menstruation, which is gcnci*ally 
 accompanied by debility and by liability to various hysterical or neuras- 
 thenic symptoms. 
 
 Causation. — -Atrophy is common, indeed it is the rule, in old age, 
 when the organ is not enlarged by the previous results of child-bearing, 
 by chronic inflammation, or by other affections leading to its hypertrophy 
 as a whole or in part. The amenorrha)a of phthisis and other debili- 
 tating diseases is sometimes associated with atrophy of the whole organ, 
 although in such cases the latter is doubtless often a congenital rather 
 than an acquii-ed state. In these instances the general disease alone 
 requires treatment. Atrophy may also occur after pregnancy, from an 
 excess in the process of involution. T have mentioned (p. 128) one 
 extreme case of this, but doubtless it occurs in a very limited degree 
 
200 IXFLA3IMATI0X OF THE TTERTIS, 
 
 in many instances, accounting for some cases of a single birth not 
 followed by others, or not until many years have elapsed. Many times, 
 however, such prolonged pauses are due to chronic inflammation. Pro- 
 tracted lactation has been assigned as one cause of atrophy, although an 
 opposite condition of things has seemed, in my experience, more often 
 to result, and is more consistent with the view that mammary imtation 
 is a utero-ovarian stimulant. Great hsemon'hage during parturition, and 
 duiing involution, is another alleged cause, as is also the action, partly 
 mechanical and partly vital, of surrounding inflammatory adhesions. It 
 is stated also, by F. Barber, to have occurred after the removal of fibroid 
 tiunoiu's, and by Battey, after the removal of the ovaries. Great 
 obscurity, however, surrounds the whole matter of causation. 
 
 The atrophic uterus is diagnosed precisely as is the congenitallr 
 small one, the sound being used most careftiUy, and these two are 
 difierentiated by their history, and by the absence in the former 
 case of the marked and distinguishing anatomical peculiarities of 
 infantile utems. 
 
 Treatriient. — If the atrophy be from old age or from general debility, it 
 must, as far as regards local measures, be left alone. If it appears to 
 result from the eifects of super-involution, and the woman is still of the 
 child-bearing age, and if the atrophy leads to dysmenorrhcea rather than 
 amenorrhoea, as it may do when the ovaries and general system are 
 otherwise in full working condition, dilatation of the cervix and the 
 introduction of an intra-uterine stem pessary are pennissible, to stimu- 
 late the uterus to growth. The amount of sensibility of the organ is the 
 best guide as to the safety of this procedure. 
 
 Inflammation of the Uterus {Metritis). 
 
 Under this heading we have to consider what is perhaps the most 
 important and at the same time the most difficult part of gynsecology, 
 the latter especially to the student and young practitioner. The im- 
 portance of the subject no one who has been in charge of a cliniqxie, 
 where the women of the poorer classes constitute the majority of the 
 patients, will deny; although it does not in any way follow that he must 
 adopt the foolish and reprehensible plan of basing a special gynseco- 
 logical pathology upon this or any other single pathological departure 
 frequently met with. 
 
 The newest and most brilliant achievements of modern gyneeco- 
 logical surgery are all very well in their way. Ovariotomy, hyster- 
 ectomy, vaginal plastics, etc., are most striking in their results, when 
 
OE METRITIS. 203 
 
 we see them grouped in the practice of the few, but they are only 
 concerned with a small fraction of human suftering, compared with 
 that which is daily and hourly, too often vainly, demanding relief 
 at the hands of the great body of the medical profession, on account 
 of chronic inflammatory afiections of the uterus. Sometimes as the 
 cause, sometimes as the eflPect, of other uterine diseases, or of various 
 morbid states of the system, metritis meets us at every turn, and for 
 want of the time and hygienic conditions necessary to its cure, it con- 
 tinually baffles our efforts at pei'manent relief. The pure physician 
 scornfully ignores it, or turns it over to the w^omb doctor. The pure 
 surgeon, or even the specially gynaecological surgeon, is often occupied 
 with more enticing subjects, the charlatan preys upon it, and the all- 
 round practitioner too often gives it up in despair, and applies his local 
 remedies, only in the hope or the expectation that the patient will, by 
 and by, transfer her case to some one else. The difficulties of the sub- 
 ject depend not only upon the intractable natui'e of so many of the 
 cases, but also upon the obstacles w^hich many meet Avith in acquiring 
 such a clear knowledge of the pathological facts involved as will fit in 
 with and lead to definite principles of treatment. I have found the 
 mere nomenclature of the subject more difficult to the student than 
 might be supposed by those who have gradually become accustomed to 
 it, through long experience in special clinical work ; and when a ready 
 familiarity with such terms as chronic endocervicitis, acute fundal paren- 
 chymatous metritis, and the like, has been acquired, his first few years of 
 home practice seem to dislocate once more his precise theoretical notions 
 on the subject, and to reduce him again to a state of doubt and diffi- 
 culty in the management of cases which will not observe the clinical 
 distinctions he has laboriously mastered. And lastly, in his daily prac- 
 tice, as in his reading, he finds the exciting causes of inflammation, and 
 the various results which arise from it in diff"erent patients, so inter- 
 mixed, that another element of great practical difficulty arises. This 
 description may be overdrawn in the case of some practitioners, but I 
 know that it faithfully describes my own case at one time, as well as that 
 of many who have honoured me with their confidence. I hope to meet 
 some of these difficulties by indicating, in the first place, as clearly as I 
 can, the separate forms of metritis, which are pathologicall}-, and often, 
 though by no means always, clinically, quite distinct from one another ; a 
 knowledge of these separate forms and of their distinctive appellations, 
 being a necessity for those who would understand what is written on 
 the subject in current literature, and the only sound basis for rational 
 treatment. Secondly, I hope to discuss the treatment of metritis in its 
 various separate or combined foi-ms, without being too much hampered 
 by the above distinctions; and, thirdly, I will endeavour, as far as 
 
202 VAEIOUS FORMS OF METEITIS. 
 
 possible, to keep separate the complications which flow from, or are 
 the after results of, inflammation of the nterus, though dealing with 
 them in the pages immediately following. 
 
 To understand then the different types, forms, or degrees of uterine 
 inflammation, it is necessary to bear clearly in mind three things. 
 
 In the first place, the uterus consists of two distinct portions, the 
 body and the neck. These are distinct anatomically, shaped differ- 
 ently, separated from one another by the internal os, and lined with a 
 different form of epithelium, having totally different glandular struc- 
 tures. They are equally distinct physiologically, the cervix taking no 
 part in the wondrous monthly changes in, and exfoliations of, the uterine 
 mucous lining, nor in the provision for the coverings and nutrition 
 of the impregnated ovum. They are, therefore, distinct pathologically 
 also, being liable in very different degrees to the invasion of malig- 
 nant affections, and to the attacks of inflammation. Hence we have a 
 clear division of metritis into two forms, fundal or corporeal (I intend 
 to use the latter term, as less liable to cause mistake), and cervical. 
 
 Metritis may be (A) corporeal, (B) cervical. 
 
 2ndly. The uterus, whether body or neck, consists of two elements — 
 not the sole ones, but the sole ones for our purpose — a parenchyma and 
 a mucous lining. These are also distinct from one another, anatomically, 
 physiologically, and pathologically. The one element may be inflamed 
 with or without the other, and a knowledge of the separate affections 
 of each is of great practical importance in treatment. A local, or even a 
 general remedy, intended to affect the mucous lining of a viscus will 
 not affect in a similar way its surrounding parenchyma. The physician 
 treats bronchitis on other principles than pneumonia, intestinal atony 
 by other means than intestinal catarrh, so it is with the uterus. 
 
 Metritis may be (A) parenchymatous, (B) mucous. 
 
 To indicate the latter we use the prefix endo-. 
 
 Hence we have — 
 
 1. Corporeal parenchymatous metritis. 
 
 2. Corporeal endo-metritis. 
 
 3. Cervical parenchymatous metritis. 
 
 4. Cervical endo-metritis. 
 
 Lastly. All inflammations may be acute or chronic, and although in all 
 cases there may exist the intermediate " subacute " forms, in none are the 
 boundary lines between acuteness and chronicity more practically dis- 
 tinct than in uterine inflammations. Hence we divide metritis, for the 
 purposes of description, into eight forms : — 
 
 a. Acute corporeal parenchymatovis metritis. 
 
 h. Chronic corporeal parenchymatous metritis. 
 
 c. Acute corporeal endo-metritis. 
 
ACUTE PAl{ENX'HY]\rATOUS METEITIS. 203 
 
 d. Chronic corporeal eudo-metritis. 
 
 e. Acute cervical parenchymatous metritis. 
 
 f. Chronic cervical parenchymatous metritis. 
 
 g. Acute cervical endo-metritis. 
 h. Chronic cervical endo-metritis. 
 
 Every one of these terms has a definite meaning, representing unmis- 
 takably a pathological state, and the very short period required to 
 familiarise himself with them will not be wasted by the student. When 
 the term "corporeal" is dropped, as it is by many writers, it must be 
 understood, unless a term pointing to the cervix is used ; and the 
 term " endo-cervicitis " is but a shortening of cervical endo-metritis. 
 We shall see that some of these terms, e.g., chronic cervical endo- 
 metritis, or acute corporeal parenchymatous metritis, describe aftections 
 met with almost entirely alone, while others are so frequently combined 
 as to be of less individual clinical importance. It will be well, therefore, 
 instead of attempting to describe the symptoms, signs, and treatment of 
 each of the eight forms of metritis, to try now to group them, as nearly 
 as possibly as they group themselves under clinical observation. In the 
 first place we will separate the acute from the chronic forms of uterine 
 inflammation, and I think it will be apparent that this is a useful and 
 practical division. 
 
 Acute Inflammation of the Uterus. 
 
 This may aff"ect the jDarenchymatous and mucous tissues, together or 
 separately,— much more commonly the mucous than the parenchymatous 
 tissues alone, — and may attack either the body or the cervix, or both. 
 
 Acute Parenchymatous Inflammation is, fortunately, not very com- 
 mon, and is nearly always traumatic or septic in its origin, although 
 occasionally met with as a result of cold or sudden suppression of men- 
 struation. Among the traumatic causes we may include the unfortunate 
 use of dilating or cutting instruments on the cervix, injurious intra-uterino 
 treatment, tearing of the cervix during labour, or septic absorption after 
 labour or after pelvic operation, in the various ways in which absor])tion 
 is possible. Proceeding from these causes, it is seldom quite uncompli- 
 cated. To some degree, either the mucous lining of the uterus (endo- 
 metritis), or its peritoneal covering (peri-mctritis), or the cellular tissue 
 of the pelvis (para-metritis) are generally involved at the same time, but 
 the purely uterine inflammation may be the marked and almost sole 
 fcatui'c of the case. 
 
 Symptoms. — Acute ])elvic symptoms, with high fevei", are present from 
 
204 TKEATMENT OF ACUTE 
 
 the first, and the pain and tenderness are almost completely localised. 
 They will be experienced even on slight pressure over the fundus uteri, 
 or upwards against the cervix, or especially on bi-manual pressure at both 
 ends of the uterus. The uterus, although it seems heavy, is not fixed, 
 as it speedily becomes, however, if there be much inflammation of the 
 surrounding structures, leading to the exiidation of lymph below, around, 
 or above the organ. A previous attack of this, of Avhich there should be 
 a distinct history, may, however, have fixed the uterus in any position. 
 AVhatever swelling there is will be evidently connected with the uterus, 
 and will have the contour of that organ, enlarged but not altered in 
 shape. Whenever there is abdominal tympanites, or when sickness is a 
 prominent symptom, the peritoneal covering of the uterus and its con- 
 tiguous parts is almost certainly involved. If the cervix is involved as 
 well as the body, the swelling and tenderness will be felt there also. 
 There will be little or no purulent discharge from the os externum, un- 
 less the mucous lining also participates in the inflammation. An 
 absolutely pure and uncomplicated acute metritis of this kind is 
 seldom met with, signs of pelvic inflammation being generally found 
 also if carefully sought for. While it continues it is always of grave 
 import. Evidences of general toxaemia are apt to present themselves 
 at any moment. If the afiection remain local it will probably sub- 
 side in a comparatively short time, either completely disappearing, or 
 leaving behind it a condition of chronic tenderness and pain. Sup- 
 puration may occur within the uterine walls, and this may be of a 
 multiple character, discovered, perhaps, only after death, as multiple 
 pysemic abscess ; or it may concentrate and burst into the cavity of 
 the organ, and ultimately end in recovery. But uterine abscess, fortun- 
 ately rare, is at all times a dangerous phenomenon, owing to the 
 numerous absorbent points Avhich are met Avith in the organ. 
 
 Treatment. — The treatment of uncomplicated, or only very partially 
 complicated, acute parenchymatous inflammation of the uterus resolves 
 itself into (a) the removal of any persistent cause ; (5) the relief of 
 prominent symptoms, especially pain ; and (c) the reduction of fever. 
 
 The removal of persistent causes must never be forgotten, especially 
 in puerperal cases. I take this opportunity of strongly reminding the 
 practitioner that septic poisoning has tAvo distinct clinical forms. In 
 the one, we have the absorption of a contagium vivum, of living germs, 
 which seem to grow and multiply after absorption, and whose deadly 
 work is for the present almost beyond the reach of art ; in the other we 
 have the toxic influence of fluids, probably also due to bacteric associa- 
 tions, but of which nature speedily gets rid if further absorption can be 
 prevented. The former demands internal remedies, yet I fear to be dis- 
 covered, which shall so influence the living germs within the system as 
 
PARENCHYMATOUS METEITIS. 205 
 
 to reduce them to innocuousness ; for these we look to the practical 
 results of the patient work of Koch, Pasteur, and other similar in- 
 vestigators. But I often wonder whether the benefit w^hich our fore- 
 fathers attributed to mercury in the treatment of acute inflammations 
 has any connection with the acknowledged germicide properties of 
 corrosive sublimate. Surely any feasible hint is worth following out in 
 this forlorn region of therapeutics. The second class of intoxicants 
 is met by the formula "wash and be clean." In every case of 
 metritis, therefore, where septic influences play a presumptive part, the 
 vagina should be frequently S3T:'inged in the most gentle yet careful 
 manner with warm water, carbolised or otherwise rendered antiseptic. 
 When this is ineffectual in speedily reducing the temperature, and other- 
 wise relieving the symptoms, a double catheter should be carefully in- 
 serted into the uterine cavity, and any products of decomposition thus 
 washed away. Of course, if any post-partum or other debris are percep- 
 tible to touch, and for this end the cervix may require dilatation, they 
 should be carefully removed by the finger or the curette. 
 
 The second indication, relief of pain, is of almost equal consequence. 
 In all visceral affections pain is apt to be one of the chief destroying 
 agents, and " to obviate the tendency to death " is the foremost object 
 of the physician. The subcutaneous injection of morphia is generally 
 the most satisfactory way of using opiates in this aff"ection, but morphia 
 suppositories, or even opium or morphia by the mouth, may be used ; 
 however opium is given, it should be given freely. When opium does 
 not agree, belladonna may be iised, in suppositories of gr. iii. of the ex- 
 tract, or a much larger quantity may be smeared on the abdomen. The 
 application of warmth also fulfils the condition of relieving pain. Hot 
 fomentations, medicated with laudanum, are useful for this purpose, 
 unless the weight of a good large linseed poultice can be borne ; and 
 the water which is injected into the vagina for antiseptic reasons, should 
 be as warm as it can comfortably be used. Unless there is too much 
 local suffering, the patient may, according to Emmet's method, have the 
 pelvis well raised, and brought towards the side of the bed, when a 
 continuous stream of hot water may be allowed to flow from a reservoir 
 raised above its level. 
 
 The third indication, the reduction of temperature, is chiefly of im- 
 portance in septic cases. For this purpose the use of hot applications 
 may be abandoned, and cold may be applied to the abdomen and even to 
 the extremities in ice-bags, or applied to the head by Thornton's ice-cap, 
 consisting of a long tube curled into the form of a cap, through Avhich 
 a stream of ice-cold water continuously runs. Quinine, in full doses (gr. 
 v. to X. or even xx.), has also a great reputation for its antipyretic quali- 
 ties, though I confess it has nearly always disappointed me. Salicine in 
 
206 ACUTE ENDO-METEITIS. 
 
 its various forms I have found more reliable, although its depressing 
 action must be watched. Fifteen grains of sodii salicylat. may be given 
 every few hours. Veratinim viride, TTl^iii. to v. of the tincture, fre- 
 quently, is much relied on by many American writers for the reduction 
 of the pulse, and, to some extent, of the temperature ; and tinct. aconiti, 
 H\_ii. to v., has a similar reputation here. My colleague, Dr Leech 
 warmly extols the use of Antipyrin, a compound introduced by KnoiT 
 of Erlangen, and now pretty widely used in Germany. Filehne finds 
 that " it eflfectually reduces febrile temperatures in doses of 30 grains, 
 rarely causing vomiting, and never other evils" {Ifedical Chronicle, 
 Oct. 1884, p. 51). Dr Leech is, however, evidently of the same 
 opinion as myself, that the reduction of temperature has been too 
 often taken for granted as involving the cure of the affection which 
 causes it. 
 
 In addition to these main indications, the boAvels should be kept quiet, 
 as will be done by the opiates, but the rectum should be gently emptied 
 by enema at the commencement, or afterwards if it become loaded with 
 scybala. Fluid nutriment must be given from the first, as the stomach 
 will bear it, and stimulants, when exhaustion is showing itself and the 
 temperatu.re is ranging high. Abdominal leeching in the commence- 
 ment, and free blistering of the abdomen when the acute stage is fairly 
 past, have each their strenuous advocates ; and it is sometimes almost 
 impossible to doubt the good effect of either, especially the foiTaer. 
 
 Acute Endo-metritis. — Acute inflammation of the mucous lining of 
 the uterus, with but little parenchymatous extension, may result from, 
 precisely the same septic, traumatic, or other causes as the parenchy- 
 matous form, which we have just been describing ; but the extension of 
 gonorrhoeal or non-specific acute vaginitis is also a frequent cause, and 
 especially the abuse of vaginal injections when purulent vaginitis is pre- 
 sent. Under these circumstances the body and the cervix are apt to be 
 both equally affected, although the chronic affection very frequently im- 
 plicates the latter without the former. There are the same symptoms of 
 heat and tenderness in the mucous as in the parenchymatous inflamma- 
 tion, but these are, at first at any rate, even more distinctly uterine, pre- 
 senting less resemblance to peritonitis. The cervix is acutely sensitive 
 to touch, and there will be found very early a flow of pus from its 
 cavity, mingled in very acute cases with bloody streaks. The intro- 
 duction of a sound, if attempted, which it should hardly ever be, is 
 productive of gi-eat pain, although the cervix is iisually patulous. This 
 affection is apt to be complicated, by and by, with extension backwards 
 to the Fallopian tubes or ovaries, and peritonitic symptoms thv;s be- 
 come developed, which may, in gonorrhoeal extension, prove rapidly 
 fatal. We have less to fear in these cases from general septicaemia 
 
CHRONIC METiilTIS. 207 
 
 than in parenchymatous inflammation, and more from local inflammator}- 
 extension. 
 
 The treatment, while the acute stage lasts, is not very different from 
 that of parenchymatous inflaunnation. The relief of pain, and the 
 reduction of fever by antipyretics, the latter less often an urgent 
 necessity, are conducted on the same principles ; but, bearing in mind 
 the dangers of further extension by contiguity or by the infective puru- 
 lent discharge, vaginal injections must be very carefully managed. A 
 strong stream must always be avoided ; the freest possible outflow must 
 be provided; the raised pelvis, with consequent backward pressure of 
 the injected fluid, is inadmissible, and intra-iiterine injection is to be 
 totally prohibited. It is only when the affection has become chronic 
 that intra-uterine applications of any kind, carefully prepared for by 
 dilatation of the cervix, can be considered as available means of 
 treatment. 
 
 In this brief, but I think sufficient, description of acute inflammation 
 of the uterus — of its two main components, parenchyma and mucous 
 membrane— we have been able to regard these structures apart, for 
 practical purposes, while admitting that their pathological aff"ections are 
 often to some extent merged and combined. 
 
 Chronic Inflammation" of the Uterus. 
 
 In describing chronic inflammation of most organs, one drifts into it, 
 as it were, from the acute stage, and undoubtedly many cases of chronic 
 metritis, or endo-metritis, are simply the after stages of clearly marked 
 acute attacks. But acute metritis of any kind is fortunately very rare 
 in comparison with the number of cases of chronic disease we meet with 
 in the body or cervix, parenchyma or mucous lining. If the chronic 
 stage does not originate de novo, at least we may say that its acute 
 forerunner is often evanescent or unnoted, and its localisation as a cer- 
 vical or a corporeal, a mucous or a parenchymatous, affection, is often 
 more distinct than in the acute form. Convenience for descriptive pur- 
 poses can alone decide in Avhich order we should speak of the four chronic 
 inflammatory lesions — cervical endo-metritis, corporeal endo-metritis, cor- 
 poreal jKirencki/niatous metritis, and cervical parenchymatous metritis. 
 
 Chronic Cervical Endo-metritis. — This is so common an aff"ection 
 that the gynaecologist might almost be pardoned for considering it as 
 normal, at any rate in the married woman. As a simple catarrhal 
 affection it is only second in frequency to vaginal catarrh or leu- 
 corrhcea, and if its discovery and local treatment were always an im- 
 
208 CHROXIC CEEVICAL EXDO-METEITIS. 
 
 perative necessity, a large proportion of oxir women "would have to be 
 life-long patients for so-called "ulceration of the womb." Very few 
 women, in hospital practice, do not, if examined, show some slight 
 sign of erosion of the os externum (see Frontisj)iece No. 2), with some 
 purulent or muco-purulent discharge from it. Ranging upwards from 
 this, there is every degree of the affection, up to that in which we find 
 the OS and cervix uteri torn, bloody, everted, bathed in puriilent dis- 
 charge, covered with abundant granulations, swollen, and often enlarged 
 by inflammatory hypertrophy of the parenchyma as Avell (Frontispiece 
 No. 5). It is advisable to regard the slighter forms of this affection 
 apart from the more severe, although there may be no precise boundary 
 line capable of accurate definition. 
 
 Symptoms. — In an ordinary case of cervical endo-metritis, such as is 
 of almost every day occurrence, the symptoms may be almost absolutely 
 nil, or there may be a considerable amount of lumbar pain, and general 
 malaise, accompanied by profuse leucorrhoeal discharge externally. If 
 menstruation is increased or otherwise disordered, this will generally be 
 due either to some amount of affection of the mucous membrane of the 
 body, or to inflammatory hypertrophy of the parenchymatous tissue, or 
 to an excessive amount of granular degeneration of the mucous mem- 
 brane of the cervix, the result of long-continued affection, or to some 
 other concomitant affection of the womb. It is very seldom that the 
 patient does not suffer from debility and angemia, from derangement of 
 her digestive system, and from general depression of nerve force. On 
 examination there may or may not be tenderness of the affected part, 
 but the speculum alone will fully reveal the diagnostic signs. These are 
 twofold, — 1st, the occun-ence of characteristic discharge from the os uteri, 
 and 2nd, the appearance of the miicous membrane itself, as far as it can 
 be seen. The discharge is in most cases tnily purulent, bathing the 
 Avhole surface around and within the os, or sometimes only oozing out in 
 drops. The purulent discharge is, however, often absent for a time, and 
 its place is taken by a clear, glairj^, tenacious fluid, exactly like unboiled 
 Avhite of egg, which is most difficult to Avipe away completely, requiring 
 several applications of the cotton-tipped probe, both dry and moistened 
 with glycerine. The appearance of the os itself will vary according to 
 the long or short continuance of the affection, and Avill often alter much 
 at short intervals, or owing to very trivial remedies. In few cases is 
 there not some redness, if it be only at the small orificial point, but the 
 membrane is nearly always puffy and swollen, and covered with fine 
 velvety granulations of a brightish red colour ; the opening is generally 
 freely patulous, and the granular condition extends inwards as far as can 
 be seen, and outwards over the vaginal portion of the cervix. This 
 characteristic erosion and granulation of the cervix, denuded of its 
 
CimONIC CERVICAL ENDO-METRITIS. 209 
 
 purulent covering, are the first objects usually shown to the student of 
 gynsecology, and soft as they are when not lying on a hypertrophied cervix, 
 they soon become familiar to the educated touch, without the aid of the 
 speculum. Bear in mind that they are in no sense ulcers, but simply 
 alterations of the mucous secreting surface. Not infrequently we find 
 that the special glands of the cervix, the glandulse Nabothi, assert their 
 existence by projecting from the raw surface, and if their contents 
 become puriform, we have an appearance much the same as in vaginal or 
 vulvar follicular inflammation ; this is especially true in those cases which 
 succeed to or occur during pregnancy, when the glands are hypertrophied 
 as a normal condition (Frontispiece, No. 3). The whole cervix may be con- 
 siderably swollen and enlai'ged from mucous tumefaction alone, but this 
 enlargement is increased indefinitely when there exists at the same time 
 chronic thickening of the parenchyma. The contour of the os and cervix 
 may be j)erfect; it will be in a nullipara who has had no surgical experi- 
 ences ; but in those who have borne children it is often, I had almost said 
 generally, fissured to some extent, and the erosion will extend into the 
 fissures (Frontispiece, No. 4). Such fissures are, however, frequently met 
 with in women who have no present cervical metritis, and with a perfectly 
 healthy covering of mucous membrane, but when they exist to a great 
 extent, especially if they are lateral, they cause much gaping of the os, 
 and undoubtedly they add to the difficulty of cure, and tend to promote or 
 perpetuate the chronic inflammatory condition. Their surgical treatment 
 has during the last few years become a subject of considerable discussion, 
 but, bearing in mind our desire to separate the consideration of metritis 
 from that of comjDlications which are not essential to it, we shall return 
 to that matter again, and we shall also consider a little more minutely 
 in the next chapter the varieties of these chronic local affections. 
 
 Treatment. — Taking the affection of chronic cervical endo-metritis in 
 its most common and only moderately severe form, how far can it be 
 made the subject of legitimate and successful treatment? The first 
 thing to bear in mind is that it is almost always an expression of con- 
 stitutional or general disorder, and this applies equally to those cases 
 where there is nothing more than a catarrhal discharge, and to those in 
 which the signs of more advanced jDathological changes are manifest, 
 ('hronic endo-cervicitis of the hospital out-patient room is almost incur- 
 able, for the simple reason that Ave cannot cure the underlying constitu- 
 tional state. To cure the disease we must, as in chronic vaginitis, first 
 cure the patient. To recapitulate all the steps which may, in individual 
 cases, be necessary, would be to write a treatise on hygiene. The food 
 must be made suitable to the patient's digestion, which must in t\u-n be 
 remedied when faulty. All the resources of the physician may be called 
 forth to combat impaired nutrition in its protean forms, and to restore 
 
 o 
 
210 THE TREATMENT OF 
 
 healthy innervation. In the next place we must ask ovirselves, Is the 
 cervical afifection a result of the disordered circulation due to uterine or 
 pelvic disease of another character — to flexions of the Literus, to pelvic 
 congestion of ovarian origin, or to old pelvic inflammatory mischief? 
 If so, these must be treated pari passu, or generally as antecedent to 
 successful removal of the cervical condition. Next we must see if there 
 is anything wrong with the sexual relations of the patient. Masturba- 
 tion is a difficult matter to approach. I believe it to be more rare in the 
 female than is often supposed, in spite of some very objectionable state- 
 ments and experiments which have recently appeared in our periodic 
 literature, and to which I prefer not to make more specific reference ; 
 bat there are cases in which it becomes the diity of the physician to 
 suspect, and to give such advice as his most delicate instincts will 
 suggest. Abuse of the marital functions can always be ascertained 
 through the husband. Too frequent child-bearing has but one sure 
 remedy. Frequently-repeated miscarriages are the bane .of female 
 married existence. Next, the possibility of upward extension of chronic 
 inflammation from the vagina must be borne in mind, and chronic 
 vaginitis must be treated in the usual way, especially if there is any 
 gonorrhoeal taint. All these things being borne in mind (and though to 
 the tyro they may seem interminable, yet to the practical physician 
 they for the most part fall in with his daily routine of observation and 
 instruction) what remains to be done of a local nature, and how far will 
 it conduce to successful removal of the affection ? I fear it is an 
 undoubted fact that much opprobrium has been cast upon medicine, and 
 especially upon its gynsecological department, by the ignorant practice 
 of long-continued local applications to the uterus, in the vain hope of 
 curing " ulcerations," which are no ulcerations at all, but merely the 
 evidence of a disordered mucous membrane, which in its turn is only an 
 evidence of other uterine disease, or of a system below par. To treat 
 cervical endo-metritis it is not enough to be able skilfully to intro- 
 duce a speculum, and to be furnished with a list of caustics, as long as 
 the patient's or practitioner's endurance. A complete knowledge of 
 uterine, ovarian, and pelvic disease is necessary, without which local 
 applications may often be continued ad infinitum with no results except 
 of the most fleeting nature, or, still worse, with results of a baneful 
 character. Yet it is but reasonable, and it is true, that while more 
 important means are being pursued to obviate the causes of cervical 
 catarrh or inflammation, some local treatment, at the same time, may 
 greatly expedite a permanent cure. What, then, are the juvantia et 
 losdentia to be used or avoided? Speaking of such ordinary cases as 
 have been described, I have no hesitation in placing in the latter class — 
 in the class of hurtful remedies — all powerful escharotics which have for 
 
CHRONIC CERVICAL ENDO-METRITIS. 211 
 
 their purpose, or effect, the destruction of the membrane itself, of its 
 mucous follicles, or of any other physiologically essential structure. 
 Nitric acid, fluid nitrate of mercury, glacial acetic acid, chromic acid, the 
 actual cautery, caustic potash, and other strong remedies of this kind, 
 must be utterly tabooed as wrong in principle and in practice. They 
 may for a time arrest the action of a suppurating surface, by utterly 
 destroying it, but they leave untouched the sources of disease, and, as 
 long as there is any mucous surface left, the unhealthy action will con- 
 tinually recommence. When all is destroyed we shall only have the 
 disease transferred to the deeper tissues, with every symptom, except 
 perhaps free suppuration, aggravated. Moreover, we shall almost cer- 
 tainly bring about a state of contraction of the passage which may lead 
 to much subsequent suffering from dysmenorrhoea or hsematometra. To 
 be of use, local remedies should be of such a character as will merely 
 modify disordered action, and should stop far short of destruction. A 
 list of such remedies need not be a long one ; we must trust to their 
 judicious and timely use rather than to their numbers. Such a list 
 would comprise — 
 
 1 . The use of cervical tents. 
 
 2. Scarification or incision. 
 
 3. Hot water. 
 
 4. Antiseptic and astringent vaginal injections. 
 
 5. Glycerine and giyceroles. 
 
 6. Other local alteratives ; carbolic acid ; iodine ; iodoform ; nitrate 
 
 of silver ; bismuth ; sulphate of zinc. 
 
 1. Tents. — The use of tents (fig. 29) is limited in endo-cervicitis, and 
 when the affection is even subacute it should be forbidden. When, 
 however, the red villous surface is thick, and when it is difficult oi- 
 impossible to apply remedies within the cervix, the introduction of a 
 small tent for a few hours (I prefer the sponge tents for this purpose) 
 will produce the requisite amount of dilatation, and its compressive 
 action will often be found to excite absorption to a considerable degree. 
 A clean, well-carbolised tent, not retained too long, will seldom do more 
 than this, but in irritable patients, or when there is any febrile action 
 present, or when there is any evidence, or even suspicion, of former 
 pelvic inflammation, the risk of other consequences should never be run. 
 
 2. Scarification or Incision of the os externum. This remedy is also 
 one requiring consideration before it is used. When the os uteri is con- 
 tracted, when dysmenoxThoea is present, and when there is considerable en 
 gorgement of the surrounding viscera, two or three incisions, \ in. deep, 
 dividing what may be termed the external sphincter, will often do good 
 by letting a little blood flow, and if prevented from healing by the occa- 
 sional insertion of the point of a bougie, the enlarged opening of the os 
 
212 THE TKEATMEXT OF 
 
 will be of use in the subsequent treatment. Frequent scarifications 
 are seldom, if ever, necessary, and are never without some risk, 
 however slight, from septic absorption. 
 
 3. Hot Water. — I have already so often referred to the value of 
 Emmet's treatment by hot-water injections (105° to 110°), with the 
 raised pelvis, as a means of diminishing pelvic congestion, that I need 
 only here state that the practice is also of not infrequent advantage in 
 cases of chronic cervical endo-metritis, as a means of combating the 
 symptoms of pelvic fulness and tension, which are sometimes a conse- 
 quence of the cervical affection, but more often a cause of its long per- 
 sistence. It may be used, night after night, for a week or two, imtil 
 the symptoms have abated, and it does not contra-indicate the use of 
 other remedies during the day. 
 
 4. Antiseptic and Astringent Vaginal Injections. — As a rule, mere astrin- 
 gent vaginal injections have little influence on endo-metritis. They do not 
 reach the whole of the affected part, and their use may even prove iiTita- 
 ting and hurtful. But, bearing in mind the frequency with which 
 catarrhal extension from the vagina to the cervix takes place, and also the 
 important part played by leucoc;}i:ic bodies in the propagation and causa- 
 tion of suppurative disease, it will be found that in many cases, where 
 chronic puinilent discharge is abundant, Avhether from the cervix itself or 
 from the vagina, copious antiseptic injections of carbolic acid, boracic acid, 
 or other substances mentioned in connection Avith vaginitis, exert a marked 
 and favourable influence on ordinary endo-cervicitis. They can be used 
 by the patient herself in the intervals between the physician's visits. 
 
 5. Glycerine and Glyceroles. — Glycerine exerts a remarkable local 
 influence on the uterus, not exactly specific, but dependent on its pro- 
 peity of extracting moisture from the uteiais and from the contiguous 
 parts, thus tending to diminish their bulk, and altering the action of 
 their secreting surfaces. It is therefore, in all cases of metritis, and 
 especially where the cervix is chiefly affected, a most valuable remedy. 
 Even when merely injected into the vagina (§i. ad. aquse sii.) it occa- 
 sionally produces beneficial effects, but to assure its full action it must be 
 used in the form of tampon, as directed above. Under this treatment, 
 continued for a week or two, or alternated nightly with the hot-water 
 treatment, many most unpromising cases speedily improve. The swelling 
 of the cervix diminishes, and the discharge, at first more abundant but 
 more watery, diminishes also, while tenderness and the feeling of weight 
 disappear. It is a veritable local alterative, and injures nothing. No 
 speculum is needed for its use. The patient herself can insei-t the plug 
 and push it steadily but gently home with the vaginal injection tube. 
 The glycerine plug may also be made the means of using astringent or 
 antiseptic substances, such as do not require to be accurately applied to 
 
CHRONIC CERVICAL ENDO-METRITIS. 213 
 
 the cervix, and the glyceroles of tannic and carbolic acid are especially 
 useful. They may be used in the proportion of about one-half to one- 
 fourth of the officinal strength. 
 
 6. Other Local Alteratives. — Very many substances have thus been 
 used, and highly recommended. I have pronounced strongly against 
 those which are too powerful or escharotic, on grounds Avhich I think 
 valid, except in cases of special severity, to be afterwards separately con- 
 sidered. The best local alterative I know is carbolic acid, used only of 
 sufficient strength. Pure carbolic acid ranks to a slight extent with the 
 destroyers of tissvie. But diluted two or three times with glycerine, and 
 applied to the affected surface only, it exerts a healthy alterative influ- 
 ence, while its sedative action on pain is not lost. My colleague, Dr 
 D. Lloyd Roberts, was one of the first to call attention to this beneficial 
 use of carbolic acid. Iodoform ranks perhaps next as a useful and 
 safe alterative, but its nauseous smell is somewhat against it. Mixed 
 with four or five parts of balsam of tolu or of oil of cassia, it is sufficiently 
 active, and its unpleasantness is much diminished. Iodine exerts its 
 alterative influence when applied locally to the cervix. It is strong 
 enough for this purpose in a solution of 20 grs. to the ounce of glycer- 
 ine, with a few drops of spirit, and I think that, as for most local 
 remedies, glycerine is the best solvent, the absorption being slower 
 and more cei-tain. All these remedies must be applied carefully and 
 accurately to the abraded and secreting surface of the os and cervix. 
 For this purpose the Playfair's probe (fig. 9) suffices, and the duck-bill 
 or bi-valve speculum will be necessary if there is much laceration. The 
 probe is slightly bent, so as to follow the cervical canal, then well coated 
 with cotton. The fluid is thoroughly soaked into it, and all redundant 
 fluid is wiped off. The outer circle of granulation is smeared with it, and 
 it is passed into the cervix as far as possible withont force. Such fluid 
 as tends to run down into the vagina is wiped away, or a dossil of cotton 
 moistened with glycerine may be placed at the upj^er end of the vagina, 
 with a thread attached by which the patient may remove it. Where 
 iodine is used, this plug is especially desirable, to avoid injury to the 
 patient's linen. With regard to all these applications, it must Ijc borne in 
 mind that they are only part of a system of treatiucnt, tliat their good 
 eftects will be observable after a very few applications, at intervals of 
 from three to seven days, if at all, and that the absence of visible results 
 should lead, not to perpetual and useless repetition, but to a renewed 
 search for other than local means of treatment. Nitrate of silver has 
 been much abused by being applied in stick, and Avith great frequency. 
 Used thus, it produces destructive effiscts, but applied only occasionally, 
 in moderately strong solution, say 15 grs. to the ounce, it sim])ly modi- 
 fies or alters the state of the parts, and is a iisei'ul addition to oui' 
 
214 CHEONIC CEEVICAL ENDO-METEITIS. 
 
 remedies of the kind. Sul2:)hate of zinc or copper is open to nearly the 
 same objection. In ordinary endo-metritis, the sticks of the solid salts, 
 intended to be inserted into and left in the cervix, become too escharotic. 
 There is no objection to these agents as stj^tics merely, in strong 
 solution, or lightly applied in the solid. In irritable states, when all 
 local applications or examinations seem to aggravate discomfort, and 
 increase the signs of disease, bismuth nitrate or carbonate, is often of 
 great value. It should be used as nearly as possible piu'e, in fact applied 
 to the raw surface in powder, by a pledget of dry cotton, or by insufflation. 
 The oleates of lead and zinc have, however, a similar soothing effect. 
 
 I have spoken of a graver type of chronic cervical endo-metritis, in which 
 the use of remedies, otherwise forbidden, may be necessitated (Frontis- 
 piece, No. 5). Such cases are characterised by the kind of granulations 
 met with, these being thick, sprouting, and vascular to a much greater 
 degree, unamenable to ordinary alteratives, and preventing any success 
 in creating again a healthy surface. The glandular tissue is largely de- 
 stroyed. Such cases are always complicated with parenchymatous inflam- 
 mation, and often with corporeal endo-metritis, and they are especially 
 common in connection with wide, gaping tears of the cervix. They are 
 generally, if not always, the sequel of neglected treatment, or of treat- 
 ment based from the first on the use of destructive local applications. 
 But now the destruction of fungating tissues becomes a necessity, in 
 the hope that nature will still supply some sort of reparative covering 
 of the parts, even if it be physiologically imperfect. In such cases, a 
 fair trial having been given to the remedies just described, especially to 
 the use of hot water, glycerine, and iodine or carbolic acid, something 
 more must be done to check the wasting discharges, purulent and often 
 sanguineous, to relieve continual pain, and to restore a passively 
 quiescent, if not absolutely healthy surface. The thick fungosities must 
 be completely destroyed, and, the necessity being recognised, no half 
 measures are advisable. The question of reuniting the torn edges of the 
 fissures which may exist will be discussed further on. To destroy the 
 unhealthy diseased surface, and to restore Avhat, by comparison, may be 
 termed a healthy one, two methods are at our disposal — the one by me- 
 chanically scraping and tearing them away, the other by destroying them 
 with escharotics. For the foi-mer purpose, the whole visible fungating 
 surface, when well exposed by the duck-bill speculum and adjuncts, maj- 
 be shaved with a sharp knife, just as is done preparatory to plastic stitch- 
 ing of torn portions ; indeed, it is very probable that much of the good 
 effect ensuing from some of the plastic operations referred to is the result 
 merely of the paring away of diseased tissues. A curette is commonly 
 used for the purpose. This instrument, originally invented or used for the 
 purpose by Recamier, has been previously described, and any of the modifi- 
 
CHEONIC CORPOREAL ENDO-METRITIS. 215 
 
 cations by Sims (tig. 58), Thomas, Simpson, or others, will serve for the 
 cervix. This is well exposed and fixed, and every portion of redundant 
 granulation is freely scraped away. Heemorrhage is then arrested by the 
 application to the whole surface of strong iodine solution (lin. iod.), or 
 of carbolic acid (1 in 5 or 6 parts). Only seldom is a plug required for 
 heemorrhage alone. The raw surface is subsequently treated as in ordinary 
 endo-metritis. 
 
 For chemical destruction of the redundant granulations any of the 
 strong escharotics may be used, but nitric acid is most frequently 
 employed in non-malignant disease. It requires the same free exposure 
 of the parts. Every portion must be freely touched, care being taken 
 to allow none to run down into the vagina, and it is a necessary precau- 
 tion to pack a pledget of cotton, well soaked in carbonate of soda or 
 potash solution, into the upper part of the vagina below the projecting 
 cervix. This receives and neutralises any overflowing drops. On the 
 whole the removal by curette or knife is the more satisfactory plan, but 
 the nitric acid may be used if a second or third operation be required. 
 
 Chronic Corporeal Endo-metritis. 
 
 We turn now to endo-metritis of the fundus or body of the uterus. 
 This is, fortunately, to any great extent, a much less common affection 
 than that of the cervix, although authorities differ as to their precise 
 relative frequency. It is clearly demonstrated by numerous post- 
 mortem observations that endo-metritis frequently terminates abruptly 
 at a boundary line corresponding with the os internum, the upper 
 or the lower portion, corporeal or cervical, being alone affected. 
 But there is considerable difference of opinion as to the frequency 
 of cases in which no such boundary line exists, where undoubted 
 and visible cervical endo-metritis is accompanied by that of the body 
 of the uterus. As the symptoms of the two affections scarcely differ, 
 except in degree, the question is frequently insoluble in individual cases, 
 and the presumptive evidence in favour of the combination can only be 
 found in the existence of enlargement of the uterine body, in the tender- 
 ness of the fundus which is felt on'thc introduction of the sound, — often 
 a highly characteristic feature of corpoi'eal endo-metritis existing alone, — 
 in the resistance of an apparent slight case to rational treatment, and 
 in the much greater liability, in the corporeal affection, to menstrual 
 ti'oul^les. It appears probable, however, that many cases of the corporeal 
 endo-metrial affection recover spontaneously when the accompanying 
 cervical affection is cured ; and this may or may not depend on the more 
 complete organic change which the corporeal niucouH membrane pcriodi- 
 
216 CAUSATIOX AXD TEEATMEXT OF 
 
 cally undergoes. Although WiUiams and others have taught us much 
 as to the very different anatomical relations which the corporeal mticous 
 membrane bears to its subjacent structures from those which are met 
 with in the case of the cervix, and although we know how different are 
 the physiological functions of the body and cervix, yet jDathology has, so 
 far, done little or nothing to elucidate differences of clinical importance 
 between the chi'onic inflammatory affections of the body and cervix, 
 beyond showing that chronic inflammation may afiect each separately 
 and solely, or in combination ; and it is not without consideration that 
 I have omitted much as yet quite unreliable information as to the patho- 
 logical bearings of the whole subject. 
 
 Causation. — In addition to the causes which lead to cervical endo- 
 metritis, obstruction to the menstrual flow, with consequent retention of its 
 products within the utems for a time, ranks as a not infrequent cause of 
 the corporeal disease. This may occur from cold, shock, exanthematous 
 fevers, or other causes of acute suppression, or from frequent retention 
 due to stenosis of the cervix, and accompanied by dysmenoiThoea ; and a 
 large proportion of this, as well as of all other forms of chi'onic inflam- 
 mation, is traceable to irregular convalescence after parturition, and still 
 more after abortion. In obstinate displacements of the utenis, either 
 flexions or prolapse, we frequently have accompanying corporeal endo- 
 metritis, greatly reheved by their reposition. The displacement or the 
 metritis may figiu-e as cause or effect of each other in turn. In the case 
 of pol}q)us or of sub-mucous fibroids also, the accompanying leucorrhoeal 
 discharge is not infrequently the result of an actual chi'onic inflamma- 
 tory state. The influence of the syphilitic cachexia in producing chronic 
 endo-metritis is not clearly determined. As in cervical endo-metritis, 
 there is frequently a predominant afiection of the glandular element of 
 the tissues, accompanied by vascular proliferation ; and there is the same 
 tendency, in neglected cases, to gradual destiniction of the glandular 
 structures, which is perpetuated in every new monthly rebuilding of the 
 lining wall. Sterility is the laile, as might be supposed, during the con- 
 tinuance of corporeal endo-metritis ; and when conception does occur, it 
 probably implies some return to the condition of health, which, if abor- 
 tion can be avoided, may prove permanent. I know cases, however, 
 where, in spite of all care, severe chronic endo-metritis and normal preg- 
 nancy have alternated for several years. 
 
 The treatment of chronic endo-metritis of the body of the utems is 
 conducted on the same principles as is that of the cervix, although the 
 circumstance of its comparative inaccessibility to local remedies throws 
 special difficulties in our way. All that has been said before as to the 
 supreme necessity for hygienic treatment, and as to the removal, if pos- 
 sible, of uterine displacements, and of aU causes of uterine engorgement 
 
CHRONIC CORPOKEAL ENDO-METRITIS. 217 
 
 or irritation, applies equally here. I am satisfied also that the same 
 distinction should be drawn between the use of the milder alterative local 
 applications and of the more destructive ones. It is as barbarous and 
 as unscientific hastily to apply strong destructive acids to the interior of 
 the uterus as to the cervix ; to the former it is even more hurtful, and I 
 cannot but think that curetting of the interior of the uterus has also, 
 of late years, been much over-done. The introduction of remedies into 
 the cavity of the uterus is not so light a matter as mere book descriptions 
 might lead many a tyro to suppose. None but gynaecologists are aware 
 how often its unskilful or unprepared-for employment leads to acute 
 or subacute attacks which leave matters worse than before. Turning 
 back to oux list of local remedies in cervical disease (p. 211), let us see 
 how, and how far, they are available in the corporeal affection. 
 
 1. The use of tents, and of scarification of the os externum, is occasion- 
 ally required for the same purposes as in cervical disease, but it is more 
 frequently a necessity in the corporeal affection, partly because this so 
 often depends on obstructive dysmenorrhoea, when dilatation in some 
 form may be considered as curative in itself, and partly because the 
 application of internal remedies to the uterus demands as a preliminary 
 that there should be a clear inlet for the introducing medium, and a 
 clear outlet for all superabundant fluids, and for all coagTila or albu- 
 minoid products to which the remedies may give rise. 
 
 2. The use othot water, in the same way, has the same great beneficial 
 effect as in cervical affections. 
 
 3. Vaginal injections, other than those of hot water, cannot in any 
 way directly affect the corporeal disease, but indirectly they may prove 
 useful as local tonics or as destroj-ers of leucocytic conveyers of disease, 
 the influence of which may extend in every conceivable direction, and is 
 not bounded by anatomical sphincters or even organic tissues, although 
 so competent an observer as Mr Wharton Jones is not yet satisfied on 
 this point {Lancet, Oct. 11, 1884, p. 6.30). 
 
 4. Glycerine, used as above directed, exerts an influence on every form 
 of uterine or pelvic engorgement, and should therefore not be forgotten 
 even in a case of the most clearly-defined endo-corporeal affection. 
 
 5. Loccd Alteratives} — I feel inclined to limit the number of local 
 alteratives as strictly as before, and, however numerous the suggested 
 i-emedies of the kind may be, personal conference with many dis- 
 tinguished specialists confirms me in the belief that these fulfil nearly 
 all the requisite indications. Carbolic acid, iodoform, iodine, and nitrate 
 of silver may be taken as at any rate the types of substances to be 
 
 ' I use this somewhat vague word " alterative" in all cases as meaning thatwliieli 
 influences beneficially the nutrition of parts, or of the whole system, as the case may 
 be, independently of any other very clearly definable action. 
 
218 METHODS OF APPLYING EEMEDIES 
 
 used ; and if they do not avail to produce the desired effects, I fear that 
 little can be hoped for from others of a similar kind. These four 
 remedies, or others that may be experimented with, may be used in the 
 following modes : ^ — 
 
 (A.) By Medicated Tents. — There are two ways in which the tent may 
 be made instrumental in introducing remedies into the uterus. By the 
 one method the substance intended to be used is mixed with gelatine, 
 gum, or cocoa butter, in such proportions as to obtain sufficient temporary 
 coherence to allow the mass to be rolled into a pencil and inserted 
 through the os internum, it being then left and allowed to melt. Unless 
 the OS be well dilated, something in the form of a special instrument is 
 required. If the mass is moderately firm and the os moderately dilated, 
 Barnes's instrument (fig. 31) may sufl&ce, but under other circumstances 
 the tent must be placed in a large truncated catheter with a well-fitting 
 stylet — a small piston tube, in fact — and so pushed through the os 
 internum. The other form of medicated tent is the ordinary sponge 
 instrument, impregnated at its first construction with the necessary 
 fluids or solutions. Alteratives or astringents can undoubtedly be thus 
 introduced, but however agreeable it may be to fulfil two indications 
 by one procedure, there is always the objection that the drug thus used 
 is retained for many hours, no matter what its effects. I think this 
 method is therefore inferior to others, except in the case of antiseptic 
 remedies, in reasonable quantities. 
 
 (B.) As Ointments. — Most remedies may be introduced in this form, 
 
 Fig. 106. — Ointment Syringe. 
 
 and in any requisite strength, and the purpose is thus fairly well served, 
 when a slow alterative action is required. The best excipient is vaseline, 
 
 ^ Giving, as I advisedly do, such a limited number of substances applicable for our 
 present purpose, I think it right nevertheless to mention the following list of medicinal 
 agents for intra-uterine application, taken from Dr P. Munde's work on Minor 
 Gynsecology : — 
 
 1. Caustics. — Mild : nitrate of silver, iodised phenol, carbolic acid, pyroligneous 
 acid. Strong : nitric acid, chromic acid, acid nitrate of mercury, bromine, chloride 
 of zinc, actual cai;tery. 
 
 2. Astringents and Sty2Mcs. — Sulphate of zinc or copper, alum, nitrate of silver, 
 tannin, persulphate or perchloride of iron, tincture of iodine, hydrastis, eucalyptus, 
 resin, pinus canadensis. 
 
 3. Alteratives. — Iodine, iodoform, iodised phenol, galvanic current. 
 
 4. Stimulants. — Carbolic acid, faradic current. 
 
 5. Narcotics. — Opium, belladonna, iodoform. 
 
 6. Disinfectants. — Carbolic and salicylic acid, thymol, permanganate of potash. 
 
 7. Oxytocic. — Ergot. 
 
TO THE INTEKIOK OF THE UTERUS, 219 
 
 and with one drachm of this may be incorporated carbolic acid, gr. i. ad 
 iii., iodoform gr. v., tannin gr. x., plumb, iodid. gr. v., zinci sulpho-carbo- 
 latis gr. v., or other similar agents. A syringe with a long vulcanite 
 nozzle (fig. 106) is suitable for this pu.rpose, if the ointment is semi- 
 fluid. 
 
 (C.) As Solid Substances. — Morsels of nitrate of silver, sulphate of 
 zinc, or other powerful agents, may be introduced into the uterus by 
 modifications of Lallemand's well-known porte-caustique, but the effect is 
 so uncertain, often so severe, and so incapable of being localised at the 
 desired points, that this method seems to me to possess no advantage 
 over others of a more certain character. I have no experience of insuffla- 
 tion of solid substances, such as iodoform in powder, into the uterus, 
 except in post partzim septicaemia, but if such powders seemed desirable, 
 I would prefer to introduce them adhering to an ordinary cotton-coated 
 Playfair's probe well smeared with vaseline. 
 
 (D.) As hijections. — Nothing is more easy than to introduce a small 
 vulcanite or metal nozzle into the uterus, and through it to inject the 
 smallest quantity of the most attenuated solution, of any desired sub- 
 stance, into the uterine cavity. Previous dilatation of the cervix and the 
 use of a double tube should, one would suppose, make absolutely sure 
 that, however the uterus may contract under the stimulus, there would 
 follow no forced entrance of any of the fluid into the narrow openings of 
 the Fallopian canals, no shock to the system from suddenly dilating the 
 uterus, and no peritonitis from either of these causes. Yet with all these 
 precautions, intra-uterine injections have often proved fatal from the 
 above causes, and in able hands. Certain as they are, therefore, to con- 
 vey the remedy to all parts of the surface, I look upon them with the 
 utmost suspicion, and would advise the young practitioner, at any rate, 
 to have nothing to do with them in endo-metritis. I need hardly say 
 that this condemnation in no way applies to the use of the full sized 
 double catheter, with well dilated os and cervix uteri, for copious intr.i- 
 uterine injections of hot or cold water, of antiseptic fluids, or of iron <ir 
 iodine solutions, in the atonic hzemorrhages or foetid retentions of 
 labour, abortion, or intra-uterine tumours. 
 
 (E.) By Fainting or Sivahbing the Uterine Mticotis Lining. — This is, 
 and will, I believe, continue to be the most available mode of applying 
 nearly all substances, alterative, astringent, antiseptic, or even corrosive, 
 to the interior of the uterus, in ordinary gynaecological practice. It 
 fulfils all the necessary conditions, applying the remedy in any required 
 strength to all parts of the endo-metrium, by means of common and 
 easily-managed apparatus. A well-made Playfair's probe, and some 
 good absorbent cotton-woul, and, most important of all, tlie acquired skill 
 of applying the one to the other in s\;fhcient l)ulk, are tlie sole rccjuisites. 
 
2-20 IXTEA-UTEKINE MEDICATION. 
 
 The cotton must be firmly twisted on to the applicator, so that there may 
 be no risk of its slipping off, and yet its outer layers must remain loose 
 enough to absorb fluid easily and freely, and all superabundant fluid 
 must be removed. The cervix must be sufficiently patulous to allow of 
 its passage, or miist be dilated by bougies or by tent. The probe, more 
 or less curved, is passed at once to the fundus uteri, and gently turned 
 round so as to sqiieeze out the fluid, and apply it to the whole surface. 
 Such applications of alterative substances may be made every three or 
 four days, the solutions used being of the same strength as those for the 
 cervix. 
 
 In very chronic cases, when the discharge of pus is excessive, where the 
 uterus is heavy, and the wearing back-pain is constant, and especially when 
 menorrhagia or metrorrhagia exist, it may be presumed that, as in obsti- 
 nate cervical disease, the surface has become covered with thick sprouting 
 granulations, necessitating the use of the curette or of strong acids. 
 With such presumed conditions, it is always advisable to dilate the 
 cervix fully, and to introduce the finger for the purpose of ascertaining 
 the facts positively. Curetting can then be performed while the cervix 
 is still patulous. It will be much more easy if the opening be wide, and 
 free vent will also be given for the debris. An examination of this 
 
 with the microscope 
 will set aside any pos- 
 sible doubt as to the 
 existence of malig- 
 nant fungus of the 
 
 FiG.lOZ.-Atthill'sIntra-utermeCammla. ^ body of the uterus. 
 
 The curette used 
 should be capable of being bent at will, yet strong enough in the handle 
 to admit the use of a little pressure. I prefer a thin blunt wire (fig. 
 58), to a cutting edge, for intra-uteriue work. The loop is passed to 
 the fundus and then methodically drawn downwards, scraping all 
 affected parts of the iiterine wall successively until they give the impres- 
 sion of being quite smooth. The cotton-wrapped probe must then be 
 introduced, medicated with moderately strong carbolic or iodine solu- 
 tion, for the purpose of applying these substances to the raw surface, of 
 preventing septicity, and of promoting expulsion of all debris. As a 
 rule the uterus contracts freely, and aids in the latter object. 
 
 If escharotics are preferred, the instrument of Atthill (fig. 107) is 
 of great value. It is a kind of intra-uterine speculum, thi-ough which 
 the probe, glass rod, or wooden skewer, bearing nitric acid, can be safely 
 introduced into the uterine cavity. In severe chronic cases, such as 
 described, but in these alone, its use is often followed by speedy im- 
 provement. The necessity for a sufficient amount of previous cervical 
 
CHKOXIC COEPOKEAL METRITIS. 221 
 
 dilatation is obvious. Chromic acid or bromine may be used in a similar 
 way. In the preference which I have thus shown for, and in the con- 
 fidence which I have endeavoured to inculcate in, mild alterative local 
 treatment of endo-metritis in contra-distinction to the more heroic, though, 
 perhaps in some cases, ultimately necessary means, I am aware that I 
 differ from many whose opinion I deeply respect. It is one of those points, 
 however, in treating of which I should be unfaithful to my task if I did 
 not insist on the results of my own experience. I take it for granted 
 that the milder remedies suggested are faithfully used and not merely 
 played with, and that the use of the stronger remedies is to be con- 
 sidered as justified by the fair trial of the milder, and not as a con- 
 fession of previous error. 
 
 Chronic Corporeal Parenchymatous Inflammation. 
 
 The whole pathology of this subject is very obscure, for although we 
 ixndoubtedly encounter acute metritis of the uterine parenchyma, the 
 changes which are met with in the chronic form are, unless in the very rare 
 instances of chronic abscess, not so evidently of inflammatory origin. 
 They are of the nature of a hypertrophy of the connective tissue of the 
 organ, as apart from its muscular elements, and it would be difficult to 
 say how they differ from Avhat we shall afterwai'ds meet with in sub- 
 involution of the uterus. It must be borne in mind, however, that the 
 ultimate tendency of inflammation in most structures is towards connec- 
 tive tissue accumulation, as we see, for instance, in the so-called fibroid 
 or cirrhotic degeneration of other organs. Clinically we do have a chronic- 
 ally hypertrophied condition of the uterine tissue, sometimes evidenth- 
 commencing as acute inflammation, although more often not clearlj- trace- 
 able to this. It is moreover often associated with endo-metritis, although 
 not infrequently free from such association. Leaving the further eluci- 
 dation of its intimate nature to the pathologist, we shall treat of it as a 
 clinical phenomenon and by f;xr too common a one. The student should 
 be familiar Avith the term "areolar hyperplasia," which many writers, 
 following Thomas, use to describe the hypertrophic state characteristic 
 of the disease. 
 
 The causation is to be found, in the majority of cases, in something- 
 interfering with recovery from labour or abortion. Thus a state of 
 acute or sub-acute post partum inflammation may eventuate in the 
 chronic condition. Endo-metritis may, by extension, or by mere irrita- 
 tion and hyperaemic tendency, lead to the parenchymatous enlargement. 
 Subinvolution, if the two things be not pathologically almost one, may 
 ultimately lead to, or be inseparable from, chronic metritis, and it is just 
 at the time of involution that changes in the uterine connective tissue 
 
222 THE NATUEE AND TREATMENT 
 
 are most liable to occur, sometimes by absorption, sometimes by deposit. 
 Retention of post-partum products, lacerations of the cervix, and the 
 habit of miscarriage, all tend to irritation and hypersemia, and may all 
 aid in producing chronic metritis. The same may be said of the pelvic 
 inflammations or congestions so rife in morbid recovery from labour or 
 miscarriage. These exciting pelvic causes exist, although less frequently, 
 in the non-puerpera. The absolute neglect of endo-metritis, or its too 
 early treatment by heroic remedies, may equally be credited with an 
 occasional share in the etiology of the parenchymatous disease. Uterine 
 displacements, especially flexions or prolapse, are most commonly asso- 
 ciated with parenchj^matous inflammation or hyperplasia, but they are 
 eff'ects of the disease quite as often as causes. The weight of the hyper- 
 trophy causes the displacement, but the displacement interferes with 
 the circulation, and may cause or aggravate the chronic enlargement. 
 
 Symptoms. — I cannot say that, as regards symptomatology, I can name 
 any well-marked symptom which distinguishes the parenchymatous from 
 the mucous disease. The symptoms of pressure on the rectum, or bladder, 
 or blood-vessels, are more frequent in the former, but as often as not 
 these are due mainly to resulting displacements. Increased size of the 
 uterus, minus free purulent discharge, may be said to be the difierenti- 
 ating sign, as also the greater tendency to menorrhagia or slight 
 metrorrhagia which is found in the parenchymatous affection, except 
 when the endo-metritis is complicated with free granulations. 
 
 Diagnosis. — Owing to the enlai'gement of the body of the uterus, which is 
 the main feature of chronic parenchymatous metritis, there is a possibility 
 of mistakes in diagnosis, especially in those cases where the function of men- 
 Htruation is in abeyance, or, as is much more commonly the case, excessive 
 or irregular. The uterus may be thus moderately enlarged in early preg- 
 nacy, or when it is the subject of fibroid tumour, or polypus, or fundal 
 cancer ; and pelvic exudations of lymph or solidified blood (perimetritis or 
 heematocele), may simulate or accompany the enlargement of chronic 
 metritis. The possibility of pregnancy simulating or coexisting with 
 chronic metritis must never be forgotten, and until this can be set 
 aside, the use of the sound is, of course, forbidden. In early pregnancy 
 it will seldom happen that some of its characteristic symptoms and 
 signs are not present, sufiiciently to make us at least suspend judgment 
 for a time. The suspension of menstruation for one or more periods is, 
 per se, prohibitory of the use of the sound, imtil time has been allowed to 
 ascertain whether enlargement goes on at the normal rate. The state 
 of the cervix characterising pregnancy, its softening, and apparent 
 shortening, are apt to be doubtfully in evidence during its earliest 
 months, and are often obscured by pre-existing cervical metritis. But 
 a careful bi-manual examination will reveal sufficient of the anteversion 
 
OF PAKENCHYMATOUS CORPOREAL METRITIS. 223 
 
 and anterior vaginal roof-stretching which exist in pregnancy, and will 
 .show that, instead of an equally enlarged and tender uterus, as in 
 metritis, we have one which is broader antero-posteriorly, which can be 
 felt clearly in the anterior vaginal fornix, which can also be felt^j^er rectum 
 as a comparatively soft bulging mass, and which is much less clear in out- 
 line to the fingers pressing downwards from the hypogastrium, than the 
 solid thickening of metritis. It must be borne carefully in mind that some 
 of the less certain symptoms of pregnancy— enlargement of the mammse, 
 and even darkening of the areolee, nausea and vomiting, and signs of 
 pelvic pressure on vessels or nerves— may all exist in chronic metritis. 
 
 A small fibroid or other growth of the uterus may for a time be mis- 
 taken for chronic metritis, but if the history of the case be carefully 
 studied, and, pregnancy being set aside, if the sound be used to ascertain 
 the character and contents of the uterine cavity, and if the sj^ptoms of 
 fibroid disease, afterwards to be described, be carefully borne in mind, 
 mistake can only be temporary. The enlargement of metritis preserves 
 the normal contour of the uterus. It never flattens out and expands 
 the cervix uteri as we shall see that polypus or fibroid often does, and 
 lisemorrhage of a metrorrhagic rather than a menorrhagic character is 
 much more common in the case of uterine tumour. The presence of 
 peri-uterine exudations is most clearly ascertained by the history of 
 previous inflammation, with high temperatures, and by the fact that 
 the uterus is firmly fixed in its place, while not infrequently that place is 
 an abnormal one (see Chap. XIX.). 
 
 The treatment of parenchymatous inflammation of the body will 
 frequently require, and for similar reasons, the use of some of those 
 remedies which we have already mentioned in connection with endo- 
 metritis. If endo-metritis itself be present in any degree it will meet 
 with our earliest attention, as being very frequently the forerunner 
 and the exciting and continuing cause of the parenchymatous affec- 
 tion. But, independently of this, there are certain remedial measures 
 in common. Thus, the frequent use of the glycerine plug and the 
 hot- water injection are eqiuxlly valuable here as in endo-metritis. Biit 
 there are remedies which act much more specially on the hyper- 
 trophied condition of parenchymatous disease. Few cases of long con- 
 tinuance are not benefited by, and many can hardly be benefited with- 
 out, the use of ahsorhent drugs. Among these, iodine in the shape of 
 iodide of potassium, or occasionally iodide of iron, holds the foremost 
 place. At any time, if it will agree with the stomach, this remedy may be 
 followed by fiiirly evident results ; but the more closely the affection 
 is connected wdth the post-puerperal period, the more likely is it to 
 prove beneficial. I think it has, of late years, been too much neglected 
 in favour of the less cff'ectual absorl^ents, the bromides ; but a combina- 
 
224 THE TEEATMEXT OF CORPOREAL METRITIS, 
 
 tion of the two is often desirable, especially when there is hsemorrhage 
 and reason to suppose that this is partly due to ovarian complication. 
 The famous waters of Kreuznach owe their reputation to a belief in the 
 action of their iodine and bromine constituents. So will it be, I believe, 
 with Woodhall in Lincolnshire when further developed as a spa. Other 
 waters, by their alkaline or tonic properties, may be beneficial in 
 vaginitis and endo-metritis, but these two are almost unique in their 
 action as absorbents. I have a firm belief also in the action of mercury, 
 judiciously used, in cases of old-standing metritis. Very small dose's 
 (gr. J- and less) of the bichloride, given with quinine or other tonics, 
 will produce remarkable softening and lessening in many cases which 
 cannot be traced to syphilitic origin. Attempts have been made to pro- 
 duce absorbent action by the introduction of iodine into the cavity of 
 the uterus. In the absence of distinct endo-metritis, I would strongly 
 advise abstinence from what will probably only succeed in setting it up. 
 Another most important indication is to diminish the local congestion, 
 which plays so important a part in keeping up all the discomforts of 
 metritis, and which, if not the cause of it, at any rate prevents the 
 curative action of remedies. Emmet is so well aware of this prominent 
 and ruling phenomenon, that all he has to say about metritis in his 
 valuable work on gynsecology is, " see Congestive Hypertrophy." 
 
 The diminution of local congestion is brought about by the glycerine 
 or hot water plans of treatment already referred to, and these are 
 aided by the occasional use of saline or other not over strong aperients. 
 Frequent recourse to the recumbent position, with the pelvis raised, will 
 assist in this, and very important indications in this direction are secured 
 by treatment of a mechanical nature. The correct treatment, by appro- 
 priate pessaries, of flexions, or versions, or prolapse of the uterus, when 
 they are found to coexist, as cause or effect, wnth chronic metritis, is the 
 foremost of these indications. I advise the young practitioner not to be 
 too anxious to ascertain, as it is often impossible to do, whether displace- 
 ments are due to inflammatory hypertrophy, or inflammatory hypertrophy 
 is due to displacement, before he sets to work to remedy both. The great 
 point is to use the least irritating form of uterine support at first, and 
 to watch its effects most carefully until assured that it relieves, or at least 
 does not aggravate, pain and discomfort. The means to achieve this 
 end are treated of in Chapter XII. But even if there be no version or 
 flexion of the uterus, and no very evident tendency to prolapse, it will 
 be found that many, or most cases, are benefited by a certain amount of 
 artificial raising of the uterus, or by the prevention of downward pres- 
 sure. The exact level at which relief is found can only be ascertained 
 by experience in the individual case, but certainly it is a fact that a 
 uterus lifted up too high by a mechanical support will develop painful 
 
BY RAISING THE UTERUS. 
 
 225 
 
 symptoms very similar to one which is dragging uiDon its supports. The 
 clothing of Englishwomen is, for the most part, so constituted as to press 
 downwards the abdominal and pelvic viscera. The use of braces in some 
 form or of a " petticoat bodice " without circular tapes is therefore indi- 
 cated here. Elastic abdominal bandages are much in vogue for the 
 purpose of diminishing downward pressure on the pelvis. The majority 
 of those sold in the shops simply increase it by compressing the abdo- 
 men. To be of any use they must be curved in front, 
 so as to lift up the abdominal contents by getting 
 below them. Mere chronic inflammatory enlargement 
 of the uterus seldom raises the organ sufficiently out 
 of the pelvis to enable the belt to affect it otherwise 
 than in a downward direction; and its use should, 
 therefore, in this affection, be confined to very stout 
 women with pendulous abdomen, or to those cases 
 where the heavy uterus seems to press much forwards 
 upon the bladder and symphysis pubes. Some form 
 of pessary will generally be found useful, for a time 
 at least. The Hodge or lever pessary (fig. 165), 
 the most valuable of all for backward or even downwards displace- 
 ments of the uterus, is available here if accurately fitted, and if the con- 
 gestion and tenderness of neighbouring parts will bear its pressure. 
 But in uncomplicated chronic corporeal metritis, — uncomplicated, that 
 is, by flexion or version of the uterus, — a soft watch-spring elastic 
 pessary (fig. 108) will generally answer the purpose best ; its size will 
 determine the height at which it will fix the uterine descent, and must 
 be altered until found effective 
 in the prevention of discomfort. 
 When the cervix is also affected 
 it will prolapse through the ring 
 of the pessary, and may become 
 more swollen, and even be 
 strangled thereby. In such cases 
 the perforated diaphragm (fig. 
 109) is a necessary adjunct to 
 the ring. The chief reqiiisito in 
 either case is to see that the upper or posterior rim of the pessary is 
 introduced behind the cervix uteri; it may be left in other ways to find 
 its own level. 
 
 Other remedies than those calculated directly to promote absorption 
 or to diminish congestion are available, although probably it is largely 
 by their indirect influence in the same way that they act beneficially. 
 
 Scarification oj the cervix^ leeches being inconvenient in many Avays^ is 
 
 Fig. 109.— Watch-spring Ring Pessary, with 
 perforated India-rubber Diapliragra. 
 
226 THE TEEATMEXT OF COEPOEEAL METEITIS. 
 
 strongly recommended by many as tending, when frequently employed, 
 to diminish, hypereemia of the whole organ. It is difficult to see how it 
 can be of use in those cases where, above all things, a healthy state of 
 nutrition is required, but in subacute exacerbations it may occasionally 
 be used with advantage. If any distinctly enlarged cervical follicles are 
 visible, the scarificator should take them in its coui-se. I have no 
 experience of scarification of the body of the uterus itself, except by the 
 cui'ette in endo-metritis. 
 
 Ergot, by its specific action on the uterus, tends to develop the force, 
 and bring into play the action of its muscular element. It thus exerts 
 a sort of astringent action on the parenchyma, which is of special value 
 when this chi'onic condition is accompanied by passive haemorrhage, 
 either at or between the normal periods. The mere hardening of the 
 tissues thus jDroduced should be beneficial also by expelling any serous 
 infiltration accompanying passive congestion; and, although this may be 
 very theoretical, is it not possible that the bracing of the muscular tissue 
 may aid by its pressure in promoting absoi'ption of undue connective 
 tissue deposit ? Twenty or thirty drops of the liquid extract may be 
 given three or four times a day for lengthened periods, and the dose in- 
 creased whenever menstruation is excessive or inter-menstinial haemorrhage 
 is present. In a few cases the feeling of contraction is felt so painfully 
 that it is desirable to withdraw or diminish this remedy; either a special 
 idiosyncracy of the patient, or the presence of sub-acute inflammation in 
 some part of the uterus may account for this painful action. 
 
 Counter-irritation has occasionally a beneficial effect on the symptoms 
 of corporeal metritis, though more frequently any such effect is doubtful 
 or evanescent. Iodine freely painted on the lower part of the abdomen, 
 small blisters to the groins, and similar procedures too often only serve 
 to amuse or occupy the patient, but in tedious and painful cases their 
 use is permissible if we are content with small results. 
 
 Sedatives are hardly ever advisable, in the form of opium exhibited by 
 the mouth, in so chronic an ailment, but when the patient is more than 
 usually distressed, a sujDiDository or pessary of morphia (gr. \) and ext. 
 belladonna (gr. ii.) is the best Avay in which relief can be afforded. 
 
 "VNTien disease of the cervix accompanies that of the body, the local 
 treatment of the former may largely influence the latter. Thus iodine 
 or other remedies applied to the cervix may act as absorbents on the 
 whole organ, and the amputation of redmidant portions of the diseased 
 cervix has often been followed by absorption of excessive corporeal hyper- 
 trophy. I am not prepared, however, to recommend, as has been done, 
 the removal of portions of a healthy cervix, in the hope that absorption 
 will follow in the diseased body of the uterus. In this affection, as in 
 all other chronic local disease, the promotion of a healthy state of 
 
CHKONIC CERVICAL PAEENCHYMATOUS METRITIS. 227 
 
 system is a sine qua non. The patient should have as much open-air 
 exercise as possible without bodily fatigue. Exercise must be very 
 carefully prescribed, and every renewal of discomfort (real, not imagin- 
 ary) must be the signal for a revised order on the subject. A sea 
 voyage, when it can be carried out with the comforts of a floating hotel, 
 is often most beneficial. The use of tonic bathing, either in the sea or 
 in the brine baths of Pyi-mont, Kissingen, or Droitwich, has often seemed 
 to me a most efficient adjunct to the other hygienic means of treatment 
 in purely chronic cases, and the judicious use, under proper medical 
 sanction, of the tepid douche, the sitz-bath, and other hydrotherapeutic 
 appliances, is not Avithout value in similar cases. Physiological rest of 
 the uterus, as far as sexual relation is concerned, should be advised in 
 all cases requiring treatment. The Weir Mitchell system is occasionally 
 of use in old cases of metritis, but its influence is so general, rather than 
 local, and it bears so much more on conditions of nervous or mental 
 depression, that I have thought it advisable to speak of it separately 
 elsewhere (see Chap. IV.). Some further observations on the treatment 
 of this aff"ection will be found at p. 253. 
 
 Chronic Cervical Parenchymatons Metritis. 
 
 Pathologically this must be viewed in a similar light to the analogous 
 affection of the body. Commencing as a more or less acute form of 
 inflammation, and creeping imperceptibly onwards, it tends to hyper- 
 trophy of fibrous or connective tissue, and leads to enlargement of the 
 organ, either retaining its ordinary shape or altering it by attacking one 
 portion more than another. At its commencement it is nearly alwaj's 
 associated Avith inflammatory affection of the body, or with endo-mctritis 
 of the cervix. Most frequently the latter state continues with it, and 
 we have Ijoth thickening and hardening of the parenchyma, and abrasion 
 and suppuration of the mucous membrane, but occasionally the state of 
 hypertrophy or "areolar hyjierplasia" of the cervix remains alone to be 
 ilealt with. 
 
 SymjHoms and Diagnosis. — When at all excessive, it produces the 
 usual discomforts of chi'onic uterine disease already described. A digital 
 examination will reveal the altered shape and size of the cervix, the os 
 being nearly always patulous, and the only affection for which it is 
 likely to be mistaken is the indxii-ation of malignant disease. The chief 
 points of difference — they will be again refen-ed to — are the free mobility 
 of the uterus, whicli remains in metritis, although it may be limited by 
 coexisting pelvic inflammation, but which is early lost in cancer ; the 
 more intense hardness of cancer, which seems to involve tlie mucous cover- 
 
228 CHEONIC CEEVICAL PAEENCHYMATOUS METEITIS. 
 
 ing as well; the frequent presence of the ordinary appearances of cervical 
 endo-metritis along with the hypertrophic thickening of the parenchyma, 
 or on the contrary the deep indtirated ulcer of cancer; and the much greater 
 tendency in the latter affection to severe pain and haemorrhage, though 
 these are often wanting, especially the pain, till a late stage. In the 
 early stages of some forms of cancerous disease, when the kind of indur- 
 ation is our only test, the most perfect tactus eruditus may be occasion- 
 ally deceived for a time, but a careful watching of the case and its 
 progress will soon remove the difficulty, and if in a doubtful case the 
 induration is removable by amputation, this will at once afford the best 
 chance to the patient, and furnish the means of microscopical diagnosis. 
 Treatment. — The judicious treatment of accompanying endo-metritis, 
 the use of absorbents, medicinal and local, as just directed, and the sup- 
 port of the uterus so as to diminish its tendency to congestion, furnish 
 our means of treatment in ordinary cases. But the enlargement of the 
 cervix is sometimes so great, so distressing by pressure downwards, or by 
 tending to produce prolapse of the whole organ, that special surgical 
 means of relief are not infrequently called for. Instead of mentioning 
 these immediately, I propose, in accordance with our plan, to dismiss 
 now the subject of inflammation of the uterus as such, and to deal with 
 uterine conditions which may be considered as accompaniments or 
 results. This will lead us to speak next of certain chronic affections of 
 the cervix uteri. A certain amount of repetition will be unavoidable. 
 
ULCERATIONS (?) OE ABRASIONS OF THE CERVIX. 229 
 
 CHAPTER IX. 
 
 Diseases of the Utekus — contimced. Ulcerations and Abrasions, Hypertrophy, 
 and Lacerations of the Cervix Uteri. Clironic Hypertrophy and Subinvolution 
 of the Body or Cervix. 
 
 In this chapter we shall require constantly to refer to the previous one for 
 the explanation of the origin of many or most of the abnormal conditions 
 described, yet some of the affections to be mentioned may be independent 
 of any recognisable inflammatory origin. With an eye solely to clinical 
 usefulness, we shall now discuss them from the standpoint of local 
 troubles chiefly amenable to local treatment, surgical or otherwise. 
 
 Ulcerations (?) or Abrasions of the Cervix Uteri 
 
 {Non-malignant). 
 
 As soon as the speculum was introduced into practice, it became evident 
 that the mucous lining and covering of the cervix uteri were liable to 
 changes which were most striking to the eye, and which were so easily seen 
 by any one endowed with a very moderate amount of skill, that undoubt- 
 edly an epidemic of "ulcer of the womb," with its special treatment, 
 set in, and I fear it can hardly be said to have yet subsided. The idea 
 of ulceration, i.e., destruction of tissue, has held its ground along with, 
 and is no doubt partly due to, the unfortunate nomenclature first given. 
 Pathologists are, I think, now almost entirely agreed that the majority 
 of these red, often tender and bleeding, though frequently symptomless, 
 "ulcers," are simply the evidences of hyperaimia, with perhaps slight 
 exfoliation of the outer epithelial cells, due to chronic congestion or 
 inflammation of the uterine mucous membrane; to this, the simplest 
 form (Frontispiece, No. 2), the term abrasion or erosion is applicable. 
 In some cases the redness is simply due to the fact that the columnar 
 epithelium of the deeper parts of the cervix has grown down into the 
 place of the squamovis form, which is found near the os externum, and 
 that its unwonted situation and hyperajmic accompaniments give to the 
 surface an appearance of erosion. In a more advanced stage there is con- 
 sideralDly greater thickening and apparent i-awiess of the part, duo to 
 
230 VAPJOUS FOEMS OF CERVICAL 
 
 granulations, such as are seen on other mucous surfaces, and evidently due 
 also to the presence of numerous villi. By many these villi are still sup- 
 posed to be enlargements of the normal subjacent papillae, denuded of 
 their epithelial covering, but the most recent investigations tend to show 
 that they are mere formations on the surface, and that they are still 
 covered with epithelium (Galabin, Ohst. Trans., vol. xsii. p. 156). In 
 no sense, therefore, are they ulcers, but simply unhealthy sproutings. 
 It is this form which we have described in the last chapter as the 
 granular state of the cervix (Frontispiece, No. 4). In all these mani- 
 festations of chronic endo-metritis we have shown that the essentials of 
 treatment consist mainly in attention to constitutional states of the 
 body, in prevention of pelvic congestion, in the application of mild altera- 
 tive local remedies as occasional adjuvants, and, in a few cases, in the 
 application of powerful escharotics, or destruction of the surface by the 
 knife or curette. When the ducts of the subjacent glands become 
 obliterated, we have small cysts formed, which by their prominence give 
 
 rise to little projections, often white 
 and purulent — the so-called folli- 
 cular form of erosion or granulation 
 (Frontispiece, No. 3). The nature of 
 the affection is the same, although 
 its appearance is thus somewhat 
 altered, but the occluded glands 
 add to the irritation and chronicity, 
 
 Fig. 110. — Fibsuied Ceivix, with Gi'anular , i t j i i 
 
 Mucous Membrane (Schrceder). '^^^^ recovery may be hastened by 
 
 scarifying at least the more promi- 
 nent of them. Where the os uteri is sodden and patulous, from the con- 
 tinual pu.rulent discharges of endo-metritis, and still more in cases where 
 tearing (fig. 110), especially bilateral tearing, of the cervix exists, eversion 
 of the inflamed os uteri takes place, and we have ectropion to a greater or 
 less degree (Frontispiece, Nos. 4, 6). This condition, when covering a 
 parenchyma also the subject of chronic inflammation or induration 
 (Frontispiece, No. 5), adds materially to the difiiculty of cure, and, as 
 we shall see jiist now, may demand surgical measures for its treatment. 
 When an erosion or granvilar inflammation has passed away, there is 
 often, though not always, a certain amount of bluish discoloration left 
 for a considerable time, but unless there has been something more than 
 this, or unless powerful escharotics have been used, the surface does 
 not exhibit a cicatricial appearance. The student should bear in mind 
 that a considerable erosion or even ectropion may be hidden by the 
 tubular speculum pressing together the sides of the cervix, so that if 
 this be used for local applications, it is well occasionally to employ n 
 duck-bill with its necessary accompaniments, or an expanding speculum. 
 
EROSION, GRANULATION, AND ULCERATION. 
 
 231 
 
 such as Cusco's or Reid's. lu ninety-nine out of every hundred case^i 
 of " ulceration " of the cex'vix, the above are the conditions met with. 
 
 It cannot be denied, however, that although this is the true nature 
 of these affections, occasionally we may have, from friction, or from over- 
 causticing, or even as a mere result of inflammation, spots of true 
 ulceration, not very dissimilar in appearance, but resisting treatment 
 longer and causing some cicatricial contraction. 
 
 I have already spoken of the possibility of confounding these erosions 
 and granulations, when situated on a hardened base, with the early stages 
 of cancer. The deep ragged ulcer of cancer, with its hard edges and 
 foul discharge, should never be mistaken when fairly developed, but it 
 is the incipient induration of cancer, without or with only the slightest 
 commencement of ulceration, and before the uterus is fixed by infiltra- 
 tion, that may 
 sometimes be a 
 cause of anxious 
 doubt, and which 
 should then al- 
 most always lead 
 to surgical treat- 
 ment, as if the 
 more serious affec- 
 tion were present. 
 True chancrous 
 ulcers are seldom 
 found on the sur- 
 face of the cervix, 
 and their diag- 
 nosis is most diffi- 
 cult in the ab- 
 sence of information as to the cause. The edges are sharp and 
 precipitous and their surfaces deep, quite unlike erosion, but not 
 so unlike some forms of cancer. There is one form of true ulcera- 
 tion also to which the cervix uteri, in common with the surroundine: 
 vagina, is liable, viz., that which takes place in prolapse of the 
 uterus when it appears externally. It is then exposed to the 
 external atmosphere, to constant irritating Icucorrhoca, and to fric- 
 tion against the limbs or clothing, while from its very position it is 
 in a state of constant passive congestion. Every beginner will soon 
 become familiar in hospital practice with this form of ulceration (fig. 111). 
 It is usually found at the lower extremity of the prolapse, but some- 
 times on portions of the vagina which are still unextrudcd. Large 
 patches occur, and they almost always have the a[)pcarancc of an indo- 
 
 FiG. 111. — Prolapsus Uteri, with Ulceration (Thomas 
 
232 NON-INFLAMMATOEY 
 
 lent ulcer with thick sodden edges, rounded and not sharp. These 
 impart a false appearance of depth, and give to the uninitiated a some- 
 what appalling idea of an old prolapse. Fortunately their cure is easy 
 enough on one condition, viz., that the uterus be replaced and carefully 
 retained in its normal position. No applications are of any use without 
 this, though if there be more than ordinary irritability of the ulcer, a 
 little zinc or bismuth ointment will serve temporarily to allay it. The 
 uterus once replaced and retained in its proper position, however, 
 passive congestion and its attendant low vitality are removed and the 
 ulceration proceeds to get well of itself, often in an incredibly short time. 
 I have seen an ulcer as large as a crown piece, and apparently a quarter 
 of an inch in depth, which had disappeared so completely in three weeks 
 that a careful inspection was necessary to trace its former outline. In 
 fact, although I have followed the prevailing fashion in describing these 
 as true ulcers, the frequent rapidity of their disappearance without cica- 
 tricial remains, would lead to the belief that, in these cases also, the 
 term is sometimes a misnomer. Free injection into the replaced vagina 
 of carbolised water, hot, tepid, or cold, according to circumstances, is all 
 that is really necessary, and that only for the sake of cleanliness and 
 antisepticity. 
 
 Hypertrophy of the Cervix. 
 
 We are still on the border-land of metritis, seeing that the great 
 majority of cases of enlarged cervix uteri are due to its influence. 
 But enlargement may occur, as far as we know, without inflammation, 
 from sub-involution, for instance, (although in this case the occurrence 
 of previous inflammation is merely " not proven ") or from original de- 
 velopmental causes, where inflammation seems to be out of the question. 
 We speak here of the cervix uteri as it is commonly vmderstood in 
 clinical practice, viz., as that portion of the uterus which projects into 
 the vagina. Between the vaginal reflexion and the true body of the 
 uterus, or os internum, there is still a portion of cervical tissue — 
 the supra-vaginal portion — which is liable to become hypertrophied, 
 either alone or along with a similar condition of the uterine body, and 
 which plays an important part in prolapsus uteri and other aff"ections, 
 which we shall by and by consider. It is, however, from its surround- 
 ings, little amenable to the surgical treatment which we fearlessly apply 
 to the intra-vaginal portion. 
 
 Non-inflammatory enlargement of the intra-vaginal cervix is 
 met with in the form of long conical cervix, to which I have already 
 referred (p. 198) in connection with the stenosis which generally accom- 
 panies it. The stenosis is mainly confined to the os externum, and, as 
 
HYPERTEOPHY OF THE CERVIX. 233 
 
 far as it and its consequent dysmenorrhoea are concerned, a small back- 
 wards incision, kept open for a time by the passage of a bougie, generally 
 suffices to afford relief. But in extreme cases the length of the cervix 
 — for it is rarely enlarged much in circumference — may become a source 
 of infinite trouble. It produces all the symptoms which are more often 
 the result of prolapse of the whole organ — constant dragging and feel- 
 ing of bearing down, diffictilty of locomotion, occasional pressure on the 
 bladder or rectum, and vaginal catarrh or sub-acute vaginitis. It may 
 even protrude externally as a pseudo-uterine prolapse, and become 
 ulcerated as has just been described. In such a case prolapsus 
 uteri will always be suspected, and is by non-experts often diagnosed. 
 But an examination will show that the finger can pass high into the 
 vagina, and sweep around the projecting cervix without pushing it 
 materially upwards. A body not unlike a turgid cow's teat will thus 
 be made out, and the fundus uteri will be found at or nearly at its 
 normal height on bi-manual examination. Combined manipulation of 
 the extreme cervix and fundus will show their continuity, and the pass- 
 age of the sound will show a much increased total uterine length ; 
 while, if there is still any doubt, a recto-abdominal and recto-vaginal 
 examination will show how much of this increased length is above and 
 how much below the summit of the vagina. For this non-inflammatory 
 hypertrophy, with its accompanying discomforts, there is only one 
 remedy — amputation. Absorbent drugs or applications have no 
 effect. 
 
 To accomplish this object great ingenuity has been employed in the 
 invention of methods, showing at any rate some consensus of opinion as 
 to its necessity and advisability. Yet I feel bound to quote the opinion 
 of Emmet on the opposite side : — " I advance the statement," he says, 
 " without qualification, that this operation, as at present applied, is to a 
 great extent a malpractice, and is attended by more evil consequences 
 than any other procedure now resorted to in this branch of surgery. 
 In fact, I am satisfied from experience that removal of the cervix is 
 never called for except in some forms of malignant disease " (op. dt. 
 p. 484). I can hardly resist the temptation to place alongside of this 
 quotation another from the same eminent siirgical authority, in which 
 (p. 145) he says : — " Under the guise of surgery, the uterus has been 
 subjected to a degree of malpractice which would not be tolerated in 
 any other organ of the body." This is, fortunately, not the dictum of 
 a physician of the old school, and is one of tlie most pregnant sentences 
 in Emmet's admirable surgical work. Although, however, it is the case 
 that, in inflammatory hypertrophy, wlierc the cervix has been torn, 
 operations of a plastic kind are often preferable to, and more scientific 
 than, amputation, yet I ])clicvc the latter to be necessary in some of those 
 
234 
 
 AMPUTATION OF THE CERVIX 
 
 Fig. 112.— Fallen's Operation for 
 Elongated Cervix Uteri. 
 
 cases in which elongation is congenital and not connected with inflam- 
 matory conditions. 
 
 Fallen {Brit. Med. Jour., 1883, i. 852) describes what he terms 
 
 " wrong implantation " of the vagina on 
 the cervix, so that a long intra-vaginal 
 cervix with almost normal total length of 
 the uterus would mean high implantation 
 of the vagina upon it, and not enlarged 
 cervix. In such cases he recommends the 
 removal of a circular band of the mucous 
 covering of the upper part of the cervix, 
 and the lifting up of the cervix by stitch- 
 ing together the borders of the circular 
 wound thus made. In fig. 112, the surface, 
 A B C D, is pared raw, and then C D is 
 stitched up to A B, so as to sling up the 
 cervix in its own shortened mucous cover- 
 ing. I have no personal knowledge of 
 the proceeding. 
 
 Amputation can be performed in two 
 ways, by knife or by ecraseur. There 
 are four things necessary to be avoided : — 
 
 1st. The recurrence of severe or fatal haemorrhage. 
 2nd. Araputating too high, so as to risk opening into the peritoneum. 
 3rd. Leaving a stump which will not cicatrise within a reasonable 
 period ; and 
 
 4th. Allowing the cervical canal to become permanently obliterated 
 or stenosed. 
 
 Haemorrhage is prevented by the use of the ecraseur, but it can 
 always be arrested by styptics and the subsequent use of the vaginal 
 plug. This may seriously interfere, however, with the success of some 
 of the more complicated procedures with the knife. Amputation too 
 high can in any case be avoided by passing a uterine sound, and so raising 
 the whole organ to its full height, but without further pressure than is 
 necessary for this. A careful recto-vaginal examination while the cervix 
 is thus held will show clearly how much of it is distinctly intra-vaginal, 
 and, the sound being withdrawn, a portion of this alone is acted on. A 
 raw stump is left by the ecraseur and by simple excision with the knife 
 or scissors, but I have found this prone to heal shortly, especially if 
 free injections of antiseptic fluids ai-e perseveringl}^ used ; in the 
 same way the raw surface left by the removal of fibroid polypi heals 
 rapidly. Various attempts have been made, which will be men- 
 tioned immediately, to eff"ect union by first intention, by stitching 
 
BY ECEASEUK, 235 
 
 together the cut mucous edges, and thus covering the stump at once. 
 Contraction of the canal is more hable to occur with the ecraseur, 
 although it can never be depended on not to arise, unless the case be verj- 
 carefully watched. The early and occasional introduction of a bougie, 
 or the wearing of a glass stem (iig. 99) for some time after the opera- 
 tion, must be used in all cases. 
 
 Amputation of the Cervix by Ecraseur. — For amputation with the 
 ecraseur the galvano-cautery wire is infinitely preferable to all other 
 instruments, the only objections being its expense, its want of portability, 
 and the liability of all forms of battery to go wrong just when wanted. 
 The last objection is the most valid. 
 
 The first thing to do is freely to expose the cervix with the duck-bill. 
 A vulcanite duck-bill of precisely the same form as the metallic instru- 
 ment is useful for such purposes, and it is not liable to injure the 
 electric current by a chance contact with the wire. The platinum-loop 
 is now slipped on to the cervix to the requisite height, and tightened, 
 while well under view and touch, until it just slightly depresses the 
 surface, or a slight gutter may be cut in the mucous membrane. No 
 retention of the Avire by metallic needles is permissible, and as platinum 
 will bear only a very limited strain, the thickest wire should be used, 
 which an actual trial has shown that the battery is strong enough to 
 bring to a white heat. There is no objection to a bone needle for the 
 purpose of fixing the wire, provided that it can be pushed through the 
 cervix withou.t excessive dragging downwards. Contact with the battery 
 is now made, care being taken to remove the fingers from the neigh- 
 bourhood of the platinum loop. No traction must be made on the 
 ecraseur, otherwise the cervix may be simply denuded of its mucous 
 covering, but the tip of the cervix must be held steady by an assistant 
 with a hook or vulsellum, while he carefully keeps it out of the way of 
 the electric instrument. With the first sign of electric-heat action, — a 
 slight frizzling sound, or an equally slight appearance of smoke, — the 
 operator commences to turn very gently the screw which tightens 
 the wire-loop. No force must be used in this way, but the tightening 
 must follow, not lead, the cutting action of the hot wire. Suddenly it 
 will 1)0 found that all resistance to the screw ceases, and the instrument 
 and the cervix must be then rapidly removed together, while tlic person 
 in charge of the battery is warned simidtaneously to break ofl:' the con- 
 nection. If a non-electric ecraseiu' must be used, the ordinary chain 
 instruments are too clumsy for this purpose ; even those which have a 
 comparatively fine chain, and are curved in the shank, are inapplicable, 
 unless the cervix is so low that without any force it protnides through 
 the vulva. Tlie wire ecraseur is better suited for the present object. 
 Its wire can be bent at right angles to the instrument, and applied very 
 
236 AMPUTATIOX OF THE CERVIX BY THE KNIFE. 
 
 much as the jDlatinum wire of the electric instrument. A curved needle, 
 or a straight harelip pin if the cervix is very low, may be passed through 
 the cervis at a point below that at which amj)utation is safe or desirable, 
 and left there after the wire has been made to surround the cervis 
 just above it. 
 
 Amputation of the Cervix by Knife or Scissors. — We may set aside 
 the use of scissors for this purpose. For many vaginal or uterine 
 operations they have advantages over the knife, which are none the less 
 great because they commend their use especially to the inexperienced 
 oj)erator, but the density and extent of the tissue to be divided in com- 
 jDlete amputation place the scissors, however skilfully curved on the 
 flat, or the edge, at a disadvantage. If the cervix can be well drawn 
 do"mi, and if we have ascertained beyond doubt how much may safely be 
 removed, the circular sweep of a good sharp bistoiuy will do what is 
 wanted. Haemorrhage will be free, and will probably require the use of 
 the tamioon, besides the ap|)lication of a styptic, but it can be diminished, 
 (Dr almost prevented, by slipping a stout india-rubber ring just above the 
 ]3oint at which amputation is to be made. This must be removed 
 slowly after the amjDutation by snipping through it gradually with 
 scissors. 
 
 Marion Sims has complicated this plan by stitching the vaginal 
 mucous covering of the cervical stump to the vaginal wall ; the rubber 
 ring, if used, must of course be removed first. I fail to see the advantage 
 of this plan. It may assist somewhat in keeping open the cervical 
 canal, but can never obviate the necessity for the use of other means for 
 that purj)ose. In a case where there was even a suspicion of malignancy 
 of the cervical enlargement it would obviously be inadvisable. 
 
 Hegar advocates the use of a plan which seems more likely to promote 
 healing of the stump by first intention, viz., uniting by several stitches 
 the edges of the mucous membrane Avhich covers, and of that which 
 lines, the cervix. The intervening raw surface is thus furnished at once 
 with a mucous covering. Goodell, after considerable experience of this 
 plan, states that union and primary healing take place " more or less." 
 
 A still more complex but very efficient form of amputation, introduced 
 by Marckwald and modified by A. R. Simpson, consists in first passing 
 three wire sutures through the cervix at the required height, then splitting 
 the cervix wdth scissors or knife up to the same height, exposing the sutures 
 at their point of perforation. Each of them is then hooked down through 
 the split cervix and its loop is cut, so that we have each half, anterior 
 and posterior, included in three wires, with their ends hanging do\^^l. 
 A good portion of each artificially made lip of the cervix is now cut off, 
 and the stitches are tightened and twisted : other stitches may be in- 
 troduced, Avhcn necessary to secure adaptation of the mucous edges. 
 
INFLAMMATORY HYPERTEOPHY OF THE CERVIX. 237 
 
 This operatiou is described more fully at page 259 of Hart and Barbour's 
 Manual of Gynaecology. It resembles in many waj's the procedure 
 required for the remedy of tears of the cervix. 
 
 To the general practitioner I have no hesitation in saying, that if he 
 meet with an undoubted case of elongated cervix of congenital origin, 
 which is causing distressing symptoms by its pressure, and which is the 
 only apparent cause of dysmenorrhoea or sterility, he is justified in 
 amputating, and that he will succeed best by the use of the galvano- 
 cautery ecraseur. His chief care must be to keep well within the 
 vaginal portion, to avoid stripping or scalping the cervix instead of 
 cutting it right through, and to carefiilly keep open the cervical canal 
 during the process of healing. 
 
 Inflammatory Hypertrophy of the Intra-vaginal Cervix.^ — Very 
 considerable enlargement of the cervix may be met with as a result 
 of chronic metritis, or, as far as we can disentangle the two affec- 
 tions, of sub-involution ; and long after any accompanying endo-metritis 
 may have passed away, this, by its weight, may tend to cause very great 
 discomfort, and may lead to prolapse of the whole organ. Such enlarge- 
 ment varies much in shape, but rarely resembles the conical cervix of 
 which we have just been speaking. If equal in all parts it presents a 
 shorter and much thicker body for observation and treatment, the 
 OS externum being usually large and patulous. More often, however, 
 the anterior lip, or the posterior, or some irregular portion, is much more 
 hypertrophied than the rest, and this even in women who have borne no 
 children, and in whom there is no splitting of the cervix from previous 
 delivery. That complication I speak of farther on. Given such a cervix, 
 with its accompanying discomforts, — for it may exist with hardly any, — 
 what is to be advised? I woiild say, first, carefully inquire whether 
 there is any further chance of doing good by internal or local alterative 
 drugs. They will almost certainly have been tested to the fullest extent. 
 Next, try what the use of pessaries, as afterwards recommended for 
 uterine prolapse, will do to relieve all discomfort, and to afford a fresh 
 chance, by preventing continual congestion, for alterative remedies and 
 hygiene to cure the affection ; and thirdly, if these measures fail, or have 
 been previously tried, or if the enlargement is so great and the discom- 
 fort so severe that they are unlikely to be of service, removal of the 
 offending part, wholly or partially, must be undertaken. 
 
 If the enlargement is tolerably equal all rovmd, and if it distinct!}- 
 projects into the vagina, when tested as above directed for the congenital 
 form, I have nothing to add to what I have said above as to the varioiis 
 methods of amputation. Fritsch proposes in such cases to remove two 
 large wedge-shaped pieces, one from the front and the other from the 
 back of the cervix, and to unite tlie edges of each gap separately. The 
 
238 LACEKATION OF THE CEEVIX, 
 
 result is very similar to that obtained by Marckwald's somewhat more 
 complicated proceeding. But if one portion, say the anterior lip, is much 
 more hypertrophied than the rest, it will frequently suf&ce to remove 
 that portion alone. It is just in such cases that the suspicion of com- 
 mencing cancer sometimes arises, and this would at once decide the 
 question of removal. It will depend a good deal on the surgical pro- 
 clivities and experiences of the practitioner which plan of removal he will 
 adopt. The shape of the hypertrophied part will also help to decide. 
 If it can be included, without fear of slipping, in the galvanic ecraseur 
 wire, that will probably be used. If a harelip pin or curved needle can 
 be passed through it, so as to retain the common wire ecraseur in place 
 till it fairly bites, that may be the resource, but if it presents, as it often 
 does, a thick mass tapering rapidly downwards, the best plan will be to 
 pass through it, with a curved needle, two, three, or more wires, to slip 
 over them and it the firm india-rubber ring, while with knife or scissors 
 the portion below the wires is removed. They are then tightened and 
 twisted so as to co-aptate the raw edges, and the elastic ring is subse- 
 quently removed. The wire stitches in this and all similar proceedings 
 should not be removed imtil at least a week after the operation, and may 
 often remain twice as long. As a result of this abscission of the most re 
 dundant portion of the hypertrophied cervix, we frequently see the sub- 
 sequent absorption of the remainder taking place very rapidly, and what 
 is more, it seems to have a result of the same kind on hypertrophy of the 
 body. It is therefore desirable not only for the primary obj ect in view 
 but also for the secondary one thus indicated. I have seen so much 
 mischief produced by attempts to destroy hypertrophied portions of 
 cervix by potassa fusa, in the hope that it would also lead to absorption 
 of chronic corporeal hypertrophy, that I can use only one word to express 
 my advice on the matter — Don't. 
 
 Laceration of the Cervix Uteri. 
 
 We have next to discuss a -subject that has occupied much attention 
 during the last few years. When I first commenced practice, next to 
 the treatment of "ulcer of the womb" by the constant application of 
 nitrate of silver and other caustics, the great achievement of those who 
 aimed at distinction in gynaecology was slitting up the cervix uteri for 
 dysmenorrhosa and sterility, by the various hysterotomes which were 
 then coming into vogue. Many unnecessary operations were performed, 
 and a practice which has its legitimate sphere was brought into much 
 discredit. 
 
 It is only some tAventy jenrs since Emmet first performed his opera- 
 
HYSTERO-TRACHELOREAPHY. 239 
 
 tion for the cure of lacerated cervix, about thirteen since he published 
 (in 1869) his first paper on the subject, and not more than ten, since, by 
 a second paper (Avier. Joiir. of Obst, Nov. 1874), he succeeded in fully 
 drawing the attention of the profession generally to its^merits ; and already 
 there are symptoms, especially among our American brethren, of a 
 mania for cervix stitching. If only a tithe of the cases reported on the 
 other side of the Atlantic are genuine and successful, they speak volumes 
 in favour of at any rate the boldness and skill of the American practi- 
 tioner. Henry Bennett, at the International Medical Congress held in 
 London in 1881, pointed out some of the ludicrous aspects of this revol- 
 ution in practice ; but such questions are not to be finally decided in 
 this way. The cervix uteri does require division or amputation, under 
 fitting circumstances, and its lacerations do also require to be remedied 
 by stitching, with a similar limitation, Emmet's wise caveat Avith regard 
 to uterine surgery in general, quoted above (p. 233), being always borne in 
 mind. If there is a place for ridicule, it should be brought to bear upon 
 those phases of gynaecology which seem to presume that " slitting-up " 
 or " stitching-up," or otherwise surgically treating at all, is the natiiral 
 fate of the genital organs of women — or upon that curious tendency 
 which every now and again manifests itself to assign all female troubles 
 to one prominent lesion — to uterine inflammations, displacements, lacer- 
 ations, or other abnormal conditions. 
 
 It is a mistake to suppose that Emmet was the first to recognise the 
 bearing of lacerations of the cervix on many diseases of that organ. I 
 remember Sir James Simpson, in 1855, at the Edinburgh Maternity 
 Hospital, telling me that a torn cervix was a most common cause of 
 aggravated cervical disease ; and he spoke so as to give me the impres- 
 sion that this was a commonly acknowledged fact, though undoubtedly 
 if was not. Henry Bennett also called attention to this condition 
 (Uterine Inflammation, 2nd ed., 1849, p. 25). But the duck-bill specu- 
 lum and the silver suture were then not in use, and uterine surgery 
 in its recent developments was therefore unknown ; so that lacerations 
 were considered as irremediable aggravations rather than as curable 
 causes of uterine disease. To Emmet undoubtedly belongs the merit 
 of clearly pointing out the numerous effects that flow from lacera- 
 tion of the cervix, and (jf describing a practical operation for its 
 cure. 
 
 The operation has been termed hystero-trachelorra-phy, but it is just 
 a little odd to find so competent an authority on the matter as Emmet 
 himself saying that — " It would be but human nature for the unin- 
 itiated" {qtiery, patient or practitioner?) "to dread the severity of an 
 operation so termed." The horrors both of female disease and of its 
 surgical treatment have been not a little enhanced in this direction of 
 
240 
 
 CAUSATION AND FOEMS OF 
 
 late years by some of Emmet's compatriots, and their German imitators 
 or models. 
 
 Causation. — That laceration is due, in most cases, to the .effects of labour 
 at full term is undoubted ; but it would appear to be as yet undecided 
 whether long and tedious or over-rapid labours are the most destructive 
 to the cervical tissues. Too prolonged labour, however, probably gives 
 rise to the greatest number of cases, although the too early use of the 
 forceps, with undilatable os uteri, cannot be held guiltless. Not a few 
 cases were traced by Emmet to abortions or premature delivery, and espe- 
 cially, as might be expected, in cases where this had been brought about 
 artificially. He found, after very careful collection of statistics, that 
 over 32 per cent, of all fruitful women coming under his care in private 
 practice, suffered from laceration. My own more limited experience 
 
 would lead me to con- 
 _ _ sider this estimate as 
 
 not very much too high, 
 — an appalling prospect 
 indeed, if we are to con- 
 clude that all or most of 
 these patients require a 
 difficult surgical opera- 
 tion. The sting which 
 ansesthetics were sup- 
 posed to have taken from 
 the curse " in sorrow 
 shalt thou conceive," 
 would be restored with 
 a vengeance, and not 
 a slight addition would 
 be made to the "sweat of the brow" predicted for the other sex. 
 The fate of the perineum would prepare us for operative measures 
 on a sufficiently extensive scale, but surely nothing approaching to 
 this. 
 
 Forms. — Laceration may occur in any direction at the time of delivery, 
 but unless carefully sought for, on account of haemorrhage, it is then 
 nearly always overlooked ; indeed, by the finger alone, as any student may 
 satisfy himself, it is most difficult to ascertain the outline of the cervix 
 at all, immediately after delivery. The anterior lip is most apt to suffer, 
 and that chiefly towards its left side. The pressure of the long diameter 
 of the head, in its first and most common position, explains that. But 
 antero-posterior lacerations are more apt to heal during convalescence, 
 with little or no permanent depression, and lateral tears are more often 
 the cause of permanent trouble. We may have every variety of form — 
 
 Fig. 113. — Stellar Laceration of the Cervix Uteri 
 (Emmet). 
 
OF CERVICAL LACERATION. 
 
 241 
 
 stellar (fig. 113), unilateral (fig. 114), bilateral, or otherwise. I omit 
 here those cases of cervico-vaginal rupture which leave permanent records 
 in the form of fistular communications with the bladder or rectum. 
 
 Results. — As regards the results of rupture of the cervix, we may dismiss 
 them, as encountered at the time of occurrence, in few words. The chief 
 resvdt is hsemon-hage, and it is necessary for the obstetrician to bear 
 this in mind, as he must also remember the corresponding affection of 
 the perineum, when severe primary post-partum haemorrhage occurs in 
 spite of well-contracted uterus and complete expulsion of the secundines. 
 I have never known a case where the ordinary treatment of post-ioartum 
 haemorrhage has not sufficed to arrest haemorrhage from the cervix alone, 
 but a small sponge, soaked in tincture of iodine, four times diluted, and 
 pressed against the torn cervix by a forceps, has in one or two cases 
 been of immediate service. I can imagine a case, however, where, as 
 
 Fig. 114. — Unilateral Tear of the Cervix Uteri (Emmet). 
 
 has been done by Fallen, the primary stitching of the parts might be 
 necessary. It would, under the circumstances, be infinitely more difii- 
 cult than the primary operation on the perineum, though its details will 
 be simple enough to those who understand the operation required b}' 
 laceration as a cause of subsequent trouble. The consequences of torn 
 cervix, as a chronic affection, are of much greater importance. There 
 can be no possible doubt that it acts, both as a cause of chronic cervical 
 endo-metritis, and as an agent which retards or prevents the cure of that 
 affection by ordinary means. If deep, it leads almost necessarily to a 
 state of ectropion, to the cversion of the mucous membrane of the cervical 
 canal ; and the friction of this everted surface against the vaginal walls, its 
 contact with tlic vaginal secretions, and its liability to injury in the marital 
 relation, and on all great exertion, — all these circumstances tend to 
 render it a matter for very careful consideration whether, by operative 
 
242 LACERATION OF THE CERVIX UTERI, 
 
 means, it can be eliminated from the morbid chain of cause and effect. 
 Parenchymatous enlargement of the cervix surely follows in its wake, as 
 an extension of inflammatory mischief from surface to substance ; and 
 this enlargement increases the ectropion, and thereby spreads the super- 
 ficial inflammation. Where we have had cervical tearing we have also 
 an increased tendency to those peri-uterine inflammations which so often 
 depend on septic absorption from torn surfaces ; and the result is an 
 organ less fitted to contend with its own local difl&culties. Sub-involu- 
 tion, or chronic parenchymatous inflammation of the uterine body, adds 
 to the general weight and congestion, which diminish the chances of 
 curing the cervical condition. Menorrhagia, dysmenorrhoea, abundant 
 leucorrhoea, and, of course, all the usual dependent train of symptoms, — 
 back-ache, hysteria, and so forth, — are thus in a sense traceable to torn 
 cervix, and the fashion for the moment is to trace them to this source 
 almost alone. But it should be clearly understood that old lacerations of 
 great depth, and in all directions, may exist without a single morbid 
 symptom, and without involving any necessity for surgical interference. 
 I desire to make myself personally responsible for this statement of fact. 
 On the very day of writing this I have had occasion to examine a lady of 
 sixty- two years of age, — the mother of six children, and one who has been 
 known to me for over twenty years as free from any trace or suspicion 
 of uterine disease, — on account of a little haemorrhage, which turned out 
 to be due to a small herpetic ulcer of the vulva ; and I found a cervix 
 split completely across transversely and as deeply as possible, and with 
 three radiating tears, two anteriorly and one posteriorly. I introduced a 
 duck-bill speculum and widely separated the cervical lips, and found not 
 a trace of redness in any corner of the fissures. 
 
 That acquired sterility Avill often follow in the wake of this affection, 
 when complicated with some of the preceding symptoms, and that the 
 removal of such symptoms will occasionally be followed by pregnancy, does 
 not seem to require the amount of discussion and proof that has been be- 
 stowed upon it. It seems to be also pretty certain that the cervix uteri, 
 thus everted and exposed to irritation, is more liable to the invasion of 
 epithelioma, though I know not in what degree, nor are there any accurate 
 statistics to prove the fact ; as a result of the affection, or of its concomit- 
 ants, we may also have, in addition to the effects already mentioned, 
 various reflected neuroses, neuralgia of the uterus, with or without 
 dyspareunia, and greater liability to menstrual disorders or uterine 
 displacements, as well as tendency to abortion or tedious labour when 
 pregnancy occurs. 
 
 Treatment. — It is therefore of great importance to decide three ques- 
 tions — (1) When is an operation, demanding considerable skill in the prac- 
 titioner, and some fortitude in the patient, called for ? (2) How can this 
 
XOX-OPEKATIVE TREATMENT. 243 
 
 be avoided by prophylactic or other means ? And (3) if once decided on, 
 what is the best mode of its performance? I take the second question first, 
 and in reply I have no hesitation in saying that Emmet, the origin- 
 ator of the operation, has himself provided us with the surest means of 
 preventive treatment, as far as regards operation, for these lesions. To 
 those who will consult his observations {op. cit., p. 624) on the manage- 
 ment of a case of vaginal fistula previous to operation, or will refer to 
 my remarks on the subject (p. 129), or who have noticed how these 
 tistulte improve, and sometimes spontaneously heal, under the hot-water 
 treatment by injection, I can affirm that a like result will often follow 
 if the plan be employed early in laceration of the cervix uteri. 
 If recognised at the time of delivery, the use of copious, tepid, 
 antiseptic injections should be made from the beginning, and, indeed, 
 for other reasons, this is advisable in all cases of delivery. In every 
 case it would be well if a careful vaginal examination were made within 
 three, or at most four, weeks after confinement. If this were universally 
 done, many other conditions requiring early management would be 
 iliscovered in time, and certainly this condition of laceration of the 
 cervix would not give the trouble in after-life which it imdoubtedly 
 <jften does, It can by that time be diagnosed with certainty by the 
 finger, and its extent can then be ascertained by the duck-bill specu- 
 lum. The hot-ivater treatment now comes into play. The attendant 
 must be shown how to manage the syringe and the overflow^ stream, 
 with the patient on her back and the pelvis well raised, and an 
 injection must then be given at least night and morning for a few 
 days, and once daily or nightly for two or three wrecks, even after the 
 patient feels able to go about freely. I have tried warm injections in 
 this way for a considerable period, but have only been acquainted 
 with the value of hot water (105^ and upwards) since the publication 
 of Emmet's first edition. My somewhat limited experience of its use 
 since then, in these cases of recent rupture of the cervix, has, however, 
 convinced me that we possess here a means of promoting union of the 
 torn surfjices to a sufficient practical extent, without permitting their 
 invasion by granular sprouting, which renders permanent adhesion very 
 difficult or perhaps impossible. It is too much, however, to hope that 
 the plan of invariable examination at the right time will ever be fully 
 carried out, especially among the poorer classes, though certainly a 
 male patient who had ever endured anything corresponding to the pangs 
 of labour would "jump at" the idea of an investigation "to see that all 
 was right again," and his adviser would probably insist upon it. 
 
 Supposing, however, that no means have been taken during the 
 puei'peral month, or within a short subsequent period, to promote 
 adhesion of a torn cervix, or to ensure that such fissures of the cervical 
 
244 OPEEATIVE TEEATMEXT FOR 
 
 rim as may remain are covered with healthy mucous tissue, it is still 
 possible, in my opinion, to bring about the same result, at a much later 
 period, without operative interference, if the instructions given above 
 for the management of cervical erosion are fairly carried out, especially 
 the negative ones as to strong caustics. If, treating the unhealthy 
 siuface by powerful caustics or escharotics at this stage, we destroy all 
 the superficial tissue and render it incapable of recovering its normal 
 condition, or of extending to the parts which are torn, there will 
 be nothing for it, laceration or no laceration, but destruction, by 
 the knife or other means, of the unhealthy structures which have taken 
 its place. If the less heroic plan of mild alterative local applications, 
 combined with the means I have pointed out for removing pelvic con- 
 gestion, for lifting up the uterus to a moderate extent, so as to avoid 
 uterine congestion, and for improving the general health by alterative 
 and tonic treatment, be followed out, the torn cervix, toi-n in a moderate 
 degree at any rate, may retard but will not prevent complete recovery. 
 
 Operative Interference — When not called for. — Our first question, 
 When is operative interference required for the cure of cervical fissures 1 
 is thus partially answered ; I mean an operation for the paring of the 
 torn surfaces and their union by stitches. I would say that an opera- 
 tion of this kind is not called for — 
 
 1. When the laceration, though deep, but strictly confined to the 
 cervix, is covered with healthy mucous tissue. 
 
 2. When the condition of the parts is recent and such that there 
 is a fair prospect of cure by the simple means above indicated. 
 
 3. '\\Tien there is evidence of sun'ounding pelvic inflammation, or 
 inflammation of the body of the uterus such as may accoimt for the 
 persistence of cei-vical disease, or which would almost inevitably be 
 aggravated by a formidable surgical operation on the cervix. 
 
 Operative Interference— When called for. — After this negative 
 statement we are boimd to state when, in our opinion, paring of the 
 torn edges of a lacerated cer.'ix and reparation of the tears by stitching 
 is called for. I would, Avith my present experience, limit this to cases 
 where — 
 
 1. The torn surfaces are covered by thick granulations, which have 
 resisted the simple means advised for the cure of cervical endo-metritis, 
 and where evidently nothing but the curette or powerful escharotics 
 Avill avail. 
 
 2. Where the lacerations, and their consequent results, had produced 
 considerable ectropion of the cervical canal, or great alteration in shape 
 of- the cervix itself, such as would probably require ablation of some 
 portion, and 
 
 3. Not as Emmet puts it " when the woman sufiers from neuralgia," 
 
LACERATIONS OF THE CERVIX UTEPJ, 245 
 
 but when neuralgia oi' nervous phenomena of severe character can be 
 traced by excKision to nothing else than uterine origin, and to the pos- 
 sible involvement of uterine nerves in the cicatricial tissue of the cervix. 
 In this case, and in this alone, are we warranted in operating on a lacera- 
 tion covered with healthy tissue, and unaccompanied by great hyper- 
 trophic distortion of the cervix. ^ 
 
 Method of Operation. — It remains to describe the simplest method 
 of operating for the condition of lacerated cervix. In the first place, 
 Emmet lays as much stress on the value of long-continued preparative 
 treatment as he does in the case of an operation for vesico-vaginal fistulse. 
 Without such preparative treatment the slightest provocation, he says, 
 will suffice to bring back all the former symptoms. I can well believe it, 
 for the so-called " preparatory " treatment consists in following out pre- 
 cisely those maxims which we have just advised for the cure of ordinary 
 erosions and enlargements of the cervix, with or without tearing, and 
 with or without surrounding inflammatory affections of the utei'ine body, 
 ovaries, broad ligaments, cellular tissue, or peritoneum. Hot water in- 
 jections, a suitable pessary, glycerine plugs, puncturing enlarged follicular 
 cysts, and the application of iodine or astringents to the eroded surfaces, 
 — these sum up the whole matter. When the preparatory treatment has 
 been fully carried out to the extent proposed, viz., to the removal of all 
 tenderness, it might be well to make quite sure that the further opera- 
 tion is required at all. Opinions differ much as to the difficulty of 
 the operation and the time for its performance. Fallen considers the 
 oj)eration difficult of perfomiance {Brit. Med. Jour., May 21, 1881). 
 Jonathan Hutchinson (Holmes's System of Siirgery, iii. 420) says : — " The 
 oj^eration is a simple one; the uterus is drawn down, the edges of the 
 fissure are pared, and sutures inserted." Emmet refuses to operate as long 
 as there are any traces of pelvic cellulitis. Goodell considers persistent 
 pelvic cellulitis as a ground for operation. Martin of Berlin operates 
 during its existence, and without preparatory means, as Simon of 
 Heidelberg does in vaginal fistulas. 
 
 ^ As this operation is luidoubtedly entitled (according to the practice, M'hich will 
 ere long render Greek or Latin mere child's play to the medical student, in com- 
 parison with the biographical language inflicted upon him) to be termed " Emmet's 
 operation," it is only right to allow the originator to define the necessary conditions 
 for its performance in his own words. He says (o^;. cit.. p. 467) — "I would state 
 that in every instance where the condition (lacerated cervix) is evident, and where 
 enlargement of the uterus still remains, or where the woman suffers from neuralgia, 
 I consider an operation necessary, notwithstanding the parts may have comjiletely 
 healed." I cannot accept this definition of the operative indications. I estimate 
 that about fifteen operations a week, for the one affection, Avould be the result of my 
 doing so at the present time. The acquirement of a special reputation in the matter 
 would doubtless increase the number for a time, until, like slitting up the cervix, the 
 practice became universal, and was by its abuse discredited. 
 
246 emmet's opeeatiox foe 
 
 If the question of operation be decided in the afl&miatiTe, the patient 
 is placed in the left lateral position, the cervix is exposed in the 
 usual way by the duck-bill speculum, and is drawn dowm by hook or 
 vulsellum. A copious vaginal injection of very hot water, given 
 just before the operation, will gTeatly tend to prevent haemorrhage, but 
 if the tissues are at all soft, it is better to suiTound the base of the cer- 
 vix with a thick wire dra\^Ti tight by means of a small ecraseur or tour- 
 niquet, which is left in position. The surfaces of the laceration are now 
 to be freely pared by scissors or knife, in such a way that the raw edges 
 on opposite sides will freely unite when placed together. Each side of the 
 tear must be denuded separately, and any convexity or bulging it may 
 have acquired must be thoroughly pared flat. In troublesome or com- 
 plicated cases it may be advisable to operate on successive portions at 
 different times. Considering the varieties that exist in the direction of 
 these tears, it is impossible to portray intelligibly to the ordinary medi- 
 cal reader the appearance of their denuded surfaces. But to one 
 accustomed to plastic operations, and no other should attempt this, it is 
 sufl&cient to recognise fully the depth and the length of the laceration, 
 and the shape of the organ desired to be restored. Before operation, 
 the surfaces must be hooked together as far as possible, so as to assume 
 the desired shape, and thus give a clear idea of how much redundant 
 tissue will require to be shaved off to admit of proj)er juxtaposition. 
 Small minor diverging fissures may be included in the surface SAvept 
 clear in the walls of the main one. 
 
 A description of the mode of treatment of a simple bilateral tear must 
 suflice, and for hints as to the management of more complicated fissures, 
 the reader is refeiTed to Emmet's work. In figs. 115, 116, 117, and 
 118, AC B and A D B represent diagrammatically the opposite surfaces 
 of a complete tear, A B being their angle of union, in the centre of which 
 is 0, the lumen of the cervical canal. A C B and A D B have to be 
 pared and vivified, and stitched together in such a way as to permanently 
 adhere, while leaving a free passage outwards from to the surface at 
 CD. A strip e/ (fig. 115) on one flap, and a similar strip g hon the 
 other, will have to be left unpared, othem'ise the canal of the cervix 
 uteri will be closed, and these strips of unpared tissue must be wider at 
 the lower end of the cervix, to allow for the greater shrinking which 
 takes place in that part of the repaired organ. The parts to be freshened 
 mil therefore correspond with the shaded portions of fig. 115, and when 
 placed in position, e Avill adhere to ff and / to h, leaving a wide and 
 patent canal. The stitching, still shown in a purely diagrammatic form 
 in fig. 116, is accomplished thus. For the sake of clearness only three 
 stitches, Nos. 1, 2, and 3 are shown, and these only on one side, but it may 
 be necessary to use four, five, or more, at intervals of -|- to -J of an inch. 
 
LACERATED CERVIX UTERI. 
 
 247 
 
 The effect of placing C and D in apposition, and then tightening these 
 stitches, commencing with the uppermost, cannot fail to be apparent, but 
 figs. 117 and 118 will probably make it even more so. The denudation of 
 the surface is best performed by shai'p scissors, commencing at the apex or 
 lowest part, and removing each side of each flap, if possible, in one piece. 
 Short, curved needles are the most convenient for introducing the 
 wire stitches, and it is essential to have a good holder, such as that of 
 Hagedom (fig. 41). If the parts are very hard, it may be necessary to 
 use edged needles. No. 26 wire is generally the most suitable. The 
 
 FiK. 117. 
 
 Fis. lis. 
 
 C D 
 
 Figs. 115, 116, 117, 118.— Four figures illustrating diagranimatically tlie steps of 
 Emmet's Operation for the Repair of the Lacerated Cervix Uteri. The letters and 
 figures refer to the text. 
 
 stitches, when twisted, are cut off about half an iiich from the cervix, and 
 the ends are turned down parallel to its length, so as to cause no irrita- 
 tion of surrounding parts. They may be removed from the seventh to the 
 tenth day, the upper one first, so that, if adhesion be not complete, the 
 lower ones may be left m situ. Fig. 119 shows the denuded surfaces, 
 after Emmet. 
 
 According to Munde, tlic operation is almost painless, except as regards 
 the intnjduction of the stitches, and though he deprecates the practice 
 in ordinary cases, he speaks pretty confidently of the possibility of oper- 
 
248 
 
 emmet's operation for 
 
 ating without anaesthesia at his " office " or consulting rooms, and sending 
 the patient home by car to pursue her usual avocations, and to return 
 for the removal of the stitches in a week. Should this hint be largely 
 taken up, I fear that the occurrence of severe and even fatal pelvic in- 
 flammation or secondary haemorrhage will soon add to the suspicion with 
 which this operation is even now regarded by many of our foremost 
 gynaecologists. 
 
 One further precaution after the operation should be mentioned. If 
 retroversion has been present before the operation, it will probably 
 return when the patient begins to move about, and there will thus 
 be caused a strain upon the young cicatrix, which it will probably 
 be unable to stand. A Hodge pessary should therefore be inserted as 
 
 Fig. 119. — Lacerated Cervix after denudation (Emmet). 
 
 early as possible, and the uterus kept in an anteverted position. Emmet 
 lays great stress upon this, and very properly, and I would further 
 supplement the advice by recommending the practitioner who has suc- 
 cessfully performed "hystero-trachelorraphy," to dismiss from his mind 
 the notion of having achieved a " cure-all" and to remember that every 
 single symptom attributed to the lesion under consideration may exist 
 in its absence, and may remain or return in spite of its temporary 
 remedial effect. 
 
 I am indebted to my colleague, Dr W. J. Sinclair (of the Manchester 
 Southern Hospital), who has had some experience in this o])eration, for 
 the following statements : — 
 
 1. The operation is more difficult of performance than descriptions of 
 
LACERATED CEKVIX UTERI. 249 
 
 it might indicate, and should not be undertaken without some previous 
 experience of plastic operations in parts more easily reached. 
 
 2. A uterine tourniquet of any kind is an inconvenience. In most 
 cases some bleeding is an advantage, improving the condition of the 
 tissues. When the haemorrhage is excessive, if the denudation of the 
 upper end of the laceration be quickly completed, and the uppermost 
 suture be at once introduced and twisted tight, the amount of bleeding 
 will be sufficiently moderated. 
 
 3. Elaborate preparation of the patient appears to be unnecessary. 
 Operations on a uterus fixed by the condition of the surrounding tissues, 
 or in case of great hy^Dertrophy, are followed by perfectly satisfactory 
 results, the uterus becoming movable and less tender, and diminishing 
 in size. 
 
 4. When there is much hypertrophy of the cervix, it is difficult to 
 bring the outer edges of the denuded surfaces into perfect contact 
 without cutting away a large amount of tissue or throwing great strain 
 upon the sutures. In one such case an excellent result was obtained by 
 the use of small quilled sutures to bring together the deeper parts and 
 superficial interrupted sutures for the vaginal edges. 
 
 5. In case of laceration of both sides, it is better to perform two opera- 
 tions. The double operation is a very formidable proceeding. The 
 haemorrhage is less under control. It is difficult to properly shape the 
 future canal, and to stitch without occluding it. After a successful opera- 
 tion on one side, the condition of the cervix so improves as to make the 
 second operation comparatively trifling. 
 
 6. Partial failure will ensue unless great care is taken with the lower 
 end of the fissure which is destined to complete the ring of the external 
 OS, in analogy with the operation for hare4ip. 
 
 7. The sutures should be left ten days at least; the only failure 
 observed was owing to their too early removal. 
 
 8. During the introduction of the sutures the uterine sound may be 
 steadied in the canal by an assistant, or it may be passed repeatedly 
 during the operation, to ensure that the canal is sufficiently wide. 
 
 9. Improvement in the patient's condition may come more slowly than 
 is generally expected, and the operation must often be looked upon as 
 merely a step in the course of treatment of a uterine disease. 
 
 Some of these observations, it will be seen, are antagonistic to the 
 teaching of Emmet. Some have a very pregnant meaning to those who 
 can read between the lines. Not being able to speak myself ex cathedra, 
 I dare not endorse them. Time must be allowed to settle many points, 
 both in tlic estimation and in the execution of the operation. 
 
250 THE CAUSATION AND SYMPTOMS 
 
 General Uterine Hypertrophic Enlargement. 
 
 Enlargement of the whole uterus may be due to a variety of causes — 
 to the presence of intra-uterine polypi, to fibroid growths, to malig- 
 nant disease, or other causes ; but this woiild seem to be the most fit- 
 ting place to mention that chronic condition of enlargement which is due, 
 sometimes to chronic corporeal metritis, sometimes to sub-involution, and 
 which is variously described under these two terms, or under the terms 
 hypertrophy or hypei-plasia. The pathology of this condition is not so 
 clearly made out that we can generally attempt to differentiate between 
 its forms, except in the way of assigning inflammation or abnormal 
 recovery from pregnancy as presumptively predominating causes. In the 
 sequel of both we have an addition to the fibrous or connective tissue 
 elements of the organ, rather than to the muscular. When pregnancy 
 has not pre-existed, we can only look upon this as the fibrous degenera- 
 tion which modern pathology has shown to follow on chronic inflam- 
 mation in so many other situations, and when pregnancy has preceded, 
 and when inflammation has not been demonstrable in any acute form, 
 we can only say that there is no sure ground for contradicting those who 
 agree with Edis that it is "much more reasonable to look upon this 
 condition as depending upon aiTest of involution of the puerperal uterus 
 than to regard it as the termination of a latent, undemonstrative, acute 
 inflammation, the symptoms of which were so obscure as not even to 
 have been observed." Time will doubtless solve the problem, and I 
 cannot but think that one common factor will be shown to predominate 
 in all these cases. 
 
 Causation. — Various causes would seem to conduce to this final hyper- 
 trophic result. In the unmarried, inflammation of the mucous lining (endo- 
 metritis) is a frequent precursor, although this affection is certainly less 
 common than in the married. Menstrual troubles, especially those forms 
 of dysmenon-hoea which lead to frequent engorgement of the uteiiis, or to 
 obsti-uctive dysmenorrhoea, seem also to play a part. Unfruitful coition 
 also is often clearly recognisable as a cause. In those who are too fraitful, 
 who rapidly bear children, and still more in those who have frequent mis- 
 carriages, there is a special proclivity to chronic uterine enlargement, 
 and the same result seems to follow on too prolonged lactation, which 
 can seldom be carried on beyond nine months withovit deteriorating the 
 systemic forces of the mother. After confinement the causes are ap- 
 parently very numerous, but may be summed up in those which 
 interfere with healthy nutrition of the tissues, or those which lead to 
 hypersemia of the pelvic organs. All departures from the state of general 
 health, such as great mental depression, or diathetic disease, the occurrence 
 of anaemia from hsemon-hage or otherwise, may be placed in the foraier 
 
OF UTEEINE HYPEETKOPHY. 251 
 
 category ; and irritation of the ntei-us by retained clots or secretions, 
 by neglected tears of the cervix, or even by foetid discharges — displace- 
 ments of the uterus from too early exertion after labour, and engorge- 
 ment of the pelvis from cardiac or other visceral disease, may be placed 
 in the latter. The want of the healthy uterine stimulus afforded hj 
 normal and moderate lactation is often, and I think fairly, assigned as 
 a further predisposing cause. After abortion most of these causes 
 come into play in an even greater degree, and the unpreparedness of 
 the uterus for the physiological processes of parturition fully accounts 
 for this. 
 
 We may thus summarise the causes of chronic uterine hypertrophy 
 as — 
 
 1. Chronic inflammation of the utervxs itself or of the adjacent parts. 
 
 2. Sub-involution after labour or abortion, from — 
 
 (a) Impaired nutritive powers. 
 (h) Hypersemia or congestion. 
 
 (c) The want of the contractile stimulus afforded by lactation. 
 
 (d) Retained products of conception. 
 
 (e) Physiological unpreparedness for delivery. 
 
 3. Over-frequent labours or abortions. 
 
 4. Excessive lactation. 
 
 5. Uterine engorgement, from — 
 
 (a) Frequent or unfruitful coitus. 
 
 (b) Menstrual troubles, especially obstiaictive dysmenorrhcea. 
 
 (c) All forms of pelvic congestion. 
 
 Syviptoms. — Whatever the causation, the increase in its bulk gives 
 rise to a tendency of the uterus to fall lower than usual in the 
 pelvis, and increases the tenderness and weight of the organ, and 
 this is ajiparent rather on bi-manual examination than on the passage 
 of the sound — the bulk and thickness rather than the length of 
 the cavity being increased, though that also may be in excess of the 
 normal to a moderate degree. To the increased weight are due a sense 
 of fulness or bearing-down, with symptoms of pressure on the bladder or 
 rectum, or of dragging pain in the region of the ovaries or broad 
 ligaments. Menorrhagia is seldom absent, and is often excessive and 
 wasting, adding to the other sovirces of impaired nutrition, and there is 
 often some tendency to inter-menstrual discharge. These hemorrhages; 
 together with the accompanying pain, often lead to the suspicion of even 
 more grave organic disease. Displacement of the uterus backwards 
 (retroversion or retroflexion) is a very constant sequel of the affection, 
 adding to the discomfort and increasing the congestion of the organ; or 
 anterior displacement may predominate. Not infrequently we have that 
 lax state of the supports which permits of alternate backward or forward 
 
252 UTERINE HYPEliTEOPHY : ITS DIAGNOSIS 
 
 d.isj)lacement, or of prolapse. In addition to the other symptoms, we 
 have, in many instances, sympathetic enlargement of the breasts and 
 darkening of the areolae, with nausea and vomiting, and other nervous 
 sympathies w^hich may lead to a suspicion of early pregnancy. 
 
 Diagnosis. — The state under consideration is most apt to be mistaken 
 for early pregnancy, or for a fibroid tumour, and more rarely for 
 cancer of the fundus uteri. A careful examination of the menstnial 
 functions, and some patience, are required to avoid the first mistake in 
 differentiation, and our chief diagnostic physical signs will be found in 
 the presence or absence of the softened cervix of pregnancy, and still 
 more in the shape assumed by the uterus, and ascertainable by bi-manual 
 examination. In hypertrophic enlargement the uterus is enlarged 
 equally, and in its later stages, at any rate, the substance is firm and 
 hard. In pregnancy, on the other hand, there is distinct bulging of the 
 anterior Avail of the uterus, and the substance is softer and more indistinct 
 to the touch. Also, if actual contraction of the uterine muscular tissue, 
 w^hile under examination, could be made out, the strongest evidence 
 would be afforded in favour of pregnancy. It is seldom if ever felt 
 under other circumstances. 
 
 The existence of a small fibroid tumour can generally be differentiated 
 by dilatation of the cervix and exploration of the interior of the uterus, 
 and by the history of the case, but in many instances the diagnosis is 
 for a time very difficult, and may have to be left in doubt till further 
 growth of the fibro-myomatous affection or diminution of the hypertrophic 
 enlargement helps to clear it up. The existence of any decided irregu- 
 larity of the surface of the uterus would point to the presence of fibroid 
 tumours. 
 
 Cancer of the body of the uterus only is comparatively a rare affection. 
 Its history is one of short duration, of severe and localised pain, and of 
 violent haemorrhage and foetid discharges, but in cases of doubt the 
 diagnosis can only be arrived at by dilating the cervix sufficiently to 
 allow of the passage of a blunt curette, and by a careful microscopic 
 examination of any scraps which can be thus removed. Sarcoma will be 
 more fully alluded to when speaking of fibroid tumours, or of the 
 affection itself 
 
 Before referring to the treatment called for by this condition of con- 
 nective tissue hypertrophy, or hyjDcrplasia of the body of the uterus, I 
 should mention the fact, now recognised by all pathologists, that that 
 portion of the cervix uteri which lies above the insertion of the vagina, 
 and which to the finger alone would appear to be a portion of the body, 
 is often affected by hypertrophy, either alone, or along with the intra- 
 vaginal cervix, or with the body. Much ingenuity has been shown in 
 devising nomenclature for such localisations of the one pathological state. 
 
AND TREATMENT. 
 
 253 
 
 but I think sufficient is said for all practical purposes at present, if I call 
 attention to the fact that the uterus may appear to be very low in the 
 vagina, in fact completely prolapsed, without much apparent elongation 
 of the cervix, and yet with retention of the fundus, at or about its normal 
 height (fig. 120), and that where this occurs it is frequently due to elon- 
 gation of the supra-vaginal portion of the cervix. This will be again 
 referred to when speaking of the diagnosis and treatment of prolapsus 
 iiteri. 
 
 The treatment of this affection can never be undertaken without its 
 being accompanied by a careful attention to other disorders which may 
 stand in relation to it as causes or as effects, not infrequently as both. 
 Thus the endo-metritis which is so frequent a concomitant demands 
 those local or general remedies described above. The same remark applies 
 to chronic inflammation of the pelvic structures or its resulting exu- 
 dations (Chap. XIX.). Displacements of the uterus must be treated by 
 efficient supports, and the treatment 
 must be accompanied jmH passu with 
 that of the hypertrophic state. Even 
 though the latter may have been the 
 sole cause of the former, it is aggravated 
 and kept up by its continuance. The 
 general health must be attended to, and 
 all means observed which are otherwise 
 required for the improvement of the 
 nutritive processes and the removal of 
 anaemia. Among these, iron is strongly 
 denounced as almost a poison by Tait 
 and some other writers, when there is 
 any tendency to haemorrhages, though 
 quinine, strychnine, cod-liver oil, and the 
 like are approved of. I cannot join in the 
 condemnation of iron, if given in small 
 and digestible doses. The constitutional treatment must specially 
 include attention to the free action of the bowels by small doses of salines. 
 This not only promotes digestion, but diminishes pelvic congestion. If 
 the functions of the heart or liver arc disordered, they also demand 
 appropriate treatment, such disorders being fertile sources of passive con- 
 gestion. Kxaow^ prophylactic means, wc must note the judicious manage- 
 ment of labour or abortion, including prolonged recumbency witho^'ut 
 too much restraint, tlae encouragement of natural sxickling, and the 
 free use of ergot during the first puerperal weeks. This is, I believe, a 
 necessity with all those atonic women who form the majority of our 
 town ].opulation. I have already referred to tlie advisability of an 
 
 Fig. 120.— Hypertrophy of the Supra- 
 Vaginal Portion of the Cervix Uteri 
 (Schrceder). Pseudo-prolapse. 
 
254 THE TREATMENT OF 
 
 examination of the utenis a few weeks after the occurrence even of natural 
 labour, to ascertain the existence or otherwise of torn cervix, lateral 
 pelvic exudations, &c. Another important prophylaxis is found in the 
 prevention of prolonged standing, in all women employed as shopkeepers, 
 or otherwise subject to it, and especially at the menstrual periods. 
 Physiological rest of the organs is also a factor of great importance. No 
 woman should, if possible, become impregnated for two or three months 
 after labour, and still more after miscarriage, and if any symptoms of sub- 
 involution have been developed the period should be still more prolonged. 
 Among curative measures, the most important, in all cases w-hich 
 succeed to labour or miscarriage, is to make perfectly certain whether 
 any of the products of conception have been retained, and if so, to 
 remove them. Small portions of placental structure or of membrane 
 may remain long adherent, and whether there is or has been any foetid 
 discharge or not, are always to be suspected when metrorrhagia or even 
 menorrhagia is persistent. In such cases the os may be patulous 
 enough to allow the passage of a finger into the uterine cavit}', while 
 the fundus is depressed by the other hand, and an anaesthetic greatly 
 assists the manipulation. "\^Tien this is impossible, a tupelo tent, and a 
 second, or a third if necessary, must be inserted. For the removal of 
 such adherent portions the finger alone may suffice, but may require 
 to be supplemented by a blunt wire ciu-ette (fig. 58), and the removal 
 must be followed by an injection of carbolised water into the uterus 
 through a wide double catheter. If much engorgement or subacute 
 inflammation seems to exist, the use of the glycerine plugs and the 
 hot-water vaginal douche is now of ser^^ce, and lessening of all the 
 symptoms will speedily follow. I seldom or never now use scarification 
 of the cervix in such cases unless it is otherwise indicated. Among 
 internal remedies, ergot is, j^o.^'^ excellence, the one on which reliance is to 
 be placed, and it should be given freely ; 30 or 40 minims of the liquid 
 extract, or 3 grains of Bonj can's ergotine three or four times daily, at 
 least. TVTiether it acts mainly by producing contraction of the vessels, 
 and thus diminishing h^qDersemia, or by astringing the whole uterus 
 through its muscular tissue, I do not pretend to say, but its action in pro- 
 ducing temporary and permanent diminution in size is often undoubted. 
 Strychnia and quinine, both as tonics, and in reference to their specific 
 action on the uterus, may be given at the same time, and if the heart 
 and circulation generally are feeble, digitalis or convallaria may be com- 
 bined with advantage. The salts of potash have been highly lauded by 
 Bintz as having a specific action on uterine involution, and provided the 
 salt is soluble and not repugnant to the digestive organs, it is, accord- 
 ing to him, immaterial which is given — the citrate, chlorate, or bromide. 
 The latter of these fulfils the further object of allaying ovarian or pelvic 
 
UTERINE HYPEETEOPHY. 255 
 
 uneasiness, and, holding the action of the potash as still sith judice, should 
 be preferred. Whether iodine or mercury in its mildest forms have an 
 absorbent action in true sub-involution or hypertrophy, is much doubted 
 by many, if not most, writers. My own experience leads me to believe 
 that in some cases, and I cannot pretend to differentiate them from others, 
 I have occasionally seen rapid benefit from both of these agents. The 
 free and frequent painting of the cervix and upper end of the vagina with 
 tincture of iodine may be resorted to, and seems occasionally to produce 
 an absorbent action on the body of the organ, but, in the absence of 
 speedy results, the practitioner must avoid dallying thus with his patient's 
 time and purse. The treatment of lacerated cervix has been fully 
 dwelt on, and both that and amputation of redundant portions are 
 undoubtedly often followed by diminution in size of the enlarged fundus. 
 The treatment of these affections of the uterine body by destruction of 
 the cervix, or a portion of it, by potassa fusa, is, in my opinion, simply 
 barbarous. If any good result is ever produced, it is at the expense 
 of future suffering. 
 
 There is no use, however, in disguising the fact that when the body 
 of the uterus is once chronically hypertrophied, it is apt to be so for 
 life, or till long after the menopause. Its attendant symptoms, or 
 rather its attendant accidents, may be prevented by judicious care while 
 its existence remains, but these attendant consequences are so numer- 
 ous, especially in the form of uterine displacements, that no efforts, 
 harmless in themselves, should be spared to diminish it, while the too 
 frequent futility of all treatment should lead us to abstain from mea- 
 sures which may do serious mischief and which have no assured success. 
 I cannot, however, in this affection, endorse the opinion of Goodell, who 
 says — " I have come to the conclusion that he is the most successful 
 gynaecologist who is intelligently the most pluckj^, and that, no matter 
 how severe or how mild the treatment of uterine disorders, the percentage 
 ■of accidents will be about the same, and that a very low one." 
 
256 FIBROID TUMOUES OF THE UTEEUS. 
 
 CHAPTER X. 
 
 Diseases of the Uterus — continued. Fibro-myomata or Fibroid Tumours 
 Uterine Polypi. Fibro-cystic Tumours. 
 
 Fibro-myomata or Fibroid Tumours. 
 
 Although these growths are excessively common, we know almost 
 absolutely nothing of the causes which give rise to them. We do know 
 that they arise, for the most part, if not universally, during the period 
 of sexual fertility (Oerum of Copenhagen, in 1002 autopsies, found 
 no case under twenty years of age; 1 in 150 vmder thirty; and 12 
 per cent, after forty), that before puberty they are almost unknown, and 
 that after the menopause they very frequently shrink, or at any rate 
 cease to grow ; that they are most common in those who have borne 
 children, and that they are not traceable to previous inflammation, to 
 traumatic causes, or, as far as we can tell, to endemic influences, 
 although the negro race exhibits a special liability to them. Hence we 
 deduce the belief, probably a correct one, that they are associated as 
 accidental redundancies with those changes of tissue which are perpetually 
 recurring, from month to month, in the uterus. 
 
 In size they may vary from that of a pea to that of the largest melon. 
 The uterus may contain but one, or it may contain an enormous number 
 of them (fig. 121). Physically, they vary considerably, from a pearly- 
 white colour and dense hardness, to a reddish-grey aspect and much 
 softer consistency. These two extremes of colour and consistence are 
 partly due to a gi'eater or less vascularity, and partly to the predomin- 
 ance of the fibrous or muscular element. The less vascular and the more 
 fibrous, the whiter and firmer are these growths. They are generally 
 attached but loosely to the surrounding muscular tissues, except at one 
 or two points, and the loose tissue around them forms a sort of capsule. 
 There is, however, no time capsular membrane ; and when the muscular 
 element prevails, there may be little (if any) boundary between tumour 
 and uterine wall. Their vascular connection Avith the uterus is generally 
 limited, and often seems to be almost entirely severed ; but the uterine 
 wall in their neighbourhood is often very rich in large vessels ; so 
 much so, that the uterine souffle is often heard over them as distinctly 
 
THEIR VAEIETIES. 
 
 257 
 
 as it is over the pregnant uterus, a phenomenon also occasionally due to 
 their own vascularity (see below). Their microscopic structure is that of 
 combined fibroma and myoma (of connective tissue and unstriped muscu- 
 lar fibre) ; the former generally, but by no means always, predominating. 
 These structures are grouped together in many bundles and distinct whorls, 
 which are often apparent enough to the naked eye ; and on a section 
 being made there is frequently a rough appearance, due to the bulging 
 outwards of the whorls. Whatever nerves are traceable into their struc- 
 ture are usually little sensitive to pain. There are often loose interspaces 
 between the bundles of tissue, and these are liable to serous infiltration, 
 causing variations in the apparent size and hardness of the same tumour at 
 different times. According to Klob, they are liable to lymphangiectasis, or 
 
 Fig. 121.- -Multiple Fibroids of the Uterus (Boivin et Duges). 
 
 dilatation of their lymphatic channels ; and Virchow describes a cavernous 
 type, where the blood-vessels are largely developed. This form is also 
 accompanied by the uterine or falsely-named placental sotiffle. These 
 feattires, and others to be afterwards mentioned, account for the occa- 
 sional occurrence of large pseudo-cysts (fig. 122) {see " Fibro-cystic 
 Tumours "), which alter the physical characters of the growths very 
 much, and add greatly to the difficulty of their diagnosis. Occasionally, 
 though rarely, abscess may form in the substance of large fibroids, 
 giving rise to agonising pain. I aspirated one such tumour several 
 times, and finally got rid of this complication, while leaving i\\c tumour 
 otherwise untouched. 
 
 These growths may alter or degenerate in other ways. Occasionally 
 complete involution or disappearance takes place ; this will be more 
 
258 UTEFJNE FIBEOID TUMOURS, 
 
 particularly mentioned in relation to treatment. Fatty degeneration 
 frequently occurs, and is generally associated with arrest of growth, or 
 even disappearance ; and Klein wachter expresses a belief that, in mul- 
 tiple fibro-myomata, many of the centres have a definite career of de- 
 velopment impressed upon them from the first. Calcification is a rare 
 sequel, but has led to attempts at cure by the administration of the 
 chloride of calcium. Naturally calcified fibroids have been expelled as 
 
 Fig. r2"2.— Uterine Filu-oids, with Cnvemous Structure (Fibro-cystonia) in one 
 of them (Schrceder). 
 
 a species of uterine calculus. (Gangrene, from the destruction of the 
 vascular connection, is by no means unknown, and the result of this 
 may be spontaneous attempts at expulsion of the dead mass, — successful 
 occasionally, or leading to death by septictemia. It is a moot point 
 whether true cancer is ever developed in their substance, but I feel almost 
 absolutely certain that I have, more than once, seen the development 
 of rapid sarcoma in fibroids of long and slow gro^\'th : and this is 
 
THEIH VARIETIES AND TYPES. 
 
 259 
 
 ^ 
 
 consistent with the similarity between the ultimate histological con- 
 stituents of these two forms of tumour. 
 
 Fibroids are most commonly developed in the body of the uterus, — 
 and it is advisable to consider those of the cervix separately. The pos- 
 terior wall of the uterus is more liable to their presence than the anterior, 
 and the side least of all. Similar structures are met with, although 
 comparatively rarely, in other parts of the genital apparatus where mus- 
 cular structures exist, such as the ligaments, Falloi^ian tubes, ovaries, 
 vagina, or vulva ; aiid a similar form of tumour, though rarely large, is 
 met with in the male prostate. The uterus itself (even those portions 
 which are not themselves in- 
 vaded) is altered in shape and ■ • ''"^\ 
 consistency by the presence 
 of a fibroid growth. Thus a 
 fibroid mass at the lower por- 
 tion may cause general hyper- 
 trophy in its strictest sense, 
 just as obstacles to the action 
 of the heart cause tnie hyi^er- 
 trophy there ; the mucous 
 lining which covers a fibroid 
 may also hypertrophy or 
 attenuate, and the whole organ 
 may, by even a small fibroid, 
 be tilted backwards or for- 
 wards, pushed downwards, 
 dragged upwards, or even 
 turned inside out in the form 
 of inversion {rj.v.). In the 
 case of subserous fibroids, i.e., 
 those growing from the outer 
 wall, there may be no en- 
 largement, but even atrophy 
 nf the uterus. I removed one weighing 12 lbs. by abdominal section, 
 when the uterus was of extreme infantile type and size, the supra- 
 \-aginal portion of tlic cervix forming a fine pedicle of less than half 
 an inch in diameter. 
 
 Types of Fibroid Tumours. — It was a true clinical instinct which 
 first led t(i the division of these tumours into three types — the inter- 
 atitial, the subserous, and the stib-niucous (fig. 123). All fibroids are in a 
 sense " interstitial," seeing that they all take their origin from the middle 
 or parenchymatous coat of the uterus ; but in the permanently intei-- 
 .stitial form thcv remain imbedded in the substance of tlie wall, iiicreas- 
 
 Fjg. V2o. — Typical Varieties of Fibro-niyouiata, 
 semi-diagrammatic. 1, sub-serous ; 2, sub- 
 mucous ; 3, interstitial ; 4, iutra-uteiine poly- 
 poid ; 5, cervical. 
 
260 TYPES OF UTERINE FIBROIDS, 
 
 ing, when large or numerous, the size of the Avhole organ, but not 
 tending to protrude outwards or inwards, and so to become pedunculated, 
 as is the case with the other foims. 
 
 The sub-serous, or sub-peritoneal type, on the other hand, makes its 
 way by growth in an outward direction, and protrudes from the surface 
 in a more or less polj-poid form. The pedicle may become so thin as to 
 allow the tumour to float freely in the abdominal cavity, and this 
 may cause difficulty in diagnosis as to its uterine origin ; or, retaining 
 more or less of a sessile character, the tumour may drag the uterus up, 
 elongating its cavity to double or treble the normal lenglh. Adhesions 
 may occiu- to sun-ounding parts, and the original pedicle may be 
 stretched to the extent of severance — the fibroid thus transfening itself 
 to completely new quarters. Twisting of the pedicle, leading to gangrene 
 of the tumour, has been met with, but this is a more frequent occurrence 
 with ovarian tumours. 
 
 The sul-mticous variety gTows towards the cavity of the uterus, and 
 has also a tendency to pedunculation. When the pedicle becomes distinct, 
 such tumours are kno-\Mi as "uterine fibroid polypi." Owing to its 
 invasion of the uterine cavity, the sub-mucous variety of fibroids gives 
 rise to by far the most serious symptoms, and as this is also the form 
 which is most easily within reach of surgical interference it is in every 
 way the most important. Fig. 123 shows diagrammatically the several 
 types of fibroid. 
 
 The presence of large fibroid growths is consistent with impregna- 
 tion and delivery at full time. In a case attended by me, which 
 had been, previous to impregnation, observed by Martin of Berhn 
 and Sir Spencer Wells, I found, after dehvery, a tumour much larger 
 than a cocoa-nut and diu'ing the period of noiTaal involution I 
 commenced giving large doses of iodide of potassium. Whether as a 
 result of this, or not, I am of course unable to say positively, but rapid 
 diminution commenced from the first, and in less than a year there was 
 no trace of fibroid left. Others have also noticed this tendency to 
 absorption during the post-puerperal involution period, and Schroeder 
 gives a list, with references, of thirty-six recorded cases of disappearance 
 of fibroids at that or other times, although only one-sixth of the member 
 were stated to have occurred during the post-puerperal time. The usual 
 result of large fibroid growths is, however, sterility of more or less 
 mechanical causation, or abortion from interference with the normal 
 process of gestation. 
 
 Symijtoms. — The symptoms caused by a uterine fibroid vary very 
 greatly, this variety being due mainly, though not wholly, to the mode of 
 its implantation. In siib-serous or even, not very infrequently, in intersti- 
 tial examples, there maybe absohitely no subjective symptoms at all, and 
 
AND THEIR SYMPTOMS. 261 
 
 their discovery, even when of considerable size, may be purely accidental. 
 I have several times been consulted by ladies recently married, whoso 
 husbands were the first to suspect that there was something wrong, 
 though the mere fact of marriage had in one or two of these produced 
 hypersemia, and led to some discomfort unfelt before. The sub-mucous 
 form is rarely, if ever, free from symptoms. In a general way the 
 symptoms may be defined as consisting of : — 
 
 1. Menorrhagia. 
 
 2. Metrorrhagia. 
 
 3. Dysmenorrhoea. 
 
 4. Pressure symptoms upwards. 
 
 5. Do. do. downwards. 
 
 1. Menorrhagia is undoubtedly the most common symptom, and is 
 scarcely ever absent in the sub-mucous variety, rarely in the inter- 
 stitial. It may creep on gradually, and almost unnoticed at first, or 
 may be developed pretty acutely. It depends on the irritation, and 
 consequent hypersemia, often with chronic thickening, to which the 
 lining of the utei'ine cavity is subjected, and it is the chief source of 
 danger. The same condition of the mucous membrane may cause per- 
 manent leucorrhoea, but this is by no means so constant. Whenever 
 a woman of thirty years of age or thereabouts begins to suffer from 
 menoiThagia, fibroid tumour must be strongly suspected and searched 
 for. 
 
 2. Metrorrhagia frequently accomj)anies menorrhagia on very slight 
 provocation, and sometimes occurs suddenly, and with excessive violence. 
 
 ■ Death has occurred in this way as the first and only symptom. The 
 discharge thus caused, or even that caused by menorrhagia, is not free 
 from danger in other ways than by its mere excess ; its retention may 
 give rise to septicaemia. About two years ago, in consultation witli one 
 of my colleagues, I saw a lady, who had a violent attack of flooding, there 
 having been no previous menorrhagia or other s3'mptom of disease. 
 She had, very properly, been plugged before I saw her. On removing 
 the plug a large sub-mucous fibroid was clearly discernible, the os being 
 widely dilated by its pressure. Little or no further hajmorrhage 
 occurred, but on the third day the temperature ran up to 105°, tlic 
 pulse followed suit ; there were slight rigors and some anomalous head 
 symptoms, and she died in a very few hours, evidently of septicremia. 
 
 3. Dysmenorrhoea, when it occurs, is due either to the mechanical 
 obstruction to the flow, with consequent uterine forcing, or to the reten- 
 tion of clots with a similar uterine action, or to the general congestion, 
 with or without a certain amoiuit of endo-metritis, or perhaj^s to flexion 
 of the uterine body and canal. 
 
 4. Pressure symptoms upwards are nuich more rarely felt than niiglit 
 be supposed from the enormous size often attained bv these growtlis. 
 
262 SYMPTOMS AND PHYSICAL SIGNS 
 
 Indigestion may show itself in various ways, the cause being at first 
 httle suspected. The pressure on the abdominal walls is so gradual that 
 it is often long unfelt, but respiration and general circulation are ulti- 
 mately interfered with. Neuralgia of very indefinite seat is also common, 
 and as with other abdominal tumours, chronic peritonitis may be set up. 
 Yet, though the latter result does occur, the great infrequency of ab- 
 dominal inflammatory adhesions, or of ascites, may almost be said to 
 distinguish fibroids from tumours of a more malignant natiu-e. 
 
 5. Pressure symiotoms downwards in the pelvis are, on the other hand, 
 very common, and, next to hsemorrhage, their results constitute the chief 
 danger of this afi"ection. Such symptoms are apt to be aggravated at the 
 menstnial periods. The bladder or urethra is chiefly interfered with, and 
 sudden retention of urine is often the first symptom which leads to a diag- 
 nosis. The constant pressure of even a small fibroid in the anterior wall 
 of the uterus may set up true cystitis, which I have often seen treated, 
 and of course ineffectually, as the sole aff'ection. Pressure on the rectum 
 may cause constant tenesmus and constipation, and the pelvic veins and 
 nerves are aflfected as they are in pregnancy. Paraplegia is a very rare 
 result of the pressure. Pressure on one or both ureters may occasion 
 stasis in the renal flow and consequent hydronephrosis, and Matthews 
 Duncan has especially pointed out the occasional, though fortunately rare, 
 occurrence of ursemic poisoning and death in this ^\i\.j. There is no more 
 miserable state than that of a woman, in whom a fibroid tumour has de- 
 veloped with sufiicient rapidity and latency to become incarcerated within 
 the true pelvis. The irremediable pressure symptoms are constantly on 
 the increase. As soon, therefore, as such a growth is discerned, of any size, 
 steps should be taken to raise it above the brim of the pelvis, if possible. 
 
 The symptoms of a strangulated sub-serous fibroid are those of collapse, 
 combined with the physical signs of tumour, thus resembling those 
 produced by a sloughing sub-mucoiis one. All the symptoms due to a 
 fibroid may and do often abate after the cessation of the menstrual 
 epoch, and more or less shrinking of the mass may also then occur. The 
 same change may, though it comparatively seldom does, happen spontane- 
 ously before this period, and, as I have mentioned above, is met with 
 as an occasional accompaniment of x>ost-2KirUi7n involution. This may be 
 looked on as the most satisfixctory natural attempt at cure. Other nK)ri' 
 or less unsatisfactory attempts are made by pcdunculation or slough- 
 ing, or enucleation of the mass, and its subseqiient expulsion by uterine 
 contraction; but these will be best referred to when speaking of what 
 can be done by art in the way of c\u-e. 
 
 Physical Signs. — The i^hj-sical signs of fibroid growths are those ascer- 
 tained by abdominal palliation and ausciiltation, by bi-manual examina- 
 tion, by the sound, and, in tlie sub-muco;is variety, by dilatation of the 
 
OF FIBKOID TU.MOUUS. 26I-> 
 
 curvix. If the tumour is large enough, there is felt above the pubes a 
 tirni, hard, uou-fluctuating, rounded mass. It is perfectly smooth, as a 
 rule, but there may be distinct knobs of similarly smooth hard tissue, 
 or an equally distinct sulcus in the mass, — both of which indicate the 
 existence of multiple growths. The tumour is generally freely movable 
 from side to side. It may be quite central or quite lateral. It never, 
 in my experience, shows contractility when grasped with the hand, and 
 it is generally, though with some exceptions, almost painless to the 
 touch. A distinct souffle is not very infrequently heard, which cannot 
 be distinguished from the uterine souffle of pregnancy. On combined 
 manipulation we can detect the physical signs of smaller fibroid tumours 
 than can be made out as above. The uterus is felt to be larger and 
 heavier than normal, except in the case of very distinctly pedimculated 
 sub-serous growths. Nevertheless, it is freely movable, unless the tumour 
 is very large, or has previously excited pelvic inflammation. The shape 
 varies, but it is seldom quite that of a gravid uterus of the same 
 size, though it may resemble it very closely, and the consistency is 
 firmer. There may exist a decided offshoot, most commonly behind, 
 which is totally unlike anything else of purely uterine origin, though an 
 adherent ovai'ian tumour may cause difficvilty in diagnosis. In the case 
 of large tumours the whole brim of the pelvis may be blocked by a solid 
 mass, from some portion of which the cervix iiteri will be found to project. 
 The cervix is thus to be detected ordinarily as a distinct nipple, more or 
 less of the normal size and shape. It has never the characteristic 
 softening of j^regnancy, biit may be abolished and stretched out over 
 the mass in the intra-uterine or sub-mucoiis variety, as it is at the full 
 time of pregnancy or during labour. 
 
 The sound will give valuable evidence, if it can be introduced at all, 
 which is not always possible; it will, in the case of large tumours, show 
 a greatly elongated cavity, and as this may be twisted and inaccessible 
 to the ordinary soimd, a gum-elastic one may be used. The direction 
 of the sound will show the direction of the cavity, which may be traced 
 in any direction, either as following the centre of an interstitial, or bend- 
 ing round a sub-mucous growth. When pregnancy can be set aside, and 
 when uterine enlargement undoubtedly exists along with uterine haemor- 
 rhage, dilatation by the sponge or tupelo tent admits the finger, which 
 can thus detect, in the case of sub-mucous fibroids, the presence of a 
 solid mass bulging into the uterine cavity, and adherent to its walls. 
 
 Small fibroids, growing outwardly from the anterior or posterior ex- 
 ternal wall, can only be made out ])v careful l)i-in;uiual examination, 
 which shows their continuity with the uterus, and their mobility with 
 it, wliile the fundus is felt as a separate ]>rotul>ei'iuirt\ a fart corroborated 
 l)y the passage of the soiuul within it. 
 
264 THE DIAGNOSIS 
 
 Diagnosis. — The diagnosis of uterine fibroids, generally easy, is some- 
 times fraught with great difficulty. The following conditions may be, 
 and have occasionally been, mistaken for it : — 
 
 (1) Pregnancy; (2) ovarian tumours; (3) hsematometra and hydro- 
 metra; (4) chronic metritis or hypertrophy; (5) cancer; (6) pelvic exuda- 
 tions — peritonitic, cellulitic, malignant, or from hsematocele; (7) u.terine 
 flexions; (8) extra-uterine foetation ; (9) feecal accumulation ; (10) growths 
 of the bony pelvis. 
 
 Briefly, these may be difi'erentiated as follows : — 
 
 1. Pregnancy has a history of suppressed menstruation versus menor- 
 rhagia in the case of fibroid growths. Mere sympathetic signs, such as 
 swelling of the breasts, sickness, &c., are common to both afiections. 
 Pregnancy has a very definite rate of increase in the size of the tumour, 
 and the swelling is w^anting in hardness, is always of one definite shape, 
 and is often contractile on manipulation. The changes of the cervix in 
 pregnancy are equally definite. The uterine souffle is infinitely more 
 common in pregnancy, but not per se diagnostic. The foetal heart must 
 be watched for, and if necessary waited for, in all doubtful cases, until the 
 safety of using the sound is assured. Ballottement is never met with even 
 in the case of intra-uterine or polypoid fibroid growths. I attach little 
 importance to the purple discoloration or pulsation of the vaginal walls; 
 I have seen them as great with a fibroid as in pregnancy. In all doubt- 
 ful cases the safe plan is to wait and watch, and avoid rash diagnosis 
 {see Appendix). 
 
 2. Ovarian Tumours.- — Small solid ovarian growths may closely re- 
 semble sub-serous fibroids, but complete separation from the uterus, 
 ascertained by bi-manual examination, and the absence of increased 
 menstruation, or of lengthening of the uterus, indicate ovarian 
 tumour; also great rapidity of growth, or the presence of ascites will 
 distinguish sarcomatous ovarian growths, true slow-growing fibroids of 
 the ovary being excessively rare — the presence of fluctuation in the 
 tumour points almost certainly to ovarian origin (but see Fibro-cystic 
 Tumours). A small ovarian tumour glued to the uterus by inflamma- 
 tion is indistinguishable except by aspiration and examination of the 
 fluid contents, if any. Large ovarian tumoui's should seldom be mistaken 
 for pure fibroids ; their physical signs will be discussed later. Cysts of 
 the broad ligaments or Fallopian tubes may for our present purpose be 
 classified along with ovarian cysts. 
 
 3. Hmmatometra and hydrometra (see Chap. VI.), besides their 
 fluctuating or elastic properties, and the recognisable occlusion of the 
 genital canal at some point, have a very definite and distinguishing- 
 history of their own, and absence of haemorrhage is also a distinguishing 
 feature. 
 
OF UTERINE FIBltOIDS. 265 
 
 4. Chronic metritis or hypertrophy, which we discussed in the last 
 -chapter, has also a history connecting it with some puerperal or other 
 causation. It never assumes the size of very large fibroids, is never 
 multiple or divided in shape, but it must be confessed that a moderate 
 sized interstitial fibroid and a quiescent chronic hypertrophy cannot 
 always be differentiated by physical signs ; their histor}', past or future, 
 is our sole guide. 
 
 5. Malignant disease of the fundus uteri has often for a time the same 
 physical signs as a fibroid growth, but generally commences later in life. 
 Its rapid increase, its predominating painfulness, its greater tendency to 
 metrorrhagia, its rapid fixation, and its early accompaniment by foetid 
 or watery discharges, soon excite suspicion, and lead to dilatation of the 
 cervix and exploration of the cavity, with microscopic search for the 
 cancerous elements. The diagnosis can only be made certain in this 
 way. But multiple sarcoma may for a time retain every one of the 
 characters of multiple fibroid growths. The presence of tumours in 
 other organs w^ould point to malignancy. 
 
 6. Pelvic exudations of lymph, coagulated blood, or malignant deposits, 
 may resemble fibroids in their hardness and apparent connection with 
 the uterus. The history of a pelvic inflammation or hsematocele is there 
 to guide us, and the comjDlete fixation and imbedding of the uterus 
 confirm' our difi'erentiation. The sound will probably show the uterus 
 to be normal in size, though perhaps altered in position by the exudation. 
 But if deposit has occurred round a pre-existing fibroid, with no distinct 
 previous history of its own, time and careful watching of the process of 
 absorption in the exudation may alone reveal the double character of the 
 ■disease. 
 
 7. Uterine versions, and still more flexions, may, without care, be easily 
 mistaken for small fibroids of the anterior or posterior wall, though the 
 reverse is more often the case. A smooth rounded mass in Douglas's 
 pouch, or in front of the uterus, easily movable with that organ, may be 
 either. Mere symptoms are in no way diagnostic, neither is the direc- 
 tion of the cervix. But the direction taken by the sound, and its power 
 of completely moving the body of the uterus and replacing it in its 
 normal situation, reveal the true chai'acter of the aff"ection. A bi- 
 manual examination should always be made before and after reposition 
 by the sound. If the uterine contour can be thus traced, it will show 
 that the replaced uterus has still adherent to its wall a small projecting 
 fibroid, which, by its weight, caiiscd the displacement. 
 
 8. Extra-uterine Foetation. — This comparatively rare affection, whose 
 pathology appertains rather to obstetrics, has occasionally been mistaken 
 for fibroid tumour, though much more often for a tumour of the ovary. 
 The distinct history, up to a certain point, of pregnancy, then, perhaps, 
 
266 DIAGNOSIS or uteeine eibkoids. 
 
 that of a severe attack of pain and collapse recovered from, or the con- 
 timied signs of pregnancy, with those of a living child, and the various 
 signs which differentiate a uterine from a non-uterine tumour, are our 
 main guides. Growth is more rapid than with a fibroid, attacks of 
 peritonitis are more common, and the tumour may show signs of fluid 
 contents, with or without aspiration. 
 
 9. Fcecal Accuviulations. — I would not insert this were it not that I 
 have lately seen a fibroid mistaken more than once for an accumulation 
 of feeces. If the physical signs were not sufiicient to prevent this 
 the result of treatment would soon prove so. 
 
 10. Bony growths of the pelvis are more fully discussed in obstetric 
 works. 
 
 The diagnosis of the three types of fibroid tumour — sub-peritoneal, inter- 
 stitial, and sub-mucous — from one another, is not always possible, yet it 
 is highly important, before deciding on any mode of surgical treatment : 
 the chief reliance must undoubtedly be placed on a careful estimate 
 of the physical signs observed bi-manually, or with the aid of the sound 
 or cervical dilatation. We must endeavour thus to make out not onl}' 
 the fact of a solid uterine growth, but its whereabouts in relation to the 
 organ. Purely sub-peritoneal fibroids are usually very hard, slow in 
 growth, often multiple, and unaccompanied by much heemorrhage or 
 menorrhagia. If pedunculated they are also generally painless, but when 
 they are sessile they are sometimes the most painful of all, the pain being- 
 constant, and not irregular and expulsive, as in the case of intra-uterine 
 growths. The interstitial tumours are usually quicker in growth, and 
 take an intermediate place between the sub-peritoneal and the sub- 
 mucous in relation to pain and haemorrhage. Haemorrhage and mucous 
 discharges are most frequent with the sub-mu.cous, as is also pain of 
 a distinctly spasmodic, forcing, and intermitting character. In all 
 our calculations as to treatment, it is necessary, however, to bear in 
 mind that the proved existence of one uterine fibroid of any of the three 
 clinical types is presumptive evidence of the real or potential existence 
 of others which ma}' assume a different relation to the uterine Avail or 
 cavity. 
 
 Treatment. — The treatment of fibroid tumours is, in virtiie of their 
 extreme frequency, a matter of great importance, and it is highly 
 desirable that every practitioner should have clear ideas of what can 
 and what cannot be done in this direction, even though he may not be 
 prepared himself to imdertake some of the more serious operations 
 which have been j)i"oposed. As a preliminary, it is desirable to sec 
 what Nature occasionally attempts herself 
 
 There are six ways in which Nature may be said to undertake the 
 ciu-e of fibro-myomata : — 
 
nature's effokts at cuke. 2G7 
 
 T. By absorption. 
 
 2. By the mcuopciuse, which may lead to absorption, complete or 
 
 partial, or to mere quiescence and arrest of growth. 
 
 3. By extrusion into the uterine cavity as polypi, and subse- 
 
 q\ient expulsion. 
 
 4. By calcification, with arrest of growth, ciuiescence, or expul- 
 
 sion as foreign bodies. 
 
 5. By ulceration of the mucous covering and ex- y 
 
 pulsion. \ enucleation. 
 
 6. By sloughing of the whole mass and exi)ulsion. \ 
 
 1. Of absorption we have already spoken. Recorded facts leave no 
 doubt as to its occasional occurrence at the menopause, or during 2^osf- 
 partum involution, or otherwise. Common exi^erience demonstrates its 
 infrequency, except in the first instance. 
 
 2. The quiescence of all symptoms, and cessation of growth, without 
 absorption, are not uncommon at the menopause, and may occur previ- 
 ously or subseqiiently. The cessation of the periodic hyperemia explains 
 this fully enough at the menopause ; when occurring at other times, we 
 have yet to seek for the true explanation, unless it is to be found in 
 Kleinwachter's observation, mentioned on page 258. 
 
 3. ',' Polypisation," to coin a word, occurs equally in the sub-serous and 
 sub-mucovis varieties. The former it affects by diminishing their uterine 
 connections, and lessening their circulation, thereby doubtless retarding 
 their growth — the latter it aff'ects very differently. Projecting them 
 into the holloAv muscular uterus, it increases for a time the gravity cf 
 the symptoms, but as the uterine contraction is encouraged and the 
 pedicle becomes elongated, expulsion through the cervix, and finally, in 
 very favourable cases, complete separation, occ\ir. Art can imitate this 
 by those remedies which lead to uterine contraction, and l)y surgically 
 assisting the final evulsion of the mass. 
 
 4. Calcification is but a rare occurrence, and attcnq)ts to produce it 
 artificially have so far proved futile. 
 
 5. Ulceration of the mucous covering, from tension or ijressure. 
 (jccurs every now and again in large sub-mucous tumours, and as a result 
 the fibro-myoma bulges through, and by uterine pressure maj^ finally be 
 "enucleated" and cast forth. Naturally or artificially this is a dangerous 
 resource. Time and prolonged muscular effort arc required when the 
 attempt is Nature's, and either from this caiise or from septicemic 
 changes during the process, the patient is apt to sink unrelieved. 
 
 G. Sloughing of the whole mass is a still more dangeroiis alternative, 
 and I am not aware that any one has dared to copy it except in the case 
 ( )f complete polypus. 
 
 We may divide the methods of treatment into those which nrc pallia- 
 
268 PALLIATIVE TREATMENT 
 
 tive of symptoms and those -which aim at cure, though, of course, they 
 will sometim.es overlap. 
 
 Palliative Treatment. — The symptoms which we are chiefly called on 
 to palliate are those due to excessive weight and to the consequent 
 pressure on the pelvic viscera, — the rectum, bladder, &c., — and those 
 caused by excessive sanguineous discharges — menorrhagia or metrorrhagia. 
 The mere weight of a fibroid may be made bearable in two ways. When 
 it is large and above the pelvic brim, a well-fitting abdominal belt is of 
 great service, provided that it lifts and does not press down the mass. 
 When smaller, and still within the true pelvis, a watch-spring pessary 
 with a diaphragm (fig. 109) will often give great relief, partly by its 
 mechanical support, and partly by thus diminishing the tendency to 
 passive uterine congestion. A Gariel's air-pessary (fig. 140) is sometimes 
 useful in the same way, and its continuous use tends gradually to lift the 
 mass above the pelvic brim in cases where this cannot be done at once. 
 The tendency of fibroids to temporary oedema, which has been fomierly 
 mentioned, adds for the time being to their weight and size, and when 
 this is suspected moderate saline purgation is of service, especially at 
 the pre-menstrual periods, and if accompanied by rest. Circumferential 
 pressure on the bladder, rectum, and pelvic vessels and nerves is not 
 only productive of great discomfort, but if the tumour cannot, as it 
 increases, pass upwards beyond the brim, may prove fatally obstnictive. 
 Whenever, therefore, the growth assumes large proportions, no effort 
 must be spared to raise it upwards and give it room for expansion. 
 For this purpose it may be necessary to place the patient on her knees 
 and elbows, or rather knees and chest, thereby assisting the pressure 
 made from the vagina or rectum. It should also be borne in mind that, 
 as in the retroversion of the gravid uterus, the sacral promontory ofiers 
 an obstruction which may be evaded by deviating our pressure towards 
 one or the other side of it. Placed in this position, two or more fingers 
 are introduced into the A^agina, and steady pressure is made in the 
 required direction. A second or third attempt will often succeed when 
 a first has failed, and pressure by one or two fingers through the rectum 
 is often more effective than through the vagina. When small fibroids 
 lead to displacement of the uterus, the same treatment by pessaries is 
 demanded as in other cases of the same malposition. 
 
 The menorrhagia and metrorrhagia of fibroids are verj' unamenable to 
 treatment. Such remedies as seem to diminish ovarian hypersemia arc 
 calledfor,in addition to the diminution of general congestion by mechanical 
 support. Bromide of potassium and cannabis Indica may be especially- 
 named. Ergot of rye, by producing uterine contraction, has also a power- 
 ful and a beneficial effect. It should be given for some daj-s previous 
 to the period, and increased during its existence. In a few cases it 
 
OF FIBIiOID TUMOUKS. 269 
 
 seems to do harm and increase the flow, bnt experience of the individual 
 case is the only test. The regular administration of quinine or 
 strychnia has also a tonic and anti-hsemorrhagic effect on the uterus 
 affected by a fibroid. Marriage should be forbidden to the unmarried 
 sufferer, and physiological rest enjoined on the married. 
 
 An attack of metrorrhagia or even menorrhagia may be so severe as 
 to threaten extreme depression or imperil life. In such cases temporary 
 and sometimes extreme measures are required. I have found hot-water 
 bags to the spine occasionally successful, but if not speedily so they must 
 not long be trusted to. The insertion of a piece of ice into the vagina 
 will sometimes cause rapid cessation, but although I have never seen it 
 actually follow, I cannot avoid the dread of inflammatory reaction in the 
 pelvis. Opinion, in many cases such as these, is at present in a state of 
 fluctuation between hot and cold applications. I have now several times, 
 though with some fear, used Emmet's hot-water vaginal injections in 
 fibroid metrorrhagia, and in every case it has seemed to be successful. 
 Above all things avoid the hesitating plan. Here, as in post-jmrtum 
 hsemorrhage, it is the spasm produced by heat or cold that is mainly 
 wanted. Plugging may become absolutely necessary, and, unless the 
 cervix is widely dilated, it is better to plug the cervix uteri than the 
 vagina. One or more tents must be introduced. They should be 
 removed in six or eight hours, and others introduced if the flow continues 
 unchecked. The dilatation of the cervix thus produced will often sufiice 
 to stop the tendency to extreme haemorrhage for long periods. I can 
 hardly endorse the explanations of this fact which I have hitherto seen, 
 but I have none better of my own to offer. Seeing that the hcemorrhage 
 in these cases proceeds mainly from the uterine mucous membrane, and 
 not from that covering the fibroid, the practice of swabbing the cavity 
 with an astringent is rational and often useful, and tincture of iodine, 
 only once or twice diluted, is the best of all, for antiseptic reasons. A 
 Playfair's probe is the best introducer. It is very difficiilt to explain 
 the action of freely incising the tumour itself, or of slightly dividing the 
 cervix in several places by the hysterotome or thermo-cautery knife. 
 Both of these plans are recommended in most systematic treatises. 
 They undoubtedly tend to the furtherance of expulsion or lowering of 
 sub-mucous fibroids ; and, when polypisation is distinctly in progress, I 
 have no hesitation in acting upon the latter suggestion, but I dread the 
 possible result in other cases. When menorrhagia is excessive, by its 
 long duration, rather than by its severity, it may to a certain extent, 
 and with safety, be cut short by passing a plug or successive plugs of 
 the glycerole of tannin and carbolic acid up to or within the cervix. 
 Within recent times the arrest of hscmorrhage has been sought by the 
 removal of the ovaries and the consequent artificial production of the 
 
"270 MEDICINAL REMEDIES FOR FIBROIDS. 
 
 menopause. I prefer to consider this under the heading of curative 
 treatment. Let me merely say here that removal of the ovaries has 
 distinctly been proved to cause cessation of fibroid growth and of con- 
 sequent heemorrhage, and that it has in some few cases entirely failed 
 to do either. 
 
 Curative Treatment. — The curative treatment of fibroids may be fitly 
 -divided into the medical or medicinal, and the surgical. 
 
 As regards the medicinal, the fallacies are endless. We do not know in 
 any case the probable rate of grow^th, or the periods at which that 
 growth may increase or cease. Spontaneous absorption has been already 
 stated to occur occasionally. In the case of smaller tumours, diagnosis 
 from hj^Dcrtrophy is not always certain, and the constant involutionary 
 changes of the uterus — post-partimi, post-menstrual, or ]3ost-inflamma- 
 tory — may deserve the credit we give to our remedies. 
 
 Iodide of potassium would seem to be the most likely of all remedies, 
 or iodine or potassium in various forms. I confess myself unable, after 
 twenty-five years' experience, to say how far they are effective. I have 
 given them in the fullest doses with no more effect than so much water. 
 I have seen very remarkable diminution under their action, but I never 
 could in any case of the sort free myself from the suspicion that natural 
 involution might be the true factor. The same remark applies to the 
 use of the natural waters of Kreuznach or Woodhall. Qlldema and, 
 apparently, solid bulk, have diminished occasionally, but only occasionally. 
 In the only cases of persistent diminution I have seen natural involution 
 undoubtedly played a most important part. Agnosticism is as allowable 
 in medicine as in theology, perhaps more so. The bromide of potassium, 
 which, of course, includes its potassium element, was firmly believed in 
 by Sir James Simpson as a powerful remedy for fibroid tumours. I 
 fear I can only recommend it as a sedative of discomfort, and as an 
 ovarian sedative in haemorrhage. The chloride of calcium (3ss. ter die) 
 has been proposed, to calcify the mass and thus lead to cessation of 
 growth, or to attempts at expulsion, which may be completed by art. 
 General calcification of the system Avould be somewhat of a calamity to 
 the patient, and I fail to see how the very hypothetical action of the 
 remedy is to be directed to one organ only, and even to one special 
 portion. 
 
 Ergot of rye, as we have seen above, may diminish haemorrhage for a 
 time by increasing uterine contractility. Hildebrandt was the first to 
 claim for its subcutaneous injection into the body the power of pro- 
 ducing real absorption of fibroid tumours. Atthill of Dublin has strongly 
 supported this view, as has also A. R. Simpson. I am utterly at a loss 
 to account for the remarkable results said to have been attained by 
 them. I have used it, as prescribed by Hildebrandt, in a wliole ward 
 
THE SUKGICAL THKATMEXT OF FJIUiiJIDS. l?7l 
 
 full of patients, whom I have gathered for thJ inirixjse. I have avoided 
 in most cases, though not in all, the production of local abscesses. I 
 have tried it most perseveringly in consultation practice, and, beyond the 
 trifling contraction and diminution of menorrhagia Avhich result from 
 ergot otherwise administered, I have found no permanent result. To 
 those who wish further to investigate the matter, I would recommend 
 an injection of Bonjean's ergotine, gr. iii. ; chloral hydrate, gr. i. ; and 
 distilled water ^ viii., — or of n^ x. of Tanret's solution of ergotinine. This 
 should be used every other day, and deeply introduced into the cellular 
 or muscular tissues of the Imttock, until success or failure is apparent. 
 A single injection or two in this way, when time is of great importance, 
 is a useful precursor to the ordinar}- use of ergot as a hfemostatic. 
 
 Electrolysis has been freely tried by Cutter of Boston and others, 
 and many cases are reported where its persevering use has appeared to 
 be followed by arrest of growth, or even shrinking and disappearance. 
 But the statistics I have seen have not appeared to differ sufficiently 
 from those which might be obtained from a number of untouched cases. 
 Emmet, moreover, states that many deaths have occurred from peri- 
 tonitis and metritis in cases treated by electrolysis. The results of an 
 almost completely animal diet, also recommended by Cutter, on verv 
 doubtful theoretical grounds, are open to the same criticism. 
 
 The mrgical treatment of fibroids demands very careful consideration. 
 Some of the procedures recommended are the outcome of the successful 
 results of ovariotomy, and this has, perhaps, led to a more sanguine 
 estimation of their safety and value than is yet justified hj facts. The 
 removal of those tumours which exist almost from the first as intra- 
 uterine polypi, or which have in time become such, will be spoken of 
 shortly. With regard to them, surgical treatment has long been in 
 vogue and is eminently successful, and the methods of operation arc 
 matters of pretty general agreement. AVe are now concerned only with 
 those fibi-oids which are sub-serous, whether pedunculated or not, with 
 the interstitial form, and with the siil>mucous varieties which have not 
 
 undergone pol}qDisation. The first of these — the sub-serous fibroids are 
 
 usually free from distressing sj-mptoms, except occasional severe pain ; 
 and as long as life is in no way imperilled ])y that, or by hremon-hagc, or 
 by incarceration in the pelvis, a serious operation is uncalled for and in- 
 admissible. But if the mass can be distinctly ti.scei'taincd to be connected 
 with the uterus by a very thin pedicle, removal by abdominal section is 
 about as safe as ovariotomy. The other two forms often give rise to so 
 much suffering or weakness, only very partially remediable by medicine, 
 that an operation of moderate gravity, and with a fiiir chance of success 
 would be willingly encountered, and may l)e imperativelj^ called for. It 
 nnist not be forgotten, however, in the calculation, that a fibroid of one 
 
272 REMOVAL OF THE UTERINE APPENDAGES. 
 
 kind, or in one locality, is very apt to be accompanied or followed by- 
 others of different localisation. 
 
 Two operations are proposed in imitation of natural processes of cure, 
 viz., (a) the removal of the ovaries, in order artificially to bring about 
 the menopause, with its frequent, though not constant, cessation of 
 hsemorrhage and growth ; and (6) enucleation and evulsion of the 
 mass. The former is applicable to all the three types of fibroid, — the 
 latter to the sub-mucous only, or to interstitial growths which are 
 practically sub-mucous. 
 
 In addition to these two methods, (c) removal of the tumour through 
 the abdominal wall, Avith or without a segment of the uterus ; and (d) 
 removal of the combined uterus and tumour in the same way, or per 
 vaginam,~a.re operations which are at present demanding and securing 
 the fullest discussion at the hands of our profession. 
 
 (a) The most recent and the least dangerous of the two former 
 operations is removal of the ovaries. This was performed, though not 
 for the same purpose, within a few weeks of the same time, by Battey 
 in America, Hegar in Germany, and Lawson Tait in England. Battey 
 was the first to publish his case in America, and the operation is there- 
 fore known there as Battey's. But there is much obscurity as to whether 
 this title is reserved for removal of presumably normal ovaries, and if so, 
 whether it should include their removal for this purpose only or for 
 other purposes. I have a strong objection, not universally shared, to 
 this biographical form of nomenclature. Normal ovariotomy, oophorec- 
 tomy, and the like terms, have also each special difiiculties in the way of 
 application. Removal of the ovaries to imitate the menopause, and thus 
 to imitate nature's most common method of arresting the troubles of a 
 fibroid growth, expresses all that we want at present. But removal of the 
 ovaries alone is not all that is recommended. Without endorsing any 
 particular views as to the function played by the Fallopian tubes in men- 
 struation, their tendency to enormous congestion at the periods must be 
 admitted ; and whether this is an inherent property, or a mere accom- 
 paniment of other local congestions, there is on all hands a tacit under- 
 standing, due to the persistent teaching of Lawson Tait, that they 
 should accompany the ovaries, of which they are in a sense the mere 
 ducts. I have endeavoured to form an impartial estimate of the value 
 of this operation for our present purpose, and have come to the con- 
 clusions— 
 
 1. That with antiseptic precautions, in their truest sense, and with a 
 fair experience of abdooiinal surgery in the operator, the operation is 
 often by no means a very serious or difiicvilt one. The removal of ovaries 
 known to be the seat of chronic inflammation, and with chronic inflam- 
 matory surroundings and adhesions, is a totally diff'erent matter. Occa- 
 
ox ACCOUXT OF FIBKOID TUMOUES. 273 
 
 sioually, however, when the operation is undertaken on account of fibroid 
 tumours, very great and almost insuperable difficulties arise in finding or 
 removing the ovaries and tubes. 
 
 2. That in a very large proportion of cases, though not in all, the 
 expected result as to the fibroid follows. I cannot more exactly esti- 
 mate the proportion of successes. 
 
 3. That the gravity of the operation is much less than that of enu- 
 cleation and evulsion, or of removal of the utervis, or of a sab-serous 
 fibroid, imless it is one with an exceedingly small pedicle. 
 
 For these reasons, I would advise that, in the case of a fibroid accom- 
 panied by very exhausting hsemorrhages, and when these had failed to 
 yield to careful treatment as above described, and when the natural 
 menopause is not presumably near at hand, recourse should be had to 
 this operation. No statistics can ever give absolutely the comparative 
 risk to life and happiness, of the operation on the one hand, and of the 
 continuance of such symptoms on the other. There will always be room 
 for that judicial quality of mind which is the highest gift of the phy- 
 sician, and for the same quality, in a limited degree, on the part of the 
 patient. 
 
 (b) Enucleation is at best a somewhat barbarous proceeding, although 
 sometimes we are driven to it as our only resource. There are three 
 steps in the operation : — (1) sufficient dilatation of the cervix ; (2) 
 making an opening in the mucous covering of the tumour; and (3) 
 evulsion of the fibroid mass. Dilatation may be sufficient to begin Avith, 
 and certainly the most suitable cases are those where a large sub-mucous 
 fibroid, although quite unpedunculated, has bulged downwards so far as 
 to thin the os and cervix uteri, and to dilate it as in the later part of the 
 iirst stage of labour. Otherwise, dilatation must be completed artifi- 
 cially, and the more rapidly the better, by one or other of the dilators 
 mentioned before (p. 186), followed up by Barnes's fluid obstetric dilators, 
 if the presence of the tumour will permit of their introduction. An in- 
 cision of at least an inch, better two inches or more in length, is now 
 made in the capsule of the tumour by a probe-pointed knife. It should 
 be nearly half an inch deep, unless the capsule is evidently thin and 
 gapes easily. The cautery knife is well adapted for this purpose if the 
 tumour can be freely exposed to view by the duck-bill. It aftbrds less 
 danger of septiccemia or hsomorrhage. If bleeding is severe it must be 
 arrested by a well-adapted styptic plug. In some cases we may prefer 
 to cease here, and to trust to the effect of the incision to arrest or 
 diminish the chronic hsemorrhage ; and in course of time spontaneous 
 expulsion may occur, to be aided by the free use of ergot, or by arti- 
 ficial traction. When, however, we have decided on the urgent neces- 
 sity for operation, it'' is better to proceed to inuiiediatc enucleation. 
 
274 ENUCLEATION OF FIBROIDS. 
 
 The tumour must first be separated from its attachments as far as pos- 
 sible, — sometimes an easy, sometimes a most difficult and dangerous 
 proceeding. Various instruments have been devised for this purpose by 
 Simpson, Sims, Thomas, and others ; but the operator's finger, a good 
 strong steel male sound, and a blunt-edged lithotomy scoop are sufi&cient. 
 The first should be used as much as possible, the others only in aid. 
 The mass is now well seized by the strongest vulsellum available, and 
 attempts at dragging it through are made, alternately with further 
 attempts at separation. As the hold of the vulsellum loosens it must 
 be renewed, and a certain amount of torsion comes in aid of both separ- 
 ation and evulsion. It may be necessary to further enlarge the os by 
 nicking its edges slightly in several places, or to divide the tumour by 
 the ecraseur, cutting as much as possible in its long axis, and avoiding a 
 straight cut across. Under favouring circumstances, a large tumour 
 may thus sometimes be removed rapidly and safely, but sometimes por- 
 tions, or the whole, must be left, with great risk of septicaemia. The 
 shock may be fatal, and I have known the uterus to be completely in- 
 verted, and subsequently reduced. The difficulty does not cease even 
 when the tumour is in the vagina, but no obstetrician need despair when 
 he has got this length. The free use of iodine or carbolic acid to the 
 interior of the uterus certainly minimises the septic dangers. On the 
 whole, I think I have rightly described the operation as a " barbarous " 
 one ; and, with the possibility of arrest of symptoms by removal of the 
 ovaries within our reach, I would reserve it for those cases only where 
 nature had fairly commenced the process by sloughing of the wall, or of 
 the tumour, or by very considerable intra-uterine protrusion, which was 
 not sufficiently rapidly tending to polypisation, whilst the symptoms were 
 extremely urgent. 
 
 (c) Excision 2>Gr Ahdominem of even very large fibroid growths, has 
 been frequently performed with perfect safety, and, in the case of sub- 
 peritoneal growths, with a distinct and not very large pedicle, is 
 not a very formidable operation. The pedicle may be transfixed, like 
 that of an ovarian tumour, with strong silk, tied in two or more parts, 
 taking care to tie a second ligature firmly round the whole pedicle, the 
 ends being cut short and left to take care of themselves as in ovariotomy. 
 It is also a desirable precaution to tie separately with silk or gut any 
 large vessel that is to be seen in the pedicle, and to invert and unite 
 the peritoneal edges of the stump. But this procedure is safe only 
 with tumours which give rise to so few urgent symptoms in general, 
 that they do not justify the opening of the abdominal cavity. As a 
 matter of fact, it has not infrequently been through errors of diagnosis 
 that they have been exposed. 
 
 Is it possible to remove, with any reasonable safety, sessile sub- 
 
EXCISION OF FIBROIDS HYSTERECTOMY. 275 
 
 peritoneal growths, or, what is practically the same thing, interstitial 
 growths with little or no intra-uterine tendency, but which nevertheless 
 cause grave and dangerous symptoms 1 The removal of these involves, 
 as a matter of course, the removal of some portion of the uterine wall, and 
 the opening of its cavity, and there is no more serious operation than this 
 in the whole of surgery. With regard to ordinary cases of sessile tumours 
 of the uterus, the dangers of removal are so great that I prefer, instead 
 of discussing them, to sum up the whole in the words of Mr Knowsley 
 Thornton, from an able paper read at the Annual Meeting of the British 
 Medical Association (Brit. Med. Jour., Oct. 13, 1883):— "I have per- 
 formed partial hysterectomy three times, and all the patients died. 
 (3nce I used the Wells's ovariotomy clamp, and it caused a slough which 
 extended in the wall of the uterus, and caused death from septicaemia ; 
 then I tried ligatures and sutures of the flap, and the patient died of 
 septicaemia; then I tried simple ligatures applied by transfixion, and 
 the patient also died of septicaemia. I shall not again in any case 
 attempt a partial hysterectomy, as I am convinced that it is both safer 
 and easier to remove the whole organ, and deal with the cervix instead 
 of the uterine wall." No one doubts the comparative safety of removal 
 of the ovaries. Mr Thornton gives fifteen cases only, but of these all 
 recovered ; ten have entirely ceased to menstruate, and have lost their 
 tumours ; one has irregular menstruation, bu.t the tumour is diminished 
 to one-third, and is diminishing ; one has had no further menstmation, 
 and the tumour is going fast ; one continues to menstruate, and the 
 reduction of the tumour is not marked, but she no longer floods or has 
 pain ; two others are too recent for any certain prognosis. 
 
 (d) Complete Hysterectomy. — Is it possible that the result of either 
 partial or complete hysterectomy, together, of course; with tlie removal 
 of the ovaries and Fallopian tubes, can possibly vie with oophorectomy 
 in safety or success ? Nearly all who have attempted these operations 
 —Wells or Keith, Bantock or Thornton, Tait, Pean, Billroth, Hcgar, or 
 Schrosder — are agreed that complete hysterectomy is less dangerous than 
 the partial form, and less difficult of accomplishment. But even in com- 
 plete removal the mortality is frightful. Keith alone has had any reason- 
 able success. Instead, therefore, of attempting a description of the various 
 methods that have been proposed, of the clamps and constrictors devised 
 for securing the pedicle externally, or of the means of arresting haemor- 
 rhage from the uterine or other pelvic blood-vessels, I will content myself, 
 as more consistent with the scope of this work, with a quotation from one 
 who cannot be considered, at any rate, a coward in regard to abdominal 
 operations, or as over-burdened with conservatism or anti-surgical pre- 
 judices. Lawson Tait {One Thousand Cases of Abdominal Section, pam- 
 phlet, 1884) says:— "I now come to speak of hysterectomy, concerning 
 
276 SUMMAEY OF TEEATMENT OF FIBKOIDS. 
 
 which I may say at once it is an operation which I detest. Its mortality 
 is fearfiiL Sir Spencer Wells has had over 50 per cent, of deaths, and my 
 own mortality has been 35 per cent. Bantock has recently had a ran of 
 bad luck ; the mortalitj^ of other operators is not fully displayed, and 
 
 Keith alone has had brilliant results There can be no doubt that 
 
 for uterine tiimours the extra-peritoneal method of dealing with the pedicle 
 
 is the only one admissible The details and methods of operation 
 
 elaborated by Bantock are, on the whole, the best I have seen ; but there 
 is something Avanting yet to complete success. Every patient, or at least 
 nearly every one, Avho recovers from hysterectomy does so, as it were, by 
 the skin of her teeth. These cases never go on straightforwardly to re- 
 covery as ovariotomies do. The amount of worry which is given me bj* 
 every case of hysterectomy, even Avhen successful, is such as to be almost 
 beyond the recompense of any fee, and the disappointment inflicted by 
 every death is quite indescribable." Comment on the foregoing is 
 needless. 
 
 The Avhole subject of the treatment of fibroids of the iiterus, setting 
 aside those Avhich become intra-uterine polypi, is not very satisfactory, 
 considering their very great frequency, bu.t I will endeavour to summarise 
 it according to our present light. The figures are, of course, intended 
 to be roughly approximate, not precisely statistical. 
 
 Given 100 fibroid tumours, 50, at least, Avill require scarcely any 
 medical or surgical treatment. They will have no troublesome 
 s}iTiptoms, and many of them will be discovered by accident alone, or 
 will not be discovered at all. 
 
 In the remaining 50, menorrhagia, or some form of pressure trouble. 
 will lead to diagnosis, and demand treatment of some kind. I think it 
 is not too much to say that, of these, the great majority may be rendered 
 perfectly endurable, and compatible with enjoyment of life, by the means 
 recommended above as medicinal, but including the appliances required 
 for lifting up the mass, either by belt or pessary, and occasional minor 
 surgical proceedings, such as scarification, until the menopause brings 
 still further relief or complete cure. 
 
 Some 10 per cent, of the 50 (too large a proportion, I think), may 
 require the aid of the operating surgeon. In, certainly, not more than 
 one of them is he driven, perforce, to the repulsive proceeding of vaginal 
 evulsion. In the remaining nine, removal of the ovaries will, with com- 
 pjiratively little danger to life, cure the predominant symptoms, and even 
 ensure absoi-ption of the mass in all but a mere fraction of the number. 
 These fractions, spread over the Avhole community, amount, of course, 
 to a considerable number of cases, and, so far, Ave may say that A\'hen 
 there is any kind of pedicle to be got for such tumours, along Avith 
 the containing uterus, which is often not the case, the Avhole mass 
 
FIBROID TUMOUKS OF THE CERYIX. 
 
 277 
 
 may be removed, with a mortality of some 40 or 50 per cent, of cases 
 operated on.^ 
 
 Up to the present, the great bahxnce of surgical opinion is in support 
 of the belief that it is an advance in practice to treat the stump or 
 pedicle outside the abdominal wall, but it should not be forgotten 
 that the extra-peritoneal treatment of the ovarian pedicle was a great 
 advance upon previous methods, until time had disclosed safer modes of 
 dealing with it intra-peritoneally. 
 
 Before speaking of those cases which assume the form of uterine 
 polypi, and which are not only much more amenable to surgical treat- 
 ment, but which almost invariably demand it, it is advisable to say a few- 
 words on the subject of cervical tumours. 
 
 Fibroid Tumours of the Cervix. 
 
 True fibro-myomata are met with here as in the body of the uteiiLS, 
 but with comparative iufrequency (fig. 124). They can hardly, even 
 when small, remain interstitial very long, but soon tend to bulge into 
 the cavity of the cervix, dilating it, and 
 giving rise to severe hgemorrhage and 
 dysmenorrhoea, and then emerging in a 
 more or less polypoid form into the 
 vagina. These are certainly the most 
 amenable of all to enucleation or to 
 treatment as polypi. I am convinced 
 that I have not infrequently seen small 
 hard fibroids of this kind disappear by 
 absorption, after being compressed by 
 the action of tents. True, such small 
 sessile growths may have been diflacult 
 to diagnose with absolute certainty from 
 the products of inflammatory exudation, 
 but the absence of a history of inflam- 
 mation, the state of the rest of the 
 cervix, quite free from disease, and in 
 more than one case, the presence of 
 
 uterine fibroids elsewhere, have seemed to })laee the matter be3'on(l 
 a doubt. I fear there is no way in which the practice could be 
 extended to small commencing growths of the body of the \itcrus, 
 oven were they diagnosed early enough. In other cases, fibroids of 
 
 1 Tliu stmlent will liiid n, very complete statistical suininaiy of cases of ^'astrotoniy 
 for fibro-inyomata by Bigulow in the Am. Jour, of Obst. for 1SS3 and 1884. 
 
 Fk;. 124.— Cervical 
 assuming the 
 (Schnvder). 
 
 Fibroid Growth 
 polypoid form 
 
278 UTEKINE POLYPI. 
 
 the supra-vaginal portion of the cervix, grow rather towards the periphery, 
 pushing their way towards the peritoneal cavity. From their low posi- 
 tion these are very likely, if large, to give rise to incarceration of the 
 tumour in the pelvis, but fortunately there is a considerable capabilitj^ 
 of stretching in the cervix, which permits of them, or of masses low down 
 in the body, rising up, and of the formation from the cervix itself of a 
 mobile pedicle. In another class of cases, extension takes place behind 
 or within the vaginal wall, almost as it does in malignant disease, 
 although, of course, it is more localised. The elements of fibro-myomata 
 exist in this situation, and, practically, such growths become vaginal 
 fibroids, although extreme caution is required in attempting to remove 
 them, owing to the proximity of the peritoneum. 
 
 Uterine Polypi. 
 
 Although the majority of uterine poljqDi, at least of those of any con- 
 siderable size, are really special forms of fibro-myoma, forms which bring 
 them under the influence of much more effective means of treatment, it 
 seems to be considered by nearly all writers the best plan for clinical 
 purposes to treat of them separately, but it will clear the ground if we 
 first allude to those forms of poljq)us which are not fibro-myomata at all. 
 All other kinds might be most properly described under one name, viz., 
 "mucous polypi." Casual variations in their density, and other physical 
 characters, have led to a good deal of special nomenclature, which is 
 very unnecessary, and only confusing to the student or practitioner. 
 The ordinary mucous polypus is small — from the size of a pea to that of 
 a filbert, rarely much exceeding the latter. It contains the glands, con- 
 nective tissue, epithelium, and sometimes muscular fibre, of the mucous 
 tissue from which it springs. It is nearly always very vascular, and of 
 a bright red colour to the eye. In a few instances I have seen it en- 
 dowed with some of the acute sensibility of the vascular caruncle of the 
 urethra, which it may closely resemble in appearance. Its favourite situ- 
 ation is just within the os uteri, or it may, though very rarely, grow from 
 the outer wall of the cervix, and a little more commonly, from the miicous 
 wall of the uterine body ; it has been detected there when dilatation, and 
 exploration by the finger, have been used for the diagnosis of the cause 
 of uterine haemorrhage. Its covering partakes of the character of the 
 epithelium of the part from which it springs. Sometimes it contains 
 within itself a hollow cavity, the result of a dilated Nabothian or other 
 uterine gland — the hollow polypus ; sometimes there are several hollows 
 in its structure, of similar origin — the channelled polyjDus ; and occasion- 
 ally it is tougher and larger than usual — the fibro-cellular polypus. 
 
MUCOUS POLYPI OF THE UTERUS. 279 
 
 These and other additional names are useless, except for the pathological 
 museum. Wherever it exists, it may be quite harmless. I have often 
 found it by mere accident. But it is much more often the cause of 
 hsemoiThages, totally disproportioned to its size and apparent powers of 
 mischief. It is said to be the polypus itself which bleeds in such cases, 
 but I fancy the source of haemorrhage must also be, as with the fibro- 
 myomata, from the irritated and congested mucous membrane with 
 which it is in contact, especially as the also frequently accompanying 
 leucorrhosal discharge is undoubtedly from this source. Fatal haemor- 
 rhage has occurred in this way, and it was a fatal case of this kind which 
 led Simpson to work out the suggestion of Shakespeare's son-in-law in the 
 shape of the uterine tent. I am not quite certain, however, whether 
 this was not a fibroid polypus. The haemorrhage, which sometimes 
 closely resembles in periodicity the normal discharge, is apt to be mis- 
 leading. I had a case of pregnancy at nearly full term sent to me for 
 ovariotomy, in which a small mucous polypus of the cervix had kept up 
 an almost regular menstruation, which had deceived the ]3ractitioner, and 
 still more willingly the patient; and I have seen three or four cases 
 where undoubted ovarian tumours had doubts thrown upon their diag- 
 nosis, owing to the persistent monorrhagia and metrorrhagia thus caused. 
 Dysmenorrhoea and sterility may be caused by any form of poly- 
 pus \yhich blocks the outlet or inlet of the uterus. These mucous 
 polypi are often extremely soft, and are thus likely to be overlooked 
 on mere digital examination, even when hanging from the os uteri, by 
 the uninitiated or careless examiner. I have known half a dozen well- 
 advanced students fail thus to detect one as large as a coffee bean. It 
 is very probable that the primary causation of mucous polypi is to be 
 met with in inflammatory degenerations of the uterine mucous mem- 
 brane, especially of its smaller cysts. 
 
 The treatment of mucous polypi may be described in a few words. 
 When discovered in the cervix, or near it, they must be seized with a 
 polypus forceps, with a catch on the handle, and snipped or twisted off'. 
 If discovered within the uterus, they must be scraped off with the 
 curette. 
 
 Under the title of placental or fibrinous polypi, the retained products 
 of pi-egnancy and delivery have been described. This is a complete 
 misnomer. Every practitioner ought to be aware that, after abortion or 
 delivery at full time, some decidual or foetal structures may remain, giving 
 rise to haemorrhages with clots, often more or less attached to the uterine 
 wall, and decoloi'ised by time and pressui'e. When the history of the 
 case points to these, the uterus must be explored, and these remnants 
 must be removed by ovum forceps or curette, but nothing is gained by 
 calling them polypi. The same remarks apply to those instances where 
 
280 
 
 FIBEOID POLYPI OF THE UTEEUS. 
 
 the dysmenoiThoeal membrane, or the decolorised blood-casts of the dys- 
 menorrhoeal utenis are met with (p. 181). Larger and somewhat more 
 complicated mucous polypi are described here and there in pathological 
 literature. I have never met with any of them, but their treatment 
 would be precisely similar, miless large enough and firm enough to 
 require the ecraseur. 
 
 We return now to the fibro-myoma or fibroid tumour in its polypoid 
 form (figs. 123, 125). Histologically there is nothing more to be said 
 about it. Occasionally it appears to be a true polypus from its earliest 
 stage, and is then usually small ; generally it is the more or less slow 
 
 IDrotrusion into the 
 uterus of an inter- 
 stitial growth. It 
 may vary in size 
 from a pea to an 
 adult head. 
 
 Its sympto'tns — 
 haemorrhage, leucor- 
 rhoea, pain, and 
 occasionally foetid 
 discharges, dysmen- 
 oiThoea, expulsive 
 efforts, supra-pubic 
 swelling, or intra- 
 vaginal protrusion 
 from the uterus, or 
 complete dilatation 
 or thinning of the 
 lower segment — 
 have all been more 
 Diagnosis and treatment alone concern us 
 
 Fig. V15. — Fibroid Polj-pus of the Uterus 
 (Churchill et Leblond). 
 
 or less indicated above, 
 now. 
 
 The diagnosis will depend on whether the mass is strictly intra-uterine, 
 or wholly or partially extruded from the os externum. When within 
 the uterus, there are the usual symptoms of sub-mucous fibroid tumom-s, 
 and the whole question at issue is whether pedunculation has taken place, 
 or to what extent. This, however, is sometimes a very difficult problem. 
 I have known the dangerous and difficult process of enucleation attempted 
 on a tumour which was subsequently shown to be attached to the uterus 
 by a very fine pedicle. Full dilatation of the os, if not naturally in- 
 duced, is a primary indication. Anaesthesia is often necessary, to enable 
 such an introduction of the hand into the vagina, and of the forefingers 
 into the uterus, as may be required to reach the uterine insertion of the 
 
DIFFERENTIATIOX BETWEEN POLYPUS AND INVERTED UTERUS. 281 
 
 mass, and ascertain how far it is sessile and broad-based, or how far 
 pedunculated. The sound, especially a flexible one, must aid us when 
 we cannot otherwise reach ; but I have found that many very able prac- 
 titioners are unable, from want of special experience, to estimate the 
 direction which either a firm or a flexible sound is taking if its course be 
 sinuous. I fear it is too often only when attempts to apply an ecraseui- 
 are made that a correct conclusion is come to as to whether the tumour 
 has the desirable pear shape, and whether that is such as to compel the 
 ecraseur to slip backwards to the uterine insertion, or forwards off the 
 tumour. The use of two sounds or flexible catheters passed on opposite 
 sides of the growth, and then manoeuvred together, is capable of defining 
 very clearly the shape and attachments of the mass, but sometimes the 
 pedicle is excessively short. When the tumour pi-ojects through the 
 cervix the diagnosis may be simple enough, or it may still be fraught 
 with difiiculty. If the pedicle can be easily reached, and is felt to be 
 decidedly smaller than the mass, and growing from one side of the 
 uterine wall, we have all the diagnostic signs required. To assist in 
 ascertaining these facts, the tumour should be grasped with a vulsellum ; 
 and while the digital examination is made with one hand the other 
 should, by the vulsellum, draw down or repress the tumour, as may be 
 found necessary to get the finger past it, or to bring its summit within 
 reach. ,The uterus should be firmly pressed down into the pelvis by an 
 assistant. 
 
 Differentiation between Polypus and Inverted Uterus. — ^If the polypus is 
 more or less protruded through the cervix, and its narrow pedicle is not 
 very apparent, it is liable to be mistaken for an inverted uterus, and, as 
 this mistake might lead to fatal results, and has been made by men of 
 the highest experience and skill, it should be a rule never, even in the 
 simplest case, to omit to ascertain the diagnostic points which diff"eren- 
 tiate the two affections. A careful bi-manual examination will tell us 
 whether we have a body corresponding to the uterus, above the line at 
 which the mass leaves the os uteri. If this is clearly the case, the affec- 
 tion cannot be inversion. An examination per rectum, aided by abdominal 
 pressure, will bring this out still more clearly, and, if there be the least 
 iloubt, a sound passed into the bladder and manccuvrcd in connection 
 with the finger in the rectum, will confirm the presence or absence of the 
 uninverted uterus. In moderately thin women, the cup-shaped depres- 
 sion felt in complete inversion, instead of the round fundus uteri, can be 
 well made out. The sound is always required to complete the diagnosis, 
 but the previous bi-manual examination guides us nuich in its use. If 
 there be inversion, the sound will not enter the uterus, or pass any dis- 
 tance beyond the cervical rim, while in the case of a polypus, at some 
 ])oint, if not all round, it will pass the normal distance or upwards. 
 
282 TEEATME^■T OF 
 
 Adhesions sometimes take place between the polj'pus and the -^'all of the 
 uterus, and I have had, from this cause, to divide two distinct and firm 
 pedicles, but I have never known adhesion all round, so as to prevent the 
 passage of the sound at all points. In such a case, the bi-manual exam- 
 ination, and a careful study of the history of the case, pointing to 
 inversion or the reverse, should still suffice to make the case clear. 
 When possible, it is better to take the history as only of secondary 
 diagnostic importance, and to rely on the physical sigTis alone. The 
 inverted utenis is much more tender than a polypus, and resents the 
 application and tightening of a wire ligature. It is not advisable, 
 however, to resei-ve the diagnosis till this stage of the proceedings, and 
 the fact even is not universally true. In tolerably recent cases of inver- 
 sion, the bleeding and congested wall of the litems is totally different 
 from the smooth pale wall of an ordinary polypus, but this must not be 
 too entirely relied on for diagnosis. If the openings of the Fallopian 
 tubes are visible, they of course settle the question. It is well to bear in 
 mind that a heavy or strongly extnided polypus may invert the uterus 
 partially, or even entirely [see Chap. XIII. ). 
 
 I do not think it necessary to differentiate polypus from prolapsus 
 uteri or elongated cervix. I cannot imagine the most careless bungler 
 mistaking either affection for a polypus. 
 
 Treatment. — The treatment of fibroid polypi is invariably by removal, 
 the sole questions being as to time and method. When the pedicle is 
 evidently within reach, the time requires no consideration. The sooner 
 the growth is removed the better. If the examination is a difficult one. 
 requiring angesthetics, it is better to proceed at the same sitting ; other- 
 wise, unless the patient is rapidly deteriorating, it is better to wait for 
 the middle of an intemiensti-ual period. In the case of large polypi with 
 broad pedicles, or only entering on the stage of polypisation, the amount 
 and effect of hEemon-hage will guide us as to the time. If life is daily 
 being imperilled, and the htemoiThage is little under control, we must 
 proceed, however conscious of the great difficulties before us, but if we 
 are satisfied that we can maintain the patient at her present health 
 standard for a time, or even improve it, then, undoubtedly, it is better 
 to wait until, by the spontaneous uterine contractions, aided by full and 
 frequent administration of ergot, the polypisation can be made more 
 complete. 
 
 As to the methods of removal, we have a considerable variety to 
 choose from, but as ecraseurs of various kinds are being gradually 
 improved, all other methods are yielding to them. Mere twisting off, by 
 strong forceps, is only applicable to a very small number of true fibroids ; 
 the pedicle should not be much thicker than a goose-quill. The long 
 popular plan of passing a whip-cord or other ligature round the pedicle- 
 
UTEEINE POLYPI. 2 8 1:? 
 
 by two parallel but separable tubes — Gooch's cannula, — then tightening 
 the ligature, and leaving the whole mass to become gangrenous, is 
 deservedly abandoned. Cutting the pedicle by a sharp hook or by 
 scissors is more free from danger of septicaemia, but may cause serious 
 haemorrhage. Aveling's polyiDtrite (fig. 126) is a most handy instru- 
 ment in cases with moderately thick pedicles, say the thickness of 
 the thumb, but which are large enough otherwise to make the passage 
 of a wire ligature difficult. The hollow hook is guided round the 
 pedicle, and the straight bar is easily screwed up so as to make a 
 completely bloodless amputation. The instrument should, however, 
 be made more carefully, and of better metal than is usual, otherwise 
 the cutting bar is liable to be laterally deflected, and to catch on one 
 side of the hollow hook after it has cut through the bulk of the pedicle. 
 When this occurs, as it has occasionally done with me, I have been 
 obliged to use the whole instrument as a powerful but clumsy torsion 
 agent, to complete the separation. The ecraseur is undoubtedly our 
 sheet anchor in all difficult cases of polypus. As the galvano-cauter}' 
 instruments are gradually improved, this form will probably take 
 
 Fig. 126.— Aveling's Polyptrite, with slight modification of the Screw. 
 
 precedence of all others. Meanwhile I have great hesitation in 
 passing soft, fragile platinum Avires beyond my reach, and of course 
 beyond my digital control when in action, up to the fundus uteri, 
 and in working with them, while I have no absolute certainty as to 
 their steady and continuous action after they are imbedded in the 
 tissues. The chain ecraseur (fig. 54) is the most powerful ; if one has it 
 once passed round the tumour, and on to something like a definite 
 pedicle, it is bound to go through. But its limpness, and the tendency 
 of its links to become entangled, are great drawbacks to its introduction. 
 On the whole, I believe that at the present time the surest method of re- 
 moval of intra-utcrine fibroid polypi is by the common wire ecraseur. A 
 strong, thick, well-annealed, and therefore flexible, steel wire is for most 
 cases the best. For further remai'ks on the various ecrascurs tlie 
 reader is, however, referred to (Jhap. III., p. 73 et seq. There are 
 cases in which wc feel convinced of the existence of a distinct pedicle, 
 and yet in which the tumour is so large, or the pedicle so short, tliat no 
 ordinary ecraseur can be passed over the mass. If we cannot allow for 
 
-84 FIBEO-CYSTIC TUMOUES 
 
 the element of time, and feel that we must at once interfere, there is 
 nothing for it but to diminish the size of the polTjJus. We must take 
 the risks of the haemorrhage and septiceemia involved. If an ecraseur 
 can in any way be made to bite on any portion of it, that portion 
 must be removed. If this cannot be done, then, seizing the lower end 
 by a strong vulsellum, we must, by knife or scissors, excise as much as 
 possible, controlling the hgemon-hage by styptic plugs, and trasting by 
 ergot to induce further extrusion at the next sitting. Although I have 
 succeeded in this way in finally getting at the pedicle of a large intra- 
 uterine fibroid polypus, and ultimately removing the whole of it with 
 -safety, I feel much sympathy for any one who may be placed in the same 
 circumstances. 
 
 Fibro-cystic Tumours of the Uterus. 
 
 The chief interest of the so-called " fibro-cystic " tumours (fig. 122) of 
 the uterus lies in the fact that, although rare in this country, they have 
 often served as pitfalls for the ovariotomist. Given a large and rapidly 
 increasing abdominal tumoui', springing from the pelvis, and containing 
 within it evident cystic cavities, the chances are so strongly in favour of 
 its being an ovarian tumom^, and so slightly in favour of its being uterine, 
 that, in spite of many doubtful indications, few ovariotomists of note 
 have not at one time or other been led to enter on an operation for the 
 removal of the former, and found that they must either abandon the 
 operation or proceed to extirpation of the uterus with the latter. Such 
 a thing as a true fibro-cystic uterine tumour, that is, a tumour partly 
 fibro-myomatous and partly consisting of cysts with membranous cyst 
 walls, does not exist. Schroeder certainly mentions a few rare instances 
 of dermoid or apoplectic cysts of the uteinis, and abscess, Avith a kind of 
 cyst wall, has not infrequently been met with, but I am not aware that 
 the former of these has ever been encountered along with or within fibroid 
 tumours. But undoubtedly the fibro-myoma is occasionally liable to 
 infiltration within its walls, which may be only temporary or may assume 
 a permanent form. It is doubtful as yet how far the dilatation of the 
 lymphatic channels contributes to this pseudo-cyst formation. Be that as 
 it may, it is certain that occasionally, though rarely, we find accumu- 
 lations of fluid within the meshes of a fibroid, which render its diag- 
 nosis from ovarian tumours very difficult. In such cases the general 
 .s}Tnptoms and signs, the menon-hagia, elongated uterine cavity, &c., 
 will most probably be those of uterine growths, but the presence of the 
 cystic phenomena, so rare in fibroids and so common in ovarian tumours, 
 would incline the balance of opinion in favour of the latter, if we had not, 
 
OF THE UTEKUS. 285 
 
 in all doubtful cases, the means of examining the nature of the con- 
 tained fluid removed by aspiration. In these doubtful tumours, it is, I 
 think, imperative to have recourse to the aspirator. The question 
 then remains, Have we any certain means of ascertaining by physical 
 appearance, or by chemical or microscopic tests, the difference between 
 ovarian and fibro-cystic fluids ? We shall mention shortly what is known 
 as to the former, especially the common, if not constant, presence of 
 certain granular cells with definite reaction under chemical reagents. 
 and of columnar epithelium, but for the present the following summarv 
 from Garrigues (Am. Jour, of Ohst., 1882, July, p. 682), may be con- 
 sidered as the most recent information as to the character of fibre i 
 cystic fluids : — 
 
 " All cases in which a sufiiciently large quantity of fluid was witli- 
 drawn, and coagulated spontaneously, promptly, and completely, have 
 proved to be fibro-cysts of the uterus, but coagulation takes place only 
 in the fliiid from a minority of fibro-cysts. The presence of a fluid 
 which, after a long exposure to the air, precipitates fibrinous clouds, or 
 which gelatinises on addition of blood or serum, does not prove that it 
 comes from a fibro-cyst. Atlee's fibro-cell is not always found in 
 uterine fibro-cysts, and may be present in ovarian cysts. None of the 
 other microscopical elements, more or less changed epithelial cells, found 
 in uterine cysts, have any diagnostic value. Columnar epithelium cells 
 are never found in uterine cysts." 
 
 The fluid when first aspirated is usually of a clear yellowish character, 
 and is free from paralbumen. Should a tumour not be clearly separable 
 from the uterus, and shoiild its fluid present the above-named character- 
 istics, it may with almost absolute certainty be diagnosed as non-ovarian. 
 In ovarian tumours the uterus is usually depressed forwards or backwai'ds, 
 and with a fibroid or fibro-cystic one it is usually dragged upwards and 
 elongated, but these signs are not to be absolutely relied on, and the 
 examination of the fluid is of great importance. 
 
 Supposing that we thus feel fairly certain of the fibro-cystic uterim- 
 growth, its treatment will not vary in principle from that of a simple fibroid. 
 It is generally subserous, and interference in any form will depend on 
 the gravity of the pressure, ha3morrhage, or other symptoms. If removal 
 be decided on, it Avill almost certainly involve that of the uterus itself. 
 The effect of removal of the ovaries on such a tiimour is not j-et sufii- 
 ciently worked out, but a few cases are ah'eady recorded which tend to 
 show that these fibro-cysts may ]:)c amenable to the same laws that 
 govern the pure fibroids in this respect. As a nilc, the administration 
 of ergot produces, at least temporarily, a marked diminution in the size 
 of these tumours, acting probably in the same manner as upon solid 
 fibroids temporarily infiltrated with seiiim. 
 
286 UTERINE DISPLACEMENTS. 
 
 CHAPTER XL 
 
 Diseases of the Uterus — continued. Uterine Displacements. Their General 
 Mode of Causation. Prolapse of the Uterus and. Vagina. Pseudo-prolapse 
 Elevation of the Uterus. Forward Displacements, Anteflexion and Anteversion 
 Backward Displacements, Retroflexion and Retroversion. Mobile Uterus 
 Lateral Displacements. 
 
 Having now considered most of the affections which tend to increase the 
 weight of the uterus, and many of those which cause relaxation of its 
 supports, we are in a position to take up those alterations in its position 
 which are so frequent a result of undue weight or faulty support, and 
 which often demand the patient care of the practitioner. The uterus 
 may be depressed downwards — i:)rolai:)S'us ; or it may be dragged up- 
 wards — elevation ; or it may be tilted backwards — retroversion ; or for- 
 wards — anteversion ; or laterally — lateroversion ; or it may be bent on 
 itself like a retort, backwards, forwards, or laterally — retroflexion, ante- 
 flexion, and lateroflexion. All these abnormal states will require notice, 
 and in connection with the first — prolai:)Sus — it is impossible to dissociate 
 the similar affection of the vaginal walls. 
 
 General Causation of Uterine Displacements. 
 
 Setting aside any original or congenital tendency which may exist 
 towards these affections, as for instance towards anteflexion in the case 
 of infantile uterus, there are certain causes which, singly or in combina- 
 tion, tend to the production of all forms of displacement; and it will 
 save considerable time, and I think promote clearer vieAvs, if we enumerate 
 these causes now, referring again to them individually, in connection with 
 each separate displacement, when they play a more than usually import- 
 ant rble. To have a firm grasp of this general or possible causation is 
 the only sure way to understand any individual case, or to apj^ly any 
 rational treatment. I will not enter into the controversy — now surely 
 dying out — between what may be called the mechanical and the vital 
 schools of opinion and practice in relation to uterine displacements. 
 Now and again it will happen that we cannot, without much pain and 
 injury, do anything to replace, or to mechanically retain in position, a dis 
 
THEIR GENERAL CAUSATION. 287 
 
 "placed uterus, until we have removed or greatly mitigated the cause, and 
 altered the general health. On the other hand, it will often happen that 
 all attempts to i-emove the cause will fiiil vmtil we remove the version, 
 flexion, or prolapse ; the cause and the effect have become interchange- 
 able and mutually injurious. In the majority of cases we shall have 
 carefully to feel our way while endeavouring to fulfil both indications at 
 once. A congested and displaced uterus often requires to be kept in 
 position, to remove its congestion, and a prolapsed or retroverted uterus 
 cannot long be kept comfortably in position if we neglect to remove 
 its congested state. The student will find this whole subject exhaus- 
 tively treated, from opposite points of view, in a series of articles by 
 Hermann and by Graily Hewitt in the Lancet, extending over the later 
 weeks of 1884 and the earlier ones of 1885. 
 
 The Causes op Uterine Displacement may be grouped as follows : — 
 I. Whatever increases the weight of the uterus. 
 II. Whatever diminishes the uterine supports. 
 
 III. Any undue pressure from above. 
 
 IV. Any undue traction from below. 
 
 The form which the disj)lacement takes will depend on the direction 
 of the pressure or traction, and on the site of the increased weight or 
 diminished support. In detailing these points more fully, we shall now, 
 fortunately, be referring, for the most part, to pathological conditions 
 already described, instead of being obliged, as hitherto, to frequently 
 refer to facts which had still to be considered. 
 
 Under Class I. we may have the following — 
 
 1. Chronic Hypertrophy of the Uterus, with more or less constantly 
 active or passive hypersemia. This is the most common cause of all in 
 the maiTied, taking displacements as a whole ; in the virgin it is more 
 often a result. It includes chronic metritis and sub-involution. When 
 mainly corporeal, its first tendency is to version rather than prolapse. 
 When mainly cervical, its tendency is to prolapse rather than 
 version. 
 
 2. Tumours of the Uterus, especially fibro-myomata. The influence 
 of small fibroids in the anterior or posterior wall of the fundus towards 
 producing versions must be manifest ; that of tumours which do not 
 materially destroy the balance is, of course, towards the production of 
 prolapse, although, as we have seen, this is most frequently counteracted 
 by other circumstances, in the case of large fibroids. The condition of 
 incarceration in the pelvis greatly increases the pressure in any direc- 
 tion. 
 
 3. Pregnancy, if too frequent, or if accompanied b}' unaccustomed 
 exertion, or if followed by sub-involution, or if recmnbcncy be neglected 
 while involution is going on, has a constant tendency to become the pre 
 
288 THE GEXEEAL CAUSATIOX 
 
 disposing or exciting cause of displacements. The neglect of the involu- 
 tion period after abortion does so still more. 
 
 4. Menstrual Engorgement. — This factor acts in two ways. Either, 
 from the various conditions which have been mentioned as giving 
 rise to menorrhagia and dysmenorrhoea, the uterus is periodically 
 heavier than normal at these times, while perhaps no special pre- 
 cautions are taken ; or if menstiaiation at first be normal, the patient, in 
 the case especially of shopwomen or others laboriously employed, is com- 
 pelled to stand at these periods for many continuous hours, or to exert 
 great muscular force. Depression of the uterus follows and leads to 
 engorgement, and in its turn, engorgement leads to further displace- 
 ment. In all the above cases the part played by congestion or hyper- 
 semia is evident, while the tendency to increase of congestion by the 
 altered position of the uterus is not less so. 
 
 Under Class II. we have the following — 
 
 5. Ruptured Perineum. — The bearing of this on uterine prolapse has 
 been much disjDuted. It is quite true that the perineum in no way 
 directly supports the uterus, unless there be ah-eady prolapse, but its 
 extensive rupture, as has already been shown, allows of prolapse of the 
 vaginal walls, and these, in their turn, fail to support the bladder and 
 rectum, and ultimately drag down the uteiiis. It is for this reason that 
 a primary operation for torn perineum is so essential as a preventive, 
 and a secondary one is often so ineffectual as a cure for prolapse. 
 
 6. Destruction of the Pelvic Fascia, of that portion which is attached 
 to the coccyx behind, to the pubic arch in front, and to the tubera ischii 
 laterally. — The importance of this lesion is only beginning to be fully 
 understood, biit, as stated at page 71, its estimation may probably lead to 
 modifications in the secondary operation for ruptured perineum. 
 
 7. Kelaxed Vagina. — The vagina is supposed by many to act as an 
 actual support of the uterus, a sort of hollow muscular pillar. This 
 is disputed by others, and I must confess myself unable to see very 
 clearly how it can act thus, but of the clinical fact that chronic leucor- 
 rhoea, and other causes which tend to soften, and stretch, and diminish 
 the muscular tone of the vagina (whether we regard it as a muscular tube, 
 or as merely a horizontal slit), are most apt to be followed by uterine 
 displacement, I feel no manner of doubt. 
 
 8. Stretching of the Uterine Ligaments. — We are here again on con- 
 troversial ground. The xiterine ligaments are — (a) The broad ligaments or 
 lateral peritoneal folds. Their influence as regards its descent maybe doubt- 
 ful, until it becomes very low, but they must have some constant effect on 
 its forward or backward depression, (h) The round ligaments. These are 
 so rudimentary in character that I can well believe they have less effect 
 in health or disease than was formerly supposed, although we shall, by and 
 
OF UTERINE DISPLACEMENTS. 289 
 
 by, see that artiticial shortening of them has some influence at any rate on 
 the cure of retroversion and proh\pse. (c) The utero-sacral baiids. These 
 bound Douglas's pouch on either side, and occasionally are strong enough 
 to catch the already retroverted uterus, and hold it down between their 
 folds. It would seem to me that they must have a decided effect in 
 supporting the uterus, (d) The utero-vesical folds. These are more 
 feeble, and, having their attachment to the bladder in front, are liable 
 to constant change. On the whole, there is some ground for the dimin- 
 ished importance as supports attached by many recent writers to the 
 vagina and uterine ligaments. Yet the uterus does not rest like a log 
 on the pelvic floor, which is so admirably adapted to expedite the 
 expulsion of the foetus. Although these supports are slighter and more 
 easily overcome than was formerly believed, they are supports, and 
 interference with them is an important link in a chain of untoward 
 events. 
 
 9. The Absorption of the Pelvic Fat and Connective Tissue.— In old 
 age, or under other circumstances, this tends materially to permit of 
 uterine descent, especially if the organ is over-weighted ; and too little 
 importance has, I think, hitherto been attached to the support aff"orded 
 by the vascular and semi-erectile element, and also by the few muscular 
 rtbres, contained in the connective tissues. 
 
 Under Class III. we have — 
 
 10. Great Muscular Efforts of any kind. — Their influence is obvious, 
 (iraily Hewitt traces 43 per cent, of displacements in unmarried or 
 sterile women to such causes. 
 
 11. Tight Clothing. — This, however slow, is certain in action, depres- 
 sing the pelvic contents, stretching all supports, and causing pelvic 
 congestion, and consequent uterine weight. 
 
 12. Abdominal Growths or Exudations. — This section includes such 
 factors as ascites when extensive, abdominal tumours of every kind, and 
 ovarian tumours when they have passed above the brim and overlapped 
 the uterus. It depends on other circumstances whether they merely pro- 
 trude the uterus downwards, or press it forwards or backwards. The 
 effect of exudation of blood or lymph, afterwards to be described under 
 pelvic hsematocele or inflammation, is to displace the uterus in various 
 ways, but also to fix it there, and prevent further displacement ; very 
 many cases of displacement are, I believe, due to the eff"cct of former 
 attacks of para-metritis, wliich may have escaped notice at the time. 
 
 13. Frequent Distention of the Rectum, Sigmoid Flexure, or 
 Bladder.— Wlicthcr these" are owing to the atonicity of the organs, or to 
 the difficulties which modesty often imposes on Avomen, the result is the 
 same. The eff'ect is usually chronic and persistent, but may occasionally 
 be traced to one special occasion. The eff'ect of a repeatedly over-filled 
 
290 GENEEAL CAUSES OF DISPLACEMENTS. 
 
 bladder in promoting backAvard displacement of the uteiTis requires 
 hardlj any explanation. 
 
 14. Chronic Cough. — This, especially in the aged, has often no mean 
 share, if not in originating, at any rate in increasing displacement, in 
 "whatever direction it may have occiuTed. 
 
 15. Sudden Falls. — These are very frequently the apparent originators 
 of displacement, especially of retroversions. In unmarried Avomen. 
 especially, a few questions will often elicit, in otherwise inexplicable 
 cases of retrovereion, a history of a fall from a horse or conveyance, or 
 in skating. 
 
 Under Class lY. we may enumerate — 
 
 16. Prolapse of the Vagina, — leading to traction upon the uterus, by 
 the vesical or rectal distention of the prolapsed wall. 
 
 1 7. Contracted Lymph, the ultimate result of inflammatory exuda- 
 tions. — This may drag the fundus laterally or otherwise, while the cervix 
 may have been pushed and fixed in quite an opposite direction {see 
 peri-metritis, kc, Chap. XIX.). 
 
 18. TJterine Polypi. — These tend, when within the uteras, to increase 
 its weight, and, when extruded from it, to drag it downwards. 
 
 19. Hypertrophy of the Cervix. — This may be so great as to act in a 
 similar manner. As we shall see, however, it may, by its growth, only 
 simulate descent, the fundus remaining at or about its nomial level {see 
 Pseudo-prolapse) . 
 
 20. Operations on the Uterus. — These must, I fear, be increasingly 
 added to the causes of, at any rate, downward displacement. While freely 
 admitting the boon which has been conferred on gynsecology by the 
 introduction of the duck-bill speculum, with its accompanying facilities or 
 necessity for drawing down the uteiais by booklets, I must once more 
 earnestly protest against the increasing tendency to make use of such 
 proceedings on all occasions. For frequent and simple inspections of 
 the OS, the application of ordinary remedies, the passage of a sound under 
 ordinary circumstances, and the like proceedings, no one is justified in 
 dragging the uterus about in this way, and it must be a matter of thank- 
 fulness that the ordinary practitioner is prevented, by want of sufl&cient 
 assistance, fi-om copying the example of some of our experts. 
 
 We come now to the consideration of the particiilar forms of displace- 
 ment, and as I have given the etiology of these in general terms, so we 
 shall find it a matter of practical convenience to mention under a separate 
 section the various mechanical supports which have been devised for 
 their i-cmedy (Chap. XII.). 
 
PROLAPSUS UTEKI : ITS CAUSES, ETC. 291 
 
 Prolapsus Uteri. 
 
 This term signifies descent of the organ. It may be described as 
 partial, when the uterus is still grasped by, and is still within the vagina, 
 or complete, when it has wholly or largely escaped beyond the sphincter 
 vaginse. Other subdivisions are inadvisable, being liable to miscon- 
 struction, through the dissimilar \ise of similar terms b}^ various 
 writers; thus the term "procidentia" has been used by some as synony- 
 mous with prolapse, by others as expressing an inferior, and by others 
 a superior degree of the affection. 
 
 Causes. — Almost every etiological condition given above may lead to 
 l>rolapsus uteri, and few cases exist where several of these factors do 
 not co-exist ; bat if I must emphasize the relative frequency with 
 which they may be credited, I would say — (1) that the most common, 
 though by no means an absolutely constant factor, is the dragging pro- 
 duced by pre-existing prolapse of the vaginal walls ; (2) that relaxa- 
 tion of the natural supports plays the next most important part, 
 whether this is to a certain extent congenital, or produced by the various 
 means described above ; and (3) I would attach a somewhat subsidiary 
 importance, though it is seldom entirely absent, to the effects of 
 increased weight or pressure, at any rate at the commencement ; all these 
 conditions are most frequently the result of parturition. 
 
 Physical Api^earances. — Swelling of the organ takes place ere long, 
 owing to the passive hypersemia caused by its position ; and hyper- 
 trophy, quite similar to that of chronic inflammation, both lengthens 
 the cavity and destroys the typical pear-shape. This, together Avith 
 the thickening of the inverted vaginal wall, gives to the protruded 
 organ a bulbous appearance, at the lower end of which lies the more or 
 less patent os. The inverted vagina, besides being thickened, has its. 
 riigsc stretched and smoothed out, and, b}" and by, the epithelii;m, in 
 contact with the air and with the neighboiu-ing thighs, assumes the 
 form of epidermis. Ulcerations, formerly described (p. 231), ai-e fre- 
 quently caused, which look very formidable, owing to their size and 
 thickened edges (fig. Ill), but fortunately these heal rapidly when 
 the hypersemia, due to position and to the effects of friction, is ol)viatcd. 
 I'emembering the attachments of neighbouring organs, it will be 
 evident, that when the uterus is fully prolapsed, the bladder will 
 be dragged down somewhat over its anterior surface ; behind it there 
 will also lie a pouch of the rectum, and 'at a higher level, the stretched 
 and elongated peritoneal pouch of Douglas, and within that, coils of in- 
 testine may settle, adding to the size and irreducibility of the mass. A 
 slight degree of prolapse is doubtless verj' common, giving rise to only 
 
292 
 
 PEOLAPSUS UTERI 
 
 a limited amount of discomfort, and being difficult to ascertain with 
 absolute certainty. Any of the ordinary causes may be at work for many 
 years, but not in sufficient force or in sufficient combination to produce 
 more than this trivial effect, until. some sudden impetus is given. In 
 all cases of hj'pereemic affection of the uterus we occasionally iind, 
 empirically, that a very little temporary mechanical support leads to the 
 abrogation of the more distressing symptoms, and this is doubtless due 
 to the relief of slight prolapse. The mode in which the graver forms of 
 prolapse gradually take place is not always similar, and depends on the 
 kind of causation. Very rarely, indeed, does the uterus drop straight 
 
 downwards, retaining its 
 normal inclination, but it 
 usually follows the typical 
 axis of the pelvis— the suc- 
 cessive axes of the brim, 
 cavity, and outlet (fig. 127). 
 After complete protrusion 
 the cervix again points dis- 
 tinctly downwards or even 
 backwards. It is not very 
 difficult to understand how 
 a primarily heavy fundus 
 uteri may originate, increase, 
 or perpetuate any of these 
 stages (fig. 128), or how a 
 weighty cervix may tend to 
 make them less apparent, or 
 how the primary descent of 
 the anterior or posterior 
 vaginal walls, respectively, 
 may render anteversion or 
 retroversion of the uterus 
 more prominent at the commencement. The general tendency is 
 towards the changes in uterine position during descent, which I have 
 diagrammatically indicated above. 
 
 The symptoms are the usual gynaecological ones of pelvic weight and 
 dragging, and lumbar pain, with discomfort in, or interference with, the 
 functions of the rectum and bladder or lower limbs (uterine lameness). 
 In severe cases, the bladder cannot be thoroughly emptied unless after 
 replacement, and the urine may thus become ammoniacal, or purulent. 
 In a few instances gangrene has occurred, with sloughing of portions 
 or of the whole of the uterus. More or less chronic vaginitis is 
 common, leading to leucorrhcca and to abrasions, or to adhesions which 
 
 Fig. 127. — Stages of Prolapsus Uteri in 
 ordinary cases. 
 
ITS CAUSES AND DIAGNOSIS. 
 
 293 
 
 prevent replacement. Menstruation may be quite normal. The 
 appearance of an external protrusion may be gradual or may occur 
 suddenly owing to some undue exertion, the patient attributing the 
 whole affection to this cause. 
 
 Diagnosis may be difficult in slight or incomplete pi'olapse. The 
 symptoms just mentioned, and the relaxed w^alls of the vagina, together 
 perhaps with a history of occasional former protnxsions, are generally, 
 however, quite sufficient to ensure the requisite treatment. Causing 
 the patient to cough or bear down forcibly, or even to stand up while 
 doing so, will, if necessary, ensure certaint3^ The affection, when com- 
 plete, can hardly be mistaken for anything but the following : — (1) SimjDle 
 vaginal prolapse; (2) pseudo-prolapse of the viterus ; (3) inversion ; and 
 (4) polypus of the uterus. The first of these can only be differentiated 
 by securing the fullest amount of protru- 
 sion possible, and then ascertaining the 
 position of the uterus. It will still al- 
 ways be difficult to say that some amount 
 of uterine falling does not exist, unless 
 that organ is fixed by adhesions, an 
 occun'ence not very common when vaginal 
 protrusion exists. Pseudo-prolapse, or 
 that state where, the fundus uteri remain- 
 ing at or about its normal level, h}^3er- 
 trophy of the cervix gives rise to an 
 appearance of prolapse, will be discussed 
 a little further on. Inversion of the 
 uterus has a history of acute origin, 
 generally after labour, and of continuous 
 and exhausting hsemoiThages, totally 
 foreign to uncomplicated prolapse {see 
 Chap. XIIL). Polypi have also their special history of haemorrhage 
 and expulsive pain, but in neither case should a proper manipulation 
 and attempt at reduction allow of any difficulty in diagnosis. The 
 absence of the os uteri at the lower end in either case, the character 
 of the mucous covering, and perhaps the discovery of the Fallopian 
 orifices in inversion, the firm cervical ring embracing the pedicle of 
 a polypus, and generally that of an inversion — these points should 
 remove all doubts that could possibly arise. Mistakes hei'c wo\ild show 
 luipardonable carelessness rather than the presence of diagnostic diffi- 
 culties. 
 
 Treatvient. — The treatment of prolapse, when there is external pro- 
 tnision, always demands, in the first place, its reposition by taxis. In 
 ordinary cases this is easy enough, remembering, if the prolapse is large, the 
 
 Fig. 128. — Prolapsus Uteri, with per- 
 sistent Retroflexion (Schrceder). 
 
294 TREATMENT OF PEOLAPSUS UTERI, 
 
 j)elvic axes. When the vagina is much everted, and bulges distinctly in 
 front of and behind the uterus, the vesical portion should be first repressed, 
 then the uterus, then the rectal portion. • It is in this order that descent 
 commonly occurs, but although this is correct in theory, and for the most 
 part in practice, it will sometimes answer best to repress the uterus 
 first. A very few cases are met with, where adhesions of the vaginal 
 walls or of the prolapsed peritoneal pouch render replacement impossible. 
 In such cases the practitioner would have to exercise his ingenuity, as 
 in large irreducible herniee, in inventing the most suitable kind of bag 
 truss. But pressure will nearly always succeed. The weight of the 
 uterus may be reduced by prolonged rest, by application of cold, by 
 scarification, and by compression of the lower end, as in phimosis. The 
 pressure of the loaded rectum or bladder must be taken off" by enemata 
 and catheterisation. In the event of pregnancy, premature labour will 
 seldom be required, and in the much rarer event of a large dependent 
 polypoid growth coexisting with prolapse, this must be primarily 
 treated. Taxis having thus su.cceeded, recumbency, with well raised 
 jDelvis, should be maintained for some time, and any tendency to cough 
 should if possible be obviated. Ulcerations will quickly heal in this way, 
 also much of the u.terine engorgement passes quickly away. The next 
 question to determine is what means are to be taken to keep the uterus 
 in position. In the case of comparatively young women, who are suflfi- 
 ciently well circumstanced to allow of continuous rest, an attempt should 
 always be made to accomplish this without mechanical supports. For 
 this purpose powerful astringent injections of alum, sulphate of zinc, or 
 the like, as mentioned under chronic vaginitis, are the most suitable 
 agents. We are now and then rewarded for a few weeks' treatment of 
 this kind by permanent results. Cotton or tenax plugs saturated with 
 the glycerole of tannin, or vinegar or other astringents applied by a 
 piece of sponge, left for several hours at a time, or medicated vaginal 
 suppositories of tannin or other astringents may be tried, if the 
 vagina does not too much resent them. While this is going on, every 
 means should be taken to improve the general health and to promote 
 diminution in the size of the uterus, especially by using glycerine in connec- 
 tion with the astringent remedies, and by the frequent use of Emmet's 
 hot-water treatment. If, after a fair trial of these means, the result is 
 not satisfactory, and prolapse still occurs, or in cases of old standing, 
 or, unfortunately, in most poor women who have to earn their livelihood, 
 artificial support must be used. The kind of pessaries most suitable 
 will be discussed in the next chapter, along with those required for other 
 displacements. In those cases where pessaries fail, either because they 
 cannot be borne, or because they are insufficient to keep up the tumour, 
 or when the patient, for various reasons, elects to try some more effective 
 
SURGICAL AND OTHERWISE. 
 
 295 
 
 means of repression than the constant use of a pessary, there are sur- 
 gical means still at om* disposal. 
 
 The repair of an obliterated perineum might at first strike one as the 
 most useful procedure of this kind ; but experience shows that it is 
 useless to hope for great results from the secondary operation, after 
 prolapse has occurred to any great degree. The perineum alone, whether 
 it is normally whole or has been so made by stitching, cannot long support 
 a superincumbent uterus. The operation at the time of rupture, or 
 before prolapse has commenced, is invaluable, but subsequently it seems 
 only to give a little firmer footing to certain kinds of pessary, and that 
 for but a short time. The only hope derivable from the secondary 
 operation is when it is performed 
 fairly early, or when not only the 
 perineum but a good portion of the 
 posterior vaginal wall is included in 
 the freshening process. Narrowing 
 of the vaginal wall, by creating raw 
 . surfaces and bringing them together, 
 has been tried in all manner of 
 ways. Powerful caustics used for this 
 purpose are, I believe, abandoned, 
 their action being uncertain and 
 dangerous. One cannot sufl&ciently 
 wonder at the boldness and novelty 
 of the suggestion to produce gon- 
 orrhoea ai'tificially, with this end in 
 view. Considering the number of 
 ordinary cases of gonorrhcEa where 
 adhesion does not occur, and the 
 whole moral and physical aspects of 
 the proposal, Dr Chippendale cer- 
 tainly bears away the 2:)alm for an original, though unreliable, suggestion. 
 Many of our more eminent gynaecological surgeons have vied with each 
 other in inventing diff"ercnt modes of bringing about vaginal contraction. 
 Some have proposed operating on the posterior vaginal wall ; others, and 
 those the more recent, have, following the suggestions of Marshall Hall, 
 preferred the anterior. A lax'ge triangular surfiicc with its base above 
 is generally acted upon. Some, like Sims, pare only its two con- 
 verging limbs (fig. 129), leaving, when these are brought togethei", a 
 pouch above. Others, like Emmet, consider this pouch objectionable, 
 and pare a margin round the whole triangle (fig. 130). Others again, 
 like Schrocder, freshen the whole surface, and are not quite so particular 
 as to its triangular form. Many other modifications are suggested, Le 
 
 Fig. 129. — Siins's Operation for Diminishing 
 the Vaginal Calibre, Elytrorraphy (after 
 Thomas). 
 
296 
 
 TEEATMEXT OF PEOLAPSUS UTEEI. 
 
 Fort suggests the freshening of a strip on both anterior and posterior 
 vaginal walls, and their union so as to form a double vagina. Gut 
 sutures, which do not require removal, would be most satisfactory for 
 this purpose. It is not my purpose to describe the details of these opera- 
 tions. They will always be confined to the siirgeon who has a special 
 predeliction for, or skill in, such procedures. When carefully performed 
 they undoubtedly afford temporary relief in that limited number of 
 cases where pessaries fail, and they greatly increase one's admiration of 
 the skill of the operator, — of their peniianent result the less said the 
 l:)etter. Complete closure of the vagina, at or near its outlet, with the 
 exception of a small aperture in front, offers, in the case of old women. 
 
 Fig. 130. — Emmet's Operation of ElytroiTapliy (after Tliomas). 
 
 a better chance of permanent retention of the utenis, and the higher 
 the closure can be carried the longer will the support last. Caneva 
 of Milan makes a suggestion which may possibly turn out to be 
 fniitful. The English student will find the necessary reference to it at 
 page 23, vol. i., of the Lancet for 188.3. He proposes, without opening the 
 peritoneum, to unite the peritoneal covering of the uterus, Avhich is held 
 up by an intra-uterine sound, to the layer covering the anterior abdominal 
 wall. The facility with which peritoneal surfaces unite is notorious, and 
 various modes of keeping them temporaril}'- together by stitches will 
 suggest themselves to any one accustomed to abdominal surgery ; the 
 difficulties involved in the danger of speedy stretching of these 
 
PROLAPSUS VAGINA. 297 
 
 adhesions, in the possible interference with the bladder, and in the 
 derangement of uterine function, if the operation is perfoiTaed early 
 in life, are no less manifest. The operation of Alexander for retro- 
 version and retroflexion (see page 317) will probably prove to be a safer 
 and more certain means of treating some cases of prolapse than this. 
 
 Having thus considered the condition of prolapsus uteri, we shoidd 
 still devote a few words to prolapse of the vagina alone, and to that 
 condition which we have considered to be best described by the term 
 " pseudo-prolapse " of the utems. 
 
 Prolapsus Vaginae. 
 
 Prolapse of the vagina, especially of its anterior wall, is, as has been 
 seen, very frequently the precursor of uterine prolapse. It is seldom that 
 anterior prolapse, or cystocele, as it is termed, from its relation to the- 
 bladder, exists long without dragging the litems down to some extent. 
 but cases do occur in Avhich the latter organ seems to be in no way 
 affected. Posterior prolaj)se — rectocele — is most frequently a secondary 
 occvuTence to the anterior form, with or without uterine affection, but 
 from constant overloading of the bowel, combined with diminished powei- 
 in the perineum, it may occur alone, leaving the uterus completely 
 unaffected. In this form of posterior prolapse the rectum only may be 
 involved, or the dragging upon that part of the pelvic contents may be 
 so great as to draw dowTi and greatly stretch Douglas's peritoneal pouch, 
 which also may contain within it a mass of intestinal folds. The bulky 
 swelling thus caused is termed an enterocele. 
 
 Among the general causes of misplacements mentioned above, the 
 most important here are the weakening of the vaginal walls themselves, 
 caused by pregnancy and labour, by deficient involution of the whole 
 structures after the latter, by chronic catan-h of the passages, or by 
 senile absorption of fat. The influence of frequent long retention of 
 the contents of the bladder and rectum, and, above all, the want of sup- 
 port involved b}- the total or partial destruction of the perineum, play no 
 mean part. 
 
 The syvijytoms are only varied from those of prolapsus uteri by tlu 
 greater or less prominence of those referring to the bladder or rectum. 
 
 Treatment. — As regards treatment, rest and recumbency, astringent 
 lotions or pessaries, and careful attention to the wants of nature, will 
 often do much, as in uterine jorolapse. The restitution of the perineum 
 is more likely to prove permanently useful than when the uterus is 
 involved, and the same remark apjjlies to operations for naiTowing or 
 occluding the vaginal canal. The more appropriate pessaries or supports 
 will be alluded to below. 
 
-298 
 
 UTEEIXE PSEUDO-PEOLAPSE, 
 
 Uterine Pseudo-Prolapse. 
 
 I have ventured to give this name to a condition Avhich by some is 
 included in the term uterine prolapse, while by most recent writers it is 
 described and distinguished as a totally different aifection. In a sense 
 both are right. It is a prolapse of at any rate a portion of the utems, 
 of its lower extremity, and it does not necessarily involve a prolapse of 
 its fundus or body, that portion remaining at or about its normal level. 
 It is, however, of considerable importance to differentiate between true and 
 pseudo-prolapse, especially when operative interference is required. The 
 explanation of this somewhat paradoxical state of matters is simple 
 enough. In certain cases, as we already know, the cervix is enormously 
 enlarged and elongated, while the body may be little if at all affected 
 
 {intra-vaginal hypertrophy). If the 
 utei-us as a whole is thus leng-thened, 
 its cervix may prolapse alone, or only 
 partially draw down the body. This 
 hypertrophy or elongation of the cervix 
 may, as we have also seen, be confined 
 to that portion which is below the 
 vaginal reflexion (fig. 131). It is for the 
 most part a true hypertrophy, although 
 often a product of metritis, and may, in 
 a modified form, be congenital. 
 
 The diagnosis of this form of hyper- 
 trophy, as regards its differentiation from 
 true prolapse, should not be difficult. If 
 the whole organ be pushed up to its full 
 height, without force, the protrusion of 
 the cervix into the vaginal canal will be 
 quite evident, and the sound wiU show 
 the increased total uterine length, while it will be evident that most 
 of this can be accounted for by the elongated cervix alone. 
 
 Treatment. — Pessaries are usually, under these circumstances, of little 
 avail, but one or two forms will be mentioned which may in the slighter 
 cases give relief Surgical interference is generally required, either on 
 account of dysmenorrhoea or of interference with the marriage relations. 
 We have already (p. 2.34) described the forms and methods of amputa- 
 tion required, and expressed an opinion as to their occasional advisa- 
 bility. If Fallen's views and practice there described should generally 
 commend themselves, we presume that they will be carried out before 
 the stage of external protrusion has been reached ; in fact, if lie is 
 
 Fig. 1.31. — Hypertrophy of the Intra- 
 Vaginal Cervix, with Pseudo- 
 Prolapse of the Utenis (Schrre- 
 der). 
 
OR PliOLAPSE OF THE HYPERTROPHIED CERVIX. 299 
 
 right in supposing that there is often no real elongation of the cervix, but 
 only a wrong vaginal implantation upon it, there is no reason why Ave 
 should then speak of pseudo-prolapse at all. Under such circumstances 
 there might be true prolapse, partially remediable by his special operation. 
 
 In certain cases, however, uterine hypertrophy is now well known tc 
 confine itself neither to the intra-vaginal cervix nor to the body of the 
 organ, but mainly to that jDortion of the cervix which lies above the 
 vaginal reflection {supra-vaginal hypertroiyliy). The result of such a 
 state of matters will also, if extreme, be to produce pseudo-prolapse, — 
 prolapse of the external os without lowering of the fundus to any great 
 degi'ee (fig. 120). There are various explanations of this form of hyper- 
 trophy, the simplest, of course, being an appeal to the fact that hyper- 
 trophy is sometimes confined to the body, sometimes to the intra-vaginal 
 cervix ; and the inference being that there is, therefore, no reason whj' 
 the intermediate portion should not sometimes be also chiefl}^ affected. 
 But there is every reason to believe that mere stretching of the organ 
 from some cause, with or Avithout hypertrophy, may give rise to pseudo- 
 prolapse. Prolapse of the bladder with its vaginal covering tends to 
 produce jarolapse of the uterus also ; but if the body is well held in 
 place, either by its ligaments or by any adhesions, the traction may act 
 mainly on the cervix, and thus become one cause of stretching. 
 Galabili points out another, in the grasjD which the vulva may take of the 
 cervix when suddenly extruded, seizing and partially strangling it, and 
 acting against the elastic ligaments and attachments of the uterus. 
 This cause can, however, act but seldom, as in so many cases we have a 
 ruptured perineum, and these sudden stretchings avouM require to be 
 very frequently repeated. 
 
 Diarjnosis. — The diagnosis of this form of pseudo-prolapse is more 
 liiflicult than Avhen it is dependent on intra-vaginal lengthening of the 
 cervix. The sound can seldom indicate, in such cases, the boundarj^ 
 line betAveen cervix and body, and rectal or bi-manual examination is 
 not much more clearly indicative of it. I should not be prepared to 
 pronounce further in the Avaj^ of diagnosis than b}- stating that, if the 
 sound shoAvs consideral)le elongation of the whole uterus, — say to four 
 inches, — if the intra-vaginal cervix is not notably elongated, and if bi- 
 manual examination shoA\'s no great circumferential enlargement of the 
 body, Avhile the os externum lies on the perineum or jjrotrudcs outside 
 the vulva, it is almost certainly the supra-A'aginal cervix Avhich is elon- 
 gated by local hjqDertrophy or by stretching, and the case is one of pseudo- 
 prolapse. 
 
 Treatment. — Pessaries can do for this affection an amount uf service, 
 intermediate betAveen that Avhich they do for true prolapse and for the 
 intra-A'aginal pseudo-prolapse. As regards operatiA'e relief, I confess that, 
 
300 
 
 VERSIONS AND FLEXIONS OF THE UTEEUS. 
 
 with the difficulty of diagnosis in view, and with a knowledge of how 
 the bladder in front, and the peritoneum behind, may dip down 
 
 along with the hypertrophied supra- 
 vaginal cervix, I must decline to 
 recommend for frequent adoption 
 any form of amputation which 
 takes account of any portion of 
 the cervix except that which is 
 clearly intra-vaginal ; although it 
 is certainly possible, with great 
 care, by means of V-shaped inci- 
 sions (fig. 132), to remove a por- 
 tion of the supra-vaginal portion, 
 as is done for the removal of epi- 
 thelioma. I should generally pre- 
 FiG. 132. — V-shaped Incisions for Kemoval fer to treat the case as one of 
 of Cancer of the Cervix (Schrojder). o.i., ordinary prolapse, trusting to medi- 
 OS uteri internum. ■ ^ r. 
 
 cinal means or to the lifting up 
 
 of the uterus, to remove the hypersemia, or stretching, or whatever it 
 may be, which is inducing this particular condition. 
 
 Elevation of the Uterus. 
 
 This displacement may be dismissed with a sentence or two. It occurs 
 in the case of pregnancy after the first three months, and of certain lai'ge 
 fibroids, or when the uterus is dragged up by ovarian or other tumours, 
 or when it is pushed xip by tumours below it. It may also be dragged 
 up by abdominal adhesions, or pushed up by exudations in the pelvis. 
 In all such cases it is the causative disease which requires considera- 
 tion, not the secondary condition of elevated uterus. 
 
 Versions and Flexions of the Uterus. 
 
 Preliminary Remarks. — Before speaking of the anterior, posterior, or 
 other versions of the iiterus, it will be well to clear the ground by a 
 few observations. In the first place, it should be noted that the term 
 displacement would cover something more than vei'sion or flexion. The 
 whole uterus may be pushed or drawn backwards, forwards, or sideways 
 without any disturbance of the angle at Avhich it lies to the horizon or to 
 the plane of the pelvic brim, or without any bending of its separate 
 
PKELIMINAIIY KEMAKKS. 301 
 
 portions upon one another. In this case we have displacement certainly, 
 but not version or flexion, according to their ordinary definition. There 
 iire no special English terms for this kind of displacements, and we may, 
 once for all, summarily dismiss them with almost the same sentences 
 that we have devoted to uterine elevation. Tumours or exudations 
 outside the uterus, or growing from its own walls, may push it, or 
 contracting adhesions may drag it, in various directions. In all such 
 cases it is the pushing or pulling agent which alone demands attention 
 and treatment. We must seek to remove, if we can, the tumour, (^r 
 exudation, or adhesion. 
 
 By version of the uterus (fig. 133, No. 2) we indicate a species of dis- 
 location, hj flexion (fig. 133, No. 4) rather a species of deformit}^, with or 
 without dislocation. In version the fundus is directed abnormally from 
 its usual position (fig. 134, No. 2), causing the axis of the whole uterine 
 canal to be changed, while it retains its normal and almost straight 
 direction, and the cervix accordingly points in the opposite direction to 
 the fundus. We may, for practical purposes, disregard the very slight 
 curve of the canal forwards which is found in the normal condition. In 
 flexion, on the other hand, the fundus or upper part of the uteiais is 
 unduly bent forwards, backwards, or laterally, while the cervix or lower 
 portion either retains its natural position (fig. 133, No. 3), or bends in 
 the same direction as the upper portion (fig. 133, No. 4), or points in the 
 opposite direction (fig. 133, No. 5), a combination of version and flexion 
 thus resulting ; the amount of total flexion of the orgaix is determined 
 by these factors. In a minority of cases it is the fundus which retains 
 the normal direction (fig. 133, No. 6), while the lower segment under- 
 goes flexion, and these cases are chiefly those where the flexion is due to 
 the influence of contracted pelvic exudation. 
 
 Several factors tend to induce the tendency to flexion rather than 
 version, or to engraft the former condition upon the latter. AVhile 
 admitting much deficiency in our knowledge of the action of the uterine 
 ligaments and supports, the upper end of the organ is undoubtedly more 
 mobile, or mobile over a larger arc, tlian is the lower, so that a greater 
 leverage power is exerted b}' pressure upon the fundus than elsewhere. 
 This explains how pressure exerted against the fundus may cause version, 
 but also how version may speedily tend to flexion or bending of the organ 
 also. In not a few cases there exists also a congenital tendency to undue 
 flexion, at any rate anteriorl3\ We have noticed this especiall}^ in the 
 infantile type of uterus, and when this tendency, however slight, exists, 
 everything in the shape of downwards pressure will tend to exaggerate 
 it. In cases where small tumours exist within tlic uterine walls, the 
 higher they arc placed, the greater will their tendency be to cause 
 flexion rather than version of the organ. Again, there exists in many 
 
302 
 
 lo 
 
 ul 
 
 ul 
 o 
 
 < 
 
 -I 
 
 in 
 
 (5 
 
 o 
 
 DC 
 < 
 
 § 
 
 a: 
 o 
 
 s 
 
 h 
 
 o 
 
 2 
 
 t3 S 
 ? •r' 
 
 u 
 
 =2 
 
 2 
 
 2-? 
 
 UJ 
 
 tu "S 
 
 o 
 
 53 Ph 
 
 < 
 
 
 _l 
 
 -S i^ 
 
 D. 
 
 a o 
 
 to 
 
 ei -=1 
 
 [b c3 
 
 (0 
 
 >0 
 
 Q 
 
 Q 
 
 i 
 
 o 
 
 < 
 
 CD 
 
 
 fi "S 
 
 !h 
 
 o 
 
 n 
 
 f-. 
 
 
 CD 
 
 "o 
 
 f-" 
 
 cS 
 
 
 cq 
 
 
 
 6 
 
 o 
 
 ;? 
 
 c3 
 
 m 
 
 
 f-i 
 
 s 
 
 C 
 
 (U 
 
 f= 
 
ANTEFLEXION OF THE UTERUS. 
 
 3oa 
 
 instances some softening or thinning of the uterine walls, especially 
 about the junction of cervix and body ; this may also be congenital, or 
 it may be due to the former existence of some amount of flexion, or it 
 may be the flaccidity sometimes caused by chronic metritis, when the 
 whole organ is not stiffened by chronic fibrous deposits. The too fre- 
 quent overfilling of the bladder 
 exerts a paramount influence on 
 the production of backward ver- 
 sion, but the influence of loaded 
 rectum on forward versions is not 
 exactly corresponding. The blad- 
 der not only pushes the uterus 
 back, but, as a bag of fluid, may 
 overlap it, and press or bend it 
 down in the abnormal position 
 (fig. 135). The rectum, lying- 
 lower, and containing more solid 
 contents, and being moreover 
 more strongly retained in position, 
 does not act similarly. But 
 whether there is a tendency to 
 forward or backward displacement, the intestines by their weight tend 
 always to increase it. They may, in forward displacement, crowd down- 
 wards into Douglas's pouch and so assist in its continuance, or in back- 
 ward displacements they may, by mere downward pressure, confirm 
 and render continuous the wrong impetus towards i-etroflexion once 
 given by the bladder. 
 
 Fig. 135. — The Bladder overlapping a Retro- 
 ilected Uterus (Scliatz). 
 
 Anteflexion. 
 
 Causation. — As we have seen, this is not infrequently congenital, or in 
 cases where the uterine wall is soft, or there is enlargement of the fundus 
 from any cause, it easily occurs, in spite of the contrary action which 
 the moderately filled bladder might be supposed to exert. The utero- 
 vesical connections are lax, and, if flexion once exists, the full bladder, 
 instead of unbending the uterus, simply pushes the whole organ downwards 
 in its anteflexed condition, and, when emptied, allows it to remain so flexed. 
 When anteflexion is met wdth in women who have not borne children, it 
 may almost be assumed that there was a certain amount of congenital 
 abnormality, unless a fibroid growth can be made out ; but in those who 
 have bonic children, the causation may lie in any of those circumstances 
 which we have already described as common to all forms of displacement, 
 and it will often be impossible to say which of these has taken the 
 
-304 SYMPTOMS OF AXTEFLEXIOX. 
 
 leading joart. But when the flexion is sharp, and unaccompanied hx 
 other signs of infantile uterus, and especially if there is any loss of 
 mobility, there will always be a strong presumption that pre-existing 
 peri-uterine inflammation has had some share in the causation, and, as 
 Schultze has pointed out, this may act either directly by dragging down 
 the fundus or pulling the cervix forwards, or indirectly by retracting 
 the sacro-uterine ligaments. The student will understand this better 
 when he has studied the various pelvic inflammations. 
 
 The Syrnptonis are as indefinite as in most other forms of uterine disease. 
 Bladder troubles are natm-ally very common — frequent micturition, 
 occasionally incontinence or retention of m-ine, now and again cystitis — 
 but there may be not a single bladder symptom. Back-ache, loin pain, 
 leucorrhoea, and the like, are also frequent, sometimes absent. Xo one 
 is justified, from such symptoms, in deciding anything but the necessity 
 for a careful physical examination. Sterility is, of course, very frequent, 
 but the physical obstacles to the progress of the semen, which may be 
 overcome in a case of unruptured hjTaen with intense vaginismus, are 
 not xinconquerable in the case of a flexed cervix. Dysmenorrhcea most 
 frequently, though by no means always, is a marked symptom or result of 
 anteflexion, although I am aware of the delicate ground on which I stand 
 in making this assertion. Turning to the causes of dysmenon-hoea, 
 I find (1) that the neuralgic constitution is, as shown in every way, very 
 common in those who have an infantile development of the u.teiiis and 
 ovaries, and that this temperament shows itself in the form of dysmen- 
 orrhoea of neuralgic or ovarian character. (2) I find that engorgement 
 of the fundus is not unusual in cases of bent uterus, and that dysmen- 
 orrhoea may thus naturally be expected, although the general engorgement 
 of the whole organ during menstruation has a tendency to stiffen its walls, 
 and so, to a certain extent, to straighten its canal, the one circumstance 
 tending by its effects to counteract those produced by the other. (.3) I 
 know that the bending of a flexible tube does diminish its calibre almost 
 to extinction. A Higginson's spinge or a baby's sucking-bottle presents 
 a familiar example. Hence difiiculty in all but the most gradual and 
 liquid flow. (4) If the flow is retarded by this cause, I know that intra- 
 uterine coagrdation is a physiological result, involving the exj)tilsion of the 
 coagulum and consequent dysmenorrhoea. All these causes of dysmen- 
 on-hoea may occur individually, or may be combined, in flexed uterus. 
 But beyond these theoretically presumptive reasons why dysmenorrhoea 
 should not infrequently accompany anteflexion, I can assert that, time 
 after time, the straightening of the uterus by sound, or even by digital 
 pressure, has caused the temporary cessation for months of dysmenor- 
 i-hoea which had lasted for years, and has occasionally resulted in its 
 permanent cure. The fact that in comparatively rare instances we have 
 
DIAGNOSIS OF AXTEFLEXIOX. 305 
 
 well-marked anteflexion, with no great neuralgic tendency, with no 
 apparent uterine engorgement, and with the regular and painless flow of 
 an unclotted and liquid menstrual discharge, through the bent uterine 
 canal, does not in any way invalidate the assertion that dysmenorrhoea 
 is a most frequent symptom and result of uterine anteflexion. In ante- 
 flexion in the multipara, thei'e is less tendency to dysmenorrhoea of a 
 violent character, owing, doubtless, to the greater patency of the 
 canal. 
 
 Diagnosis. — The diagnosis of anteflexion should not generally be very 
 diflicult, if we bear in mind its physical signs, which should, in the first 
 place, at any rate, be made out bi-manually. The cervix may be in its 
 normal jjosition, while a rounded body is felt through the anterior 
 vaginal fornix (fig. 133, No. 3), or the cervix may point forwards as in 
 retroversion, but the fundus is still to be made out anteriorly instead of 
 posteriorly (fig. 133, Xos. 4 and 6). The chief point is to be assui-ed 
 that the rounded body in front is really the fundus, and, if so, that it is 
 not the fundus or body of an impregnated uterus. "Whenever there is the 
 slightest doubt on this latter point, the use of the sound is inadmissible, 
 but we must trust to our knowledge of the changes of the cervix occumng 
 dm'ing pregnancy, and to the fact that the uterus is not only to be felt 
 unduly forwards in pregnancy, but is also enlarged backwards to some 
 extent.' If necessary, we must await further developments. A fact, not 
 generally noted, should be borne in mind, viz., that in sharj) anteflexion 
 the anterior lip of the os is often swollen and oedematous, owing to inter- 
 ference with its circulation. This is not, therefore, in any way diag- 
 nostic of pregnancy. It is stated by Leishman that an anteflexed fundus 
 uteri, felt through the partially filled bladder, has been mistaken for the 
 ballottement sign of pregnancy. This could only happen where one sign 
 alone was depended on, and the absence of pregnancy sufliciently 
 advanced to be capable of producing ballottement could easily be made 
 out by bi-manual examination. Fibroid growths of the anterior wall are 
 less frequent than those of the posterior. They naturally simulate ante- 
 flexion, or produce some amount of it. The direction of the soinad, and 
 its power of entirely removing the flexion, combined if necessary with 
 supra-pubic examination, shoiild clear up this doubt. Pelvic exudations 
 of blood or lymph are occasionally confined to one situation in front of 
 the utenis. Their history, the uterine immobility they cause, the totally 
 different shape of the mass, when examined bi-manually, from that of a 
 flexed uterus, and the direction of the uterus, ascertained by the sound 
 or bi-manual touch, give sufficient evidence of their true nature. Vesical 
 calculus or tumour, by the urgency of its symptoms, will call for examina- 
 tion of the bladder itself, and this, together with the vaginal exploration, 
 will show where the seat of swelling really exists {see Chap. XXII.). 
 
306 THE TKEATMENT OF 
 
 The yoiiug practitioner miist never omit to alloAv for a slight amount of 
 anteflexion, something nearly approaching to No. 3, fig. 133, as the 
 almost noi-mal state of the virgin uterus. 
 
 Treatment. — The treatment of anteflexion is much more unsatisfactory 
 than that of the opposite condition. Its frequently congenital origin, and 
 the greater difficulty of applying artificial supports, account for this. 
 In cases of congenital flexion, where there are no urgent symptoms, 
 it is much wiser to refrain from all local treatment. We are most 
 likely to set up congestion or inflammation of the fundus, and so to 
 create the symptoms. There can, however, be no objection to mere 
 bi-manual reposition without the use of the sound ; but I have only 
 seldom found much permanent effect on the flexion. In those cases 
 where dysmenorrhcea first leads to investigation, the careful use of the 
 sound as a repositor should be tried, care being previously taken, by 
 rest and a few glycerine plugs, to reduce any hypersemia. No force 
 must be used, and but little pain should be caused. In passing 
 the instrument the fundus should be pressed up by the finger so as 
 to aid in straightening the uterine canal. The flexion, whether at 
 the OS internum or not, should be coaxed or tired, not forced. The 
 sound once in, if there are no adhesions, the body should be raised 
 to quite its normal height, or even somewhat retroverted, bearing in 
 mind the instructions given above as to the kind of rotation 
 which is j)ermissible. If the handle of the sound is brought well for- 
 wards in front of the pubes without any rotation, the normal elevation 
 of the fundus or more is attained, and the handle must then be swept 
 slowly round in a wide circle, its point being regarded as a stationary 
 centre. This manoeuvre may be repeated two or three times between 
 two menstrual periods, and if no great irritation follows, a somewhat 
 larger sound or bougie may be used each time. Some troublesome 
 cases are thus curable, that is to say, the patient loses her dysmen- 
 orrhcea, or, if married, sometimes becomes pregnant. In the latter case 
 the cure is generally permanent, both as regards symptoms and as 
 regards the physical condition of flexion. Unfortunately we can 
 seldom say this of posterior displacements, although their immediate 
 treatment is more easy. For the relief of the dj'smenorrhoea of ante- 
 flexion the division of the cervix, as recommended for stenosis, is often 
 of considerable service. When the bend is in the cervix itself, and 
 especially if it be at or close to the vaginal insertion, this plan is some- 
 times invaluable, but common sense would assure us that it can hardly 
 affect the symptoms when the bend is much higher up, as it is apt to 
 be in cases occurring in multiparas. All that was said before (p. 188) 
 in favour of a single backward incision, applies here. It should divide 
 the posterior lip more than half-Avay up to the level of the vaginal 
 
UTERINE ANTEFLEXION. 307" 
 
 insertion, and after it has been made, a sound should be passed to ascertain 
 whether the entrance to, and consequently the exit from, the uterus 
 has been made clear. If there be still difficulty, a probe-pointed knife 
 should be passed, edge backwards, a little beyond the upper end of the 
 cut, and the cervical parenchyma should be divided a little further, as 
 much care being taken not to go beyond the cervical wall as is required 
 in the most delicate of surgical operations. The line of the first 
 incision, and of that made by the knife afterwards, are respectively shown 
 in fig. 136. The object of this incision is not only to enlarge the 
 canal, but to cause its axis to become more conformable to that of the 
 body. Care will be necessary for a con- 
 siderable time, to keep open the wound 
 thus made, by occasionally passing a 
 bougie, or by introducing a glass stem ; 
 pessary at intervals. No doubt this opera- 
 tion is liable to abuse, but when the other 
 means for the treatment of dysmenorrhoea, 
 including slow dilatation by bougies, have 
 been found unavailing, it is perfectly j,^^_ i36.-Iucilns orthe Cervix 
 justifiable and frequently successful. I required in certain cases of 
 
 think I have made it clear, but may as Anteflexion (after Sims), ac, 
 
 well repeat again, that all local measures '?' preliminary incision; ad, 
 ^ to J v.tvoLi.iv.0 its completion m extreme cases. 
 
 of this kind are to be anteceded by the 
 
 careful removal of all removable causes of displacement. The treats 
 ment of anteflexion by means of intra- or extra-uterine supports is 
 mentioned further on when describing the various pessaries in use. 
 It is here that our treatment is so much more unsatisfactory than it 
 is in backward flexions or versions. In no case of anteflexion should 
 the possibility of previous pelvic inflammation be forgotten, lead- 
 ing us to caution in the use of all local treatment, and pointing 
 to the possibility of good results from tonic and absorbent remedies, 
 such as are indicated in all chronic cases of the inflammatory affec- 
 tion. Such flexions as No. 6, fig. 133, are especially the result of 
 former small cellular inflammations, bending the cervix forwards. 
 
 Anteversion. 
 
 This is, in one sense, a much less common aflbction than anteflexion ; 
 in another sense it is more frequent. The congenital element in causa- 
 tion tends always to flexion, and therefore, in nullipane, anteflexion is 
 the predominant form of forward displacement, while in multipara) the 
 reverse is the case. 
 
308 ANTEYEESION, ITS CAUSATION, SYMPTOMS, 
 
 Causation. — The causes of pure anteversion are much more frequently 
 met with after delivery or abortion, though by no means invariably; 
 they are, however, common causes, and a certain degree of anteversion 
 is, therefore, common in the married. But as a forward dip of the 
 fundus uteri, constantly altered by the condition of the bladder, but 
 roughly corresponding, in medium dilatation of that organ, to the axis 
 of the pelvic brim, is normal, it is most difficult, or impossible, to say, 
 in many instances, whether anteversion exists or not. The presence of 
 its usual causes, and the undue excess of symptoms of bladder pressure, 
 are often our only warrant for believing it to exist. Such a complete 
 npset of the organ as is sometimes met with backwards (fig. 134, No. 3), 
 where the fundus lies low in Douglas's pouch and the cervix points 
 almost directly upwards, is almost an impossibility in forward displace- 
 ment. It would require the rarest possible combination of circumstances 
 to produce it. In pregnancy we have a physiological rather than a 
 ]3athological anteversion ; and the circu.mstances which lead to the 
 pathological state are chiefly those which cause the uterus to assume 
 something of the size, weight, and fulness observed in early pregnancy. 
 There must be increased weight of the organ, while its walls are not 
 so much softened by disease or by congenital causes as to allow of the 
 flexion which Avould otherwise ensue. Chronic corporeal metritis fulfils 
 these conditions, so does sub-involution. Interstitial fibro-myomatous 
 growths, or small isolated sub-mucous or sub-serous tumours, if their 
 power is not exerted directly downwards from the summit of the fundus, 
 also tend to produce anteversion. In a few cases an original ante- 
 flexion becomes converted into an anteversion by inflammatory or sub- 
 involutional complications which stiffen the uterine wall, and Schroeder 
 mentions, and I have myself observed one or two instances, where the 
 temporary engorgement of* the menstrual period had, temporarilj^, a 
 similar result, — where No. 3 or even No. 4 of the displacements shown 
 in fig. 133 became for the time being No. 2. Cj'stocele, or prolapse of 
 the anterior vaginal wall, is apt to create anteversion as the first stage 
 of prolapsus uteri, although the uterus, yielding to the pelvic curves, 
 and dragged down by the posterior vaginal wall also, most frequently 
 becomes subsequently retroverted. 
 
 Symi^toms. — The symptoms of anteversion are those of the disease 
 which causes it, — of chronic metritis, fibro-myoma,&c., — with some aggra- 
 vation of those of bladder-pressure. In extreme cases the cervix presses 
 backwards on the rectum so much as to cause much constipation and 
 tenesmus. In all cases the cervix felt through the rectum is a very 
 prominent feature, and conveys the idea of greater displacement than 
 really exists. There is nearly always some difficulty or discomfort in 
 locomotion. 
 
DIAGNOSIS, AND TEEATMENT. 309 
 
 Diagnosis of minor degrees is, as we have seen, rather a deduction from 
 the observance of general facts than an absolute certainty ; but there 
 should be no great difficvilty in the way of differentiation from other affec- 
 tions whicli may simulate anteversion. Above all things pregnancy must 
 be eliminated, or, if that cannot be done, the diagnosis must be deferred. 
 But, given the existence of a cervix uteri pointing more than usually back- 
 wards, of a somewhat weighty mass to be felt by bi-maaaual examination 
 in front, and of an organ which is at all movable, the only question is, 
 What is the cause of the anteversion, whicli in itself is apparent enough ? 
 
 Treatment, therefore, resolves itself, in nearly all instances, into the 
 treatment of that cause. General constitutional treatment is of value 
 as it bears upon this. Frequent, if not constant, dorsal decubitus is of 
 service, as aftbrding relief to many of the prominent symptoms. Vaginal 
 astringents or suitable pessaries will aid, in the slighter cases, in dimin- 
 ishing cystocele, or operations on the perineum may act in the same 
 way. Ai'tihcial supports will be found to be effective only as they 
 maintain the whole vaginal tract in situ, or as they lift up the 
 otherwise diseased uterus and so diminish its passive hyperaemia. In 
 short, there is, I believe, no special treatment of anteversion apart from 
 that of its causes. Sims has suggested shox'tening the anterior wall of 
 the vagina by plastic operation, and so pulling forwards the cervix and 
 lifting the fundus. I do not think this could be effective with the usual 
 heavy and enlarged viterus, which leads to real and unmistakable ante- 
 version. 
 
 Backward Displacements of the Uterus. 
 
 General Remarks. — Although cases of congenital retroflexion are re- 
 corded, yet they are so rare that we may, for practical purposes, consider 
 backward displacement of the uterus as purely an acquired condition. 
 There is one element at work which is continually tending to produce a 
 temporary displacement in this direction, viz., the action of the full 
 bladder ; and it is not difficult to imagine how, even in the virgin, and 
 with a normally heavy uterus, a sudden jolt under these circumstances 
 will increase the displacement, and how the superincumbent pressure of 
 the abdominal viscera, now acting on the front of the uterus instead of on 
 its posterior siirfacc, will perpetuate tlic condition, and xUtimately render 
 natural recovery impossible. This is undoubtedly the actual causation 
 in many cases met with in the luunarried or uulliparous woman. 
 Whether version or flexion result will depend on the flexibility of the 
 uterine wall, or on the pei'sistence of pressure on the fundus. Con- 
 sidering the frequency witli which the fenude bladder is luiduly dis- 
 
310 BACKWAED DISPLACEMENT OF THE UTEEUS. 
 
 tended, it is astonishing how seldom we meet with the result. I can 
 account for this only in two ways — first, that many cases of uterine 
 retroversion are not recognised until marriage or pregnancy increases 
 the symptoms, or for the first time causes them to appear ; and, second, 
 that the anterior uterine ligaments have much gTeater power than has 
 been attributed to them by most modem physiologists. 
 
 As might be expected, retroversion is generally the precursor of retro- 
 flexion. An organ with normally stiff walls, and, still more, one with 
 walls stiffened by disease, will at first simply tilt over ; and then, as per- 
 sistent pressure weighs down its fundus, bending will follow ; but the 
 partiality occasionally shown by the interstitial hypertrophy of chronic 
 metritis, or by sub-involution, for separate portions of the uterus, for its 
 intra-vaginal or supra- vaginal cervix, or for its body, will equally account 
 for the occasional presence of flexion from the first. The greater or less 
 relaxation of separate portions of the ligamentous supports is doubtless 
 also a factor in hastening or retarding the tendency of the uterus to bend 
 on itself. 
 
 The convenient space aff"orded for a backwards-turned fundus uteri, 
 in Douglas's distensible peritoneal pouch, accounts for the frequency 
 of the condition, and also allows of its comparatively easy recognition. 
 In the post-puerperal state, the heavy uterus gravitates backwards, 
 owing to the position on the back usually enforced on the patient, and 
 this is aggravated by the firm binding of the abdomen which, for various 
 reasons, is adopted. A frequent change of position is therefore very de- 
 sirable. Exudations of lymph behind the uterus, with their subsequent 
 partial absorption and contraction (fig. 27), account for a certain number 
 of cases of backward displacement, but the displacement is much more 
 commonly primary, while the inflammation, and its result in irretriev- 
 ably fixing the uterus, are secondary. I have already referred to the 
 fact that, in prolapse of the uterus, "anteversion is common in its 
 earliest stages, owing to the dragging of the anterior vaginal wall, but 
 that backwards displacement occurs at a later stage. Small fibroid 
 growths are more common in the posterior than in the anterior wall of 
 the uterus, and therefore more often figure as causes of displacement, or 
 sources of difficulty in diagnosis. 
 
 Eetroflexion. 
 
 The causation of this affection (fig. 134, No. 5) has beeii almost entirely 
 indicated in the foregoing remarks. The uterine body is nearly always 
 enlarged by sub-involution or chronic metritis, or by mere engorgement. 
 The enlargement may be independent of those causes, as when a fibroid 
 
RETROFLEXION, ITS PHYSICAL SIGNS AND SYMPTOMS. 311 
 
 id present. The over-distended bladder, or the usuid post-pnerperal 
 position, or some temporary shock, gives the impetus backwards. Then 
 come into phij the rehixed state of the ligaments, the pressvn-e from 
 above of the intestines or of the loaded ceecum, and the softening of the 
 uterine wall, due to recent parturition or to other causes, to complete 
 the state of more or less permanent flexion. In the unmarried, 
 retroversion is the more common result of any of these non-puerperal 
 causes, although flexion is by no means unknown. 
 
 Physical Signs. — On bi-manual examination the cervix will be found 
 pointing downwards, generally with a forward tendency (fig. 134, No. 5), 
 the result of previous retroversion. It is seldom that flexion is so 
 great that the cervix points backwards (No. 6). The bend is most 
 commonly at or about the os internum. The cervix may sho\v patho- 
 logical changes of its own, — hypertrophy, laceration, chronic endo- 
 cervicitis, tkc, — but the posterior lip is very often swollen and oedemat- 
 ous, independently of these. The fundus lies more or less low in 
 Douglas's pouch, and its continuity with the cervix is easily traceable. 
 Owing to the usual causations the walls are generally thickened, and 
 the cavity is shown by the sound to be somewhat lengthened. It is to 
 be remembered that these conditions become increased, as an effect of the 
 flexion, as well as entering into its causation. At the point of flexion 
 I have rarely noticed any perceptible thinning of the wall, either at 
 the concavity or convexity. This agrees with Barnes's experience, 
 although not with that of some other writers. The fundus is felt to be 
 freely movable in most cases, and can be replaced, but not very 
 infrequently it is tied down by adhesions. I have occasionally suspected 
 such adhesions at one visit, and subsequently found them not to exist, 
 and this has been explained by the fact that the utero-sacral ligaments 
 may grasp the fundus laterally, and so temporarily' retain it in situ. 
 Hermann insists that the pressure of the utero-sacral ligaments on 
 the venous circulation of the retroflexed uterus is a fertile source of 
 further passive engorgement, and through this, of dysmenorrhcea or 
 menorrhagia, when they accompany backward displacement. The ovaries 
 are more or less dragged down with the uterus, and may often be felt 
 bi-man\u^lly, lying beside or even behind it. In too many cases, when 
 there has been subsequent inflammatory action, they become adlicrent 
 to it or to their surroundings, and furnish the greatest difficulty in tlic 
 way of applying pessaries for the support of the organ. 
 
 Symptoms. — The symptoms of retroflexion partake of the usual vague 
 character, although, in a multipara, it is very often easy enovigh to feel 
 pretty sure of its existence from symptoms alone. Occasionally there 
 are hardly any, but this is not common. Some time ago I saw a lady on 
 account of a totally different disease, who informed me that a celebrated 
 
312 THE SYMPTOMS AND DIAGNOSIS 
 
 American lady doctor had diagnosed uterine retroflexion. As there was 
 not the remotest symptom of any uterine aff'ection that I could elicit, 
 I was tempted to express strong doubts about the matter, but on 
 examination I found a very complete retroflexion. The patient does 
 not believe either of us, and will wear no pessary. The only result, 
 rather than symptom, in her case, is sterility for several years after the 
 rapid succession of two normal labours. Generally, however, we have 
 the usual utero-pelvic troubles, back-ache being especially prominent. 
 Defsecation is interfered with, and the patient can often tell that there is 
 something pressing on the bowel and obstructing it. Pressvire on the 
 bladder is more frequent in pure retroversion. The symptoms of 
 chronic metritis, parenchymatous or mucous, are those which ordinarily 
 lead to investigation. As the case goes on, they become exaggerated, 
 and are apt to lead to menorrhagia or even metrorrhagia. Dys- 
 menorrhcea is a much less prominent feature than in anterior flexion. 
 Menstruation has usually been well established before retroflexion takes 
 place, and the canal is patulous. Neuralgia, and tendency to varix 
 in the lower extremities, are frequent, the causation being obvious. 
 Paraplegia is also occasionally a result. I have seen but three cases, in 
 all of which it was undoubtedly not due to organic nerve disease. In two 
 it got well shortly after reposition, and in one it yielded to Weir Mitchell's 
 treatment by massage, &c. Sterility is a common, though by no means 
 constant, result. If impregnation does occur, abortion is, however, very 
 apt to ensue, and many, if not most, of the cases of retroversion of the 
 gravid uterus met with are not purely accidental, but date their origin 
 to an already retroverted or retroflexed uterus, which fails to ascend 
 above the pelvic brim. It will be seen that I have confined my remarks 
 to backward displacement of the non-gravid uterus. 
 
 The diagnosis of retroflexion depends on a correct appreciation of the 
 above symptoms and signs, and on the replacement of the fundus by the 
 fingers or the sound, when this is not prevented by adhesions. If the 
 student will look back to the statement of the occasional abnormal 
 occupants of Douglas's pouch (p. 7), he will find there an enumeration 
 of the substances which might be mistaken for a retroflexed fundus. 
 Of these, fibroid growths, pelvic exudations, or ovarian tumours, are the 
 chief sources of error. Fsecal accumulations, prolapsed ovary, abscess, 
 hernia, and extra-uterine foetation, may be dismissed ; they have special 
 characteristics or histories which should prevent permanent error. 
 Small fibroid tumours, which may, however, coexist with some amount of 
 retro-displacement, are recognised by careful bi-manual examination, 
 which reveals the change in the whole uterine shape or size, while 
 replacement by the sound is only partial, if it occurs at all. In all cases 
 of doubt of this kind, great assistance is derivable from rectal examina- 
 
OF EETEOFLEXIOX OF THE UTEKUS. 313 
 
 tiou, alone or combined. Pelvic exudation, whether of coagulated blood 
 or of l}Tiiph, is recognised by its history, — sudden commencement in 
 haematocele; febrile symptoms, &c., in inflammation, — and by its complete 
 immobility, and extension laterally or forwards. Of course, a retro- 
 flexed uterus may be surrounded by such exudation, when the diagnosis 
 will require much care and time, and no practical benefit will be derived 
 from hasty attempts. In the absence of acute febrile symptoms, the 
 sound will detect the direction of the uterine canal among the surround- 
 ing deposits. Small ovarian tumours, or the prolapsed ovary, when 
 enlarged by inflammatory deposits, may resemble the fundus uteri in 
 contour and position, and may give rise to some difficulty. As a rule, 
 their complete isolation from the uterus may be made out bi-manually, 
 but, if adhesion has taken place, the pain of a pi'olapsed and inflamed 
 ovary is very characteristic ; the softness of ovarian cysts distinguishes 
 them from fibroid outgrowths, and, in the rare complication of a solid 
 ovarian growi;h adherent to the uterus, it may be impossible to say that 
 it is not a fibroid outgrowth, but the direction of the uterine canal will 
 show that it is not the retroflexed fundus. 
 
 The 2^rognosis of retroflexion is, I fear, not a very bright one. If re- 
 placeable, it can generally be kept in situ by pessaries, and all serious 
 symptoms may be removed. Even if j)regnancy follow, and all the 
 hostile conditions may be supposed to be in abeyance, while there is every 
 chance to avoid their recurrence after delivery, the flexion nearly ahvays 
 returns sooner or later, and may again require artificial support. The 
 more early it is detected the greater ought to be the chance of the 
 juvantia et loedentia — the helping or the hindering conditions — being 
 reversed in power, but that is all that can be said. Paul ]\lunde, in 
 the American Journal of Obstetrics of October 1881, has gone into the 
 question of prognosis more carefully than any other writer of whom I 
 am aware, but he leaves the matter pretty much as tlms stated. 
 
 The treatment of retroflexion will be most profitably discussed in con- 
 nection with that of retroversion. 
 
 Eetroversion. 
 
 Causation. — Whenever the bladder is distended to its fullest extent 
 the uterus is retroverted, that is to say, in the upright position, its 
 fundus may be as far back as, or further, than its cervix. But normally 
 the presence of the full bladder prevents any other cause of retroversion 
 from intervening between it and the uterus, and after urination, the 
 uterus, if not permanently dragged back by pathological weight, too 
 powerful for its ligamentous attachments forwards, returns to the normal 
 
314 EETKOVEKSION, ITS SYMPTOMS AND PHYSICAL SIGNS. 
 
 condition. A sudden strain, however, at this time, or a fall while 
 skating, or on the slippery footpath, gives a little further impetus back- 
 wards, or even the increased weight of the menstrual period, and still 
 more of a uterus enlarged or congested from any other cause, prevents 
 the normal resilience, and permanent retroversion commences. It is 
 kept up by superincumbent pressure, as we have described above, and 
 either remains as a retroversion, as is not uncommon in the unmarried, or 
 eventuates in a retroflexion. 
 
 As regards symptomatology, there is nothing to be added to what has 
 been said about retroflexion. Undoubtedly many cases occur with few 
 or no permanent symptoms, and of these many may right themselves, 
 undetected by the physician and unaided by art. When symptoms do 
 arise, they are similar to those of retroflexion — perhaps there is a little 
 more tendency to bladder symptoms, from the pressure of the rigid cervix 
 on that organ. 
 
 The physical signs are obvious enough when the retroversion is simple. 
 The cervix points directly forwards instead of backwards (fig. 134, No. 2), 
 and in extreme cases it may point upwards (fig. 134, No. 3). There 
 is nothing in front of it corresponding to an anteflexed fundus, but, on 
 the contrary, the uterine body can be traced backwards by the 
 finger, and even downwards, low into Douglas's pouch, without any 
 sulcus such as is felt in retroflexion. Bi-manual examination confirms 
 the impression thus produced, by showing that there is nothing to be felt 
 above, in the ordinary position of the fundus uteri, unless we tilt it up by 
 pressure backwards on the cervix. Eemembering how retroflexion is so 
 frequently the mere sequel of retroversion, it is not surprising that in 
 most cases of the former we have a considerable degree of the forwards 
 pointing cervix of the latter (fig. 134, No. 5), that the two aff"ections are 
 in fact combined. If there is no suspicion of pregnancy, the sound can 
 be passed backwards, perhaps with some difficulty, and then, first, 
 combined with rectal touch, it can show the presence of the movable 
 fundus in Douglas's pouch, and afterwards, used as a replacer, it can 
 bring the fundus forwards within reach of the hand pressed downwards 
 through the abdominal walls. In this way there should never be any 
 difficulty in differentiating the forwards pointing cervix of acute ante- 
 flexion from that of retroversion, and the other affections liable to be 
 mistaken for retroversion are precisely the same as those which require 
 differentiation from retroflexion. 
 
 Treatment. — The treatment of retroflexion and retroversion consists 
 of— 
 
 1. The replacement of the organ in its normal position, 
 
 2. Its retention there. 
 
 3. The removal, sometimes previously, sometimes subsequently, but 
 
TEEATMEXT OF llETROFLEXION AND RETROVERSION. 315 
 
 generally simultaneously, of the causes which led to the displacement, 
 or of the results which have followed it. 
 
 The retroverted or retroflexed uterus may be replaced in many 
 instances by the hand alone. The forefinger of one hand is used j^r 
 vaginam to press the cervix well backwards, which pressure, in simple 
 retroversion, or slight cases of retroflexion, involves a corresponding 
 movement forwards of the fundus ; the other hand is used to reach the 
 fundus through the abdominal wall and to draw it forwards. If the 
 operator stands in the usual position, at the side of the couch, while 
 the patient lies on her back, he will find it most convenient to use the 
 right hand internally, and while the cervix is being repressed by the 
 index, the middle finger may assist in raising the fundus, and bringing 
 it within reach of the left hand, used from above. In some cases it 
 may be necessary to increase our leverage power by reaching the fundus 
 through the rectum with the left forefinger, w^hile we repress the cervix 
 jyer vaginam by the right, the operation being afterwards completed as just 
 described. In most cases, however, except where there may be a suspicion 
 of pregnancy, or where there is an irritable state of the uterus, reposition 
 by the sound is, in my opinion, preferable, although I know that this is 
 hardly the general opinion. While the titerus is retained in position by the 
 sound, we can also much more satisfactorily introduce the most usual 
 form of pessary. No special uterine repositor other than the sound is 
 necessary. Schroeder strongly recommends the use of an intra-uterine 
 stem pessary for the purpose of reposition in uterine flexion. If a 
 straight stem of this kind (fig. 99) can be introduced, it converts 
 the flexion into a version, and the bi-manual method of reposition can 
 then be used more effectively, the pessary being subsequently removed, 
 or left in situ, as may otherwise be considered desirable. In retroversion, 
 or in retroflexion, when the os v'-- ' o.~ lot point directly backwards, 
 the sound may be used from the ^ with its convexity forwards, the 
 operator pushing up the fundus with the directing finger after the 
 instrument is lodged in the cervix. With a little coaxing, and gentle 
 l)ressure of the handle towards the pubes, the instrument enters the 
 l)ody up to its full depth. If the cervix, in retroflexion, points very 
 much backwards, it may be necessary to introduce the sound with its 
 point forwards and convexity backwards, and then, by a totir de mattre, 
 to turn the point backwards, which will bring the cervix more into a 
 line with the fundus, and enable us to proceed as before. We are 
 generally advised to bend the instrument very freely in cases of sharp 
 retroflexion, so as to get it round the acute bend, but this should not 
 be overdone ; tact and jjractice will succeed without it in most cases, and 
 the sound is more fitted for its action as a repositor when its curve is 
 not too acute. We have generally a pretty certain knowledge whether 
 
316 
 
 EEPLACEMENT OF EETEOFLEXION OF UTEEUS. 
 
 the uterus is mobile or fixed, before attempting replacement by 
 sound ; but whether we have or not, all attempts at reposition in this way 
 must be made slowly and gently, as if adhesions were present, and as if 
 we knew the uterine walls to be soft, and easily perforable by the point. 
 The great mistake that may here be made by the tyro is in simply 
 twisting the sound round on its long axis. That would certainly bring 
 the point forwards, but the fundus uteri might not accompany it, but 
 simply let it pass through its wall. First gently pass the handle 
 backwards against the perineum (fig. 137) — this in itself will lift up 
 the fundus, though permitting still of some retroversion — then keep 
 the point as far as y^ou can stationary, and give the handle a wide, slow", 
 and gradual circular sweep round the uppermost or right buttock, till 
 its roughened side, which represents the concavity of the curve, is 
 turned forwards instead of backwards, while the shank presses against 
 the pubic arch. A reference to our diagram will show that a little 
 
 i Jb a 
 
 Fig. 137. — Eeplacemeut of the Retroverted or Eetroilexed Uterus by the Souud. The 
 three movements, as represented in the three figures to the right, and, as explained 
 in the text, are from a to h. 
 
 advance in reposition has been thus made, but that we are still far from 
 even normal anteversion. The uterus is almost perpendicular, but if 
 the handle is now once more repressed against the perineum, the point 
 will pass directly forward, or rather the convexity will press the cervix 
 directly backwards, and reposition is complete. During this time the 
 directing finger should never leave the cervix, so that we are fully 
 informed of what is taking place. Of late years I have observed an 
 increasing tendency to recommend manual reposition instead of replace- 
 ment by the sound, and I cannot help associating this with what I 
 believe to be a retrograde rather than a forward movement in gynsc- 
 cology, viz., the use of the sound, when the os is perfectly patulous, with 
 the aid of the duck-bill speculum, instead of in the manner recommended 
 in Chap. I., without a speculum at all. In many instances it will be 
 advisable now to apply a Hodge or other similar pessary, as will be after- 
 
alexandee's opeeation foe its eetention in place. 317 
 
 wards described, before withdrawing the sound, but in others it may be 
 better to see what the uterus will do when left to itself for a time, or merely 
 to support it by inserting a temporary plug of cotton or sponge into the 
 anterior vaginal fornix, which will tend to keep the cervix backAvards. 
 It is rarely necessary or advisable to place the patient on her knees and 
 elbows, or knees and thorax (genu-pectoral position), for the reposition 
 of an ordinary backward displacement, although the position is of great 
 service when w^e act per rectum on the longer leverage of a retroverted 
 gravid uterus, or of a uterus bearing a fibroid growth. Should the uterus 
 be in a state of subacute inflammation, only the most gentle attempts 
 at manual reposition may be desirable, or even these must not be pro- 
 ceeded with, imtil, by the means formerly indicated — the hot-water 
 injections, glycerine plugs, &c. — this complication has been overcome. 
 If adhesions are present, they mtist on no account be forcibly interfered 
 with, but by the continued use of the just mentioned remedies, com- 
 bined with alterative or absorbent medication, they must be removed, 
 or rendered less liable to resist interference. This does not always prevent 
 us from giving partial support, or even from promoting gradual stretch- 
 ing of the adhesions by the use of elastic pessaries, such as the watch- 
 spring ring or the inflated Gariel's air bag. This leads once more, and 
 for the last time, to the mention of uterine supports. The treatment 
 of the various affections which add to the size and weight of the uterus, 
 and which, as I have said, must be conducted both before and after 
 replacement, includes no small portion of our four previous chapters. 
 
 It is not in accordance Avith the design of this work to recommend or 
 describe operative proceedings of novel character, Avhich must as yet be 
 considered as quite on their trial. Yet the able and moderate way in 
 which Dr Alexander of Liverpool has placed before the profession a sur- 
 gical remedy for prolapse and posterior displacements, and the evidence 
 which seems to be already accumulating in its favour, com2:)el me to 
 notice a proceeding which I have not yet personall}^ tested, but which 
 1 hope to test at an early period. 
 
 In 1882, Alexander advocated, not perhaps with absolute originality, 
 the cutting down on and shortening the round ligaments, as a means of 
 curing backward displacements of the uterus. Since then, others have 
 copied or modified his operation, and he has published the results in a 
 small volume (London, 1884, Churchill). I have laid but little stress on 
 these ligaments as uterine supports, but it may be the case that they act 
 more powerfully than we suppose as a sort of extra check-rein, or that, 
 although they are normally of little iniportance, " we can make tliem of 
 use in cases of uterine displacement." The operation cannot be very 
 difficult, except in very stout subjects. An incision, one to two inches 
 long, is made on each side, from the spine of the pubes, u])wards and 
 
318 UNDULY MOBILE UTEKUS. 
 
 outwards ; the external abdominal rings are cut down upon, and the end& 
 of the round ligaments are raised by a blunt hook. The uterus is now 
 replaced by sound, and held in place, while the ligaments are drawn out 
 till they are felt to hold it sufficiently upwards and forwards. They 
 are then fixed by wire sutures to the pillars of the abdominal rings, and 
 the wounds are treated antiseptically. A Hodge, or in some cases a stem 
 pessary, is introduced and worn for some time. The results given by 
 Alexander and others are sufficient to convince me that, although time 
 may modify our estimate of the degree of permanent success attainable, 
 we have here a new method worthy of extensive trial. 
 
 Unduly Mobile Uterus. 
 
 I should mention here a condition sometimes met with, and which I 
 have known to be productive of rather ludicrous discrepancies in diag- 
 nosis. In clinical work, especially, I long ago found that a most 
 intelligent medical officer and myself were apt to be in absolute 
 disagreement as to whether a patient suffered from forward or back- 
 ward displacement ; and, on reference to existing facts, that one of us 
 — as often one as the other — was obliged to convict himself of what 
 appeared to be a most careless mistake. It was the old story of the 
 chameleon. We had seen the case at different times, and under varying 
 conditions. With a heavy hypertrophied uterus and relaxed supports, 
 it sometimes happens that the ordinary result in prolapse does not ensue 
 to any great degree, but that, instead, the uterus rolls about and is dis- 
 placed anteriorly and posteriorly according to immediate circumstances. 
 There may be all the usual utero-pelvic troubles, varying in degree or in 
 relative severity from day to day. I have not been able to trace the 
 difference which Schroeder finds between flexions and versions, in their 
 symptomatology under these circumstances, but I can most fully endorse 
 his opinion that the treatment of such cases by elastic ring pessaries is 
 eminently satisfactory, while means are being taken to reduce the size 
 of the uterus or strengthen its supports. Another source of fallacy in 
 connection with backward displacements is recalled to me here, and I 
 mention it chiefly because I have come across no reference to it in any 
 of the ordinary works on gynsecology. We may have, apparently, a 
 well-marked case of retroversion or retroflexion. All the tests except the 
 sound have shown this ; but on endeavouring, in the most gentle manner 
 possible, to pass the sound in the usual forward direction, it so passes 
 without the slightest difficulty. One at once supposes an error in diag- 
 nosis, and that the swelling in Douglas's pouch must have been some- 
 thing other than the fundus uteri. But it is entirely gone. The only 
 
LATEKAL VERSION OK FLEXION OF THE UTERUS. 319 
 
 possible deduction is that the uteiais was so soft and flexible as to 
 yield to the passage of the sound, although that was made in the wrong 
 direction and as gently as possible. My friend and colleague Dr Steell, 
 formerly resident physician to the Manchester Royal Infirmar}', assisted 
 me very much in working out this fact, which had occasionally given 
 rise to some differences of opinion between us as to the diagnosis of cer- 
 tain cases. 
 
 Lateral Displacements. 
 
 This form of flexion or version need not long detain us. I have seen 
 it once or twice in what I believed to be a congenital form, freely move- 
 able and without uterine enlargement ; but it is generally the result of 
 pelvic exudations, which tend to fix the organ in its acquired position. 
 Physical examination will alone lead to its detection. The symptoms, 
 when the uterus is not fixed, are usually slight ; and if a pessary be re- 
 quired, it must be a Hodge, or a Graily Hewitt cradle, moulded so as to 
 give prominence to the one side, or some form of intra-uterine stem may 
 be necessitated. In all other cases it is the removal of the exudation 
 which must be sought for. I once succeeded in curing dysmenorrhoea 
 due to, firmly-fixed laterally-flexed uterus, by incising the convex side 
 of the cervix, precisely as is done with the posterior Avail in anteflexion. 
 It is important to be as sure as possible how much of the lateral swell- 
 ing felt in these cases is uterine and how much pelvic exudation, and 
 this knowledge can only be attained by careful bi-manual examination. 
 
320 THE USE AND ABUSE OF PESSAEIES. 
 
 CHAPTER XI I. 
 
 Diseases of the \JTERUS~contmued. Mechanical Supports used in tlie Treatment 
 of Displacements of the Uterus and Vagina. Belts, Pessaries, &c. 
 
 Although I have reserved the description of the pessaries and other 
 mechanical means which are used for the support of the displaced uterus 
 until a separate chapter, and although many of these, especially the Hodge 
 pessary, are suitable in various forms of displacement, it will still be 
 advisable to preserve a sort of order, although not too strictly, according 
 to the kind of displacement involved. 
 
 The Use and Abuse of Pessaries.— For the general practitioner or 
 student, I am convinced that the appreciation of a small number of 
 pessaries is infinitely more valuable than that of too large a number, 
 and I feel almost called upon to apologise for the number here referred 
 to. I would strongly advise all students to let alone the more com- 
 plicated forms. They have nearly always been evolved from the 
 study of some special and peculiar case, such as may seldom occur again. 
 That the use of pessaries has been abused no one can deny. They were 
 better unused altogether than used without a clear indication of their 
 necessity, and without a full knowledge of what is and what is not to be 
 expected from them ; but certainly Matthews Duncan has overshot the 
 mark when he states {Clinical Lectures, page 359, Churchill, 1883) that 
 pessaries " are always harbourers of dirt, and they always keep the mind 
 watching the part ; they are all liable to decay, and require, if long used, 
 to be renewed. They are all undesirable additions to the contents of the 
 pelvic excavation, and if they are efficient, must, of course, cause more 
 pressure than that caused by the organ or organs which they keep in 
 altered position, though perhaps on different parts." It is a great pity 
 that this sweeping statement was not placed in immediate juxtaposition 
 with the wise counsel which follows a little further on : — " Look upon 
 pessaries as a surgeon looks on a truss, not medicinal, otherwise than as 
 a mechanical means of procuring healing, comfort, and safety to your 
 patient." I first met with the former quotation in a foreign journal, 
 accompanied with strong adverse comments, and I felt sure that on con- 
 sulting the original work I should find some qualification. The second 
 quotation is all that could possibly be desired in the way of recommenda- 
 tion of the judicious use of pessaries. 
 
GENERAL REMARKS ON PESSARIES. 321 
 
 If I have described, and even figured, sonic forms of pessary which 
 I would fain regard as obsolete, it is not without full consideration. 
 They are to a large extent in common use, and do fulfil certain indica- 
 tions, although not those which are most desirable, and they are still 
 preferred by many patients and some practitioners. To have avoided 
 all mention of them would, I believe, have led the young practitioner into 
 the belief that I had failed to notice useful means of treatment, rather 
 than that I had condemned them after full experience, and on rational 
 grounds. One of the main secrets in adapting a pessary is to be sure 
 that the uterus is properly replaced, that the pessary used is of proper 
 size, and that while supporting the uterus it does not interfere with 
 sun-ounding organs, healthy or diseased. The hotly disputed question 
 as to the order in which we should proceed — whether we should first 
 subdue all previous causes of displacement and then proceed to retain 
 the replaced organ if necessary, or Avhether we should first replace and 
 support the organ, and then attack the causes— hardly deserves much 
 attention. Probably neither side in the contest Avould fully accept the 
 alternative conditions thus laid down, but many of them have argued 
 almost literally in this sense, on one side or the other. In media via 
 tutissimus ibis. If the causation or the effect of a displacement is such 
 that it renders the presence of a pessary painful or injurious, wait till it 
 is subdued, but if a proper support can be made to afford comfort, and 
 is properly watched, it will in almost every case render the removal of 
 the causation or of the effects infinitely more easy. 
 
 General Remarks as to Pessaries. — The question has also been 
 raised whether, in the absence of any symptoms arising from a displace- 
 ment that may have been accidently discovered, any mechanical supports 
 should be used. In prolapse this question will never trouble us. This 
 must be remedied, without pessaries if possible, but with them if neces- 
 sary. In posterior displacements I would say almost the same thing, but 
 in anterior displacements, which are so often congenital, I would advise to 
 leave well alone. It is 7iearly always advisable to try what simple re- 
 placement can do, aided by the means we have already described ; in those 
 displacements which are anterior it sometimes succeeds in at any rate re- 
 moving urgent symptoms, and the inferiority of our mechanical means of 
 retention induces us to trust more, in such cases, to this alone. No pessary 
 of any land should be umuatched. They arc all foreign bodies, and may 
 most unexpectedly give rise to symptoms due to their pressure on the 
 surfaces with which they are in contact. The practitioner should insist 
 on their occasional inspection by some one duly qualified. If this advice 
 be neglected by the patient, but only then, the blame for any untoward 
 result lies upon herself. Every 2^cssary shoidd he considered as possibly 
 rAirative, as a means of inducing permanent self-retention of the organ 
 
322 
 
 BELTS, AND PERINEAL PADS AND BANDS. 
 
 supported. We may have but little hope of this, but the possibility 
 should always influence us in deciding on the kind of pessary used, 
 if there be any choice open to us. We should always aim at de- 
 creasing instead of increasing the size and strength of our pessaries, 
 and having introduced one, our treatment should always aim, if pos- 
 sible, at doing without it. In every case the use of a pessary should 
 he accompanied by daily antiseptic injection. After these few and very 
 general observations, let us see what can be done mechanically for the 
 retention in situ of the displaced uterus. 
 
 Prolapsus Uteri vel Vaginae. 
 
 {a) Treatment of Simple Prolapse.— The simplest procedure is to 
 prevent extrusion through the vulva by apac? and p)erinecd land (fig. 
 138). If the vaginal protnision is great, or if the uterus is already- 
 lowered until it approaches the ostitim vagince, this will seldom do more 
 than give a little very temporary comfort, but in the earliest stages of 
 
 vaginal protrusion, it may be 
 relied on for a time until, by 
 repair of the perineum, when 
 that is destroyed, or by strict 
 attention to the condition of 
 the bowels and bladder, by 
 the use of local astringents, 
 and by other means, the tone of 
 the vaginal wall is recovered. 
 An india-rubber air-pad, such 
 as is now frequently used for 
 trusses, fixed to a perineal 
 band which can be easily re- 
 newed, is the most comfortable form, but this, and all other forms 
 of band covering the vulva, are very objectionable, owing to the 
 almost constant presence of leucorrhoea. Strangely enough, the use 
 of an ahdomincd helt is popularly much relied on, and is not unfre- 
 quently prescribed for the relief of all forms of "bearing down.'" 
 One would suppose that it would only bear or press down all the 
 more. It is well, therefore, to state what is the real use of abdom- 
 inal belts or bandages. A firm, broad, circular, abdominal bandage 
 can only act in one of two ways ; it may simply compress the 
 abdominal contents, thereby forcing them downwards into the pelvis, 
 or upwards against the diaphragm, neither of which results is desirable ; 
 
 Fig. 138.— Simple Pad, with Belt and Straps. 
 
SOLID BALL PESSARIES. 
 
 'P.")?. 
 
 or, as Goodell has well pointed out, it may, in old age, prevent the 
 bow-shaped curvature of the back and the changing obliquity of the 
 pelvis which is apt to follow in its wake. In old women, therefore, or 
 in those who have prematurely lost the muscular strength of youth, it 
 can alone do any good. But if an abdominal belt is so constructed that 
 it makes firm pressure at its lower edge, with only moderate elastic- 
 support above, it may be iiseful in other cases. It will tend to lift up 
 the superincumbent Aveight of the intestines, and so relieve their down- 
 wards pressure on prolapse, or on backward or forward displacements. 
 In the last instance it will also tend to prevent the weight of an 
 enlarged and anteverted uterus, such as we often find at the commence- 
 ment of prolapse, from creating as much discomfort as it otherwise 
 Avould. Such a belt can only be of tise to those whose abdomen is so 
 far prominent as to bring it within the reach of its lifting power. 
 These considerations should be borne in mind by every one who recom- 
 mends an abdominal belt. I cannot undertake to recommend one or 
 more out of the scores advertised for sale. 
 
 Without any thought as to what should be the aim of all pessaries, a 
 former genei'a- 
 tion of practi- 
 tioners hit upon 
 a certain means 
 of keeping back 
 the prolapsed 
 
 uterus; this was p^^^ 139.— Ball Pessary of hard material. 
 
 to insert a ball 
 
 of wood, or a more or less modified oval or disc-shaped mass, of the 
 same or other hard material, into the vagina, sufficiently large to 
 prevent extrusion. If there was any kind of vaginal sphincter left, 
 this answered the purpose, in a kind of way, well enough. It buried 
 the uterus out of sight and out of reach, and it even kept back 
 the prolapsed vaginal walls, if a sufficiently large instrument was 
 used. All such hard unyielding blocks of wood or other solid material 
 were unfitted for curative purposes. They were apt to ca\ise great 
 iiTitation, especially when encrusted with vaginal deposits, and they 
 required from time to time to be increased in size, destroying 
 all vaginal contractility. The globular specimens (fig. 139) were fur- 
 nished with a small loop of tape, for the purpose of extraction, but that 
 very soon rotted, and great difficulty often arose in consequence. 
 Thousands of these are yet, I am informed, sold annually, but I 
 know of no physician who has any acquaintance with the subject 
 who has not abandoned them in fiivour of supports of a more elastic 
 character. 
 
324 
 
 AIE PESSAEIES. 
 
 Another somewhat old-fashioned method of treatment is, in certain cases, 
 of much greater value, and should not be lost sight of, viz., a pessary of 
 some soft jDorous material, which can also be medicated at will. Oakum 
 or tenas is as good a material for this purpose as any ; sponge, on ac- 
 count of its tendency to fcBtor, requires incessant watchfulness. A small 
 compressed ball of the former, saturated with decoction of oak bark 
 or with diluted vinegar, or any other suitable astringent, can be intro- 
 duced daily by the patient, and is easily withdrawn by a string pre- 
 viously attached to it. In the slighter cases of prolapse of the uterus 
 or vagina, this method, combined with as much rest as possible, will 
 sometimes effect a cure in a few weeks. The addition of glycerine to 
 the astringent, or its occasional alternate use, is advisable when the 
 uterus is enlarged, and renders the plan more effective. I should be 
 sorry to see this simple method entirely abandoned. It has a distinct 
 sphere of action, and, even in clironic old-standing cases, it is often 
 
 temporarily substituted with ad- 
 vantage for the more elaborate 
 instruments. 
 
 The most generally useful fonn 
 of support is an elastic ring, 
 which can be easily compressed 
 and elongated for the pm-pose 
 of introduction. Such rings are 
 made of various substances, 
 originally of india-rubber alone 
 (Mayer's india-iaibber rings), 
 but more recently of a circlet 
 of whalebone or watch-spring, covered with a thick layer of india-rubber. 
 The watch-spring rings (fig. 108), when properly tempered, are invalu- 
 able. They adapt themselves to the surfaces with which they are in 
 contact ; they yield to their varying movements, and, if used of a size 
 sufficient to ensure retention, and yet not larger than what is required 
 for the purpose, they can often be successfully replaced by smaller ones 
 in a comparatively short time. They allow of local medication, they do 
 not interfere with the married life, and with a very little education the 
 patient can withdraw, clean, and replace them. I regret exceedingly 
 that I cannot see eye to eye on this point with so competent an observer 
 as Bantock (^The Use and Abuse of Pessaries, 2nd ed., 1884). If it is 
 found, as sometimes happens, that the uterus tends to dip much Avithin 
 their circle, this can be prevented by adapting a thin perforated 
 diaphram of india-rubber (fig. 109). As we shall see shortly, these 
 Avatch-spring pessaries are often of great use in retroversion, with or 
 without prolapse, and I have foimerly refeiTed to their use in the case 
 
 Fig. 140. — Gariel's Air Pessary, globular- 
 
YAGINAL STEM PESSAEIES. 
 
 S2l 
 
 of uterine hypertrophy or fibroid tumours. If sufficiently elastic, and 
 rightly fitted, they produce vaginal irritation and leucorrhcea only in those 
 cases Avhere every form of pessary is resented and contra-indicated. 
 
 Next to elastic rings, we may place, as suitable pessaries for pure 
 prolapse, the elastic balls, or pear-shaped india-rubber instruments, 
 furnished with a tube and stopcock, whei'eby the patient can herself 
 inflate them with an 
 air syringe — Gariel's 
 pessary — (fig. 140). 
 I cannot recommend 
 them in the earlier 
 stages of prolapse, 
 but when the vaginal 
 walls are irrepres- 
 sible, or in the pro- 
 lapse of old age, or 
 during early preg- 
 nancy complicated with prolapse, they are often most servicable. It 
 is better to insert the inflating tube at the base of the pessary, when 
 pear-shaped, rather than at its apex, so that the former will lie lower : 
 the bearing of this on prolapsed vagina must be obvious. 
 
 We must next mention a totally different type of prolapse pessary, 
 
 Fig. 141. — The Roser and Scanzoni Hysterophor. 
 
 Fig. 142. — Bames's Gutta Perclia Stem, 
 with Bands. 
 
 Fig. 143.— Dulfin's Pessary for 
 Prolapse. 
 
 that whicli depends for its support and retention, not on the grasp it 
 may liave, however elastic, on the vaginal wall, but on some kind of 
 stem depending from it, which is secured by a belt or other means to 
 the body of the patient. One of the best known of these on the 
 
326 
 
 EXTEENALLY SUPPORTED PESSARIES. 
 
 Fig 144.- 
 
 -Wliitehead's modification of Simpson's 
 Pessary. 
 
 Continent, and apparently in America, is the " hysterophor " of Roser, 
 or its modiiications by Scanzoni (fig. 141) and Lazarewitsch. It con- 
 sists of a ball, large enough to support the uterus without distending 
 the vagina, attached to a curved arm of spring material. The upper 
 
 end of the outer shank 
 of this arm is connected 
 with an external pad 
 and belt. The flexibility 
 or spring of the support- 
 ing arm must be varied 
 with every case. Other 
 globular or cup-shaped 
 supports have their stems 
 supported by a more or 
 less complicated perineal 
 band, attached also to 
 a belt before and behind. 
 We may instance among 
 these Barnes's (fig. 142) 
 or Dufiin's (fig. 143), 
 which latter is furnished 
 with a ball and socket joint attached to a perineal plate, supported again 
 by a perineal band. A little practical experience is sufficient to disgust 
 one with all bands of the kind, which are constantly affected by 
 the excretions of the rectum, vagina, and bladder, and are usually 
 
 too expensive for perpetual 
 renewal. Sir James Simpson 
 adopted a very simple means 
 of retaining, by external sup- 
 ports, a uterine pessary. Un- 
 fortunately he used it for 
 intra-uterine stem pessaries, 
 which, dangerous at any time, 
 are still more so when fixed 
 to an unyielding support, but 
 Whitehead of ]\Ianchester very 
 early adopted the plan for 
 the support of a vaginal cup 
 or stem (fig. 144). The figure explains itself, if Ave regard the portion 
 which is to be applied to and fixed over the pubes, as made of metal 
 which can be bent by the practitioner at will, but which is stiff enough 
 to retain its grip. 
 
 A favourite pessary for prolapse in America seems to be Cutter's. 
 
 Fig. 145. — Cutter's Pessary for Prolapsus Uteri. 
 
EXTERNALLY SUPPORTED PESSARIES. 
 
 327 
 
 It consists of the Roser-Scanzoni bent stem, without its flexibility or 
 -spring. The outer limb bends i-ound tlie perineum, and is attached 
 liehind by an elastic cord to an abdominal belt ; the vaginal limb is 
 furnished with a great variety of terminations of hard material, which 
 press in front of the uterus for anteflexion, behind for retroversion or 
 flexion, or, as rings and cups, support the prolapsed uterus, or as intra- 
 uterine stems straighten its flexions and hold in normal position its 
 versions (figs. 145, 160, 171). My comparatively small experience of this 
 variety of pessary — for I seldom consider any kind of support by a stem, 
 especially an inflexible one, advisable — is not favourable. They recall 
 
 Fig. 146. — Clay's Copper Wire Pessaries. 
 
 to me too forcibly certain copper-wire pessaries witliout an}' coating or 
 thickening of india-rubber, which I have secured for the Obstetric 
 Museum of Owens College, and which are attributed to the veteran 
 Manchester ovariotomist, Dr Charles Clay (fig. 146). 
 
 With regard to all these externally-supported pessaries for prolapse, 1 
 have come to look upon them as instruments wlujse use is to be entii'ely 
 deprecated until we are satisfied that, owing to the age of the patient, 
 the recuperative and resilient powers of the vagina and uterine supports 
 are no longer to be depended on, until we are also satisfied that the 
 weight of the uterus caiuiot reasonably be expected to be reduced by 
 medicinal or other means, and that tlie repair of the jierincnm or other 
 
328 
 
 VAPJOrS PESSAEIES 
 
 surgical proceedings do not afford a fair chance of keeping back the pro- 
 trusion. 
 
 I must not, however, omit to mention a form of instrument which 
 although it has a downward projecting stem, is not dependent on that for 
 its action, — the Zwanck's pessary. This instrument consists of two 
 lateral wings, which are easily approximated for introduction, but which, 
 by a stem furnished wdth a screw, can after- 
 I y\ V': . wards be separated to any extent desired. It 
 
 has become so well known as to be mentioned 
 in almost every recent gjmsecological work with 
 which I am acqiiainted, and many slight modi- 
 fications have been introduced, chiefly with a 
 view to cheapening it (fig. 147). When the 
 wings are expanded it is simply an old-fashioned 
 solid plaque, with the additional discomfort of 
 its depending stem, and with no guarantee that 
 it will retain its position with its long diameter 
 from side to side, and resting on the ischial 
 planes. I cannot see how in any way it differs 
 from the old-fashioned wooden shelves or balls, 
 except in the mode of introduction or removal. 
 A former student of this school of medicine, Dr Barr of Burj, has modi- 
 fied it very materially. Instead of the stem and expanding screw, he has 
 fixed upon it a stiff" -india-rubber ring, which permits of the approxima- 
 tion of the wings for introduction, but compels their separation when in 
 situ (fig. 148). He has thus abolished one source of great discomfort in 
 
 its use, and has also, although to a 
 very slight degree, remedied the 
 inflexible character of its lateral 
 
 Fig. 147. — Zwanck's Pessary, 
 cheap form, in Gutta 
 Percha and Wire, in com- 
 mon vise, but dangerous 
 on account of its liability 
 to break. 
 
 Fig. 148.- 
 
 -Barr's modification of Zwanck's 
 Pessary. 
 
 pressure. 
 
 With regard to all these pessariess 
 for prolapse of the uterus, and those 
 which are subsequently mentioned, 
 it Avill be found that, although at 
 first they may suit well, they are 
 liable after a time to become somewhat irksome. This may involve the 
 necessity of a change in size or form of the pessary ; but in many 
 instances, if the patient can now be persuaded to adopt for a short timc' 
 the recumbent position, or, in the earlier stages of prolapse, to lie a!< 
 much as possible on the abdomen, the uterus is so far relieved as to 
 allow of reintroduction, or possibly of their discontinuance. 
 
 Another point of general importance is to remember that the uterus 
 resents being lifted to too hiuli a level as much as it does beinp; allowed 
 
FOR PEOLAPSUS UTERI. 
 
 329 
 
 to drop too low. If our pessary is not as comfortable as it might be, it 
 is well to see whether it does not lift the uterus too high. In fact, the 
 insertion of a proper pessary is an act requiring time and study of the 
 individual case. It is possible to iit an army with contract boots, and 
 has to be done, but in using pessaries the dentist rather than the army 
 contractor must be oi;r model. 
 
 h. Treatment of Prolapse with Anteversion, Retroflexion, &c. — 
 So far, we have spoken of prolapse as if it were merely a descent of the 
 uterus, ignoring, as in old-standing cases we are often compelled to do, 
 the fact that anteversion or retroflexion is often a prominent feature at 
 its commencement, and that retroversion or retroflexion usually accom- 
 panies its later stages. Its successful treatment by artificial supports 
 will, in cases Avhere these conditions predominate, be therefore best 
 attained by those means which at the same time remedy the anterior or 
 posterior displacement. If at the commencement we can in any way 
 raise up a heavy, sub-involuted, or chronically inflamed (and at the same 
 time anteverted) 
 uterus, we may 
 check the first be- 
 ginnings of its pro- 
 lapse, and we may 
 f)romote its rapid 
 decrease in size. 
 Emmet lays great 
 stress upon this, 
 although he unfor- 
 tunately gives us 
 little encouragement as to how it is to be done. On the contrary, he sa}s : 
 — " Retroversion and prolapse are the only forms of displacement for the 
 correction of which we possess any reliable, or, as a iixle, safe mechanical 
 means." I believe, however, that the use of the flexible watch-spring ring- 
 is of ser\'ice in this as in other displacements, while other means are being 
 used for diminishing uterine engorgement ; and I have not entirely lost 
 faith, in occasional and exceptional cases, in the pessaries afterwards to be- 
 mentioned as of service in anteflexion, althougli I cannot attacli the same- 
 value to them which their inventors, Scluilze, Fowler, Hewitt, Thomas, 
 and others seem to do. The retroversion or retroflexion of prolapse is a 
 totally different matter. It may be the original cause of the prolapse, or 
 it may only Vje acquired in the descent ; but wliiclievcr may be tlie case, a 
 well-fitted retroversion pessary is often the surest means of ciirinj: 
 or relieving the prolapse. In such cases, one or other of the various 
 forms of the Hodge pessary is generally the surest method of pre- 
 venting the prohipse, wliile it is the only certain mechanical method of 
 
 Fig. 149.— Hewitt:'^ Oval Levtr Pessary. 
 
330 PEOLAPSE IX CO-MBIXATIOX WITH EETEOYEESIOX, ETC. 
 
 treating the retroversion. Its rigidity even may become an advantage 
 by preventing the tendency of the vaginal wall to become everted. 
 Galabin, Schroeder, Hewitt, and others have so far modified it as to take 
 the ring of coated co^Dper wire, of which it is itself only a development, 
 and to make of it an oval, with a single curve. This is reproduced in 
 thicker and less flexible material (figs. 149, 150), and will sometimes be 
 found to be a very useful pessary in prolapse complicated with retro- 
 flexion or version. The elastic watch-spring ring will, however, be found 
 very often to assume almost the same position and function. The tend- 
 ency to protrusion of the vaginal wall is also met, in the case of the Hodge 
 pessary, by the bars with which it is sometimes furnished (fig. 151); and 
 in the case of the elastic ring pessaries the diaphragm partially fulfils the 
 .same purpose. I have frequently found protrusion of this kind to be 
 
 Fig. 150. — Galabin's Oval Lever Pessary; 
 position wlien in situ, the patient's 
 face towards the reader's right. 
 
 Fig. 151. — Greenhalgh's modi- 
 flcation of Hodge's Pes- 
 sary. The broader end 
 used lower, and furnished 
 with Bars to prevent Pro- 
 lapsus Vaginfe. 
 
 benefited by taking a long Playfair's or Thomas's anteversion pessary, and 
 using it upside down as a Hodge (fig. 152). The spring, which is intended 
 to keep one bar in front of, and the other behind, the cervix uteri, in ante- 
 version, is found to act beneficially on the vaginal walls, especially the 
 posterior one. The same result may be arrived at by using a very long- 
 Hodge, and bending back the lower end so as to bring it up parallel with 
 the main body. As far as I understand him, the same idea seems to have 
 occuri'ed to Emmet (o]}. cit., p. 376). For prolapse of the anterior 
 vaginal wall, especially of its lower part, as well as for prolapse of the 
 urethra, Skene's pessary (fig. 153) is often highly eff'ective. 
 
 To sum up the whole subject of mechanical supports in uterine and 
 vaginal prolapse, I would say that they not only play a very important 
 and useful role, but also that they may do very much to alleviate human 
 .suff'ering, and even to cure the disease entirelv. In minor cases an 
 
PESSARIES FOR VAGINAL PROLAPSE. o31 
 
 •attempt should always be made to do without mechauical support, 
 although experience of hospital out-patients must often compel us to 
 modify this dictum. Rest, local astringents, and the treatment of uterine 
 hypera3mia, must pi'ecede mechanical treatment, and may be expected 
 to obviate it. When these cannot be fully carried out, or fail in effect, 
 mechanical sujDport must be applied as an adjuvant, or, in too many 
 instances, as the sole resort. If retroversion or anteversion exist in an}- 
 marked degree, treat them rather than the prolapse. If the prolapse 
 
 Fig. 152. — Anteversion Pessary. 
 Playfair's modified. Occa- 
 sionally useful in Prolap- 
 sus Vaginae when used with 
 the double Ijars downwards. 
 
 Fig. 153. — Skene's Pessary lor 
 Cystocele. 
 
 predominates, or is the sole affection, use only elastic and intra-vaginal 
 pessaries, especially the watch-spring ring, with or without diaphragm. 
 If driven to use external supports, use those only which are elastic and 
 resilient. Never use solid lumps of hard material, however scientifically 
 shaped, except in the case of old women whose days are nearly run out, 
 who cannot well be injured by the necessity of using larger instraments 
 in the future, and who ought not to be subjected to plastic operations 
 which can, in their case, only interest a clinical class. 
 
 Anteflexion. 
 
 The treatment of anteflexion by pessaries is eminently unsatisfactor}-. 
 The mechanical necessities of the case are obvious enough, but, unfortu- 
 nately, it is too often impossible to fulfil them at all, or without consider- 
 able danger. Two leading ideas predominate. According to the one, 
 we must find some kind of instrument which will obtain a secure hold 
 within or outside of the vagina, wliile some portion of it, projecting above 
 and in front of the rest, presses upwards into the anterior vaginal fornix, 
 in front of the cervix, and holds up the superincumlient fundus uteri, 
 j)rcviously elevated as much as possible by sound or bi-manual manipu- 
 
532 
 
 HEWITTS AND THOMAS S 
 
 Fig. 154.— He-witt's Cradle 
 Pessary for Anteflexion, 
 in situ. 
 
 lation. According to the other, we must introduce something into the 
 uterine cavity which, by its stiffness, will compel the bent uterine canal 
 to remain straight. It is assumed, of course, that all possible care is 
 taken previously or simultaneously to remove all ascertainable pressure 
 on the uterus, all undue Aveight of the organ, 
 and all dragging upon it by a prolapsed 
 vaginal wall. I will simply mention a few 
 of each of these types of pessary which have 
 obtained most general acceptance, and then 
 endeavoiu^ to appreciate their value. 
 
 Among those which aim at obtaining an 
 intra-vaginal support., probably the most 
 generally known is that of Graily Hewitt. 
 The wide reputation of the inventor, and 
 the extreme attention he has given to the 
 subject of uterine displacement, have ensured 
 this. Fig. 154 shows the instrument in its 
 original form, as made ou.t of a simple copper 
 ring covered with india-rubber, and placed 
 in situ. Fig. 155 shows the modification it 
 assumes when made of vulcanite. The next 
 in order is Thomas's (fig. 156) — that at any rate which is most widely 
 knoAvn as his. It consists of a Hodge pessary with an anterior projection 
 which opens forwards by a spring. This can be closed during introduc- 
 tion, and afterwards protrudes upwards into the anterior vaginal fornix. 
 He has of late years considerably modified this, the new form being- 
 shown in fig. 157. Gal- 
 abin has introduced a 
 very popular instru- 
 ment (fig. 158). The 
 thicker portion lies in 
 front of the cervix. 
 Fowler's pessary (fig. 
 159) seems also to be 
 very extensively used in 
 America and England, 
 although I confess to 
 having only very imper- 
 fectly tested its action. 
 Of anteflexion pessaries which depend for support on external means, 
 I need only refer to Cutter's (fig. 160). The summit is, of course, 
 placed in front of the cervix, and there it is supposed to remain. The 
 prolapse modification has already been shown. 
 
 Fig. 155. — Vulcanite modification 
 of Hewitt's Cradle Pessary. 
 The space between the sup- 
 porting knees is filled up. 
 
 Fig. 156. — Thomas's 
 Anteversion and 
 Anteflexion Pes- 
 sary, original 
 form. 
 
ANTEFLEXION PESSAEIES. 
 
 533 
 
 Of intra-uterine stem pessaries, as they are termed, I must first 
 mention Simi^son's (fig. 102). Its stem is composed, half of copper and 
 half of zinc, and it terminates in a bulb which is pierced below, so that it 
 admits a small sound for the purpose of introduction. Barnes's stem 
 pessary (fig. 103) also combines the copper and zinc in alternate spirals, 
 and is therefore much more flexible. I should also mention here 
 
 Fig. 157.— Thomas's Auteversion and Anteflexion Pessary, latest form. 
 A, shows the instrument. B, a somewhat earlier form, in situ. 
 
 Meadows's glass stem (fig. 99), to which I have often referred as useful for 
 maintaining the patency of the cervical canal after operations. In order 
 to obviate the tendency of these instruments to slip out, expansile 
 stems have been introduced by Chambers, Routh, Greenhalgh, Boulton, 
 and others. Fig. 161 shows the vulcanite pessary of Chambers with 
 the ingenious instrument for its introduction. In order to obviate the 
 same danger, and also to avoid unnecessary and sometimes dangerous 
 
 Fig. 158. — Galabin's Auteversion 
 Pessary. 
 
 Fig. 159. 
 
 -Fowler's Anteversion 
 Pessary. 
 
 uiflexibility, Greenhalgh has introduced a stem pessary (fig. 162) of 
 nidia-rubber, the expansion at the inner end of which disappears when it 
 is being introduced on a probe, but returns when the probe is withdrawn. 
 I have had this modified by Mr Wood of Manchester by the introduction 
 of less than an inch of metal tubing about the centre, thereby obtaining 
 complete stiff"ness at the point where it is wanted. The instrument 
 
334 
 
 VAEIOUS PESSAEIES 
 
 generally sold as Greenhalgh's is more suited in size to a bovine than a 
 human uterus, but it can be had, if insisted on, of reasonable dimensions. 
 Finally, these stem pessaries are to be met with, combined in various 
 ways Avith intra-vaginal instruments, to assure their retention, and to 
 combine the effect of the two. Hewitt's (fig. 163) and Wynn Williams's 
 
 (fig. 164) may be instanced. 
 They are used also for retro- 
 flexions. 
 
 As regards the first class of 
 pessaries, those with intra- 
 vaginal support, and aiming 
 at the direct elevation of the 
 anteflected fundus uteri, there 
 is one gTeat objection, viz., 
 that they cannot directly hold 
 up the organ, unless so tightly 
 held by the vagina, and so 
 secured in their position, that 
 they can hardly be borne by 
 the patient. This applies, I 
 am sure, to Hewitt's, Thomas's, 
 Galabin's, and the rest. I 
 am borne out in this objec- 
 tion by many of our foremost gyngecologists, but the objection does 
 not lead me, with many of these writers (Schultze, for instance) to 
 entirely reject the instruments. I have fairly tried most of them, and 
 have not, as Thomas suggests may be the case with doubters, used them 
 upside down. Occasionally I have found relief ensue from the use of 
 
 Fig. 160. — Cutter's Anteversion Pessary. 
 
 Fig. 161. — Chambers's Intra-uterine Stem Pessary for Uterine Flexions, 
 with Introducer. 
 
 Hewitt's, Thomas's, and Galabin's instruments, but generally I have 
 found that they either failed to remain in the desired position, or gave 
 rise to too much irritation to be borne, or were simply inert. Only in 
 the cases where they were unbearable could I satisfy myself that thej- 
 made any direct pressure on the anteflected fundus. I feel driven to 
 the conclusion, therefore, that their action, when successful, depends 
 
FOR ANTEFLEXION. 
 
 335 
 
 Fig. 162.— Greenhalgh's India- 
 Paibber Stem Pessary. 
 
 oil some different princiiDle from that generally assumed, and I more 
 
 than suspect that they act mainly by pushing forwards the upper 
 
 part of the vagina, thereby pulling forwards the cervix uteri, and so 
 
 lifting up the fundus. When anteflexion is very complete, this will 
 
 have little or no effect upon it, but if 
 
 the uterus has a certain amount of stiffness 
 
 in its anterior wall, the fundus is lifted 
 
 up, the moderately distended bladder gets 
 
 in front of and below it, and helps to com- 
 plete the effect. Whether this explanation 
 
 is correct or not, it has led me to try the 
 
 effect of the simple watch-spring ring, with 
 
 its upper end guided to the front of the 
 
 cervix, and of an ordinary Hodge pessary, 
 
 with its convexity in the usual direction 
 
 backwards, but with its upper bar in front 
 
 of the cervix, and I think I have obtained 
 
 better results in this way than I formerly 
 
 did from any of the pessaries specially 
 
 intended for anterior displacements. In treating of the Hodge pessary, 
 
 I will, refer to this matter again, but I have been recently much 
 
 struck with the fact that both Schultze and Marion Sims have, each in- 
 dependently, modi- 
 fied the Hodge pes- 
 sary for retrover- 
 sion in such a way 
 that it becomes, to 
 all intents and pur- 
 poses, a large Graily 
 Hewitt's pessary 
 turned the wrong 
 way forwards ; and 
 in both cases the 
 good effects are at- 
 tributed to the 
 dragging back of 
 the cervix by pres- 
 sure backwards on 
 the vagina. I fancy 
 that a good many of our modem modifications of the ring pessary would 
 be the better of a little study in positions other than those intended, 
 and that a great deal of simplification and a little more certainty might 
 thus be aiTived at. 
 
 Fig. 163. — Hewitt's Intva-uteriuc Stem, witli Vaginal 
 Suiiport. 
 
:336 
 
 INTEA-UTERINE STEMS CAUTIONS. 
 
 I have only mentioned Cutter's anteflexion pessary as one having 
 •external support, and supposed to press up the anteflexed fundus, and, 
 in the face of the general good opinion of it which most American prac- 
 titioners seem to entertain, I dare hardly urge the disadvantages which 
 it seems to me to possess. It can do no good unless it is A^ery firmly 
 tied up to the waist. Without that it cannot support the fundus or 
 stretch the anterior vaginal fornix, unless the patient walks most warily. 
 If too firmly tied, it may do incalculable mischief ; if too laxly, it may 
 press in front to-day and behind to-morrow. If I were compelled to use 
 it, I should bend its ujDper extremity very much forwards, and trust to 
 its retaining its anterior position, owing to this bend making it more 
 difficult to turn round, and I would look to its acting in the same 
 manner as the preceding pessaries, as a lever, with the weight at the 
 fundus, its power exerted through vaginal tension 
 on the cervix, and its fulcrum somewhere inter- 
 mediate. 
 
 Cautions and Precautions. — The intra-uterine 
 stem pessary, if we had to deal with dead por- 
 tions of a living patient, would furnish us with 
 every requisite for the mechanical treatment of 
 a flexed uterus. Only insinuate a straight rod 
 into a bent uterus, and it also becomes straight, 
 and thus by pulling or pushing the lower end 
 of the straight rod the inclination or version of 
 the whole organ can be made and retained just 
 as we think theoretically right. But the uterus 
 is alive, and in many cases, although fewer than 
 one might supjDose, resents this sort of treat- 
 ment ; and its resentment leads to endo-metritis, pelvic cellulitis, or 
 various nervous sympathies. Hence the great differences that exist 
 between various authorities as to the danger or utility of intra-uterine 
 stems. Schroeder, for instance, advocates their use, in preference to that 
 of the sound, for mere reposition, and for permanent wear in many in- 
 stances. Emmet, on the other hand, says they are only hurtful and 
 irrational, no tolerance is ever really established, and their use is to be 
 compared to a similar treatment of chordee by a straight rod. It is 
 more pleasant to refer to foreign than to native extremes of opinion on 
 this point, although the latter would not be difiicult to quote. Simpson's 
 and Barnes's galvanic instruments are intended to stiraulate the un- 
 developed uterus to further development and growth. In the absence 
 of other agents for the purpose, I will not say that they are never 
 permissible or useful in this way, but they demand extreme caution. 
 They should never be long enough to touch the fundus. The uterus must 
 
 Fig. 164.— WynnWilliams's 
 Intra-uterine Stem Pes- 
 sary, with. Vaginal Sup- 
 port, The end of the 
 Introducer is seen below. 
 
ANTEFLEXION PESSARIES. 337 
 
 be previously ascertained by the sound to be insusceptible to irritation, 
 and the instrument should be furnished with a cord by which the 
 patient can Avithdraw it on the occurrence of any pain or discomfort. It 
 should be removed during menstruation. The hard expanding stems are 
 still more liable to cause inflammatory results by their pressure on the 
 uterine walls, and before using them it wou.ld be well to try whether a 
 small elastic ring with diaphragm will not ensure the retention of the 
 simple stem. Greenhalgh has published some remarkable curative 
 results from the use of his india-rubber stems, results which are hardly 
 borne out in the practice of others. I have frequently seen the stiflfest 
 and most resilient of them completely doubled up by a uterus with 
 strong tendency to anteflexion, but nevertheless I have occasionally seen 
 them remedy the dysmenorrhoea of anteflexion very remarkably, and 
 with no untoward results. I do not think that the most ingenious 
 combinations of stems, and Hodge or ring pessaries in one, will ever 
 become popular, although I greatly admire the skill which has been shown 
 in the production of many of them. 
 
 To sum up the question of the use of pessaries in anteflexion. In the 
 congenital form, without dysmenorrhoea, it is advisable to avoid their 
 use entirely. In the same form, with marked dysmenorrhoea, try fairly 
 what can be done by dilatation by graduated sounds alone. If its 
 efli'ects are transient, before having recourse to incision of the cervix, 
 try tentatively a Hewitt's or Galabin's pessary, or try first the elastic 
 I'ing or the Hodge, as I have advised above. Failing to remove the 
 symptoms in this way, the very careful use of a stem, Greenhalgh's by 
 preference, with the modification suggested above, is perfectly allowable, 
 if the practitioner bears in mind the necessity for incessant watchful- 
 ness. The free incision of the cervix may then be had recourse to, 
 although in many cases the practitioner of considerable special exiDcrience 
 will probably proceed to this at an earlier stage. 
 
 In anteflexions occurring later in life and after pregnancy, the general 
 treatment of uterine congestion or hypertrophy is the main resource. 
 Incisions or dilatations of the cervix are of little avail, the flexions being 
 generally corporeal ; and the elastic ring sujjpoi't or the appi'opriate 
 abdominal belt are mainly reliable, as aids during the time while the 
 efifects of sub-involution, chronic metritis, or congestion are being com- 
 bated. 
 
 Anteversion. 
 
 In accordance with what we have already seen as to the causation 
 and treatment of anteversion, there is little or nothing to be said about 
 special pessai-ies for this affection. Stem pessaries are useless or may 
 
 Y 
 
538 
 
 VARIETIES OF THE HODGE PESSARY 
 
 be hurtful, and while steps are being taken to remove the congestion, 
 hypertrophy, or morbid growth which is the cause of the anteversion, 
 the su]3ports found useful in anteflexion, especially those mentioned in 
 the last paragraph, will be found to aid in the process, to relieve hyper- 
 semia, and to mitigate the difficulty of locomotion, which is sometimes a 
 noticeable feature. 
 
 Eetroversion and Retroflexion. 
 
 The treatment of backward displacements by pessary is much more satis- 
 factory than that of those which are forwards. Of all the appliances which 
 are used for this purpose, the pessary of Hodge of Philadelphia (fig. 165), 
 or some modification of it, is the most generally effective. I shall, there- 
 fore, mention its mode of action somewhat fully, and refer to several of 
 its modifications. It is now to be had in all sorts of material. Gutta- 
 percha is very objectionable and liable to crack ; copper or other flexible 
 wire, covered with a thick coating of india-rubber, is by far the most 
 ^ -g easily moulded to suit any par- 
 
 ticular case, the great deside- 
 ratum being to have a rather 
 thick coating of good material, 
 and to have the requisite com- 
 bination of firmness and flexi- 
 bility in the wire. Good 
 india-rubber does not, as some 
 assert, tend "to produce vagin- 
 itis or foetid discharges; it 
 turns white in a short time, 
 but any evil effects are due to 
 errors in shape or size of the 
 pessary, or to the neglect of 
 the regular injections required 
 with all pessaries. The instrument should be easily moulded into any 
 form by the fingers, and yet should have firmness enough to resist bend- 
 ing during introdiiction. I nearly always use this material for the first 
 tentative pessary, and when a good specimen is met with, I should advise 
 the practitioner to make a note of the maker and to see that he is in future 
 supplied with the same material. Hard polished vulcanite is somewhat 
 cleaner for wear, as is also the newer material commonly called celhilite. 
 But a spirit lamp or a sand-bath are reqviired to soften these sufficiently 
 for moulding. Block-tin, or other pliable metal, possesses some of the 
 advantages of each kind ; it can be moulded by the fingers, and is not 
 
 Fig. 165. — Hodge's Lever Pessary for Posterior 
 Displacements (from his original work). A, 
 front view ; B, profile. 
 
FOR RETEOVEESION AND EETEOFLEXION. 339 
 
 very corrosible. On the whole, however, I prefer to use the india-riibbei- 
 instruments whenever I have not at hand a perfectly suitable vulcanite- 
 one, or wherever there is the least difficiilty in adjustment. Having, 
 perhaps after several slight remouldings, succeeded in obtaining a perfect 
 fit, it is possible to mould a vulcanite one into the same form or to get 
 a surgical instrument maker to do so, either from a drawing or from the 
 wire pessary. To all those who are engaged in country practice, or who 
 have a good deal of gynaecological work, I would tender the advice to 
 provide themselves with a good supply of simple circlets of wire-rubber 
 of various sizes. If the practitioner only knows sufficient of the subject, 
 he can, out of these, make for himself nearly 90 per cent, of the pessaries 
 he will ever require. A sqiieeze into the oval form, and a slight bend on 
 its long axis gives him Hewitt's prolapse pessary (fig. 149). A little 
 compression of one end of the oval and a more or less sigmoid curve gives 
 him not only a Hodge, hut almost every variety of the Hodge. Graily 
 Hewitt's anteflexion pessary (fig. 154) is easily formed, by one who 
 knows it, out of such a ring, and an ingenious man can, by slight indent- 
 ations of the surface, create not inefficient substitutes for the cross bars 
 of some forms of Hodge, and by a little gutta-percha can imitate the 
 thickened portions of others. A skilled gynsecologist, with a few of 
 these and a few soft watch-spring rings, can do infinitely more to 
 relieve suff'ering than a mere pedant can with a large array of special 
 pessaries. 
 
 The Hodge pessary does not always act on precisely the same prin- 
 ciple. Occasionally it is used as an unyielding support, its lower end 
 pressing pretty firmly against the anterior wall of the vagina, or against 
 the subjacent bony structures. Its upper end or bar is thus pressed 
 into the posterior vaginal fornix, not to bear up the fundus, as is errone- 
 ously supposed, but to draw back the cervix, and so to act by leverage 
 in raising the fundus, the power acting by traction on the cervix uteri, the 
 weight being at the fundus, and the fulcrum between, as with anteversion 
 pessaries. The lever, like all levers, is freely movable, but the leverage 
 is in the uterus, while the pessary is fixed. This is, however, by no means 
 the most common nor the most desirable action of the Hodge pessary. 
 It has all the disadvantages of the hardest pessaries, as explained undci- 
 the heading of prolapse. Occasionally, and temporaril}', it may be 
 necessary, but should always be avoided where j^ossible. The most 
 valuable use of the Hodge is as a lever in itself. The lower end is free 
 to ascend or descend, the centre clings to the vaginal walls laterally, 
 but without undue pressure, and the upper end plays in the posterior 
 vaginal fornix. In standing or in inspiration, the wciglit of tlie abdom- 
 inal contents presses downwards and backwards, and caiiscstlic lower end 
 of the pessary — the power — to descend. Through tlic fulcrum, somewhere 
 
340 
 
 THE HODGE PESSAEY 
 
 Fig. 166. — Hodge's Lever Pessary 
 in situ. 
 
 towards the centre of the pessary, the weight, that is, the parts resting 
 on the upper end, is raised, thus the posterior vaginal fornix is pushed 
 upwards, and the uterine leverage comes into play secondarily, not from 
 
 a hard and fixed pressure, but from a 
 lever spring, as elastic as that of the 
 best of carriages. 
 
 A Hodge pessary used thus hangs as 
 in fig. 166. Bear ever in mind that this 
 is the true use of the instrument, and 
 that to use it as a firmly fixed support, 
 although rarely it is necessary, is much 
 less scientific. 
 
 But various circumstances compel us 
 to modify the Hodge pessary, or render 
 its use unfruitful. The posterior vaginal 
 fornix may be so small that a swinging- 
 pessary will not remain within it. A 
 temporary use of the fixed Hodge, or 
 temporary packing of the vagina with 
 pledgets of cotton, well directed back- 
 wards, or the use of a watch-spring ring, will often amend this condition 
 of matters, and distend the fornix so as to allow of the proper use of 
 the Hodge. Those who look upon the spring pessary as very apt in 
 this way to cause ulceration, must either have used it much too large, 
 or cannot have had the extremely flexible instruments which are now 
 universally obtainable. They are as soft and yielding 
 as any air-inflated pessary. 
 
 Again, adhesions may exist, which, although they 
 admit of considerable reposition of the uterus, drag- 
 it back again so as to resent the presence of the pessary, 
 or push it out of the fornix. Here, again, a spring- 
 ring of small size may be borne, and may slowly over- 
 come the adhesions, or it may be necessary to gradually 
 stretch them by means of frequent packing with 
 FiG^167.— Thomas's carefully-placed pledgets and tampons. This method 
 will sometimes safely overcome adhesions which did 
 not permit of reduction at all. 
 Or, further, the uterus may have such a tendency to flexion 
 that its fundus rolls over the top of the pessary, which sinks into 
 the sulcus above it, and thus adds to the uterine irritation and con- 
 gestion. This may be overcome by making- the upper extremity 
 thick and bulbous, as in Thomas's instrument (fig. 167), or Green- 
 lialgh's, where the thickening is caused by an inflated rubber pad, or by 
 
 Retroflexion Pes- 
 sary. 
 
AND ITS MODIFICATIONS. 
 
 341 
 
 modification of Hodge's 
 Lever Pessary. 
 
 using Galabin's prolapsus pessary (fig. 150), with tlie thick extremity 
 uppermost. 
 
 Again, the lower portion of the vagina may be contractile and of 
 good tone, and may resent the width of the Hodge pessary. It cannot 
 swing easily, but becomes a fixtvire. Albert 
 Smith first recognised this, and compressed the 
 lower end so as to make it almost pointed, while 
 he bent the tip backwards as in fig. 168. Most 
 of the pessaries now sold as Hodge's have more 
 or less of this useful modification, but there is no 
 advantage in pointing the instrument so much 
 as in Albert Smith's. The actual curve required, 
 either at the upper or lower extremity, can onh" 
 be determined in each individual case. 
 
 But the opposite condition may obtain. The 
 vagina may be so loose at its low^er end that an 
 ordinary Hodge will invariably fall away. This 
 
 can be remedied in two ways. In slight cases it Fig. 168.— Albert Smith't; 
 may suffice to broaden the lower end, or simply 
 to use the instrument iipside down; or the 
 lower end may be made a little wider, while the lower bar is entirely 
 cut away. Left in this state, the open lever pessary, as it is termed 
 (fig. 169), is a somewhat dangerous instrument, its ends being apt to 
 perforate the vagina ; but, w^ell coated with rubber, and closed by a firm 
 elastic band of the same, containing no wire, 
 it is freer from this danger and sometimes 
 useful, although it requires very careful 
 watching. 
 
 Another circumstance may call for modifi- 
 cation. The extreme fundus in retroflexion 
 may be exceedingly tender, and unable to 
 bear the contact with the top of the Hodge, 
 or it may be the utero-sacral ligaments which 
 exhibit this tenderness. The former difficulty 
 may be obviated by broadening the top bar and 
 depressing its centre, so that its pressiu-c is 
 bilateral and not median ; or occasionally by 
 the use of Greenhalgh's air-inflated ujjpcr bar. 
 When the ligaments are tender, tlic top must, 
 on the contrary, be narrowed. Or an adherent or prolapsed ovary, to- 
 wards either side, may make the pressure insu})portal)le, — a very frequent 
 cause of failure. Here we must try what can be done by depressing 
 one corner, or otherwise as ingenuity may suggest. 
 
 Fic. 169.— Tlie Open Lever 
 Pessary. 
 
342 
 
 INTEODUCTION OF THE HODGE PESSAEY. 
 
 Fig. 170.— Modified 
 Hodge Pessary, 
 with Diaphragm. 
 
 Once more, the Hodge pessary may support the uterus, but allow the 
 
 vaginal wall to prolapse. We have already discussed this complication, 
 
 but by filling up the centre of the pessary with a thin india-rubber 
 
 diaphragm (fig. 170), or by crossing it with bars (fig. 151), this difficulty 
 
 may often be overcome, though not infrequently it 
 
 will call for other means {see pp. 297, 330). 
 
 I have thus mentioned pretty fully the variations 
 in the Hodge pessary which ma}'' be required in pos- 
 terior displacements. 
 
 A word as to the mode of introduction. Eeposi- 
 tion of the uterus must precede insertion of the 
 pessary. Yet I am surprised how often I am con- 
 sulted in cases where I am told a Hodge pessary does 
 no good, the practitioner having, although making 
 an accurate diagnosis, used the pessary without any 
 attempt at replacement. If introduction is at- 
 tempted by the hand alone, the instrument is held by its lower bar 
 and introduced in the axis of the vulva, one side towards the pubes, the 
 other towards the perineum, all pressure being made on the latter. 
 The forefinger is then passed between its sides, and when it reaches the 
 upper bar it must at once push it back into the hollow of the sacrum, 
 
 Avhile it rotates the whole instrument 
 so as to accommodate it to the lateral 
 slit shape of the vagina. It is thus 
 carried behind the cervix and into posi- 
 tion, requiring only a careful examina- 
 tion to see that it lies thus. But the 
 end will sometimes slip in front of the 
 cervix, and has a strong tendency to do 
 so. If this happens, it must, at the 
 cost of some pain, be withdraAvn some- 
 what by traction on the lower end Avith 
 the left forefinger, while the right, still 
 in the vagina, slips it under and behind 
 the cervix. In the great majority of 
 cases, however, it is preferable to intro- 
 duce the sound first, making sure of 
 complete reposition ; aiad while the 
 sound is still in xitero, the pessary is 
 slipped over its handle, introduced at first as before, then pushed into 
 position as before by the right forefinger, while the sound is held by the 
 left hand or by an assistant. Both manoeuvres certainly require a 
 certain amount of tact and experience, but that with the sound in 
 utero is the less painful and more certain. 
 
 Fig. 171. ^Cutter's Pvetroversiou 
 Pessary «i situ. 
 
OTHER EETEOVEESIOX PESSARIES. Mo 
 
 Cutter's retroversion pessary (fig. 171), with its external support, is 
 open to the same objections as his anteversion one, but is equally 
 approved by many writers. With great care as to the exact tension on 
 the waist-belt, I doubt not that it is sometimes servicable. 
 
 In obstinate cases of flexion, and in those only, the intra-uterine stem 
 may be necessitated. When, in such cases, there is suflicient tolerance, 
 such a pessary as that of Wyma Williams (fig. 164) or Hewitt (fig. 163) 
 may be tried, and after a time the vaginal support may suffice without 
 the intra-uterine portion, but I have always preferred, in such cases, to 
 strengthen the uterus first by a simple stem, then to introduce a Hodge, 
 modified according to circumstances, and finally to withdraw the stem 
 and trast to the Hodge alone. 
 
 In concluding the subject of pessai'ies, I must again express my 
 opinion that they have a considerable value in the treatment of uterine 
 diseases. This value depends also, I believe, chiefly on the careful 
 study of a very small number, on the capacity of the practitioner to 
 mould or adapt them to the individual cases, on the care with which 
 they are watched, and on the simultaneous observation and treatment of 
 conditions other than the mere displacement. While apologising for 
 the large number I have mentioned, I must equally apologise for the 
 omission of many, all of them the outcome of careful study by personal 
 friends and others. No ingenious practitioner can fail to invent many 
 new pessaries — new as regards the requirements of individual cases, 
 but often worse than useless when grouped in a manual such as this. 
 Braxton Hicks, Playfair, Wells, Scattergood, Godson, Bantock, Gehrung, 
 Blackbee, Hitchcock, Routh, Peaslee, Schultze, Emmet, Wright, Blake, 
 Meadows, and a host of other writers, foreign and British, have added 
 valuable pessaries to our list. I claim to have made myself, as far 
 as possible, acquainted with most of them, and to have simply done my 
 best to make such a selection as would be most useful to the class of 
 readers I have in view. If the selection consists mainly of those in 
 vei'y common use, I think the fact is not to be placed entirely to my 
 discredit. To repeat, I would strongly advise the young practitioner to 
 study carefully, while using sparingly, only a few forms, and to be 
 satisfied with the assurance derived from careful watching, that ho 
 knows how, with them, to do good without accompanying evil, before he 
 ventures upon more complicated forms or inventions of liis own. 
 
344 INVEKSION OF THE UTERUS. 
 
 CHAPTER XIII. 
 
 Diseases of the Uterus — continued. Inversion. 
 
 Inversion of the uterus is fortunately a somewhat rare occurrence. Yet 
 it is sufficiently common, and its effects, when it does occur, are so 
 grave, that it must always be an affection of great interest to the 
 gyiisecologist as well as to the obstetrician. According to Crosse of 
 Norwich, whose paper (Trans, of Prov. Med. and Surg. Assoc, 1845) is 
 still the best record in English, 350 out of 400 collected cases occurred 
 from delivery, 40 of the remaining 50 being due to the traction of polypi. 
 It will, therefore, clear the ground for us if I say a few words as to the 
 causation, symptoms, and treatment of the affection as it occurs to the 
 obstetrician, following them with the details of the chronic affection, 
 however produced. 
 
 Acute Puerperal Inversion, 
 
 The mode of production of acute inversion, from theoretical as well as 
 practical points of view, is of great interest, although it concerns the 
 obstetrician rather than the gynsecologist. When inversion is complete, 
 the whole body of the organ is, as the name of the affection implieS; 
 turned inside out, lying within the vagina or protruding between the 
 thighs of the patient, the placenta being still attached, or having been 
 previously expelled. The cervix does not, as a rvile, completely share 
 in the inversion, so that it forms a ring round the protruded mass, 
 within which the finger or a sound can be inserted to the extent of an 
 inch or more, meeting, however, with a complete obstruction beyond 
 this. This inversion of the body is shown diagrammatically at fig. 172, a. 
 At a later stage, or when the inversion is due to the dragging of a 
 tumour, complete inversion of the cervix may also occur, but this is 
 almost always associated with prolapse of the vaginal Avail, and conse- 
 quent cystocele. It is essentially a chronic stage (fig. 172, h). But in 
 many instances, probably more than we are aware of, only partial 
 inversion takes place. The weakest or heaviest portion of the body, — 
 that to which the placenta is or has been attached, — bends inwards 
 
THE ACUTE PUERPERAL FORM. 
 
 345 
 
 more or less, but does not go beyond the level of the os internum at the 
 utmost (fig. 172, c). Another form of inversion is described by Duncan 
 (fig. 172, d), in which it is the lower part of the organ that seems to be 
 primarily inverted. Although this condition does occur, it would seem 
 not to be included in the ordinary sequence of events in complete 
 inversion, although it agrees with the interpretation given by Taylor of 
 one form of the affection. 
 
 Complete inversion of the body during parturition cannot be a very 
 common occurrence. I have never been present at a case myself, and 
 West states that in 140,000 recorded labours connected with the Dublin 
 Lying-in Hospital and the London Maternity Charity, it was never once 
 met with. Yet most gynsecologists must have seen several chronic- 
 cases, indubitably dating back to confinement. One explanation of this 
 is to be fox;nd in the fiict that complete inversion is not alwaj's ini- 
 
 Fig. 172. — Stages and Degrees of luversiou of tlie Uterus, a, chronic inversion as 
 ordinarily encountered ; b, complete inversion of the cervix ; c, partial or commencing 
 inver.sion of the fundus ; d, inversion commencing at the lower portion of the body. 
 
 mediate. It may occur only partially-, as mentioned above, and this 
 partial form may cither right itself, or may, after an interval of a fc^\ 
 days, end in complete extrusion. Such cases, if attended by a midwife 
 or not very careful practitioner, may be overlooked, and the shock, or 
 hajmorrhage, or even death ensuing may be ascribed to other causes. 1 
 am tolerably certain that this cn-ersight happened in all the cases of 
 chronic inversion wliicli have couie under my own notice, excc])t one 
 that was non-puerperal in its origin. 
 
 Causation. — The causation of puerperal inversion has given rise tc 
 much wx'iting and to many ingenious theories. If these arc not ahvayt- 
 apparcntly consistent with one another, it is because, of several un- 
 doubted factors, all are not equally or invariably present. A predisposing 
 condition of the uterus probably exists in many cases, and this may 
 consist either of a general want of tone, making j^artial inversion more 
 easy, of an irritable state of fibre, or of a tendency to fixtty degeneration 
 
346 THEOEIES OF CAUSATIOX 
 
 in the whole or portions of the organ. As an immediate cause, traction 
 upon the umbiHcal cord by the accoucheur has long held its place in 
 2:)rofessional estimation. If one thinks of the powerful action which, as 
 by a child's sucker, might be thus brought into play, the idea is a most 
 natural one. Yet any one who knows what midwives' jDractice is, cannot 
 fail to see that nature almost completely resists any such danger as this. 
 The simple and immediate complete inversion of the uteims in this way, 
 and from this cause alone, must be infinitely rare, but in all probability 
 the first tendency to partial inversion may often be thus given. The 
 same remark applies to the traction caused by an abnormally short cord, 
 especially in instrumental or artificial manual delivery. 
 
 Sudden spontaneous delivery is also mentioned as an occasional cause, 
 especially when the patient has not assumed the recumbent position. 
 Yet sudden delivery generally means powerful uterine action, and that, 
 us a rule, means perfect resistance to the descent of the fundus. 
 
 Tearing of the cervix during the passage of the child would cei*taiuly 
 appear to have a tendency to destroy much of this self-resisting power, 
 by paralysing the action of the lower end of the uterus. I do not 
 happen to have seen this mentioned as a cause, but it appears to me to 
 be quite probable, although I have no actual evidence to adduce. 
 
 But undoubtedly one chief cause is to be found in some eiToneous 
 distribution of muscular contractility, leading, on the one hand, by its 
 deficiency, to flabbiness and prolapse of the wall, — which may be in- 
 creased by placental traction or by pressm-e from above, — and, on the 
 other hand, by its excess, leading to expulsion doA\mwards of the pro- 
 truded portion. These errors combine in various degrees to produce the 
 relatively active or passive types of inversion of Matthews Duncan, types 
 which exist, but which are degrees rather than separate forms of the 
 same causation. Every one is familiar with irregular contraction of the 
 uterus at some part of its area, and, although perhaps less familiar, 
 irregular inertia or non-contraction, especially at the site of the placenta, 
 is also a common occurrence. Fui-ther, a certain amount of fatty de- 
 generation, even previously to delivery, is met with more abundantlj- 
 in the latter sitiiation ; and many pathologists have described a similar 
 condition as occurring in the neighbourhood of intra-uterine fibroid 
 growths. 
 
 Thus there are three theories of production, all more or less correct. 
 (1) The partial and comparative softening of one portion of the uterus 
 causes internal prolapse of that portion, and this drags the rest down- 
 wards through the cervix (passive tendency) ; (2) partial prolapse of 
 this kind causes expulsive efforts of the remaining portion of the uteinis 
 which acts as on a foreign body (active tendency), and (3) softening and 
 eversion, perhaps tearing, of the cervix, tend to permit lowering of the 
 
OF INVEKSION. 347 
 
 tipper portion passively, and this also leads to active expulsive effects. The 
 nearest approach therefore that I can make to a definition of the usual 
 causation of puerperal inversion is as follows : — (1) The uterus may or may 
 not be predisposed by disease of its walls ; (2) some portion of its body, 
 generally the placental portion, is in a state of flabbiness or inertia 
 which tends to prolapse of that poi'tion ; (3) this j^rolapse may be in- 
 creased by traction on the cord, or by the superincumbent pressure of 
 the auxilitiry forces of labour, — diaphragmatic, thoracic, or abdominal, — 
 by " bearing down," or by faulty methods of manually assisting the con- 
 tractions of the uterus through the abdominal walls ; ^ (4) other portions 
 of the uterus may be normally or abnormally active and contractile ; 
 (5) if this applies mainly to the fundal portion, its effect is wholly in the 
 direction of protrusion ; (6) if it applies mainly to the lower segment 
 its effects will be one of two : (a) either it Avill tend to keep back the 
 prolapsed portion, and so limit the inversion to a partial degree and 
 temporary existence, this fortunately being the ordinary result, or (h) 
 if the prolapse be fairly within its grasp, it may, on rare occasions, tend 
 to complete the expulsion, and so complete the chain of causation. 
 
 When prolapse commences near the cervix, complete inversion seldom 
 occurs, the tonic action of the rest of the uterine muscles tending rather 
 to withdraAV than to expel it, but an occasional departure from this 
 rule is not difficult to explain theoretically. In cases where the uterus 
 descends only after a few days, partial inversion or internal prolapse is 
 doubtless present from the first, corporeal contraction is efficient, but, 
 either from torn cervix or other causes, contraction of the lowest uterine 
 zone is deficient. 
 
 Sym2:)toms and Diagnosis. — The immediate symptoms of inversion are 
 collapse and hasmorrhage, followed occasionally by rapid death. The 
 collapse will at once draw attention to the fact of something serious 
 having gone wrong, and will lead to instant investigation, and it must 
 be borne in mind that a well-marked partial inversion, not passing 
 through the cervix, may cause as serious an amount of shock as one 
 Avhich is complete. The practised obstetrician at once grasps the uterus 
 through the abdominal wall, to ascertain whether inertia is present, and 
 he finds, either that the iiterus is entirely absent, or that it has an 
 imusual contour, presenting a cup-shaped depression on its sui-face. 
 A vaginal examination immediately follows, and in complete inversion 
 the state of matters is abundantly clear. If no foreign body is felt in 
 the vagina, the cervix is rapidly examined in search of tears, and the 
 fingers are then passed into the uterus. If partial inversion is present, 
 a bi-manual examination can hardly fail to discover the internal jivotru- 
 
 J Expression of the placenta from above, by manual pressure, may, like all otlier 
 useful procedures, be overdone. 
 
348 DIAGNOSIS AXD TEEATMEXT 
 
 sion and the external depression of the uterus. Two mistakes only are 
 possible. A partial inversion may be, and has been mistaken for an 
 intra-uterine polypus or fibroid, but careful bi-manual examination should 
 never fail to avoid this error ; or a complete inversion may be mistaken 
 for a fibroid polypus which has been extruded along with the child. In 
 the case of the latter the uterus will still be found in situ, and the 
 pedicle of the polypus can be traced into it, or found to be adherent to 
 one side, while at the o|)posite side the finger is not arrested as it is, at 
 all points, in complete inversion. If the j)lacenta is still completely ad- 
 herent, the heemorrhage may be quite absent, but this is usually great 
 when it is partially or completely separated. When inversion occurs 
 after a few days, there Avill probably have been some shock and ligemor- 
 rhage at the time of delivery, which are renewed, along with violent 
 after-pain, at the time of complete protiaision. An examination would 
 detect the same physical signs, and if the symptoms at the moment 
 of delivery did not demand this, as they undoubtedly should, their 
 secondary occurrence should put the practitioner on his guard. 
 
 Treatment. — Immediate shock must be overcome by stimulation, and 
 there is no better form than the subcutaneous injection of 20 minims of 
 sulphuric ether, once or twice repeated if necessary. A subcutaneous 
 syringe with ergotine, moi-phia, and ether, should be within reach of 
 every accoucheur. Eeposition of the inversion must follow as speedily- 
 as possible. If the placenta is still adherent, it should first be removed, 
 secundum artem. There is little to be gained by returning it along with 
 the fundus, when that is possible, while there is great danger of the 
 recurrence of the accident, esj)ecially if the placenta should turn out to 
 be adherent. There are not the same divergencies of opinion as to the 
 mode of reduction here as in chronic inversion. The extremity of the 
 mass is to be grasped by the fingers, compressed as much as possible, 
 and pushed up within the remainder, the uterus being secured and 
 steadied by the other hand on the abdomen. On the immediate occur- 
 rence of the accident this is not a difficult proceeding to a practised 
 obstetrician, but a few hoiu's later the difficulties increase, the swelling 
 becomes strangulated at its neck, and its bulk becomes correspondingly 
 increased. Still the mode of taxis remains the same, or we may have 
 recourse to the plan of trying to replace the last inverted part, the neck, 
 first, as in hernia, following that up by pressure on the fundus. In all 
 cases of quite recent puerperal inversion, the educated hand is a safer 
 and more efiicient means of reduction than any mechanical contrivance 
 wliich may be brought to bear on the uterine walls. 
 
OF ACUTE INVERSION. 349 
 
 Non-Puerperal Inversion. 
 
 Spontaueous inversion of the unenlarged uterus would seem to be 
 almost impossible, and the impossibility has been carefully demonstrated 
 by very high authorities. Yet it is almost impossible to resist the evi- 
 dence which has been adduced as to the actual occurrence of such a 
 thing, by equally high authorities. The same remark applies to spon- 
 taneous reposition of old-standing inversion. Both occurrences may, 
 however, be regarded as freaks of nature, and as hardly coming within 
 the range of practical experience or expectation. Great distension of 
 the uterus by retained fluids has been noted as leading to inversion, 
 occurring, no dovibt, much in the same way as after delivery. But the 
 great majority of non-puerperal inversions, at least 80 per cent., are 
 due to the traction of polypi or other intra-uterine growths, especially, 
 according to A. R. Simpson, of sarcomata. The mode of production 
 needs hardly any explanation, especially if it is true that in the neigh- 
 bourhood of such growths the uterus often undergoes fatty degenera- 
 tion, and consequent softening and liability to internal prolapse. Such 
 inversions are accompanied and preceded by the tumours which cause 
 them, and the important j)oint is to remember the possibility of such 
 dragging down of the uterine tissue. In any case where there is a doubt 
 as to the boundary line between uterus and tumour, Avhen there is not a 
 very distinct pedunculation between them, the uteinis must have the 
 benefit of the doubt in applying the ecraseur, or otherwise removing the 
 abnormal mass. Small portions of fibro-myomata thus left behind 
 speedily shrink and disappear ; and the inversion, if it does not spon- 
 taneously return, can be dealt with subsequently to removal of the larger 
 portion of the tumour, but a small portion of the protruded uterus re- 
 moved by mistake probably means death to the patient. 
 
 Chronic Inversion of the Uterus. 
 
 Whether this results from the rare condition of spontaneous inversion, 
 from traction by uterine growths, or, as in the vast majorit}^ of instances, 
 from parturition, or, very much more rarely, from abortion, it is an 
 affection demanding great care in diagnosis and great skill in treatment. 
 
 Si/mptoms. — The symptoms of chronic inversion are those which are 
 common to many other uterine diseases. The most common is that of 
 almost constant metrorrhagia, together with menorrhagia, which may in 
 a short time wear the patient out, or may last unchecked for many years. 
 Together with tliis there arc great utero-i)e]vic discomfoii:, licaring- 
 
350 CHROXIC IN^^ERSION. 
 
 down, tenesmus, troublesome urination, difficult locomotion, muco- 
 purulent discharge, and aneemia. However these symptoms are grouped 
 thej imperatively call for an examination, w^hereupon there is discovered 
 an abnormal intra-vaginal substance, or an extra-vaginal protrusion 
 combined with more or less prolapse of the vaginal walls. There is nearly 
 always a history of acute puerperal inversion, although it is astonishing- 
 how difficult it occasionally is to put this into shape, in the case of hospital 
 patients. The tumour varies much in its character. It may remain 
 of considerable size, or, by the process of involution, may be reduced to 
 that of the normal unimpregnated uterus. In comparatively recent 
 cases it is raw and bleeding ; in very old cases it may be as smooth 
 as a polypus. Careful examination (the duck-bill speculum assisting if 
 the mass is not extra-vaginal) will show the absence of an os uteri at its 
 lower extremity, and the presence of depressions corresponding to the 
 Fallopian orifices. It is usually pretty sensitive, but this must not be 
 depended on as a diagnostic symptom. Its shape varies much, from 
 that of a bulbous pear to that of a cow's teat. At the summit of the 
 tumour it is surrounded by the rim of the cervix iiteri, into which, unless 
 there be great vaginal prolapse, the sound enters for a short distance 
 all round. The symptoms of partial inversion, when chronic, are much 
 the same, and call for an intra-uterine examination, when a bulbous 
 projection will be found within the uterus, which may give rise to greater 
 diagnostic difficulty than the complete form. 
 
 Diagnosis. — As regards diagnosis, there are fortunately not many 
 things for which a complete inversion may be mistaken. These are pro- 
 lapsus uteri or pseudo-prolapse wdth intra-vaginal hypertrophy of the 
 cervix, malignant growths from the cervix, and fibro-myomata of a poly- 
 poid form. The presence of the os uteri at its lowest extremity is alone 
 sufficient to differentiate prolapse in any form, and this will be combined 
 with the absence of the encircling cervix at the summit of the tumour. 
 Malignant growths have sufficiently distinctive symptoms to render any 
 mistake very improbable. I can hardly imagine the most compact 
 of cauliflower excrescences of the cervix being mistaken for an inverted 
 uterus, however raw and bleeding or even foetid the latter might be. 
 The differentiation between jDolypus and inversion is not so simple. 
 When men of the calibre of Barnes and Emmet admit having com- 
 menced amputation of an inverted uterus in mistake for a polypus, 
 lesser men may admit the possibility of error although the signs 
 of distinction are clear enough on paper. Symptoms and previous 
 history go for little or nothing. The former may be precisely the same 
 in both diseases, the latter may be utterly misleading. But there are 
 certain physical tests which, if thoroughly used in all cases, doubtful or 
 not, should entirely prevent mistake. The signs Avhich are common to- 
 
DIFFEEENTIATIOX FEOM POLYPUS, ETC. 351 
 
 u jiolypus and au inversion are those of a dependent tumour, around 
 the summit of which can be distinctly felt the rim of the os uteri. 
 Nothing should be trusted to the consistence of the swelling or to the 
 presence or absence of tenderness when compressed. This is usually 
 greater in the case of inversion, but not invariably. It has been stated 
 that the tissues of an inverted uterus will sometimes be found to contract 
 on being handled, while such is never the case with a fibroid polypus, 
 thus presenting a difFerentiating sign such as has been mentioned in 
 connection with the diagnosis of pregnancy from uterine growths. If I 
 encountered the phenomenon, although I never have, I should feel that 
 much weight attached to it, but it must, I think, be confined to very 
 recent cases of inversion. The usual differentiating signs are these : — 
 (1) In the case of inversion, the sound will not pass more than a very 
 short way into the uterus in any direction, while in polypus, it will. 
 at one side or the other, pass the normal length, or even further. 
 Complete adhesion of a polypus to the whole rim of the cervix is a very 
 rare occurrence. (2) Bi-manual examination, in the ordinary way, will, 
 in inversion, reveal the absence of the uterine body above the cervix, and 
 if the patient is moderately thin, a distinct depression will be found to 
 occupy its place. In the case of polypus the uteras is evidently present, 
 although it must not be forgotten that it may be retroflexed, and lie in 
 Douglas's pouch. (3) Rectal examination will bring out still more 
 distinctly the same distinguishing facts, especially if the vaginal tumoiir 
 be drawn downwards by hook or ^mlsellum. The finger can thus, 
 through the rectal wall, be hooked into the hollow upper extremity of 
 the inverted uterus. (4) If the finger be retained in the rectum, and a 
 sound introduced into the bladder, the presence or absence of the utei-us 
 in its normal site between the two can be very clearly made out, unless 
 in the unfortunate presence of intra-peritoneal inflammatory exudation. 
 
 (5) In the case of inversion the stretched round ligaments and Fallopian 
 tubes ai'e dragged within the imnatural depression of the outer Avail, 
 and may often be distinctly felt on bi-manual examination (fig. 173). 
 
 (6) A careful inspection of an inversion will reveal the orifices of the 
 Fallopian tubes, nothing of the kind being found upon a polypus. 
 
 The diagnosis of incomplete inversion in a chronic form is more 
 difficult. If the os uteri recpiires dilatation this must be accomplished 
 as in the case of supposed intra-uterine growth, the general symptoms 
 of which- will not be diff"erential. The finger will cncoimter a projecting 
 mass, and the only certtiin means of separating this from a polypus, a 
 fibro-myoma, or a malignant growth, consists of a careful bi-manual 
 examination of the utennc walls. Even if a fibroid be certainly present. 
 this manipulation is called for for other reasons, and it will help t<' 
 detect the existence of any accompanying partial inversion. 
 
352 
 
 TEEATMENT OF IXYERSIOX. 
 
 Treatment of a mechanical character is almost invariably called for 
 The continual haemorrhages and wasting discharges are such as cannot 
 be tampered with. Only about the menopause, or when repeated 
 attempts at replacement have been unsuccessful, could one trust for a 
 time to the use of powerful astringent applications or cauterisation of 
 the whole surface of the inverted organ. If a poljqjoid growth is found 
 to be dragging the iiterus down, that must, of course, be at once 
 removed by ecraseur, great care being taken to ascertain its true 
 boundary. I have no experience of the treatment of a chronic partial 
 inversion apart from a fibroid growth, but if I were assured of its exist- 
 ence I should endeavour occasionally to repress it by the end of a rectal 
 
 bougie introduced 
 through the os, 
 and I should not 
 hesitate to admin- 
 ister ergot fre- 
 quently and freely. 
 Uterine tonicity 
 thus induced 
 
 would, in the case 
 of moderate in- 
 version, tend to 
 reposition rather 
 than to further ex- 
 trusion. At any 
 rate I would test 
 it. The surgical 
 treatment of a 
 complete chronic 
 inversion consists 
 in reposition or 
 amputation. The 
 
 latter is, of course a mere last resource. Until reposition has been 
 thoroughly tested it is not to be dreamed of One grave risk renders 
 amputation imdesirable, in addition to the danger of haemorrhage. The 
 cup-shaped depression of what is now the inside of the uterus, may 
 contain, in addition to the Fallopian tubes, or even an ovar}-, a portion of 
 intestine. The more chronic the inversion, however, the less is the 
 <ianger of this. The rim becomes greatly contracted, and the intestine, 
 if formerly there, is withdrawn. I never heard of a strangulated hernia 
 produced in this way, but a little inflammatory adhesion, fortunately 
 very rare, might lead to it. 
 
 Amimtation might doubtless be safely performed in some instances 
 
 Fig. 173. — Inversion of the Uterus (Martin). This diagram shows 
 especially the invagination of the Fallopian Tubes and Romid 
 Lisranieuts within the Inverted Uterus. 
 
BY AMPUTATION. 606 
 
 by the galvanic ecraseur alone, but fatal heemoniiage may nevertheless 
 occur, and it is very desirable, after operation, to assure the continued 
 inversion of the stump, until its peritoneal lining has had time to adhere, 
 and to shut out from the abdomen any pui'ulent or septic discharge. 
 It is therefore desirable to adopt precautions in this direction. Many 
 methods have been proposed, -which will be found described in works of 
 a more purely surgical character, but after a very careful study of 
 these I should be inclined to adopt the following combination: — I would 
 first insert three or four long gat threads through the summit of the 
 mass. I would next apply the whip-cord of an ecraseur around the 
 mass, below the sutures, and tighten it almost to the point of strangu- 
 lation. I would then amputate with the galvano-ecraseur at least 
 two-thirds of an inch lower still. Some care would be required to 
 keep the ligatures, whip-cord, and platinum wire from contact, but 
 intelligent assistance would easily effect this. The mass thus removed, 
 I would carefully examine the stump, and tie with gut ligatures any 
 'iivided vessel that was evident. I would then very slowly slacken 
 the whip-cord ligature, tying again any bleeding vessel if necessary. 
 The whip-cord (preferable to wire on account of its easy relaxibility) 
 being now safely removed, the stump would remain perforated with 
 the long gut ligatures. The more or less sound and secure appear- 
 ance of the stump would then determine whether they should be tied 
 over its surface and all but one cut short, or whether they should be 
 gently withdrawn, one being tied and its end being left for a few days as 
 a hold upon the mass in case of accident. Another expedient might' 
 prove of value, viz., to insert at first, through the summit of the stump, 
 -a needle curved at a somewhat acute angle. The sharp end of this 
 should afterwards be guarded by a button or shot. If left in situ 
 for a few days, it would prevent retraction of the stump until tlie 
 peritoneal surfaces were adherent. Amputation must, however, as I 
 have said, be considered as at best a last resort. Its mortality is great 
 when most skilfully performed, although, as is the case with many other 
 operations, successful results have been attained when it was performed 
 by mistake and with little precaution. If j^erformed on a young woman, 
 although menstruation occasionally takes place from the stump, there is 
 evidently danger of hajmatocele at future menstiiial periods, and this 
 should tend to limit the operation still further to cases met with after 
 the menopause. 
 
 Reduction of the invention is the ])r(iper treatment of the chronic 
 disease, and sucli reduction is possible after an indefinite period, and, I 
 believe, in the vast majority, if not in all cases. It is, however, by no 
 means the comparatively simple proceeding wliich is involved in replac- 
 ing a recent inversion. The resistance b(jth of tlie uterine mass and of 
 
354 METHODS OF EEDUCING 
 
 the now thoroiTghly contracted cervical band is against us, although fortu- 
 nately we are seldom opposed by the results of adhesive inflammation. 
 The number of methods, varying very considerably, that have been pro- 
 posed, is an index of the difficulty occasionally met with, not, as the 
 student might suppose, of the frequency of the affection. Among these 
 I may simply recapitulate the methods of Barnes, Barrier, Bockendahl, 
 Byrne, Capuron, Courty, Duncan, Emmet, Hicks, Martin, Noeggerath, 
 A. R. Simpson, Tyler Smith, Tate, Thomas, Viardel, Valentine, Watts, 
 and White. On the whole, the most satisfactory combination of methods 
 would involve the grasping of the uterus with the whole hand, anaes- 
 thesia being almost imperative. With the tips of the fingers the 
 encircling cervix is dilated as much as possible, while pressm-e is made 
 upon the uterine mass with the palm. The uterus is steadied from 
 the abdomen with the other hand, or it may be possible to depress it 
 by one or two fingers in the rectum, and hooked over its cup-shaped 
 upper extremity. When partial reversion is thus made, much is gained 
 by directing the pressure, now made by the fingers upon the fundus, 
 towards one corner, the opening of one Fallopian tube, according to 
 Noeggerath's suggestion. Pteversion takes place more easily in this 
 way than from the extreme summit. I believe that few cases would 
 resist this simplest method of treatment if it were persistently applied, 
 and repeated if necessary on several occasions. I have not seen it fail, 
 but my experience has been comparatively small. 
 
 As additional expedients, I may mention Thomas's plan of pressing 
 down a long cone of boxwood through (not perforating) the abdominal 
 wall, into the uterine depression, thus assisting at first in the dilatation 
 of the cervical ring. Much damage might possibly be done in this way 
 to intervening soft viscera, and it is only applicable to the case of a thin 
 Avoman. A certain amount of assistance of the same kind may be 
 given by two or more fingers in the rectum. Barnes has recommended 
 small incisions into the rim of the cervix so as to allow of more perfect 
 dilatation, but there is great danger of fatal laceration occurring. Tait 
 has attempted covmter-pressure, by a finger passed into the bladder 
 through the dilated urethra, and Emmet has even suggested a free 
 incision into the floor of the bladder for this purpose. We are not, 
 however, all equally skilled Avith him in stitching such openings up 
 again. He has also made the suggestion that, when reposition is only 
 partial, the ground gained may be maintained by temporarily uniting 
 the sides of the cervix with wire svitures, the wires supporting the 
 partially reverted fundus. The bold proceeding of Thomas, Avhich in- 
 volves opening the abdominal cavity and dilating the cervix from above 
 with a sort of glove-stretcher, has proved fatal, and in A. R. Simpson's 
 hands was unsuccessful. Certain ingenious apparatus, Avith an egg-cup- 
 
THE INVEETED UTEEUS. 
 
 355 
 
 shaped extremity at one eud and a strong spring at the other, which is 
 pressed against the body of the operator, have been used to take the 
 phice of the hand. I feel sure that the hand is safer and, so to speak, more 
 intelhgent in its action — more apt to vary its pressure as emergency 
 requires, although its use may be more fatiguing. If success has not 
 followed the persistent use of the taxis as described above, some advance 
 may have been made, and, whether or not, there is still no reason to 
 despair of ultimate reposition. The application of a lesser degree of 
 force continuously maintained has succeeded in the most apparently 
 hopeless cases. When partial progress has been made, an elastic bag, 
 similar to a large Gariel's air-pessary, or to a Barnes's uterine dilator — a 
 " colpeui'ynter " as it is frequently termed abroad— furnished with a tube 
 and stop-cock, is inserted into the vagina and slowly filled with air to as 
 full an extent as can be borne. The pressure thus made is so eqviable 
 that it is bound to act on the most yielding point, and in not a few 
 instances it has been found that _ 
 
 inversions partially restored 
 have yielded to its influence. 
 A firm strap covering the per- 
 ineum and vulva easily pre- 
 vents its external protrusion. 
 The pressure can be partly or 
 wholly relaxed and restored 
 again at will. Water may be 
 used instead of air and is per- 
 haps more effective. In order 
 to direct the pressure more 
 certainly in the right direction, 
 the vagina should be packed at 
 
 its upper part with steadying plugs of cotton, soaked in carbolic glycerole 
 of only moderate strength, and placed round the uterus, but this will in- 
 volve their complete renewal every two or three days. More than one case 
 is recorded, commencing with one by Bockendahl, in Avhich complete suc- 
 cess has followed the use of this method, without any previous manipu- 
 lation, and although Emmet considers it dangerous, and liable to induce 
 pelvic cellulitis, I cannot think that it can be worse in this respect than 
 violent manipulations. 
 
 Another form in which gradual and constant pressure against the 
 inverted fundus can be maintained, is by means of a stem pessary with 
 a cup-shaped upper extremity to support the organ, and with its lower 
 extremity fastened to a waist-belt by firm elastic bands, similar to, but 
 stronger than those used for Tait's uterine dilator. It is still more 
 necessary with this form of pressure tluui with tlic elastic air or water 
 
 Fig. 174. — AveliDg'.s Uterine Repressor, 
 for Chronic Inversion. 
 
:356 TREATMENT OF INVERSION. 
 
 bag that the uterus should be retained in its proper axis by packing 
 with tampons. The length of the stem, and its curvature, will have to 
 be decided for each individual case, according to the length of the 
 vagina, the amount of the descent of the inversion, and, to some extent, 
 the resistance of the perineum, which may require the stem to be 
 somewhat S-shaped in order to obtain accurate pressure in the proper 
 direction (fig. 1 74). Dr Aveling informs me that with this, his instru- 
 ment, seven cases have been cured, the time required being about two 
 days. 
 
CA^•CEI: OF THE CEKVIX UTERI. 857 
 
 CHAPTER XIV. 
 
 Diseases of the Uteilus — continued. Malignant Diseases. Cancer of tlie Cervix, 
 Cancer of the Body. Sarcoma. 
 
 It is not my inteiitiou to enter into the many debatable questions con- 
 nected with the pathology of cancer. Whether the generally received 
 view that it is, in all cases, a product of epithelial cells, or whether that 
 of VirchoAV, and Huge and Veit, which traces it to connective tissue, or 
 that which traces it to a fluid blastema poured from the blood, be the 
 correct one, I am not in a position to decide. That it is more common 
 in woman than in man, that it has certain affinities for the white races, 
 that it is to some extent (although perhaps less than was once supposed) 
 influenced by heredity, and that it nevertheless often seems to arise fronj 
 local irritation, I assume as facts. Whether it is always the local mani- 
 festation of a general cachexia, or whether it may sometimes be a purely 
 local affection, with a strong tendency to involve the system in cachexia. 
 I may well leave undecided, in the face of the strongly divergent 
 opinions held by the very highest pathological and surgical authorities. 
 Those who are interested in this question would do well to study the 
 interesting debate which took place at the Pathological Society, in 
 March 1874 (Lancet, vol. i., 1874, page 372, Arc). We must treat the 
 subject from its purely clinical aspects. And the first point of clinical 
 interest to be noted is that, while the affection is exceedingly common, 
 painfully common, as a disease of the cervix, it is comparatively rare 
 as a disease of the body of the uterus. 
 
 The necessity for a separate consideration of the disease as affecting 
 these two separate localities is as great as, or even greater tlian, that for 
 a separate consideration of cervical and corporeal metritis. 
 
 Cancer of the Cervix Uteri. 
 
 This may occur in several very diffei-ent forms — forms differing not only 
 in general appearance b\it in rapidity of growtli, mode of spreading, lia- 
 bility to constitutional affections, and last, not least, amenability to treat- 
 ment. But for all this the disease is one and the same — cancer. Perhaps 
 the best division of the foiins of cervical cancer is the following, which 
 
358 
 
 CLINICAL VAEIETIES 
 
 represents tolerably clearly distinguishable clinical varieties, although 
 as might be expected, the distinction is not always equally well marked. 
 We may have — 
 
 1. Superficial epitheliomatous ulceration of the cervix (fig. 175). 
 
 2. Soft papillomatous sprouting from the inner or outer wall of the 
 cervix (fig. 176). 
 
 3. Mushroom-like and moderately solid and firm sprouts (figs. 177 and 
 132). 
 
 4. Nodules of the parenchyma, tending to ulceration and excavation, 
 (fig. 178). 
 
 1. Superficial Epitheliomatous Ulceration of the Cervix, — the 
 " cancroid " of some writers, — is characterised by ulcerative destmction 
 of the surface, with very little, or long-deferred, induration or infiltration 
 of the subjacent tissues. It is a true epithelioma, and has little or no 
 
 Fig. 175. — Superficial Cancerous 
 Ulceration of the Cervix 
 (Schrceder). 
 
 Fig. 176. — Cauliflower Excrescence of the 
 Cervix (Simpson). 
 
 tendency to papillary sprouting. At one time it was considered as not 
 belonging to the true cancers, but its secondary affections are as truly 
 malignant as those of the other forms. Unfortunately this variety is 
 rare ; I say unfortunately, because, when seen in its typical form, early 
 in its career, and before infiltration has extended deeply, it afibrds con- 
 siderable hopes of amelioration, or even of cure, by ablation. After a 
 time deep infiltration does occur, and it becomes difficult or impossible 
 to separate a case of this kind from one which commenced as an infil- 
 tration of the parenchyma and terminated in ulceration. This superficial 
 form of the disease is often very slow in its progress, and many cases 
 closely assimilate to what Sir Charles Clarke termed "corroding ulcer." 
 Dr John Williams described this affection, in an able paper, at the 
 Obstetrical Society, in March 1884, and gave his reasons for believing 
 it not to be cancer at all. 1 m\ist confess that when I find that Scanzoni 
 
OF CANCER OF THE CERVIX. 
 
 359 
 
 Fig. 177.— Mushroom-like Cancerous 
 Fungus (Scliro3der). 
 
 considers it to be encephaloid, Courty— epithelioma, and Matthews 
 Duncan — lupus, while Wm. Duncan looked upon it as lupus which 
 has assumed an epitheliomatous character, I feel inclined provisionally 
 to retain it as coming under the present heading, doubting the exist- 
 ence of two separate affections, one malignant, the other not, but which 
 it seems impossible to differentiate to 
 the satisfaction of any large number 
 of observers. 
 
 2. Papilloma, or cauliflower excres- 
 cence, ^ is characterised by its extreme 
 tendency to proliferate in the form of 
 villi, Avhich are largely covered with 
 epithelial cells. It takes on the form 
 of a soft bleeding fungus, which grows 
 very rapidly, and here also there is 
 usually very little infiltration of the 
 hard tissues, for a considerable time. 
 In some cases there is a very decided 
 pedicle of hardish tissue, which would, 
 as regards malignancy, appear to vary 
 very njuch in its histological characters, 
 and in others the papilloma is merely 
 an addition to a subjacent, infiltrated, scirrhous or medullary mass. 1 
 have seen a papilloma so large as completely to pack the vagina, but 
 which, after removal, left hardly any hardening of the cervix, and did 
 not return for two years. It grows chiefly from the vaginal aspect of 
 the cervix, and yet has not much tendency to involve the vaginal wall 
 by contact. The true cauli- 
 
 flower epithelioma is, like 
 the epitheliomatous ulcer, 
 less relatively common than 
 from its accessibility one 
 might desire. 
 
 3. The Mushroom - like 
 Fungus is much more dense 
 than the papilloma. It is 
 often not very unlike tlic flower of a small coxcoml), altliougli it varies 
 in colour from a red to a dull greyish brown. In every way it is 
 intermediate between the last and the next variety, sometimes inclining 
 to the soft villous pattei-u, witli little subjacent hardening, sometimes 
 havnig a very decided pedicle, and sometimes sprouting on the surface 
 
 1 The term " caulinower excrescence" is not applied to small vascular papillo- 
 mata, althou^di tliere may be no intrinsic pathological distinction. 
 
 Fk; 
 
 178. — Sni.ill Cancerous Nodule, with section 
 of the same (Schrojder). 
 
360 CAUSATION, peoCtEess, and symptoms 
 
 of solid malignant deposit. I believe that it is also intermediate in its 
 mode of origin, commencing at one time as a superficial growth and 
 extending its infiltration inwards, at another, as a sequel of a growth 
 which was originally quite sub-mucous. For this opinion I have only 
 clinical observation to guide me, and I do not profess to have follow^ed 
 the matter histologically. Ulceration and excavation follow, sometimes 
 slowly, sometimes very rapidly, in the wake of this form, as they do 
 eventually in all other forms of cancer, however they may originate. 
 The part of the cervix nearest to the os iiteri is usually the first affected 
 in this way. 
 
 4. Nodular Deposits in the sub-mucous tissue, or at least apparently 
 so, are the most frequent varieties of cervical cancer. They may be 
 scirrhous or medullary, — that is, they may contain a greater or less 
 proportion of fibrous tissue, and may show a greater or less rapidity of 
 growth. The medullary, or more cellular and more rapidly-growing 
 form, is the more common. The tendency of both forms is to approach 
 the surface, and to give rise to ulcerations of a rapidly-spreading char- 
 acter, with or without the intermediate sprouting described under No. 3. 
 But their tendency is also to rapidly multiply by extension into the 
 surrounding cellular tissue, or upwards into the uterine body, or down- 
 wards into the vaginal sub-mucous connective tissue. 
 
 In one or another of the above clinical forms, more or less typically 
 displayed, the practitioner will encounter cancer. 
 
 Causation. — I have nothing further to say on this head. The general 
 causation is yet quite obscure, except as far as the known facts of heredity, 
 gouty and other dyscrasiae, race, sex, and climate bear upon it. With re- 
 gard to the last, Haviland {Lancet, vol. ii., 1868, p. 737) has gathered 
 many curious facts, which deserve following up. Continued mental de- 
 pression is thought by Scanzoni and many other authorities to have a 
 strong predisposing influence. That chronic inflammatory disease of the 
 cervix cannot have much influence as an excitant is abundantly evident, 
 but that it becomes one when associated with laceration is maintained by 
 most recent American authorities. Emmet says (op. cit., p. 496) : — " I 
 have never known a woman to have any form of epithelial cancer of the 
 uterus unless she had at some time been impregnated. Moreover, I believe- 
 that nearly all, if not all, cases of ej^ithelioma, or cauliflower growth, have 
 their excitory cause or origin in a laceration of the cervix. It springs from 
 the effort to repair a local injury, and may develop from a recent laceration, 
 or it may occur after a change of life." I can only say that I have seen 
 several cases of epithelial cancer in women who have never been im- 
 pregnated, and that one sees scores of cases of cancer " after a change 
 of life," both in the breast and the uterus, without previous laceration 
 of the cervix. I think it highly probable that the irritation of a torn 
 
OF CANCEK OF THE CEKYIX. 361 
 
 cervix has a somewLat predisposing, or at any rate a localising influence, 
 but the truth will be more dispassionately ascertained after a few more 
 years have passed. The influence of depressed vital forces is as certain 
 here as in other forms of cancer in either sex, especially the depression 
 due to rapidly-commencing senility. Few cases occur below twenty or 
 above sixty. 
 
 Progress. — The extension of nodular cancer is sometimes frightfully 
 rapid, and may destroy life by the accompanying dj^scrasia before ulcera- 
 tion has occurred. Some years ago I saw a case with the late Dr Ogden 
 Fletcher, where, at a certain date, a vaginal examination was made, and 
 detected nothing abnormal. In two weeks there Avere abundant nodules 
 in and around the cervix. In two more the finger could not enter the 
 vagina, and in about seven weeks altogether the patient died. But few 
 such rapid cases as this occur. In a very rough way cancer may be said 
 to last from one to two years, but much will depend on the form, the 
 mode of extension, and the possibility of at any rate temporary re- 
 moval. I have seen several cases, also, Avhere progress has become quite 
 stationary for considerable portions of time, — two or three years, — so as 
 to give rise to considerable doubt as to the diagnosis, although the subse- 
 quent termination confirmed it. The ultimate results are alike in all 
 cases, deep penetrating iilcers, spreading by contiguity or arising at fresh 
 points, eating into the tissues and destroying life by pain, hsemorrhage. 
 and wasting discharge ; and infiltration of the surrounding parts, leading 
 to fresh ulcerations and to metastatic deposits in the neighbouring glands, 
 and in all parts of the body. In the first form, superficial epithelioma, 
 the ulceration generally commences about the os externum, and may foi- 
 a long time continue superficial, gnawing its Avay up into the cervix or 
 towards the adjacent vagina. In the papillary forms ulceration arises 
 in the surrounding infiltrated tissue, although bleeding and discharge 
 take jjlace from the sprouting mass. In all forms, but especially the 
 nodular, the bladder is reached through the connective tissue which 
 separates it from the \iteiais, and sloughing of its walls produces ragged 
 fistulas. The ureters may be early affected, and thxis are produced 
 either fistulse or blocking of their canals by infiltration, with subsequent 
 hydronephrosis and urasmic poisoning. The rectum is less frequently 
 opened, and the peritoneal pouch of Douglas, or other portions of the 
 peritoneal membrane, are rather included in the infiltrated mass than 
 liable to be laid open. 
 
 Sym2)toins. — The symptoms Avhich characterise cancer of the uterus, in 
 any situation, are general cachexia, haemorrhage, foetid discharge, and 
 pain. The well-developed canceroi;s cachexia is usiu\lly a sequel of the 
 otlier symptoms, but in many cases it will be found that a rapid loss of 
 weight and general feeling of malaise have preceded all else. As a rule, 
 
oQ2 SYMPTOMS AXD DIAGNOSIS 
 
 hsemorrhage in some degree, is the first symptom \\'hich attracts atten- 
 tion. It may be very slight, or alarming in quantity, at its first onset. 
 Hsemorrhage, however slight, occurring after the menopause, or produced 
 by some slight, apparently trivial cause, is always most suspicious, and 
 should lead to investigation, although no other symptom is present; 
 it may assume the form of menorrhagia or of frequent slight metror- 
 rhagia. As the disease progresses this symptom increases, draining the 
 system, or sometimes suddenly imperilling life ; but often, in the latest 
 stage of all, the heemorrhage may become insignificant. "When fi'equent 
 haemorrhages are suppressed, pain is very apt to increase. Along with 
 the hsemorrhage, or speedily succeeding to it, we begin to have the very 
 characteristic discharge of cancerous ulceration. This discharge is of a 
 watery character, pale and dirty-looking, or tinged with blood, and in- 
 tensely fffitid. The foetor is undoubtedly due to ulceration, or to the 
 shreds of gangrenous tissue which are cast off from papillomata. 
 
 Pain, although a characteristic sjTiiptom, is a somewhat variable one. 
 It is not uncommon to have one's attention called by haemorrhage to a 
 very considerable amount of nodular infiltration and ulceration, or to 
 sprouting epithelioma, in the entire absence of pain. But sooner or later 
 pain also comes on, as the infiltration becomes wider and involves the 
 connective tissue ; sharp, lancinating, or burning, extending to the 
 loins, thighs, or abdomen, generally worst at night, it becomes in many 
 instances intolerable, and the only relief is to be found in inordinate 
 and gradually increasing doses of opium or other sedatives. Every 
 function of the body ultimately becomes impaired. Sleep is fitful or 
 impossible, digestion fails, diarrhoea or constipation adds to the discomfort, 
 and wasting. Dysuria is often an early symptom, then perhaps follow 
 the horrors of vesico-vaginal, and perhaps also of rectal fistulse, and we 
 •ire only too thankful when death closes the scene. 
 
 Diagnosis. — Unfortunately, malignant disease of the cervix rarely 
 comes under notice until pain or hsemorrhage calls attention to it ; before 
 that time the disease has obtained a firm hold. A very early cancroid 
 epithelioma might be mistaken for granular erosion, or for a chancre. 
 Chancre, however, is excessively rare in this site, and a history should be 
 obtainable, hj cross-examination or otherwise, which should obviate 
 error. Inoculation might be desirable in very rare emergencies, but 
 ablation, with subsequent careful microscopic examination of the portion 
 removed, Avould be the wisest course in a case where syphilitic disease 
 was not highly probable. Granular erosion (Frontispiece, No. 2) of so 
 small a surface is nearly always of the simplest character, and should not 
 be mistaken for a true cancerous ulcer, which from the first has a sharjDly- 
 defined edge and excavated surface. A commencing papilloma could only 
 be mistaken for a similar growth of benign character, for condyloma, or for 
 
OF CANCER OF THE CEUYIX. 363 
 
 the fuugosities of long-continued or over-treated chronic endo-metritis, 
 with or without haceration and ectropion (Frontispiece, No. 5). The 
 existence of the first of these — non-maUgnant papilloma — is doubted by 
 many. Certainly there are examples which present no traces of the 
 characteristic cancer nests under the microscope, and which do not 
 return after ablation. I have seen one such as large as a chestnut. It 
 is very doubtful, however, what would be the future of such a growth if 
 left alone, and as a matter of precaution it should be treated as if it 
 were malignant. Condylomata in this site are rare ; their syphilitic 
 origin is generally traceable, and the occasional application of a little 
 calomel, with vaginal injections, will speedily produce an improvement 
 which would be diagnostic. The granular condition of old metritis has 
 a history of chronicity, and an accompaniment 'of cervical purulent 
 discharge, which ai'e totally distinct from the manifestations of an epi- 
 thelioma, which has no such sj'mptoms. The j^ossibiliti/ of the latter 
 being grafted on the former, or even, in rare instances, of its being 
 excited by it, must not, however, be forgotten. A small, sessile, malignant 
 fungosity of the more compact kind, with a slightly infiltrated base, 
 might, I think, be mistaken for a chronic cervical metritis. I never 
 happened to see one in so early a stage that mistake was long possible. 
 The thoroughly protruded fungus, Avith thick border, projecting from 
 smooth and apparently healthy mucous tissue, is nearly alwa^'S suffi- 
 cient for any one who has previously seen a sample or two of the 
 malignant disease, and the earliest commencement of ciiimbling down, 
 with foetid discharge, has generally appeared. In a doiibtful case a 
 very short observation of the progress from bad to worse would sufl&ce 
 for diagnostic purposes. Nodular cancer, before it has reached the stage 
 of ulceration, presents the greatest difficulty. If the nodules are 
 multiple, and especially if any of them are traceable into the surround- 
 ing tissues, leading to diminution of uterine mobility, without histoi'y 
 or signs of pelvic inflammation, there can be little doubt as to their 
 malignant nature. If it turn out that the nodules were sarcomatous 
 instead of cancerous, the practitioner may be held guiltless of any great 
 eiTor in diagnosis, and little if any difference will accrue to the patient. 
 But a single early malignant nodule is hardly distinguishable from a 
 .small fibroid of the cervix, or a limited chronic induration, or even from 
 a deep-seated swollen follicle of the cervix. The soft pulpiness or 
 oedema of one lip, due to uterine flexion, should be distinguishable 
 at once. A puncture would detect a doubtful follicle. But small 
 fibroids or hj^Dertrophic enlargements, and single cancerous nodules, 
 present few certain signs for differentiation. H\'pertrophic enlarge- 
 ments are less easily isolated from apparently liealthy tissue than the 
 new growths. Fibroids and liypertrophies present a harder consistence. 
 
864 DIAGNOSIS AND DIFPEEENTIATION 
 
 although a more yielding one than carcinoma, unless it is quite of scir- 
 rhous type, which is not common, but this refinement is hardly appre- 
 ciable to the ordinary touch, and is by no means universally met with. 
 The mucous covering of a malignant nodule appears to be much more one 
 with it, more adherent to it, than that of the other two growths, but the 
 same necessity for great tactile experience exists here. From these two 
 signs a practitioner of great experience would, I believe, make a 
 diagnosis which would be right in a great majority of cases, but I feai- 
 this is all that can be said. If fibroid or hypertrophy Avere diagnosed 
 we should probably be led to make use of uterine tents, as recommended 
 in former chapters. Both these affections, especially the latter, often 
 yield considerably to tents, owing to absorption, while Spiegelberg 
 asserts, and others have found, that carcinoma is not so aff'ected. 
 Positive absorption in this way might be considered as differential 
 against cancer, but negative results would hardly affect diagnosis. 
 Schroeder puts the dilemma in a very agreeable form, when he says : — 
 "It is not unimportant to bear in mind that we rarely have an 
 opj)ortunity to see carcinoma at so early a stage, consequently in 
 doubtful cases we are almost invariably dealing with benign changes.'' 
 We may with equal propriety soothe ourselves with this pleasant reflec- 
 tion in all cases where early malignant disease is not easily differentiable, 
 but the patient would hardly derive as much satisfaction, if the method 
 of diagnosis were made plain to her. Apart, however, from actual 
 removal of the affected structures and microscopical examination, there 
 are no other signs or symptoms than those mentioned, or which can be 
 termed pathognomonic. 
 
 The diagnosis of advanced and ulcerated cancer presents few or no 
 difficulties. So says Schroeder. Thomas, on the other hand, says: — " I 
 know of no disease of the genital organs of the female, unless it be 
 pelvic peritonitis, which so frequently gives rise to eiTors of diagnosis 
 with the inexperienced." They are both speaking of ulcerated cancer, but 
 as Thomas's list of the affections liable to be confounded with it includes 
 sloughing polypus, uterine fibroids, sarcoma of the uterus, and retention 
 of products of conception, it is evident that he is taking together cancer 
 of the body and cancer of the cervix. His other items are inversion of 
 the cervix from laceration, papillary hypertrophy of the cervix, syphilitic 
 ulcer, and areolar hyperplasia of the cervix with metrorrhagia. We have 
 referred to most of these in connection with early cancer of the cervix. 
 
 An advanced epitheliomatous ulceration cannot well be mistaken for 
 anything else. The deep-rooted ulceration, its history, its almost certain 
 association at this stage with multiple malignant deposits, its hsemor- 
 rhages, pain, and foctor are sui generis. Only the rarest forms of chancre 
 could lead to error. 
 
OF CANCER OF THE CEEVIX. 365 
 
 Advauced cauliflower excrescence (fig. 176) is also like nothing else. 
 One can just imagine a bleeding inverted uterus, or a partially slough- 
 ing and foetid polypus being mistaken for a large malignant papilloma, 
 but only by one who would not take the trouble to investigate the 
 history, the physical properties, and the attachments of the mass. A 
 malignant, solid, mushroom-like sprout ulcerates early and character- 
 istically, the ulceration usually commencing at the part nearest the 
 OS uteri, and having the sharp overhanging edges, and apparently deep, 
 foetid, cavity which are so diagnostic of cancer. 
 
 As regards nodular cancer, when at all advanced, there is one great 
 distinguishing feoture, the fixation of the iiterus which it causes. Mere 
 non-malignant enlargement of the cervix leaves the uterus mobile. 
 Cancer fixes it early. The infiltration spreads rapidly to the surround- 
 ing connective tissue, and even when the finger cannot detect its nodules 
 there through the vagina or the rectum, it ascertains the partial or com- 
 plete immobility of the organ in every direction thus produced. The 
 exudation of lymph or blood in pelvic disease has a similar effect, as may 
 have also the existence of large fibroid growths of the uterus itself In 
 the absence of these, fixation of the uterus is a sign of great and almost 
 pathognomonic value in cancer, even from a very early stage ; and, apart 
 from the fact that non-malignant pelvic exudations have usually a well- 
 defined history of their own, they have special tendencies to assume 
 characteristic forms and invade particular portions of the pelvis, as 
 described in Chapter XIX. 
 
 Ulceration, based upon the hardened nodules of the immobile cervix, 
 is perfectly characteristic. It has sharp nodular edges excavated under- 
 neath, crumbles superficial!}' under the touch, and yet the crumbling- 
 surface is felt to be superficial, and its foetor is now excessive. The 
 radiating fissures of a torn and everted cervix uteri, with its covering of 
 eroded or granular mucous membrane, are not combined with immobility 
 of the organ, and their history and appearance are sufficiently diagnostic 
 to one with any experience of the two affections. 
 
 In making the diagnosis of any case of cancer, extreme gentleness of 
 touch is desirable. The finger should be passed along the posterior 
 vaginal wall, scarcely touching any projecting mass, if possible, xnitil it 
 is beyond it, and then should gently palpate it with the pulp of the 
 finger turned towards it. Without this precaution great hfcmon-hage 
 may be caused. The speculum should not be iised except in doubtful 
 cases, or for purposes of operation, or other necessar}'- treatment. 
 
 Treatment of Cancer of the Cervix. — The treatment of cancer of tlic 
 cervix may be divided into (1) the medicinal agents administered 
 internally for the CTire of the disease or the ])alliation of its symptoms ; 
 (2) tlie local medicaments wliicli are applied for citlicr of tliese purposes ; 
 
366 TREATMENT OF 
 
 and (3) the operative means which are used, also with either of these 
 two aims. 
 
 Medicines are, I fear, of little or no avail as curative agents. From 
 time to time some enthtisiast imagines that he has discovered such an 
 agent. But such discoveries speedily fall into oblivion, under the test 
 afforded by general experience. Perhaps two only have had, or still 
 retain, any hold on professional estimation — arsenic and iodide of 
 potassium. No one with any extensive experience can have failed to 
 see, in many instances, a wonderful improvement in the general condi- 
 tion of cancer patients under the steady use of small doses of arsenic. 
 It appears to me to act much in the same way as it does in certain cases 
 of aneemia. The general condition is improved, and, if the local disease 
 were not there, the so-called cachexia might perhaps be diminished. I 
 do not feel justified in withholding it in any case where I think I have 
 removed the local disease, or where ansemia is a leading symptom. 
 Iodide of potassium is used almost quite empirically. I have never seen 
 a case of cervical cancer materially influenced by it, but I have a list of 
 seven cases of what I believed to be cancer of the breast, and two of the 
 tongue, all of which diagnoses Avere confirmed by surgeons of great 
 experience, where every trace disappeared under the use of this remedy. 
 Both tongue cases and one of the breast cases had reached the stage of 
 ulceration. Knowing what we do of the alliances and resemblances of 
 syphilitic growths and cancer, all these cases may be fallacious as guides, 
 although every care was taken to exclude mistakes in this way. I have 
 also seen three or four cases where apparently glandular cancer or 
 sarcoma of the breast, coming on about the menopause, while fibroid 
 tumours of the uterus in the same patients were shrinking, has dis- 
 appeared during the administration of full doses of iodide of potassium. 
 
 As palliatives, the use of internal remedies is more extensive. There 
 is a stage at which opium may be said to be our sole resource. 
 Other sedatives or narcotics may be required, according to the idio- 
 syncracies of the patient, but opium is the sheet anchor. Beware, 
 however, of beginning too early with large doses. The pain of cancer 
 sometimes subsides for a considerable time, and we have no right to 
 deprive the unfortunate patient of a clear brain during those penulti- 
 mate weeks or months of a closing life. Medicinal astringents, given 
 to arrest hasmorrhage, serve little other purpose than to disorder the 
 digestive organs. Even ergot is liable to do more harm than good, by 
 promoting uterine muscular contraction. The dietetic treatment of a 
 case of cancer may be summed up briefly:— avoid stimulation further 
 than seems absolutely necessary, give as much bland and nutritious 
 food as the patient can digest, carefully regulate the bowels by the 
 mildest aperients available, and extract what benefit you can from iron. 
 
CAXCER OF THE CERVIX. 3G7 
 
 qiiiniue, cod-liver oil and other agents of a similar kind. Mr Thomas 
 Windsor, one of the most careful and accurate observers with whom 
 it has ever been my pleasure to be associated, had a case, not published 
 I believe, in which he first removed the eyeball and orbital contents, 
 and afterwards some portion of the bones, unsuccessfully, for cancer. The 
 fungus returned and could not further be interfered with. The patient 
 perfectly recovered after living for some months, on the advice of a 
 quack, on nothing but small biscuits of flour and water and without 
 salt. This is the only fully authenticated fact of Avhich I am personally 
 cognisant in favour of the starvation treatment of cancer. Neither 
 I nor my patients have ever been bold enough to try it, or to rely for 
 any long time on any of the dietetic cures yet recommended. 
 
 Local Ai)2ilications. — (a) Curative. 
 
 No one, I think, now-a-days dreams that we have specific agents 
 which can burrow into the tissues in search of the roots of a cancerous 
 tumour and dig them out, while leaving intact the surrounding healthy 
 tissues, although it is impossible to maintain the inherent impossibility 
 of such substances. Such proceedings are mainly confined to quacks whci 
 prey upon the ignorant or despairing. The attempted cure of cervical 
 cancer by caustic applications is reserved for cases of epithelioma, which 
 ai'e limited in extent and ap]parently imaccompanied by deep infiltration. 
 Even here the results are, I fear, always evanescent. In patients whc- 
 object to the use of the knife, they may be tried, and if tried, the most 
 powerful caustics are the only ones available. Bromine in solution 
 (1 part^ in 5 of spirit) I have found much less effective than it is usually 
 stated to be. Its selective action for the malignant tissues is I fear but 
 a remnant of old superstitions, yet with that reverence for authority of 
 which one can never entirely divest oneself, I occasionally try it again. 
 The potassa fusa cum calce surely destroys everything with which it 
 comes in contact, and a small malignant fungus may be thus entirely 
 got rid of, but it comes again. The utmost precaution is necessary tt- 
 avoidthe action of the deliquescent salt from spreading. The duck-bill 
 speculum should be used, the cervix thoroughly exposed and dried. 
 Plugs of cotton soaked in vinegar are placed carefully around it. The 
 caustic mass is firmly pressed for a few moments against the affected 
 part, and the vaginal cavity is freely washed out subsequently with 
 vinegar diluted with two parts of water. A plug soaked in glycerine 
 and vinegar (equal parts) is carefully left in contact with the os uteri 
 for some hours. Chromic acid is less effective, and nitric acid is too 
 superficial in action. I suspect that in a few years nothing will be 
 heard of these caustics in relation to cancer, except as to their occasional 
 use after excision, when it is doubtful how far the diseased parts have 
 been entirely reached. As an agent of this kind chloride of /.inc has 
 
:3(38 PALLIATIVE AND OPERATIVE TREATMENT 
 
 many warm advocates. The galvano-cautery knife can do all that they 
 (zem do, and with much more definite regulation. 
 
 (b) Palliative. — Local applications can, however, do much as pallia- 
 tives, by checking haemorrhage and lessening foetor, and so prolonging 
 life and diminishing misery. Pessaries and suppositories of morphia 
 and belladonna I consider as medicines rather than local applications. 
 
 For the relief of fostid discharge thymol is one of the most efficient 
 agents. It is less irritating, less offensive itself to many people, and 
 less liable, when constantly used, to induce eczema, than carbolic acid. 
 A solution of 1 in 800 parts of water, Avith the addition of a little 
 glycerine, may be injected very gently and very frequently, or a white 
 vaseline ointment with 20 grains to the ounce, the thymol being dis- 
 solved by the aid of heat, may be smeared over the fungoid mass. 
 Good carbolic acid is not, however, offensive to all, and a 2| per cent, 
 solution, or a vaseline ointment of 1 in 40, may be used. Weak solutions 
 ^gr. ^ _ 1 ad si) of bichloride of mercury may also be used. Iodine is 
 hardly applicable for deodorising purposes alone, but carbolised iodine, 
 that is a combination of carbolic acid 1 part, and tincture of iodine 7 parts, 
 is a valuable application, in solution or otherwise. A completely new 
 combination ensues, and the iodine is decolorised. I believe this com- 
 bination was first recommended by Dr Boulton. Iodoform has, to my 
 sensations, such a vile odour of its own, which nothing thoroughly 
 covers, and which so enters into combination with the foetor of cancer, 
 aggravating both, that I have almost ceased to use it for cancer in private 
 practice. In hospitals, or where one can depend on very careful applica- 
 tion of just sufficient quantity to the right spot, it is more serviceable. 
 The investigations now being- carried out by my friend Dr Priestly, 
 imder the direction of the British Medical Association, may perhaps 
 tend to show that it has other properties which would still farther com- 
 mend its tise. Salicylic acid is free from all odour and is equal in many 
 respects to the above mentioned remedies, as far as concerns the parts 
 with which it can be placed in actual contact; 30 grains dissolved in half 
 ;m ounce of flexible collodion is a popular remedy for warts and corns; 
 I have recently applied it to fungating masses of cancer, when the ap- 
 plication was possible, without exciting much hcemorrhage, and I can 
 recommend the practice as producing something more than a mere 
 deodorising effect. The powerfully hypnotic and somewhat depressing 
 action of chloral hydrate have deterred me from using it locally in 
 sufficient quantity to be of use as an antiseptic. 
 
 For the arrest of li£emorrhage, various local remedies are available. 
 The carbolised iodine and the preparation of salicjdic acid just mentioned 
 are often very effective, but more powerful styptics are frequently 
 required. The glycerole of tannin is one of these. The perchloride of 
 
OF CANCER OF THE CERVIX. 369 
 
 ii'ou (liq. ferri perchlor. fort.), is also a powerful astringent, requiring to 
 be cai-efully applied to the bleeding mass, and in obstinate cases almost 
 pure carbolic acid may be safely painted on the raw surface if it be not 
 very large. Sulphate of zinc, alum, or any of the vegetable astringents 
 suitable maj' be applied in powder, but the result is a pultaceous clot, 
 which is difficult of removal without further hsemorrhage. Plugging 
 the vagina for the hsemorrhage of cervical cancer should never be had 
 recourse to without grave consideration. If styptics fail, and partial 
 or complete removal of the disease is not possible, it may, however, 
 become a necessity. If done at all, it must be done carefully and 
 effectively with the aid of the speculum, and the utmost care must 
 be exercised in removing the plug. 
 
 Operative Procedures. — In every case of operation upon a cancerous 
 cervix the operator should clearly place before himself the question, — 
 Can I remove the whole of the cancerous structure, and so give the 
 patient a faint chance of complete recovery, or at any rate of arrest for 
 a considerable time, or can I only remove such portions as may be neces- 
 sary to put a temporary stop to hsemorrhage and foetid discharge, and 
 so prolong life for a short time or render it more endurable 1 More- 
 ovei", it is his duty to give full information to the patient or her friends 
 ujion the point. I know of no greater cruelty or fraud than the per- 
 formance of an operation, perhaps of successive operations, upon a 
 patient in whom pain and hsemorrhage are greatly in abeyance, and in 
 whom infiltration is so great that extirpation is impossible, while hopes 
 are held out of a successful issue. 
 
 In certain cases, too seldom seen by the practitioner in time, there is 
 a reasonable prospect that the whole of the diseased tissues can be re- 
 moved by operation on the cervix. These cases are those of — (1) a 
 superficial epitheliomatous ulcer of the cervical canal or surface, with 
 no evidence of deep-seated infiltration ; (2) an epitheliomatous fungus, 
 however large, where there is the same absence of evidence that the 
 sub-mucous tissue or surrounding parts are infiltrated ; (3) nodular 
 cancer, ulcerated or non-ulcerated, which is confined to a j)art of the cervix, 
 or which is within the reach of the knife or galvanic ecraseur, or wliich 
 may, by good fortune, turn out to be not cancerous after all. In all these 
 cases ablation is justifiable and desirable, even in the absence of severe 
 hsemorrhage or pain. 
 
 In the first instance — that of the superficial ulcei* — the knife is the only 
 satisfactory means. The cervix must be fully exposed by the duck-bill 
 speculum, and drawn down within i-cacli of easy manipulation. With a 
 fine sharp-edged knife the cervix is then thoroughly pithed — that is, a 
 deep sluuing is cut a\\ay from the interior, all round if necessary. The 
 portion removed should be wedge-shaped (fig. 132); the point of tlie wedge 
 
 2 a 
 
o70 EEMOYAL OF CAXCER OF THE CEEYIX. 
 
 terminates at the os internum, while the base includes the whole thick- 
 ness of the cervix. The finger is then used to detect whether, in the raw 
 surface, any hard infiltration points are to be felt. If so, they must be 
 shaved away as far as the thickness of the cervix will permit. An 
 expert o|)erator, like the late Marion Sims, has occasionally left behind 
 only a mere shell of the upper part of the cervix, little thicker than 
 paper, and he has published some few permanent cures, and many cases 
 of prolonged recovery from all symptoms of disease. After the opera- 
 tion it is advisable to touch the Avhole raw surface with Paquelin's 
 cautery. This both an-ests hsemon-hage and diminishes the risk of septi- 
 caemia. Plugging of the cervix for several days afterwards with carbolic 
 glycerine plugs, or with more potent astringents, is also desirable, as 
 secondary hsemoiThage is not uncommon. It is doubtful how far any 
 process of stitching together the edges of the V-shaped incisions thus made 
 is of advantage. 
 
 For the removal of fungoid growths, especially if large, the galvano- 
 cautery ecraseur is the most satisfactory method, and it must be made 
 to include as much of the cervix as possible. If induration extend 
 upwards into the canal, the knife must subsequently be used as above 
 indicated. 
 
 In nodular cancer, or suspected cancer, the cervix must be freely re- 
 moved as recommended in certain cases of hypertrophy. The galvanic 
 wire is often superior to the knife, but the latter may come to its aid as 
 in the removal of epitheliomata. 
 
 In advanced cancer, removal of as much as possible is still advisable 
 in certain cases. Where there is deep infiltration of the cellular tissue, 
 with fixation of the uteiiis, or where the uterine body has become 
 affected, or where ulceration has spread to the vagina, there can, of 
 course, be no chance of cure ; but hfemorrhagic and other discharges 
 may be greatly abated, and the patient's health temporarily but very 
 materially restored, the cachectic appearance disappearing for a time. 
 If the general symptoms are quiescent, although the disease must be ad- 
 vancing, no operation is permissible under these circumstances. Pain 
 is not in itself an indication for interference, for pain is nearly always 
 due, not to the mere cervical disease, but to its extension beyond the 
 cervix, and beyond the reach of operative means. Hfemorrhagic and 
 other discharges of a rapidly-wasting character, a:id which cannot be 
 controlled, are our sole wan-ant. For the removal of these we must 
 simply remove as much of the bleeding mass as is possible with safety. 
 The ecraseur will cut away the bulk of a protruding mass, and the 
 curette, scoop, or knife may he freely used on such soft portions as escape 
 its influence. The patient or her friends must always be fully informed 
 of the nature and scope of the operation. 
 
CAXCEE OF THE UTERINE BODY. 
 
 371 
 
 To sum up the surgical treatment of cancer of the cervix : — 
 
 1. If diagnosed in its earliest stages, which it seldom is, remove at 
 once by the knife, cauter}', or ecraseur, as above directed. 
 
 2. In very early epithelioma, caustics, especially potassa cum calce, 
 may be tried, if the patient objects to operation. 
 
 3. If complete ablation is impossible, relieve pain, and check hsemor- 
 rhage and foetor by internal remedies and local applications as above. 
 
 4. When discharges are great, and not amenable to local applications, 
 remove fungating masses as far as possible, and return if necessary to 
 local applications. 
 
 It will be seen that I have said nothing of the removal of the whole 
 uterus. I prefer to discuss this formidable proceeding after considering 
 how cancer affects the body of the organ. 
 
 Cancer of the Uterine Body. 
 
 Cancer of the uterine body (fig. 179), when not an extension from 
 cervical cancer, is fortunately very rare, furnishing probably not more 
 than 2 or 3 per cent, of the w^hole numljer of uterine cancers, 
 although A. E. Simpson and some other 
 writers give a very much higher proportion. 
 It is a strange fact that, unlike cervical 
 cancer, the majority of cases are met with 
 in nulliparse, and this would doubtless be 
 considered as confirmatory of their opinions 
 by those who, like Emmet, trace cancer of 
 the cervix in all cases to cervical tearing- 
 after labour, although it may also, and Avith 
 naore force, be pleaded as showing that 
 uterine cancer, like all other cancers, may 
 be totally independent of any such trau- 
 matic causation. It is met with as an 
 ei^ithelioma or as a nodular encephaloid 
 infiltration, leading to a proliferating fungus 
 in the one case, or to a single or multiple 
 solid enlargement in the other. If life is Fig. 179.— Cancur of tlie Body of 
 sufficiently prolonged, there is ulcerative the Uterus affecting a large 
 
 '^ ^ * ' . portion of the mucous lining 
 
 excavation of the uterine wall, infiltration (Schrndn). 
 
 of surrounding tissues, and metastasis to the 
 
 glands or elsewhere, just as in cervical cancer. The epitheliomatous 
 fungating variety is the most common, the variety, by the way, whicli 
 is, in the case of tlie cervix, most often attrilnited to trauiuutic causes. 
 
872 SYMPTOMS, DIAGNOSIS, AND TREATMENT 
 
 Symptoms and Diagnosis. — The symptoms are those of pain, haemor- 
 rhage, foetid, discharge, uterine enlargement, and induration, and, as the 
 former three of these are generally more early developed than in cervical 
 cancer, it might be supposed that the corporeal form would be more 
 easily diagnosed. Such is not the case however, for, independently of 
 the fact that the sources of the discharge are out of reach-, there are 
 many other affections which may give rise to most or all of the same 
 symptoms, and, as many of these are exceedingly common, suspicion 
 naturally turns in their direction. An enlarged uterus, with pain, 
 haemorrhage, and foetor may mean cancer of the uterus, with which, for 
 the present, we will associate sarcoma, but it may also mean several 
 other things more frequently encountered; five especially may be noted — 
 fibi-oid tumours or polypus, chronic metritis, retained products of con- 
 ception, intra-uterine non-maliguant fungosities, and, lastly, foreign 
 bodies. 
 
 Fibroid tumours or polypi constantly give rise to all the above- 
 mentioned sj-mptoms except foetor, and even this may be present, and, I 
 think, undistinguishable with certainty from that of cancer, when 
 sloughing of the mass, or of even of a small portion of its covering, occurs, 
 or when there is prolonged retention of discharges. I can recall the 
 case of a lady suffering from fibroid tumour — as diagnosed by myself, by 
 my colleague Dr D. L. Roberts, and by a most intelligent family prac- 
 titioner. She was subsequently seen by two gentlemen, whom I should 
 regard as almost the highest possible English authorities in surgical and 
 medical gynsecology respectively, who diagnosed cancer, and counselled 
 non-interference. Yet a post-mortem examination showed that she died 
 from nature's attempt at enucleation of a fibroid. There was a cancerous 
 family history, and intensely foetid discharge towards the close; but I 
 had the advantage of seeing the case early. The only diagnostic means 
 in such a case is free dilatation of the cervix and examination of the 
 uterine wall with the finger. If a large, firm, smooth tumour is felt, the 
 chances are very greatly against its being malignant. If ulceration exists, 
 a careful examination of the discharges may aid in diagnosis. 
 
 Chronic metritis also gives rise to moderate enlargement, to haemor- 
 rhages, and often to pain, and, if there be retained menstrual products, 
 to foetor. Dilatation and digital exploration are again our sole resource, 
 and mistakes can only arise if Ave find any soft thick vegetation at any 
 point or points. This might be malignant papilloma or merely the 
 gTanulations of chronic endo-metritis, or, much more rarely, a soft 
 mucous polypus. An expert might, I think, nearly always be relied on 
 to make the diagnosis by his tactus eruditus, together with his practical 
 skill in eliminating and putting together the points in the history of the 
 case, but removal of some portion of the mass, by curette, Avill solve the 
 
OF CORPOREAL CAXCER OF THE UTERUS. 373 
 
 difficulty, if the fragment be subjected to competent microscopical ex- 
 amination. It is very easy, however, to follow the prevailing example, 
 and to speak of microscopic examination of such products as if it were 
 the simplest matter in the world, or as if an accurate knowledge could 
 be attained by the study of a few woodcuts. I believe that no reliance 
 is to be placed on examinations of the kind unless the examiner is to a 
 certain extent an expert in the making and staining of sections, and in 
 other processes which involve a degree of skill to which I fear it will be 
 very long before the average practitioner can attain. 
 
 Retained placenta or other products of conception have a history of 
 their own, which should put us on our guard ; dilatation, and examina- 
 tion of removable portions, may reveal placental or membranous struc- 
 tures or even the cj'sts of hydatiginous moles. 
 
 Foreign bodies in the uterus are rare, but I have known a portion of 
 a stem pessary, and of a broken sponge -tent, produce symptoms closely 
 allied to those of cancer. In the latter case, the foetor, after three 
 months' retention, was declared to be pathognomically cancerous. I was 
 enabled to detect the difference, not by my sense of smell, but from 
 having received the confession of the practitioner in attendance. It is 
 not the sole instance in which error has been avoided by consultation. 
 
 The diagnosis of uterine cancer from surrounding pelvic inflammation, 
 with or without abscess, should not be difficult to one who will study 
 the historical facts and make a careful bi-manual examination. The 
 combination of pain, hsemorrhage, and foetor, with uterine fixation and sur- 
 rounding nodulation, and without a very clear history of fever and inflam- 
 mation, must, in the case of pelvic inflammation, be very rare. 
 
 Treatment. — The treatment of corporeal uterine cancer, when fairly 
 developed, and that is almost tantamount to saying when rationally 
 diagnosed, is a very hopeless business. Pain may be relieved by opiates 
 or other sedatives. Hasmorrhage may be checked by swabbing with the 
 strongest astringents, or occasionally by plugging the cervix. Foetor is 
 less under conti'ol than in the cervical form, bvit may also be diminished 
 by swabbing with antiseptics, or by very careful intra-utcrinc injections 
 with a double catheter, or still better by the insertion of soluble pencils, 
 with carbolic acid, iodoform, or other antiseptics incorporated in gelatine 
 {see Medicated Tents, p. 218). The main practical question is, Can surgery 
 do anything to completely remove the disease? No liope can be held out of 
 completely renioving even a commencing malignant papilloma, or of dis- 
 secting away with the knife any suspicious undcrl3'ing infiltration. All 
 that can be done in tliis way is to give temporary relief from hemorrhage, 
 l)y scraping off with some form of curette or scoop the softest portions of the 
 sprouting mass. One procedure alone could give any hope of removing 
 the disease, — removal of tlic entire oi'gan ; and this is an operation of so 
 
374 SAKCOMA OF THE UTEEUS. 
 
 serious and so difficult a nature, so essentially modern in its rational 
 conception, and upon Avhicli there are as yet so many differences of 
 opinion, that it would be well still to delay its notice until we have 
 spoken of the remaining forms of malignant disease which may affect 
 the uterus, and which may call for the employment of such extreme 
 measures. 
 
 Sarcoma of the Uterus. 
 
 In deference to the prevailing pathology of the day, which looks upon 
 sarcoma as an affection of connective tissue, and upon cancer as an 
 affection of the epithelial element, I have separated these two affections, 
 both truly malignant when fully developed. There is, however, a vast 
 amount of confusion among our pathologists and gynsecologists as to the 
 differences or affinities which exist between carcinoma and sarcoma, and 
 the relation of each of them, in the way of evolution, to non-malignant 
 growths, is as yet almost unknown. As regards sarcomata of other organs 
 especially, I have seen many amusing differences of opinion betAveen the 
 clinical practitioner Avho removed them and the pathologist who ex- 
 amined them, differences Avhich subsequent watching of the patient 
 solved as often in favour of the one as of the other. 
 
 Speaking not as a histologist or pathologist, biit as a clinical observer. 
 who would desire all the help he can get from pathological histology. 
 I have no hesitation in saying that, when sarcoma of the uterus, ovaries. 
 or other organs, chiefly resembles clinically the fibroid or non-malignant 
 diseases of those organs, it should be treated as such, and that when it 
 clinically resembles cancer, it should similarly be treated as cancer. 
 The same remark applies to adenomata, myxomata, and other allied 
 affections, the differentiation of which, when affecting the uterus, must 
 be made rather in the dissecting-room than at the bedside. It is to be 
 hoped that a fair proportion of the future British practitioners will be 
 able to accomplish the former task, the latter Avill, I fear, long remain 
 impossible to them. 
 
 Sarcoma of the cervix, that is, non-cancerous disease of the cervix, of a 
 decidedly malignant character, tending to idceration, and extension bv 
 contiguity or metastasis, and yet of purely sub-mucous origin, is rare, 
 unless we admit our ignorance as to the difference between nodular 
 cancer and sarcoma. Sarcoma of the body of the uteriis (fig. 180) is, on 
 the other hand, more common than cancer, like which, it may appear in 
 a nodulated interstitial form, hardly differing from fibroid growths, but 
 having generally less apparent capsulation. In all clinical particulars, 
 symptoms, multiple character, or the like, sarcomata may resemble 
 fibroid tumoiirs at first, and there is the strongest possible reason td 
 
SARCOMA OF THE UTERUS. 
 
 375 
 
 believe that they may gradually become developed from true tibroid 
 growths. The development of interspaces with mucoid contents, 
 constituting myxosarcoma, is closely analogous to the formation 
 of the fibro-cystic growths. Like cancer also, sarcoma may develop 
 upon the internal wall, not with early sprouting as in the epithelio- 
 matous form of cancer, but as a swelling or protuberance very 
 like a soft sub-mucous fibroid. Microscopically it more often shows 
 the presence of the round than the spindle-shaped sarcomatous 
 histological element. The mass may to the eye resemble a pure fibro- 
 mj'oma, or may have a much softer and more encephaloid appearance. 
 Ulceration is slower and less complete than in cancer, but in some cases 
 there is little distinction 
 in this respect, and the 
 relation of the two forms 
 of disease is still further 
 shown by the occasional 
 inter-proliferation of epi- 
 thelial cells (the carcino- 
 sarcomata of Klebs). 
 Metastatic deposits may 
 take place either in con- 
 tiguity or at a distance. 
 I have seen metastatic 
 deposits of a true en- 
 cephaloid character follow- 
 ing the removal of what 
 so good an observer as Mr 
 Jonathan Hutchison de- 
 clared to be true sarcoma 
 of the testicle. I cannot 
 see how any one Avho has 
 any strong opinion on the 
 doctrine of evolution can 
 fail to see in all these 
 facts, and in spite of 
 certain specific histological differences, a gradual scale of ihnclupmenf 
 or retrogradation from the benign fibro-myoma to sarcoma, and again 
 perhaps to cancer. ^ 
 
 Symptovis. — Pain is later than in cancer, earlier and more cmuuiun 
 than in fibroids, l)ut there are many exceptions to this. Jliemorrhage 
 
 ^ If, as lias been recently suggested, fibroid growths may be jiroducts of the gouty 
 diatliesis, otiier highly suggestive evolutional hypotheses arise, ami there may yet be 
 found a rational basis for the dietetic treatment of all these atVeetions. 
 
 Fig. 180. — Sarcoma of the Body of tlie Uterus 
 (Selin.Mler). 
 
376 EXCISION OF THE UTEEUS 
 
 may be early and great, as with sub-mucous fibroids, and from the same 
 increased hypersemia. Later it may be due, as in cancer, to ulceration. 
 Foetor is less common than in cancer, but there is often the same watery 
 discharge. 
 
 Diagnosis. — Setting aside chronic metritis, and the retained products 
 of conception, of which sufiicient has been said above, the main ques- 
 tion arises. Is the disease fibroid, cancerous, or sarcomatous? This 
 cannot be always answered at once. ^Vhen ulceration has not occurred, 
 the disease mostly resembles fibroid tumour. Its softer consistency and 
 its rapidity of growth may point to the malignant type. If it assume a 
 polypoidal form, removal and subsequent examination will afford a 
 means of differentiation. The so-called recurrent polypi of some writers 
 are examples of sarcoma. When softening and ulceration have occurred, 
 sarcoma mostly resembles cancer, and a careful examination of scrapings 
 by the curette must decide, if possible, the difference ; but in all cases of 
 doubt we are driven back on the sound practical rule of treating the 
 case as we would do in fibroid or cancerous disease respectively. 
 
 Treatment. — I have nothing further to say on this head beyond what 
 is involved in the last sentence. 
 
 Excision of the Uterus for Malignant Disease. — We have already 
 spoken of removal of the uterus in the case of irreducible inversion, and 
 have expressed the opinion that it should rarely if ever be required. In 
 relation to fibroid tumours also, we have decided that various other means 
 of treatment, including removal of the ovaries, when absolutely necessary, 
 present such chances of success that the terrible alternative of removing 
 the uterus, together with an immense fibroid enlargement, should with 
 almost equal rarity present itself. Excision of the whole uterine body 
 and cervix, for malignant disease, has been recently introduced to the 
 profession by Freund of Breslau, although isolated attempts in the same 
 direction had been previously made by Santa, Blundell, Recamier, 
 Hennig, and others. The jDhysician or general practitioner will not be 
 called upon to undertake such an operation under any circumstances, so 
 that we shall not concern ourselves with the methods and appliances 
 needful for its execution. But it may fall to the lot of any one to de- 
 cide the question, yea or nay, and it is therefore desirable to obtain as 
 clear views upon the subject as are as yet obtainable. 
 
 The results, so far, are by no means encouraging. Thomas, in 1880 
 {o20. cit., p. 598), gives, quoting from Schmidt's Jahrhilcher, the results 
 of proceedings in this direction : — " Freund had performed fourteen 
 operations, with eight deaths, five recoveries, and one incomplete opera- 
 tion. Of the five recoveries one died from a return of the cancer, one 
 from pleuritis, and a third is now suffering from a return of the cancer. 
 Of the remaining twenty-five operations of which the results are known " 
 
FOR MALIGNANT DISEASE. 377 
 
 (they will certaiul}' omit few successful ones) " which have been recorded 
 by various operators, nineteen died, five recovered, and in one case the 
 operation was incomplete. Of these five successful cases, in three the 
 cancer returned." The net result in the thirty-nine cases is, that twenty- 
 seven have died from the operation, leaving twelve to account for. But 
 of these twelve, two were incomplete cases, i.e., they left the patient 
 alive, I suppose, but dying of cancer. Ten remain. Of these, one has 
 died of pleurisy. We will put her down to the credit of the operation, 
 and suj)pose that there was no septic or malignant cause for it, and that 
 she would not have had a return of the cancer. Nine remain. Of 
 these, four are known to have a return of the cancer, of whom one has 
 already died of it. Four remain, of whom all that we can say is, they 
 have not yet been reported to have died of cancer. I expected great 
 things from the discussion of this subject at the meeting of the British 
 Medical Association in August 1883, but have found nothing to alter 
 the impression conveyed by the above statistics. The discussion at the 
 Eighth Annual Meeting of the American Gjaasecological Society, held at 
 Philadelphia in September 1883, was still more antagonistic to the 
 operation. Dr Jackson of Chicago, who introduced the subject, "knew 
 of eight cases in Chicago, seven of which were fatal." Of the fatal cases 
 only one (his own) had been published. He estimated Freund's mortality 
 at more than 72 per cent., exclusive of those patients in whom the disease 
 might return [Aon. Gyn. Trans., vol. viii.). With these figures, and 
 those of Hegar, Kaltenbach, and Paggia before me, none of which are 
 more favourable, I have no hesitation in saying to the practitioner that, 
 unless he can find a patient who, on the first indication of cancer of the 
 cervix or fundus, — the latter a condition rarely diagnosed, — is bold 
 enough to run the terrible immediate risks involved by removal of the 
 whole uterus, and to shut her eyes to the almost certain return of the 
 disease, he had better leave the operation out of his calculations. No 
 general practitioner will think of performing it himself; and if he 
 wishes to know the relative disadvantages of vaginal or abdominal re- 
 moval, and the mode of avoiding fatal results by haimorrhage or other- 
 wise, in either case, he will find abundant references in the works of 
 Thomas, of Hart and Barboui", and of Schrosdcr, referred to above. 
 
 Extirpation of the whole uterus for malignant disease may become a 
 somewhat safer procedure in the future, when its indications and mode 
 of performance have been sim[)lificd and made more clear, and when we 
 have found some more certain specific against the return of the disease. 
 For the present it had better be left in the hands of those wlio may be 
 successful pioneers, but who arc not for the time being desirable medical 
 advisers. With so distingnislicd an authority on surgical gynaecology 
 as Emmet, I might well say that " we will not enter into the merits of 
 
378 HYSTERECTOMY 
 
 this operation for the removal of cancer of the uterus, or more than 
 question if any permanent advantage, on this condition, can possibly be 
 found." 
 
 Since the foregoing lines were written, I have, through the courtesy 
 of Dr Jackson of Chicago, received a full copy of his paper above 
 referred to, and I cannot resist making two very apposite quotations 
 from it. " What are the facts ? As we must all admit that, so far, no 
 remedy has been discovered Avhich has power to remove a hypothetical 
 blood poison, so it is notorious that in almost all instances in which 
 surgical operations have been done for the removal of this disease — 
 whether by knife, scissors, cautery, or caustic — they have only been of 
 temporary benefit, if beneficial at all. Nevertheless, so long as these 
 procedures were comparatively free from danger to life, so long as they 
 could not be fairly charged with doing actual harm, they were doubtless 
 proper in many cases, because they added, for a time at least, to the 
 patient's comfort. It can hardly be claimed or admitted that operations 
 for cancer in every part of the body have usually done more than this, 
 the instances in which the disease has been permanently cured, or in 
 which life has been lengthened by them, being quite exceptional. But 
 when the operations themselves become so dangerous as to destroy 
 70 per cent, of lives in a few hours or a few days; and when, of 
 the few who escape the operator, 50 to 78 per cent, die from 
 return, or rather continuance, of the disease within a few months ; and 
 when, further, of those Avho yet remain, all, or nearly all, die as soon as 
 though no operation had been performed, we may very properly cry a 
 halt, and stojD to consider whether our calling, thus exercised, is beneficial 
 or injurious." Again — " Notwithstanding the very unfavourable results 
 of excision of the cancerous uterus, can we expect that the operation 
 will be abandoned 1 I think not. Schroeder is reported to have said 
 that if the disease should return, in five cases out of six he would still 
 operate. Does any one suppose that an additional one-sixth would alter 
 his determination 1 Many other sxirgeons look upon the operation with 
 favour, and they will doubtless perform it when opportiinity offers. 
 Operations that are likely to kill are spoken of as ' brilliant,' and the 
 popular clinics are those at which the largest number are done for 
 removal of kidneys, spleen, uteri, and portions of livers, stomachs, and 
 intestines. Spectators admire and applaud, they are rarely permitted 
 to witness the quickly-following death.'' I agree with his final 
 summary. 
 
 " 1. Diagnosis of uterine cancer cannot be made sufficiently early to 
 ensure its complete removal by extirpation of the uterus. 
 
 " 2. When the diagnosis can be established, there is no reasonable 
 hope for a radical cure, and other methods of treatment, far less 
 
FOi; iMALIGXANT DISEASE. ri/i' 
 
 dangerous than excision of the entire organ, are equally effectual iu 
 ameliorating suffering, retarding the progress of the disease, and pro- 
 longing life. 
 
 " 3. Extirpation of the cancerous uterus is a highly dangerous 
 operation, and neither lessens suffering — except in those whom it kills- 
 nor gives reasonable promise of permanent cure in those who recover. 
 Hence it fails in all the essentials of a beneficial operative proceeding, 
 and should not be adopted in modern surgery." 
 
 The elaborate and exhaustive discussion on the subject of extirpation of 
 the uterus for cancer, by the British Obstetrical Societj^, is jiist concluded 
 as I go to press. It seems in every Avay to corroborate the views I have- 
 maintained. Without referring to the opinions of individual speakers, I 
 agree Avith the Avords in Avhich the Lancet (March 14, 1885) concludes 
 its notice of the debate : — " No evidence is as yet forthcoming that total 
 extirpation of the uterus for cancer of the body either prolongs life or 
 relieves suffering, Avhile, on the other hand, the mortality after the 
 operation is knoAvn to be large, and early recurrence extremely frequent. 
 The facts knoAvn unequivocally condemn total extirpation for cancer of 
 the cervix, and are decidedly unfavourable to its practice for cancer of 
 the liody of the uterus." 
 
380 PEOLAPSE OF THE OVAKY. 
 
 CHAP TEE XV. 
 
 Diseases of the Ovaries. — Prolapse. Neuralgia. Inflammation, Acute and 
 Chronic. Peri-ovaritis. Abscess. Apoplex}'. Ovarian Tumours, Solid and 
 Cystic. 
 
 I HAVE already referred (p. 135) to the congenital abnormalities of the 
 ovary, and under the heading of Infantile Utervis (p. 194) I have referred 
 to certain clinical results of their imperfect development. 
 
 Prolapse of the Ovary. 
 
 This has also been referred to (p. 8). If carefully sou^ght for by 
 bi-manual examination, the ovary, more often the left one, may not 
 infrequently be found to lie in Douglas's pouch, considerably lower than 
 is normal. 
 
 Symptoms. — In some instances this prolapse gives rise to no symptoms 
 whatever, but in others it may occasion pain in defecation, or on con- 
 nection, and now and again this state gives rise to a considerable 
 amount of sympathetic nervous disturbance. All the symptoms are, 
 however, very aj)t to vary at different periods. Once prolapsed, the 
 organ is constantly liable to hypersemia, and to temporary or permanent 
 enlargement. Most frequently this state of matters leads also to men- 
 orrhagia and dysmenorrhoea. In women who have not yet borne chil- 
 dren, there is no necessary connection with displacements of the uterus, 
 bvit in those who have, this organ is most frequently sub-involuted and 
 retroflexed. There is always a dull sickening pain when the prolapsed 
 ovary is pressed, and this, with careful re-examination, after the bowels 
 have been unloaded, will serve for its diagnosis from a fsecal nodule. I 
 have, however, known such a nodule obstinately remain after several 
 injections. The cause of displacement may be congenital or accidental, 
 and although it is met with in the vinmarried, no doubt most of the 
 cases are due to incoixqDlete recovery from the puerperal period. 
 
 The treatment of this affection will depend on whether the ovary is 
 adherent or not. In all cases, rest, copious hot vaginal injections, and 
 free but mild purgations may be tried first. If there is no adhesion, 
 
NEUEALGIA OF THE OVARY. 381 
 
 the organ may be replaced bi-manually, and in this Avay the ditliculty is 
 sometimes finally got rid of. Or the patient may be made to assume the 
 knee-breast position in bed several times a day, her clothes being loosened, 
 and air admitted to the vulva by elevation of the perineum. The result 
 Avill be the same as in the use of the duck-bill speculum, and the pro- 
 lapsed organ will roll downtvards towards the abdominal wall, and out 
 of the pelvis. Goodell sjDeaks very highly of this practice. The use of 
 a small Gariel's air-pessary for short periods will tend to render the 
 replacement permanent. In cases of adhesion, the methods used for 
 reducing hj^Dcreemia, together Avith attention to the bowels, will some- 
 times put an end to all symptoms, the prolapse remaining ; but in cases 
 of great suffering, where this does not suffice, removal of the organ may 
 become our only resource. DisjDlacement of the ovary towards and 
 through the inguinal ring, in the form of inguinal or labial hernia, has 
 already been referred to (p. 54). 
 
 Neuralgia of the Ovary. 
 
 This is a condition so often diagnosed in ordinary practice, and the 
 so-called "irritable" ovary is so frequent a subject for treatment, that 
 it cannot be entirely overlooked in our list of ovarian affections. In most 
 cases of female disease there is some undue pain on j)ressure over one 
 or both ovaries. In many this pain is almost constant, even without 
 pressure. In others it is remittent, and has all the shooting and shift- 
 ing characters of a true neuralgia. In some it is evidently the fons et 
 origo of dysmenorrhoeal suffering, and in not a few, all the nervous 
 symptoms from which the patient may suffer seem pretty clearly trace- 
 able to it, as to a reflex origin. I have no doubt that it is our deficient 
 means of investigation which compel us so often to fiill back on this 
 one ill-defined condition for diagnosis and treatment. Eemoval of the 
 ovaries has shown us that in many of these cases there is actual 
 degeneration of the tissues of the organ — slight cystic degeneration or 
 chronic fibroid contraction. In others there is doubtless hj^ersemia 
 and chronic congestion of the organ. In some we have general pelvic 
 disease, which shows itself most prominently in the most tender of the 
 pelvic contents. 
 
 No case of neuralgic or irrritable ovary should therefore be finally 
 diagnosed and treated as such, imtil every effort has been made to 
 detect something further back in the chain of causation of pain. But 
 there will remain a residuum of cases in which nothing but ovarian pain 
 can be detected. In these we must use the general treatment which 
 we would employ in any otlier form of neuralgia. We must avoid all 
 
382 ACUTE INFLAMMATION OF THE OVAEY. 
 
 the causes of pelvic congestion which are avoidable. We must beware 
 of opium. General, certainly not local, massage often acts as a charm 
 in such cases, and when we are fairly satisfied that health is breaking- 
 down, nerves are becoming a source of torment, and the mental condition 
 is deteriorating, while no other cause can be diagnosed than the wearing 
 ovarian pain, and none of the lines of treatment now indicated seem to 
 avail, we are, I think, justified in entertaining the question of removal of 
 the organs. Experience shows that this will often reveal an organically 
 diseased condition Avhen it could otherwise only be suspected. I cannot, 
 however, admit even the occasional necessity for this operation, under 
 these circumstances, without strongly insisting that every effort shotild 
 previously have been made to obtain the advice of the most competent 
 authority as to the local condition of the parts affected, and without also 
 reminding the reader that this is a very different procedure from that of 
 removing the ovaries on account of neurotic conditions, which are only 
 doubtfully traceable to ovarian causation. 
 
 Inflammation of the Ovary. 
 
 1. Acute Inflammation. — As has been stated above, many cases of 
 so-called ovarian neuralgia, especially those wdiich are associated with 
 menorrhagia, are doubtless due to -congestion or h^qDeraemia. Such cases 
 are often met with in the young and growing school-girl, whose education 
 is being conducted on masculine principles, or in the newly married. 
 These cases may insensibly merge into inflammation, although it is im- 
 possible to say how often this occurs. The removal of the causation, as 
 far as possible, is the surest method of preventing this imtoward result, 
 and I can confirm Tait's strongly expressed opinion that a great diminu- 
 tion of suffering is to be obtained from the use of ergot in continuous 
 and moderate doses, along with the administration of bromide of potas- 
 sium diu'ing the inter-menstrual period. 
 
 Causation. — Under the heading of causation of acute ovaritis we must 
 admit this chronic or intermitting hypereemia as having a predisposing 
 influence, along with other uterine or pelvic affections Avhich tend to 
 hypera^mia of the pelvic organs. The exciting causes are mainly — (1) 
 septic or contiguous inflammation after confinement ; (2) the extension 
 of o-onorrhoea or gleet ; (3) certain dyscrasial diseases, especially the 
 exanthemata and rheumatism ; (4) sudden suppression of menstruation ; 
 and (5) local injur}-, which may act either directly or by septic extension. 
 Almost everj'thing, in fact, Avhich may cause pelvic cellulitis or pelvic 
 peritonitis (q.v.) may also cause ovaritis. The great difficulty in 
 determining the real causation lies in the fact tliat ovaritis and pelvic 
 
CAUSATIOX AND SYMPTOMS. 383 
 
 iiiflammatioii are so almost universally combiiaed that their differeutia- 
 tion, or even the fact of their association, is often most difficult to ascer- 
 tain. We know not when a pelvic inflammation leads to aff'ection of 
 the ovary, or when the reverse is the case. 
 
 (1) Numerous 2)ost-7)iorte7n examinations prove the fact that the septic 
 effects of Metria or Puerperal Fever often include destructive inflamma- 
 tion of the ovary, and all analogy would tend to confirm the belief that 
 they would sometimes excite that form of inflammation which ends in 
 chronic impairment of the organ as a physiological instrument, by fibrous 
 deposit and contraction. 
 
 (2) Gonorrhoea and gleet, acting by the extension of their virus, are 
 so fully recognised elsewhere as excitants of inflammation in the uterus. 
 Fallopian tubes, and peritoneum, that no wonder need be felt that the 
 ovary often partakes in the baneful influence. That it alone, sometimes, 
 though rarely, is afiected, seems strange, but not more so than the many 
 inexplicable selections and aversions which are often shown by the same 
 or other poisons in other paints of the body. 
 
 (3) I have already referred to destruction or retarded development of 
 the ovary, during the course of scnrlatina and other zymotic diseases, in 
 the early periods of life. Acute rheumatism (and perhaps other blood 
 disorders) should be added to the list ; indeed, this affection, occurring 
 at an age when its symptoms are masked, through the want of definite 
 expression on the part of the sufferer, with its results in cardiac, renal, 
 ovarian, and nerve disease, is still in need of an expositor. At a later 
 age, we have sometimes very distinct metastasis of these affections to 
 the ovary. Mumps especiall}-, among z^-motic diseases, ought, according 
 to theory, to affect the ovary as it does the testicle. I have no proof of 
 this, however, but, on the contrary, I know of two cases where, imme- 
 tliately after ovariotomy, the patient contracted mumj)s, and where there 
 was no effect on the general symptoms, or on the remaining ovary. 
 
 (4) The sudden suppression of menstruation, however produced, can 
 be easily comprehended as a cause of sudden liyperremia, and consequent 
 inflammation of the ovai-y, or any predisposed pelvic viscus. 
 
 (5) Local injury, in the form of a blow, can rarely, if ever, affect the 
 ovary alone, but all the misuses of sounds, pessaries, tents, or even in- 
 jections or tamponings, may inflame it, in common with, or separately 
 from, other pelvic organs. The same ma}' be said of all the septic in- 
 fluences produced by the same means. 
 
 S//m2)tovis. — The symptoms of acute ovaritis arc, sudden and cinitinu- 
 ous agonising pain in the region of one, or rarely of both, ovaries. There 
 is often great anxietas, and lying on the back is es})eciall3' painful ; 
 together with this, there may or may not be dysuria and painful defeca- 
 tion. On examination, wliirli will often be so painfid as to reijuirc 
 
384 ACUTE 0VAr;iTis, diagnosis axd teeatmext. 
 
 ansesthesia, the swollen organ is distinctly to be made out, and if 
 ansestliesia is not used, it is found to be intensely painful to touch. 
 
 Diagnosis. — The symptoms above given do not enable lis with any 
 certainty to differentiate ovaritis from inflammation of the suiToimding 
 parts, nor are the physical signs very conclusive. The unilateral pain 
 and swelling, when well marked, are distinctive from metritis or pelvic 
 peritonitis, but they are equally met with in pelvic celkilitis, and, apart 
 from the fact that some measure of this generally coexists with ovaritis, 
 the differentiation is difficult, and often impossible. If the painful 
 swelling is clearly separate from the uteiais, and especially if it is mobile, 
 we may be fairly certain that it is mainly ovarian or Fallopian, rather 
 than cellular, while, if it is diffused, and renders the uteiiis immobile, 
 we may safely pronounce in favour of the cellular tissue as the principal 
 element involved. 
 
 Treatment. — As long as antiphlogistic remedies remain upon our list 
 they will be required here to their fullest extent. Light warm poultices 
 to the hypogastrium, leeching of the perineum or inguinal regions, and 
 full doses of opium are necessary, and will give great relief. Afterwards, 
 bhsteriug of the ingoinal regions, by strong iodine liniment or other- 
 wise, has a positive effect, explain it as we will. The rectum furnishes 
 a useful means of treatment, by suppositories of opium and belladonna. 
 It should be gently unloaded by warm water enemata, when ascertained, 
 per vaginam, to contain feecal masses, but purgation is otherwise \erj 
 undesirable, as it is in all acute pelvic or abdominal inflammations. 
 
 2. Chronic Infianunation. — Chronic inflammation of the ovaries is an 
 affection much more common than the acute disease, yet, owing to 
 various circumstances, its accm-ate differentiation is stiU more difiicult. 
 Neuralgia, or mere hj'persemia, and chronic inflammation, shade so 
 insensibly into one another, and chronic inflammation of the sui-rounding 
 tissues is so common an accompaniment, that in many instances we 
 must regulate our treatment under a certain amount of doubt. 
 
 The symptoms are those of chronic and wearing pain in the ovarian 
 reoion ao-o-ravated for the most part at the menstrual period, and often 
 showino-, as pointed out by Priestl}', a marked exacerbation midway 
 between the periods. The left side is by far the most commonly 
 affected, owing probably to the differences in the ovarian veins for- 
 merly mentioned, and also to the disturbing influences of the rectum 
 and sigmoid flexure. The pain is generally increased by standing, or 
 by locomotion, by sexual intercourse, defecation, or digital examina- 
 tion. It may shoot in various directions, — down the thigh, into the 
 rectiim, or elsewhei-e. Contraction of the lower abdominal muscles of 
 the affected side is common, and renders palpation more difiicult, while 
 it protects the tender organ. Disordered mensti-uation, especially dys- 
 
CHKONIC OVARITIS CAUSATION AND DIAGNOSIS. 385 
 
 menorrliooa oi- menorrhagia, is seldom entirely absent. Sympathetic pains 
 may occur in all parts of the body, — ^in the breast, head, or elsewhere, — 
 and changes very similar to those of pregnancy are sometimes found in 
 the former of these organs, while tissue changes may arise from the 
 reflected nervous condition thus occurring. Galabin goes the length of 
 saying that such changes are the usual cause of non-traumatic cancer of 
 the breast. Hysteria, in its manifold forms, and graver neurotic diseases, 
 such as epilepsy, hystero-epilepsy, paraplegia, or even mental derangement, 
 are occasionally undoubted results of the prolonged pain, malnutrition, 
 and general irritation of chronic ovaritis, but the greatest caution is 
 necessary in assuming their relations as cause and effect. In one instance, 
 of which I am aware, a dose of male-fern forestalled the intended opera- 
 tion of removal of the ovaries. Prolapse of the ovary is often discovered 
 in this affection, and assists materially in the diagnosis. Chronic ovarian 
 inflammation is apt, like that of most other viscera, to be followed by 
 a cirrhotic condition, which often leads to symptoms very similar to 
 those afterwards described as accompanying cj'^stic degeneration. 
 
 Causation. — Chronic inflammation may result from so many, and 
 often from such obscure, causes, that I may simply refer the reader again 
 to those of acute ovaritis. The normal periodic hypersemia, when 
 exaggerated from any cause, all morbid conditions of the uterus or pelvis 
 which lead to frequent or constant congestion, the abuse, and, according 
 to Duncan, the moderate use of alcohol, and all undue excitement or 
 abuse of the sexual functions, may be added to the category. 
 
 Diagnosis. — The lines which this must follow are already sufiiciently 
 indicated. Careful local examination must differentiate uterine disease, 
 which is frequently accompanied by pain in the groin. Neuralgia must 
 be assumed where the subject is a likely one, and when distinct ovarian 
 enlargement cannot be made out. Hj'peraemia is undistinguishable, 
 except by a continued observation of the case, and of its obedience to 
 anti-hyperajmic remedies. The differentiation of Fallopian enlarge- 
 ments and congestion is as yet in its infancy. It will be referred to in 
 Chapter XVIII. The physical signs given under acute ovaritis are 
 equally serviceable here to differentiate pelvic inflammation. The early 
 stages of cystic or other degenerations of the ovary arc hardly dis- 
 tinguishable. In the absence of clear signs of abscess of the ovary 
 (q.v.), it is, I think, impossible to distinguish between those forms of 
 chronic ovaritis where there is follicular inflanunation with or without 
 purulent results, and those where there is chiefly fibroid increase as well 
 as contraction, with or without cystic degeneration. The patliology of 
 the whole subject is only in course of investigation, and hardly as yet 
 possesses great clinical significance. 
 
 The treatment of chronic ovaritis is spoken of almost lK)i)clcsely by 
 
 2b 
 
38(5 CHKONIC OYAEITIS TEEATMENT. 
 
 most of our authorities, except by those who advocate ablation of the 
 organs. Judging from hospital experience alone, I shoiild be inclined 
 entirely to agTee with them ; yet in those cases where the patient can 
 and will submit to the necessary restraints or conditions, permanent 
 su.ccess by curative measures might, I think, be frequently claimed. The 
 key-note is to try to investigate as far as possible the neuralgia, or hyper- 
 semia, or surrounding inflammatory accessories or features of the case, 
 so that those means of treatment which specially bear on these condi- 
 tions may be prominently insisted upon. When the neuralgic or even 
 the nervous element seems to predominate, much may be done by the 
 early adoption of rational employment or educational occupations. 
 Standing, working, or studying, in greater moderation, and with due regard 
 to periodic rest, w^ould prevent or cure many cases in the young. The 
 constant use of the treadle sewing-machine, harmonium, itc, should 
 also be avoided. Tonics, bathing, change of air, and the like remedies, 
 are often as effectual as they are imperatively required. Physiological 
 rest of the sexual organs is as necessary in the married. When hyper- 
 semia seems to predominate, the use of mild laxatives, of bromide of 
 potassium, of ergot, as before-mentioned, in the yoimger subjects, and 
 of glycerine plugs and hot- water injections in the married, j)roduce 
 beneficial results almost as marked as in uterine disease. The remedies 
 somewhat empirically prescribed above for neuralgia or congestive dys- 
 menorrhoea, or menorrhagia, ma}- be again referred to. In cases where 
 exudation in or ai'oimd the ovary is suspected, or clearly diagnosable, 
 iodide of ]3otassium or bichloride of mercury sometimes works like a charm. 
 There is no denying the fact, however, that under the most favourable 
 conditions, many cases of chronic ovaritis defy ouv attempts at any- 
 thing more than temporary relief, and that removal of the affected organ 
 may be fairly taken into consideration. I have studied a good many 
 statistics, favourable and unfavourable, together with the history of 
 several cases of operation for chronic inflammation known to myself, and I 
 have looked at the matter also from a theoretical point of view, with the 
 result that the operation is, in my judgment, infinitely more dangerous 
 than when performed for haemorrhage from fibroid disease of the utenis, 
 — ^the diagnosis being always open to uncei'tainty, the presence of 
 slumbering pelvic celkilitis being always probable, and the difliculty due 
 to extensive adhesions being always equally probable. . I am satisfied 
 also that the number of unpublished fatal cases is very great. I have 
 only thrice felt justified in recommending the operation for this affec- 
 tion. In one case the patient died, almost a happy release; in the 
 second she recovered, but is now again suffering from what I shoiild 
 diagnose as " chronic ovaritis," if I did not know that there is no ovary. 
 The third has sought and obtained corroboration of the advice from three 
 
PEKI-OVAEITIS ABSCESS OF THE OVARY. 387 
 
 of our most distinguished British ovariotomists, but meanwhile has added 
 another baby to the population, and has recovered from her symptoms. 
 I do believe that a certain small number of cases are suitable for this 
 operation, but I also believe that the very highest diagnostic skill, and 
 extreme urgency in the symptoms, can alone justify it at the present 
 time. Operation merely on account of the nervous affections accom- 
 panying or supposed to proceed from ovaritis, must be justified or con- 
 demned on wider grounds. 
 
 Peri-Ovaritis. 
 
 This is a term in such frequent use that I cannot avoid introducing it 
 here. But it is merely to be regarded as an expression which conceals 
 our ignorance of the real pathology of the case. Inflammation about 
 the ovary may mean either an extension from its substance to its cover- 
 ing, or from its surroundings to itself, and it includes both the peri- and 
 the para-, the peritoneal and the cellular elements, which are to a cer- 
 tain extent distinguishable in pelvic inflammations. If inflammation 
 nhout the ovary can be diagnosed as separate from ovaritis, Ave have 
 simply pelvic peritonitis or pelvic cellulitis to deal with, and these will be 
 discussed in a succeeding chapter. 
 
 Abscess of the Ovary. 
 
 This affection, as distinguished from suppuration occin'ring in ovarian 
 cysts, is comparatively rare, and our present powers of diagnosis again 
 fail us, for we can seldom differentiate it from abscess of the pelvic 
 tissues, or within the Fallopian tubes. It would be a great advantage 
 if we could do so, for it would lead to mv;ch earlier interference, either 
 by aspiration or by abdominal section, the wall tif the suppurating 
 ovary, or of a Fallopian abscess (pyo-salpynx), being much more apt to 
 burst into the peritoneum, and so produce fatal i^eritonitis, than the 
 thickened lymph which surrounds a pelvic abscess. Acute or chronic 
 ovaritis may, either of them, bo followed by abscess, and the occurrence 
 of rigors, very high night temperatures, and obscure fluctuation, will 
 point to tlic probability of suppui'ation. No doubt ovarian abscesses 
 occasionally find their way into the rectum, vagina, or bladder, but in 
 such cases they can rarely be distinguished from the products of pelvic 
 inflammation. All that I can say with regard to treatment is this, that if 
 we are convinced that abscess exists in the ovarian region, and if there 
 has been reason to suspect ovaritis previously, no time should be lost in 
 
388 OVARIAN APOPLEXY, 
 
 pursuing active treatment. Aspiration per vaginam with a very fine 
 trocar will satisfy us as to the purulent nature of the contents ; and if 
 the cavity rapidly fill again, an exploratory abdominal incision, with a 
 view to removal or other treatment of the suppurating sac, will be 
 justified in proportion to the extent of our confidence as to the strictly 
 ovarian or Fallopian origin of the swelling. 
 
 Ovarian Apoplexy. 
 
 Every time an ovum is thrown off there occurs a small apoplectic 
 effusion into the Graafian vesicle, and this may increase to such an 
 extent as to become a pathological phenomenon. Dilatation of the 
 cavity may occur, to the size of a small apple, and rupture may then 
 give rise to a not very uncommon cause of pelvic haematocele. Or an 
 ovary which is already subject to cystic disease may, through rupture of 
 a cyst wall, become affected with apoplexy, independently of the 
 menstrual hyperaemia, and this may also burst into the peritoneal cavity. 
 Farre and other pathologists consider that some cases of persistent 
 ovarian cysts are due in their commencement to an apoplectic discharge 
 of the former character. Looked at from the clinical point of view, 
 ovarian apoplexy may be encountered in one of two forms. In the 
 first, we have, at a menstrual period, sudden and severe pain in one 
 ovary, with a certain amount of shock and no rise in temperature. 
 Examination may divulge a soft, fluctuating, isolated tumour in the 
 region of the affected organ. Under these circumstances, hsemorrhage 
 is to be strongly suspected, and every effort must be made by rest, cold 
 applications to the abdomen or vulva, and avoidance of careless manipula- 
 tion, to restrain the apoplectic flow and prevent rupture. In spite of the 
 fact that a minute rupture does necessarily occur when the ovum is 
 discharged, these means seem occasionally to be effective in preventing its 
 extension, and it appears very probable that in many cases we have some 
 form of abortive ovulation without rupture. In the event of gradual 
 although tolerably rapid disappearance of the unilateral swelling, the diag- 
 nosis may be considered to have been confirmed. In the second clinical 
 form rupture occurs as an early, if not the first, symptom, and Ave have still 
 more collapse, symptoms of loss of blood, and ultimately all the physical 
 signs which will be described as characterising pelvic hsematocele. If 
 ovarian cystic degeneration has been previously ascertained, or if the 
 event occurs during menstruation, the ovarian origin of the hsematocele 
 will be highly probable. It must certainly be entertained in trying to 
 arrive at some conclusion as to causation, but the further consideration 
 of the untoward symptoms and of their treatment can only be fitly 
 undertaken when speaking of hsematocele {see Chap. XIX.). 
 
OVARIAN TUMOURS, 389 
 
 Ovarian Tumours. 
 
 The pathology of these growths has now for several years occupied a 
 raost important place in medical literature. Through their study much 
 light is being thrown upon the pathology of other organs of the body, 
 and the means of diagnosis are also being rapidly increased, with the 
 result of still further improvements in the success of that most brilliant 
 of modern surgical proceedings — ovariotomy. To attempt anything like 
 a complete resume of what has been done in this matter, would be 
 entirely beyond the scope or special limitations of the work. All that I 
 can do is to give such a description of the ordinary forms of ovarian 
 growths as will serve to render diagnosis secure, and to decide the 
 question and methods of operation. 
 
 The literature of the subject is immense, but the English student will 
 find all that he requires, or references to all, in the following works : — 
 Sir T. Spencer Wells, On Ovarian and Uterine Tumoiint, Churchill. 
 1882; Lawson Tait, Diseases of the Ovaries, Cornish, 1883; AVilson 
 Fox, " On Cystic Tumours," Med. Chir. Trans., vol. xlvii. page 227 ; 
 Cullingworth, " Solid Tumours, The Literature of," Obstetrical Trans- 
 actions, vol. xxi. page 276 ; Eisner "On Dermoid Cysts," Dublin Jour, 
 of Med. Science, vol. Ixxiii. page 376, 1882; Garrigues, "Contents of 
 Ovarian Cysts," Am. Jour, of Obstet., vol. xxv. page 1 et seq. ; Harris 
 and Doran, Jour, of Anat. and Phys., vol. xv. 1881 ; and Clinical and 
 Pathological Observations on Tumours of the Ovary, cCt., by Alban 
 Doran, 1884. 
 
 It is desirable, for practical reasons, to separate the tumoiirs of the 
 ovary into (A) the solid, and (B) the cystic forms, although this involves 
 the abandonment, in a certain sense, of the division between malignant 
 and non-malignant types, and leads to other pathological heresies. 
 Atonement will, as far as possible, be made for this in the course of our 
 observations. 
 
 (A.) Solid Ovarian Tumours. 
 
 Solid tumours of the ovary may be divided into (1) the fibroid or 
 non-malignant ; (2) solid sai-comata ; and (3) solid cancerous growths. 
 
 It is noteworthy in this connection that, according to Klein and Alban 
 Doran, the ovary contains fibrovis connective-tissue, non-striped muscle, 
 spindle-shaped cells which arc probabl}' rudimentary types of connective 
 tissue, and cells of more or less epithelial character, independently of its 
 follicles and blood-vessels. Hence these are all the elements required 
 for the development of fibroma, myoma, sarcoma, and cancer. 
 
 Tubercle, encliondroma, and some other more rare aifcctions are not 
 of sufficient clinical importance to require notice here. 
 
390 
 
 SOLID TUMOURS OF THE OVARY. 
 
 1. Fibroid Tumours. — The very existence of such a thing as a non- 
 mahgnant sohd fibroid of the ovary is denied by many, and undoubtedh' 
 it is rare. But that a slow-growing sohd mass (fig. 181), undistinguish- 
 able by the eye from a fibro-myoma, or fibroid of the uterus, may occupy 
 the place of one or of both ovaries, and that it may be removed without 
 recurrence, is an established fact. I have now thrice removed such 
 tumours myself, and CuUingw^orth (loc. cit.) has fully placed the fact 
 on record by reference to a somewhat extensive literature. It is true 
 that histologists are somewhat in doubt as to the true nature of some of 
 those tumours which have been submitted to them. They recognise a 
 large basis of true fibro-myomatous tissue, but they are apt to find 
 aberrations from this type presenting round or spindle-shaped cells of 
 sarcoma, especiall;f the latter, which bring the tumours within the 
 
 range of the malignant type. On 
 the other hand, two tumours which 
 I presented to the Manchester 
 Medical Society in 1879, which 
 were as hard, firm, and glistening 
 white as any uterine fibroid, but 
 which, in deference to the general 
 opinion of ovarian pathologists, 
 and from the fact that they Avere 
 accompanied by much and fre- 
 quently recurring ascitic fluid, I 
 termed sarcomata, were shown by 
 my colleague, Dr Dreschfield, to 
 contain only the normal fibro-myo- 
 matous tissue, and the patient 
 from whom they were removed is 
 now alive and well. I have already expressed my opinion that the 
 evolution of sarcoma from normal fibroid tissue requires further 
 investigation, but I have no hesitation in saying that a smooth, 
 solid growth may arise in the ovary, may slowly increase, as a uterine 
 fibroid increases, even to a considerable size, may give rise to ascitic 
 accumulation, as a uterine fibroid occasionally though rarely does, and 
 may be removed with a fairly confident expectation that there will 
 be no return. These masses present somewhat of the contour of 
 the normal organ, and they have generally a very distinct pedicle. 
 Three large tumours of the kind which I have removed from two 
 patients had each of them pedicles not larger than the little finger. 
 It is noted by Doran that the ovarian ligament is often much 
 thickened in cases of fibroid of the uterus, as well as ni similar 
 disease of the ovary. 
 
 Fig. 181. — Myoma of the Ovary (Doran). 
 
FIBROIDS SARCOMATOUS AND CANCEROUS. 391 
 
 2. Solid Sarcomata, as already mentioned, are not very distinguish- 
 able clinically from solid fibroids. They are perhaps hardly so firm in 
 texture, even when of the spindle-celled and most common variety, and 
 when the round cells predominate, or still more in alveolar sarcoma, 
 they are certainly softer. It is the after-history, the occurrence of 
 secondary deposits and marasmus, which would chiefly difi"erentiate them, 
 but the doubtful nature of their malignancy before removal, and the 
 freedom from return which so often follows the removal of apparentlj- 
 true sarcomata, forbids us absolutely to decide their nature in this way, 
 by a waiting process. 
 
 3. Solid Cancerous Tumours. — Cancer of the ovary also, may occur as 
 a solid mass covered Avith the same smooth wall as fibro-myoma or 
 sarcoma. The almost constant coexistence of ascites cannot alone be 
 taken as a distinguishing feature of such growths ; but the very rapid 
 growth of the mass, the greater accompanying pain, the cancerous 
 history, or the marked cachexia (when present), and the tendency to 
 become speedily fixed to the surrounding parts, are suflicient to place us 
 on our guard in the matter of diagnosis and prognosis. Fowlis {Brit. 
 Med. Jo^ir., 1878) has shown that, in cases of malignant disease of the 
 ovaries or abdominal organs, we may often detect certain characteristic 
 cell-groups in the ascitic fluid surrounding them, but I am not 
 aware that he has shown this phenomenon to exist in the case of a solid 
 ovarian malignant tumour which had not begun to sprout beyond its 
 coverings, or to become attached to surrounding parts. Although such 
 liberated cells may wander about, bacteria fashion, in search of new 
 fields of growth, it has j-et to be shown that they can perforate 
 the wall of a free ovarian mass. Cancer is also found, when a primary 
 iiflfection, as a spi-outing cauliflower-like mass developing on the surface of 
 the slightl}' enlarged ovarj- and remaining for a time unattached to the 
 surrounding parts. Such a mass, with its inevitable ascitic accompani- 
 ment, could hardly be diagnosed from peritoneal cancer. I was once 
 induced to make an exploratory incision in such a case, and was fortu- 
 nate enough to find it free from adhesions, but the patient died on the 
 third da}^ from septicsemia; the pedicle showed, on post-morte7)i examina- 
 ti(3n, no trace of cancer, although I doubt not that ere long there would 
 have occurred a return of the disease, as liappens in the form of papillo- 
 matous disease which, as we shall see, is frequently met with in con- 
 nection with cjata of the ovar}-. 
 
 The diagnosis of solid ovarian tumours presents considerable dilficulty. 
 The clinical points of diff'erence between those wliich are practically 
 l)enign and those which are malignant have been already referred to. 
 The presence of ascites is common to each, and is in no way difibrenti- 
 ating, although its absence is opposed to the iilea of malignancy. Free 
 
392 
 
 DIAGNOSIS OF SOLID OYAKIAN TUMOURS. 
 
 mobility of the mass is strongly in favour of its non-cancerous character. 
 but it is more liable to be impacted within the pelvis than a uterine 
 fibroid. This is especially the case when both ovaries are affected, as 
 they frequently are. 
 
 But the greatest difficulty lies in differentiating a solid growth of the 
 ovary from a uterine fibroid, and yet the diagnosis is of great import- 
 ance, for while, as we have seen, the uterine fibroid is reluctantly 
 attacked by operation, the solid ovarian tumour nearly always demands 
 removal. Its tendency to malignancy, its almost constant accompani- 
 ment by ascites, which returns after tapping, and the comparative safety 
 of its removal, all point to this. I give briefly, and in tabular form, the 
 distinguishing points : — 
 
 Solid Ovarian Tumour. 
 
 1. Site. — This is lateral in all cases, 
 but may be bi-lateral. 
 
 2. Mobility. — In the earlier stages this 
 is perfect; later on the brim of the pelvis 
 may fix the tumour, or, especially if 
 malignant, it may contract adhesions. 
 
 3. Bate of Growth. — Comparative 
 rapidity is the rule, slowness the excep- 
 tion; the infrequent fibroid cases do not 
 invalidate this rule. 
 
 4. Pain. — Setting aside that which is 
 due to pelvic incarceration, pain is the 
 rule ; absence of pain is, however, a 
 tolerably frequent exception. 
 
 5. Disorder of Menstruation.- — Diminu- 
 tion or suppression of the discharge is 
 the rule. 
 
 6. Leucorrlicea or Offensive Discharges. 
 — These are absent unless uterine disease 
 coexists. 
 
 7. Pressure symjjtoms on nerves, vessels, 
 bladder, or rectum may or may not be 
 present. 
 
 8. Ascites is a very constant accom- 
 paniment. 
 
 9. Physical State of the Uterus. — The 
 cervix is normal in form unless cervicitis 
 coexists. The whole organ is normal in 
 length, as ascertained by the sound. Its 
 normal contour can generally be made 
 out bi-manually alongside of the tumour, 
 and it may be possible to isolate it from 
 
 Uterine Fibroid Tumour. 
 
 1. Site. — This is often central, but 
 may be lateral or even bi-lateral. 
 
 2. Mobility. — This corresponds with 
 that of the uterus ; very large fibroids 
 may be fixed, subserous ones may be very 
 mobile, but, when moved by abdominal 
 palpation, they carry the uterus with them 
 more distinctly than ovarian growths. 
 
 3. Pate of Groivth. — Slowness is the 
 rule, rapidity the exception. 
 
 4. PfiMi..— Fibroid growths of the 
 uterus are for the most part painless, 
 except from incarceration or by the pres- 
 sure they may cause ; there are, however, 
 exceptions. 
 
 5. Disorder of Menstruation. — Menor- 
 rhagia or metrorrhagia is the rule. 
 
 6. Leucorrhcea or Offensive Discharges. 
 — The former is often present, the lattei- 
 occasionally, owing to retained uterine 
 discharge. 
 
 7. Pressure symptoms may or may not 
 be present. 
 
 8. Ascites is very rare. 
 
 9. Physical State of the Uterus. — The 
 cervix may be normal in form, or, if the 
 fibroid is interstitial or submucous, it 
 may be shortened or abolished, forming 
 part of the mass. This in itself would be 
 entirely differential, but it does not occur 
 in sub-peritoneal fibroids or those whose 
 
TREATMENT OF SOLID OYAKIAX TUMOUES. 393 
 
 the tumour, although it is often displaced site is in the fundus. The cavity of the 
 laterally, backwards, or forwards. whole organ is generally increased in 
 
 length, and it is difficult or impossible to 
 separate the uterus bi-manually from the 
 tumour. This can only be done in the 
 case of sub-peritoneal growths with a fine 
 pedicle and without accompanying inter- 
 stitial growths. 
 
 There is hardly a single point in the above diagnostic table which it 
 would not be possible to criticise adversely. Yet, taken en hloc, these 
 furnish our sole means of diagnosis between uterine fibroids and solid 
 ovarian tumours. I would endeavour to give a more practical value to 
 the whole by saying that if a smooth rounded solid tumour can be felt 
 above and beloAV the pelvic bi-im, if it is accompanied by ascites, if the 
 cervix uteri cannot be distinctly traced into it, as a part of it, and if 
 pain and pelvic pressure symptoms are continuous, we are justified in 
 regarding it as a probably ovarian solid tumour, and in making an 
 abdominal incision for its diagnosis or removal. The diagnosis and differ- 
 entiation of pregnancy, normal and extra-uterine, are sufficiently dwelt 
 on elsewhere, and any other points in connection with the diagnosis of 
 solid ovarian tumours will be more fully introduced when considering 
 the diagnosis of the much more common cystic forms. 
 
 Treatment. — As there is no known method of influencing these growths 
 by medicinal means, treatment resolves itself into removal or expect- 
 ancy. There are no facts on record, so far as I am aware, which 
 demonstrate any tendency towards spontaneous cure, such as those met 
 with in the case of uterine fibroids, iinless an occasionally recorded case 
 of partial calcification can be taken as showing such a tendency. The effect 
 of the menopause upon them is not certainly known, bitt, owing to their 
 frequently malignant character, is probably adverse rather than otherwise. 
 On the other hand, there is abundant evidence of continuous growth, of 
 increasing severity of symptoms, and of frequent liability to malignancy. 
 Such being the case, removal by abdominal incision (ovariotomy) is 
 advisable in every instance. Two circumstances alone should lead to 
 hesitation, — doubt as to the diagnosis and certainty as to malignancy 
 and pelvic adhesion. A preliminary tapping of the accompanying ascites 
 is perfectly justifiable, and very frcquentl}- most desirable. An examina- 
 tion of the ascitic fluid, and a careful re-examination of the mass in its 
 absence, tend materially to render certain our diagnosis ; but as soon as 
 we are satisfied that the tumour is not uterine, or even when in doiibt 
 on that point, if ascites return, an abdominal incision should be i-ecom- 
 mcnded, for the jDurpose of removing any diagnostic doubt, and of 
 excising tlie tumour when possible. In connection with this, I should 
 mention a fact which 1 Iiope ere long to elucidate more fully, viz., that 
 
394 CYSTIC OVAEIAN TUMOUES. 
 
 the opening of the abdominal cavity, and the exposure of irremovable 
 malignant growths within it, along with a thoroughly antiseptic washing 
 of the peritoneum, have several times been followed, in my experience, by 
 remarkable subsequent retardation in the growth of the malignant mass. 
 One such case I should now like to put upon record. L. J. W., a mill- 
 worker, was confined at Middleton, on December 9, 1883. I saw her next 
 day on account of what was supposed to be an extra-uterine foetation. 
 There was a tumour on the right side, resembling in many respects a 
 full-grown foetus. No tumour had existed before impregnation. A 
 month afterwards she was sent to me at the Manchester Royal Infirmary. 
 The tumour had then doubled in size, and at the earnest request of her 
 friends I made a free abdominal incision to make sure of its nature. I 
 thus exposed, in the presence of several of my colleagues, an immense 
 cancerous growth, the existence of which we never doubted, and with 
 the adhesions of which I took care not to meddle. The wound was 
 stitched. JSTo febrile sj'mptoms followed, and the patient went home to 
 die. Six months afterwards I heard that she was alive and fairly well 
 in health; and on March 10, 1885, Mr Stelfox, of Middleton, writes 
 me : — " She is attending to her household duties and in fairly 
 good health ; the ■ tumour has lost that peculiarity of outline Avhich 
 caused me to suspect extra-uterine pregnancy, and now presents to the 
 touch a firm, painless, and slightly movable mass. A second tumour, 
 or a subdivision of the primary one, situated in the left side of the 
 abdomen, is freely movable." This is not the ordinary course of un- 
 touched intra-peritoneal cancer, and the case is by no means unique 
 after abdominal section, otherwise I would not have reported it here so 
 fully. The whole subject of ovariotomy and of exploratory incision is, 
 however, discussed further on. 
 
 (B.) Cystic Ovarian Tumours. 
 
 Cystic affections of the ovary are infinitely more common than solid 
 ones, as a moment's consideration of the anatomy and functions of the 
 organ would lead us to expect. Even in very early infancy cystic en- 
 largements are often found, most of which probably ultimately disappear, 
 by rupture or otherwise, but in rare instances they become the site of 
 large cystic growths, such as we find in the adult. As a rule, however, 
 persistent cystic growths are a product of maturity. Looking at them 
 from the clinical rather than the pathological point of view, althoiigh T 
 trust not Avithout due regard to the latter, the following classification 
 seems to be desirable : — 
 
 1. Ovarian follicular degeneration. 
 
 2. Dermoid cysts of the ovary. 
 
CYSTIC OVAEIAN DEGENERATION. 395 
 
 3. Unilocular ovarian cysts. 
 
 4. Multilocular ovarian cj'sts. 
 
 5. Malignant ovarian tumours of cystic character. 
 
 I do not adopt the term " adenoid " as applied to any of these growths, 
 although it is most convenient to the pathologist, and adopted by such 
 authorities as Sir Spencer Wells and Mr Lawson Tait. If, according to 
 Wells, it is applicable to all tumours " composed of gland structure hi 
 variously altered conditions," or, according to Tait, it " classes them 
 with reference to the tissue from which they originate," " without giving 
 any theoretical explanation of their formation," it is so vague a term, and 
 so inclusive, as to be altogether useless. In fact, the latter writer says : — 
 " All non-cancerous tumours of the ovary are, therefore, adenoid ; " and 
 again, " cancerous growths, on the other hand, introduce tissue which is 
 either not found in the gland normally, or they produce it in a form 
 which is immature " {loc. cit., p. 137). This almost admits that, like 
 the rest, they may originate in, or be composed of, immature gland 
 tissue. 
 
 1. Follicular Ovarian Degeneration.— Under this title I wish to 
 indicate a t^-pe of ovarian disease to which attention has been much 
 turned during the last few years. Strictly speaking, the word " tumour " 
 is not applicable to it, for the ovaries maj'- be no larger or even less than 
 normal, although completely destroyed by cystic disease ; in other cases 
 there is considerable enlargement. De Sinety and other foreign writers 
 speak of cystic ovaries, in opposition to the term cysts of the ovary. The 
 ovary is perfectly recognisable as an organ, although its normal tissue is 
 almost entirely replaced by numerous small hypcrtrophicd glands or 
 follicles, or by a smaller number of larger size. It may be a pathological 
 error to classify these cystic degenerations separatcl}', as they no doubt 
 sometimes shade off into those larger growths which almost destroy the 
 ovarian identity, and which are included in our other classes. Biit, 
 clinically, they form a distinct group. Although not as a rule giving rise 
 to large tumours, with all the consequent signs and symptoms thereof, 
 they seem to play a very important role in the production of other 
 ])henomena of disease. It is now, T believe, generally admitted that a 
 very large proportion of tlie ovaries which have been removed, not 
 as tumours, but for relief of tlie hremorrhage from uterine fibroid 
 tumours, have been affected in this way. This latter ftxct justifies us in 
 placing them in a separate category ; for every ovariotomist knows that, 
 in spite of this frequent connection witli filtvoid tumours, it is tlie rarest 
 thing possible to find a real ovarian tinnoui- (•iniil)iiie(l with a large 
 uterine fil)roi(l, — certainly much more rare than it would be if these 
 " cystic ovaries " were merely the child-parents of ovarian cystomata. 
 Moreover, in cases of severe and incurable menorrhagia, (luitc indc- 
 
396 DERMOID CYSTS 
 
 pendent of fibroid uterine tumour, when the ovaries have been removed 
 as a last resource, this cystic condition is found to exist as almost cer- 
 tainly the cause of the symptoms. Now, in the early stages of true 
 ovarian tumours, we do not meet with menorrhagia or metrorrhagia as 
 a symptom, — another strong reason for classifying these abnormal de- 
 generations in a category by themselves. Althou.gh Fox, Rokitansky, 
 Ritchie, Duncan, De Sinety, and many other observers have described 
 these morbid structures, Tait has chiefly insisted on their practical bear- 
 ings {op. cit., p. 113 et seq.). Considering how strongly he maintains 
 their effect in producing menorrhagia, I should like much to know 
 whether he does not consider that this has a tendency to modify his 
 views upon the subject of ovarian stimulation in ordinary menstruation. 
 It may, therefore, be considered that this is a type of cystic disease of 
 the ovary which tends, not so much to produce enlargement as to de- 
 stroy or pervert the function of the ovary, and to absorb by pressure 
 its remaining tissue. This form of disease should be borne in mind in 
 every obstinate case of menorrhagia, in every supposed neuralgia, or 
 hypersemia, or chronic inflammation of the ovary, and must weigh 
 with us in deciding the important question of removal in such cases. 
 These growths are very liable to contract adhesions, and there is reason 
 to think that their follicles often rupture, producing slight attacks of 
 pelvic haematocele or inflammation. 
 
 As regards the question of diagnosis, I fear we have no other test than 
 is to be found in the existence of some enlargement, combined with the 
 presence of some of the hsemorrhagic or dysmenorrhoeal conditions just 
 alluded to, and that we can only check the hypothesis thus arrived at 
 by patient attempts at cure. The next decade will probably bring about 
 something of a more certain and satisfactory character on these points. 
 
 The treatment of follicular ovarian degeneration can hardly as yet be 
 considered, then, per se. It must rather be said to constitute an ele- 
 ment in deciding the question, Shall we remove the ovaries for the pur- 
 pose of curing certain afi'ections which it so frequently accompanies, and 
 of which it may be the efiicient cause 1 
 
 2. Dermoid Cysts. — These are growths, always of a cystic character, 
 most commonly of ovarian origin, although occasionally found in every 
 part of the body, and so peculiarly distinguished, physiologically, patho- 
 logically, and clinically, that no one can dispute their claim to a separate 
 classification. A very good sketch of the history and literature of the 
 subject will be found in a paper by Eisner {loc. cit.). Their distin- 
 guishing feature is that they are found to contain hair, teeth, atid other 
 dermoid structures — -whence their name. But true bony tissues, brain 
 matter, muscular fibre, and other structures have also, though more 
 rarely, been discovered. 
 
OF THE OVAKY. 397 
 
 Causation. — Various theories liave been broached with a view to ex- 
 plaining the occuiTence of these unique growths, theories which I cannot 
 pretend here to discuss at any length. 
 
 This much is certain, that they have nothing to do with impregnation 
 of the patient who bears them — they are in no way allied to extra- 
 uterine foetation. Their invariably congenital origin is sufficient to prove 
 this. The possibility of their being the rudimentary structures of 
 an ovum within an ovum may be admitted, although many circum- 
 stances render this very improbable. The same may be said of their 
 origin in the abortive attempts of an unimpregnated ovum to produce 
 some of the structures which would normally arise after impregnation. 
 If they occurred only in the ovaries, this theory would be most tenable, 
 and it would be supported by analogies met with in comparative an- 
 atomy. Doran throws out the hint, that possibly the unimpreg-nated 
 ovum may develop as far as the undivided blastema, which would 
 explain the x>M mell condition of its elements, as opposed to their 
 disposition in regular order, in the impregnated one. 
 
 Parthenogenesis, or that condition met with in certain lower animals, 
 where one impregnation is succeeded by two or more consecutive genera- 
 tions of independent life, has also been brought to bear on the explana- 
 tion of, the phenomena — unsuccessfully, I think. 
 
 On the whole, the theory most in accordance with all the facts is that 
 which supposes that in a variety of ways, and in very varying circum- 
 stances, the epiblast becomes included in abnormal situations, and there 
 develops more or less perfectly its characteristic tissues. To discuss the 
 subject more fully would entail many minute embryological details. 
 
 Symptoms. — Be the causation what it may, a tumour is not unfrequenth- 
 met with of cystic form, sometimes multilocular, more often unilocular, 
 with moderately thick walls, and true dermoid lining of epithelial type. 
 True hair follicles are also present, and even sweat glands, and plenty of 
 sebaceous follicles. The contents of these cysts are mainly sebaceous and 
 fatty. At the normal heat of the body this usually remains fluid, but 
 if tapped, the fluid freezes as it emerges from the cannula, and deposits 
 itself in little worm-like heaps, which are absolutely characteristic and 
 diagnostic. The cannula is easily choked, not only by this coagulation, 
 but by the numerous hairs which are found in the tumour. These, 
 light-coloured for tlie most part, although I have seen them quite 
 black, are either scattered through the mass or rolled into inextricable 
 balls. Teeth, often wanting in enamel, or otherwise rudimentary, are 
 often found also (fig. 182). Paget found 300 of them in one tumour, 
 a very possible number if the last-named theory of causation be true, 
 but too many for an included foetus. The dermoid cyst is not alwavs 
 solitary. Double or ever multiple ones have been found. The com- 
 
398 
 
 DEEMOID CYSTS 
 
 bination of a deiTaoid cyst with an ordinary mnltilocnlar one, I have 
 met with, the dermoid sub-cyst being discovered by accident. The 
 dermoid mass probably existed before the polycystic growth, but T 
 can hardly believe, with Fleisch, that a multilocular cyst can have 
 developed a dermoid one in its walls. It is not unworthy of remark, 
 also, that malignant disease may occasionally develop within the 
 boundaries of a dermoid cyst, or be developed, according to Thornton, 
 in the pelvis, after its removal. There is plenty of rudimentary con- 
 nective tissue in these tumou.rs to account for the development of 
 sarcoma. Free dermoid cysts vary in size from a small apple, or less, 
 to the size of a foot-ball. While existing as mere congenital- monstrosi- 
 ties, they may remain 
 dormant and escape 
 notice dm'ing a long life. 
 In this condition they 
 are virtually a part of 
 the body, and as such do 
 not excite any untoward 
 symptoms — pain, as- 
 cites, or the like. But 
 something occurs, it may 
 be a blow, the establish- 
 ment of menstruation, 
 marriage, pregnancy and 
 delivery, or one knows 
 not Avhat, that changes 
 the inert physiological 
 redundancy into an irri- 
 tated cystic growth. 
 Then one of two things 
 follows. Either rapid 
 increase takes place, with little change otherwise in the nature of the 
 tumour, and we are called on to diagnose what is supposed to be a new 
 formation ; or suppuration occurs, adhesions follow, and we find that, 
 through the bladder, or rectum, or abdominal Wcill, hairs, teeth, or sebace- 
 ous matter are beginning to be discharged. In the latter case the 
 diagnosis will present but little difficult}-. The extruded hairs, sebaceous 
 and fatty matter, perhaps cholesterine, and occasionally teeth, are quite 
 characteristic. Nothing but the extrusion of a av ell-developed extra-uterine 
 fcetus could in any Avay give rise to eiTor. But such a case Avould have 
 a clear and distinct history of its own — a history of pregnancy and missed 
 labour, accompanied by the normal increase of the foetus and folloAved by 
 inflammatory suppuration. Besides, although portions of true bone are 
 
 Fig. 182.— Dermoid Cyst of the Ovary (Dorau). 
 
OF THE OVARY. 399 
 
 met witli in dermoid cysts, we never have the small limb bones which 
 are so characteristic of a decomposed foetus in process of expulsion. 
 
 Treatment. — The question will at once have to be solved, w^hethev 
 it is preferable to assist expulsion by the newly-formed outlets or to cut 
 doAni into the abdomen and remove the tumoixr. Each case will have to 
 be decided on its own merits. If there were reason to believe that very 
 extensive adhesion of the tumours had taken place, and if free discharge 
 were occurring, by vagina, or rectum, or abdominal wall, it would probably 
 be the safest plan to aid nature's efforts by carefully dilating the open- 
 ing, by the constant use of antiseptic injections, and by gently extracting 
 such portions as seemed to require assistance. On the other hand, if the 
 tumour can be pretty clearly defined, if it is movable, or if the opening- 
 has occurred into the bladder or uterus, it Avould be the wiser plan to 
 proceed to ovariotomy, using such means as suggested themselves at the 
 time to close the opening into the affected viscus by carefully uniting 
 its peritoneal edges. 
 
 Should we merely be called on to diagnose a tumour of uncertain 
 nature, a good deal will depend on whether it is sufficiently flaccid to 
 allow of fluctuation being made out, and this is very frequently not the 
 case. A round, smooth cyst, of uncertain date, with few antecedent 
 symptoms, very loosely attached to uterus or pelvis, would excite sus- 
 picion of its dermoid nature, and would probably lead to tapping with a 
 small trocar. This would solve the difficulty, if the characteristic 
 fatty and sebaceous matter were found in the smallest quantity, and 
 still more so, if a single hair escaped. If recourse was not had to 
 tapping, the diagnosis from other ovarian cystic tumours is impossible 
 with certainty, and our treatment Avould be directed on the same prin- 
 ciples as are applicable to other forms. In the event of the tumour rolling 
 freely about, and not giving rise to certain fluctuation, a solid ovarian 
 mass, of non-malignant nati;re, or a loosely attached fibroid of the uteiiis 
 would be suggested. The two simple dermoid cysts which I have re- 
 moved by ovariotomy were both instances of this form. In the one, 
 owing to doubts which I felt, I made an exploratory tapping, and thus 
 satisfied myself as to the true diagnosis ; in the other, I thought I was 
 about to remove a solid mass which had recently become extremely pain- 
 ful, and which might possibly be a degenerating ovarian fibroid. In 
 the presence of a doul:)tful diagnosis, a sound nilc of practice is to 
 abstain from interference as long as there arc no other symptoms than 
 the existence of the growth, but to proceed to exploratory incision 
 if increase of growth is manifest, and if the symptoms and signs 
 point rather to ovarian than uterine disease. It may here be noted 
 that the mortality after the removal of dermoid cysts is less than that 
 after ovanotomy in general. Twisting of the pedicle, afterwards to be 
 
400 UNILOCULAE OVAEIAN CYSTS. 
 
 mentioned, occurs in these groAvths with considerable frequency (01s- 
 hausen). 
 
 3. ITiiilocular Ovarian Cysts. — On the threshold we are here met with 
 a difficulty. It is stated by many that unilocular cysts of the ovary 
 do not exist, except in the dermoid form just described, or as very small 
 infantile cysts. The truth of this as a pathological dictum cannot be 
 determined, except by those who are still working out the difficult, and 
 as yet obscure, pathology of the origin of ovarian cysts in general. But 
 if we adopt the rough general idea, that the numerous Graafian vesicles 
 of the ovary are the origin and site of cystic disease, there is everything 
 to account for its generally multiple character, but nothing to negative 
 the possibility of its occasionally unicystic existence. If we look upon 
 hsemorrhagic discharges into follicle or stroma as at least an occasional 
 origin, the same may be said. If, according to Eokitansky's views, 
 ovarian cysts are largely due to exudation into newly-formed connec- 
 tive tissue, still there is nothing to negative the possibility of unilocular 
 rather than multilocular distention of this stroma, and if glandular 
 conversion into cyst is caused by alteration or retention of contents, 
 or by changes in the gland walls, still one or many cysts may be the 
 result ; and it is certain that when the tumour is polycystic at the 
 commencement, absorption of the partition walls frequently occurs, 
 greatly diminishing the number of cavities, if not reducing them to one 
 single cyst. We are driven back upon clinical observation, and we 
 certainly find cases in which, to all intents and purposes, a large ovarian 
 tumour consists of one cyst. Probably there may always be other small 
 cysts discoverable by minute investigation — potential successors or 
 future accompaniments of the one which constitutes the de facto tumour. 
 The tumour, however, is there, and by its s^inptoms demands diagnosis 
 and treatment rather than pathological discussion. If no multiplicity 
 of cysts, no solid or apparently solid portions, can be made out, our 
 diagnosis is aided in certain directions, we are removed from the ever- 
 present difficulty of mistaking a uterine fibro-cyst for an ovarian cystoma. 
 On the other hand, we are more likely to mistake an ovarian tumour for 
 a simple cyst growing from neighbouring parts, and so to adopt the more 
 simple means of treatment which are often effective in their case. 
 
 Having said this much, I think we are justified in merely making a 
 clinical suggestion with regard to these really or apparently unilocular 
 tumours, and then referring the consideration of them to a future page. 
 The practical observation I Avould make is this: — Wherever our investi- 
 gations lead us to suppose that we may have only one cyst rising from 
 the pelvis, there is a possibility that it may not be ovarian, but one 
 of the numerous other cystic growths or developments which Avill after- 
 wards be mentioned, and accordingly a preliminary tapping is advisable. 
 
MULTILOCULAK OVARIAN CYSTS. 
 
 401 
 
 I have myself seen parovarian cysts cured in this way, obscure ascitic 
 accumulations diagnosed, renal cysts made out, which would otherwise 
 have been impossible, and even true ovarian cysts so much relieved for 
 several years as to justify the operation in the eyes of the patient, if not 
 of an enthusiastic ovariotomist. The nature of the cyst contents, and, 
 even still more important, the mode of its refilling, are important factors 
 in diagnosis thus ascertained. 
 
 4. Multilocular Ovarian Cysts. — Undoubtedly the most common form 
 assumed by tumours of the ovary is that of the multilocular cystoma (fig. 
 183). It is very difficidt to estimate their frequency. As a hospital phy- 
 sician or a consultant, I should look upon them as exceedingly common, 
 while it is a fact that, during some fifteen years of extensive personal prac- 
 tice, I never met with a case among my own patients. Even now, five out 
 of six cases I meet with come from a much wider area than that of Man- 
 chester. By a multilocular 
 cystic tumour we mean one 
 which is divided by septa into 
 many, often into thousands of 
 separate cysts, a few of wdiich 
 may largely predominate over 
 the others, and every one of 
 which may contain fluid con- 
 tents varying in viscidity, 
 colour, and otherwise. Liquid 
 glue, thin isinglass solution, 
 watery fluid, coffee, pus, 
 mucus, blood — these and many 
 other terms might be used to 
 describe the physical appearance of the contents of cysts which may be all 
 met with in one tumour. The origin and nature of these tumours is a 
 matter which still awaits more complete investigation, our knowledge of 
 it, in spite of the earnest studies of many of the foremost ]3athologists 
 of the day, being still most unsatisfoctory. That they arc not all patho- 
 logically the same, either in their origin or in their subsequent mode of 
 growth, appears to be certain. The division into those which are due to 
 the separate development of ovarian follicles, coalescing into one mass and 
 covered by one wall, and those which increase, and increase rapidly, by 
 the proliferation of cysts within parent cysts, has much to recommend 
 it. But late observers have thrown much doubt upon this distinction. 
 I am bound to confess that I am unable to speak Avitli any assurance on 
 the point, and I must refer my readers to the writings quoted above, 
 especially to those of Alban Doran and Wilson Fox. Non omnia possumtis 
 omnes, and it is wiser in this case, as it would be in many others, for 
 
 2c 
 
 Fig. 183. 
 
 -Multilocular Cystoma of tlie Ovarj- 
 (Churchill et Leblond). 
 
402 
 
 MALIGNAIs'T OVAEIAN TUMOUES 
 
 clinical writers who have not the time to conduct histological investiga- 
 tions for themselves, not to swear too dogmatically in the words of any 
 anthority. That the Graafian vesicles play an important part, whether 
 by simple distention, by distention and coalescence, by degeneration of 
 those which have never fully developed, or by degeneration of their con- 
 tents, as in the case of the corpus luteum, is undoubted. Other possible 
 sources of origin were suggested when speaking of unilocTilar cysts (p. 400). 
 The general remarks on the diagnosis and treatment of ovarian tumours 
 which will occupy the next chapter will mainly concern these multi- 
 locular cysts, and will be understood as refei-ring to them when not 
 otherwise stated. 
 
 5. Malignant Ovarian Tmnours of Cystic character. — The existence 
 of solid sarcoma or carcinoma of the ovary has already been refeiTed to, 
 but many of the cystic forms of tumour are equally malig-nant, either 
 
 from their commencement or in 
 their subsequent developments. 
 The presence of colloid matter in 
 the cysts of an ovarian tumour 
 has been considered by many as 
 per se evidence of their malignant 
 character. Its resemblance to the 
 colloid m.atter of cancers of the 
 breast, stomach, omentum, &c., 
 renders this at least probable. 
 Yet the large number of ovarian 
 tumours which contain this sub- 
 FiG. ]84.-IncipientPapmomatousCystof the stance, and which show no sign 
 Hilum. The free portion of the Ovary o , n, i • xi. 
 
 . ^ , . . i„ /■n^-..„T,\ of retiu'n after removal, is rather 
 
 projects above, posteriorly (Doran). ' 
 
 opposed to this view. It is in the 
 greatly proliferating examples where this substance is usually encoun- 
 tered, and, as we shall see, it is these which chiefly tend to assume 
 malignancy. Colloid contents should, I think, be regarded, not as proof 
 of malignancy, but as bearing strongly, although by no means positively, 
 in that direction. It is to the excessive tendency to multilocular, and 
 especially to intralocular sprouting, that we must look as exhibiting 
 most clearly the cancerous tendency. In certain cases we find that the 
 interior of some cysts, if not of all, is filled with fine racemose fungous 
 papiUomata (fig. 184), the tendency of which is, sooner or later, to per- 
 forate the walls and to invade the surrounding parts with true cancer- 
 ous infiltration, especially towards the lower and posterior part, the 
 hilum of the tumour. It has been my misfortune, and must have been 
 that of others, to operate on tumours which presented all the appear- 
 ance of ordinary multilocular cysts at their upper part, but which were 
 
OF CYSTIC CHARACTER. 403 
 
 found to be inextricably incorporated with the pelvic peritoneum by sprout- 
 ing masses of true cancerous tissue below. It is in this form of tumour 
 also that malignant disease is too often found to spring up in the pedicle 
 or in other organs, soon after successful removal. I have above owned my- 
 self to be sceptical as to the causation of this by cancer cells which have 
 escaped through an apparently unbroken wall. Another way in which 
 malignant disease arises in apparently benign multilocular tumours is by 
 the thickening of their walls and septa, and the rapid development 
 therein of the round and spindle-shaped cells of sarcoma. A true cysto- 
 sarcoma is thus produced, which is almost as malignant in its progress 
 and results as a cancerous proliferating growth. It will be seen that I 
 have largely assumed the possible evolution of cancer and sarcoma 
 from presumably non-malignant structures, and I know of no instances 
 in pathology where this inter-relation of malignant and non-malignant 
 growths is more discernible, in the present stage of our knowledge, than 
 in tumours of the ovary. There seems to be no bridge between fibro- 
 mata and solid sarcomata, nor between common multilocular growths 
 which are removable with certain success, and the fungating cystic 
 cancer which has fixed its deadly hold upon the surrounding tissues. 
 
 After this brief sketch of the various forms of ovarian tumours, Ave will, 
 in the succeeding chapter, treat of them more in common, and proceed 
 to mention the essential points in their clinical characters, behaviour, 
 •symptoms, diagnosis, and treatment. 
 
404 THE SIZE, COVEEIXGS, A2sD CONSISTENCY 
 
 CHAPTEE XVI. 
 
 Diseases of the Ovary — continued.. Ovarian Tumours. Their Size, Coverings 
 Consistencj', Vascular and Kervous Supply, Pedicle, Contents, Progress, Acci- 
 dents, and Complications. Their Symptomatology and Physical Signs. Their 
 Diagnosis and Differentiation. 
 
 Before proceeding to tte symptomatology, diagnosis, and treatment of 
 ovarian tumours, there are several other points in connection with their 
 physical characters, progress, accidental accompaniments, and the like, 
 which demand notice. I have not considered it necessary to pursue 
 any very strict sequence in describing these, but they are all of im- 
 portance to the student who wishes to obtain a proper estimate of the 
 facts which enter into the calculations of those who undertake an opera- 
 tion for their removal, and who desires to have a clear idea of its diffi- 
 ctdties and its prognosis. 
 
 1. Size. — The size of an ovarian tumour is an unknown quantity. Mere 
 cystic degeneration may add somewhat to the nonnal size of the ovary, or 
 maybe accompanied by contraction of the organ. Sohd tumours gTow more 
 or less rapidly ; the more truly sarcomatous or cancerous, the more rapid 
 the growth. If left alone, such growths may attain the dimensions of an 
 adult head, or more. Dermoid cysts, if not suppurating, seldom attain 
 a size larger than a football, and are usually smaller. Cystic or malig- 
 nant-cystic growths are perfectly unlimited in their power of expansion, 
 sometimes weighing, with thin contents, as much as 30, 50, or even 
 150 lbs. The unilocular or paucilocular examples furnish the most 
 extreme instances of size, simply because they have less tendency to 
 develop cell-proliferation in other directions, and they are thus less 
 frequently cut short in their growth by the death of the patient. 
 
 2. Covering. — The outer wall of an ovarian tumour, unless there are ad- 
 hesions, is smooth and glistening, and is covered by a layer of ill-developed 
 columnar or cuboid epithelium, although, when the tumour becomes 
 large, this becomes endothehal in character, and is apt to be so in all cases 
 on the portion adjoining the pedicle ; below this are layers of connective 
 tissue, mingled with a cei^tain amount of muscular fibre, also in greater 
 quantity towards the pedicle, or rather towards the ovarian ligament. 
 On opening the abdomen, we have at once a pretty clear indication as to 
 
OF OVARIAN TUMOURS. 405 
 
 whether our diagnosis has been correct. Solid tumours, when thus ex- 
 posed, vary much in appearance ; but the usual cystic tumour has a clear, 
 bluish, pearl-like aspect, which is very characteristic. It differs entirely 
 from the dull, bluish aspect of the unopened peritoneum, from the livid 
 appearance of a uterine fibrocyst, and from the somewhat drab aspect of 
 the gravid uterus. But too much assurance must not be based upon 
 this phenomenon. I have seen a large uterine fibroid with all the char- 
 acteristic appearance of an ovarian cyst, and I have also seen a very 
 multilocular ovarian cyst as purple and congested as a uterine fibrocyst. 
 The thickness of an ovarian cyst wall differs in every case, as also does 
 its friability ; and it is only after an operation has been commenced that 
 this can be ascertained. In some instances, portions, or the whole of the 
 wall of a cystoma, have a dull greenish appearance, looking almost as if 
 it were gangrenous; this is said by Dor an to arise from the presence of 
 embryonic rather than well-formed connective tissue in its substance. 
 Dermoid cysts ai'e much less smooth and silvery, and of a duller grey 
 colour, often with somewhat party-coloured patches. The inner lining of 
 large cysts is often endothelial, but in small and more complex ones we 
 have columnar epithelium, which, as we shall see, furnishes an element in 
 diagnosis by the aspirated contents. 
 
 3. Cohsistency. — This is ascertained by abdominal palpation, or, to a 
 limited extent, by vaginal examination, and will depend, of course, 
 mainly upon the presence of more or less cystic contents, and upon the 
 comparative fluidity of these. It is advisable, however, to mention here 
 some sources of fallacy. As is the case with all abdominal tumours, 
 the tyro is apt to mistake the mere effect of pressure on an unstable 
 and loose mass for fluctuation ; this can be avoided by having it 
 fixed by another pair of hands, and by applying carefully the tests for 
 fluctuation, checked by pressing the edge of a palm on the tumour, 
 midway between the supposed fluctuating points. If true fluctuation is 
 not present, this prevents the resemblance to a wave of fluid. I have 
 already said that a very tight cyst with scarcely fluid contents, such as 
 we find in dermoid tumours, is, when not adherent, liardly distinguishable 
 from a floating solid mass. In like manner, a large multilocular tumour, 
 or a portion of one, consisting of innumerable small cysts, may be so 
 hard and unyielding as to be indistinguishable from a solid mass. The 
 carefully-ascertained existence of one or two really fluctuating points in 
 the mass, and the history and progress of the growth, along with other 
 signs, will generally prevent error in this respect ; but such cases demand 
 the most careful investigation of everything which can throw light xxpon 
 them. It may be said at once that a very large pelvic tumour, of un- 
 doubtedly rapid growth, and without marked symptoms of uterine disease, 
 is, although apparently solid, probably polycystic and ovarian. 
 
406 THE YASCULAE SUPPLY, PEDICLE, AiS^D CONTENTS 
 
 4. Vascular and Nervous Suj^ply. — The vascular supply is derived 
 from the pedicle of the tumour, and varies considerably. Sometimes 
 very large artei'ies are found, and still larger veins, ramifying upon 
 the walls of the tumour, and liable to injury by tapping. At other 
 times the vascular supply is greatly diminished by the stretching 
 of the main vessels, and by degenerations in their walls. In solid 
 tumours the larger vessels are usually to be met with only in the pedicle, 
 but in cystic growths they may be found anywhere. In some cases, 
 where firm adhesions have occun'ed, large vessels enter through these, 
 and they may ultimatel}" afford the main supply ; such adhesions are to 
 be practically considered as additional pedicles, and treated by ligature 
 or cautery. The nerve supply is often abundant, but, from a clinical 
 point of view, is unimportant. 
 
 5. The Pedicle. — The pedicle of an ovarian tumoiir is of no mean im- 
 portance, the existence of such a stiaicture in the vast majority of cases 
 having alone rendered ovariotomy a reasonable and successful operation. 
 The pedicle of a solid ovarian tumour, and for the most jDart of a dermoid 
 one, is usually a thin and well-stretched projection from the peritoneum 
 — a mesovarium in the langaiage of the anatomists, — but that of the 
 common cystic growths varies considerably. It may be broad and thin, 
 or thick, or it may be long, and easily encircled with the finger. It con- 
 sists of the whole or of a portion of the broad ligament, sometimes much 
 thickened and elongated, at other times very thin and fragile. The 
 Fallopian tube is generally attached to it, having the appearance of a 
 long pink fleshy mass, and sometimes appearing very like a portion of 
 small intestine. Its abrupt termination in the fimbriated extremity 
 differentiates it from this, however. The utero-ovarian ligament is also 
 traceable in the pedicle, although sometimes both it and the Fallopian 
 tube run up to the tumour mth an interspace between them and the 
 true pedicle, and I have more than once seen the ovarian pedicle 
 tied and a large tumour removed, the Fallopian tube not entering into 
 either. The enlarged ovarian vessels also form part of the pedicle, and 
 it is their great size which renders the treatment of the divided pedicle 
 so important. Occasionally the multilocular cystoma is sessile, has no 
 definite pedicle, and this is especially apt to be the case with those which 
 show malignant tendency in the form of papillomatous sprouts • they 
 have pushed their way downwards between the layers of the broad liga- 
 ment. In the not very common case of complete fusion of cystic 
 growths of each ovary, the double pedicle may be the first circumstance 
 to call attention to the fact. 
 
 6. The Contents. — We are not concerned now with solid tumours, nor 
 with dermoid cysts, which have been sufficiently described. In very small 
 cysts, chiefly in those of early life, and often probably of evanescent 
 
OF OVAKIAN TUMOURS. 407 
 
 character, the ovum has pretty constantly been found as a constituent, 
 but in larger growths it is sought for in vain, either because it has really 
 disappeai'ed, or because the mode of formation may not have involved 
 true ovum-bearing vesicles. But fluids of various physical characters 
 are found in all cystic growths, and some knowledge of these is necessar}- 
 as a means of diagnosis. Much doubt, however, still hangs over many 
 of the statements Avhich have been most authoritatively made as to the 
 distinctive chemical and microscopic appearances of these fluids. One of 
 the most exhaustive researches into this subject is that of Garrigues 
 (Amer. Jour, of Ohstet., 1882). After all his labour he is driven to the 
 conclusion "that the examination of the fluids affords a very valuable 
 aid to diagnosis, but that it would be rash to base a diagnosis on the 
 character of the fluids alone." 
 
 We look to the physical characters, to the chemical nature, and to the 
 microscopic appearances of ovarian fluids for some guidance in diagnosis, 
 and of each of these it may be said that Ave may have characteristics 
 which afford a very strong amount of probability when present, but Avhich 
 may not be present, or which, if present, must be considered as cor- 
 roborating, but never as directly outAveighing, the evidence derived 
 from other means of examination. 
 
 (a) Of the physical characters thus much may be said, that a very 
 clear or pale straAV-coloured fluid, of Ioav specific gravity, is opposed to 
 the diagnosis of ovarian cystoma, other things being equ.al, but that 
 nevertheless it is met Avith in unilocular or paucilocular cystic 
 tumours, and sometimes in the individual cysts of multilocular tumours. 
 Very distinct viscidity, especially if combined with the peculiar colora- 
 tions mentioned above (p. 401), is exceedingly strong evidence in favour 
 of an ovarian source. The more gluey and tenacious, the more certainlj- 
 is the fluid ovarian. The specific gravity is liable to all sorts of varia- 
 tions ; but the higher it is, the more probably is the fluid ovarian, 
 and the more certainly is the tumour multilocular. Roughly, Ave may 
 estimate the specific gravity of ascitic fluids as from 1010 to' 1015, of 
 the fluid of parovarian cysts as still lighter, and of that of ovarian cysto- 
 mata as 1015 and upwards. Spontaneous coagulation, even sloAA'ly, is 
 a rare phenomenon Avith ovarian fluids, whereas ascitic fluid generally 
 coagulates after a time, and fluid from a uterine fibro-cyst generall}"- 
 does so very rapidly. 
 
 {b) Of the chemical characters Garrigues maintains that " no chemical 
 product peculiar to ovarian fluids has been found." They generally 
 coagulate Avith heat to a considerable extent, but the same thing applies 
 to many other fluids Avhich might be mistaken. The absence of this 
 phenomenon Avould throAV very strong doubt on the diagnosis of OA^arian 
 cyst. Much stress has been laid on the presence in ovarian fluids of par- 
 
408 
 
 THE MICEOSCOPIC APPEAEANCES 
 
 albumin, a substance which, coagulating by heat and nitric acid, redis 
 solves or becomes gelatinous when boiled with an excess of acetic acid. 
 I have seen so many mistakes with this test, modified in various ways, 
 that I regard it as a source of error rather than of certainty, and we 
 know almost nothing more practically certain with regard to other 
 modifications of albumin. 
 
 (c) The microscopic appearances are somewhat more important than 
 the chemical characteristics, although the real interest is confined to one 
 or two bodies. Eed blood-corpuscles, various undefined granular mat- 
 ters, pus or pyoid cells, cholesterine, oil globules, — these, with other less 
 common substances, are, one or the other, met with in the fluids of ordi- 
 nary ovarian cysts, but they have nothing of a distinctive nature about 
 
 them. They may all be found 
 in many of the other collections 
 of fluid which are liable to be 
 mistaken for ovarian. But on 
 two microscopic objects great 
 stress has been laid, as being- 
 diagnostic of ovarian cystic 
 growths. The first of these con- 
 sists of what is now pretty 
 generally known as " DrysdaWs 
 corpuscle "; the second is true 
 columnar einthelium. 
 
 Granular bodies (fig. 185, a) 
 have long been described as 
 
 „ ,0= Tvr- • f ^.^. t- abundantly present in ovarian 
 
 Fig. 185. — Microscopic appearance 01 the most '^ J- 
 
 characteristic contents of Ovarian Cystomata. fluids, by Bennet and others, 
 a, compound granular cells of Gluge ; b, j^^^ ^^ ^ests have been given to 
 Drysdale's corpuscles ; c, the same treated , . , . ■ t ,^ n ■ •^ 
 
 with acetic acid ; d, columnar epithelium. distinguish them from similar 
 
 bodies found elsewhere. T. M. 
 Drysdale claims, however, to have discovered a peculiar form of cell, with 
 special microscopic appearances and micro-chemical behaviour, only 
 met with in ovarian tumours, or, at any rate, in no " other abdominal 
 dropsical fluids." This granular cell (fig. 185, b) (Garrigues maintains that 
 it is not a cell, but an epithelial nucleus in a state of fatty degeneration) 
 is round or oval, transparent, containing many fine, clear granules, but 
 no nucleus. It varies in size, but is commonly about that of a pus cell. 
 Acetic acid renders the granules more distinct, the cell more trans- 
 parent (fig. 185, c). Ether renders the granules nearly transparent, but 
 does not change the cell. These tests, especially the former, seem to 
 distinguish it from pus, white blood cells, lymph, or other cells of similar 
 appearance. The question whether these bodies are pathognomonic 
 
OF OVARIAX FLUIDS. 409 
 
 has yet to be decided. Of their frequent occurrence in ovarian fluids 
 there can be no doubt, nor, I think, of their great rarity elsewhere, so 
 that we must consider their discovery in any doubtful fluid as having at 
 least great weight. 
 
 The other important structure, tiTie columnar epithelium (fig. 185, d), 
 is due to desquamation from the lining walls of the cysts, especially of 
 the smaller ones. When fairly seen, in side view, their importance is 
 very great, if not absolutely pathognomonic. They are found also, how- 
 ever, in cysts of the Fallopian tube and broad ligaments, but in no other 
 tumours, except perhaps cysts of the pancreas. The presence of cilia on 
 these epithelial bodies is rare ; and it is as yet doubtful whether this 
 is not confined to cysts of the parovarium or tubes, and therefore 
 diagnostic of their origin. Some of these points must be a little 
 further referred to when speaking of the differentiation of ovarian 
 tumours, but the presence of columnar epithelium and of Drysdale's 
 cells or nuclei is the most reliable datum to be obtained from an examina- 
 tion of the fluid contents of ovarian tumours ; according to Garrigues, 
 however, " there is no pathognomonic morphological element in ovarian 
 fluid;" and, after weighing the evidence afforded by Fowlis, Thornton, and 
 Keith, he also says : — " Neither the quantity, nor the size, nor the shape, 
 nor the • arrangement of the elements found in cystic fluids enable us to 
 tell that the cyst is sarcomatous, or carcinomatous, but only that it is 
 ovarian" (Garrigues's "Summary," loc. cit., pp. 681, 682). 
 
 Progress of Ovarian Tumours. — -The progress of a cystic degeneration 
 cannot be estimated. There is reason to think that it may continue for 
 many years with little change, but constantly giving rise to menstnxal 
 troubles, and occasionally to ovaritis, pelvic cellulitis, abscess, or hemato- 
 cele, by one of which it may terminate life. Dermoid cysts remain long- 
 stationary, and perhaps free from symptoms, but, as we have seen, they 
 may become suddenly excited to growth or suppuration. The progress of 
 a solid tumour is influenced by its malignancy ; and, as that is the laile 
 rather than the exception, we usually find rapid development after the 
 first discovery. Of true cystic tumours it may be said that the rapidity of 
 growth is in proportion to their tendency to the polycystic form ; but this is 
 not without exceptions, especially as regards the refilling Avhich takes place 
 after tapping. Now and again, cysts, even those in tumours distinctly of 
 multilocular character, remain almost stationary for indefinite periods, but 
 these are very exceptional cases. It may be stated roughly, as the result 
 of many special inquiries, that the duration of life from the first com- 
 mencement averages under three years ; and this is rightly to be taken as an 
 element in determining the propriety of removal, and to be placed, with all 
 its miserable accompaniments, after allowing for the immediate risk of life, 
 in opposition to the prospect of future healthy existence after operation. 
 
410 COMPLICATIONS OF OVAKIAN TUMOUES. 
 
 Accidents and Complications.— Ovarian tumotirs are liable to various 
 complications, which add to the difficulty of diagnosis or of treatment. 
 It is, of course, possible to meet with an ovarian tumour in conjunction 
 with any other affection which might be mistaken for it, or which, from 
 the dissimilarity of its symptoms, might lead to an error in diagnosis. 
 Such cases call for the exercise of the highest diagnostic skill and the 
 most careful weighing of every symptom afterwards to be described, but 
 one or two specially frequent complications must be here mentioned. 
 
 Thus (a) the tumour may be double — that is, there may be one grow- 
 ing from each ovary, generally of very similar character. Solid tumours 
 often grow thus, and cystic ones not infrequently. With regard to the 
 latter, the diagnosis is exceedingly difficult, — often impossible; fortu- 
 nately it is not very material. In a very small number of cases of double 
 ovarian cystomata, fusion of the two tumours takes place, through 
 atrophy of their contiguous walls, a source of difficulty and doubt to the 
 operator, but quite unrecognisable before operation. The bilateral growth 
 of solid tumours increases the difficulty of diagnosis from uterine 
 fibroids, which are so often multiple. 
 
 (6) Pregnancy may coexist. This must never be left out of view as a 
 possibility, not only at our first examination, but at any futvire stage of 
 the disease. Experience shows that, in such cases, where the pressure 
 symptoms are severe, a large cyst may safely be tapped, removal being 
 then adjourned till after delivery ; but that, in the case of rapidly-growing , 
 multilocular cysts, either the induction of premature labour, or ovariotomy 
 during pregnancy, may be called for. A careful consideration of the risks 
 involved either way would appear to me to point to the preferability of 
 the former operation in the majority of cases, although there is room for 
 a different decision in certain circumstances, and the patient, if intelli- 
 gent, should be allowed some share in the decision. 
 
 (c) Adhesions. — There is a constant tendency towards the contraction 
 of adhesions with neighbouring structures ; so much so, that these may 
 fittingly be termed complications rather than accidents. The presence 
 of ascites tends, in the case of solid tumours, to prevent or diminish 
 such adhesions, but the multilocular, or even the unilocular, or paaci- 
 locular cysts are seldom exempt from some slight amount. Both from 
 symptoms occasionally observed, and from the existence of these adhe- 
 sions, it is evident that inter-current attacks of sub-acute or latent 
 peritonitis are not infrequent, but their relation to adhesions is not 
 definite. Fortunately, adhesions are generally slight, and to the omen- 
 tum, or at the upper and anterior part of the tumom-, where they are 
 comparatively easy to deal with, but extensive and firm adhesion may 
 occur to the intestines, vermiform appendix, bladder, uterus, pelvic 
 lining, ureter, liver, diaphragm, or stomach. If on deep inspiration and 
 
TWISTING OF THE PEDICLE, ETC. 411 
 
 expiration the tumour can be seen to move freely below the abdominal 
 wall, we have a tolerable assurance against the presence of firm or close 
 adhesions in front or above, but the existence of deep pelvic adhesions, 
 even those due to malignant sprouting, is difiicult and often impossible 
 to ascertain, although a careful bi-mannal examination may lead to sur- 
 mise, by showing fixity of the uterus, or signs of pelvic infiltration. 
 
 Other complications, from their greater rarity, partake more of the 
 nature of accidents, sometimes of the most serious character. Among 
 them we may here mention — 
 
 (a) ImjKiction in the Pefoi's.— This can only occur with small tumours, 
 but may occasionally give rise to retention of urine or pressure on the 
 rectum, and may cause the recognition of a tumour not previously sus- 
 pected. The accident is much less common than Avith uterine fibroids, 
 and demands the same treatment by pushing up the mass over the pelvic 
 brim. If evidently cystic, recourse may be had to aspiration per vagi- 
 nam, partly as a means of diagnosis, and partly in the hope of cure, and 
 the same treatment is called for in those cases where the descent of the 
 head is opposed in labour. I have twice thus permanently ciu-ed cysts, 
 ovarian, or in the neighbourhood of the ovarj-, during the progTess of 
 labour. 
 
 {(3) Twisting of the Pedicle. — This is a common enough accident, 
 although not to a sufficient degree to produce any decided symptoms. 
 Some Avriters, Gallen for instance, speak of this as a happy termination 
 of ovarian cysts, leading to gradual atrophy, bu.t the 2^ost-mortem proofs 
 of such a result are not numerous. More frequently the results are 
 disastrous. In some cases the twisting appears to be comparatively 
 sudden, and in these especially, owing to the compression of the vessels, 
 hsemorrhage may occur into the cysts to an alanxiing extent, or fatal 
 rupture with hsematocele, or gangrene of the whole mass may ensue. 
 The sudden occurrence of symptoms of collapse in the subject of an 
 ovarian tumour will always point to the accident as probable, and all 
 authorities are now agreed as to the advisability of immediate operation 
 under the circumstances. The pedicle, if long, may also become en- 
 tangled around a knuckle of bowel, producing strangulation, and con- 
 striction of the pedicle itself has been caused by contracting bands of 
 lymph. Either of these events, if highly probable, would equally demand 
 immediate operation or exploration. The causes of ordinary and slow 
 twisting of the pedicle ai*e doubtless to be found in more than one direc- 
 tion. Ordinary movements of the body, acting upon a tumour which is 
 often heavier on one side, and free to move laterally, while much com 
 pressed above and below, and the action of the loaded rectum or sigmoid 
 flexixre, are probably the more usual of these. Dermoid cysts would 
 seem to be specially liable to the accident. 
 
412 VARIOUS ACCIDENTS AND COMPLICATIONS 
 
 (y) Separation of the Tumour. — As a result of the accident just men- 
 tioned, or possibly from mere atrophy of the pedicle, the normal attach- 
 ment has occasionally disappeared, and the tumour has become attached 
 by adhesions, as by a new pedicle, to surrounding parts. Such changes 
 being gradual, can hardly be diagnosed, but this possibility has to be 
 borne in mind in ovariotomy, and the presence of such adhesions may 
 modify the influence of twisted pedicle. 
 
 (S) Intra-cystic Hcemorrhage. — Some amount of this is not very infre- 
 quent, as sho-mi by the more or less sanguineous contents of certain cysts, 
 but, owing to the occasionally great size of the vessels, and the distensibility 
 of the cysts, it may be fatal. The smaller or more frequent hsemorrhages 
 may give rise to intense anaemia. The accidental tapping of a large vessel 
 may produce similar results. Sudden collapse and general symptoms of 
 haemorrhage, with increased feeling of distention, point pretty clearly to 
 the nature of the accident, and if the symptoms are of sufficient gravity 
 to imperil life, and death is not too sudden, immediate operation is 
 called for. 
 
 (e) Intra-cystic Inflammation. — This also occurs, sometimes spontane- 
 ously, sometimes owing to blows or injuries, and sometimes owing to 
 careless, septic tapping. The results may be confined to the interior of 
 the tumour, producing suppuration in one or more cysts, with hectic and 
 severe pain, or the inflammation may spread to the external wall and 
 peritoneum, producing intense peritonitis, or the inflamed cyst may 
 rupture, Avith the same result. So long as the symptoms of inflamma- 
 tion are slight, and likely to be temporary, interference with the tumour 
 is to be deprecated until their subsidence ; but marked hectic showing 
 probably extensive intra-cystic suppuration, or violent peritonitis show- 
 ing one or other of the previous accidents, demands immediate operation, 
 and this is often followed by the happiest result, and almost instan- 
 taneous subsidence of the dangerous symptoms. . 
 
 (^) Gangrene. — This has been referred to as an occasional result of 
 strangulated pedicle, but it may also occur from inflammation, or from 
 unknown causes. Its result, if unrelieved by immediate operation, is 
 certain. 
 
 {y\) Rupture. — This may ensue, as above stated, from hsemon-hagic 
 distention or from suppuration. But, either from injury, or from dis- 
 tention by the usual contents, a cyst may give way into the peritoneal 
 cavity. The same thing has not infrequently followed on tapping, owing 
 to the slipping of the trochar. The result diff'ers widely in difi^erent 
 cases. Rarely — too rarely — a permanent cure ensues, the peritoneum 
 absorbing the fluid, and the cyst not refilling. I have met with two 
 such instances of cure, one spontaneous, the other after tapping. In 
 the latter the fluid was so thin and watery as to suggest a parovarian 
 
DURING THE GROWTH OF OVARIAN TUMOURS. 413 
 
 cyst, the former was also apparently unilocular, and with thin contents. 
 When the fluid is irritating, great shock may follow, to be recovered from 
 with subsequent renewal of the growth of the tumour, or violent or fatal 
 peritonitis may result. Even very tenacious fluids do not always seem 
 to have this efiect. 
 
 Instances are not rare also of the rupture of ovarian cysts into the 
 vagina, rectum, bladder, uterus, or pierhaps Fallopian tubes, or even on 
 to the external surface. Spontaneous cure has also arisen in this way, 
 but a fistulous opening, or one which reopens from time to time, is a more 
 common result. Such spontaneous ruptures with a happy issue can- 
 not in any Avay be relied on as an element in our calculations as to treat- 
 ment, but, on the contrary, the possibility of fatal haemoiThage or peri- 
 tonitis, or of the extension of malignant disease in this way, is an argument 
 in favour of early operation. 
 
 [6) Kidney Disease. — Besides the accidents and complications just 
 mentioned, the frequent concomitance of Bright's disease should be 
 noted. This furnishes an element of great hesitation in operating, but 
 albuminuria may be present, as in pregnancy, from pressure on the renal 
 circulation, and general or local oedema may coexist. No doubt, also, 
 organic kidney disease may be due to great or long-continued pressure 
 on the ureters, but this, to one who does not too greatly concern himself 
 on 'the production of favourable statistics, should furnish an argument 
 in favour of operation rather than the reverse. The certainty of marked 
 renal degeneration should therefore be proved by clear microscopic 
 evidence ere we are deterred from operating in an otherwise suitable 
 case. Pleuritic and pericardial effusions likewise occur, independently 
 of renal disease, and do not serve as absolute deterrents from operation. 
 I have seen both rapidly disappear after it. 
 
 Symptomatology op Ovarian Tumours. 
 
 Of the symptomatology of cystic degeneration enough has been said. 
 Menstrual troubles, with or without special ovarian tenderness or swelling, 
 constitute the main results, although, considering the frequency with 
 which this lesion is met in the 2>ost-mortem room, there is reason to believe 
 that it may not infrequently exist without any striking symptoms at all. 
 The symptoms of a latent dermoid cyst are simply those which may 
 occur from its pressure, as in other tumours, and its physical signs are 
 those of a cyst or a solid tumour according to the tenacity of its contents. 
 Solid ovarian tumours give rise to few or many symj)toms according to 
 the rapidity of their growth. The pressure symptoms do not differ from 
 those of the cystoma. Actual pain, apart from pi-essure, will depend 
 largely on the existence of malignancy. There is, as has been said, a special 
 
414 THE SYMPTOMATOLOGY 
 
 tendency to ascitic accnmulation, wherein such soUd tumours differ from 
 uterine gro^ivths or ordinary ovarian cystomata. As regards derange- 
 ments of menstruation and other general sjiiijotoms, all that need be 
 said is included in the symptomatology of cystomata. 
 
 Cystomata, or cystic gTOwths in their earlier stages, most frequently 
 give rise to no symptoms or to none sufficiently lu-gent to lead to their 
 detection. Hence it is that we seldom meet with them \mtil they have 
 arrived at the size, say of a cocoa-nut, or ujitil they have risen well above 
 the pelvic brim. If they are discovered before this it is most frequently 
 by accident, drmng the examination for some supposed uterine affection, 
 or because their partial incarceration in the pelvis, fi'om rapid gTOwth or 
 inflammatory adhesion, has caused pressure on the bladder or rectum, 
 with obstinate constipation or suppression of mine, or they are discovered 
 as obstacles to the progTess of delivery. The symiDtoms of pressure on 
 the bladder, rectum, pelvic vessels, and nerves to which they may give 
 rise, most fe-equently disappear or diminish to a great extent when they 
 fairly rise above the brim, which they do the more readily, the more 
 fluid their contents, or the less polycystic they are. Occasionally, 
 although very rarely, great pain is felt in a small cyst, necessitating 
 early interference. 
 
 As the tumour increases in size, the first and only symptom may be a 
 noticeable increase in the abdomen, similar to that met with in preg- 
 nancy, although seldom observing the same rate of speed. Usually it is 
 either much slower or much more rapid. A certain amount of men- 
 strual change generally accompanies this. By far the most commonly 
 the secretion becomes scanty or iiTegular, less frequently it is entirely 
 suppressed, rendering the similarity to pregnancy gTcater ; still less fre- 
 quently, menon-hagia is present, but I am inclined to think that this is 
 always due to the coexistence of other disease. In one such case the 
 haemorrhage was due to a small mucous polypus of the cervix, in 
 another to an intra-uterine fibroid polypus the size of a walnut. 
 Menorrhagia is oj)posed to the diagnosis of ovarian tiunours, but not 
 prohibitive. The symptoms of upwards pressure may next begin to 
 present themselves with more or less rapidity, viz., dyspnoea, nausea and 
 vomiting, with palpitation. The vesical and intestinal pressure may 
 stiU continue or may have totally disappeared, but there is frequently 
 oedema of the lower limbs and abdominal wall. Albuminuria is a not very 
 infrequent accompaniment, owing to pressure on the renal circulation. 
 Many of the ordinary general symptoms of pregnancy are often found 
 accompanying the growth of the tumour, and these should never mislead 
 the wary, although they impose the necessity for caution. Darkening of 
 the areolae and milky secretion in the breasts are not uncommon, 
 and I once met with abundant kvestine in the urine. Pain is a very 
 
OF OVAEIAN TUMOUKS. 
 
 415 
 
 variable concomitant ; with large tumours there is often none, at other 
 times it is severe and constant, and undoubtedly this is sometimes due 
 to the existence and stretching of adhesions or to the presence of slight 
 attacks of peritonitis. Emaciation sooner or later sets in, increasing the 
 strange appearance of the now perhaps enormous abdomen. Intestinal 
 disorders, diaiThoea, gastritis, enteritis, latent pleurisy, <fec., set in, and 
 the patient gradually sinks from the wear and tear of these, from the 
 pain, if it be present, and from the impoverishment of the system, if 
 none of the fatal accidents mentioned above supervene. 
 
 There is a great tendency during ovarian disease to the deposit of 
 pigment (nigrities) on the forehead, abdomen, or elsewhere, just as often 
 occurs in pregnancy. Sir ,^ 
 
 Spencer Wells has graphic- 
 ally described and figured 
 (fig. 186) a type of facial 
 expression {fades ovari- 
 ana) which is very char- 
 acteristic of many chronic 
 cases. He says, in a priv- 
 ate note : — " For many 
 years past I have tested 
 the diagnosis between 
 uterine and ovarian tum- 
 ours by the physiognomy 
 before examining the abdo- 
 men of a new patient. I 
 have been right nine times 
 out of ten. Sometimes I 
 have guessed that both a 
 uterine and an ovarian 
 one were present and have 
 been right." Let not the 
 young beginner, however, trust too much to this, if at all ; the excep- 
 tions are numerous and sometimes striking. 
 
 The Physical Signs which accompaiiy these symptoms are those 
 which depend on the presence of a globular mass arising from the pelvis 
 and projecting upwards into the abdomen, the globular mass being more 
 or less soft and fluctuating within its own limits. 
 
 This does not, of coui'se, apply to small tumours still within the pelvis. 
 These are only to be detected by vaginal or rectal, and by bi-manual 
 examination. If the student will turn to the table of abnormal con- 
 tents sometimes found in Douglas's pouch (p. 7), he will see the various 
 similar objects met with there. The characteristic marks of an ovarian 
 
 Fig. 186.— Ovarian Facies (after Wells). 
 
416 THE PHYSICAL SIGNS 
 
 cystoma here present are a distinctly rounded substance, for the most 
 part lateral and posterior to the uterus, but with occasional exceptions, 
 separable from the uterus by the finger, or still better by bi-manual 
 examination. It is elastic or even fluctuating, movable in the pelvis, 
 and the finger in the rectum can often detect a distinct band of tissue — 
 its pedicle. Adhesive inflammation may alter some of these signs by 
 fixing the mass to the pelvis or to the uterus, and it may not be possible 
 to be absolutely sure of the diagnosis except by awaiting further de- 
 velopment or by aspirating the contents, and so setting aside the 
 possibility of abscess or other fluid mass. 
 
 Larger growths, perceptible in the abdomen, have the following 
 physical characters, usually so well marked that they may be taken as 
 diagnostic. Rare and most puzzling exceptions to nearly every one of 
 these signs are met with, but I think I should be doing more harm than 
 good by attempting to enumerate them here. For example, I have seen 
 a thin flaccid cyst, which, on refilling after tapping, allowed the intes- 
 tines to envelop it in front, giving resonance all over anteriorly and 
 deep dulness in the flanks, which was completely altered by change of 
 position. Again, I have more than once seen ascitic dulness strictly 
 confined to the middle line in all positions, when there were no adhesions 
 to encyst it there. A short mesentery was the only available explana- 
 tion. Setting aside, however, such special abnormalities as these, we 
 find that — 
 
 (1) The size, shaioe, and aiopearance of the abdomen are altered. 
 
 The increase in circumference will vary in every degree, up to 50 
 inches or more, but the shape of the enlarged abdomen is generally 
 characteristic of something abnormal existing at one part and not in 
 the, general cavity. The protrusion may be, often is, very decidedly 
 lateral but even if it is central, it is a protrusion, and it has not that 
 broad, flattened appearance which is found in ascites. Only very large 
 and flaccid, and almost unilocular cysts give rise to anything like this, 
 and even they do not bulge out the flanks and allow the front of the 
 abdomen to flatten down to the same degree. In doubtful cases mea- 
 surement of the abdomen in various lateral directions will assist the 
 eye. The appearance of the abdominal walls differs much. In some 
 cases the veins are enormously distended, linice alhicantes, similar to 
 those of pregnancy, are present, or there is great oedema. In others fat 
 predominates and masks all else. In others, again, the walls are thin 
 and emaciated, permitting us to see clearly the movements of the sub- 
 jacent tumour during respiration. The appearance of the umbilicus is 
 not very characteristic. I have seen it much hardened and hyper- 
 trophied, bulged out, flat, or even retracted. 
 
 2. Palpation shoius variations from the normal. 
 
OF OVAFJAN TUMOUES. 
 
 41^ 
 
 If the tumour is only moderately large, its outline can generally bo 
 felt as something abnormal. It may feel like a tense soft ball, or 
 it may vary in apparent hardness, appearing like a gravid uterus, or 
 even a uterine fibroid, or it may, and most commonly does, exhibit 
 different degree of hardness at different points. It is never contractile. 
 as the gravid uterus frequently is, but contraction of the abdominal 
 wall may closely simulate this. If very large, the tumour may be 
 indistinguishable from other parts of the abdomen, but all the natural 
 elasticity of the walls is then absent, or, in the case of a huge single cyst. 
 the universal presence of fluid is manifest. 
 
 3. Percussion shoivs manifest dejoartures from the normal. 
 
 When not complicated with early adhesions, the tumour rises in front 
 of the intestines, just as the gravid uterus does, so that they are pushed 
 laterally, upwards, 
 and backwards. 
 There is, there- 
 fore, an area of 
 dulness on percus- 
 sion, which is quite 
 abnormal (fig. 187, 
 b), and which occu- 
 pies the front of the 
 abdomen, from the 
 pubes upwards to a 
 certain level. This 
 area, if not very 
 oreat is generallv ^^'^' '^^'^' — Comparison of areas of duluess in Ovarian Cystoma. 
 ^ , ' ° ' "^ and Ascites (Wells). The dark parts are dull. A, Ascites. 
 
 much greater to- B, Ovarian Tumour. 
 
 wards one side, and 
 
 compares with the resonance deep down in the flanks or above the level of 
 the tumour. Special, and often tempoi'ary circumstances, such as a loaded 
 colon or stomach, a full bladder, or the coexistence of slight ascites, may 
 often interfere in one or other direction with this sign ; but subsequent 
 examinations, with precautions against repetition of the cause of error, 
 will prevent any permanent mistake. The consulting physician, who is 
 often called on to decide the question of diagnosis at one interview, 
 must make mental exceptions for such difiiculties, while it is the fault 
 of the practitioner in charge if he cannot more leisurely solve them for 
 himself. 
 
 There are two distinguishing marks in the percussion of an ordinary 
 ovarian tumour which should never be lost sight of: — {a) The upper 
 limit of the dulness, whether the tumour is central or lateral, has its 
 convexity upwards, we have a dull-soundincr globe, pressing resonant 
 
 2 D 
 
418 THE PHYSICAL SIGNS 
 
 intestines upwards and laterally around its circumference (fig. 187), 
 while (h) the dulness remains much the same in its relations to the 
 abdominal surface however we turn the patient on her side, the rolling 
 of the tumour being limited by its pedicle. These features are, of 
 course, common to many other cysts or solid growths ; but in the case 
 of dulness due to free fluid in the peritoneum, its area will gravitate 
 with the fluid down into the flanks or lower portion of the abdomen, the 
 intestines will float, as a gas-containing mass, to the front, the line of 
 dulness will have its concavity upwards, and, on turning the patient on 
 to one side, the intra-peritoneal fluid must descend, thus leaving the 
 upper flank, dull before, now more resonant. 
 
 4. Fluctuation is usually pi'esent at some jJoint, and it is circumscribed 
 in extent. With a large unilocular cyst, crowding the whole abdomen, 
 such fluctuation may be felt between almost any two points ; but with 
 smaller tumours, and especially with those which are very multilocular, the 
 fluctuation has very distinct limits. One portion of the area of dul- 
 ness may fluctuate freely, while the rest is apparently solid and non- 
 fluctuating, or the skilled touch may discover separate areas of fluctua- 
 tion side by side, hardly afi"ecting one another, or varying in the degrees 
 of apparent fluidity or viscidity which thej present. Such differential 
 areas of fluctuation, as I may call them, are seldom if ever met with 
 except in ovarian cystomata. But the absence of distinct fluctuation, 
 even in a true ovarian cystoma, is sometimes caused by great thickness 
 of the abdominal walls, by the same feature in the walls of the cyst, by 
 the extreme viscidity of the contained fluid, and by the multiplicity of 
 the cysts and the absence of any predominating one. 
 
 5. Auscultation shoivs the absence of the auscultatory signs of pregnancy. 
 Remembering, and making allowance for what we have said as to the 
 
 possible coexistence of pregnancy, there is nothing to be heard in 
 an ovarian tumour resembling the 120 to 180 beat of a foetal 
 heart. It may convey the sounds of the aorta, but the pulse of the 
 patient, if counted, will remove this source of fallacy. Can the sounds 
 of the so-called uterine souffle of pregnancy be simulated by an ovarian 
 tumour, as undoubtedly they can by a vascular or cavernous uterine 
 fibroid % Authorities generally say no ; but I have heard a most typical 
 souffle over a portion of a multilocular ovarian tumour, — the diagnosis 
 being proved by its removal, — the only vise of the sign is, therefore, to 
 very partially corroborate other strong evidences of pregnancy or uterine 
 growth. 
 
 6. Physical examination, per vaginavi, per rectum, or bi-7nanually, 
 shows certain positive or negative diagnostic conditions. 
 
 The OS and cervix uteri are normal, unless changed by chronic metritis. 
 They never expand, and shade off into the tvimour above, as in pregnancy 
 
OF OVARIAN TUMOURS. -±19 
 
 and some cases of intra-uterine fibroid. The tumour itself can sometimes 
 be felt per vaginam, sometimes not, or it may be more easily reached per 
 rectum. It will depend on its particular degree of cystic development, 
 whether it appears to be soft or fluctuating, or hard and unyielding ; but 
 tumours with large cysts above are often composed of masses of small ones 
 below, with much connective tissue, and they then appear to be solid. 
 "When the tumour is very high, it sometimes drags the utervxs up with it 
 to an abnormal degree, or it may push it up almost out of reach, above 
 the pubes. Adhesions are much to be feared in this case. With 
 small tumours, the uterus is almost always anterior, but afterwards, 
 this position may be retained, or the uterus may be pushed laterally 
 or pressed backwards, retroverted or even retroflexed below the tumour. 
 When the tumour has got fairly above and upon it, it may be 
 driven very low in the pelvis, or even prolapsed, along with the anterior 
 or posterior vaginal walls. The sound shows a normal length of the 
 organ, unless uterine complications exist. It shows also the direc- 
 tion of the organ, and, unless the pressure of the tumour is very great, or 
 adhesions have formed, it shows independent mobility of the uterus — the 
 timiour being moved or held steady from the abdomen by an assistant 
 while the sound in utero is manipulated. 
 
 The concurrence of a majority of the above symptoms and physical 
 sig-ns points tolerably certain to an ovarian tumour, but there are many 
 sources of fallacy, and we come now to the 
 
 Diagnosis and Differentiation. 
 
 Considering that probably no living ovariotomist, however eminent, 
 has failed to make mistakes in the diagnosis of a disease of Avhich, com- 
 monly, " he who runs may read " the true nature, it is not to be won- 
 dered at that the whole subject of its differentiation is necessarily 
 incomplete even in the fullest and most elaborate monographs, such 
 as those of Wells, Atlee, or Peaslee. How much more must this be 
 the case in a general text-book ! In the diagnosis of other gynae- 
 cological affections of a local nature we have usually to decide, and 
 that mayhap with difficulty, between three or four, or at most 
 half a dozen possibilities; but a glance at the table below, itself 
 perhaps not absolutely complete, will show how many sources of error 
 there are here. Some of these affections are common, and so closely 
 allied to ovarian tumours that it is often impossible to be certain of 
 their diagnosis before operation ; with a few this is of comparatively 
 little importance. Others are also common, but mistakes in diagnosis 
 are of the utmost seriousness. Others again arc very rare, or may 
 rarely simulate ovarian disease, so that even the most experienced have 
 
420 
 
 THE DIAGiS'OSIS AND DIFFEEENTIATIOX 
 
 had few opportunities of practically studying their differential signs. I 
 have endeavoured so to arrange the table that, on afterwards considering 
 its details seriatim, some due proportion may be given to this relative 
 clinical importance. The most common, and therefore the most dan- 
 gerous, of these sources of error are italicised. These have given rise 
 to the great majority of the mistakes that have arisen. 
 
 Table of Affections which mat be, or have been, confounded 
 WITH Ovarian Tumours. 
 
 I. Small Ijttra- pelvic Ovarian Tumours are liable to be 
 
 MISTAKEN FOR— 
 
 1. Tumours of the broad ligaments, nearly 
 
 always cystic. 
 "2. DilaMtion of the Fallopian tubes — • 
 
 hydrosalpinx, &c. 
 
 3. Pelvic lymph — peritoneal, or in the 
 
 connective tissue. 
 
 4. Pelvic abscess. 
 
 h. Pelvic hsematocele — peritoneal, or in 
 the connective tissue. 
 
 6. Pregnancy. 
 
 7. Extra-uterine pregnancy. 
 
 8. Eetroverted or reti'oflexed uterus. 
 
 9. Fffical accumulation. 
 
 10. Uterine Fibroids. 
 
 11. Pelvic cancer. 
 
 12. Osteomata of pelvis. 
 
 13. Vaginal prolapse — rectocele, entero- 
 
 cele, or cystocele. 
 
 II. Abdominal or Pelvi-abdominal Ovarian Tumours are liable to 
 
 BE mistaken for — 
 
 A. Pelvic Cysts, including — 
 1. Cysts of the broad ligaments. \ 2. Spinal cysts— spina bifida. 
 
 B. Inti-a-peritoueal Deposits or Fluid Accumulations. 
 
 1. Ascites. I 4. Pelvic abscess. 
 
 2. Pelvic hsematocele. 5. Pelvic or peritoneal cancer. 
 •3. Pelvic lymph. I 
 
 1. Pregnmicy. 
 
 2. Moles. 
 
 3. Hydramnion. 
 
 4. Heematometra 
 .5. Hydrometra. 
 
 C. Uterine Enlargements, due to — 
 
 6. Physometra. 
 
 7. Fibroids. 
 
 8. Fibrocysts. 
 
 9. Cancer. 
 
 1. Fat. 
 
 2. Hypertrophy 
 
 3. OEdema. 
 
 4. Abscess. 
 
 1). Abnormalities of the Abdominal "Walls. 
 
 5. Cysts. 
 
 6. Solid growths. 
 
 7. Spasm — phantom tumour. 
 
 1. Kidney. 
 
 2. Spleen. 
 
 3. Liver. 
 
 E. Cysts of Extra-pelvic Structures. 
 
 4. Pancreas. 
 
 5. Peritoneum. 
 
OF OVARIAN TUMOURS. 421 
 
 F. Hydatids of any Abdomiual or Pelvic Organs or Structures. 
 
 G. Visceral Growths or Displacements, including Cancer of the 
 
 1. Kidneys. i 4. Lymphatic glands. 
 
 2. Liver. 5. Peritoneum. 
 
 3. Spleen. i tj. Omentum. 
 
 H. Distention of Viscera. 
 
 1. Tjnnpanites. 
 
 2. Distended stomach. 
 
 3. Fffical accumulation. 
 
 4. Di-stended bladder. 
 
 5. Hydronephrosis and dis- 
 
 tended ureters. 
 
 6. Hydrosalpinx, pyosalpiiix, 
 
 kc. 
 
 L Extra-uterine Pregnancy. 
 K. Spinal Abscess. 
 
 The first group, that which deals with the affections simiilating small 
 intra-pelvic ovarian tumours, may be treated with great brevity. I have 
 given above the physical signs which characterise such small ovarian 
 tumours, and any marked departm-e from these will excite doubt, at least. 
 In most cases delay is justifiable and advisable, until the mode of growth 
 and development renders the diagnosis more certain. In cases of doubt, 
 and yet of urgency, aspiration will furnish some negative evidence at 
 least, and enable us to set aside abscess or haematocele, while the presence 
 of clear fluid will render the diagnosis of a cyst of some kind almost 
 quite certain. The remotest probability of pre^rea^ic^/ will always enforce 
 delay. Cystic tumours of the broad ligaments — of which more anon — 
 can rarely be differentiated in this stage ; the presence of very watery 
 fluid on aspiration may render their existence probable, but that is 
 all. Fallopian distention, of non-inflammatory kind, presents equal 
 difficulty ; it rarely reaches great dimensions, and, if removal become 
 advisable, a mistake would not be of very great importance. Purulent 
 Fallopian distention is more likely to be mistaken for i^elvic abscess than 
 for small ovarian tumours, and either of the former will have a distinct 
 history of inflammation, which may lead to aspiration. If the presence 
 of a cyst had not been noted previous to the occurrence of these inflamma- 
 tory symptoms, it is hardly possible to differentiate a small suppurating 
 ovarian cyst, and treatment by aspiration or by abdominal section would 
 be equally called for, or uncalled for, in either case. Exudations oflympJi 
 into the pelvis, as well as the exudations of blood due to luematocele, give 
 rise to swellings, which remain to be described in a subsequent chapter. 
 It must suffice here to say that they gradually become harder and harder 
 after their first pouring forth, that they have a very distinct history 
 of inflammation in the former case, or of shock and sudden supervention 
 in the latter, that they have special peculiarities of shape and position, 
 and that they are utterly fixed and welded into the sun-ounding textures, 
 
422 DIAGNOSIS . FEOM 
 
 SO that it is impossible to see how they can well be mistaken for a smooth 
 globular and movable ovarian tumour. The diagnosis of a retroverted 
 or retroflexed uterus has been fully given ; its reposition, or the passage 
 of the sound into its cavity, is conclusive against the diagnosis of 
 ovarian tumour. The pitting on pressure of a /cecal mass should at once 
 excite suspicion, and lead to an examination per rectum, or to the use of 
 enemata. No one ought by any possibility to mistake a prolapsed vaginal 
 wall for an ovarian cyst. Its careful replacement is sufficient for the 
 diagnosis, and a coexisting cyst, large enough to press down the vaginal 
 walls, should easily be recognised by bi-manual examination, and by the 
 other marks significant of pelvi-abdominal tumours. Bony growths of 
 the pelvis are distinguishable by their position, their immobility, and 
 their intense hardness. Fibromata and fihro-cystoma.ta of the uterus are 
 more fully noticed under the next section. When small, subserous, and 
 confined to the pelvis, their differentiation from small ovarian tumours 
 may be a matter of difficulty ; it will depend on a very careful examina- 
 tion of their connection with the uterus, bi-manually and by sound. 
 If they possess a long pedicle, and there is no great general uterine 
 enlargement nor menstrual disorder, their slow rate of growth and 
 innocuousness may lead to sufficient certainty for all practical purposes, 
 although it may not be absolutely diagnostic. 
 
 The diagnosis of abdominal or pelvi-abdominal ovarian tumours is a 
 matter of much more practical importance, and one much more fre- 
 quently called for. Of the sources of error here, four stand out with so 
 much greater prominence than the others that they will be first and 
 more fully discussed. These are cysts of the broad ligament, ascites, 
 fibroids and fibro-cysts of the uterus, and pregnancy. 
 
 Cysts of the Broad Ligament. — Up to the present time I have refrained 
 from more than mentioning the fact that, not very infrequently, cystic 
 growths may arise from some portion of the broad ligament, which very 
 closely simulate tiiie ovarian cysts, and which have undoubtedly been 
 (jften removed without the difierence of origin having been discovered. 
 A good deal of discrepancy exists even in the most recent treatises as 
 to the real origin and pathology of these cysts. By most Avriters the 
 small tubes of the parovarium (fig. 199) are credited with being their 
 original site, and these are also credited by Alban Doran with the 
 tendency to develop cysts which are prone to papillomatous degenera- 
 tion ; by others they are spoken of as cysts of the peritoneum itself, 
 growing from between the layers of the broad ligament ; a stray ovum 
 has also been supposed capable of producing a similar cyst, and the 
 so-called hydatid of Morgagni occasionally develops a cystoma. The 
 most recent evidence would tend to show that simple benign cysts, 
 such as we are about to mention (fig. 188), spring from the broad 
 
CYSTS OF THE BKOAD LIGA.MENTS. 
 
 423 
 
 ligament itself, while those which have a teuclcucy to degenerate have 
 more frequently their origin in the parovarian tubviles, but, owing to 
 the difficulty of differentiation of these before operation, we may still 
 continue to use the terms "parovarian" cyst and "broad ligament" cyst 
 as practically synonymous, so far as regards differentiation from true 
 ovarian cystomata. The cysts of this kind, Avhich may be and often are 
 confounded with ovarian cysts, are generally unilocular, although not 
 universally so, but even those which have a thin septum or two are not 
 ilistinguishable on palpation as multilocular. Tait, and some others, go 
 the length of saying that every unilocular cyst of this region is not 
 ovarian but parovarian (I use the common term). Their contents are 
 thin and watery, very slightly albuminous, and of low specific gravity, but, 
 according to the same authority, they sometimes have the character of 
 viscidity, high specific gravity, and coloration, which arc found in true 
 ovarian cysts. They 
 are often separated 
 from the ovary and 
 Fallopian tube by a 
 pedicle, and may thus 
 be removed, leaving 
 these structures intact. 
 Their walls are said to 
 be lined by epithelium 
 of varying character, 
 including sometimes 
 the columnar, and the 
 discovery of this in the 
 contents would there- 
 fi)re not be of differ- 
 ential value unless it were ciliated. Paralbumin is said to be invariablj- 
 absent from their contained fluid, but I fear that paralbumin must be 
 rc'-arded as a myth for practical diagnostic purposes. Most authoi'ities 
 maintain that after tapping they may never return, and I agree with them as 
 far as my experience goes; but others, Tait again among the rest, say that it 
 is only a question of time. Their growth is usually rapid, sometimes slow. 
 From all this, four questions arise: — (1) What are their resem- 
 blances to ovarian tumours ? (2) What are their diff"erences 1 (3) Can 
 they be positively differentiated ? and (4) If so, cul bono? 1. Taking 
 it for granted that they are always apparently unilocular, they 
 have no resemblance to a tumour which is solid or which has 
 masses of apparently solid substance incorporated with it. They only 
 resemble, therefore, those ovarian tumours which have one large pre- 
 dominating cyst. But these they resemble conii)letoly. in tlicir position 
 
 Fig. 388. — A simple Broad Ligament Cyst (Doran) 
 
424 DIFFEEENTIATION BETWEEN ASCITES 
 
 and consequent physical signs, in their fluctuation, and in the localisa- 
 tion of their fluctuation and permission dulness, and its comparative un- 
 changeableness in various positions of the patient. Their physical signs 
 are therefore alike, unless we admit the impossibility of a unilocular 
 ovarian tumour ; and even then we must also admit the impossibility of 
 deciding whether a tumour is really unilocular until we have removed it. 
 I utterly repudiate the idea of Atlee that the most experienced hand can 
 diiferentiate the thinness of fluctuation in a parovarian cyst from that in 
 many tnae ovarian cysts. 2. What are the difl'erences between ovarian 
 and parovarian cysts? The character of the contained fluid in the 
 latter is the only one Avhich is at all generally relied upon— its watery 
 colour, transparency, and fluidity — and this can only be certainly 
 ascertained by tapping, and, as we have seen, this is not universally 
 acknowledged to be certainly differential. 3. Can we, therefore, posi- 
 tively diff'erentiate the two things? I believe not; and that all we can 
 say is, that an apparently thin iinilocular cyst is very possibly not 
 ovarian but a cyst of the broad ligament, and that if it entirely disappears 
 on tapping, leaving no evidence of a thick cyst wall or of other cysts, 
 and emitting a clear watery fluid, it is most probably so. 4. The 
 advantage of attempting the diagnosis depends on whether it is true that 
 such cysts, after tap|)ing, frequently, or even occasionally, are per- 
 manently cured, or even if they are sometimes cured for several years. 
 On the latter point all are agreed, on the former there is discrepanc}* 
 among the best authorities. I am perfectly certain that they may dis- 
 appear for so man}?- years, that a return is more probably due to a fresh 
 tumour than to a refilling of the old one. I consider this an argument in 
 favour of tapping an apparently thin-walled unilocular tumour, partty 
 invalidated, however, by the remote jDOSsibility of its containing the 
 elements of proliferating papilloma; but beyond this I consider the 
 differentiation of no importance, and henceforth I will include these par- 
 ovarian or broad-ligament tumours along with those of undoubted ovarian 
 origin in considering their differentiation from other abnormalities. 
 
 Ascites. —In simple and uncomplicated cases, it ought to be easy 
 enough, by palpation and percussion alone, to distinguish an ovarian 
 cystic tumour from free fluid in the peritoneum. The typical dulness in 
 the flanks, and resonance in front, of ascites, and the reverse conditions 
 in connection Avith tumours, have been mentioned (fig. 187), and should 
 always be carefully marked out in the dorsal decubitus. If this is done, it 
 is easy to ascertain the changes which occur in the areas of dulness or 
 resonance when the position of the body is changed from side to side, or 
 by raising the shoulders or pelvis. As is the case in many other circum- 
 stances, the difference between light and firm percussion at the margins 
 of dulness has considerable diagnostic value. An ovarian tumour beino- 
 
AND OYAKIAN TUMOUES. -^'25 
 
 globular, the upper margin of dulness, when the finger is lightly placed 
 on it, and the percussion is light, will not correspond with the summit of 
 the tumour. If, therefore, the percussed finger or pleximeter be pressed 
 more firmly just above the margin, and the percussion be made more 
 forcibly, the slightly overlapping intestine will be displaced upwards, and 
 the dull sound of the convexity of the tumour will be brought out, so 
 that the convex area of dulness will be correspondingly increased up- 
 wards to the extent of an inch or more. Supposing, however, that 
 we have only peritoneal fluid, with floating intestine, and a re- 
 sonant area with its convexity downwards, firm percussion below the 
 limit of this will displace the fluid, and will bring out the resonance of 
 more intestine, which was prevented by its normal attachments from 
 rising to the summit. To those who have studied percussion in the 
 only true Avay, viz., as an interpreter in the first place merely of the 
 physical condition of what is below ; and then, secondarily, by a process 
 of reasoning, as bearing on various presumptive facts, the diagnosis of 
 an ascending pelvic tumour containing fluid, from free fluid in the abdo- 
 minal peritoneal cavity, is perfectly simple, and might be entirely relied 
 upon if it were not for the fact that adhesions of organs occasionally 
 occur, from even slight inflammatory attacks, and prevent those organs 
 from obeying the physical laws Avhich their specific gravity would other- 
 wise impose upon them. The complications thus produced are some- 
 times so extraordinary that the utmost skill is baffled in arriving at a 
 certain diagnosis, and nothing is left but to make an exploratory incision 
 for the purpose of deciding the question ; but the more common sources 
 of error must be indicated. By inflammation of the peritoneum, acute 
 or chronic, the intestines may be so bound down that they cannot rise 
 above the peritoneal fluid, and so the laws of gravity are set at defiance, — 
 or the mesentery is in some cases abnormally short, with a similar result, — 
 or adhesions may occur between portions of the peritoneum, so that an 
 ascites is really encysted, and that in front of the abdomen ; — or tubercular 
 or cancerous deposits may so mat together the intestines, and cause encyst- 
 ment of portions of the accompanying ascitic fluid, that a multilocular 
 cyst, with its dTilncss at some definite places and fluctuation at others, 
 is almost perfectly simulated. 
 
 I must indicate here the chief means on which we rely for a decision be- 
 tween ascites and ovarian cysts. The jyercussionsiqnshsLYe been already men- 
 tioned. They rarely fail xis except in the case of enormous unilocular cysts, 
 or equally enormous ascitic distentions, or inthccaseof pcritoniticadhcsions. 
 Tapping or exploratory i)icision are then our onlj'' resources, and these will 
 be more fully discussed under the heading of treatment. The history of the 
 case is, of course, of very great service, but it may also mislead. In ascites, 
 from whatever cause, we have generally long-continued ill-health or violent 
 
426 DIFFEKENTIATION BETWEEN ASCITES 
 
 inflammatory symptoms ; whereas in ovarian tumour the patient's health 
 is often long unimpaired, and considerable weight is due to this, but not 
 too much, especially if the physical signs are not in accordance with the 
 presumption derivable. I have opened the peritoneal cavity and found 
 the peritoneum quite half an inch thick in front from chronic peritonitis, 
 with tubercular nodules all over its lower portions, when a most intelli- 
 gent practitioner had failed to detect any evidence of rise in temperature 
 or other inflammatory or tubercular conditions during a period of more 
 than a year. This patient has, moreover, enjoyed perfect health for over 
 twelve months since the operation, and it shows no signs of deteriorating. 
 The coexistence of cardiac, hepatic, renal, or other visceral disease must 
 always be carefully sought for. I knoAV of one case where an examina- 
 tion of the heart only a few hotirs before a proposed ovariotomy led to a 
 reinvestigation of the case, and a perfect assurance of its ascitic nature. 
 General dropsy, of course, and oedema of the loiver extremities most fre- 
 quently, are more common in conjunction with ascites than with ovarian 
 tumour. The shape of the abdome?i is flattened in ascites, in ovarian 
 tumour it is protuberant ; but this landmark is partly lost when either 
 disease has attained to its utmost limits. The protuberant umbilicus is 
 more common in the former affection, while the false ribs more readily 
 bulge outwards and give a peculiar form to the thorax when pressed 
 by a very large ovarian cystoma than when pressed by ascitic fluid, 
 which has less resistance elsewhere. The aortic j^ulsation is more readily 
 felt through a tense ovarian cystoma than through a tense ascitic abdo- 
 men. If the phenomenon is present without much pressure of the hand, 
 it speaks strongly in favour of the former, but it also points to the 
 necessity for looking for some tertium quid. The phenomenon of abdo- 
 minal hallottement, i.e., the sensation which is given to the fingers when, 
 pressed suddenly and firmly upon a fluid sac, they encounter a floating 
 and apparently solid mass which gently rebounds, is often encountered 
 with ovarian cysts containing others much smaller and more tense, but 
 it is also found in ascites when that is caused or accompanied by solid 
 tumoui-s of any kind which are not fixed. I have seen it thus cause mis- 
 takes in diagnosis rather than render assistance. A single and small 
 included mass thus felt in a very large fluid cavity is, ceteris paribus, 
 rather in favour of ascites. Examination per vaginam or per rectum 
 throws very great light on many cases of doubt. In the case of an 
 ovarian tumour of any size, the uterus is nearly always deflected in some 
 direction, chiefly towards the pubes, and often pretty firmly pressed 
 there, while in simple ascites it retains its normal position as a rule, and 
 can be felt by the sound to be suspended there as lightly as in the normal 
 condition. A very large unilociilar or almost unilocular cyst may hardly 
 l)e ])erceptible as bulging downwards thvdugli tlic iiclvic brim, or, if it is, 
 
AND OVAlilAX TUMOUitS. 427 
 
 there will probably be true fluctuation between the examining finger and 
 the hand on the abdomen. Ascites may give the same positive oi- 
 negative signs. If, however, there is a biilging mass in Douglas's pouch, 
 which, though not hard, is yet evidently less fluid than the abdominal 
 swelling, wc have very strong evidence indeed in favour of ovarian cysts 
 of multilocular character. A pretty hard mass felt here may still be the 
 lower end of an ovarian cystoma, but it may also be pelvic cancer or 
 uterine fibroid, or sarcoma of the ovary, or other matters accompanying, 
 and probably the cause of, the ascites. One diagnostic point of very 
 great, although not of absolute importance, still remains, viz., the evidence 
 furnished hy the fluid drawn off from a doubtful case by aspiration or 
 tapping. Can an absolute diagnosis be made in this way, supposing 
 always that no admixture of ascitic and ovarian fluids has taken 
 place 1 The discovery of true columnar epithelium in the fliiid would, T 
 think, be certain evidence in favour of tumour, but not so the negative 
 evidence derivable from its non-discovery. The ovarian corpuscles 
 of Drysdale, before referred to (p. 406), and often more easy of dis- 
 covery than columnar epithelium, are said to have been found in ascitic 
 fluid, although certainly they are very rare, Avhile they are equally 
 common in ovarian fluids. The physical and chemical differences of the 
 two fluids are marked when typically ijre&ent. Spontaneous coagulation 
 is not confined to nor is it always present in either, but it is very rare 
 in the ovarian cases and moderately common in the ascitic ; when prompt 
 and complete it is, however, almost invariably due to neither, but to a 
 uterine fibrocyst. Very pale watery fluid is found in unilocular cysts, 
 especially those of the broad ligaments. Any great amoimt of viscidit}- 
 is almost certainly ovarian, but slight degrees are not diagnostic. If 
 the specific gravity is over 1018, it is most likely an ovarian fluid, 
 but Garrig-ues has found it 1025 in ascites ; below 1010 a cyst of the 
 broad ligament, or an exceptional cyst in a cystoma is probable. Both 
 ovarian and ascitic fluids coagulate on boiling, and the further test for 
 paralbumin in the former is discredited. On the whole the physical 
 appearance when well marked, or the discovery of columnar epitheliixm 
 and perhaps of Drysdale's cells, can alone be greatly depended on. 
 
 The coexistence of ascites with solid ovarian tumours is rather the 
 rule than the exception, but it ma}^ also coexist with ordinary cystomata, 
 thus rendering doubtful tlic evidence obtainable from percussion and 
 also from aspiration ; and the bursting of small cysts, or their opening 
 by tapping, may commingle the two fluids. Such cases should be borne 
 in mind as possible, but operation under mistake will in such a case be 
 more advantageous than the contrary procedure. I have purposely 
 omitted to mention several diagnostic points insisted on by writers of 
 eminence, imt which are not accepted by cithers of eciual weight. The 
 
428 DIFFEREXTIATIOX BETWEEN UTEEINE FIBEO-MYOMATA 
 
 difficulties in certain cases are great enough without encumbering the 
 tjro with many facts on which he is told he must not rely. 
 
 There is one other soiirce of difficulty in the differentiation between 
 ascites and ovarian tumour which is fortunately a rare one ; I allude to 
 the presence of gases in an ovarian cyst. This, if extensive, would 
 completely invalidate all our iTiles as to physical examination. I am. 
 not aware, however, that it has ever occurred except in a case that had 
 been diagnosed previously to the formation of gas, the complete change 
 in all the formerly obsei-ved signs leading to escape from error. Air 
 admitted on tapping may produce this result, or some accidental com- 
 munication with hollow viscera, but septic putrefaction after tapping or 
 aspiration is certainly the usual cause. 
 
 Fibroid Tumours of the Uterus. — In their very early stage these may 
 be mistaken for ovarian growths, but the differentiation of these intra- 
 pelvic growths has been sufficiently insisted on akeady. Larger fibroids 
 of the uterus have, however, been not infrequently mistaken for ovarian 
 tumours, although their physical properties are very different from those 
 of the cystic forms. But a large fibroid may at times have a certain 
 amount of softness, owing to its lax fibre or to serous infiltration, 
 and a cystoma with much connective tissue and excessively small 
 cysts may appear almost as hard and unfluctuating as a fibroid. If 
 such a fibroid happened to be sub-peritoneal, pedunculated, and un- 
 accompanied by others, there may be no clue to diagnosis from any effect 
 on the functions or phj-sical characters of the iiterus, and judgment may 
 have to be susjjended. Such a hard timiour, if growing very slowly or 
 not at all, and giving rise to few or no inconvenient symptoms, would 
 almost certainly be a fibroid, however, and in deciding on treatment 
 this view should be maintained, i.e., it should be left untouched until 
 farther developments led to a reconsideration of the matter. 
 
 The great majority of fibroids, however, so involve the uteras, or are 
 accompanied b}- others which do so, as to lead to changes in the function 
 of that organ, and to notable alterations in its form or position which 
 render the diagnosis from ovarian growths comparatively easy. It is 
 in the fortunately somewhat rare occtirrence of fihro-cystic tumours (p. 
 284), that we meet with the greatest difficulty, the evidence derivable 
 from the absence of fluctuation being there unavailable. The rarity of 
 this cystic degeneration of fibroids, although they seem to be more common 
 in America, renders their occasional occurrence the more puzzling. There 
 are certain signs and symptoms common to fibroids and fibrocysts, but 
 differential from ovarian tumoiu's, which may be best given in tabular 
 form, followed by those peculiar to fibrocysts alone. 
 
 Universal hardness without any localised fluctuation characterises the 
 pure fibroid and a very few ovarian cystomata, and localised fluctuation 
 
AND OVAIUAX TUMOURS. 
 
 429 
 
 with a considerable general hardness cliaracterises fibro-cystoma and not 
 a few ovarian cystomata. 
 
 Table of Differential Characters of Uterine Fibroids or 
 Fibro-Cystic Tumours, from Ovarian Cystomata. 
 
 A. Uterine Fibroids. 
 
 1. The age of the patient usually 
 corresponds to the child-bearing period 
 of life. 
 
 2. The tumour is generally tolerably 
 central, but not always. 
 
 3. The rate of growth is generally 
 slow. 
 
 4. Menstruation is generally profuse, 
 often dangerouslj' so. Metrorrhagia is 
 frequent. Anienorrhcea hardly ever 
 exists. 
 
 5. The uterine cavity is generally elon- 
 gated, often much so. 
 
 6. The uterus is evidently part of the 
 tumour, and moves with it. 
 
 7. The, cervix uteri may be normal, but 
 often appears as a short button-like 
 appendix to the hard mass, or it may be 
 completely stretched out as in late j^reg- 
 nancy. 
 
 8. The uterus forms part of the lower 
 segment of the tumour, and the position 
 of its true fundus is often indistinguish- 
 able. 
 
 9. Pressure signs on the bladder, rec- 
 tum, &c. , are common. 
 
 10. The general health is commonly 
 scarcely affected, except by meuorrhagia. 
 
 11. Aspiration if eniplo3-ed would give 
 negative results. 
 
 B. Ovarian Cystomata. 
 1. The age is not limited. 
 
 2. The tumour is usually quite lateral, 
 at any rate in the earlier stages. 
 
 3. The growth is usually rapid, the 
 more polj'cystic or pseudo-solid the more 
 so. 
 
 4. Menstruation is normal or deficient, 
 sometimes irregular, rarely if ever profuse, 
 unless from uterine complications. 
 
 5. The uterine cavity is normal in 
 length, or nearly so. 
 
 6. The uterus is generally separable- 
 bi-manually or by sound. 
 
 7. The cervix uteri is normal, unless 
 itself diseased. 
 
 8. The uterus is usually pushed out of 
 place, laterally, anteriorly, or posteriorly, 
 or it may be drawn up or pushed down. 
 In any case it is nearly always possible 
 to trace its body and fundus. 
 
 9. These signs are less common or ob- 
 trusive. 
 
 10. The general health is also often 
 unaffected, but emaciation, and other 
 untoward symptoms mentioned above 
 follow in the wake of large or rapidly 
 growing tumours. 
 
 11. Aspiration nearly always yields 
 some fluid. 
 
 The fibrocyst exhibits the above named phenomena with one or two 
 very important difFcrenccs, all of which tend to assimilate its signs to 
 those of an ovarian tumour, and to render its diagnosis therefrom more 
 difficult. 
 
 1. While the rate of growth is usually slow at first, as with a simple 
 fibroid, it becomes more rapid after cavities have foi-med, and may then 
 be as rapid as that of any ovarian tumour. 
 
430 DIFFEEEXTIATIOX BETWEEX PEEGXAXCY 
 
 2. Fluctuation is felt in certain spots, and these may in time occupy 
 much of the whole tumour space. Tapping or aspiration will also show 
 the existence of fluid. 
 
 3. The fibro-cystic wall is generally more Hvid than the siuface of a 
 fibroid or ovarian ttimour. But this sigTi is only of service after the 
 abdomen is opened. 
 
 It becomes, then, a very important question whether the nature of 
 the fluid obtained from a fibrocyst by aspiration is sufficient to distin- 
 guish it from that which is ovarian. From all that has yet been 
 written on the subject, the fluid of fibrocysts is established as being 
 clear, yellowish, or dark brown. ]\Iost frequently it coagulates spon- 
 taneously and very quickly, and as this rarely if ever occurs in ovarian 
 fliiids, its occurrence would be very strongly in favour of fibrocysts : 
 but the absence of the phenomenon is not of equal value. There are no 
 microscopic appearances in the fluid of a fibrocyst of differential value, but 
 the presence of columnar epithelium would be of absolute value against 
 its diagnosis, as no such sti-ucture is possible under the circumstances. 
 
 Pregnancy. — The diagnosis of early normal preg-nancy from ovarian 
 tumour, should not present any considerable difficulty. Time, the 
 uterine cavity forms a kind of cyst ascertainable by bi-manual examina- 
 tion if not otherwise. Biit the same manipulation will unmistakably 
 show its relation to, and connection with, the cervix uteri, even 
 although that stiiicture may not have yet undergone any of its nonnal 
 changes. Some at least of the ordinary signs and symptoms of early 
 pregnancy (see Appendix) will also be present, and when there is the 
 faintest doubt in the matter, it is imperatively necessary to give preg- 
 nancy the benefit of it. This is especially required in the case of the 
 unman-ied, where mistake is more likely to occm-. Xo operative prc>- 
 ceedings would be called for under even doubtful circumstances until the 
 tumour had arrived at such a size as would involve absolutely charac- 
 teristic signs in the event of pregnancy. After the fourth or fifth month, 
 although calamitous mistakes have been made, they must invariably 
 have been due to want of sufficiently careful observation, rather than to 
 the absence of the means of differentiation. In every case, when the 
 uterus is not clearly to be felt of normal size and distinct from the noM" 
 considerable tumour, every sign of normal pregnancy must be bonie in 
 mind, and its presence or absence clearly ascertained. If this be done, 
 T am convinced that mistake is impossible, at any rate in the direction 
 which is most dangerous to the patient, — where pregnancy is supposed to 
 be ovarian tumour. To mistake an ovarian tumour for pregnancy 
 would certainly bring discredit on the practitioner, but a very short 
 time will suffice to expose the error. The symptoms of pregnancy due 
 merelv to siu-rounding pressure or to various sympathies in other parts 
 
AXD OVARIAN TUMOURS. 
 
 4;jl 
 
 of the system, ultliough carefully to be noted, are never to be relied upon, 
 except as imposing additional caution ; they may almost all be absent in 
 pregnancy or present with uterine or ovarian tumours. I allude to 
 such matters as morning sickness or other digestive or resiDiratory or 
 nervous disorders, swelling of the breasts, darkening of the areola (see- 
 Appendix), swelling of the legs or vulva, congestion of the vagina, &c. 
 Among the local physical signs, some are of considerable although not of 
 conclusive importance, others are perfectly differential. In such an 
 important matter of diflTerentiation, it is advisable to give no positive 
 and final opinion, and certainly to adopt no operative proceedings, until 
 the certain signs are clearly discovered or positively negatived by time, 
 if in no other way. 
 
 Omitting then, many of the minor points, which are void of any 
 positive diagnostic force in themselves, we may tabulate the points of 
 difference which must be insisted upon between a gravid uterus of at 
 least five or six months and an ovarian tumour. 
 
 Table op Differextiation between Pregnancy and Ovarian Tumours. 
 
 Pregnancy. 
 
 1. Enlargement follows a definite rate. 
 
 2. Tumour is smooth, sometimes ob- 
 scurely fluctuating, often contractile 
 under manipulation, central, or some- 
 what to the right. 
 
 3. Venous enlargement or cedema of 
 abdominal walls is rare. 
 
 4. Jlenstruation is arrested for a period 
 corresponding with the other signs ; ex- 
 ceptions occasional. 
 
 5. Abdominal ballottement may be pre- 
 sent, also vaginal. 
 
 6. Fa?tal movements may be positively 
 felt. 
 
 7. The typical mammary areola of 
 pregnancy is very significant in a primi- 
 para, also the umbilical areola. 
 
 8. The cervix uteri and lower segment 
 of the uterus undergo specific changes 
 corresponding to the length of pregnancy. 
 
 9. The uterine souffle is often clearly 
 heard. 
 
 10. The foetal heart-sounds are abso- 
 lutely diagnostic of pregnane}'. They 
 may, however, be extra-uterine, and with 
 a dead child they are not heard. 
 
 Ovarian Tumour. 
 
 L Enlargement may be more rapid, 
 but is usually much slower. 
 
 2. Tumour is smooth or with decided 
 lobular projections, distinctly fluctuating 
 in most cases, never contractile, gener- 
 ally unilateral for a considerable time. 
 
 3. These are common in the case of 
 large tumours. 
 
 4. Menstruation is often scanty, or if 
 arrested, the date seldom corresponds 
 with the signs and history of a gravid 
 uterus. 
 
 5. Vaginal ballottement is never simu- 
 lated, abdominal occasionally. 
 
 6. There is notliing which perfectly 
 simulates fa?tal movements. 
 
 7. The mammary areola of pregnancy 
 may be pretty closely simulated, the 
 umbilical areola less seldom. 
 
 8. The cervix is normal, the uterus pro- 
 bab]}'^ displaced, but traceable beside or 
 below the tumour. 
 
 9. A jirecisely similar souflle is not un- 
 common with fibroid growths, and has 
 been heard with an ovarian tumour. 
 
 10. The fatal heart-sounds are not 
 heard unless pregnancy be present as a 
 complication. 
 
432 . DIFFEEENTIATION OF OVARIAN TUMOURS 
 
 Having discussed the most common sources of error, we must now 
 mention (in many instances very summarily) those which are of less fre- 
 quent occurrence, or less likely to cause mistakes. Following the order 
 of the table on p. 420, we find — 
 
 Spina Bifida. — This, without a distinctive history and external 
 manifestations, is so rare that it may be dismissed with the remark 
 that its fluid, according to Garrigues, has no albumin nor histological 
 elements. 
 
 Haematocele {see Chap. XIX.). — I am not aware of any mistake 
 in this direction of late years, since the pathology of haematocele has 
 been clearly worked out. With any large accumulation of blood in the 
 peritoneum or pelvic cellular tissue, there is a history of sudden super- 
 vention with shock. In a recent case, while the blood is still fluid, mis- 
 take is impossible. Subsequently coagulation takes place, the mass is 
 encysted by lymph, and becomes hard and fised, and, if intra-cellular, 
 it inter-penetrates the tissues of the pelvis below. With a badly 
 detailed history it may easily be mistaken for pelvic lymph, cancer, or 
 some other affections, but hardly for a smooth, movable, or freely fluctu- 
 ating ovarian tumour. Aspiration would detect only blood or bloody 
 serum. 
 
 Pelvic Lymph, the product of pelvic peritonitis or cellulitis. This 
 also yet remains to be described (Chap. XIX.). It will be seen that 
 we have here also a very distinguishing history of acute or sub-acute 
 inflammation, foUoAving delivery or some other travimatic or septic 
 cause, followed by exudations, which, although more or less fluid at first, 
 speedily become solid, and the relations of which to surrounding parts 
 will be afterwards fully described. A careful study of the circumstances 
 of these exudations should prevent mistake, but occasionally both 
 haematocele and inflammatory exudation degenerate into — 
 
 Pelvic Abscess. — We have here a collection of fluid, often occupying 
 much the same situation as an ovarian cystoma, and more or less encysted. 
 We still, however, have the history of the case to guide us, and we 
 have the temperature, pulse, acute pain, and other signs which point to 
 inflammation or suppuration. The discovery of pus by aspiration would 
 differentiate an ordinary ovarian tumour at once. A perfect history of 
 hsematocele or pelvic inflammation, and the absence of a previously diag- 
 nosed cyst, without inflammatory symptoms, woidd negative the diagnosis 
 of ovarian tumour, but without this source of enlightenment we might 
 possibly have to deal with an ovarian tumour which had undergone 
 suppuration within its walls. It would, imder these circumstances, be 
 our duty, by careful bi-manual examination, to try and solve the difficult 
 problem whether the case should be treated as a pelvic abscess by vaginal 
 tapping or incision, or as a suppurating ovarian cyst by abdominal section. 
 
FEOM VAKIOUS OTHER CONDITIONS. 433 
 
 The history, the apparently clear and free margin of the upper part 
 of the mass in the case of a tumour, the involvement of the pelvic struc- 
 tures below in the case of abscess, would enable an expert to come to a 
 fairly probable solution of the difficulty. 
 
 Pelvic or Peritoneal Cancer. — Pelvic cancer is for the most part 
 secondary to disease of the uterus or other viscera, and its diagnosis 
 is therefore comparatively simple. But when primary masses are met 
 with at the pelvic brim, and when they are accompanied, as they almost 
 universally are, by ascites, some of the features of a cystoma, with its 
 more solid portions dipping into the pelvis, are presented. We must 
 rely on the ordinary physical tests to prove the intra-peritoneal situation 
 of the fluid, and that being ascertained, the diagnosis of cancer as its 
 cause will depend on the hard nodulation of the mass, on the rapidly 
 increasing asthenia, and on the evident infiltration of surrounding parts. 
 Fowlis {p2:). cit.) has described certain microscopic appearances which he 
 considers as proving that ascitic fluids are connected with malignant 
 growths or peritoneal cancer, but as Knowsley Thornton and Keith have 
 each found them in connection with non-malignant growths, they need 
 not be here further insisted upon. 
 
 Molar Pregnancy. ^ — The differentiation of this condition is rather 
 from normal pregnancy than from ovarian tumour. There will always 
 be sufficient of the ordinary signs of pregnancy to delay any attempts at 
 ovariotomy, and the practitioner must depend on his familiarity with 
 obstetrics for other indications for treatment. 
 
 Hydramnion, or undue accumulation of the amniotic fluid, causes 
 a pregnant uterus, when examined only through the abdomen, to 
 resemble very closely a large unilocular cyst, but if the history of the 
 case is carefully weighed, it is only in its too rapid increase, and in the 
 undue preponderance of its fluid contents, that the uterine swelling 
 differs from what is normal in pregnancy. The physical characters of 
 the lower segment of the uterus are those of advanced pregnancy, and 
 the whole history points in the same direction. 
 
 Hsematometra. — Congenital accumulation of blood in the uterus, 
 from atresia of any portion of the genital canal (p. 147), can onh 
 be mistaken for ovarian tumour by one who ignores the history of 
 amenorrhoja, with its accompanying and characteristic j)ain, and Gradual 
 distention of the uterus, and who declines to avail himself of the 
 evidence furnished by internal examination. The history of morbid 
 parturition or traumatic accidents, followed by atresia and suppressed 
 menstruation, is with equal ease made clear by a careful utero- 
 vaginal examination ; indeed, it is mainly in deference to the fasliion 
 observed by other writers that I have included in our list either lucmato- 
 metra or 
 
434 DIFFEKENTIATION OF OVAEIAN TUMOUES 
 
 Hydrometra, or 
 
 Physometra). 
 
 Uterine Cancer,— The symptoms and signs of this affection, when 
 affecting the body, have been ah'eady mentioned. I cannot see how they 
 can lead to error in differentiation so far as ovarian tumour is concerned, 
 unless through the coexistence of ascites. Pain, hsemorrhage, foetid 
 discharges, and other symptoms are foreign to ordinary ovarian growths, 
 and the ascitic accompaniment has its own differential physical signs. 
 
 Fat in the Abdominal Walls. — This occurs to a very great, some- 
 times an enormous, extent, mainly about the time of the approach- 
 ing menopause, and has been mistaken for ovarian tumour, pregnancy, 
 fibroid tumour, and other affections. Johanna Southcott's was a case in 
 point. Althovigh the deposit is generally xmiform, it is sometimes much 
 lobulated. I have had several such cases sent to me for operation, but 
 the previous examination has never been at all careful. The whole mass 
 can be lifted up and felt to be in the walls, which when grasped are 
 evidently several inches in thickness. Not a single percussion sign of 
 ovarian tumour is clearly marked, and if the percussion is firm and 
 strong, these may be demonstrated to be absent. Vaginal examination 
 shows only normal conditions. 
 
 Hypertrophy of the other structures of the abdominal wall is much 
 more rare, but is open to the same tests. In a case of the sort, 
 anaesthesia is always advisable, as much of the apparent hypertrophy 
 may be merely spasm. A case of true elephantiasis of the walls is re- 
 lated by Atlee. 
 
 (Edema of the walls often coexists with ovarian tumour, and 
 should ahvays lead to careful examination for underlying abnormal 
 matters. The pitting on pressure is characteristic of the condition 
 itself, and a careful examination of the patient's heart, liver, kidneys, 
 &c., will reveal the caiise when subjacent tumour cannot be detected. 
 
 Abscess of the wall itself is a rare occurrence. If large, it would 
 show an isolated fluctuating tumour which might be difficult to diagnose 
 if we had no history of previous local inflammation. To the practised 
 hand, however, even then the tumour would seem to be so superficial, 
 so immovable in any way, and so unconnected with pelvic signs or 
 symptoms, that aspiration would be called for and would solve the 
 question. 
 
 Cysts of the abdominal wall, fortunately almost unique, would, 
 from the absence of inflammatory symptoms, be more liable to create 
 error. Strong suspicions would be aroused by the physical character- 
 istics which are common to them and to abscess, and aspiration would 
 show a thin serous fluid with none of the characters of ovarian fluids, 
 or even of those of the broad ligaments or Fallopian tabes. 
 
FROM VARIOUS OTHER AFFECTIONS. 435 
 
 Solid growths in the wall should be more easy to recognise thau 
 cysts. They can be lifted up and isolated from all their suiTound- 
 ings, and, if growing at all rapidly, would demand an incision for their 
 removal or diagnosis, which might in cases of doubt be termed and pre- 
 pared for as an exploratory abdominal section. The exj)loring needle 
 might furnish evidence of malignant structures. 
 
 Phantom Tumour. — This curious condition is not very rare, especi- 
 all}^ about the menopause or in recently married w^omen, and is closely 
 allied to what is known as spurious pregnancy. In both cases we have a 
 spasmodic contraction of the abdominal muscles, which at the first glance 
 closely resembles an abdominal tumour or a pregnant uterus. There is 
 nearly alwaj^s a certain amount of tympanites accompanying it, but 
 there may also be large accumulations of fat. The patient is always of 
 hysterical temperament, but there is often great doubt as to how far she 
 is aware of the mimicry she is enacting. As obstetricians are all aware, 
 she may also simulate many of the other signs of pregnancy. I have 
 kno\vn the foetal movements admirably imitated in a case where I feel sure 
 the deception w^as not intentional. Mistake in such a case for either 
 ovarian tumour or pregnancy is inexcusable. The percussion signs are 
 absolutely wanting, as are those furnished by vaginal examination. In 
 the slighter cases the tumour will disappear under steady pressure if the 
 patient's attention be otherwise engaged, or if she be made to perform 
 deep and prolonged expirations. Anaesthesia settles all possible doubt, 
 and enables us bi-manually to ascertain the normal condition of parts. 
 
 Renal Cysts. — If seen at all early, a renal cyst should hardly be mis- 
 taken for an ovarian tumour, however unilocular. It will be found to 
 occupy the lumbar region, and although gradually extending downwards 
 and forwards it will generally push the intestines in front of it. Its 
 growth is generally very slow, and careful inquiry and investigation may 
 show previoi;s or existing renal disease. There may or may not be 
 occasional very abundant discharges of urine, followed by diminution or 
 temporary disappearance of the tvimour. The increase is evidently from 
 above downwards, and there is an absence of intra-pelvic signs of any 
 kind. In any case where these physical conditions arc present, recourse 
 should be had to aspiration. If urea or uric acid be present in the 
 limpid fluid, as it frequently is, the diagnosis is perfect. The long 
 columnar epithelial cells of ovarian tumours would certainly be absent, 
 but, in the absence of distinct urinary constituents, the physical examina- 
 tion, after drawing off a considerable quantity or the whole of the fluid, 
 and careful watching of the mode of refilling, are to be mainly depended 
 on for diagnosis. I cannot help thinking that some of the difficulties in 
 the way of diagnosing tumours of pelvic origin from those which origin- 
 ate elsewhere, mentioned in various excellent treatises, are partly due 
 
436 DIFFERENTIATION OF OVAEIAN TUMOUES 
 
 to the fact that they are written by surgeons, who, however able other- 
 wise, were not so famihar with bi-manual pelvic examinations as a little 
 more extended gynsecological practice would have rendered them. 
 
 Splenic Cysts. — These are so rare that there is little known accurately 
 as to their contents. Their mode of growth downwards ought to prevent 
 mistakes. They would probably be accompanied by hsemic changes. 
 
 Hepatic cysts, with the exception of hydatids, could hardly fail to 
 escape notice long before their size and descent in the abdomen simulated 
 ovarian tumour. 
 
 Pancreatic cysts are referred to as containing fluid very like that 
 of ovarian multiple cystomata, columnar epithelium inckided, but I 
 know of no recorded case where the physical signs led to a diagnosis of 
 ovarian tumour. 
 
 Peritoneal cysts, including those of the omentum, are again very rare, 
 unless cysts of the broad ligament or encysted ascites be included. The 
 physical signs of one in the lower part of the abdomen would be such 
 that diagnosis would be almost impossible from an ovarian cystoma with 
 a long pedicle. Even tapping would only show negatively the absence 
 of the more viscid kinds of ovarian fluid and of columnar epithelium. 
 A mistaken diagnosis would here be highly exciisable, and might lead 
 to successful extirpation. 
 
 Hydatids. — I have placed these in a separate class, for although they 
 may occasionally be met Avith in any part of the abdomen, and their 
 physical signs are those of multilocular cystoma, they have certain 
 peculiarities which will generally lead to an accurate diagnosis of their 
 existence. The liver being by far the most common primary seat, the 
 tumour will, if seen early enough, be traceable downwards and not 
 upwards in its growth. Some writers lay great stress upon what was 
 termed by Piorri the hydatid fremitus ; but Cobbold asserts that this 
 scarcely differs from the ordinary impulse communicated by fluid matter 
 within any form of tumour, and Sir W. Jenner has only once in all his 
 vast experience met with it. If any of the acephalocystic vesicles are 
 discharged per rectum or otherwise, the diagnosis is rendered clear. 
 Without tapping I do not see how a hydatid mass growing from the 
 pelvis or lower abdomen is to be differentiated, but if there are corre- 
 sponding masses elsewhere, or especially under the livei', aspiration 
 should certainly be employed. This will reveal the clear watery con- 
 tents, of low specific gravity — 1011, and containing much chloride of 
 sodium — and a careful search will generally detect the characteristic 
 booklets of the Echinococcus. A mistake in diagnosis has not infre- 
 quently proved vahiable to the patient by leading to the extirpation of 
 portions of the hydatid mass, followed by the disappearance of the 
 rest. 
 
FKOM VAKIOUS OTHER AFFECTIONS. 437 
 
 Solid or Malignant Tumours of the Kidney, Liver, and Spleen have 
 figured much more seldom as causes of error than cysts of these organs. 
 Until they have attained an enormous size, they can never reach suffi- 
 ciently into the cavity of the pelvis to give rise to mistake, and a solid 
 ovarian tumour of such a size would certainly be malignant, and would 
 attract attention long before it had reached the level of these organs.. 
 That strange phenomenon, a loose kidney, has led to mistakes. It is, 
 however, a less common affection than the experience of enthusiastic 
 hospital mter7ies\yon\d lead us to believe, and it is probable that an 
 ovarian or uterine fibroid mass with a long pedicle has been more often 
 mistaken for a kidney than the reverse. The great freedom of motion 
 of a loose kidney, its resemblance to the shape of the normal organ, the 
 slowness or total absence of growth, and the non-discovery of the organ 
 in its normal situation, warrant the assumption of floating kidney, and 
 will, at any rate, stay the hand from operation until time allows of 
 further developments or shows their absence. I have twice met with 
 floating kidney in combination with renal cyst. Very puzzling cases 
 they were, but it is impossible, in a general work, to detail such excep- 
 tional combinations. 
 
 Solid Tumours of the Peritoneum, of its Glands, and especially of 
 the Omentum, are by no means of infrequent occurrence. They are 
 usually malignant, but in the omentum especially a great variety of 
 growths has been found. I have seen, in one case that was operated 
 on for ovarian tumour, an omental cyst, a fatty tumour, and a large 
 bony mass in juxtaposition. When well isolated and unaccompanied by 
 ascites, such masses can generally be diagnosed by their situation and 
 want of comiection with the pelvis, but ascites is most frequently pre- 
 sent and inflammatory adhesions may caiise it to be encysted. Aspira- 
 tion may or may not reveal the true nature of the fluid, and the matting 
 of intestines, lymph, and tumour may cause strange anomalies in the 
 percussion of the sohd parts. Mistakes have occurred in the best of 
 hands and will occur again. There is one comforting point, viz., that 
 in such a case an exploratory incision is the surest method of diagnosis, 
 and affords the only chance of remedy. 
 
 Distended Stomach and Tympanites. — Mistakes can only arise here 
 from want of the commonest precautions in the way of percussion. Tlie 
 appearance, of a tumour is often caused in this way, if the abdominal 
 walls are feeble, but here the resemblance entirely ceases. 
 
 Faecal Accumulation. — This may occur to an enormous extent in 
 the female rectum, sigmoid flexure, and colon, and the doughy mass 
 thus produced and felt above the pelvic brim may not be very unlike a 
 pelvic growth. But the history of prolonged constipation, sometimes 
 combined with a httle constant mucous diarrliaa, will i)nt us on oiu- 
 
438 DIFFEEENTIATIOX OF OVAEIAN TUMOUES 
 
 guard. The first vaginal examination will detect the solid yet pitting 
 mass above and behind, and rectal examination will complete the diag- 
 nosis, and lead to its confirmation hj the action of aperients and enemata. 
 
 Distended Bladder. — Mistake here is also inexcusable. The history- 
 of retention, perhaps of accompanying retroverted gravid uterus, the 
 local distress and constitutional symptoms in a chronic case, the central 
 tender tumour, the soft bulging of the anterior vaginal wall, — all point 
 to the necessity for the catheter, care being taken to use a long flexible 
 one. 
 
 Hydronephrosis and Distended Ureter.— The physical characters of 
 a hydronephrosis resemble those of a renal cyst, and in most, although 
 not in all cases, we have the history of urinary trouble and the presence 
 of purulent, bloody, or albuminous urine to help our diagnosis. If 
 the ureter be greatly distended, the elongated form of the tumour ma}^ 
 assist in differentiation. 
 
 Distended Fallopian Tubes. — The conditions which lead to distention 
 of the Fallopian tubes — to hydro-salpinx, pyo-salpinx, or hsemato-salpinx 
 — have yet to be described (Chap. XVIII.). If the collections so caused 
 are large, they may be difficult to distinguish from cysts of the broad 
 ligaments, or even from ovarian tumours. As they frequ.ently discharge 
 their contents periodicall}^ into the uterus, this occurrence would aid 
 materially in diagnosis. No complete account of the microscopic ap- 
 pearance of their contained fluids is known to me, but, in common with 
 ovarian tumours, they may contain columnar epithelium. This may, 
 however, be ciliated, while that of ovarian cystomata is never so distin- 
 guished. 
 
 Extra-uterine Pregnancy. — This fortunately rare condition has 
 been mistaken for ovarian tumour much less frequently than might be 
 supposed. In its earlier stages it is seldom diagnosed from normal 
 pregnancy, and unfortunately the great majority of cases terminate hj 
 rupture before the question of differentiation from other tumours is 
 likely to arise. It is when the foetus has died and become mummi- 
 fied or encysted that mistake is most likely to arise. The history of 
 the case is mainly to be relied on, — a history of lapsed pregnancy, with 
 more or less constitutional disturbance. The form of the mass is little to 
 be relied on, for every case, and they have been several, in which I have 
 been consulted about a supposed encysted foetus, has turned out to be 
 something else. I showed one such to many experts, the deceased 
 Dr M'Clintock among the number, at the time of the meeting of 
 the British Medical Association in Manchester in 1877, with what 
 appeared to be a perfectly typical history, and the only difference 
 of opinion was as to the exact position of the child. Yet it turned out 
 to be a case of pelvi-abdominal cancer. The stationary condition of the 
 
FROM VAEIOUS OTHER AFFECTIONS. 4o9 
 
 tuuiuur, combiued Avith the history, is our surest reliaucc, luid tliu diiig- 
 uosis of every such case should from time to time be revised (see further, 
 however, Chap. XVIIL). 
 
 Spinal Abscess, — Lumbar and psoas abscess will sometimes give 
 rise to irregular fluid enlargements, which, by their fluctuation, might 
 simulate a cyst. But, with anything like the ordinary history to guide 
 us, and with a careful local examination, mistake should be impossible. 
 
 This long list might have been extended, but I am satisfied that many 
 of the mistakes described by special writers have been made only by mere 
 tyros, or before the nature of ovarian growths or of the conditions mis- 
 taken for them were understood as they now are by almost every efiicient 
 practitioner. The specialist or consulting physician mtist often decide 
 this grave question of diagnosis at a single interview, but the family 
 practitioner need never do this. I would strongly advise him to direct 
 his attention at first mainly, if not solely, to. the four important sources 
 of error first described. Above all things, let him first eliminate normal 
 pregnancy. Then let him turn his attention to the differentiation of 
 uterine tumour and ascites, and afterwards try to ascertain the proba- 
 bility or otherwise of the tumour growing from the broad ligaments rather 
 than the ovary. Let him then, book or list in hand, or previously well 
 conned, go over the other sources of error. Most of them he will easily 
 eliminate. The most deceptive are omental tumours or fibrocysts of the 
 uterus, and these wall only be probable in a certain small nmnber of 
 cases ; but if at all probable, they demand the aid of the expert. In- 
 deed, I have very grave doubts whether any one who has seen but a very 
 limited number of cases is justified in finally recommending operation 
 without a consultation uf the kind, if it is at all within rcacli. AYe must 
 pass on now to the treatment of ovarian tumours. 
 
440 TEEATMENT OF OVAEIAN TUMOURS 
 
 CHAPTER XVII. 
 
 Diseases of the Ovary — continued. Ovarian Tumours. Treatment, by Explor- 
 ation, Tapping, Drainage, or Removal. Ovariotomjr and Oophorectomy. 
 
 Internal remedies are utterly powerless in the removal of ovarian 
 tumours, and it would be a waste of time to recapitulate those which have 
 been occasionally tried, or even vaunted as successful. By attention to 
 the state of the skin, bowels, &c., the patient's health may be kept at a 
 higher standard than otherwise would be the case, and for a longer time, 
 and much general discomfort may be avoided ; but having said this, we 
 have said all. 
 
 The treatment, unless the growth of the tumour is almost absolutely 
 stationary, and even then, according to most authorities, must be of a 
 surgical character. Many plans, which now appear more or less barbar- 
 ous, were in vogue before the discovery of ovariotomy, and some of these 
 continue to be mentioned in the regular text-books, and, with more 
 reason, in special monographs. I will endeavour to confine myself to 
 those which are really in use, under varying circumstances, and by the 
 leading authorities. They will resolve themselves into three — (1) tap- 
 ping in some form, (2) drainage, and (3) removal. 
 
 And first, a word or two about the slightest form of tapping, which is 
 employed only for the jDurpose of diagnosis, the instrument used being of 
 minute calibre, and only a small quantity of the fluid contents being 
 necessarily drawn off. This is generally known as — 
 
 Exploration. 
 
 The exploring needle with grooved surface is of no value here. 
 The hollow needle of the subcutaneous syringe is more suitable, 
 combined with such aspiration as the syringe, or one of a somewhat 
 larger size (fig. 51), will afford. Used M'-ith extreme antiseptic pre- 
 cautions, I have no dovibt of the almost perfect safety of this means of 
 diagnosis. The light Avhich it throws on the case may often be very 
 "slight, but in some cases, as for instance in the differentiation of puru- 
 lent accumulations or hydatids, it may be invakiable, and I do not think 
 that its use should be neglected in any case which presents evident cir- 
 
BY EXPLOKATION AND TAPPING. 441 
 
 cumstances of doubt. It may prevent a mistaken attempt at ovari- 
 otomy, or obviate the necessity for exhaustive tapping or exploratory 
 incision, either of which is fraught with a certain amount of danger to 
 life. A reference to the foregoing catalogue of possible sources of 
 error will show the numerous instances in which it is of service. 
 
 Tapping. 
 
 By this we mean the removal of the whole, or as much as possible, of 
 the fluid contained in the cavity which is tapped. It may be performed 
 either for diagnosis, or in the hope of cure, or as a palliative remedy. It 
 cannot possibly be said to be an operation without danger, but I think 
 the danger has been somewhat exaggerated, and it certainly can be 
 minimised by antiseptic precautions. The one unavoidable danger is that 
 of perforating a vessel in the walls or substance of the tumour, and so 
 giving rise to serious internal hsemorrhage. By using an instrument 
 with a very sharp point and not too sharp edges, and by introducing it 
 slowly, this danger can be minimised, although not entirely obviated. 
 It must serve as a warning against unnecessary tapping. 
 
 For purely diagnostic x>'U'rposes, the use of tapping might be much 
 limited. Mere exploration will, in all probability, sufl&ce, and if this be 
 employed in the first instance, it may help to diminish the danger of 
 any subsequent tapping, by showing that a very small trocar will suffice, 
 owing to the thinness and fluidity of the tumour's contents. If explor- 
 ation has given sufficient positive or negative evidence to complete our 
 diagnosis satisfactorily, tapping for further diagnostic purposes only should 
 certainly be avoided. Of late years certain operators — Lawson Tait, 
 Bantock, and others — have almost entirely discarded tapping for diag- 
 nostic purposes, and prefer to rely on an abdominal incision, all being in 
 readiness to proceed with ovariotomy if that should prove to be feasible. 
 I doubt not that with care, and with very careful dissection, an abdom- 
 inal incision of 2 or 3 inches may be made with almost as great safety 
 as tapping, and that much more exact information is thus obtained, but 
 the profession is not entirely composed of skilled ovariotomists, and it is 
 not every practitioner who is prepared to meet even the difficulties which 
 may arise from an adherent peiitoneum, or to fulfil the other operative 
 conditions which an incision may involve. Diseased kidneys, hydatid 
 masses, and other unsuspected abnormalities have been safely removed 
 in this way, but only by experts. A scratch upon the exposed sui-fiice 
 of such a mass may leave no option. 
 
 When fluid, which may be ascitic, or renal, or ovarian, or of other 
 kinds, is tapped for the purpose of diagnosis, it should be done by a 
 trocar of not more than No. 2 catheter size. If a pointed tube be used, 
 its point should be capable of l)eing withdrawn into tlic tube. Either 
 
442 TAPPING AS A MEANS OF 
 
 instrument should be furnished with a stop-cock. The abdominal surface 
 should be antiseptically washed, and the instrument should be thoroughly 
 soaked in strong antiseptic solution. If dulness extends well across the 
 middle line, the linea alba should be punctured, if not, the most central 
 spot of the dulness should be chosen, avoiding any evident abdominal 
 vessels. If the fluid is so viscid that it cannot escape at all through 
 such a tube, the tapping must be abandoned after aspirating, if possible, 
 a few drops. If it runs, but with difficulty, the aspirator (fig. 52) must 
 be employed ; if it runs freely, an india-rubber tube should be attached 
 to the instrument, and the fluid should be allowed slowly to descend by 
 syphon action into a vessel below the level of the bed. Above all things, 
 air must not be allowed to enter the abdominal cavity. 
 
 As a means of cure, tapping can never be supposed for a moment to 
 succeed in the case of distinctly multilocular cysts. This is adixiitted on 
 all hands. The frequent tapping of such a tumour by a large trocar 
 belongs to a past age, and is a cruel proceeding when done, as it yet too 
 frequently is, by a practitioner who simply acknowledges thereby his 
 inability to remove it and his unwillingness to ask any one else to do so. 
 How far tapping may be successful in a unilocular cyst, or in one which 
 is almost unilocular, is a matter about which there is a strange difference 
 of opinion among those best able to judge. Some tell us that such cysts 
 invariably refill if they are long enough under observation, admitting 
 however, the possibility of several years of perfect comfort and qiiiescence. 
 Others admit that cysts of the broad ligament may be so cured, but not 
 ovarian cysts. Others, again, will not admit this even wdth regard to 
 the former. But any apparently unilocular cyst may be a cyst of the 
 broad ligament, our powers of differentiation being limited. Therefore, 
 even if we admit that it is only such cysts which are thus ever curable, 
 we have not here a positive contra-indication in cysts of doubtful origin. 
 Twice I have removed the fluid from such cysts. With the general 
 characters of ovarian fluid, the patients remaining perfectly well, and con- 
 tinuing so during the two or three years that they were u.nder observa- 
 tion, while I feel certain that a return would have brought them back 
 to me. In one case, also, I tapped a cyst which from its contents was 
 probably parovarian. After a large quantity of fluid had passed the flow 
 ceased, but there still remained a tolerably large cyst. A week after- 
 wards there was no evidence of cyst, but clear signs of intra-peritoneal 
 fluid were present. This in its turn disappeared, leaving no trace of 
 any disease. The patient remained well for many months, until I lost 
 sight of her. The cannula had evidently slipped out of the cj^st, and 
 the contents, aseptic of course, had escaped into and been absorbed by 
 the peritoneum without febrile sj'^mptoms. I cannot therefore rccom- 
 meiid the entire abandonment of tapping as a ]^ossibly cvirative remedy 
 
DIAGNOSIS, PALLIATION, OE CUKE. 443 
 
 ill such cases as I have named. It is all very well for the surgeon who 
 is accustomed to such matters to talk glibly about the splendid statistics 
 of ovariotomy, the only other resource ; but I fear that most of as fail 
 to recognise the prolonged mental agony of many a patient who is pre- 
 paring for a major sm-gical operation, an agony httlq short of that of a 
 condemned criminal. Yet this ought to be taken into account when 
 rejecting the alternative of tapping in such cases, for no amount of 
 tvord-painting, or of statistical references, will ever persuade patients to 
 look upon the two operations with the same equanimity. I think that 
 when the tumour evidently contains thin watery fluid, and when there 
 is no evidence of more than one cyst, the comparative risk, and the faint 
 possibilities of cure, or the probabihties of prolonged alleviation, should 
 be honourably placed before her, together with the " pros and cons " in 
 favoiu- of ovariotomy, and that she should have the option. In such a 
 case I myself would select to take my chance of one tapping. Much dis- 
 cussion has recently taken place as to the relative danger of ovariotomies 
 when tapping has previously been performed, and when it has not. I 
 can only give the result which a careful consideration of the views of the 
 contending parties has had on my own mind. It has certainly removed 
 the impression which, following WeUs, I formerly held, that one or more 
 previous tappings are a positive advantage, rendering the system, and 
 especially the peritoneum, more tolerant of subsequent ovariotomy, with- 
 out overbalancing risks. But it has not convinced me that, in such cases 
 as we have defined, tapping is not a fairly justifiable and even rational 
 attempt at permanent cure or prolonged removal of the disease. The 
 subject is most ably discussed, although with a difterent conclusion, by 
 Bantock (A Flea for Early Ovariotomy, London, 1881). 
 
 Having limited tapping, as a curative means, to such cases, it is not 
 necessary to give instructions as to the dangerous procedure of tapping 
 secondary cysts through that first opened. It is infinitely safer to leave 
 them ;done and reserve the case for ovariotomy. The best position for 
 tapping is with the dorsal decubitus. The bladder must be carefully 
 emptied beforehand. Only when a very large trocar is used, and that 
 should rarely (if ever) be the case, is it necessary to make a preliminary 
 incision through the skin and subjacent fat. So far, tajoping by the 
 abdomen alone has been considered. Tapping through the vaginal walls 
 is a far more hazardous proceeding. There is much greater danger of the 
 entry of air and septic material, and conscc[uently of septicaemia. If 
 the tumour turn out to l)c multilocular we almost invariably perforate 
 its densest portion ; the difticulty is much greater, and the intestines 
 are more apt to be wounded. It should be reserved for the case of a 
 small intra-pelvic cyst which, for some reason, has become intolerable, 
 the true nature of which is perhaps not so clearly diag-nosablc as to 
 
444 TAPPIXG OYARIAX TUMOURS. 
 
 warrant abdominal section, or which is opposing the progress of 
 labour. 
 
 Tcqyjping as a mere 2^(iliici'tive may be employed under the following 
 circumstances : — 
 
 1. The season of the year, or various social circumstances, may render 
 the inevitable ovariotomy inexpedient at the moment, and temporary 
 relief may be absolutely necessary. In such cases one or even two large 
 cysts may be carefully emptied by separate tappings. 
 
 2. Pregnancy may coexist, in which case we have a choice of courses — 
 the induction of abortion or premature labour, ovariotomy regardless of 
 the i)regnancy, tapping, or waiting to the full term. The size, consistency, 
 or rapidity of growth of the tumoui', or the urgency of the pressure symp- 
 toms will decide the question. In a multipara, or a patient in whom 
 there is nothing to indicate a probably severe laboiu', the last course 
 seems the most advisable in the case of an ordinary slow-growing cystoma. 
 I had a patient who had two fine children between the times of diagnosis 
 and successful ovariotomy. But if the suffering be great towards the 
 latter half of pregnancy, and if a large cyst can be clearly diagnosed, its 
 contents, previously ascertained by exploration to be moderately thin, 
 may be evacuated by tapping, and that even more than once. Between 
 the induction of premature labour and immediate ovariotomy there is a 
 very decided choice of evils. If pregnancy coexist with a growing mul- 
 tilocular cystoma, and the viable period be reached, I should have no 
 hesitation in recommending the former course, and even if the pregnancy 
 is at an earlier date, my experience of the comparative safety of skilfully- 
 managed induced labour would lead me rather to side on this point with 
 the obstetrician Barnes than with the ovariotomist Wells, and to nm 
 the risk of, first an induced labour, and subsequently an ovariotomy, 
 rather than that of, first an ovariotomy, and subsequently a laboiu', 
 either as an immediate consequence, or with scarcel}- repaired abdominal 
 structures. 
 
 3. The tumour, although undoubtedly ovarian, may present such char- 
 acters of malignancy or adhesion as to forbid ovariotomy or any attempt 
 thereat, and temporary relief may be gained by tapping. Foav such 
 cases occur now-a-days. A bold and experienced ovariotomist, knowing 
 the fate of his patient otherwise, will seldom be deterred by unseen 
 though probable adhesions, unless influenced by the unworthy motive of 
 accumulating favourable statistics. In the infancy of the operation, when 
 its adoption trembled in the balance, this motive had its legitimate place, 
 but now-a-days the medical public estimates more highly an operator who 
 will not decline the most unfavourable case, if there is a chance of saving 
 an otherwise lost life, than one who has a long list of carefully selected 
 cases and therefore of successful resiilts. Even to the most selfish 
 
DRAINAGE OVARIOTOMY. 445 
 
 statistic-maker there is always the resource of separately classifying his 
 "uncompleted operations" or exploratory incisions. 
 
 The following up of tapping by the injection of iodine, as in hydro- 
 cele, is now, I think, a thing of the past. I saw two or three such cases 
 under Simpson (1855 to 1857), but the results were such as to lead me 
 to do as is done by most recent Avriters, and ignore the procedure 
 entirely. 
 
 Drainage. 
 
 I do not think that any one is now found to advocate the treatment, 
 in the first instance, of a supposed ovarian cystoma, whether unilocular 
 or multilocular, by the insertion of a drainage tube of any kind, 
 after tapping. Whether this is done per vaginam or per ahdominem, it 
 involves many months of suppurative discharge, and of corresponding 
 septic risks, and is not to be compared with ovariotomy as a safe 
 proceeding, while successful cure thu.s is exceedingly exceptional. It 
 should therefore be reserved for those cases where ovariotomy has been 
 attempted, and where, owing to the adhesions met with, the removal of 
 the tumour has been found to be impossible. When this is the case, 
 and when the tumour has not been too much broken up before the im- 
 possibility of removal is discovered, our only resource is to fix together 
 the margins of the opening in the tumour and those of the abdominal 
 wound, including both layers of peritoneum and the skin in the sutures ; 
 and to insert a drainage tube as far as possible into the substance of the 
 tumour. I have met with two such cases, and both recovered entirely, 
 after a prolonged period of hectic and purulent discharge. 
 
 Ovariotomy. 
 
 The operation which is now universally recognised under this term is 
 of such ii\iportance that it will require us to go somewhat more into 
 detail than with some other important gynecological operations. Let 
 the young surgeon, however, who is tempted, as so many now are, to 
 try his hand at an apparently favourable case, remember that removal 
 of an ovarian tumour resembles much its diagnosis, as regards fiicility of 
 performance. In some cases it would be almost disgraceful to fail, but 
 few cases are exempt from difficulties which can only be overcome by the 
 largest experience, if at all. Tlie second operation I performed seemed 
 to be a typically simple and straightforward one, yet the patient died on 
 the table, from venous hscmorrhage in the pelvis, the resi;lt, not of 
 adhesions, but of a morbid softness and friability of every structure con- 
 cerned. Had it been my first, I do not tliiuk T should ever have tried 
 
446 THE OPEKATION 
 
 again. First performed successfully in 1869 by Ephraim M'Dowell of 
 Kentucky, who had imbibed his ideas partly from the teaching of John 
 Bell of Edinburgh, ovariotomy has been gradually improved by succes- 
 sive operators, until it would now be, in skilled hands, among the safest 
 of all capital operations, if we could only assure ourselves of certainty in 
 diagnosis. The history of the subject is given in every special mono- 
 graph, and I shall not enter upon it further than by pointing to Sir 
 Spencer Wells as undoubtedly the leading introducer of the operation 
 into general notice, its consistent advocate, and its foremost improver 
 (see an interesting address by him, reported in the Lancet and Brit. Med. 
 Jour., Nov. 1884). It would be invidious to attempt to introduce other 
 names, although perhaps few woidd denj^ to Charles Clay of Manchester 
 and Thomas Keith of Edinburgh the right to exceptional mention. 
 
 Probably the most satisfactory plan will be to describe the operation 
 under ordinary and favourable circumstances, and then afterwards, under 
 separate headings, to refer to exceptionally difficult or debatable points. 
 No reference is here made to operations through the vagina, nor to 
 excision of the ovaries for other purposes than the removal of a very 
 distinct tumour. I am supposing a case in private rather than in hospital 
 practice. The general health of the patient having been looked to as 
 far as possible, and great attention having been paid to all preparatory 
 arrangements {vide Chap. III.), an experienced nurse will be placed in 
 charge of her at least two days l:)efore the operation. It will be her 
 duty — 
 
 1. To see that the patient's food the day before is light and nourish- 
 ing, and that her breakfast on the morning of operation consists only of 
 a little good beef-tea, or cocoa and toast. This should be three or foiir 
 hours before the operation. 
 
 2. She must administer an enema in the morning, and, if the patient 
 is fairly strong, a mild aperient, early the day before. 
 
 3. She must provide unlimited supplies of hot and cold water, and of 
 1 in 20 and 1 in 40 carbolic acid solution. 
 
 4. She must see that the patient is clad in a warm flannel under- 
 garment, long woollen stockings, her ordinary night dress being slit down 
 the front, above which she may wear a loose woollen jacket. 
 
 5. She must have the chamber at a temperature of 66° to 68°, but 
 not higher, as used to be prescribed. 
 
 6. She should shave the upper part of the pubes if the hair approaches 
 the line of incision. 
 
 7. She must use the catheter not more than half an hour before oper- 
 ation. 
 
 8. She must have charge of the sponges, a dozen at least, of varioiis 
 sizes, all new, and all carefully bleached with dilute hydrochloric acid, 
 
OF OVAEIOTOMY. 447 
 
 washed free of any particles of sand, and well carbolised. She should be 
 responsible for recounting them and reporting to the operator before 
 the stitching is completed. 
 
 9. She should take the evening and morning temperatures before 
 operation, and subsequ.entl}'^ as ordered. 
 
 The room shoiild be thoroughly disinfected, as much as if it had 
 recently contained a case of zymotic disease. Its furniture should be of 
 the simplest description, consisting of — 
 
 1. Two iron bedsteads and fittings. One of them is better not 
 introduced until the third or fourth day, or for a week, at least, if two 
 nurses are available. 
 
 2. One arm-chair. 
 
 3. A common strong dressing-table, 30 to 32 inches high, for the 
 operation, another for the sponges, basins, solutions, lint, strapping, &c., 
 and a smaller one for the operator's instruments. 
 
 4. A large slop pail, a few basins, a thermometer, and a good many 
 towels. A piece of old drugget or some sawdust should be temporarily 
 placed under the operating-table. An adjoining dressing-room, cleared 
 out for the use of the nurse, is an advantage. 
 
 Operation in a common surgical theatre is denounced by almost every 
 writer on the subject. No doubt, the now almost imiversal prevalence 
 of antiseptic surgery diminishes the risk, and in almost every general 
 hospital there are some surgeons who, from conviction or from careless- 
 ness, do not obey the rule. 
 
 The operating-table is placed with its foot near the window, and as 
 the operator stands at the centre of its right side, to the right of the 
 patient, his small table of instruments is placed to his right, and the 
 sponge table well behind him and to his left, the nurse being in charge 
 of it. No one else should interfere with either, unless by request. 
 Anaesthesia is now proceeded with, the administrator standing at the 
 head of the couch, and devoting his scjIc attention to his duties. One 
 other assistant stands opposite to the operator, and he should be speci- 
 ally acquainted with the steps of the operation, Init should only sponge, 
 twist vessels, or otherwise interfere, as the operator may direct. On this 
 detail different operators will vary in opinion. Another assistant to the 
 operator's left is useful, especially if the case prove a difficult one. He 
 should be intently on the watch for orders, but do nothing without. If 
 the spray is used, the apparatus must be placed to the left of the first 
 assistant, and the spray must be thrown well across the wound diag(.)n- 
 ally, not blown into the operator's face, nor directly into the wound. 
 
 Any other authorised bystanders than the one who manages tlie spray 
 should stand well behind the first assistant, au<l will see better and bo 
 less obstructivr il' i'liniislicd with ;i fni-m to stand nnoii. Anv e\ti';i 
 
448 
 
 THE OPEEATIOX 
 
 nurses or probationers should remain beside the head nurse, and one of 
 these may profitably devote herself entirely to washing the sponges. 
 
 Ansesthesia is carried to its fullest degree, and in hospital practice this 
 may be done in the general ward, the patient being afterwards wheeled 
 in on a high couch, which is immediately removed. A folded blanket 
 and waterj)roof are placed below her, another blanket over her lower 
 extremities. The night-dress is now folded aside so as to expose the 
 abdomen. Any brief final clinical observations now being made, the 
 abdomen is well washed with antiseptic solution, especially the umbilicus 
 and the apron is placed in situ. This is a sheet of thin waterproof- 
 
 FiG. 189. — Stanley's Director. 
 
 ing, in Avhich an orifice, exposing the necessary surface only, is made, 
 8 or 10 inches long, and 3 or 4 wide, according to the size and solidity 
 of the tumour, or the obesity of the patient. The edges of the opening- 
 are smeared underneath with adhesive plaster, and the folds should 
 descend on each side, well below the level of the table, up to the breast, 
 and down to the knees. It is important that the adhesive material 
 should be of good quality. 
 
 For the abdominal incision we require two or three scalpels, a pair of 
 dissecting forceps, a flat director, grooved not quite to the point (fig. 189), 
 
 Fig. 190. — Wells's Torsion Forceps. 
 
 half a dozen, at least, of Wells's torsion forceps (fig. 190), counted before 
 and after the operation, and some carbolic glycerine (1 in 8). The last 
 is occasionally applied with the tip of the finger, and serves as a 
 haemostatic and an antiseptic agent. The torsion forceps are fixed on to 
 any bleeding point, and left dependent until the peritoneum is reached. 
 They may then be used, if necessary, as common artery torsion forceps, 
 or they may be removed at an earlier stage if the number is proving 
 deficient. Their temporary hold usually sufiices to ensure the j^ermanent 
 arrest of bleeding. 
 
 The abdominal incision, unless under very exceptional circumstances, 
 
OF OVARIOTOMY. . 449 
 
 is made along the linea alba, so as to pass between the recti 
 muscles, but no great necessity exists for avoiding the edge of one of 
 these, if it is stretched over the middle line. The skin, subcutaneous 
 areolar tissue, and fat, the thick aponeurosis of the muscles, the trans- 
 versalis fascia, and the layer of granular sub-peritoneal fat, are suc- 
 cessively and slowly divided by careful sweeps of the knife, but there 
 are great varieties in these structures, and the operator should not lose 
 his head if his anatomy occasionally fails him for the moment. The 
 recognition of the peritoneum when arrived at is the important point. 
 I have seen it stripped from the abdominal wall to a terrible extent, by 
 an otherwise expert surgeon, under the impression that it was the wall 
 of the tumour ; but no one who has seen the bluish-white, glistening- 
 wall of an ovarian tumour should mistake it for the dull, dark blue of 
 the outside of the peritoneum. As a rule, the motion of the tumour 
 on respiration can be seen below, and the presence of a little intra-peri- 
 toneal fluid may cause the thin membrane to bulge outwards. It must 
 be carefully raised with the point of the dissecting forceps, cut across, 
 and divided lengthways on the director. Feeling su.re that the peri- 
 toneum is reached, or that it has been punctured, the rest of the wound 
 should be dissected down to the same level ; every bleeding point 
 should b(? twisted, the pendent torsion-forceps removed, and the wound 
 well carbolised again. The peritoneal opening is then enlarged suffi- 
 ciently to admit the finger, which guides the blunt-pointed director 
 along its internal wall, so as to allow of a free opening along the 
 whole length of the wound. The incision should terminate below, 
 about 2 inches from the pubic symphysis, thus avoiding the peritoneal 
 reflexion to the bladder. Its length upwards from that point should 
 be at least 3 inches, even when the tumour is known to be very 
 fluid, or when doubts exist as to the diagnosis, and when the operation 
 may be considered as exploratory or diagnostic. When the tumour 
 is semi-solid, the incision should be made 6 inches long at least, and 
 this length may have to be considerably increased. On this point there 
 will be further room for discussion. The incision being now completed, 
 the next point should be the completion of the diagnosis. The diag- 
 nosis should, moreover, now include not only the fact that we have an 
 ovarian tumour to deal with, but a considerable knowledge of its attach- 
 ments and adhesions. Tor this purpose a clean metallic bougie or sound 
 may be passed over the surface of the tumour in all directions where it 
 will go without obstacle, but the forefinger is the best of all sounds. 
 With this the operator can generally reach down in front to the lower 
 end of the globular mass, and can even ascertain something of its 
 attachments or pedicle, and feel the uterus and trace its fundus. Any 
 slight adhesions to the abdominal walls or omentum, which are 
 
 2 F 
 
450 THE OPEEATION 
 
 felt as thread-like bands, are easily torn off the tumour at this time, two, 
 three, or more fingers being used if necessary, but those -which are firm 
 and imyielding should be left until the cyst is partially drawn out from 
 the abdomen. 
 
 The next step is lessening the hulk of the tumour hy tapping. A trocar, 
 as large ' in calibre as a No. 1 2 catheter, and at least 6 inches long, may 
 be used for this purpose. Others of a more complicated character will 
 be described further on. It is plunged into what appears to be the most 
 fluid portion of the tumour, and before the trocar is removed a basin is 
 placed under the cannula, others being at hand, to be exchanged rapidly 
 when full ; or, if the fluid runs freely, it may at once be conveyed to the 
 pail by a piece of tubing furnished with a nozzle which slips easily into the 
 cannula. The pressure of the abdominal walls is at first suf&cient, but is 
 afterwards aided by the second assistant, who will, taking care not to 
 impede the operator, place a hand on each side of the abdomen, and gently 
 biit steadily bear up the tumour towards the wound. This also tends to 
 prevent any of the fluid escaping into the abdominal cavity, a thing to 
 be entirely avoided if possible, although it is astonishing how little effect 
 it may have on recovery. I have seen the whole pelvis and lower abdo- 
 men thickly coated with grumous, gluey material, which sponging quite 
 failed to remove, and yet with scarcely any rise in temperature after the 
 operation. Still the risk of septicaemia must be increased. As the cyst 
 gradually collapses it is drawn well on to the trocar and slowly extracted 
 by the operator. If the first cyst is not large, other cysts will have to 
 be tapped ; and as we can now clearly see what is being done, this may 
 be accomplished through the intervening septa. Some slight difference, 
 often a very great one, in the character of the fluid, will show what has 
 been done. Often, and especially if the size and shape of the whole mass 
 are not clearly known, it is better to tap fresh cysts from without as they 
 appear at the wound. Two or three trocars should therefore be at hand. 
 The withdrawal of the tumotir now continues. The operator may, in 
 a simple case, have sufficient purchase to draw forth the whole mass, 
 slowly and without force, through a very small opening. This is 
 much facilitated, however, by seizing a good-sized flaccid portion with a 
 Nelaton's forceps (fig. 191), although it is wiser not to take hold solelj^ 
 by it, but to include some more of the tumour in the grasp of the 
 fingers. With his left hand the operator from time to time explores the 
 surface of the tumour to mark his progress, and to assist, by a sort of 
 shelling out, the expulsion of tense minor cysts from within the abdo- 
 men, while in the interval of such manipulations the first assistant 
 closes the upper portion of the wound by pinching its edges together, 
 and prevents the escape of intestines or omentum. All this applies to 
 cases where there are very distinct cysts with perfectly fluid contents . 
 
OF OVAKIOTOMY, 451 
 
 but where the tumour is one dense mass of septa, with only minute 
 cysts, or large ones containing gluey matter, tajDping does not avail. 
 There is nothing for it then but to enlarge the opening in the tumour 
 sufficiently to allow the insinuation of the hand into its interior, and so 
 to remove handful after handful of the contents, a process by no means 
 pleasant-looking to the uninitiated. In such cases, also, it will some- 
 times be necessary, in order to avoid undue dragging on the external 
 wound, to enlarge it up to or beyond the umbilicus, passing to one side 
 of this. The operator must look inside and ascertain that there is no 
 intestine adherent to the abdominal wall, which he lifts on his fingers 
 while he divides it. 
 
 While the cyst is being withdrawn, firmer adhesions must he dealt luith 
 if they exist, and as they gradually come into prominence. Even 
 tolerably stout and firm ones will often yield at the point of attach- 
 ment to the tumour, if peeled carefully downwards by the finger, but 
 such must be carefully examined before they are allowed to disappear 
 in the abdomen, and if they bleed, must be either touched with the 
 
 Fig. 191. — Nekton's Tumour Forceps. 
 
 cautery, or, still better, tied with a firm silk or gut ligature, the ends 
 being cut short. A few of these ligatures, more or less, seem to 
 make no difference to the recovery, and all adhesions of omentum or 
 bands of lymph, which are really vascular and strong, are better tied at 
 once and then divided a little beyond the ligature. Close adhesions to 
 bowel or solid viscera are more serious matters If careful digital 
 separation is possible, it is the most satisfactory, anj^ raw siuface left on 
 the viscus being touched with strong solution of perchloride of iron. 
 If the scalpel or even its handle is required, it is better to leave a tliiii 
 section of the tumour-wall than to risk injuring the viscera, and the 
 cautery, Paquelin's lieing the preferable one, may be required also. 
 Posterior adhesions, and those deep in the pelvis, are only discovered 
 towards the close, and require the utmost caution. They are dealt with 
 on the same principles, and in order to see them clearly, tlie first 
 assistant must keep the intestines from rolling downwards by means 
 of a flat sponge, or small pieces of linen well soaked in antiseptic 
 solution. One or two clean, bright copper spatiilce occupy less room than 
 his hands. 
 
452 THE OPERATION 
 
 The tumour having been freed from adhesions, and lifted outside the 
 wound, will remain attached by its pedicle. The second assistant 
 should hold it up in such a way as to make no traction on this, and 
 yet to make it siif&ciently tight to alloAv the operator to examine and 
 treat it. 
 
 The Treatment of the Pedicle. — The history of the treatment of the 
 pedicle is almost the history of ovariotomy, and as it cannot be said 
 that any one plan is yet universally adopted, or is suitable for every case, 
 I shall afterwards shortly refer to others than that which I almost always 
 adopt, and which is described here. If the pedicle is anything like the 
 ordinary length or thickness, the operator seizes it with his left fore- 
 finger and thumb, and compresses it so as to ascertain that he has hold 
 of a thin portion, free from any thick vascular or ligamentous bands. 
 If it be long enough he can also ascertain this by sight. In his 
 right hand he holds a long blunt needle (fig. 192), through the 
 eyelets of which is passed a long ligature of the stoutest possible pure 
 silk, well carbolised, the silk forming a loop between the two eyelets. 
 Guided by the left hand, he pushes this through the central thin por- 
 tion of the pedicle. In the case of a very short pedicle, a curved needle 
 
 ijikiiii ■ l: 
 
 Fig. 192.— Wells's Blunt Pedicle Needle. 
 
 is advisable, and it will serve equally avcU for a long one. The centre 
 of the ligature is thus pushed through, seized, and held, while the needle 
 is withdrawn. The ligature is then cut across, and we have thus two 
 ligatures, side by side, and projecting at least 6 or 8 inches on each side 
 of the pedicle. The two halves are now tied as firmly as possible, tying 
 the two poiiiions of the pedicle, previously crossing one ligature once 
 over the other, to ensure the union of the two knots. It is a safe pre- 
 caution, although seldom quite necessary, to tie another single ligature 
 round the whole pedicle, on the proximal side of the double one. The 
 dependent ends are held up out of the way and the pedicle is cut across 
 with scissors, at least half an inch on the distal side of the knots. The 
 tumoiir is removed and the pedicle is sponged, carefully inspected, and 
 then smeared with carbolic glycerine. With a true ovarian tumour the 
 greater part of the Fallopian tube will be removed Avith the tumour. 
 A careful examination of the other ovary is now made, and if it is foinid 
 to be diseased, it is ligatured and removed in a similar way. 
 
 Next comes the toilet of the pelvis and ahdovien, together with a care- 
 ful search for any bleeding points left by torn adhesions. If the cyst 
 has been almost or quite unilocular, has been shelled out through a small 
 
OF OVARIOTOMY. 453 
 
 opening, with scarcely any adhesion, and with little or no exposvu'o of 
 the intestines, it will suffice to use a succession of small sponges carried 
 by a secure sponge holder into the more dependent parts of the pelvis, 
 especiall}^ Douglas's pouch, until they return almost pure and dry. Biit 
 if the contrary condition has been the case, it is better to carefully 
 inspect the cavity wherever bleeding adhesions are possible, to tie or 
 cauterise them if there are any, and not to close the wound until the 
 absence of haemorrhage or of its products in the pelvis can be positively 
 affirmed. The intestines are meanwhile carefully repressed by the first 
 assistant. The pedicle is now examined again, the ends of its ligatures 
 are cut off, half an inch from its surface, and it is dropped into its normal 
 site. A flat sponge, the full length of the incision, is now laid over the 
 intestinal contents and allowed to remain until the external sutures are 
 placed but not tightened ; it is then carefully withdrawn between two of 
 them, and the sponges are finally counted. It is well also at this time 
 to make sure that all the smaller instruments used are safe. 
 
 For the siitures I greatly prefer silver, although some operators, Wells 
 among the number, still use silk. They may be inserted in various ways, 
 according to the fancy of the operator, but I think that accuracy is secured 
 better and more easily by the straight perineal suture needle (fig. 42). 
 The most, important point is to secure coaptation of the peritoneal edges. 
 The needle is plunged into the skin about a third of an inch from its 
 edge, made to emerge a little further from the cut edge of the peritoneum, 
 then passed similarly upwards on the opposite side. The operator or his 
 assistant threads the point with a piece of wire, 8 inches long or there- 
 abouts, which is rapidly and easily drawn back ; the two extreme ends are 
 loosely twisted together and the process is repeated until the whole 
 wound is sutured, at intervals of about half an inch. After removal of 
 the sponge as above mentioned, the raw edges are once more smeared 
 lightly with carbolic glycerine, and the siitures are twisted and cvit short, 
 as in other suturing with silver wire. As each is drawn tight, not too 
 tight, the wound is lifted up by it, and, with a probe or director, the 
 absence of intestines or omentum is well assured, the peritoneal edges 
 are pressed into the wound, and the edges of skin are placed in apposi- 
 tion but not inverted. 
 
 In dressing the tuound the whole Listcrian system may be used, 
 but I have long adopted a somewhat more simple plan, although 
 equally based on antiseptic principles, and have been thoroughly 
 satisfied with it. The suture ends being laid flat, I lay upon the 
 wound a piece of lint at least an inch longer. This is jDreviously 
 completely saturated with carbolic glycerine, and is several plies thick. 
 Several more plies, of larger size, are placed above this and covered 
 by a still larger piece of waterproof cloth. Then four or five broad 
 
454 OYAKIOTOMY. 
 
 straps of plaster cover the abdomen from side to side and entirely ex- 
 clude the air from the dressings. If necessitated by great shrinking of 
 the abdomen, a thick layer of antiseptic cotton is placed above this, and 
 then an ordinary obstetric binder, or a many-tailed one, of flannel, is 
 applied. This dressing may be safely left untouched, except the binder, 
 for ten days, unless some unfortunate circumstance, such as great rise 
 in temj)erature, arise, necessitating an examination of, or interference 
 with, the wound. This will have healed entirely by first intention, any 
 little clots about the ligatures will be absolutely aseptic, and on remov- 
 ing the stitches the same dressing is quickly reapplied. 
 
 A certain amount of shock immediately follows the operation in most 
 instances, temperature falling to 97, 96, or lower, but this slowly passes 
 off if the patient is covered with warm blankets, and hot bottles or tins 
 are applied to the feet, limbs, and body. This should be done in every 
 case until the temperature rises above the normal. The after-treatment 
 consists in the regular use of the catheter, and occasional subcutaneous 
 injections of morphia, to produce rest and lock the bowels. The food for 
 a day or two should be almost nil ; a few teaspoonfuls of iced milk or 
 Brand's essence of beef are sufficient at first, and after a day or two a 
 larger amount of light nourishing slops is gradually allowed. Stimulants 
 are seldom required, unless the first shock is of considerable duration or 
 great extent, when the subcutaneous injection of 20 minims of sulphuric 
 ether will be found very effective. The bowels are kept locked for at 
 least a week or ten days, and then very carefully relieved by an injection 
 of olive oil. Sickness coming on immediately after operation, and con- 
 tinuing at intervals for a day or two, has not the same evil import as 
 the same symptom occurring after the first or second day. Ice, iced 
 soda water, or a little champagne, may be given with advantage, and I 
 have seen, where these had failed, a small ci;p of hot tea arrest it at 
 once. The temperature and pulse miist be carefully watched, and any 
 sudden and great rise, with or withovit rigor, will excite suspicions of 
 septic changes in the intra-abdominal serous fluid, to be met by the use 
 of the ice bag to head or limbs and by full doses of quinine. In marked 
 and severe septic inflammation of this kind, immediate relief has been 
 given by opening the Avound at its lower end or by tapping Douglas's 
 pouch through the vagina, but the use of a drainage tube will obviate 
 the necessity for this serious proceeding. Its advantages will be dis- 
 cussed later on. 
 
 After this sketch of the operation, it remains to mention certain points 
 wherein practice varies, different methods or means are employed, or 
 the circumstances of the case vary from those commonly met with. 
 
 The Use of the Spray. — I have no intention of reintroducing here the 
 question of Listerism or antiseptic surgery. I firmly believe in its 
 
VAEIETIES IN THE OPEKATION. 455 
 
 principles and adopt its practice, as is everywhere aj^parent. But mau} 
 who do this have come to the conclusion that the use of the spray has 
 certain disadvantages in ovariotomy. They allege that subsequent 
 hyperpyi'exia is often due to the large amount of carbolic acid introduced 
 into the abdomen, and that dangerous cooling of the intestines and peri- 
 toneum during the operation is apt to be caused by the condensed 
 steam. My experience as to the hyperpyrexia has been exactly the 
 opposite of this, and the cooling can be greatly prevented by having the 
 apparatus not too far off, and by directing the steam across, not into, the 
 wo\ind. I cannot feel justified, therefore, in refusing to a patient, in 
 hospital practice at any rate, this means of driving off or neutralising 
 any vitiation of the atmosphere. On the other hand, in home practice, 
 and with every precaution described above, I feel that the necessity for 
 the spray is minimised, and its slight disadvantages are less counter- 
 balanced by gains. With plenty of intelligent assistance, however, I 
 cannot see that it is contra-indicated in any w^ay. 
 
 Ancesthesia. — Setting aside the discussion whether, on general prin- 
 ciples, we should abandon chloroform and return to ether, — and I have 
 not seen it necessary to do so, except in particular individuals, — I believe 
 that Sir Spencer Wells is right in considering that bichloride of methy- 
 line, given with Junker's apparatus, is the most suitable aneesthetic 
 for ovariotomy. I have seen it followed by severe sickness, but it is 
 less often so than chloroform. The anaesthesia should be deep at first, 
 and afterwards skilfully kept up just to the verge of apparent insensi- 
 bility to pain, and it may be pushed a little deeper just before the inser- 
 tion of the superficial stitches (see p. 53). 
 
 The Ahdorainal Inciaion. — Much discussion took place at one time as 
 to the relative mortality of long and of short incisions. I think all are 
 agreed now that any proved difference depends, not so much upon the 
 size of the incision, as upon the relatively larger, more solid, or more 
 adherent tumours for which the larger incisions are required. Rather 
 than exercise any forcible traction through the w^ound, or treat strong 
 adhesions in the dark, it is advisable to enlarge the incision, even to 
 the length of 10 or 12 inches. It is well to enter the peritoneum at 
 first about the centre of the incision. The finger can then be inserted 
 downwards, and might thus detect a som-ce of danger which has lately 
 been noticed in one or two instances, viz., the adhesion of the bladder to 
 the front of the tumour. When there is great difficulty in separating 
 peritoneum and tumour in front, owing to adhesions, it is better to dis- 
 sect upwards outside the peritoneum until a point is reachetl where it can 
 be lifted by the forceps from the subjacent mass. 
 
 Tapping the Cyst. — I have described only a simple trocar for this pur- 
 pose, because I believe that, used with neatness and ])racticc, it can 
 
456 
 
 OVAKIOTOMY. 
 
 perform the work with perfect efficiency. A much larger one than No. 
 12 catheter is not of much service. Fluids that will not flow throuo-h 
 it will hardly be persuaded to do so through a larger instrument. But 
 the instrument of Wells (fig. 193), and there are several slight modi- 
 fications of it, is very cleanly. Its point is withdrawn by a not very 
 elaborate mechanism, and by its spring booklets it can soon be securely 
 attached to the flaccid cyst wall. An inexperienced operator is apt, 
 however, to tear a thin cyst by very slight traction on the inviting 
 
 hold of it he has thus 
 obtained. A piston 
 trocar, such as that 
 originally used by 
 Wells (fig. 194), and 
 furnished with a rub- 
 ber tube, avoids the 
 necessity for changing 
 vessels, and, on the 
 whole, I prefer it. Either of these instruments conveys the fluid directly 
 into the large pail which stands below the table. 
 
 The Pedicle. — There has been more variation in the treatment of the 
 pedicle than in most other respects. Most of the earlier cases were treated 
 as a ligatured vessel then was. A strong ligature, often of whip-cord, 
 was tied around it ; the tumour was cut off, and the ends of the ligature 
 were left hanging out of the wound. It is astonishing what success was 
 obtained, in spite of this septic communication with the outer world, and 
 of the secondary hfemorrhage which its removal or attempted removal 
 
 Fig. 193.— Wells's Trocar (i). 
 
 Fig. 194— Piston Trocar. 
 
 occasionally involved. The extra-peritoneal treatment was an enormous 
 advance on this. The pedicle was brought to the opening of the wound 
 and transfixed, or otherwise secured outside, while the wound was tightly 
 closed around it, and antisepticity of the projecting portion was secured 
 by tanning it with perchloride of iron. Wells's clamp (fig. 195), with 
 minor modifications by others, was the perfection of an instrument for 
 this purpose. The removable handles powerfully compressed the clamp, 
 which was then secured in position by the screw. After a certain time 
 separation took place, and the clamp was removed, leaving an extra- 
 
TEEATMENT OF THE PEDICLE. 
 
 457 
 
 cibdominal cicatrix, which generally healed speedily. But the extra- 
 abdominal clamp has in turn yielded to improved intra-abdominal 
 methods of treatment. It slipped occasionally, some time after the 
 operation ; it was apt to make serious traction on the pelvic organs ; 
 it gave rise to adhesions which impeded the uterine functions, to hernia 
 through the abdominal walls, to ulceration of formidable extent, to ex- 
 cessive vomiting after operation, and it opened a door, although a less 
 wide one than formerly, to septic poisoning from without. Of course, 
 these untoward results occurred only occasionally, but they did occur ; 
 and the tendency to each of them was diminished, if not abrogated, by 
 the use of the short-cut ligature left entirely within the abdomen. It 
 was soon found that pure silk ligatures thus used gave rise to little 
 or no further trouble, that proper application prevented all fear of their 
 
 Fig. 195.— Wells's Clamp. 
 
 slipping, and that there was sufficient minor circulation left in the 
 stump to prevent its acting as a foreign body or a slough. Granula- 
 tions freely sprout through the meshes of the silk, and in time it becomes 
 disintegrated and lost, I will not say absorbed. The greatest difficulty 
 lay with short and very broad pedicles, but these also were difficult or 
 impossible to treat with the clamp. They can be tied in more than two 
 portions. The ecraseur or the actual caiitery may also be considered as 
 a fairly safe means of dividing the pedicle, which is then left free within 
 the abdominal cavity ; but much as I value these instruments for the 
 treatment of many affijctions, safe as I consider them for the bloodless 
 division of many structures, and much as I admire the wonderfidly 
 good results of Baker Brown and Keith, I confess that I dare 
 not trust to these alone whei'c failure is so irretrievable, and when 
 
458 
 
 TEEATMENT OF THE PEDICLE. 
 
 we have such an efficient means of treatment as the intra-abdominal 
 short-cut silk ligature. There is one other method of treating 
 the pedicle to which we may have recourse, when, to use a Hiber- 
 nicism, there is not one. If the tumour is found to be firmly im- 
 bedded in the broad ligament, and with nothing that is capable of being 
 ligatured, it may be enucleated ; that is to say, we may separate the 
 peritoneal covering which exists at its lower end, and scrape or tear out 
 the tumour from within it. Great patience and watchfulness as to 
 bleeding points are required ; and when the tumour is thus finally enu- 
 cleated, the cut or torn peritoneal edges thus left should be turned 
 inwards upon themselves, and united by gut sutures. I have only had 
 one experience of the kind, and desisted early from the attempt at 
 enucleation, treating the case successfully by stitching the edges of the 
 lower part of the cyst to the abdominal wall, and com- 
 pleting the cure by antiseptic drainage. I may quote 
 the words of Lawson Tait : — "I have three times em- 
 ployed this method (enucleation) with eminently satis- 
 factory results ; but I am bound to say that, without a 
 good deal of experience in the separation of adhesions, 
 I Avould have stopped in the middle of the process and 
 left it incomplete, on account of its difficulties." 
 
 Drainage of the Peritoneum. — Marion Sims especially, 
 but not alone, has shown that death occurs in the 
 majority of abdominal wounds or operations, from the 
 septic effects of sero-sanguineoiis fluid in the lower part 
 of the peritoneum, and that if this can be washed out 
 or otherwise removed, recover}^ is possible, even in the 
 most serious cases. Twice I saved cases, evidently 
 moribund, by aspirating Douglas's pouch, and so remov- 
 ing the source of danger. But this is but a clumsj- 
 and hazardous proceeding. We ought to be able to suck up any such 
 fluids through the abdominal incision, and this is provided for if we 
 insert a drainage tube into the lower angle, and leave it protruding 
 through the abdominal opening, well g-uarded antiseptically. If we use 
 a glass tube (fig. 196), as recommended by Keith, we may thus pump 
 out with a fine syringe, whenever there is a rise of temperature, every 
 di-op of fluid from the peritoneum, or even wash it out with antiseptic 
 fluids. The idea is charming, and we thus render the penetralia of the 
 pelvis almost as open to treatment as the surface of an external wound. 
 But we thereby run some risks. In the great majority of our cases we 
 have no such septic poisoning, and we certainly make an opening for it 
 in the hands of a careless or sleepy nurse or assistant. We greatly 
 reduce the advantages of the intra-peritoneal treatment of the pedicle. 
 
 Fig. 196.— Keith's 
 Glass Drainage 
 Tube. 
 
DRAINAGE. 
 
 459 
 
 I stoutly held out against this drainage plan until I lost two consecutive 
 cases of very simple operations on fine healthy young women. Then I 
 adopted it. In the first case Ave pumped out quantities of sero-sanguineous 
 fluid twice a day, but we could not get a rise in temperature or a single 
 bad symptom to justify us in doing so. In the next case I put an india- 
 rubber cork in the tube, and left it alone till the end of five days, when 
 I took it out with every antiseptic precaution. Then the temperature 
 rose to 105, and I wished I had left it longer, or not meddled with it for 
 a longer period, but the patient did well. I treated four cases subse- 
 quently with the well-corked tube, and those in a general hospital when 
 erysipelas was somewhat rife. The taking of it out involved in each case 
 a slight rise of temperature, but not more than 
 the removal of the stitches or the first opening of 
 the bowels often does. I took care to leave all 
 fluids behind, and not to remove the cork before the 
 tube. The result of all this is to convince me that 
 if the operation has been done antiseptically, in 
 a healthy surrounding, and with the fair certainty 
 of a-septic accompaniments, we run less risk by 
 omitting the drainage tube. If these conditions are 
 evidently absent, the operation should not be done 
 at all, but if there is a doubt on the point, as there 
 must often be in hospital practice, it is better to 
 use the drainage tube, to cork it up w^ell, and, if all 
 goes well, to get rid of it within five or sis days, 
 as carefully as possible. In one of the cases above 
 referred to, a wide sinus was left for nearly three 
 weeks, the depth or dimensions of which I never 
 cared to inqxiire into too minutely. 
 
 I think I shall use the Avell-corked tube in any 
 future hospital cases, or when I know that the 
 peritoneum cannot be thoroughly cleansed, and do without it in all 
 others. In the case of the spray, one makes this rule of thumb sort 
 of distinction for less valid reasons, but in the case of the drainao-e 
 tube we have to some extent to make a choice of evils, and the 
 relative proportions of these may depend on the surrounding circum- 
 stances. It is necessary to make very sure that the tube is secured 
 so firmly that it cannot slip ; and I have found a thick india-iiibber 
 one (fig. 197), with a phlange like that of a tracheotomy tube, very 
 serviceable ; it can, if made very long, be cat down to the exact requisite 
 leng-th at the time of operating. 
 
 The Causes of Death after ovariotomy are chiefly shock, hsemorrhage, 
 and septiceemia. How far peritonitis, not due to sepsis, may sometimes be 
 
 Fig. 197. —India-rubber 
 Drainage Tube, with 
 Plug of the sa&e 
 material. 
 
460 OVAEIOTOMY INDICATIONS AND CONTEA-INDICATIONS. 
 
 a cause, it is difficult, if not impossible, to say. Wounds of surrounding- 
 organs — the bladder, intestines, ureter, &c. — figure occasionally, although 
 it is to be hoped very rarely. Strangulation of intestines in the wound, 
 by the pedicle, or otherwise, may be considered as among the preventible 
 causes. Death may also occur, as after other operations, from various con- 
 stitutional affections of the thoracic organs, kidney, liver, &c. Gradually 
 increasing knowledge of the best methods of operation is rapidly dimin- 
 ishing the mortality in every direction, but undoubtedly the greatest 
 danger lies in the various forms of septic poisoning. To extreme care 
 in cleansing the peritoneum, to the careful prevention of haemor- 
 rhage from adhesions, to the utmost attention to the a-septic condition 
 of operator, assistants, bystanders, ward surroundings, instruments, and 
 appliances, and to the proper estimation of the value of drainage, we 
 look for still further advances. 
 
 The general indications for the operation are simple enough. 
 Given an ovarian tumour which is increasing in size, or interfering with 
 the health, usefulness, or comfort of the patient, it should be removed, 
 unless, according to views enunciated above, a preliminary tapping is 
 advisable, or unless there is some definite contra-indication. 
 
 The contra-indications are becoming daily fewer and fewer. A non- 
 increasing tumour, with only trivial discomfort to the patient, should, 
 I think, be left alone, although I am not unaware of the possibility of 
 the simplest cyst developing papillomatous, sarcomatous, or other malig- 
 nant contents. I cannot, however, help thinking that in this event it 
 would warn us to interfere by departing from the innocuous conditions 
 premised. Evidences of hsemorrhage into the cyst, or of suppuration 
 within it, or of strangulation of its pedicle, or of dangerous inflammation 
 about it, are indications for immediate operation rather than delay. 
 Supposed malignancy of a cystic tumour pleads also in favour of 
 removal, unless malignant deposits are found elsewhere. The chance of 
 saving a life should outweigh the chance of damaging a table of statistics, 
 and, in respect to immediate danger, the operation is not in the same 
 category as excision of the cancerous uterus. Adhesions, however 
 extensive they are supposed to be, will not deter from careful explora- 
 tory incision. Coexisting ascites, which may fairly be suj)posed to be 
 due to the presence of the tumour, is no barrier to operation. The 
 more debilitated the patient, the greater the incentive to try and save 
 life by operation ; but the highest practical skill is necessary to decide 
 how far the health may be improved during a short delay, with suitable 
 general treatment. The whole range of circumstances which were 
 formerly described as "likely to bring the operation into discredit," 
 may now be left out of calculation, from that point of view merely. But 
 general cancer or tuberculosis, and organic diseases of other organs, 
 
OOPHOEECTOMY. 461 
 
 •\vliicli are certain to be aggravated by any opei'ation, are the only true 
 contra-indications to one who knows that he can cope with any reason- 
 able local difficulties. 
 
 Oophorectomy. 
 
 I am well aware of all the difficulties that arise when we attempt to 
 define what we mean by " oophorectomy " in contradistinction to 
 " ovariotomy." The latter is etymologically a mongrel term, the former 
 includes the latter. I leave the student to study for himself the dis- 
 cussion as to the terms "normal ovariotomy," "Battey's operation," 
 " Tait's operation," and the like — but I accept for the present a term 
 which almost every one understands to mean the removal of the ovaries, 
 not on account of ovarian tumour, but for other reasons. 
 
 The preliminary management and the first steps of the operation are 
 the same as those for ovariotomy. Too small an incision is a mistake, 
 for, although the substances to be extracted are often small, there is 
 sometimes great difficulty in separating them from their attachments, 
 or even in finding them. About 4 inches will generally suffice. The 
 division of the peritoneum must be very carefully made, for intestines lie 
 immedifitely behind it, except in operations necessitated by large uterine 
 
 Fig. 198. — Wells's Pedicle Forceps, curved. 
 
 fibroids. The fundus uteri is the first part searched for, and, guided by 
 this, we pass the finger along the broad ligament and find the ovary. 
 The uterus, with its annexes, may be carefully elevated on the sound by 
 an assistant. A forceps, similar to, but twice the size of, the Wells 
 torsion forceps, is of great use (fig. 198) to grasp the pedicle while it is 
 perforated and tied Avith silk as above directed, and in ovariotomy this 
 instrument serves a great many iiseful purposes, which each operator 
 will discover for himself. It is advisable, in nearly every case, to 
 remove both ovaries, as the cessation of ovulation and menstruation is 
 the essential object of the treatment. The experience of Lawson Tait 
 is conclusive, that this is more immediately and certainly accomplished 
 by removing the Fallopian tubes at the same time, even when they are 
 not found, as they very frequently arc, to be themselves diseased. It 
 will depend on the relation of the parts whether this is done by the 
 same ligature as that whicli isolates the ovary, or by a sci)arate one. 
 
462 INDICATIONS FOE OOPHORECTOMY. 
 
 Where no adhesions, the result of ovaritis, salpingitis, or surrounding- 
 peritonitis, exist, the operation is generally easy enough, but in the 
 contrary state of matters the greatest difficulty and danger from haemor- 
 rhage may arise, requiring the utmost skill of the coolest and most 
 practised surgeon. There is also much difficulty, in some cases of large 
 coexisting uterine tumour, in finding and isolating the structures to be 
 removed. 
 
 So much has already been said, in former portions of this work, as to 
 the indications for this operation, that I need but recapitulate briefly 
 the conclusions arrived at, conckisions which must be held with 
 modesty, owing to the very recent introduction of the procedure : — 
 
 1. As a remedy for the hsemorrhages due to fibroid tumours it has 
 now, I think, a well-established place. When such are tending at all 
 rapidly to the destruction of life, it holds out a fair chance, although not 
 an absolute certainty, of arrest, and it is preferable to operations on the 
 uterus itself, except in such cases as present a bulging submucous 
 tumour or a polypoid form. It should not be undertaken rashly, nor 
 until fair trial has been made of palliative treatment. The circum- 
 stances of the patient, as regards her means of obtaining occasional rest 
 and skilful treatment, will, here as elsewhere, form an element in the 
 decision. 
 
 2. As a remedial treatment for epilepsy or other nervous affections, I 
 look upon this operation with the gravest suspicion. Its advocates have 
 escaped the opprobrium which fell upon and crushed poor Baker Brown 
 in his advocacy of cliteridectomy under very similar circumstances, but 
 his fate should serve as a warning against undue precipitancy in asso- 
 ciating all the nerve disorders of women with local disorders of their 
 sexual organs. The great successes of massage, with its accompanying 
 dietetic and moral treatment, in such cases, surely point to the necessity 
 for general treatment, with less regard to that of the ovaries. At pre- 
 sent I should decline to sanction oophorectomy, on this account, with or 
 without the removal of the Fallopian tubes, unless I had some physical 
 indication that these organs were organically affected, and that the local 
 symptoms of this organic affection were irremovable otherwise. 
 
 3. In a w^ell-marked case of infantile uterus, with constant and in- 
 creasing dysmenorrhoea, unrelieved by treatment of the flexed canal, I 
 think this operation is justifiable. Few patients who have suffered long 
 would decline to avail themselves of it, if the whole circumstances 
 involved were fairly put to them. 
 
 4. The most important question arises as to the advisability of the 
 attempted removal of the ovaries in cases of chronic ovaritis, or of 
 diseases which cannot always clinically be diagnosed from it. We are 
 most likely to be successful, and are most fully justified when, on 
 
VAGINAL OVAEIOTOMY. 4-(J3 
 
 making the incision, cystic degeneration of the ovary is found to exist, 
 or disease of the Fallopian tube is found to be the true cause of chronic 
 distress. But the operation involves great danger when peri-ovaritis or 
 pelvic cellulitis coexist, and I should advise no young practitioner to 
 undertake it until he has fully studied not only the reported cases, but 
 some of those unreported ones of which he may hear in most of our 
 large centres of population. 
 
 Vaginal Ovariotomy or Oophorectomy. 
 
 Removal of the ovary by the vagina on account of even moderate- 
 sized ovarian tumours seems to me to present so many elements of diffi- 
 culty and danger, in excess of its removal by the abdomen, that I do not 
 feel it necessary to do more than refer the student to the special works 
 on diseases of the ovary before referred to. As regards oophorectomy, 
 to preserve our distinction between the two, I look upon the operation 
 as increased in difficulty and generally in danger by the vaginal method, 
 although I do not forget that Battey performed his earlier operations, at 
 any rate, in this manner. The patient having been placed in lithotomy 
 position, and the vagina having been rendered a-septic as far as possible, 
 the cervix uteri is drawn down by vulsellum, while with the aid of the 
 duck-bill speculum the vaginal wall is incised behind it in the middle 
 line, so as to admit one or two fingers into the peritoneal cavity. These 
 drag down the ovary if they can find it, and if it is not too adherent, and 
 bring it through the opening, and thus enable us to ligature its attach- 
 ments and remove it. The other ovary is similarly treated. If one 
 were called on to " spay" a healthy woman, or one who had merely some 
 nervous or hysterical affection, this method would doubtless suffice, and 
 a drainage tube with antiseptic irrigation would ensure fair safety after 
 the operation, but how an adherent ovary, or one removed far from its 
 normal site by uterine tumour, can be thus safely treated, I am at a loss 
 to see, and the simultaneous removal of the Fallopian tube in this way 
 presents still greater difficulties. 
 
 I feel it necessary to apologise both for the length of these observa- 
 tions on the removal of the ovary and its tumours and for their incom- 
 pleteness, but I have acted as far as I possibly could in conformity Avith 
 the intentions expressed in my prefatory remarks. 
 
464 THE FALLOPIAN TUBES. 
 
 CHAPTER XVIII. 
 
 Diseases of the Fallopian Tubes. Congenital Abnormalites, Morbid Growtlis 
 Undue Patency. Constriction. Inflammation, Acute and Chronic. Abscess 
 (Pyo-salpinx). Tubal Dropsy (Hydro-salpinx). Hsmato-salpinx. 
 
 Extea-Uterine Pregnancy. 
 
 The Fallopian Tubes. 
 
 The diseases of these organs have assumed considerably greater import- 
 ance dimng the last few years. It has long been known that they are liable 
 to inflammation, to abscess, and to enlargement from other causes, but 
 these conditions were considered to be rare, and almost impossible of diag- 
 nosis from other much more common affections — from ovarian inflamma- 
 tion, pelvic cellulitis, pelvic abscess, (fee. The progress of ovariotomy 
 and oophorectomy has revealed the fact that affections of the tubes 
 are more common than was hitherto supposed. Attention being more 
 attracted to them, their diagnosis has become somewhat more easy, in this, 
 if in no other way, viz., that instead of considering them as rarities which 
 must just be borne in mind as possible sources of en-or, we may take them 
 into consideration, in a large mimber of cases, as our starting-point for 
 framing a diagnosis by exclusion. The functional activity of the tubes 
 as sources of some of the flow during menstruation, demonstrated 
 by Beniutz and Goupil, and insisted on with characteristic persistency 
 by Tait, has accounted for some of the cases of tubal distention follow- 
 ing occkision, and has caused these organs to be regarded with greater 
 interest by the operator who looks upon the arrest of the menstrual 
 function as a primary object or a desirable sequel of his operation. 
 
 The tubes (fig. 199) vary in length from 4 to 6 inches, the right being 
 frequently the longer. They run along the upper margin of the broad 
 ligaments, curving over the ovaries and extending beyond them, one of 
 the fimbriae of the trumpet-shaped extremities maintaining a permanent 
 connection with those organs. Their ciliated lining epithelium works 
 towards the utems, facilitating the passage of the ova outwards, and 
 probably retarding the ingress of the spei-matic fluid. If it were a 
 proved fact that the inherent locomotor powers of the spermatozoa could 
 not overcome this resistance of the Fallopian cilia, we should be com- 
 
ABNOEMALITIES AXD MOIiCID (;i;OA\'TIIS. 
 
 465 
 
 lielled to admit that all previous views as to the fertilisation of the ovum 
 taking place normally within the tubes were incorrect, and that extra- 
 uterine fcEtation could only occur as a result of destruction of the 
 Fallopian cilia by inflammation or otherwise. As far as I can gather 
 from Tait's most recent work this is his view, and there is much to 
 support it. 
 
 The Fallopian tubes, when healthy, are scarcely to be made out by 
 bi-manual examination ; but when moderately enlarged by disease, their 
 peculiar twisted shape can often be very fairly defined in this way. 
 They give the impression of a knuckle of small intestine or of a bent 
 sausage, but when largely distended they may become as globular as 
 any other tumour met with in the same neighbourhood. 
 
 Congenital Abnormalities of the Tubes, of any clinical im- 
 
 FiG. 199. — The left Broad Ligament, Fallopian Tiibe, Ovary, and Parovarium, 
 .seen from behind (Henle). 
 
 portance, are usually coexistent with similar abnormalities of the 
 ovaries. A duplex trumpet-shaped extremity has been noted, but I 
 know of no instance of a double tube from one horn of the uterus. 
 Absence of the tube is found in unilateral development of the ovary and 
 uterus, but a perfect tube has been found when the ovary was quite 
 rudimentary. Occlusion of the tubes at either end may possibly be 
 congenital in some instances, Ixit it is certainly the result of disease in 
 the majority. 
 
 Morbid Growths of the Tubes, of almost all kinds, arc recorded in the 
 annals of jjatliological anatomy. There is no organ of the body in which 
 such is not the case. Cancer, sarcoma, tubercle, myomata, lipomata, 
 calcareous deposits, and tlie like, luivc all been found in the dissecting- 
 
 2g 
 
466 UXDUE PATENCY, OCCLUSIOX, AND IXFLAMMATIOX 
 
 room, but clinically they cannot at present be separated from similar 
 growths of the surrounding parts except by abdominal incision and 
 removal. 
 
 Undue Patency of the Tubes has been strongly insisted on as a fre- 
 quent occurrence by Matthews Duncan {Diseases of Worjnen, 1883). In 
 an article in the Brit. Med. Jour., of March 12, 1881, he has furnished 
 clear proof from various soiirces that this may exist, occasionally at any 
 rate. The knowledge of this fact should make us additionally careful in 
 the use of intra-uterine or forcible vaginal injections. It will also 
 account for a limited number of cases of pelvic hsematocele, and, even 
 although the normal ciliary action of the Fallopian mucous lining usually 
 prevented the ingress of spermatozoa, it might account for certain cases of 
 Fallopian impregnation and extra-uterine pregnancy. As an excuse for 
 the passage of the uterine sound beyond the limits of the uterus it may 
 serve, and sometimes no doubt correctly, but I triist that the practitioner 
 may not have an occasion to avail himself of it. In two deaths which 
 I have known, soon after this accident, but in no way connected with it, 
 there Avere no such dilatations fovmd on post-mortem examination. 
 
 Constriction and Occlusion of the Tubes, at either or both extremi- 
 ties, is of not infrequent occurrence, giving rise to dilatation. Although 
 such constrictions may be of congenital origin, they are most frequently 
 due to some form of inflammation, and occasionally to the pressure of 
 neighbouring abnormalities of the utenis or ovary. Their consideration, 
 therefore, involves that of their most frequent cause — inflammation — and, 
 together with the retention of fluids, — of pus, serum, or blood, — to which 
 they give rise, will be most fitly discussed after speaking of inflammation 
 of the tubes. Partial constriction or stenosis is doubtless an occasional 
 cause of dysmenorrhoea, and perhaps of sterility, but complete constric- 
 tion or atresia is more particularly referred to here. 
 
 Inflammation of the Tubes (Salpingitis). — Acute inflammation of 
 the tubes is usually a rapid and dangerous affection. It occasionally 
 constitutes a stage in the wide-spreading septic inflammation which 
 follows upon delivery, but under these circumstances it can hardly be 
 differentiated from the metritis or peritonitis which follow or precede 
 it. The most striking cases are those which sometimes suddenly arise 
 during the progress of acute or chronic gonorrhoea, and even in these it 
 is the communication of the affection to the peritoneum, with violent 
 peritonitis, and possibly rapid death, which often first excites attention. 
 The ordinary treatment of peritonitis is called for, but the question will 
 arise whether, during an acute attack with impending death, the patient 
 may not be saved by the heroic treatment of opening the abdomen and 
 removing the inflamed tube. It is a fact that abdominal section is not 
 only permissible, but is imperatively called for, in acute peritonitis of 
 
OF THE FALLOPIAX TUBES. -4G7 
 
 letlial tendency, in the i^rescnce of an ovarian tmnour. ^\'llc•tllel■ it is 
 the relief of tension thus produced, or, as I suspect, the antiseptic cleans- 
 ing of the peritoneum, which is perfectly brought about by the Listeriau 
 methods, or less perfectly, but still often efficiently, by other precautions, 
 I know not, but the fact is certain that peritonitis under tliis treatment 
 almost invariably subsides, and that the patient is apparently placed in 
 the same position as if no intercm'rent inflammation had existed. Acute 
 salpingitis, however, is so sudden in its origin, and violent in its progress, 
 and often so difficult to differentiate, that it will only very rarely happen 
 that a surgeon, with sufficient diagnostic skill, and experience in abdominal 
 surgery, is at hand to undertake this treatment early enough to be 
 of service. It cannot be recommended as an ordinary proceeding — the 
 risks of mal-diagnosis and insufficient operative skill forbid it. 
 
 Chronic Salpingitis is not very uncommon. The pathological anato- 
 mists have, however, yet to tell us how often it is merely an accompani- 
 ment of chix)nic endo-metritis, and the clinical physician cannot yet in- 
 form us how we are to distinguish its symptoms from those of chronic 
 ovaritis or metritis, until it has caused very serious organic changes in the 
 tubes. In chronic endo-metritis, the occurrence of sudden and occasional 
 discharges of pus from the uterus may afford probable evidence of 
 salpingitis if the cervix uteri is freely patent, but this evidence will not 
 extend beyond the range of probability unless we can detect bi-manu- 
 ally a swelling on one or both sides of the uterus, which disappears 
 after each such discharge. If we are led by this circumstance to the 
 conclusion that chronic salpingitis exists, the urgency of the symptoms 
 Avill alone determine whether we should continue to trust to tlic ordinary 
 treatment of chronic endo-metritis, or should act as we shall see we are 
 occasionally called upon to do in cases of definite pyo-salpinx with occlu- 
 sion of the tubes. The result of chronic salpingitis may, in certain cases, 
 be merely the prolongation of the duration of chronic endo-metritis. In 
 others it may be the means of exciting, at any moment, dangerous inflam- 
 mation of the peritoneum or ovary. In a third class of cases, by ob- 
 stnicting the tube, it may lay the seeds of future dysmenorrhoea or of 
 hrematocele. 1 liave no experience of attempted catheterisation or dilat- 
 ation of the tube in such cases, but, considering the degenerated condi- 
 tion of its walls, I should regard it as peculiarly dangerous, even when 
 practicable. When tlic tubes remain patent, their lining membrane niav 
 be altered, and its ciliary action destroyed, and this could liardly occur 
 without some bearing on the egress of the ovum or on the ingress of the 
 spermatic fluid, to wliich reference will again be made. But one of tlie 
 more common results of chronic sal))ingitis is to cause obstruction of tlie 
 tube at more tliau one ])oint. Its outer extremity and fimbria) may 
 liccome adliercnt to the ueighl)ouring structures, while its iiuicr extreiuitv. 
 
468 DILATATION OF THE FALLOPIAN TUBES 
 
 or any intermediate part, is sealed, and thus an accumulation of pus, 
 blood, mucus, or serum may be produced, leading to the conditions of 
 pyo-salj)inx, haemato-saljDinx, or hydro-salpinx. 
 
 Pyo-salpinx (encysted abscess of the tube). This affection no doubt 
 exists in many instances of supposed ovaritis with suppuration, and, as 
 has already been said, there is often much difficulty in differentiating 
 it from that, or from abscess due to pelvic cellulitis. Nevertheless, the 
 symptoms and signs are clear enough — upon paper. We have constant 
 wearing pain in one or both groins, increased by every movement, by 
 coitus, and during the menstrual period. We have various disorders 
 of the menstrual function, — entire suppression in some cases, irregu- 
 larity, pain, or profuse increase in others. In the latter case, one tube 
 may remain patent, but not necessarily so. Coexistent with these symp- 
 toms we have, on one or both sides of the uterus, at a greater or less 
 distance from it, a distinct, soft, obscurely fluctuating swelling, ascer- 
 tainable bi-manually. There is great tenderness in the same region, and 
 the swelling may be fixed or somewhat movable, according to the pre- 
 sence or absence of adhesions. It seldom attains a very great size until 
 after a considerable period, and has the laterally elongated direction and 
 sausage-like shape above mentioned. Such signs and symptoms, clearly 
 made out, point to the existence of tubal distention, but not necessarily 
 by pus. To complete the diagnosis of pyo-salpinx, we require a history 
 of acute inflammation, although, like all similar histories, it is often diffi- 
 cult to elicit. The inflammation may be ascribed to a chill, or to 
 sudden arrest of menstruation, but will more frequently have arisen 
 during the post-puerperal state, or during an attack of gonorrhoea. 
 Accompanying the affection, frequent rises of temperature and sudden 
 chills confirm the diagnosis of the purulent character of the swelling- 
 Occasionally a sudden catastrophe arises, from the bursting of the swell- 
 ing into the peritoneal cavity, and a few hours may bring about a fatal 
 collapse. Or the inner obstruction may give way, permitting the dis- 
 charge of pus into the utervis, and this may happen once and again, 
 and even result in permanent cure. The purulent character of this dis- 
 charge, and the temporary subsidence of the swelling, then render the 
 diagnosis almost complete. 
 
 Treatment. — That such purulent collections occasionally make their way 
 into the vagina or rectum, and so eventuate in permanent cure, exactly like 
 a pelvic abscess, I have no manner of doubt ; and that, where they have 
 so far advanced in this direction as to point into either cavity, they may be 
 successfully treated by aspiration, and irrigation with carbolised or iodised 
 solution, and drainage tube, I am also convinced. But the question 
 arises — Is this treatment always safe in a purulent tubal collection, 
 which may be loosely connected, if at all, by adhesions to the intervening 
 
BY PUS (PYO-SALPINX) Ol! MUCOID FLUID (HYDKO-SALPINX). 469 
 
 iitructures ? There is undoubtedly grave risk in «nch treatment, — 
 almost, if not quite, as great as that involved in opening the peritoneum 
 frona above. Yet the constant pain demands relief in some way, and 
 surgery can alone afford it, while the patient is living in constant danger 
 of internal rupture. Exploration by a very fine perforated needle and 
 syringe is not liable to produce dangerous results if antiseptically used, 
 and should not be despised as a means of diagnosis in an aftection which 
 always presents a certain amount of obscurity. 
 
 But when the diagnosis is clearly established, and when fixation of the 
 tumour to the pelvic roof, with evident tendency to point into the 
 vagina or rectum, are not clearly established, abdominal section would 
 seem to be the safest resource. Considerable surgical skill and experience 
 are demanded in most cases, to isolate the swelling without rupturing it, 
 and to decide what is next to be done. If it can be separated, ligatured, 
 and removed, along with the corresponding ovary, which is useless or 
 harmful if left, and often, from adhesions, more easy to remove than to 
 leave, this should be done. If numerous adhesions prevent this, and 
 still more, if the abscess has been burst during the operation, the peri- 
 toneum must be thoroughly cleansed, the torn or intentionally-made 
 opening in the cyst must be carefully stitched to the external wound, 
 and the, cavity must be healed up by antiseptic drainage. Tait and 
 others have successfully treated many cases in this way, and it seems to 
 me to be a more ra :ional and imperatively-demanded operation than the 
 search for hypothet 3ally diseased ovaries, and their removal for still more 
 hypothetically assoc 'ated nervous affections. Bearing in mind, however, 
 the great difficulties so often, if not always, resulting from adhesions, the 
 operation caxniot be placed on the same footing, either as regards safety 
 or assured advisability, as the removal of the ovaries and tubes in the 
 case of uterine fil)roi( disease. 
 
 Hydro-salpinx (tul al dropsy). By this term we indicate occlusion of 
 the Fallopian tube, as described above, and distention of its cavity by 
 serous or muco-serous fluid secreted from its walls (fig. 200). If this 
 accumulation has occurred to a considerable extent, it will closely simu- 
 late a cyst of the ovary or of the broad ligaments ; and, even if aspira- 
 tion be employed as a means of diagnosis, tliere is no special cliaractcr 
 of the fluid by which the diagnosis can be made quite certain. This is, 
 howevei*, of the less importance, seeing that large tumours of tlio kind arc 
 of rare occurrence, and that they call for the same treatment, by aspir- 
 ation or removal, as those for wliich they may thus be mistaken. Small 
 accumulations give rise to precisely the same physical signs as those 
 afforded by pyo-salpinx, but there is an absence of the marked and con- 
 tinuous inflammatory syni])t(iiiis, althoiiLih tlic chavartcristic ]iain and the 
 menstrual disorders are sometimes eiiually jiresent. 'I'here is the same 
 
470 
 
 H^xMATO-SALPINX. 
 
 occasional tendency to periodic discharge into the uterus as in pyo- 
 •salpinx, and its bearing on diagnosis is equally strong. A cure may be 
 affected by tapping per vaginam, or by abdominal incision, and the same 
 considerations would influence us in adopting either alternative plan, as 
 in pyo-salpinx. In both affections recovery occasionally occurs after a 
 spontaneous discharge of the encysted fluid by the uterus. 
 
 Haemato-salpinx, or accumulation of blood in the tubes, may be 
 independent of occlusion of their inner extremity, when it is associated 
 ■with hsematometra from atresia of the uterus or vagina. In such 
 instances the treatment is that of the atresia of the passages (p. 146). 
 Knowing, as we now do, that the tubes partake in the congestion and saii- 
 gTuneous discharge of menstruation, although it is still doubtful whether 
 this is by any means constant, it is not surprising that a tubal dilata- 
 
 FiG. 200.— Tubal Dropsy (Boiviii et Duge, 
 
 tion should sometimes contain blood, instead of seruui, mucus, or pus. 
 The infrequency of this seems to me, however, to point to the fact that 
 tubal menstrual discharge may not be so constant a phenomenon 
 as uterine. The presence of blood in a constricted tube will give 
 rise to a swelling of somewhat more solid character than when pus or 
 serum are present. Hence these tumours have been mistaken for solid 
 outgrowths from the uterus. If, however, the tubal character of the 
 disease is foirly certain, it is amenable to the same methods of treatment 
 as other tubal distentions, but aspiration will be still less likely to be 
 successful. 
 
 Lawson Tait gives the following as his statistics of removal of these 
 three forms of dilated Fallopian tube by abdominal incision (Diseases 
 of the Ovaries, 1883, p. 332). He has thus removed twenty specimens of 
 pyo-salpinx between 1879 and August 1882. All these patients have 
 
EXTRA-UTEKIXE PKEGXANCY. 
 
 recovered. He has, in the same period, removed twenty-four specimens 
 of hjdro-salpinx ; all these patients have also recovered. He mentions 
 one case of successful opening of a hfemato-salpinx, and subseqvient 
 treatment by drainage through the abdominal -wound {op. cit., p. 71), 
 but he gives no list of removals. We are bound, I think, either to 
 dispute the accui'acy of the statistics, Avhich I certainly am not pre- 
 pared to do, or to admit that so skilful a diagnostician and ojDerator as 
 the writer possesses an almost certain means of cure for a most 
 intractable and dangerous malady. Yet I am nevertheless bound to 
 say that fatal cases of this operation are, I believe, at present 
 occurring in the hands of rash imitators, who are never likely to 
 have the opportunity of acquiring similar skill. It is impossible to 
 exaggerate its difficulties when the dilated tube has to be separated 
 from numerous adhesions. 
 
 Extra-Uterine Pregnancy. 
 
 A full notice of this, hapjjily, rare affection is more suited to the pages 
 of a work on Obstetrics than to one on Gynaecology. Yet it cannot be 
 altogether omitted here, for, rare as it is, it must always be present to 
 the mind of the physician who is called upon to diagnose pelvic or abdo- 
 minal growths, and its frequent relation to the Fallopian tubes points 
 to this as the most fitting place for its introduction. The student will 
 find a very excellent description of this abnormal condition, with a com- 
 plete tabulation of cases, in a work by Dr Parry of Philadelphia (Fxtra- 
 uterh' Pregnancy, London, 1876). 
 
 ■Causation and Varieties. — It is hardly necessary for our purpose to 
 discuss the views enumerated by Parry and others as to the causation of 
 extra-uterine foetations. Those who believe, as the majority still I think 
 do, that the spermatozoa freely enter the Fallopian tubes in ordinary 
 impregnation, and there effect the commencement of individual life in 
 the ovum, will look upon constriction of the tubes from inflammation 
 in or around them as the most common cause, by preventing the descent 
 of the impregnated ovum beyond a certain point, and will also admit that 
 impregnation may be i)rutluced before the ovum enters the tubes at all, 
 while its subsequent entry is prevented by various causes — spasm of the 
 tubes, wrong application of their fimbrifc to the ovary, etc. Those who, 
 on the other liand, consider that the ciliary action of the lining mem- 
 brane of the tubes normally prevents tlie ingress of the spermatic fluid, 
 will look rather to chronic disease and destruction of the cilia, or to 
 undue patency of the tubes, as the cause of the abnormal presence of 
 the spermatoza beyond tlie uterus, and of tlicii- unttiward physiological 
 
472 GENERAL COXSIDEEATIONS EEGAKDING 
 
 action in this wrong site. Extra-nterine foetation undoubtedly occurs 
 most frequently in not very young patients, and this points to the pro- 
 bability of chronic salpingitis as having something to do with it ; but 
 it does not clear up the question as to whether it acts by producing 
 constriction of the tubes and retention of the ovum as enforced by 
 Bandl, or by producing destruction of the cilia, or dilatation of the 
 tubes, with abnormal admission of the fertilising element, as enforced 
 by Tait and partially believed by Parry. 
 
 Classification. — Most elaborate classifications of extra-uterine fcEtations, 
 according to their exact site, have been made by various writers. They 
 interest the embryologist or pathologist much more than the practical 
 gjmsecologist. For the most part, the latter finds the ovum aiTCsted 
 and developing itself in the Fallopian tube. Occasionally he notes this 
 occurring so close to the uterine end that the cavity hollowed out for 
 itself by the foetus is partly uterine and interstitial. More rarely, the 
 development of the o\aim really goes on in the horn of a bifid uterus ; 
 practically, it is still extra-uterine, unless the abnomial horn is sufficiently 
 developed to allow of a natural termination of the pregnancy. Now 
 and again the growth takes place in such intimate connection with the 
 ovary that it is difficult or impossible to say whether it commenced 
 there or at the extreme end of the tube. Once more, the ovum is 
 sometimes found developing itself within the peritoneal cavity, or 
 between the layers of the broad ligament. In such cases it cannot be 
 denied that the o^T^im may have dropped or pushed its way into these 
 situations after impregnation, and without entering the tube at all, but 
 there is most frequently a clinical history to show that at some early 
 period a rupture of the original sac, in the tube or elsewhere, took place, 
 ending, not in death from haemorrhage or peritonitis, as it too fre- 
 quently does, but in a resumption of growth in the new situation. 
 From the above description of observed facts, the student may form for 
 himself a classification into tubal, ovarian, interstitial, tubo-ovarian, 
 tubo-interstitial, intra-peritoneal, extra-peritoneal, or any other inter- 
 mediate types of extra-uterine foetation. The most common form is 
 undoubtedly tubal. 
 
 General Considerations. — The outer covering of an extra-uterine 
 foetation is foiTaed by the structures within which the ovum is lodged, 
 by the tube in the majority of instances, perhaps by the interstitial sub- 
 stance of the uterus in a few, or by rapid development of the ovarian 
 stroma in some, and certainly by gradually increasing inflammatory 
 lymph in others. The tubal wall, although the most common, is the 
 frailest envelope. It would doubtless be an advantage in such cases 
 if muscular hypertrophy of the wall, described by Simpson as a rare 
 occurrence, existed, but this covering usually gives way aboiit the second 
 
EXTRA-UTEPJXE PREGNANCY. 473 
 
 or third month, causing fatal hsematocele, or very rarely permitting fin-ther 
 develoiDment of the foetus, after recovery from the shock and heemon-hage. 
 When adhesions and accumulations of lymph have once commenced 
 around the emhryo, they are capable of further stretching and of 
 gradual increase in strength, and pregnancy may thus go to the 
 full time, with further results afterwards to be mentioned. The human 
 foetus, however, requires the placenta for its oxidation and nutrition. 
 How is the maternal element of that stiiicture obtained in such 
 cases? Wherever the implantation of the embryo occurs on a living 
 structure, vascular growth and proliferation foUoAv, and the tubal wall, 
 or the interstitial structure of the uterus or ovary, or the peritoneal 
 covering of the utenis, intestine, pelvic fasciae, or broad ligament, 
 each answers to the stimulus, and endeavours, in a more or less 
 satisfactory manner, to supply the want. In normal pregnancy, pro- 
 vision is made in the utenis for the sealing up of torn sinuses or villi 
 after delivery; but such is not the case at all, or very feebly so, in these 
 other organs or tissues. Thus it happens very frequently that nipture 
 of the tube, when pregnancy is tubal, is caused by placental growth as 
 well as by distention due to growth of the foetus ; or, wherever the 
 placental implantation may be, the corresponding maternal growth is in- 
 sufficient' and the foetus dies of starvation — a foi-tunate issue; or, again, if 
 attempts are made at removing the foetus by abdominal section, and the 
 operator forgets that if he scrape away the placenta there is no pro- 
 vision for sealing up the torn vessels of its maternal portion, the opera- 
 tion is rendered unsuccessful by uncontrollable hfemorrhage. If the 
 cord be tied and cut short, and the placenta be left alone, nature is equal 
 to the task of gTadually absorbing or otherwise getting rid of her now 
 itseless impromptu production. 
 
 A very important fact in connection with extra-uterine foetation 
 is, that the uterus so far recognises the presence of a growing- 
 embryo, although it is not Avithin its cavity, as to undergo some 
 of the vital changes which it would do in normal pregnancy. The 
 sympathetic disorders of normal pregnancy are constantly met with, as 
 we have seen they may all occasionally be in the presence of uterine or 
 ovarian tumours, but in extra-iiterine pregnancy the uterus may, and 
 generally does, increase in size, may show the slight cerA-ical changes, 
 the anteversion, and the changes in the shape of the body which 
 characterise it during the earlier months of the normal state. ^lore- 
 over, it may, and often does, develop a true decidual mucous mem- 
 brane, which it throws off either at the full time or at some antecedent 
 period, witli all the symptoms of an abortion. 
 
 SyniiJtoms and Sirjns. — It is but very rarely that an cxtra-utcrine 
 pregnancy is recognised in its eai'liest stages. There are the usual 
 
474 SYMPTOMS AND DIAGNOSIS 
 
 sj'mptoms of pregnancy, modified, it may be, to some extent, but not 
 suificiently to create alarm. The suppression of menstruation may be 
 incomplete, or last for only one or two months. It is then followed by 
 irregular and sometimes smart heemorrhages, and portions of decidua 
 may be found if looked for. After this the enlargement becomes" 
 apparent as decidedly unilateral, and is nearly always accompanied 
 by frequent acute ]Dains in the groin, and by symptoms of intercur- 
 rent inflammation. There is also, for the most part, great pres- 
 siu'e on the rectum and bladder, owing to dipping of the tumour into 
 the pelvis. These symptoms lead to a careful physical examina- 
 tion, and a tumour is discovered behind and to one side of the uterus. 
 As the tumour grows, the uterus is pushed laterally in the opposite 
 direction. If nothing occur to terminate the pregnancy, the foetal heart 
 becomes in time discoverable — ballottement may be made out as in normal 
 pregnancy, although seldom so clearly, and palpation discovers the foetal 
 limbs through the abdominal wall. These are the symptoms in those 
 rare cases which go on to, or nearly to, the full time of pregnancy. Most 
 commonly, hoAvever, the abnormality declares itself in another way, and 
 before any attempts at accurate diagnosis have been made or thought of. 
 Sudden violent j)ain occurs, which may or ma}' not be apparently caused 
 by some action of the patient, such as stooping or lifting a heavy weight. 
 Collapse rapidly follows, with all the signs of internal haemorrhage. We 
 have, in fact, a violent hsematocele, such as will shortly be described, and 
 produced by the rupture of the sac and the escape of its contents into 
 the peritoneum. The patient may be moribund when first seen, or if 
 she recover, it is after some such sequence of events as will be spoken 
 of under hsematocele, and we may never know with absolute certainty 
 whether pregnancy existed or not. Or, more rarely, she may rally from 
 the shock and haemorrhage only to find, by and by, that the tumour is 
 continuing to develop in its new surroundings. In other ways, also, the 
 abnormal pregnancy may come to an untimely and perhaps fortunate 
 conclusion. Owing to deficiency in the placental supplies, or to various 
 causes which may affect also a normal pregnancy, the foetus may 
 die at any stage. Abortion cannot follow, but the foetus remains 
 encysted, and may so remain during the mother's life, undergoing 
 mummification or conversion into adipocere, while the placental circula- 
 tion d-windles away. This favourable result is too seldom met with, how- 
 ever, in its entirety. The new foreign body ere long exerts its influence 
 as such. Suppuration is set up; the abscess bursts into the rectum, 
 vagina, or elsewhere; portions of foetal bones and other structures are 
 from time to time eliminated ; and, after a prolonged struggle, the patient 
 succumbs, or recovers with broken health. 
 
 If pregnancy goes on to the full time, the foetus may die gradually, and 
 
OF EXTKA-UTEPJXE PIIEGXAXCY. 475 
 
 without marked change in the symptoms, or there ma}' be an exact imita- 
 tion of the first stage of kibour, which dies away without result. Subse- 
 quently the foetus becomes encysted and mummified, or its sac suppurates, 
 as above described. At, or soon after, the time of foetal death, however, 
 there is usually a considerable subsidence in the size of the tumour, even 
 if it enlarge again, and the history of this symptom has been looked 
 upon as one of great importance in the differentiation of an extra- 
 uterine pregnancy from other tumours. 
 
 To sum xxp : — The results of an extra-uterine pregnancy may be — 
 
 1. Rupture of the sac from the second to the fourth month. This, 
 followed by death from haemorrhage or peritonitis, is the most common 
 result. Followed by complete recovery it is unfortunately rare, but it 
 may be followed by temporary recovery, and continued growth of the 
 foetus, with subsequent developments. 
 
 2. Death of the foetus at an earlier or later stage. This is sometimes, 
 though unhappih' rarely, followed by permanent encystment, with 
 mummification of the foetus, and practical recovery. Generally, suppura- 
 tion occurs sooner or later, with very doubtful result to the patient. If 
 she escape the constant danger from hectic, septicsemia, or perforation 
 of important viscera, she recovers. 
 
 3. Rarest of all. Successful removal of a viable child jjn- ahdonmiem. 
 
 Differential Diagnosis. 
 
 The following conditions have been, and are liable to be, mistaken for 
 extra-uterine pregnancy : — 
 
 1. Normal pregnancy. ^ 6. Fallopian distention. 
 
 2. Do. do. with retroversion ' 7. Uterine outgrowths. 
 or retroflexion. 8. Pelvic heematocele. 
 
 i. Pregnancy in one wing or horn of a 9. Pelvic inflammatory exudations or 
 
 abscesses. 
 10. Cancer of pelvis or peritoneum. 
 
 bifid uterus. 
 
 4. Ovarian tumour. 
 
 5. Cyst of broad ligaments. 
 
 1. Normal Pregnancy. — A careful study of the signs of pregnancy, 
 and an equally careful bi-manual examination of the uterus and its 
 surroundings, should suffice to differentiate this from those rare cases of 
 extra-uterine foctation which reach a stage of development beyond three 
 or four months, and in these the occurrence of occasional haemorrhages, 
 or the resumption of natural menstruation, while the tumour goes on in- 
 creasing, or the occurrence of frequent or constant pain, will frequently 
 lead to the necessity for such an examination. During the first two or 
 three months, the unnatural situation of the pregnancy is seldom sus- 
 pected until the bursting of the tumour occurs. The practitioner should 
 not place too much stress on the lateral situation of the swelling, especi- 
 
476 DIFFERENTIATION OF EXTRA-UTERINE PREGNANCY 
 
 ally to the right side, if its evidence in favour of extra-uterine pregnancy- 
 is not corroborated in other ways. Preternatural thinness of the uterine 
 walls may at later stages give rise to strong suspicion of the foetus being 
 extra-uterine. Tait mentions several siich cases, and I have seen several 
 myself, but never one in which the absence of any other strongly 
 marked abnormal symptoms, and the exercise of careful diagnostic manipu- 
 lation did not j)revent error. I have not even been driven to the use 
 of the sound, which I should not, however, hesitate to use if I could not 
 assure myself otherwise. 
 
 2. Retroversion or Retroflexion of the Gravid Uterus. — If we trust to 
 vaginal examination alone, this may very closely simulate extra- 
 uterine pregnancy. But a history of previous uterine displacement, 
 or the sudden development of pelvic pressure and urinary reten- 
 tion in the course of a normal pregnancy, without symptoms of haemor- 
 rhage, point more strongly to retroversion. Careful bi-manual examina- 
 tion will assure us of the continuity of the uterus, as felt per vaginam, 
 with the mass in Douglas's pouch, and will lead to the reposition of the 
 version or flexion, with or without anaesthesia. 
 
 3. Pregnancy in one Horn of a Bifid Uterus. — If this takes place 
 in an extremely undeveloped horn, it is practically an extra-uterine 
 fcetation, and will be followed by rupture of the sac, unless prevented 
 by a very early abortion. If, however, the larger horn is occupied, 
 or if they are both fairly well developed, pregnancy may be termin- 
 ated by normal labour. The discovery of a double cervix Avould, 
 of course, make clear the state of matters ; and in a case where 
 the tumour was manifestly one-sided, although clearly attached to 
 the uterus, while bi-manual examination revealed a fundus uteri 
 at its side, we should be fully justified, at the risk of producing 
 abortion, in dilating the cervix, and making an intra-uterine explora- 
 tion with the finger. With regard to all these cases of differentiation 
 between normal and ectopic pregnancy, I cannot do better than quote 
 the words of T. Gaillard Thomas {op. cit.) : — "Very often we hear of 
 physicians being blamed on account of diagnosis in those cases Avhich 
 suddenly die from rupture. Every medical man who countenances such 
 a charge demonstrates his want of experience, or his want of professional 
 loyalty, by so doing. Very often there is nothing in these terrible cases 
 to excite suspicion ; very generally nothing to decide us positively, even 
 when suspicion is excited." My own somewhat extensive experience in 
 doubtful cases of the kind woiild lead me to add — Granted an absolutely 
 certain pregnancy, with very strong suspicion of its being extra-uterine, 
 the probabilities are nevertheless very greatly in favour of its turning 
 out to be intra-uterine. 
 
 4. Ovarian Tumours. — If extra-uterine pregnancy were a common 
 
FKOM YAEIOUS OTHER ABNORMAL CONDITIONS. 477 
 
 condition, mistakes would undoubtedly often arise between it and the 
 earlier stages of cystic ovarian growths, although they ought to be 
 impossible when the dimensions of either abnormality are great. The 
 carefully investigated history of the case is our main reliance. In 
 ovarian tumour we have no conclusive history of pregnancy, in extra- 
 uterine pregnancy everything points strongly in that discretion. In 
 the former condition we do not hesitate for a moment to leave matters 
 to the arbitrament of time, in the latter we also wait, but we do so with 
 incessant watchfulness and frequent examinations for determining 
 evidence. Until some evidence of life in the tumour is obtained, th? 
 diagnosis may remain uncertain, but if constant wearing pain is present, 
 and the history points at all strongly to pregnancy, and if we can elimi- 
 nate normal uterine pregnancy, there can be no doubt that abdominal 
 section furnishes our surest means both of diagnosis and treatment. 
 Fortunately the necessity for this means of diagnosis is rare. At 
 a case of operation of the kind by' Dr Atlee in 1867, Sir Spencer 
 Wells, Dr Nicholayson of Christiania, Drs Burpee and Drysdale of 
 Philadelphia, and Dr Atlee's elder brother, were present, and acknow- 
 ledged that they had never been called on to diagnose a case of the 
 kind. 
 
 5. Cysts of the Broad Ligaments, and 
 
 6. Distentions of the Fallopian Tube, of moderate size, present so 
 many features in common with ovarian tumours, and so few symptoms 
 diagnostic of pregnancy of any kind, that we may place them in the 
 same category as ovarian tumours, as far as regards their differential 
 diagnosis from extra-uterine pregnancy. The history of suppurative 
 inflammation obtainable in pyo-salpinx is totally absent in the early 
 stages of abnormal foetation. 
 
 The combinations of these affections which may possibly exist are 
 utterly beyond description in a general, or even in a special work, on the 
 subject of any of them. A thorough knowledge of the signs and symp- 
 toms of each, a large special experience, and that judicial tact which 
 characterises the truly great physician or surgeon, could alone lead to 
 anything like absolutely certain conclusions. Fortunately it is just in 
 the most doubtful cases that all would be agreed as to the advisability 
 of waiting a short time for further evidence, and in the absence of 
 that, of performing abdominal section as a means of diagnosis or treat- 
 ment, not, of C(Hirse, until the possibility of normal i)regnancy had been 
 absolutely eliminated. 
 
 7. Uterine Outgroiuths. — These, while small, and therefore liable to be 
 mistaken for early extra-uterine pregnancy, are ahvaj'S hard and solid. 
 Their rate of growtli does not correspond with that of a pregnancy, 
 normal or extra-uterine. Their histoi-y is rather that of menorrhagia 
 
478 DIAGNOSIS AND TEEATMENT 
 
 than of the amenorrhoea of pregnancy, and I cannot see how, with care- 
 ful examination, bi-manually and by sound, the practitioner can be led 
 to make a serious mistake. 
 
 8. Pelvic Hcematocele.- — We have not yet considered this affection, but 
 it will be seen that it consists of a more or less sudden effusion of blood 
 into the cellular tissue of the pelvis or upon its peritoneal covering. 
 This may be so extensive as to cause sudden death, or it may, after 
 causing considerable primary shock, become hardened, surrounded by 
 inflammatory exudation, and finally absorbed, or it may end in su]3pura- 
 tion. jS'ow this, plus the antecedent symptoms of pregnancy, is almost 
 exactly the description of a ruptured extra-uterine foetation, and, in fact, 
 when this accident happens it is with a pelvic heematocele that we have 
 to deal. The only point is to determine how far it is probable that 
 extra-uterine foetation previously existed, and how far its termination in 
 rupture was the cause of the haematocele. Unless the foetus has arrived 
 at sufficient dimensions to be clearly made out bi-manually among the 
 hsemorrhagic clots, which it rarely has, the probably correct conclusion 
 can only be arrived at by an unbiassed estimate of the preceding 
 symptoms of pregnancy which may have existed, and our decision must 
 be rapid. The chief importance of trying to form a judgment on the 
 point lies in this, that if Ave are satisfied that the hsematocele is due to a 
 ruptured embryo, it is probable that the extravasation is intra-peritoneal 
 and not intra-cellular, although even this is not absolutely certain, for 
 many cases occiir (Tait estimates them at one-third) Avhere the sac of an 
 embryo bursts between the layers of the broad ligament, giving rise to 
 that form of heematocele which lies entirely below and outside of the 
 peritoneum {see Heematocele). We should, moreover, feel more justified, 
 in a dangerous case, in opening the abdomen in search of the cause of 
 haemorrhage, and for the purpose of arresting it, than when we know not 
 to what morbid affection it might be due. In a case of ectopic foetation, 
 when the patient has rallied from the primary effects of the hcematocele, 
 the foetus, as Ave have seen, may survive, and go on de\'eloping. In 
 ordinary cases of heematocele not due to foetation, or AA-hen the A^ery early 
 foetus dies, — and the sequence of events may be in both cases alike, — 
 there ensues, unless fresh heemorrhage occur, hardening and absorj)tion 
 of the mass, or suppuration. 
 
 9. Pelvic Inflammatory Exudations. — For the differentiation of these 
 from extra-uterine pregnancy, it is advisable to refer the student to their 
 symptoms and signs (see Chap. XIX.). 
 
 10. Cancer of the Pelvis or Peritoneiim. — It is rather strange that few 
 of the ordinary text-books make mention of this as likely to be mistaken 
 for extra-uterine foetation, seeing that several of the most glaring mis- 
 takes I haA^e seen have been in this direction. Cancerous deposits arc 
 
OF EXTRA-UTERINE PREGNANCY. 479 
 
 apt to assume the most remarkable shapes, and to present irregulari- 
 ties of surface, sharjD indentations, and other features, which resemble 
 very closely portions of a mature foetus. I have found the cephalic 
 structures and the contour of the ribs, or of the extremities, most accu- 
 rately imitated in this way, on abdominal palpation or vaginal touch, far 
 more than by any other abnormal affection. On four or five occasions 
 I have seen malignant masses mistaken by intelligent practitioners for 
 extra-uterine foetuses. I am satisfied, however, that in every one of 
 these a careful inquiry into the family history of the patient, a 
 minute examination of the external signs, care being taken not to attach 
 too much importance to one accidental resemblance to a foetal structure, 
 a patient study of the history and progress of the tumour, and, above 
 all, a cautious delay in forming an opinion on so difiicult a question, 
 would have avoided mistake. 
 
 Treatment. — The treatment of extra-uterine pregnancy will vary ac- 
 cording to the circumstances in Avhich we encounter it, and according to 
 the stage of its development. Three conditions, at any rate, demand 
 separate consideration — (1) The early stage of development, say up to 
 the third or fourth month, and before rupture has occurred ; (2) the 
 time of rupture ; and (3) the later stages of foetal existence, the patient 
 having escaped or survived rupture, the foetus being either alive or 
 dead. 
 
 1. With regard to the earlier stages of development, and before rup- 
 ture. The great difficulty in our way lies in the fact that the abnormal 
 condition is generally unsuspected until it is too late, or, when sus- 
 pected, the difficulty of diagnosis. is so great that the practitioner is 
 compelled to hold his hand. If we could feel absolutely certain of tlic 
 diagnosis, no one would countenance a do-nothing policy in the face 
 of the terrible, and almost inevitable danger from rupture. Tubal 
 pregnancy is by fixr the most common form, and tubal pregnancy almost 
 invariably ends in rupture, and generally in death. The differentiation 
 of other forms, less, but only somewhat less, liable to rupture, is so 
 fraught with difficulty that the tubal form may be accepted as the one 
 which must regulate our procedure. Two lines of practice arc open to 
 us. We may endeavour to arrest the life of the foetus, and so hope to 
 stay its growth and thus avoid rupture, leaving future indications to 
 nature ; or we may attempt removal of the foetus, with or without its 
 sac. For the former of these ends the administration of drugs, — of iodine 
 strychnia, mercury, &c., — to the mother has been tried, but absolutelj 
 without success. Tapping the cyst per vagmam with a very fine trocar, 
 so as to draw off tlie liquor amnii, has been successfully used ; but the 
 result is uncertain, and death from hemorrhage caiised by tlie punc- 
 ture, and from sudden collapse and rupture of the sac, lio.ve followed. 
 
480 THE TEEATMENT OF 
 
 The injection into the sac of ;| to |- a grain of morphia by a long sub- 
 cutaneous needle and syringe is less open to danger. Its effect on the 
 foetal life is, however, problematical, and fatal delay may thus ensue. 
 We have no means of gauging our probable success, at this early stage, 
 but by waiting for the result. Again, foetal death may be brought 
 about by the passage of a strong continuous electric current. One 
 electrode may, as Thomas recommends, be placed in the rectum, and the 
 other against the most prominent part of the sac, or one may consist of 
 a fine needle, insulated except at its extremity, which is inserted into 
 the tumour. I have no experience of this method, and few cases of any 
 value are recorded. One objection, however, exists to all these methods, 
 viz., that the foetus may die spontaneously, or its life may be arrested 
 artificially, but death of the placenta may not follow, and its vegeta- 
 tions may go on sprouting beyond even the normal extent, thus greatly 
 complicating any future proceedings. On the whole, I think that tap- 
 ping by fine trocar, with all its risks, is the most advisable of the 
 plans for arresting foetal life yet mentioned. It may prove of infinite 
 service by correcting our diagnosis, and I think I should adopt it in any 
 case where I felt somewhat uncertain on the point. But it is a question 
 whether the bolder and more radical plan of excision of the morbid 
 growth is not, in the long run, the safest. Use what methods we may 
 to induce the death of the foetus, and successful although we may be 
 at the time, there are still enormous risks to be ru.n afterwards. Mum- 
 mification of the foetus, or calcification of its envelopes, with prolonged 
 or permanent quiescence, is but an exceptional result. Suppuration of 
 the sac, with all the dangers of peritonitis, septicaemia, &c., is an almost in- 
 evitable sequel, sooner or later. No tyro would ever venture, I hope, to 
 take upon himself alone the responsibility of deciding in such a case, and 
 even the most experienced are hardly warranted at present in speaking 
 or writing too dogmatically ; but I cannot resist the belief that, in a 
 clear and undoubted case, the greatest ultimate safety would lie in the 
 removal of the foetus, with its containing sac if possible, by abdominal 
 incision, and the earlier the better. 
 
 2. We may be called to a case in which ruptui-e has just taken place, 
 with its inevitable shock and haemorrhage, and mvich will still depend on 
 diagnosis. If the case had previously been recognised as one of extra- 
 uterine foetation, or if the summary we can hastily obtain of the previous 
 symptoms, together with the physical signs observable, render this 
 almost certain, there lies before us only one course, if we feel equal to 
 the task, or can obtain efficient help. To trust to the staunching of the 
 internal haemorrhage by cold or other haemostatic means, is to trust to 
 the frailest of hopes. The question of how fiir the patient can stand the 
 necessary abdominal section, will, of course, be a most difficult one to 
 
EXTKA-UTEEINE PEEGNANCY. 481 
 
 decide, but it will be rendered less difficult if the practitioner will bear 
 in mind that the chance of saving his patient must utterly outweigh any 
 calculations as to the result of the operation on his own reputation. 
 The steps of the operation proposed I will condense from the words 
 of Lawson Tait: — "After the peritoneum has been opened, a careful 
 examination of the relations of the ovum must be made. If the child is 
 loose in the abdomen, it merely requires careful removal, careful avoid- 
 ance of the placenta, and the closure of the wound in the abdomen save 
 at the lower part, through which the umbilical cord must be drawn, and 
 which must be kept open for the passage of the placental debris through 
 a wide glass drainage tube. The discharge must be drawn up by means 
 of a syringe, three or four times every twenty-four hours, and the cavity 
 occasionally washed out with a 5 or 10 per cent, solution of sulphuret 
 of potassium (carbolic acid 1 in 40 ?). If the fcetus is found in a sac 
 which is not formed by the folds of the broad ligament, the sac must be 
 carefully opened in the middle line, emptied and cleaned out as w^ell as 
 possible, and then its edges must be stitched round to the edges of the 
 wound." The remaining treatment is the same. " The golden rule for 
 this operation is to avoid touching the placenta." 
 
 Even although the child were loose in the abdomen, I should search for 
 any recently ruptured sac and treat it as above. 
 
 If I found . that the rupture was within the broad ligament, and quite 
 outside the peritoneum, or if I could with any confidence diagnose this 
 without abdominal incision, I should treat the case as one of intra- 
 cellular haematocele (see Chap. XIX.). 
 
 3. Supposing that the foetation has reached a later development — 
 from the sixth or seventh month onwards. The danger of rupture is 
 now lessening, or may have been previously run, and there are probably 
 extensive adhesions which tend to prevent it, while they increase the 
 difficulty and danger of surgical interference. The urgency of the 
 symptoms will largely determine our action. If there be constant pain 
 and fever, which are evidently wearing out the patient, and the 
 child lives, excision is called for, giving the child the chance of reaching 
 the seventh month at least, if possible. A careful study of the position of 
 the sac and its probable attachments must decide the question between 
 abdominal section and opening the cyst by the cautery per vaginam. I 
 have little fancy, however, for such vaginal opei'ations. One thing is 
 certain, all experience shows that if the placenta is not contained within 
 a removable cyst — if it is attached to surrounding structures — no attempt 
 should be made to remove it. The cord should be divided by twisting 
 or by cautery, and its removal left to nature and the drainage tube. 
 With this precaution a living foitus has been successfully removed bj^ 
 abdominal incision. The treatment of a suppurating sac, at whatever 
 
 2h 
 
482 EXTEA-UTEEINE PEEGNANCY. 
 
 stage of pregnancy, demands the highest patience and skill, but many^ 
 instances are now recorded where these have overcome apparently in- 
 superable difficulties and dangers. With careful antiseptic precautions, 
 matter may be evacuated, and successive portions of foetal structure 
 assisted in their egress, until finally the cavity heals, and the cure is 
 complete. 
 
 It were quite beyond the scope of this work to attempt detailed 
 instructions in every varying case. The practitioner should possess the 
 requisite knowledge as to the nature and diagnosis of extra-uterine 
 pregnancy, but for its treatment, in all but sudden emergencies, 
 he should carefully study one or more special monographs, such as 
 that of Parry, to which I have referred above, or Mr Tait's paper 
 in the Brit. Med. Jour, of August 16, 1884. In the larger centres of 
 population, at any rate, he Avill be inexcusable if he does not share the 
 responsibility of the case with some one who may be presumed to have 
 a larger experience of emergencies of a similar kind. 
 
 Should a tumour of this nature be perfectly quiescent, existing far 
 beyond the nine months of pregnancy, and showing no sign of suppura- 
 tion, it should, I think, be absolutely left alone, the patient wearing a 
 comfortable abdominal belt. 
 
PELVIC INFLAMMATIONS AND H.EMATOCELE. 483 
 
 CHAPTER XIX. 
 
 Pelvic Disorders. Pelvic Inflammation, including Pelvic Peritonitis, Perimetritis^ 
 or Peri-uterine Peritonitis ; and Pelvic Cellulitis, Parametritis, or Peri-uterine 
 
 Cellulitis. Pelvic Hccmatocele. Pelvic Abscess. 
 
 Under the heading of pelvic disorders, it is customary (and I intend to 
 adhere to the custom) to classify two affections only, viz., inflammation 
 of the pelvic cellular tissue or peritoneal covering, and escape of blood into, 
 or upon the same, — pelvic inflammation and pelvic hsematocele. Some 
 prefer to use the term "peri-uterine" instead of pelvic. In addition to 
 these two afi"ections, we must mention a common result of either — pelvic 
 abscess. 
 
 The literature of this whole subject is enormous, although it mainly 
 dates from a very recent epoch in medical history. Owing, however, 
 to discrepancies in the views of the various writers on some of the 
 simplest questions of anatomy, to the complications in nomenclature 
 which have been introduced, to the difiiculty of obtaining j^ost-mortem 
 evidence on the questions involved, and, I may add, to the difficulty of 
 making anything of the tangled and adherent structures displayed by 
 such post-mortem examinations, the whole of this literature is most con- 
 fusing. I would advise the student or young practitioner to have 
 nothing to do with it until he has mastered the few elementary details 
 which I hope to present to him, and has verified their truth or the 
 reverse in a certain number of cases. In an ordinary practice, if he be 
 observant, he may soon have opportunities, and a very short experience 
 of hospital work will speedily bring under his notice numerous examples 
 of at least the chronic form of each of these aff"ections, affording material 
 for diagnosis and diff'erentiation. 
 
 On pelvic inflammation he may then consult Bernutz and Goupil, 
 New Sydenham Society, 1866 ; Sir J. Y. Simpson, On Diseases of 
 Women, Edin., 1872 ; Matthews Duncan, On Perimetritis and Para- 
 metritis, Edin., 1869 J W. 0. Priestley, Pepwlds's System of Medicine, 
 vol. v. 
 
 And on pelvic hscmatocle, Bernutz and (Joupil, New Sydenham 
 Society, 1866; W. 0. Priestley, Reynolds's System of Medicine, 
 vol. v. 
 
484 THE PATHOLOGY OF 
 
 Pelvic Inflammation. 
 
 One of the points which stands out most clearly throughout all this 
 literatm'e is, that there are considerable distinctions between those 
 haemorrhages or those inflammations which occur upon the peritoneal 
 covering of the pelvis, and those which occur in its cellular tissue. 
 They differ much, as might be supposed, in their physical signs, and they 
 difier somewhat also, in tj^ical cases, in their symptoms, prognosis, and 
 even treatment. In the inflammatory affections we not infrequently 
 have the two localities simxiltaneously affected, and, with regard to 
 both inflammation and hsematocele, there are cases where it is diffi- 
 cult or impossible to decide on the affected locality ; but it is always 
 desirable, both for scientific and for practical purposes, to endeavour to 
 do so. We shall therefore speak of pelvic inflammation under two 
 headings — pelvic peritonitis and pelvic cellulitis, — and of pelvic hsema- 
 tocele we shall distinguish two forms — the intra-peritoneal and the intra 
 cellular. 
 
 Pelvic Peritonitis, or Perimetritis, or Peri-uterine 
 Peritonitis. 
 
 Leaving out of consideration, for the present, the relative frequency of 
 this affection, and of the corresponding affection of the cellular tissue, we 
 mean by each of the above terms to describe an inflammation wholly, or 
 almost wholly, confined to the pelvic peritoneum or to its contiguous 
 serous surfaces. 
 
 Pathology. — There exists at first the usual hypereemic condition of 
 inflamed serous membrane. For the most part, lymph is very early 
 exuded upon the inflamed surface. In some cases this may be, as in 
 dry pleurisy, a thin solid layer, which coats the serous membrane, and 
 which may ultimately lead to the adhesion of neighbouring parts, to the 
 occlusion of serous pouches, and to the contraction of adhesions between 
 contiguous viscera. In this way, the ovaries. Fallopian tubes, uterus, 
 neighbouring intestines, or even omentum, may, each or all, acquire 
 adhesions to one another, and, in the process of contraction which 
 ensues, may become displaced, distorted, or, in the case of the hollow or 
 tubular organs, constricted, with obliteration of their canals as a result. 
 Generally, however, more or less of the effiised lymph is fluid at first, 
 and this, following the laws of gravity, trickles down into the most de- 
 pendent part of the peritoneal sac. The lowest portion is undoubtedly 
 that which constitutes Douglas's pouch, and if we picture the patient to 
 
PELVIC PERITONITIS, OR PERIMETRITIS. 
 
 485 
 
 ourselves as lying for the most part on her back, and allow for the 
 natural obliquity of the pelvis, it will not be difl&cult to form an idea 
 of the successive levels that will be reached by increasing quantities of 
 this fluid, if obstacles are not presented by former adhesions (fig. 201). 
 Inspissation of the fluid lymph soon occurs, and it is almost always 
 flocculent from the first. In this w^ay the whole speedily becomes 
 solid, or the various layers, thus inspissated, may retain between them 
 for a considerable time some remaining fluid, which is afterwards ab- 
 sorbed, or itself undergoes inspissation, or, much more rarely, degener- 
 ates into pus. In the chronic forms, successive additions are thus 
 made, often very insidiously, until the whole inspissated mass reaches far 
 up into the abdomen, and dips deeply into the pelvis, pushing the 
 peritoneum and 
 subjacent organs 
 before it. Mat- 
 thews Duncan 
 points out that 
 extensions of ex- 
 udation to the 
 higher parts of 
 the abdominal 
 peritoneum may 
 become, during 
 the process of re- 
 covery, cut off" 
 from the rest, and 
 remain w^hen all 
 traces of the aff'ec- 
 tion, in its eai'liest 
 sites, have passed 
 away. This " re- 
 mote pei'imetritis," as he tenns it, very possibly accounts for some of 
 those puzzling cases of matted intestines and lymph, with or without 
 encysted ascitic fluid, which occasionally give rise to much difiiculty 
 in the diagnosis of cystic ovarian growths. 
 
 Displacement of the uterus almost always occurs, generall}' in a 
 forward direction, and it speedily becomes fixed, as by a plaster of Paris 
 mould, in the abnormal position. It may, however, happen that fixation 
 takes place early, and in almost the normal position, or various accidents 
 may, much more rarely, lead to some lateral disi)lacement, or to elevation. 
 
 If cut into at an early stage, the exudation would nearly always 
 contain within its meshes some centres of yellow serous fluid ; but 
 ultimately it may become as hard as gristle, or consist of interlacing 
 
 Fig. 201. — Successive accumulatious of Lymph in Pelvic 
 Peritonitis. Shown in Section. 
 
486 SYMPTOMS AND PHYSICAL SIGNS, 
 
 bands of every variety of strength and thickness. The progress of such 
 exudations is towards either complete absorption, or partial absorption 
 with remaining contractions or adhesions, or towards suppuration, the 
 last result producing one form of pelvic abscess. This last termination 
 will be disregarded until we have mentioned the facts concerning pelvic 
 cellulitis and pelvic hsematocele, which may eqvially, if not more 
 commonly, give rise to pelvic abscess. 
 
 In rare septicaemic cases the fluid may be purulent from the first, or 
 from a very early stage. 
 
 Symx)toms and Signs. — The symptoms, and still more the physical 
 signs, are those which we might expect from the above mentioned 
 pathological conditions. The symptoms of general peritonitis in its 
 acute form — rigors, increased rapidity of pulse, rise of tempera,ture 
 in very varying degree, severe shooting pain, nausea and vomiting, 
 diarrhoea occasionally, and tympanites — are for the most part present, 
 but the pain, as well as the tenderness to touch, are more or less 
 limited to the lower part of the abdomen; or the latter is felt on 
 vaginal examination. When the disease commences in or has assumed 
 a chronic form, the symptoms may be very obscure, consisting chiefly 
 of backache, discomfort in the region of the bladder, leucorrhcea, 
 disordered menstruation, and other indications which are common 
 to most uterine or pelvic disorders. Indeed, it is very usual for some 
 peritonitis to occur in an almost latent form in connection with ovarian 
 tumours, displacements of the uterus. Fallopian disorders, and the like, 
 its existence being hardly suspected until we find the adhesions which 
 make these other aff"ections less amenable to treatment, or the bulky 
 exudations which render their diagnosis much more difl&cult. The 
 chronic form is almost indefinite in its duration, owing to the constant 
 tendency to relapses. The acute form, if of septic origin, as after labour, 
 or in other severe types, the gonorrheal for instance, may end fatally in 
 a few hours, or may pass gradually, and with many subacute exacerba- 
 tions, into the chronic. 
 
 The physical signs in acute pelvic peritonitis may at first be very 
 slight, amounting to little more than the evidence of great pain when 
 pressure is made by the finger on Douglas's pouch or on the top of the 
 vagina, anywhere around the uterus, or above the pelvic brim. It is 
 generally stated that while the exudation is fluid it cannot be felt by a 
 vaginal examination, as it recedes into the abdomen on pressure. But 
 I am sure, from personal experience, that inflammatory or sanguineous 
 fluid may often be felt in Douglas's pouch by gently palpating it 
 through the vagina. When solidification has taken place, the hardened 
 lymph can be very clearly felt ; and the more chronic the affection the 
 more clear is the evidence thus derived. The position of this lymph is in 
 
AND DIAGNOSIS OF PEKIMETRITIS. 487 
 
 most cases very characteristic. It will either surround the uteriis, render- 
 ing the whole roof of the pelvis hard, and fixing the uterus in its centre, or 
 it will more often greatly predominate behind, displacing the nterns, and 
 fixing it forwards behind the pubes. The reason of this is obvious, if the 
 reader has followed the statements as to the pathology. The posterior 
 swelling — that in Douglas's pouch — may remain soft and pulpy for a con- 
 siderable time after the rest of the exudation has hardened. Anteversion, 
 or retroversion or flexion, or even lateral versions of the uterus, may 
 coexist, either as the result of pushing by the first exudation or of drag- 
 ging by its subsequent contraction ; they are more common, however, in 
 cellulitis. Until the case has become chronic, it is difficult or impossible, 
 without ansesthesia, to define the upper borders of the exudation. Even 
 percussion may quite fail us, owing to the entanglement within the mass of 
 portions of intestine, which cannot float above it, as they otherwise would. 
 
 Diagnosis. — It will greatly facilitate our ariving at the differential 
 diagnosis of pelvic peritonitis if we regard it from two separate points of 
 view — if we consider it — first, as liable to be mistaken for other acute 
 affections, at a time when it is recent and acute, and when we have few 
 physical signs to guide us ; and, — secondly, as requiring differentiation 
 from several chronic affections, some of which are of non-inflammatory 
 origin, after its exudations have given rise to stable pathological lesions. 
 These divisions correspond roughly to the acute and chronic stages. 
 
 Acute Stage. — In the acute stage, pelvic peritonitis may be mistaken 
 for inflammation of the cellular tissue {pelvic celhditis), for acute lyietritis, 
 ovaritis, or salinngitis, and for recent jyelvic hcematocele. 
 
 The general symptoms of acute inflammation somewhere about the 
 pelvis, are observable from the commencement in all of these affections 
 except the last, and the}^ are apt to supervene very quickly and with 
 more or less severity upon htematocele also, after the first period of 
 shock and hemorrhagic ancemia. Recent hematocele we may, however, 
 dismiss at once by stating that its diagnosis mainly depends on the 
 absence at first of the general inflammatory symptoms. Pain there 
 may be, acute and severe, but the rise in temperature and the excessive 
 tenderness on pi'cssure are absent. Some connection with the men- 
 strual period, or with suppressed or over-profuse menstruation, is also 
 generally found in hematocele. In fact, although it is in practice too 
 often mistaken for peritonitis, it never ought to be, if the case is seen 
 within a few hours. 
 
 From acute ovarian or Fallopian inflammation, peritonitis can be diag- 
 nosed only by the very distinct lateral localisation of the pain and ten- 
 derness in the former, until tlie occurrence of exudation in the latter 
 proves its more wide peritoneal character. Indeed, I should lay it down 
 as a practical rule, that very strictly localised peritonitis is almost always 
 
488 DIAGNOSIS AND DIFFEEENTIATION 
 
 due to some coexisting visceral inflammation, and that acute visceral 
 inflammation is nearly always accompanied by some local peritonitis. 
 The history, or the sequel of the case, will alone show to which affection 
 the greater importance must be attached. 
 
 Acute corporeal metritis, joer se, is a rare affection. If it forms a part 
 of a general septic poisoning, some peritonitis will invariably accompany 
 it ; if it is traumatic, the history of the injury and the clearly-definable 
 u-terine site of the pain and tenderness, as ascertained bi-manually, will 
 guide us to the right diagnosis. 
 
 The differentiation of pelvic peritonitis from pelvic cellulitis in this 
 early stage is often impossible ; but the following symptoms or signs 
 will afford a strong clue : — 
 
 1. The formation of a distinctly resistent swelling in the pelvis, at a 
 very early period, is in favour of cellulitis, especially if the tumour is 
 not behind the uterus. 
 
 2. The pain on pressure in peritonitis is chiefly above the pelvic brim, 
 and diffused, while in cellulitis it is chiefly within the pelvis, and in some 
 one direction, more frequently in that of one iliac fossa. 
 
 3. The symptoms of nausea, vomiting, small wiry pulse, and tympanites 
 are very common in peritonitis, while in cellulitis they are usually absent. 
 
 These symptoms, taken in connection with the history and causation 
 of the case, will generally guide the practitioner aright in his estimate, 
 but fortunately differentiation at this stage is not often of supreme im- 
 portance. If he watch the course of the symptoms, and note the site 
 of the subsequent exudation, he will generally be able to say whether the 
 latter is infra- or supra-peritoneal. 
 
 Chronic Stage. — This brings us to the diagnosis of pelvic peritonitis 
 when we have definite local exudations to deal with, which, whether watched 
 during their progress or not, may be mistaken for other substances, abnor- 
 mal in their nature or in their site. There is hardly one of those sub- 
 stances which are occasionally met with about the roof of the vagina (see 
 page 7) which has not been mistaken for the exuded and coagulated lymph 
 of pelvic inflammation, yet there are certain points which should aid us in 
 at once eliminating most of them. The lymph of peritonitis is so poured 
 into the interstices of the peritoneum, so glued to them, and so fixed, that 
 whatever is freely movable, by vaginal or rectal touch, or bi-manually^ 
 may at once be set down as not coagulated peritoneal exudation. In long- 
 continued constijmtion, with frequent pain and tenesmus, I have known ac- 
 cumulations of hard faeces to be thus mistaken ; but the educated touch 
 will at once discover the pitting on pressure, the absence of almost carti- 
 laginous hardness, the posterior and left lateral position of a fsecal 
 mass, — these, and the independent mobility of the uterus, will lead to 
 an examination ^:)er rectum. Hetroverted or retroflexed uterus presents a 
 
OF PEEDIETEITIS. 489 
 
 rounded mass behind, but this is in general freely movable upwards or 
 laterally. The sound, if there be no contra-indication, will show the 
 passage of the uterine canal backwards into the swelling, and will elevate 
 the organ into its place ; or, if there be some fixity or much local tender- 
 ness, the bi-manual examination will reveal the absence of the fundus 
 uteri in its proper position. Now and again a retroflexed uterus becomes 
 secondarily involved in pelvic exudation, and fixed in its abnormal site, 
 while the globular fundus is merged in more or less of lateral hardness ; 
 but even then, careful bi-manual examination, or probing of the uterine 
 cavity, will place the uterine position beyond doubt, while the fixation 
 and extended outline of the mass will often be made clear by the history 
 of intercurrent inflammatory symptoms. 
 
 A prolajised or enlarged ovary is differentiated by its mobility, by its 
 lateral position and its relation to the uterus, and by the peculiar sick- 
 ening pain on pressure. It is usually qu.ite detached from the uterus, 
 but even if adherent, it does not in any way surround it with a brawny 
 collar as does the presence of lymph. The possibility of coexisting and 
 extensive peritonitic exudation must, of course, be borne in mind ; but 
 in this case the lymph will be the evident abnormality, the entangled 
 ovary will be matter of surmise. 
 
 Fluid collections in the Fallopian tu.bes, ovaries, or broad ligaments, 
 cannot be mistaken for the solid exudations of peritonitis, and can only 
 be confounded with its products when abscess has occurred in them. 
 
 Fihroid tumours of the uterus may sometimes require careful diff"er- 
 entiation. Their firm attachment to the uterus, which, however, unless 
 very large or impacted, they do not fix in its place, their clear and 
 well-defined outlines above and below, the absence of inflammatory 
 history, the frequent presence of menorrhagia and metrorrhagia (although 
 these may sometimes accompany pelvic peritonitis), the direction and 
 length of the uterine canal, and the relation of the cervix uteri to the 
 tumour — all these points, if carefully weighed, should establish a diag- 
 nosis beyond doubt, although here also we may have a certain amount of 
 difficulty from the occurrence of intercurrent attacks of inflammation 
 along with fibroid outgrowths. 
 
 Bony growths of the pelvic wall are sometimes spoken of as sources of 
 mistake, but their situation and evident fixity upon the sacrum or else- 
 where, their non-interference with the viscera, except in a purely mechani- 
 cal way, their intense hardness, their history and progress, and their 
 non-penetration into any of the serous or cellular cavities of the pelvis, 
 should entirely prevent error. 
 
 An extra-tUerine foettis has its own special history and symptoms to 
 guide us. A deposit of cancer, or less frequently of tuherclc, in the 
 pelvic cavity may very closely sinuilatc the solid emulation of peritonitis. 
 
490 CAUSATION AND TEEATMENT 
 
 and doubt may exist for some time as to their differentiation. The points 
 in favour of the former are its rapid and at first often painless deposition, 
 the appearance of malignant cachexia or of malignant growths else- 
 where, the constant tendency to ascites, and the rapid increase of the 
 mass, often without any symptoms of inflammation. 
 
 Exuded lymph, whether the product of pelvic peritonitis or of pelvic 
 cellulitis, and blood, the product of pelvic hsematocele, are each, when 
 they have undergone consolidation, differentiated from other swellings 
 upon much the same lines as those just indicated. But their 
 differentiation from one another will be best reserved until all three 
 affections have been under consideration. 
 
 Causation. — The most severe cases of pelvic peritonitis are those which 
 arise during the septic and inflammatory states following on delivery 
 or abortion. In these, we have not infrequently that violent and septic 
 form which may end fatally in a very few hours, the affection being 
 clearly a mere part of the general phenomena of blood poisoning. When 
 recovery takes place, it may be complete, leaving hardly a trace discern- 
 ible by examination, or, in less violent but more sthenic attacks, coagu- 
 lated lymph may remain in large quantity and for an indefinite time. It is 
 not infrequent also to meet with such exudations a considerable time 
 ■after delivery, and with a history of only very slightly marked and sub- 
 acute symptoms. In many, if not most of these cases, the exudation is due, 
 however, to pelvic cellulitis rather than to peritonitis, and presents the 
 features afterwards to be described. Setting aside these puerperal and 
 post-partuiin cases, there are very many occasional causes of pelvic 
 peritonitis. It may be simply an extension from inflammation of the 
 subjacent organs, from acute metritis, cellulitis, ovaritis, &c. In a mild 
 form it often accompanies the progress of ovarian tumours, malignant 
 growths of the uterus or pelvis, and even sometimes of benign tumours 
 of the uterus. A specially dangerous and not infrequent cause is the 
 extension to the peritoneum of the poison of gonorrhoea or gleet. 
 It is an undoubted fact that a very chronic gleet on the part 
 of the male may give rise in the female not only to chronic but to 
 extremely acute inflammation of the uterine annexes and peritoneum, 
 and this should render the question of marriage under such circum- 
 stances an exceedingly grave one. I cannot endorse the terrible statistics 
 of Noegerrath (see Chap. V. p. 119) as applicable to society here, whatever 
 may be the case in New York, but I none the less urge upon the 
 practitioner the necessity of advising the perfect cure of gleet in the 
 male before marriage. 
 
 Pelvic peritonitis may also be caused by any of those injuries or 
 septic innoculations which we have seen may follow on the use of tents, 
 sounds, pessaries, or simple incisions of the genital organs, without the 
 
OF PELVIC PERITONITIS. 491 
 
 most careful precautions, but in such cases it is usually the cellular 
 tissue which is, primarily at any rate, affected, giving rise to septic 
 phlegmon or pelvic cellulitis. In some instances pelvic peritonitis is due 
 to cold or to mental shock, with or without sudden suppression of men- 
 struation, just as ordinary peritonitis or pleurisy may be. The inflamma- 
 tion in these cases more frequently affects the peritoneum than the cellular 
 tissue. Among the causes which may be mentioned as due to medical 
 interference, I should not omit to notice the incautious injection of medi- 
 cated fluids, or even of water, into the uterus. It must not be for- 
 gotten also that ordinary tubercular peritonitis may be very much con- 
 fined to the neighbourhood of the pelvic viscera. The rupture of a 
 l^elvic abscess, of an ovarian or other cyst, of a distended Fallopian tube, 
 or of an extra-uterine foetation into the peritoneu.m, or the occuri-ence of 
 pelvic hsematocele there, however slight, will fairly complete the list of 
 occasional causes of pelvic peritonitis. As the majority of these causes 
 are also frequently assignable to pelvic cellulitis, it is as well to mention 
 again, in this context, that general septic poisoning, after labour or 
 abortion, gonorrhoeal infection, and cold or other shocks to the general 
 system, tend more especially towards the causation of peritonitis, while 
 local injuries, whether during labour or at other times, or localised 
 septic poisonings, tend rather to the causation of cellulitis. 
 
 Treatment. — The treatment during the acute stage resolves itself into 
 (1) rest of the affected parts, (2) removal of pain, (3) reduction of fever, 
 and (4) removal of sepsis, the two latter indications being closely allied. 
 
 Quietude is obtained by keeping the patient in the recumbent position, 
 by avoiding the use of purgatives in any form, by gently using the 
 catheter in severe cases, and by avoiding all stimulation except in cases 
 of .severe septic or traumatic shock. There is no use in attempting to 
 influence the situation of the lymph by changes in position. If we had 
 it in our power, I do not know that we could improve upon nature's 
 selection in this way. 
 
 Removal of pain is produced by the free exhibition of opiates, a 
 practice which has not only this result, but which also tends to quiet all 
 movements of the viscera, especially of the bowels, to aid in maintaining 
 the general systemic rest, and, it is believed, to limit the extension of 
 the disease. Much relief is also obtained by the application of a few 
 leeches to the hypogastrium, and l)y the use of light warm poultices. 
 
 Reduction of fever is produced and maintained by antiphlogistic diet, 
 — light broths, milk food, and the like. If the temperature runs very 
 high, refrigeration of the surfixce by sponging, or even by ice-bags, tends 
 rapidly to lower it ; and, as I have formerly mentioned in speaking of 
 metritis, many prefer to use ice to the hyi)ogastrium from the first, in- 
 stead uf warm applications. There should be no vacillation, however. 
 
492 TEEATMEXT OF PEEDIETEITIS. 
 
 between the two. Aconite, digitalis, and veratrum. viride have each a 
 tendency to lower the j)ulse, and, to some extent, the temperature, and 
 may be given with good effect. I may here refer to some general re- 
 marks on antipyretics at p. 205. 
 
 The removal of sepsis may in some cases demand local measures. In 
 all cases, after labour or abortion, vaginal or even uterine injections are 
 called for to remove any decomposing fluids or embryonic remains, and, 
 if skilfully given, the vaginal injections, used pretty hot, are sometimes 
 found very soothing. In non-septic cases, complete rest is for the most 
 part to be preferred. I fear that we have yet little power of reaching 
 septicaemia through systemic remedies, but quinine in large doses, or 
 salicylic acid, should have a fair trial. Mercury also, pretty generally 
 abandoned, in the old routine form of calomel and opium, may yet be 
 found to exert its germicide influence, as it probably does in the most 
 chronic of zymotic diseases, syphilis. 
 
 When acute pelvic peritonitis has become subdued, and has entered 
 on the chronic form, the constitutional treatment must be such as will, 
 if possible, produce absorption of the exuded lymph, and means must be 
 taken to prevent the ever-present tendency to recuri-ence. For the 
 former piii'pose, plentiful and nutritious but easily-digested food is re- 
 quired, resort to the open air in the easiest possible fashion, and the 
 use in moderate doses of the usual tonics, feiTuginous and otherwise. 
 For the latter purpose — the prevention of recurrence — the hot-water 
 vaginal injections, according to Emmet's plan, are invaluable, and the 
 bowels should now be carefully regulated, while the patient must very 
 slowly indeed resume her former course of life, and should remain for a 
 considerable time absque viarito. BHstering of the abdomen, and the 
 application of iodine paint or liniment, are recommended by all writers, 
 and strongly extolled by many. To be of use they must be applied 
 unstintingly, and at the time when the acute symptoms have fairly disap- 
 peared, while the exudations are as yet not hardened in the extreme. I 
 am sm'e of the fact, although I cannot entirely account for it, that iodide 
 of potassium and bichloride of mercury, each of them, sometimes produces 
 a marked absorbent effect, while in other cases they seem totally inert. 
 The use of the waters of various foreign and British springs, chalybeate, 
 iodised, or saline, is indicated here, as in the chronic inflammatory condi- 
 tions of the uterus. The consideration of the treatment of purulent 
 degeneration is reserved until we speak of pelvic abscess. All ovarioto- 
 mists are aware of the immediate subsidence of peritonitis following 
 removal of tumours, and even when nothing has been done but opening 
 into the peritoneal cavity and thoroughly cleansing its svu'face, the same 
 result has not infrequently followed. I dare not attempt, in a work of 
 this kind, to draw any general deduction from these facts, but they are 
 
PELVIC CELLULITIS, OK PAEA-METRITIS. 493 
 
 sufficient to render it possible, or even probable, that time may lead to 
 some means of differentiating those cases of perimetritis, acute or chronic, 
 in which surgical treatment of this kind may be rationally followed. A 
 very careful notation and comparison of cases, in which the desired result 
 is thus accidentally, as it were, brought aboat, is required, and I hope 
 ere long to add my quota to the collection of facts. 
 
 Pelvic Cellulitis, or Parametritis, or Peri-uterine 
 
 Cellulitis. 
 
 By this we mean an inflammation confined to the cellular tissue 
 of the pelvis. Technically, the tei-m is still more restricted ; for, 
 although psoas, iliac, and lumbar abscess may involve the inflamma- 
 tion and suppuration of certain portions of the pelvic cellular tissue, 
 it is only those inflammations, unfortvmately of very common occur- 
 rence, which primarily attack the loose tissues around the supra- 
 vaginal neck of the uterus, or between the layers of the broad liga- 
 ments, or occasionally between the utero-sacral ligamentous folds, which 
 are understood to be meant. From this point of view the term jDeri- 
 uterine is not inappropriate. In describing pelvic cellulitis, it will be found 
 that practical utility leads us to base our description to a large extent 
 on stating where it difi"ers from that which we have given of pelvic peri- 
 tonitis. Probably the cellular form is the more common, if we consider 
 only the cases met with in ordinary gynaecological practice ; but if we 
 include obstetric practice, the balance will be somewhat redressed as con- 
 cerns the severe and clearly-diagnosed cases, although the niunber of 
 slight cases of cellulitis which follow on tears of the cervix uteri or 
 perineum might, if recognised, tend to restore the preponderance of that 
 form of pelvic inflammation. 
 
 Pathology. — Inflammation of these parts follows the course of 
 ordinary phlegmonous inflammation, and may terminate in resolu- 
 tion, cicatrisation, suppuration, or sloughing. The most common 
 site of this process is at one side of the cervix uteri, from which 
 it extends between the layers of the coiTesponding bi'oad ligament. 
 Hence a common diagnostic mark of cellulitis is its lateral character. 
 But both sides may be similarly and simultaneously affected, or the 
 attack may originate in or extend to the tissue between the bladder 
 and uterus, or behind, between the layers of the utero-sacral ligaments. 
 There are various knotty points, still undetermined, with regard to the 
 precise localisation of pelvic cellulitis. The earnest student, when he 
 has time, will strive to make the best he can of these, by reference to the 
 works I have named and to others, but the simple facts now given cor- 
 
494 PATHOLOGY, SYMPTOMS, AND SIGNS 
 
 respond with all clinical experience. I have asked one or two very ex- 
 perienced anatomists the simple question whether there is really any cellu- 
 lar tissue between the layers of the broad ligament at all, and by each one 
 I have been assured that he could not answer the question except by 
 reference to gynaecological literature. A similar amount of ignorance, 
 or at any rate of divergence of opinion, seems to exist with regard to 
 the absorbent glands and ducts met with in the pelvic region, but suffi- 
 cient is known to warrant the opinion of Munde that many of the slighter 
 attacks of cellulitis are really confined to the absorbents within the 
 pelvis. Displacement of the uterus is found in pelvic cellulitis, as in 
 peritonitis, although slight amounts of either may fail to produce it. 
 Its usual direction corresponds with what might be expected from the 
 facts now given. It is rarely, if ever, fixed centrally. It is very rarely,* 
 if ever, pushed forwards and downwards as a whole. Most commonly 
 the cervix is p^ished to one side, and the whole uterus is also displaced 
 laterally, but it is more frequently latero-verted or latero-flexed than 
 laterally displaced as a whole. It may be pushed backwards against the 
 sacrum, or its cervix may be pushed or pulled in that direction, while its 
 fundus bends over in front, or the cervix may be dragged forwards at an 
 acute angle to the fundus, also bent forwards (fig. 133, No. 6). 
 
 Symptoms and Signs. — The general symptoms of acute pelvic cellu- 
 litis are those of cellular inflammation in any other region — rigors, quick 
 pulse, and high temperature. These symptoms differ from those of peri- 
 tonitis only in their varying average frequency or predominance. Eigors 
 are more common, the pulse is often less rapid, the temperature ranges 
 higher except in violent septic cases, as it does generally in parenchymat- 
 ous as compared with serous inflammations. Nausea, vomiting, and 
 tympanites are seldom present; these symptoms point rather to aff'ections 
 of the peritoneum. Severe pain is more often absent than in peritonitis, 
 and tenderness on pressure on the abdomen may be absent, but it is 
 very marked at some particular point on vaginal examination, generalh' 
 laterally. There is often considerable dysuria, and there may be 
 tenesmus, owing to pressure on the bladder or rectum by exudation, 
 or to sympathy. As with peritonitis, there are cases in which the 
 acute symptoms are almost perfectly latent, or w^here they are so slight 
 and obscure as not to lead to investigation in the early stages. 
 
 The physical signs are those arising from the exudations and displace- 
 ments mentioned above. Very early on, the seat of inflammation is 
 detectable, both by the acute pain produced on examination, and by a 
 sense of puffiness and swelling. The effiised lymph or serum cannot 
 recede before the touch as in peritonitis. Bi-manual examination maj' 
 be impossible in the more acute stage without the aid of anaesthesia, but 
 it will, by and by, disclose the existence of a tolerably defined swelling, 
 
OF PELVIC CELLULITIS. 
 
 495 
 
 wliicli becomes harder as inspissation goes on, or softer if purulent 
 degeneration take place. In an ordinary or typical case the position and 
 relations of the swelling are characteristic. Douglas's pouch is not 
 affected, although some exudation may be felt laterally and behind, 
 in the direction of the utero-sacral ligaments. An examination by 
 rectum makes the situation of this more plain. But the most frequent 
 site of exudation corresponds with that of the broad ligament, stretch- 
 nig laterally from the uterus, and seldom leaving an interspace between 
 that organ and itself. In very many cases it is quite unilateral, or, if 
 it exists bi-lateralh^, it is in quite different proportions. In front of the 
 uterus a mass is often discernible, either alone or in combination with 
 the lateral swelling, and in slight cases we may have only an isolated 
 nodule or two in one or other of the situations now indicated, the 
 result of limited local injury and Ijmiphatic absorption. The other 
 signs are derivable from the changes produced in the position of the 
 utenis, and these have been sufficiently indicated above, but it is worthy 
 of notice that in 
 cellulitis the fixation 
 of the uterus is often 
 less complete than 
 in peritonitis, al- 
 though, owing to the 
 comparative freedom 
 of movement on one 
 side, its displacement 
 may be greater. One 
 symptom when it 
 occurs, as it not un- 
 frequently does, is 
 very characteristic of pelvic cellulitis and, less so, of intra-cellular hema- 
 tocele, namely, retraction of the thigh on the affected or chiefly affected 
 side. It may almost be considered as differentiating these affections 
 from the corresponding intra-peritoneal affections. In fig. 202 we have an 
 illustration of the most common form of exudation in pelvic cellulitis. 
 
 Diagnosis. — Sufficient has been said above to indicate the lines of 
 differentiation between the peritoneal and cellular forms of disease, 
 when their exudations are fully formed or stationary, and when we have 
 not, as sometimes happens, a combination of the two affections. In the 
 post-puerperal period, the exudations of cellulitis, or even of peritonitis, 
 arc often masked by symptoms of so general a character that they are 
 apt to be overlooked, unless very carefully watched for, and there are 
 few cases in which a fresh observer, called in consultation, more often 
 excites the chagrin of the regular attendant, than by indicating to 
 
 Fig. 202.— Lateral Exudation in Pelvic Cellulitis. 
 
496 DIFFERENTIATION AND DIAGNOSIS 
 
 him these unobserved morbid conditions. To be forewarned is to be 
 forearmed. The following conditions may be mistaken for the results of 
 pelvic cellulitis : — 
 
 HcBmatocele of intra-cellular character and small extent can only be 
 differentiated by its history, and, when chronic, the diagnosis is cor- 
 roborated if the swelling is less unilateral, the uterus pushed less laterally, 
 and the vagina more occluded than is common in cellulitis. The 
 tumour in hsematocele is more likely to be soft at first, gradually hard- 
 ening, while an opposite condition is too often found in cellulitis. 
 
 Faecal masses are distinguished by their posterior site and by the 
 methods of examination so often previously referred to. 
 
 Ovarian swelling or Fallopian distention are frequently very dif&cult 
 to differentiate. Their lateral position, tenderness, and frequent accom- 
 paniment by inflammatory symptoms add to the difficulty, while their 
 mobility, when it is retained, is, on the other hand, highly differential. 
 
 Extra-uterine i:)regnancy is more likely to be mistaken for the products 
 of peritonitis than for those of cellulitis, for, although more or less uni- 
 lateral, it can generally be ascertained to be supra-peritoneal. 
 
 Fibroid uterine tumours are nearly always open to the same remark, 
 but a small fibroid of the upper part of the cervix, especially in front, 
 would closely simulate the physical signs of ante-uterine cellulitis. A hasty 
 diagnosis of such a case might very probably be erroneous, but careful 
 study of the history, and a little patient watching, would prevent mistakes. 
 
 Pelvic ahscess is most frequently only a sequel of cellulitis. The 
 differentiation that would be required would be one of the real causation 
 of the abscess {see below). 
 
 Uterine Flexions. — Retroflexion has already been referred to as a 
 source of error in regard to peritonitic exudations. It will seldom 
 simulate those of cellulitis, which never occupy Douglas's pouch, and 
 only occasionally the interspaces in the utero-sacral ligaments. Ante- 
 flexion is a more common source of error, only to be settled, unless the 
 uterus is freely mobile, by careful bi-manual examination. I have 
 already stated elsewhere that very sharp anteflexion, the cervix rather 
 than the fundus being bent forwards, is, unless in the case of very 
 evident infantile uterus, most frequently due to ante-uterine cellu- 
 litic contraction, although the bulk of the exudation may have passed 
 away. Lateral flexions are almost certain to be mistaken for cellulitic 
 deposit, unless the sound and bi-manual examination be carefully em- 
 ployed. If fixed, the causation is almost certainly cellulitic. 
 
 Malignant nodules in the pelvis might easily be mistaken for cellulitic 
 deposits or septic enlargement of the pelvic absorbent glands, but uterine 
 cancer is almost always present as an antecedent, and presents its usual 
 symptoms, local or general. 
 
OF PELVIC CELLULITIS. 497 
 
 It will be well to insert now, in tabulai* form, the main differential 
 points between pelvic peritonitis (perimetritis) and pelvic cellulitis 
 (parametritis) : — 
 
 A. Perimetritis. B. Parametritis. 
 
 1. Causation. — Many causes commou 1. Causation. — Localinjuries, especially 
 to both. General shock, general septi- in labour, sepsis from local affections or 
 cseraia, and gonorrlicea more frequent. surgical proceedings more common. 
 
 2. Acute Sijiii2)toms. — Temperature 2. Aaite Symptoms. — Temperature 
 high in general septictemia, lower in averages higher. Pulse varies. Pain 
 slighter forms. Pulse rapid. Pain severe, often less. Tenderness chiefly pelvic, 
 diffused, abdominal. Tenderness chiefly generally lateral. Vomiting and tym- 
 hypogastric, rarely lateral. Vomiting panites absent. One thigh often flexed, 
 and tympanites common. Both thighs afterwards adducted or abducted, 
 sometimes flexed. 
 
 3. Local Swelling. — Fluid, and al- 3. Local Swelling. — Distinct intra-pel- 
 most indistinguishable at first. Site, all vie swelling almost from the first. Site 
 around the uterus, but tending to distend varies, never symmetrical behind uterus, 
 Douglas's pouch symmetrically behind, most often in one broad ligament, or at 
 Subsequent extension upwards iuto peri- isolated points, e.g., behind bladder, in 
 toneal cavity. one utero-sacral ligament, or in pelvic 
 
 glands. Extension occurs along course of 
 connective tissues. 
 
 4. Uterus fixed early in normal position 4. Uterus generally displaced laterally, 
 or pushed forwards. often flexed, fixation sometimes less com- 
 plete. 
 
 5. Cervix may be normal, or apparently 5. Cervix often apparently shortened 
 shortened behind or all round. ^ at one side.^ 
 
 Causation. — As has been already stated, pelvic cellulitis may take its 
 rise in any of the causes which are also assignable to peritonitis, but in 
 mentioning these I endeavoured to distinguish which of them were more 
 commonly followed by the one or the other form of inflammation. Local 
 injuries and local mal-practice certainly cause cellulitis more frequently, 
 systemic shocks, as from cold, &c., j)eritonitis. Labour or abortion may 
 give rise to either or both, while gonorrhocal extension is much more 
 frequently to the peritoneum. 
 
 Treatment. — Whatever may be the difficulties occasionally encountered 
 in differentiating between peritonitis and cellulitis, such difficulties can 
 hardly be said to affect the question of treatment to any very o-reat 
 degree. I have read a good many elaborate descriptions of the treat- 
 ment of both affections by the same writers, and I have never been able 
 to detect any noteworthy difference except in the different order or per- 
 spicuity with which each step was mentioned. I have notliing to add 
 to the treatment given at p. 491, except to say that abdominal incision 
 is out of all question here, at any rate in the absence of suppuration 
 with rupture or threatened rupture into the ijeritoneal cavity. Perhaps 
 
 I This apparent .sliortening is due solely to the presence of exudation depressin"' 
 the vaginal fornix. Its situation in either ease is thus accounted for. 
 
 2i 
 
498 PELVIC HEMATOCELE: 
 
 we may also say that in slight attacks of cellulitis there is an especial 
 necessity for looking for, and treating antiseptically, any local sources of 
 infection about the perineum, vnlva, or vagina. 
 
 Pelvic Hasmatocele. 
 
 Of all the unfortunate mistakes which I have seen in joractice, perhaps 
 none have been more disastrous than those which involved the over- 
 looking of this affection. The knowledge of its frequent occurrence, 
 and of its well-marked symptoms, does not seem to have sufficiently 
 permeated the profession ; and I think I may say that, in a con- 
 siderable majority of the cases which I have seen in consultation, the 
 patient was being treated for something else, while, nevertheless, the 
 mere whisper of the name was often sufficient to make plain to the 
 practitioner the whole state of the case. 
 
 Effusion of blood, either above or below the pelvic peritoneum, consti- 
 tutes the essence of the disease, although purists object to the term being 
 apphed in the former case until the effasion is fixed in its place by firm co- 
 agulation or surrounding inflammatory exudations. It is quite true that 
 blood from a niptured liver or kidney might trickle do'v\'n into Douglas's 
 poixch, and yet would not strictly constitute a pelvic hsematocele, but if 
 the hsemorrhage ceased without fatal result it would s|)eedily assume all 
 the characters of one, or, if we had no clue to the source of hsemorrhage, it 
 would be impossible to assign any other name to it. The nomenclature 
 of the disease is as complicated as that of pelvic inflammation. We 
 might speak of peri- and para-uterine hfematocele as, following Virchow 
 and Matthews Duncan, we do of the corresponding inflammations of the 
 peritoneum and cellular tissue respectively, or we may temi the former 
 retro-uterine, from the position of its esiided lymph in Douglas's pouch, 
 and we may speak of the latter as pelvic thrombus, but I prefer to retain 
 the distinguishing terms of intra-peritoneal and intra-cellular hsematocele. 
 I believe, however, that it will best serve practical ends if we treat of the 
 two forms of blood-extravasation a little more in common than we have 
 done in the case of peritoneal and cellular inflammation. 
 
 Pathology. — The source of the hsemorrhage, and its accompani- 
 ment of diseased ovary, uterus. Fallopian tube, ifec, will be dis- 
 cussed under the heading of causation ; for hsematocele is in reality 
 only a result or a symptom of disease in some pelvic or neighbouring- 
 organ. From whatever source the hsemorrhage comes, its course is 
 determined on precisely the same lines as that of inflammatory fluid 
 exudation. 
 
 If intra-peritoneal, Douglas's pouch is first filled, then gradually, in 
 severe cases, the uterus is surrounded or over-topped, the eff"usion reach- 
 
ITS PATHOLOGY. 499 
 
 ing the abdominal wall. Fig. 201 represents this, and will serve to 
 illustrate intra-peritoneal haematocele as well as pelvic peritonitis. In 
 hsematocele, however, the uterus is rarely arrested in the centre of the 
 exudation and glued there, but is rather pushed forwards towards the pubes 
 and afterwards fixed in that position. In a case of doubtful diagnosis I 
 should consider central fixation of the uterus, with free exudation of either 
 blood or lymph, both in front and behind, as strongly in favour, although 
 not conclusive, of its being lymph. In certain cases it happens that the 
 intra-peritoneal exudation of lymph or of blood hardly afiects Douglas's 
 pouch at all. This may occasionally be due to congenital deficiency of 
 the pouch, but more often to its obliteration or closure by previous in- 
 flammatory attacks. The phenomenon is certainly more common with 
 hsematocele, and this accords with the view that peritoneal adhesions 
 often precede haematocele and serve as restraining media to prevent its 
 extension or limit its bounds. 
 
 When the effusion of blood is intra-cellular it takes much the same 
 variety of courses as the swelling in cellulitis, into the lateral interspaces, 
 extending from the uterus between the broad ligaments, or in other 
 directions where loose cellular tissue allows of its progress. It is, how- 
 ever, from its invariable fluidity at first, much less disposed to be pre- 
 dominantly unilateral than the exudation of cellulitis. Sometimes 
 the distention is so great as to lift up the peritoneal covering of 
 the pelvis to a very considerable extent, and so to simulate very 
 closely the swelling caused by intra-peritoneal exudation or effusion. 
 In such cases the fundus uteri may even be felt centrally from above 
 the pubes, while the solidified eff"usion rises to a higher level on each 
 side. 
 
 The changes gradually undergone by the blood are not always 
 alike. It may remain fluid or semi-fluid for a considerable time, and, 
 especially if meddlesome treatment is employed, it may pass into the 
 condition of pus, with hardly any coagulation. Much more generally, 
 however, coagulation occurs, and the mass acquires in time an almost 
 stony hardness, this being followed, as in inflammatory exudation, by 
 gradual and more or less complete absorption, or b}- limited suppuration 
 and pelvic abscess. 
 
 When intra-cellular, the limitation and encystment of the eff"usion are 
 brought about by the natural limits of the intra-cellular spaces, and by 
 the peritoneal covering above, except in those rare cases where peritoneal 
 rupture takes place and the hsematocele partakes of a mixed intra-peri- 
 toneal and intra-cellular character. 
 
 When intra-peritoneal from the first, the fluid also becomes encj^sted, 
 and is not found, after death, free in the peritoneal cavity, unless in cases 
 of almost immediate destruction of life. This encystment is caused by 
 
500 THE SYMPTOMS AND SIGNS 
 
 inflammatory adhesions of the peritoneum itself, and not by coagulation 
 of the surface. By some it is supposed that these adhesions are always 
 pre-existent, and doubtless this is often the case, owing to disease of the 
 pelvic viscera, which is also the cause of the haemorrhage. But when 
 we consider how rapidly peritoneal adhesion occurs, as for instance after 
 abdominal incisions, how frequently, if not universally, the shock of 
 hsematocele is soon followed by pulse and temperature signs of inflam- 
 mation, and how improbable it is that an ovary or Fallopian tube will 
 never rupture upon a perfectly free surface, we must be compelled to 
 believe that the investing adhesions are, very often at least, secondary. 
 The intestines are sometimes involved in this capsule of lymph. 
 
 Symptoms and Signs. — All that has now been said tends to show that 
 the mere physical signs of hsematocele, when its exudation is complete, 
 differ but little from those of inflammation. In hospital practice we 
 meet with numerous cases where the absence of any clear history renders 
 it impossible to pronounce with certainty upon the original character 
 of the disease. The more constant tendency of an intra-peritoneal blood 
 mass to push the uterus much forwards and to rise quickly in the shape 
 of a large supra-pubic tumour is worthy of notice, but is certainly not 
 pathognomonic. In the intra-cellular form strictly unilateral exudations 
 are more probably inflammatory, but deposits confined to the front of 
 the uterus may be either inflammatory or hsemorrhagic. 
 
 With these remarks the student is referred to what has been said 
 before on the physical signs of pelvic inflammatory exudations. 
 
 The symptoms, however, which accompany the onset or progress of a 
 haematocele are, in typical cases, highly characteristic, and it is to these 
 that we must often look for differentation, although the physical signs 
 may lead to a closely approximate diagnosis. It is undoubtedly the 
 case that not infrequently slight haemorrhages occur into the peritoneum 
 with few or no characteristic symptoms. No one can study the physi- 
 ology of ovulation and menstruation without being satisfied as to the 
 great probability of this. If every unfertilised ovum, every little 
 haemorrhage from a Graafian vesicle, and every escape of blood from an 
 engorged Fallopian tube, which found its way into the peritoneum, gave 
 rise to alarming symptoms, female life would hardly be worth living. 
 Small callosities in Douglas's pouch or behind the broad ligaments 
 resulting from this cause, if accidentally discovered, can hardly be differ- 
 entiated from those which may have resulted from slight inflammatory 
 attacks. But haematocele, whether intra-peritoneal or intra-cellular, of 
 any considerable extent, is accompanied by sudden acute pain in the 
 pelvis or lower abdominal regions, and by a certain amount of rapidly 
 occurring shock to the system. The pain is characterised by its sudden- 
 ness, by its most frequent, although not invariable occurrence about the 
 
OF PELVIC HEMATOCELE. 501 
 
 menstrual period, by its very frequently following on some kind of 
 unusual exertion, and, above all, by the absence, for some time, of the 
 symptoms of inflammatory fever. If these points only were borne in 
 mind we should not meet with those frequent disastrous cases where 
 acute pain of the kind is at once treated as inflammatory, by means of 
 hot poultices. Three times I have seen this occur in the families of 
 medical brethren, twice with fatal results. 
 
 The systemic shock shows itself, according to its degree, by a mere 
 feeling of faintness or exhaustion, by a small and compressible, although 
 perhaps quick pulse, by lowering of the general temperature, or by the 
 utmost degrees of fainting, vomiting, general coldness, rapid pallor, 
 pulselessness, and hiccup, in fine, by every symptom which is only too 
 familiar to the obstetric practitioner as a result of internal haemorrhage. 
 When several of these painful and depressing symptoms are present 
 in any w^oman, the practitioner should never lose sight of pelvic 
 hsematocele until he has found some other clear cause for them. If the 
 symptoms are very marked, and if he possesses a delicate sense of touch, 
 the soft bulging, pcqopy condition of Douglas's pouch, or a more distinct 
 sense of encysted fluid in some part of the pelvic cavity, will confirm his 
 suspicions, and lead to immediate anti-h^emorrhagic treatment. I can- 
 not agree' with those who maintain that even free hsemorrhagic exudation 
 into the peritoneum cannot be ascertained with moderate certainty by 
 vaginal touch. In can, at any rate, recall no such case, since I first 
 made gynaecology a special study, in Avhich I have not felt absolutel}' 
 sure of its existence, and demonstrated it to the practitioner in attend- 
 ance. With moderately large exudations of blood, the evidences of their 
 pressure on surrounding structures are seldom absent. A feeling of 
 something to be expelled from the pelvis by straining, tenesmus of 
 bowel, bladder, uterus, or vagina, with difficult, obstructed, or com- 
 pletely prevented action of the bladder or bowel are met with. These 
 symptoms are very similar to those we meet with in sudden retroversion 
 of the gravid uterus, and if pregnancy exists, or if coagulation has 
 rapidly occurred behind the uterus, simulating the retroverted fundus, 
 the diffei'entiation may be difficult to those who are unfamiliar with bi- 
 manual examination. I have on more than one occasion found practi- 
 tioners diligently endeavouring to push up a mass of retro-uterine clot, 
 under the impression that it was the retroverted fundus of a gravid 
 uterus, while they might easily have traced bi-manually the connection 
 between the cervix in the vagina and the fundus just behind and above 
 the pubes. Many cases of hsematocele are accompanied by free metro- 
 rrhagia, a circumstance often owing to the fact that the causation is due 
 to something interfering with the menstrual phenomena at the time, but 
 it is not safe to lay too much stress upon this as a diagnostic symptom. 
 
502 PELVIC H-OIATOCELE : ITS SY3IPT0MS 
 
 metroiThagia may depend on or accompany so many other affections, and 
 is so frequently absent in this. 
 
 If the case be not seen for twelve or twenty-fonr hours, other sym- 
 toms arise -which, although they are a natural and almost a constant 
 sequel of the heemoiThage, render its diagnosis from inflammation difficult 
 or impossible. Inflammation of a secondary character has, in fact, set 
 in, and we have seen how necessary this is, in intra-peritoneal cases, to 
 secure the localisation of the blood mass. Chills or rigors, elevation of 
 temperature, tenderness on pressure above or below, show that the 
 inflammatory process is at work, and only the most careful estimate of 
 the primary symptoms, unless they were very marked, will enable us to 
 tell whether the febrile symptoms and the observed physical signs of 
 exudation are those of pelvic inflammation, pure and simple, or of this 
 grafted on to a hematocele. In hospital practice the hEematocele cases are 
 nearly all of this character, and one can hardly help a feeling of 
 huzailiation in being compelled so often to commence one's clinical obser- 
 vations in the same strain of doubt as to whether the case should be 
 tabulated as one of pelvic heematocele or of pelvic inflanunation. 
 
 The coui'se of the disease is very varied. Death in a very short time 
 often occurs in the intra-peritoneal cases. If post-mortem examinations 
 were more common in private practice than they are, this would be 
 speedily apparent. Inflammation of some indefinite character gets the 
 credit of many of these rapid deaths. Hospital practice, so valuable in 
 most instances, is of no use here as an educator. Patients do not come 
 in in anticipation of a rapidly fatal hsematocele, and the cases of 
 haemorrhage that are admitted have passed the fii-st and more dangerous 
 stage. 'V\Tien the tumour, if intra-peritoneal, has become encysted by 
 inflammatory exudation, or if it is intra-cellular, it may undergo fi-om 
 time to time, especially at the menstrual periods, accessions of bulk fi-om 
 renewal or continuance of its causes, but a time comes, if the patient is 
 kept at rest, when these cease, and if the practitioner will keep his 
 surgical talents in the background, and will refrain from puncturing 
 or incising the effused mass, it will generally disappear by absoi-p- 
 tion. Suppuration, with escape of blood-clots and pus, will now and 
 again occui-, and must be treated as any other case of pelvic abscess ; 
 but in my experience, if the case is treated with masterly inactivity, 
 as regards surgical interference, this termination is very rare. In 
 chronic hsematocele, a term seldom used, although clinically con-ect, 
 as in chi'onic pelvic peritonitis, it is essential to remember the fact that 
 a long period of rest must be allowed for subacute exacerbations, before 
 adopting hygienic means which leave these out of account. 
 
 Diagnosis. — We have already described the sudden pain and shock, 
 followed by definite signs of pelvic exudation, and intercurrent attacks 
 
AND DIFFERENTIAL DIAGNOSIS. 503 
 
 of inflammation, sutiicieutly to enable ns to say, with very fair certainty, 
 when a pelvic hsematocele has occurred. As regards differentiation from 
 other affections, we must, as with pelvic inflammation, decide, first — 
 what can be mistaken for it while it is recent, and while it has given i-ise 
 to no definite physical signs — and, secondly, how far its permanent or 
 long-existing physical signs can be mistaken for other organic affections 
 of the pelvis. 
 
 Pelvic hsematocele may, in its earliest stages, be mistaken for peri- 
 tonitis or cellulitis, a mistake which should be avoided by careful 
 observation of the pulse, temperature, and other symptoms denoting 
 the presence or absence of acute inflammation of any kind, and in grave 
 cases by noting the difference between the sudden shock of loss of 
 blood and that of commencing acute inflammation. In the case of 
 cellulitis, as in hsematocele, there may be distinct pelvic tumour from 
 the commencement, but that of the latter affection is soft and fluctu- 
 ating from the first, and gradually hardens, while that of the former may 
 be, and generally is, pretty dense and moderately firm from the 
 beginning. Sudden retroversion of the uterus, especially of the gravid 
 organ, often presents, as we have seen, very similar symptoms to those 
 of hccmatocele, but bi-manual examination wall at once correct any 
 mistakCj and, although sudden pain, shock, and pressure on the bladder 
 or rectum may be similar, the signs of internal hsemorrhage are absent. 
 The bursting of an extra-uterine evihryo produces hgematocele in its 
 most violent and fatal form. To speak, therefore, of the differentiation 
 of the two aftections is hardly correct, but in any case of serious pelvic 
 hsemorrhage, it is of great importance to decide, if possible, whether 
 extra-uterine pregnancy is j)resent or not. The history of pregnancy, 
 combined with the bi-manual discovery of a non-gravid uterus, the pre- 
 sence, at the very commencement, of a definite tumour, before much 
 coagulation could have occurred, the knowledge, if it is attainable, 
 whether such tumour existed before the shock took place, and the power 
 of making out any unmistakable portion of a foetus, are the points on 
 which we must rely for a decision. In the case of a very early embryo, 
 its existence ma}^ be only a matter of surmise, and tpiite incapable of 
 demonstration. 
 
 The diffei'entiation of intra-peritoncal from intra-cellular htematocele, 
 in slight cases, may be impossible at the first, and can only be made 
 where ph3sical signs have become marked, but a localised pelvic tumour 
 at a very early stage, which is not in Douglas's pouch, and which, 
 althougli soft, does not comjDletely recede on pressure, is distinctive of 
 the intra-ceUular form. The intra-peritoncal form must be more 
 strongly suspected when the attack occurs during a menstrual period, 
 and in most cases when it is violent, and leads to much collapse, where 
 
504 THE DIAGNOSIS, PROGNOSIS, 
 
 general peritonitis follows, or where there are frequent recurrent 
 attacks. 
 
 In its later stages, when all haemorrhage has ceased, when such 
 shock as may have followed has passed away, when secondary inflam- 
 mation has ceased, and when nothing remains but a history to be 
 investigated, and physical signs to be estimated, the difierentiation of 
 the results of haematocele from other conditions is difficult and often 
 impossible. From the exudations of pelvic inflammation, physical exa- 
 mination alone cannot now give any positive assurance of differentia- 
 tion. If the history is clearly distinctive, we may rely on it, if not, we 
 must be content to remain in doubt, although fortunately such doubt 
 has little if any influence on treatment. The exudation may be mis- 
 taken for fibroid outgroivths of the uterus, especially of its posterior 
 wall, for ovarian tumour, or for some of the rarer forms of uterine con- 
 genital malformations, for chronic uterine displacements, especially retro- 
 flexions, for a still advancing extra-uterine foetation, or for cancer of the 
 pelvis. The symptoms and signs of each of these have been mentioned 
 in their appropriate places, and must be recalled to memory in making a 
 diagnosis. If this be done, mistakes of an important kind will seldom 
 be made. The immobility of the mass will itself differentiate it from the 
 majority of these sources of error — from fibroid growth, displaced uterus, 
 or ovarian tumour. We cannot poise upon the finger, or move about 
 bi-manually, a firm pelvic exudation of blood or lymph, as we can all of 
 these, tinless fixed by accompanying inflammation. Extra-uterine foeta- 
 tion has its own special history, and pelvic cancer has its own cachexia 
 and constant pain, its absence of sudden supervention, and the frequent 
 coexistence of ascites, to guide us. 
 
 The diagnosis of intra-cellular from intra-peritoneal hsematocele, in 
 this stage, and so far as it depends upon physical signs, has been 
 sufiiciently indicated, and differs little from that between para-metritis 
 and peri-metritis. 
 
 Prognosis. — An almost immediately fatal result is apt to follow intra- 
 peritoneal hsematocele when it is caused by the rupture of an extra- 
 uterine embryo or of any very vascular structure. This may sometimes 
 be averted by steps afterwards to be described, if the true nature of the 
 case is diagnosed in time. When haemorrhage has ceased, and the 
 patient can be rallied, encystment of the clot by inflammatory exuda- 
 tion speedily follows. There is still a risk, especially at the first 
 following menstrual periods, of renewed and fatal hsemorrhage, but this 
 risk gradually lessens as the ruptured parts become sealed by adhesion. 
 Once rendered quiescent, the extravasation, if large, may burst into the 
 rectum, vagina, or elsewhere, discharging clots, suppurating, and ulti- 
 mately killing by septicajmia or exhaustion, or gradually performing a 
 
AND CAUSATION OF H^EMATOCELE. 505 
 
 natural cure. I have, however, rarely seen a case where, if it was left 
 alone, this result in spontaneous rupture occurred. Suppuration before 
 rupture, and subsequent abscess, is another occasional sequel, also, in 
 my opinion, too frequently the result of injudicious aspii'ation or other 
 manipulation. As a rule, the mass hardens more and more until it is 
 completely solidified, and then, under judicious hygienic treatment, is 
 gradually absorbed. Small intra-peritoneal extravasations undoubtedly 
 get well, frequently without diagnosis or treatment. Intra-cellular 
 extravasations rarely end in sudden death, but run the same course of 
 slow absorption or ultimate suppuration and abscess as the exudations 
 of pelvic cellulitis. 
 
 Causation. — We have already spoken of htematocele as, stricth' 
 speaking, not a disease, but as a symptom of disease in various organs, 
 which may lead to the extravasation of blood. In practice, and for the 
 purposes of treatment, we cannot, however, entirely maintain this view. 
 It is with the extravasation and its results we have to deal — the causes 
 are often only surmisable, and still more often are beyond our reach, at 
 any rate until long after the attack. Still, it is most desirable to know 
 what circumstances may lead, in various cases, to hsematocele, and for 
 the purpose of prognosis, or occasionally of treatment, to try to esti- 
 mate w.hich of these is most likely to be the efficient one in the particular 
 case. No doubt a certain number of cases are wholly or partially due to 
 a predisposing condition of system — to purpura, hsemophilia, or the 
 hsemorrhagic diathesis, or to chlorosis and other diseased conditions of 
 the blood or general vascular tissues. I think I have distinctly observed 
 a tendency to this affection in those of strumous habit. The menstmal 
 period, with its increased vascular tension, may also be looked upon as a 
 predisposing cause, as may every disease of the pelvic organs which leads 
 to permanent or occasional hypertemia of the tissues, sudden arrest of 
 menstruation by shock or cold included. Among the immediate causes, 
 we m.ay set aside those which depend on rupture of organs within the 
 abdomen proper, — of aneurisms, or of extravasations from congested abdo- 
 minal viscera. These may certainly cause hasmatocele, but, as a rule, the 
 primarily non-pelvic character of the disease should be ascertainable, and 
 should lead to attempts at practice founded on this knowledge. Among 
 the most fatal causes, although by no means the most common, is the 
 rupture of an extra-uterine embryo, and we have already fully discussed 
 this in its present relations (see Chap. XVIII.). The rupture of an ovarian 
 tumour may also cause ha)matocele, as may that of an occluded and 
 enlarged Fallopian tube or of a hscmatometra, due to atresia of the 
 genital canal. In these cases the physical signs may have led to pre- 
 vious diagnosis, or remain sufiicicntly distinct to enable us now to make it. 
 Rupture of a Graafian vesicle, or of an ovai-y which is the subject of cystic 
 
506 THE TEEATMENT 
 
 degeneration, or of varicose or hsemorrhoidal utero-ovarian veins/ and 
 escape of blood from the fimbriated extremity of an engorged Fallopian 
 tube, sum up the more common causes which lead to intra-peritoneal 
 hsematocele ; and any of these ruptures may, although more rarely, occur 
 between the folds of the broad ligament, and so give rise to the intra- 
 cellular affection. Among the special exciting causes of the intra- 
 cellular variety, although doubtless they may also occasionally give rise 
 to the intra-peritoneal, we may mention violent coitus, violent blows, 
 or falls or efforts, or pelvic operations, chronic menstrual suppression 
 with engorgement, giving way of pelvic adhesions, or any other cause 
 which tends to the rupture of vessels below the peritoneum or within the 
 pelvic cellular tissue. Most of these causes may be fairly estimated by 
 a careful study of the history of the patient for some time previously, 
 when time is permitted. 
 
 Treatment. — When called to a case of hsematocele, the practitioner 
 should endeavour to ascertain as early as possible whether it is intra- 
 peritoneal or intra-cellular. In the most dangerous, — -the rapidly fatal 
 cases, — he will give the benefit of the doubt to the intra-peritoneal 
 variety. If he believes that the attack is intra-cellular, he must at 
 once abandon the idea of anything like surgical interference. Nothing 
 that he can do will compensate for the loss of the restraining influence 
 of the pelvic fascise or coverings. If the haemorrhage is not so great as 
 to be immediately threatening life, and if, by means afterwards to be men- 
 tioned, he can secure reaction, or arrest of farther systemic depression, 
 he must exercise the same caution, no matter where the eflFusion of blood 
 may be. If the effusion appears to be intra-peritoneal, he must at once 
 decide, if he can, the question of extra-uterine pregnancy. Upon the 
 decision of this question will depend the further question as to how far 
 he may fairly entertain the idea of an abdominal incision for the removal 
 of the embryo. If it appeared certain that extra-uterine pregnancy 
 existed, and if life was trembling in the balance, I do not think that, in the 
 present state of surgical knowledge, any one who had a fair experience of 
 abdominal incisions for other affections would hesitate to cut down and 
 endeavour to remove the offending abnormality. But one who had not 
 such experience would be justified in remembering that difficulties might 
 occur far beyond his power to cope with, and that a patient may recover 
 even from a ruptured embryo with the most violent hsemorrhage. If 
 <jvarian tumour were known to exist, the necessity for operation would be 
 imperative ; and if diseased and occluded Fallopian tube had been pre- 
 
 1 In connection with this, the frequent association of hrematocele and varicose veins 
 of the extremities has been noted, I cannot recall to mind by whom. Considering 
 the frequency of the latter affection, we do not gain much certainty in diagnosis' by 
 the observation. 
 
OF PELVIC HEMATOCELE. 507 
 
 viously diagnosed, the iDractice would probably be the same as in 
 abnormal footation. Setting aside, however, these clearly diagnosed 
 affections, I think that in the present state of our diagnostic and patho- 
 logical knowledge, and knowing as we do that so many cases have a 
 naturally favourable termination after the immediate shock is past, all 
 other surgical interference is forbidden. The treatment will therefore, 
 in most instances, be confined to arresting the haemorrhage and rallying 
 the patient from the shock. For these purposes she is kept absolutely 
 quiet in the recumbent position, with the head low. Cold is applied by 
 ice-bags or bladders to the lower abdomen, while it may be necessary at 
 the same time to apply warmth to the extremities. The local cold is kept 
 up for several days, serving the double purpose of a local astringent and 
 of an antipyretic. Three drugs are especially of service, all of which may 
 be administered subcutaneously — morphia to relieve pain, ergotine as a 
 vascular styptic, and sulj)huric ether as a diffusible stimulant. Alcohol 
 in one of its forms must be frequently administered by mouth or rectum 
 as long as the temperature is sub-normal ; but it must be remembered 
 that a patient can no more live and acquire strength on alcohol alone, than 
 a horse can upon the free use of the spur. Milk, eggs, or peptonised 
 meats must therefore be administered in combination. Transfusion of 
 blood, seiiim, or saline solutions, may be tried with occasional success, as 
 in haemorrhage after labour ; but cases sufficiently severe to indicate its 
 use are too often beyond its reach ere the means can be employed. As 
 the patient gradually rallies, all stimulants must be withdrawn, and she 
 must be kept on light nourishing diet, while perfect and continuous rest 
 is enjoined for many weeks. Especially must this be observed at the 
 succeeding menstrual periods, for some months. 
 
 Next comes the question, how to get rid of the stationary exudation, 
 sanguineous and inflammatory, which remains. Whatever you do, do 
 7iot try to accomplish this surgically. In the early days of our know- 
 ledge of the affection, it was supposed to be absolutely necessary to 
 evacuate the mass of blood by vaginal incision. I saw a few cases thus 
 treated in Edinburgh about 1855, and the patients all died miserably of 
 septicasmia or ha3morrhage. If the covering gives way spontaneously, 
 and the clots begin to escape jmt vaginam or ^jer rectum, it is not our 
 fault. Nature will have made some jDrovision for this in a way we 
 cannot, and all we can do is to avoid external septic communication. 
 Everything that has been laid down for the treatment of chronic in- 
 flammatory pelvic exudations applies equally here, and nothing but the 
 undoubted occurrence of abscess, or of violent septicsemic symptoms, 
 will justify us in using other remedial means of a surgical character. 
 Even aspiration by needle, as a means of diagnosis from abscess, is not, 
 I tliiiik, warranted, unless the latter occurrence is almos,t absolutely 
 
508 PELVIC ABSCESS : ITS SYMPTOMS, 
 
 certain, and as a prelude then to more free evacuation. I am not un- 
 aware that many cases are still treated by incision by leading authorities 
 in the profession, and with what they consider as favourable results on 
 the whole. In these days of antiseptic treatment this is possible, but 
 as every case of haematocele which I have seen for over twenty years 
 (and they have been exceptionally numerous, although I cannot tabulate 
 them) which did not die from immediate haemorrhage, has perfectly re- 
 covered, with suppuration in only one instance, it is impossible that 
 better results could have followed the bloody operation of incision, and 
 I am justified, I hope, in thus speaking somewhat dogmatically. 
 
 Pelvic Abscess. 
 
 Pelvic abscess, apart from the lumbar, psoas, and other abscesses 
 which have distinct clinically-recognised origins outside the pelvis, 
 may arise in rare instances very obscurely, but it may safely be con- 
 sidered here as a mere sequel to certain diseases, of which pelvic cel- 
 lulitis, peritonitis, or hsematocele (especially the first-named) are by far 
 the most common, although it occasionally results also from suppuration 
 of an ovarian tumour or extra-uterine embryo, from ovaritis or salping- 
 itis, or from breaking down of tubercle. 
 
 The symptoms which point to the occurrence of suppuration are those 
 met with in suppuration of other parts. Rigors, high but fluctuating 
 temperature, throbbing, increase of pressure on surrounding parts, with 
 tendency to hectic and profuse sweating, become engrafted on the 
 former symptoms of disease, with more or less severity according to the 
 acuteness of the suppuration. On examination, a soft fluctuating swell- 
 ing is felt through the vagina or rectum, and is often clearly definable 
 by bi-manual examination. The situation of the swelling is determined 
 by the situation of the pre-existing disease. In most instances this soft 
 swelling will have been found to be preceded by comparatively hard 
 exudation. More especially will this be the case when cellulitis is the 
 originating cause. The soft fluctuating point may be central, among a 
 mass of still hard exudation, in the case of haematocele or pelvic inflam- 
 mation ; or it may, as in suppurating ovary or Fallopian tube, present 
 no hardened circumference at all. If the progress of the case has been 
 carefully watched, and if the general symptoms of abscess are present, 
 there can be little doubt as to the diagnosis ; but in the absence of pre- 
 vious observation of the case, there may be doubt as to whether we 
 have abscess to deal with, or the fluid, although not yet purulent, con- 
 tents of a hsomatocele, pelvic peritonitis, or other afl^ection. In such 
 cases the aspirating needle will decide the question, but its indis- 
 
PROGRESS, AND TREATMENT. 509 
 
 criminate use may provoke suppuration where it did not exist, and it 
 is advisable not to have recourse to it unless abscess is almost certain, 
 or ovarian or other pelvic disease requiring immediate interference is 
 present. 
 
 The natural x>rogress of a pelvic abscess is to find an outlet for the dis- 
 charge of its contents. In acute cases it may do this rapidly, and the 
 less interference there is, the more safely ; in chronic cases there is 
 often prolonged sufiering and weakness. The site of the exit depends 
 on a variety of circumstances, — on the thickness of the surrounding 
 exudation, the position of the fluid as regards the pelvic fasciae, and 
 other less obvious causes. But however complete our anatomical 
 knowledge of the structures or tissues involved, we can seldom predict 
 where a pelvic abscess wall burst, until the process is well nigh com- 
 plete. The rectum and vagina are the most usual sites, although it is 
 often extraordinarily difficult to find the exact spot from which im- 
 mense quantities of pus escape. The bladder is unfortunately some- 
 times selected, the uterus rarely. The small intestine is sometimes 
 pierced, and on the other hand the perineum may be reached. The 
 abdominal wall above the pubes, or in the groin, above or below Poupart's 
 ligament, is a not very infrequent point of exit. Sometimes the matter 
 burrows into one of the pelvic notches, causing intense pain like sciatica, 
 and producing contractions of the thigh w^hich have led to serious mis- 
 takes in the hands of those unaccustomed to gynaecology, and lastly the 
 fluid may burst into the peritoneum with immediately disastrous results. 
 The abscess may, even if single, have a double exit, still more so if there 
 are separate foci. Every form of spontaneous bursting is liable to be 
 followed by reclosure of the opening, and repeated outbursts, either in the 
 same or other directions. Rapid death from pelvic abscess is not com- 
 mon unless the peritoneum be entered, but by wearing out the strength 
 of the patient it may lead to tuberculosis, renal disease, or other diseases 
 of malnutrition, or by the occurrence of embolism or septicaemia, it may 
 at any time cut short the life of the patient. 
 
 Treatment. — Given a pelvic abscess of the kind now indicated, the 
 practitioner will, of course, support the patient's strength while 
 deciding what further can be done, and he will probably, by the use 
 of quinine or the salicylates, endeavour to keep down hectic fever. 
 If necessary he will also not scruple to use sedatives. Beyond this 
 he has only two courses before him, — to leave the issue to nature or 
 to promote evacuation by art. But the choice, although not varied, is 
 often difficult in the extreme, especially as regards the question of time. 
 In any individual case one miglit find little difliculty in assigning 
 reasons for one course or the other, but it is a very serious matter to lay 
 down any general rules in answer to the questions. When should you 
 
510 THE TEEATMEXT OF 
 
 leave a pelvic abscess to nature, and where or how should you evacuate 
 it 1 By leaving it too long we exhaust the strength of the patient, and 
 run the risk of its bursting into the peritoneum or forming numerous 
 fistulse in opposite directions. By evacuating too soon we run the risk of 
 cutting into parts which are unprepared to prevent the lateral circula- 
 tion of the pus into the cellular tissues or peritoneal cavity. I should 
 say that, whenever the evidence of pus, and of its pointing in a given 
 direction, is clear and undoubted, natiu-e will have prepared the tissues 
 for evaciiation, and this should be at once brought about by art in the 
 direction indicated. When there is any doubt on the point it is better 
 to wait, or to employ the aspirating needle, but to adopt the latter 
 course only when the evidence is very strongly in favour of the existence 
 of pus and of pointing of the abscess. The mode of evacuation will vary 
 according to the point which nature indicates as the desirable one. If 
 the groin or abdominal wall is clearly threatened, the ordinary surgical 
 methods of opening an abscess by incision, with antiseptic precautions, 
 drainage tube, and subsequent antiseptic injections, meet every want. 
 When the vagina, the favourite point of exit, is invaded, the wall may be 
 explored with the aid of the duck-bill speculum and incised at its thinnest 
 part, or a good sized trocar may be used. In either case an india-rubber 
 drainage tube or a winged elastic india-rubber male catheter should be 
 inserted. A very great improvement in the ordinary drainage tube 
 consists in having it unperforated, at least beyond the wall of the abscess, 
 using one of considerable leng"th and calibre, and inserting a glass bend, 
 which acts as a syphon trap, at some portion of its length (see paper by 
 Dr G. E,. Robertson, Medical Chronicle, November 1884). 
 
 For the rectum the trocar is necessary, carefully guided by the finger 
 to the prominent point, while withdrawn within its cannula, and if 
 possible a drainage tube should be inserted here also for a short time. 
 If there is a doubt as to whether the vagina or rectum is most clearly 
 threatened the former should have the benefit of it, as the site most 
 amenable to subsequent antiseptic precautions. Evacuated in any of 
 these ways, a pelvic abscess Avill sometimes heal up rapidly, but most 
 frequently it has a constant tendency to refill. .The drainage tube 
 obviates this to a certain extent, but after a few days have elapsed the 
 rapidity of healing is greatly enhanced and the danger of septicaemia is 
 equally diminished by washing out the cyst with 1 in 40 carbolic solu- 
 tion, or with weak iodine solution. If a double cannula can be intro- 
 duced through the opening, the washing may be thus effected, or the 
 drainage tube may be utilised if it is not laterally perforated. In the 
 rare case of abscess pointing in front of the vagina, the bladder must 
 be carefully emptied before taking any steps towards evacuation, and 
 no such steps should be taken in the absence of a clear necessity. 
 
PELVIC ABSCESS. 511 
 
 Abscess, confined to the ueighbourhood of the ovaries or Fallopian 
 tubes, may so far simulate abscess of those organs themselves, or 
 so clearly have a tendency towards the peritoneal cavity, as to warrant 
 an abdominal section under precisely the same reasoning, jpro or con, 
 as is applicable in the case of ovarian or Fallopian abscess. I have 
 recently had quite a series of cases under my care, Avhere, previ- 
 ously to admission to hospital, the abscess had burst into the bladder, 
 giving rise to chronic cystitis and to great increase of temperature on 
 every fresh discharge into the bladder. By watching carefully for the 
 first indication of these rises, and then washing out the bladder with a 
 half satvirated solution of boracic acid, I have succeeded in producing 
 what I hope will prove a permanent cure in all of them. 
 
512 DYSPAEEUNIA. 
 
 CHAPTER XX. 
 
 Dyspareunia, Vaginismus, Sterility. 
 
 Dyspareunia, 
 
 The term "Dyspareunia," reintroduced by Barnes, was originally in- 
 tended to cover those cases in which sexual intercourse was attended 
 in the female by pain, but there is nothing to prevent our including 
 under the same term those cases in which intercourse is impossible, 
 although not necessarily painful. Marion Sims introduced the term 
 "vaginismus " to indicate a peculiarly sensitive condition of the vulva 
 or vao-ina very commonly met Avith, and manifested by intense pain and 
 spasmodic contraction of the vaginal sphincter on the slightest touch. 
 The two terms are not, therefore, quite synonymous, although they 
 cover a good deal of the same ground. The conditions which produce 
 painful spasm or vaginismus will, however, all be referred to when 
 mentioning those which give rise to dyspareunia. 
 
 I propose to devote but few words to the consideration of this 
 subject, although it is of more importance than might at first be 
 imagined by the young practitioner. Independently of their bearing on 
 sterility, the number of cases in which unhappiness is occasioned by 
 obstacles that prevent the performance of the sexual function is much 
 greater than a general practitioner of even long standing might suppose. 
 Patients will often, from a sense of mauvaise honte submit for long years, 
 or even for a lifetime, to conditions which embitter the married life in 
 various ways, and if they are driven to consult a medical adviser they 
 generally prefer to select a specialist, with whom they are not frequently 
 in contact or socially intimate. Sir James Paget, in his excellent Clinical 
 Lectures and Essays (1875), points out that the further Ave recede from 
 the savage state the more does the sexual act become less a matter of 
 intuitive knowledge and practice, and this applies in the highest degree 
 to the sex which may, from this point of view, be considered the more 
 civilised — the furthest removed from the utter sexual impudicity of the 
 brutes. 
 
 The majority, if not the whole, of the causes of dyspareunia I have 
 
VAIUOUS CAUSES OF DYSPAKEUNIA. 513 
 
 Jdere tabulated, leaving out of the list, however, those dependent on the 
 male, such as real or imaginary impotence, malformation of the male 
 sexual organs, &c. 
 
 1. Frigidity of temperament. 
 
 2. Rigidity or abnormality of the hymen. 
 
 3. Neuromata of the vulva 1 
 
 4. Cracks, or fissures, or chronic ulcers of the vulva, anus, or urethra. 
 
 5. Vascular caruncles or degenerations of the u.rethra or vulva 
 
 6. Coccygodynia. 
 
 7. Vulvitis or vaginitis. 
 
 8. Atresia or stenosis of the vagina or vulva, congenital or acquired. 
 
 9. Chronic enlargements of the uterus, especially of its cervix, from 
 inflammation, hyperplasia, fibroids, cancer, &c., with or without displace- 
 ments. 
 
 10. Pelvic congestion from any cause. 
 
 11. Pelvic exudations. 
 
 12. Ovarian tenderness or prolapse. 
 
 13. Emotional causes, or hypersesthesia without evident lesion. 
 Whatever may be the primary causes of the dyspareunia, even when 
 
 it is merely due to awkwardness or timidity, if it is not soon got over, a 
 neurotic .condition of painful spasm is apt to be set up, increased with 
 every futile attempt, and leading to a certain amount of vaginitis or 
 vulvitis, which increases the mischief; so that the state of "vaginismus" 
 should often be considered as an effect as well as a cause. This eftect, 
 however, does not always follow, for 1 not long since removed the firm 
 circular hymen of a lady who had been married fourteen years. Both 
 she and her husband had been aware of an irremovable obstacle, and 
 some attempts had formerly been made at artificial dilatation, but the 
 parts were otherwise perfectly healthy, and the wife had experienced 
 no pain or spasm of a severe character. This Avas dyspareunia, not 
 vaginismus, although the former might easily have led to the latter also. 
 1. Mere frigidity or absence of sexual desire, or even repugnance to 
 intei'course, has often been alleged to me as a cause of dyspareunia. In 
 the absence of any of the physical obstacles afterwards named, this could 
 hardly be the case for long, unless one or both parties were peculiarly 
 mentally constituted. It is strongly recommended by many writers that 
 the 3'oung married woman Avould be much the better of a little more 
 physiological advice from her mother than is usual in our staid and 
 decorous British middle class society, and doubtless this is true. But I 
 have found some such advice too often quite as strongly needed by the 
 male partner, who too frcciucntly gathers his ideas, at first or second hand, 
 from impure sources, and who is often astonished, if not disgusted, to find 
 that the sexual passion, in its grosser physical manifestations, is absent, 
 
514 THE CAUSATIOX 
 
 or only slowly and partially developed, even in a woman who may be of 
 highly sensuous appearance, and who may also be perfectly fruitfal. 
 
 2. The hymen may not only constitute a physical obstacle in itself, by 
 its undue toughness, but may become the cause of intense vaginismus 
 even when it appears to the eye to be perfectly healthy. I have reason 
 to believe that the spasm may exist in the h}-men itself as well as in the 
 sphincter vaginae and other muscles connected with the perineal centre. 
 In every case where the hjinen is clearly the cause of mischief, its 
 complete ablation, with the precautions mentioned in Chapter II., is the 
 only certain remed}'. 
 
 3. Neuromata of the vulva have been described by Simpson and 
 others, indejDendently of any vascular caruncle or other morbid appear- 
 ance, and undoubtedly one can sometimes find a spot which is intensely 
 painful to the touch, although it presents nothing abnormal to the eye. 
 I have two or three times freely excised such spots, but have found no 
 trace of neuroma such as Yirchow describes, and, moreover, have pro- 
 duced no curative results; hence I am inclined to believe that these 
 points are only evidences of a general hypertesthetic or neuralgic ten- 
 dency. 
 
 4. Cracks and fissui'es of the vulva must never be lost sight of in 
 searching for the causes of dyspareunia, especially when it does not 
 exist from the first, but comes on after a time, or even after pregnancy 
 and delivery. In the latter case they may be traumatic results of the 
 process of labour, or, in any case, they may follow in the wake of a little 
 eczema which has otherwise passed away. Their treatment is by free 
 incision, as in anal fissures. It must be remembered, also, that a fissure 
 of the anus, or even of the urethral orifice, may produce resists which 
 the patient herself cannot differentiate from those of fissure of the 
 ^Tllva. 
 
 5. Vascular caruncle of the m'ethra (p. 55) is, of coiu'se, an efiectual 
 baiTier to connection. I never, however, met with such a growth exist- 
 ing at the time of marriage, and its existence, either previously or subse- 
 quently, is pretty certain to be diagnosed and appropriately treated, aj)art 
 from dyspareunia. I have also described above (l.oc. cit.) those painful 
 caruncles which may remain as vestiges of the ruptured hymen, or 
 which occasionally aj)pear independently on the vulva. The only 
 remedy is thorough ablation. The non-protuberant vasculo-nervoua 
 degenerations of the vulva, spoken of along with the vascular cai-uncles, 
 are most common in the aged and unmarriageable, as are also the 
 intractable ulcerative degenerations described by Matthews Duncan. 
 
 6. Coccygod}iiia may be productive, among its other painful effects, 
 of dyspareunia. I have said sufiicient above (p. 59) of the varying 
 causes and treatment of this aftection, or rather group of aftections. 
 
OF DYSPAREUXIA. 515 
 
 7. Vulvitis and vaginitis, when at all acute, oi' even sub-acute, and 
 whether specific or not, are a source of great pain during, or even com- 
 pletely preventive of, intercourse. Their general and local treatment 
 are elsewhere fully discussed. They may, as we have seen, be an effect 
 of futile attempts at coitus, rather than the primary cause of the 
 dyspax'eunia or vaginismus, and the cases are too common where they 
 are the result of contagion from an uncured gleet in the husband. These 
 cases are specially intractable, and have sometimes disastrous results, 
 from extension upwards to the uterus, Fallopian tubes, ovary, or peri- 
 toneum. Every observant family practitioner could narrate some such 
 case, terminating the short-lived happiness of a young bride in life-long 
 misery or untimely death. Barnes and Marion Sims strongly recom- 
 mend the use of the vaginal dilator (figs. 36, 37) in most cases of 
 vaginitis, to keep the inflamed surfaces apart, but I have more than 
 once found the remedy worse than the disease. It is worthy of trial, 
 however, and is invaluable after all operations on the vulva or vagina 
 whei'e recontraction is to be feared. In connection with vulvitis, 
 the possibility of abscess in the glands of Bartholinus or elsewhere must 
 not be lost sight of, and, indeed, we might add to our list of possible 
 causes of dyspareunia nearly all those local affections of the vulva which 
 are mentioned in Chapter II. 
 
 8. Complete atresia, or considerable stenosis of the vagina, Avhether 
 congenital or acquired, may for the first time be brought to light by 
 ineffectual attempts at intercourse, and will lead to treatment as de- 
 scribed in Chapters V. and VI. But mere shortness of the vagina, not 
 uncommon in girls married very young, or even at any age, and shrink- 
 ing and rigidity of its tissues in women who marry late, will, if brought 
 under our notice, call for a little judicious advice to the husband. 
 
 9. Chronic enlargements of the uterxis, always apt to be accompanied 
 by displacement downwards, backwards, or forwards, may cause dys- 
 pareunia at any period of mamed life, and this they may do, either from 
 their abnormal position leading to undue pi-essure upon them during inter- 
 course, or by their tendency to induce a generally congested and tender 
 condition of the whole pelvis. Elongation of the cervix, in particular, has 
 this result, whether it be the congenitally long conical cervix, or the en- 
 larged cei*vix of chronic metritis, with or without laceration. I cannot 
 here recapitulate the treatment either of these affections of the cervix, or 
 of the inflammatory states, sub-involution, fibroid tumours, or cancer of 
 the uterus, which have been elsewhere detailed. 
 
 10. Pelvic congestion is also, as a rule, merely a result of some of the 
 above conditions, but becomes in itself a source of pain and discomfort 
 on connection; and I have known its treatment by hot-water injections, 
 glycerine plugs, or otherwise, speedily remove this complication, although 
 
516 THE CAUSES OF 
 
 it is doubtful whether this is in all cases a gain, abstention being a part 
 of the curative programme. 
 
 11. Pelvic exudations and contractions from effused lymph or blood 
 have been considered in the last chapter. Every degree of impediment 
 may be thus induced, and if it were not so, it may safely be said that all 
 attempts at connection should be forbidden, long after the exudations or 
 effusions have ceased to be recent. 
 
 12. Ovarian tenderness, from chronic inflammation, congestion, or 
 cystic degeneration, or possibly from neuralgia, may give rise to dys- 
 pareunia, not only by its own tenderness on pressure, but also by the 
 sympathetic neuroses which it may set up. The primary cause of pain 
 itself, it may speedily cause spasm and pain on the slightest touch of the 
 external parts, so as to lead to the belief that the whole mischief lies 
 there. The same thing may be said of prolapsed ovary, and mistakes in 
 these cases will only be avoided by making a complete examination of 
 the parts, with the aid of ansesthetics if necessary, 
 
 13. Mere emotional causes may cause such resistance to connection 
 as to lead ere long to the development of the vaginismic state, and in 
 certain cases, and these very intractable ones, nothing abnormal can be 
 discovered except the one feature of pain on sexual approach. 
 
 Vaginismus. 
 
 In such cases as the one last mentioned, and in others, where the 
 symptoms of vaginismus may probably have been secondary to some 
 now removed local obstacle, we are obliged to treat the affection as if 
 it constituted a disease in itself. The first step, after seeing that there 
 is complete marital separation for a time, is to soothe any existing 
 spasm or sub-acute vaginitis or vulvitis by warm opiate fomentations, 
 by injections if they can be borne, and by pessaries or suppositories 
 of belladonna (ext. gr. iii.), atropia (gr. -^-^ to -Jq), or morphia (gr. i), 
 and by the other means recommended above for the soothing treatment 
 of vulvitis or vaginitis. In slight cases these means may suffice alone. 
 At any rate, we are more free now to search for local painful causes, and 
 to remove them. No investigation for this purpose is complete without 
 ansesthesia, under the influence of which spasm relaxes, and a totally dif- 
 ferent examination of the vaginal canal is obtained. When no removable 
 external obstacle can be noted, or when such obstacle has been removed, 
 and if we are clear that there is no pelvic cellulitis or other uterine or 
 pelvic disease, one of Sims's or Barnes's dilators may be easily intro- 
 duced now, and left until the patient has recovered some time from the 
 anaesthesia. It will not generally be difficult, after this, to introduce it 
 
DYSPAREUNIA AND VAGINISMUS. 517 
 
 again without ausestliesia, and the wearing of this, or of one of increased 
 size, daily for an hour or two, may suffice to bring about a cure. Where 
 the pressure of the dih\tor cannot be borne, it may be necessary to 
 divide the sphincter as a prehminary, and this is most safely done by 
 tearing it with the two forefingers or thumbs. Simpson, following 
 Burns of Glasgow, recommended division of the pudic nerve, as at any 
 rate the best palliative treatment, in vaginismus, and he performed this 
 subcutaneously by the tenotomy knife. This procedure has, however, 
 been generally abandoned, and not improperly, seeing that it is almost 
 impossible to reach the nerve with safety owing to its proximity to the 
 internal pudic ai^tery. 
 
 The catalogue of affections which may, in rare instances, produce 
 dyspareunia, is not exhausted above, but sufficient has been said to put 
 the practitioner on the look-out for a considerable variety of causes, 
 very often not situated externally, although leading to symptoms of 
 vulvar irritation and spasm. There are very few cases where the 
 general health is not, primarily or secondarily, affected, and if local 
 treatment can be combined with temporary separation, change of air, 
 bathing, and general tonic regimen and medication, it is much more 
 likely to be successful and permanent. Eeferring once more to a 
 remark .at the commencement of this chapter, there can be no doubt that 
 vaginismus, as far as its emotional, hysterical, or neuralgic elements 
 are concerned, is to a large extent a product of modern civilisation, due 
 to errors in the physical or intellectual education of the sex, and in cer- 
 tain classes to the high pressure of the everyday life. 
 
 Sterility. 
 
 This subject may be treated with brevity almost equal to that 
 bestowed on dyspareunia, and for the same reason. What we have 
 chiefly to do is to enumerate the various causes, especially those which 
 are amenable to treatment, which may lead to barrenness or to the 
 arrest of fertility. Their treatment, where treatment is possible, will 
 have been given in the preceding pages, and will require only a few 
 remarks, here and there, as regards its bearing on sterility. 
 
 Sterility or barrenness, in any individual woman, may be congenital or 
 acquired, i.e., it may depend on her original organisation or on su})sequent 
 disease. It may also be permanent or temporary, and remediable by the 
 vis medicatrix natmre or by art ; and it may be absolute or relative, i.e., 
 it may depend on some condition in herself, which, until it is cured by 
 nature or art, will render her sterile under any circumstances, or she 
 may only be barren in relation to her present husband and not to a former 
 
518 STEEILITY 
 
 or subsequent one. Several cases are on record where sterility has 
 been the result of the connection of one husband and wife, while, after a 
 divorce, both parties had issue by another mate. I know of no such 
 case, however, where the absence of temporary disease in the female 
 during her first marriage has been thoroughly proved by physicians 
 endowed with the modern knowledge of uterine diseases and having 
 facilities for investigation. Thus a woman with chronic endo-metritis 
 may be apparently sterile, but let her be divorced and live for a time 
 absque marito, her endo-metritis may disappear, and the husband and 
 wife who were together infecund may, when married again to another 
 mate, appear to have each acquired new powers. The fact of relative 
 infertility of this kind, in the absence of disease, cannot, however, be 
 denied, but, on the contrary, is rendered probable by the fact that it has 
 been demonstrated in the case of some of the domesticated animals. 
 
 One of the most philosophical essays on this subject to which I can 
 refer the practitioner is that of Matthews Duncan, the Gulstonian lectures 
 for 1883, which are published in the first volumes of the Lancet and Brit. 
 Med. Journal of that year, and since then in separate form. They deal with 
 the matter from the point of view of comparative animal and vegetable 
 physiology, and collate also many most interesting and laboriously 
 gathered statistics on the relation of age and other non-morbid condi- 
 tions to sterility or fruitfulness. I shall endeavour to epitomise a few of 
 these observations, but the whole essay is in itself almost an epitome of 
 facts, derived from or corroborated by statistical tables. For many most 
 suggestive remarks on the causes of sterility in vegetables, or in the 
 lower animals, the student must consult the j)aper itself; but the fol- 
 lowing conclusions of the author are of value, not only as mere scien- 
 tific facts, but as bearing somewhat on the prognosis in any individual 
 case of sterility. 
 
 He estimates the number of unfruitful marriages at about one in every 
 ten. He considers that the average time after marriage for the birth of 
 a first child is about one year ; but he also adduces such strong evidence 
 that three years very freqixently elapse before this event, that there is 
 no good presumption of permanent sterility until after this term. This 
 is of considerable value, as diminishing the evidence in favour of many 
 so-called cures of sterility at this early date in wedlock. 
 
 In relation to the amount of normal fecundity in the human female, 
 he places the average interval between the birth of successive children 
 at from eighteen to twenty months, and he gives the average normal 
 physiological number of children as closely approaching to ten for each 
 fertile woman. It is perfectly evident, however, that these averages 
 are liable to so many disturbances, from an infinity of social causes, that 
 the can only be used with great caution by the practical physician. 
 
IN YAEIOUS ASPECTS. 519 
 
 Too early marriage — that is, marriage under twenty years of age or 
 thereabouts — is favourable to sterility, and still more to partial unfruit- 
 fulness, although every practical observer must know of many instances 
 which seem to tell a different tale. The average ages of commencing 
 fertility and of its cessation do not correspond with those of commencing 
 and terminating menstruation. As to the difference between the average 
 dates of the commencement of the tAvo functions, — menstruation and 
 child-bearing, — the statistics of civilised countries afford no reliable data ; 
 but in spite of instances familiar to all, the cessation of child-bearing 
 would appear to arrive, in the average woman, at about thirty-eight 
 years of age — i.e., seven or eight years in advance of the cessation of 
 menstruation. This point has already been referred to when treating of 
 the latter function. Some curious details are given as to the relation 
 of sexual desire or pleasure on the part of the woman to fertility. The 
 absence of either would appear to have some effect in diminishing fruit- 
 fulness, but how far this is due to alteration in the sexual relations, or 
 to disability for conception inherent in the woman, does not appear. 
 I know, hoAvever, of more than one tolerably large family where 
 congress has been totally devoid of sexual desire or pleasure, and 
 even of any strong desire for offspring, on the part of the wife. 
 
 But tairning from MatthcAvs Duncan I may again refer the student to a 
 very different work, — to Marion Sims's Uterine Surgery, — which, under this 
 title, treats of the mechanical obstacles to impregnation. Gynsecology 
 owes mxxch to this Avork, which was, the author has told me, to have 
 been the forerunner of a complete treatise on the diseases of women, the 
 croAvning task of his life. In it there are cei'tain details as to artificial 
 impregnation AA'hich shocked the propriety of English physicians, and 
 Avhich, personally esteeming the man as I did, I should Avish had never 
 been Avritten. But from Spallanzani dowuAvards, many experiments of 
 the kind have been tried, chiefly by continental practitioners, and the 
 best corrective I can find is the statement of Paul Munde, that " Sims 
 himself has given up the practice altogether and does not expect to 
 retuni to it again." One can easily enough imagine means of injecting 
 small quantities of fresh semen into the uterus, Avithout going into 
 details. I trust the reader Avill never meet Avith a case Avhere siich pro- 
 ceedings seem to be honourably Avithin his role. After all, Sims only 
 once apparently succeeded, after fifty-five injections, in thus inducing 
 conception, and this patient miscarried at the fourth month. 
 
 Tlic svibject of sterility, as it Avill be broixght under the cognisance of 
 the practitioner, Avill ahvays resolve itself, Avith more or less circumlocu- 
 tion, into a triiDle inquiry : — (1) Which of the pai*ties, husband or Avife, 
 is the causative agent in the childlessness, or of infecundity after one or 
 more pregnancies 1 (2) If it be the male, Avhat can be done to remedy 
 
520 THE CAUSATION AND TEEATMENT 
 
 the defect ? (3) If it be the female, as is certainly most commonly the 
 case, what can be done of a remedial nature ? 
 
 I may add a fourth question, a very pertinent one, one which a sen- 
 sible husband will always put — Would it not be better to leave well 
 alone, and accept a condition of affairs which has its social compensa- 
 tions? This is a very different question from that of — How is preg- 
 nancy, or too frequent pregnancy, to be prevented? a question which I 
 shall leave imtouched except by a few words subsequently. It is 
 only the third and fourth of these questions with which we have here 
 to deal. It is only fair, however, before subjecting a woman to 
 painful or disagreeable examinations, to ascertain from her husband 
 that there is no deformity in himself, and that he possesses the power of 
 ei'ection and emission; other points, such as the perfection of these 
 functions, and the character of the semen emitted, I gladly leave to 
 the surgeon or medical jurist. 
 
 We may at once say that dyspareunia, arising from any of the 
 numerous causes mentioned above, is a very probable cause of sterility. 
 But it will not do to insist too much upon this. Intromission, although 
 it is in some countries necessary to constitute a legal rape, is certainly not 
 necessary for impregnation. A single drop of semen once introduced 
 into the vagina may, in an otherwise fertile woman, find its way to the 
 ovum, and involve pregnancy. With the most intense vaginismus, a 
 woman may be potentially fertile, and accidental entrance of semen may 
 convert this potentiality into actuality, while the occurrence of delivery 
 may cure the vaginismus. Some of the causes of dyspareunia are, how- 
 ever, necessarily j)roductive of sterility also ; even although intromission, 
 and emission of semen are occasionally perfected. 
 
 In the first place, on the part of the female, we may have, without 
 any dyspareunia, certain conditions which destroy the vitality of the 
 semen and render it inert. We do not know all about these conditions, 
 any more than we know why, in certain cases, the examination of an 
 apparently healthy woman is productive of tolerably severe smarting in 
 the finger of the examiner. But we do know from actual experience 
 that acid solutions tend rapidly to destroy seminal vitality, while 
 moderately alkaline solutions tend rather to preserve it. Excessive 
 vaginal secretion tends therefore to infecundity, and its cure by astringent 
 and antiseptic injections or otherwise, or its neutralisation by alkaline 
 injections will often lead to impregnation which has been long delayed. 
 
 Secondly, we may have some mechanical obstacle which prevents the 
 semen passing into the body of the uterus, or, as most modern physi- 
 ologists still deem necessary for normal impregnation, into the Fallopian 
 tubes. I do not think this is the most comjnon cause of sterility, 
 although the factors that may give rise to it are very numerous, and 
 
OF STERILITY. 521 
 
 striking cures are occasionally produced by their removal. An absolute 
 barrier is of course produced in this way by complete atresia of the 
 vulva, hymen, vagina, cervix, or Fallopian tubes, the diagnosis and 
 treatment of which have been fully discussed above. A less complete, 
 although often an effective obstacle, may depend on vaginismus as above 
 described; on narrowing of the cervix uteri, of congenital or acquired 
 nature ; on the ordinary type of infantile uterus ; on elongation of the 
 cervix, either in the form of long conical cervix, or of hypertrophied 
 cervix from inflammation or sub-involution ; on tumours of the vagina, 
 especially cancer; on uterine tumours — polypi, fibroids, or cancer; — on 
 endo-metritis or torn cervix ; on uterine versions which throw the os and 
 cervix uteri out of line; on uterine flexions which bend and thereby 
 narrow the uterine canal ; on the abnormal excretion of a complete 
 uterine cast during menstruation (membranous dysmenorrhoea) ; or 
 on metrorrhagia in any form, which tends to wash back the advancing 
 spermatozoa. 
 
 Here is certainly a large number of possible causes, with all of which, 
 however, we are now, I trust, somewhat familiar. Vaginismus has been 
 quite recently described. Cervical stenosis (p. 197) will nearly always 
 occasion dysmenon-hoea when it is a cause of sterility, and this symptom 
 will be the most probable cause of our assistance being sought. In 
 such cases, as in the case of infantile uterus (p. 194), if marriage does 
 not lead to aggravation of the dysmenorrhoea, by causing uterine and 
 ovarian hyperemia, it may chance that impregnation may occur and 
 lead to the cure of the affection. The elongated conical cervix (p. 198) 
 presents an obstacle to impregnation, not only on account of the nar- 
 rowing of its canal, but also because the semen is deposited in the dee]! 
 cul-de-sac which it affords at the top of the vagina ; and the same ma}' 
 be said, although less certainly, of the cervix which is much enlarged b}- 
 chronic inflammation or hypei-plasia. Tumours of the vagina act simply 
 in virtue of their size, or, perhaps, also by leading to abundant acid 
 vaginal secretion. It is not safe to assume, however, that impregnation 
 is impossible, even with an excessive amount of sproviting malignant 
 tissue in the vagina. The action of uterine tumours is also mechanical, 
 but is no doubt aggravated by the monorrhagia and free discharge 
 of other kinds which so constantly accompany them. Many a woman 
 is sterile for many years after one or more pregnancies, owing to the 
 unhealthy state of the endo-mctrium, of the cervix alone, or of the body 
 also. The action here is not single, for many women with endo-metritis 
 or torn cervix conceive readily enough. The nature of the discharge 
 must have much to do with it, for, setting aside any chemical action it 
 may have on the spermatozoa, it is difficult to see how they can easily 
 force their way through the tough and glutinous material in the cervix. 
 
522 THE CAUSATION AND TKEATMENT 
 
 which is often proof against our efforts to remove it. But the unhealthy 
 endo-metrium of the body must also oj)pose itself to the normal im- 
 plantation of the ovxim, even when fertilised, or may lead to very 
 early and scarcely recognisable abortions. Torn cervix undoubtedly 
 often acts also by leading to early abortion. The remedy of torn 
 cervix by operative means has often been followed by pregnancy and 
 delivery after years of barrenness, although the mere condition of ectro- 
 pion of the cervix could hardly have been a mechanical obstacle. The 
 relation of acute flexions of the uterus to sterility has already been 
 sufficiently discussed. The subjects of membranous dysmenorrhoea are, 
 I believe, invariably sterile, and the physiological as well as the me- 
 chanical reason is easily to be seen. Metrorrhagia or profuse uterine dis- 
 charge of any kind is preventive of impregnation ; but if there is no 
 other obstacle, a very short intermission may sufiice to permit of its 
 occurrence, and it may then go on continuously. It will be seen that 
 the condition of infantile utems generally combines several of the factors 
 which lead to sterility, — small impermeable cervix, flexed cervical canal, 
 and accompanying retarded development or malformation of the ovaries 
 or Fallopian tubes. 
 
 A third variety of causes of sterility acts also mechanically, by prevent- 
 ing the descent of the ovum into the uterine cavity. These chiefly afiect 
 the Fallopian tubes, and may be due either to faulty development or to 
 acquired disease of those organs. Thus, in some rare cases their growth 
 is entirely arrested, in others they are displaced congenitally, or as the 
 eflFect of inflammation, so that they cannot adapt themselves to the 
 ovary and receive its discharged ova. Not infrequently they are oc- 
 cluded at one or both extremities ; and even when they are patent, their 
 lining membrane may be so altered by inflammation that its cilia 
 are destroyed, or the catarrhal state of the tubes may oppose viscid 
 secretions to the progress of ovum or spermatozoa alike. The ovary 
 as well as the Fallopian tube may contribute mechanically to the causa- 
 tion of stei-ility. If it is prolapsed or hernial, or if it is dragged out of 
 position by displacements of the uterus, the result will be the same as if 
 the Fallopian tube was displaced ; the gland and its duct being divided, 
 the product of the gland must find an abnormal site, and there is pro- 
 bably a good deal of truth in the statement of Lawson Tait — " I believe 
 that the ovum falls into and perishes in the peritoneal cavity in by far 
 the greater number of cases, and that the passage of it into the iiterus 
 occurs only in a small minority of the ova produced." Unless this is a 
 gross exaggeration, there must be many Avomen in whose case " always " 
 may be substituted for "by far the greater number." The "disap- 
 pointed ovulation " of FaiTe, where an ovum is formed but cannot be 
 discharged owing to the toughness of the ovarian wall, is another in- 
 
OF STERILITY. 523 
 
 stance of mechanical obstruction to descent of the ovum ; and we need 
 only add the many possible, and easily imaginable, but rarely diagnos- 
 able disturbances of parts which may result from inflammations of the 
 pelvic, peritoneal, or cellular tissues. For the most part the causes of 
 sterility included tinder this heading are quite incurable ; or, if they, 
 the causes, are curable, and are for other reasons cured surgically, it is 
 by operations which only render the sterility more certain. 
 
 A fourth cause of sterility lies in the production either of no ovum, 
 or of those only which are physiologically unfitted for continued 
 growth and separate life. Here we come upon ground which is to a 
 large extent covered by the work of Matthews Duncan. There are 
 certain conditions of heredity, age, and climatic and other surroundings, 
 which render a woman, as they do a plant, more or less sterile. They 
 are a most interesting physiological study, and may come to have some 
 real prognostic value when Captain Galton's life albums have become 
 general ; and when people have learned the necessity of filling them up 
 honestly, i.e., I fear, somewhere about the Greek calends. No one can 
 estimate more highly than I do the value of such scientific inquiries, 
 but it would be a mistake to suppose that in those statistical averages 
 we have as yet got a rational answer to the question — " Why is my wife 
 unfruitful 1 " All that w^e can say under this fourth heading is that if 
 we can detect serious abnormality of development in any part of the 
 genital system, this alone may suffice to account for sterility, because it 
 is very likely to be accompanied by congenital defects in the chain 
 necessary for ovulation, impregnation, and fully accomplished pregnancy. 
 If we have reason to believe, either from the history, or from examina- 
 tion, that ovaritis or peri-ovaritis, in its Avidest sense, has occurred, or if 
 we can detect cystic degeneration, or any form of tumour of the ovary, 
 we have a strong probability of sterility, but to make this a certainty, 
 we must be assured that both sides are affected. The occurrence of 
 early atrophy, or of loss of function in the ovary, following on zymotic 
 disease, or as a super-involution subsequent to pregnancy, must always 
 be borne in mind, although it can rarely, if ever, be diagnosed with 
 certainty. The bearing of syphilis, maternal or paternal, upon sterility 
 is not fully worked out ; its tendency to produce early abortion is known 
 to every obstetrician. 
 
 The discussion of the subject of sterility would be entirely incomplete 
 unless it included an answer to the fourth question originally proposed 
 — "Is it advisal)lc to leave well alone, as far as any active treat- 
 ment is concerned?" I liave seldom answered tliis question in tlic 
 affirmative to the immediate satisfiiction of my patients, Init, so far as J 
 am aware, I have never done so without, ultimately earning their grati- 
 tude and respect. 
 
524 YAEIOUS COXSIDEEATIOiS^S AS TO 
 
 In the first place, I would strongly advise the practitioner not to lay too 
 much stress upon the special importance of an heir in the particular case 
 in which he is consulted. There is no necessity for informing the patient 
 that you do not see the extreme necessity in the same light that she and 
 her husband do. But operations of complaisance are always to be 
 deprecated, and I would counsel that no risk should ever be incurred in 
 such cases, beyond what would be considered advisable in the case 
 of husband and wife, who were simply desirous of the increased happi- 
 ness of ofispring, but who were sensible enough to deprecate any pro- 
 ceedings fraught with danger to life or permanent health. 
 
 Secondly, the coexistence or non-coexistence of dyspareunia must be 
 taken into account, and the practitioner may fairly use any operative 
 means which are justifiable for the removal of this, in the hope that 
 fertility will also ensue. 
 
 Thirdly, the coexistence of serious dysmenorrhoea is still more a 
 reason for performing or even urging the performance of, operations, 
 attended with some risk, but which would hardly be justifiable if we 
 considered only their problematical eff'ect in curing sterility. 
 
 Fourthly, if dyspareunia or dysmenorrhoea are not factors in the case, 
 the practitioner is not justified in recommending any operation which 
 may be followed by serious results. He should weigh well the question 
 which every physician should put to himself before using a dangerous 
 drug — " What harm may I do in proceeding thus, and how far am I 
 certain that the risk of harm thus involved is counterbalanced by any- 
 thing like a certainty that I shall effect good?" 
 
 As a result of these considerations, I would urge that sterility, which 
 cannot be distinctly traced to local causes, and which is, therefore, pre- 
 sumably due to some kind of general law of heredity, or age, or surround- 
 ing circumstances, should never be treated otherwise than by hygienic 
 means, and that no experimental surgical proceedings are permissible. 
 If, on the other hand, there are local deformities, or arrests, or redimd- 
 ancies of growth and develoj)ment, treat them or leave them untreated, 
 as you would if the question of sterility was not before you . 
 
 In all cases of chronic inflannnatory character act in the same mamier. 
 
 In fine, however you may put the matter to the patient, you should 
 put it to yourself in this way : I will cure dysmenorrhea or dyspareunia 
 in any legitimate manner that I can, and I may thereby not infre- 
 quently cure sterility; but I will perform no operation of any serious 
 character for the last purpose alone, the risks being certain, and the 
 probabilities of success being always highly problematical. 
 
THE TREATMENT OF STERILITY, ^ 525 
 
 Prevention of Pregnancy. 
 
 I have intimated above my intention of saying a very few words 
 upon this subject. I would rather have avoided it altogether, and I 
 will fulfil the task only by a quotation. Dr Goodell (ojo. cit.) says: — 
 " In a late discussion before the British Medical Association, in which 
 some of the foremost men of England took part, it was the unanimous 
 verdict that over-breeding does not produce ill-health, so much as efforts 
 to prevent conception. There are, in fact, no harmless or available 
 means for thwarting nature's plain intention, for if they should not 
 injure the body they assuredly will the mind. I dare any political 
 economist to show me one innocuous expedient whereby conception can 
 be avoided. I challenge him to name a single preventive plan which 
 
 will not do damage either to good health or to good morals 
 
 Depend upon it, gentlemen, there are no thomless by-paths by which 
 man can skulk from his moral and physical obligations; no safe 
 stratagems by which he can baulk God's first blessing and first com- 
 mand. Therefore, as hygienists, if not as moralists; as physicians, if 
 not as patriots; as guardians of the public health, if not as philan- 
 thropists ; I charge you to frown on such practices and take a bold 
 stand against them." Subjects like these are hardly fit to be discussed 
 in the class-room, yet the young practitioner cannot be long in practice 
 without meeting with a case in which he would desire the counsel of 
 his elders. I can with confidence refer him to the last chapter of 
 Goodell's Lessons on Gymecology, as treating of such matters without 
 pruriency, yet with the utmost plainness, and in the highest moral tone. 
 
526 THE FEMALE UKETHRA. 
 
 CHAPTER XXL 
 
 Some Affections of the Female UplEThea, Ureters, Bladder, 
 AND Kectum. 
 
 In the foregoing chapters we have discussed the affections of the 
 female sexual organs, and our task might here cease. But the 
 urethra, ureters, bladder, and rectum, although common to both sexes, 
 are so intimately associated with the sexual organs anatomically, and 
 have such numerous inter-relations, that we have been obliged con- 
 tinually to refer to them, and it seems desirable to add a few brief 
 observations on some of their own more common affections. Those of 
 the bladder and urethra at any rate, and in a less degree, those of the 
 rectum, continually come under the care of the gynaecologist, and the 
 symptoms of disease in all these organs are so intermixed that it is 
 difficult or impossible, in many instances, to diagnose or treat the dis- 
 eases of one without a knowledge of those of the others. For a full 
 description of the diseases of the female bladder and urethra, the best 
 work to which I can refer the English student is that of Skene {Diseases 
 of the Bladder and Urethra in Women, W. Wood & Co., New York, 
 1878). 
 
 The Female Urethra. 
 
 The female urethra differs m toto from that of the male. 
 
 The whole canal is about 1| inch in length, but wider than that of the 
 male. Its external orifice (fig. 32) lies at the back of the vestibule, and 
 is pu.ckered and more or less prominent, so that it is easily discovered 
 by the tactus eruditus. The direction of the canal is upwards and back- 
 wards from without, and corresponds with the axis of the pelvic outlet. 
 It is, however, liable to distortion by many gynaecological affections. It 
 is furnished with both striped and unstriped muscular fibres, longi- 
 tudinal and circular. It presents numerous small villi and glandular 
 elements, and near the entrance are two small tubules (fig. 203) running 
 backwards in a parallel direction, and which may participate in and 
 prolong the duration of catarrhal or gonorrha3al inflammation. Its 
 epithelium is for the most part squamous, the cells being smaller 
 
MEANS OF EXAMIXATION. 
 
 527 
 
 than those of the vagina, but towards the inner end they become 
 columnar. 
 
 Means op Examixatiox and Diagnosis. 
 
 For the diagnosis of urethral affections we make use of Inspection 
 conducted in the same manner as that of the external genital organs 
 This shows us the existence of any e version of 
 the urethral wall, of the great majority of 
 vascular caruncles, of catarrhal or purulent 
 discharges, or of dilatation of the canal. By 
 touch we ascertain the existence of pain at any 
 portion of the canal, we may extrude from the 
 meatus caruncles, not apparent without this 
 means, and we may also, by drawing the finger 
 from behind forwards along the anterior vaginal 
 wall, ascertain the existence of urethral suppur- 
 ation. By the sound we ascertain the patency 
 and direction of the canal, the state of its 
 mucous membrane, and the presence of foreign 
 bodies. It is useful also to detect the precise 
 seat of pain or stricture. For more minute or 
 careful investigation dilatation hy the finger is 
 required. If the patient be ansesthetised the 
 little finger can, after some resistance about 
 the meatus, be inserted through the adult 
 canal, and this can be followed up by the index, if of average size. 
 The assistance of a finger or fingers of the other hand in the vagina 
 will render the in- 
 formation obtained 
 more certain, and, 
 for the exploration of 
 the bladder in this 
 way, one hand may 
 be applied to the 
 abdomen, as in the 
 ordinary bi-manual 
 vaginal examination. 
 The indications for 
 digital dilatation of 
 tlie urethra, apart from the examination of the urethra itself, will be 
 given below, as will also the description of instrumental means for the 
 same purpose. The index finger may be considered as the full 
 limit of safety to dilatation in adult females, all further stretching 
 
 Fig. 203.— Urethral Tubules 
 (Skene). The Urethra is 
 laid open, and Probes are 
 introduced into the two 
 Tubules. 
 
 Fig. 204.— Skene's Urethral Endoscope. 
 
528 MALFOEMATIONS AND VAPJOUS DISOEDEES 
 
 being liable, although not necessarily so, to produce rupture or permanent 
 incontinence. For the purpose of examining the interior of the urethra 
 by sight some form of speculum or endoscope is required. Matthews 
 Duncan uses an exceeding small Fergusson's speculum, and this 
 answers the purpose fairly well if the canal be first dilated by the 
 finger. Skene has introduced a more perfect but more complicated 
 instrument (fig. 204) consisting of a fenestrated vulcanite outer part, 
 shaped like a test-tube, of a glass tube which fits loosely within it, and of 
 a mirror which acts somewhat as that of the laryngoscope. It shows well, 
 with proper lamp accompaniment, the palish lining membrane of the 
 canal, and any variations from the normal aspect. 
 
 Malformations op the Ubethra. 
 
 Malformations of this organ are so intimately associated, as a rule, 
 Avith those of the genital tract, that the reader may be referred to the 
 same authorities for a complete account of them. But the urethra has 
 been found entirely absent when the other organs were perfect, and the 
 lower portion alone is sometimes found deficient (hypospadias), as is more 
 rarely the upper. Complete atresia is more common. The result of these 
 malformations will be either incontinence or retention of urine. Skene 
 observed a case where, from congenital atresia, the bladder was so dis- 
 tended at birth as to render delivery very difficult. For the surgical 
 relief of such abnormalities, special su.rgical works must be consulted. 
 A very rough remedy, although it may be the only available one, in case 
 of complete atresia at birth, consists in introducing a trocar as nearly as 
 i:)Ossible in the direction of the normal canal. Double urethra is a very 
 much more rare anomaly than double vagina, and may be dismissed here 
 as a pathological curiosity. 
 
 Functional Disorders of the Urethra. 
 
 These, as far as they exist, are more usefully merged in the account of 
 functional disorders of the bladder and urination. In neurotic subjects, 
 however, neuralgic pain is occasionally felt in the direction of the urethra 
 only. I have met with one or two such cases where I could find no 
 evidence of organic disease of any kind, and I have obtained relief by the 
 passage of a sound dipped in carbolic glycerine (1 in 5). There was smart- 
 ing at first, but speedy relief soon afterwards, the neurotic or neuralgic 
 state of system not being neglected. Skene i-ecommends the local appli- 
 cation of bismuth, and afterwards of aconite and opium, in such cases. 
 
 Pressure on and Displacement op the Urethra. 
 
 Quite independently of displacements of the bladder, the urethra may 
 be compressed or distorted. Fibroid and other tumours of the pelvic 
 
OF THE FEMALE UEETHRA. 629 
 
 organs may cause displacement upwards, downwards, or laterally, occa- 
 sionally producing retention of urine. This requires to be kept in view 
 in using the catheter, and permanent relief may be impossible in this wa}" 
 unless the mass is free and can be pushed above the pelvic brim. Pro- 
 lapse of the anterior Avail of the vagina may affect the urethra, either 
 bending its upper part downwards, or protruding the whole, and even 
 giving it a direction downwards and forwards, instead of upwards and 
 backwards. Care should be taken to remedy this state of matters after 
 hard labours, by the use of astringent pessaries, and by attention to the 
 torn perineum at the time of rupture. Loss of control is more apt to 
 follow partial downward displacement, and difficult urination complete 
 protrusion of the urethra. 
 
 Stricture op the Urethra. 
 
 Strictures, and even complete atresia, of the urethra are occasionally 
 the result of disuse of the canal, in vesico-vaginal fistula, but, when 
 complete, some inflammatory condition of the wall, such as is met 
 with in the male, is probably superadded. Occasionally, although less 
 frequently than in the male, contraction occurs from gonorrhoeal 
 inflammation, or from traumatic causes, caustics, &c. In many in- 
 stances the contraction is fortunately almost confined to the meatus. 
 The careful use of the sound, whenever micturition is difficult, an 
 elastic one being preferable, is the sole means of accurate diagnosis, re- 
 membering always the possibility of distortion of the canal without 
 stricture. Slow and careful dilatation seems to be safer than, and prefer- 
 able to, rapid dilatation or incision, although these plans are called for 
 in a few cases. Skene also points out that a slight stricture at the 
 internal orifice, by interfering with the functions of the bladder, may 
 give rise to retention of urine or ii-ritable bladder in a more considerable 
 degree than narrower strictures elsewhere. The diagnosis of this trouble 
 is arrived at mainly by exclusion of other causes — of external pressure, 
 prolapse, or paralysis of the bladder — and by discovering at the inner 
 extremity of the canal moderate resistance to a fvill-sized sound. 
 
 Dilatation of the Urethra. 
 
 The urethra is capable of great dilatation, independently of that which 
 is intentionally produced. I have met with a case of atresia vagina; 
 where injections had been administered per urethravi into the bladder, 
 under the supposition that they were vaginal, and for the cure of amenor- 
 rhoca. The meatus may, even under these circumstances, retain much 
 of its contractility. The centre of the canal not infrequently becomes 
 much dilated in cases of vaginal prolapse, also from the occui-rence of 
 
 2l 
 
530 VAEIOUS AFFECTIONS OF 
 
 growths within it, from chronic inflammatory thickening of its mucous 
 lining, from the passage of calcuh, or from obstruction by small growths 
 or stricture at the meatus. 
 
 The symptoms, point to some difficulty in urination, with or without 
 incontinence or partial retention. But the sound can alone clear up 
 the diagnosis, combined with digital manipulation through the vagina ; 
 it detects either a compressible swelling in the site of the canal, or 
 one rendered rigid by hypertrophic thickening. The free movement of 
 the point of the sound within it can also be ascertained. Purulent or 
 semi-purulent fluid often collects here, and is occasionally expelled in 
 quantity. Peri-urethral abscess opening into the canal will closely 
 simulate this condition, and must be differentiated by the history of 
 inflammation, by the scope of the movements of the sound, and by the 
 surrounding infiltration which it causes. 
 
 Treatment. — In moderately severe cases of dilatation it is sufiicient to 
 treat the mucous membrane by astringents, as in chronic urethritis, and 
 to support the prolapsed portion by a well-fitting pessary, as advised 
 for prolapsus vaginae and cystocele (p. 330). I have no experience of 
 excision of a portion of the wall, or of contracting it by application of the 
 actual cautery, or of temporarily opening the most dependent part, as 
 advised by Bozemann, and, as we shall see, occasionally practised on 
 the bladder in certain intractable affections of that organ. 
 
 Laceration and Fistula of the Urethra. 
 
 This may occur, either into the surrounding connective tissue, or 
 into the vagina, constituting in the latter case urethro-vaginal fistula. 
 Of fistulae of the latter kind as much has been said as comports with 
 the scope of this work. Lacerations or incomplete fistulse may be 
 the result of peri-urethral abscess, or of artificial dilatation carried 
 to too great a degree. In the former case Skene recommends, although 
 he has not practised, the method of making the fistula complete by 
 means of a vaginal incision. Judging from analogy elsewhere, this 
 would be the quickest and most satisfactory plan. The fistula may 
 heal of itself if a catheter be worn or very frequently used. Laceration 
 by over-rapid dilatation is almost certain to end in permanent incon- 
 tinence of urine. To be forewarned is to be forearmed. 
 
 Laceration or cracking, extending through the vesical orifice, is apt to 
 result from ulceration, or to follow urethritis or puerperal pressure. It 
 gives rise to severe continuous pain, much aggravated after micturition, 
 and to spasmodic incontinence — in fact, to symptoms very similar to 
 those of calculus, cystitis, or urethritis. The two latter may be elimin- 
 ated by observation of the urine and of the expressed contents of the 
 
THE FEMALE UEETHRA. 531 
 
 urethra, the former by careful use of the vesical sound. Skene, who first 
 described this condition, recommends the withdrawal of all ordinary 
 treatment for urethritis, the application to the crack solely of a fine 
 probe coated with nitrate of silver, as in the treatment of cracked 
 nipples ; more effective still, moderate dilatation of the urethra, or, in 
 stubborn cases, free incision ^^er vaginam. I succeeded in permanently 
 curing one such case by the least heroic of these methods, but the fissure 
 was easily seen and reached through Simon's dilator, w^hich is not 
 usually the case. 
 
 Urethritis. 
 
 Acute urethritis is in almost every case caused by gonorrhoeal infec- 
 tion, and its occurrence along with vulvitis or vaginitis may be regarded 
 as almost diagnostic of the specific nature of the attack. It is well, 
 therefore, in every case of inflammation of these organs, to press the 
 urethra from behind forwards, and thus make sure whether pus exudes 
 and urethritis coexists. The general treatment is that of gonorrhoea, and 
 when a sub-acute stage is reached, iodoform, carbolic acid, nitrate of 
 silver, or iodine in strong glycerine solution, may be usefully applied 
 by means of the sound. Injections are dangerous owing to the con- 
 tiguity of the bladder. 
 
 Chronic urethritis may be a sequel of the acute form, but will some- 
 times also be met with under other circiimstances — for example, in 
 urethral dilatation or prolapse, in cystitis, or from cold or prolonged 
 exertion. The same treatment is available as in the secondary stage of 
 the acute form, and may require considerable persistence. 
 
 Foreign Bodies in the Urethra. 
 
 Calculi may lodge here on their passage from the bladder, leading to 
 retention, and may be easily discovered by the cautious use of the metallic 
 sound. The canal is so distensible that with aneesthesia these may easily 
 be extracted by a small curette, such as that used by aurists (fig. 38), if 
 steadied by a finger in the vagina, and recourse will seldom be required 
 to urethrotomy. Pins, beads, or other substances introduced from 
 without, or irregular shaped bodies which may have entered the bladder 
 first, such as foetal bones or ftccal concretions, must be dealt with 
 by dilatation and subsequent extraction, entire or in fragments. 
 
 Abnormal Growths in the Urethra. 
 
 These have been elaborately classified according to their pathological 
 nature, but a brief notice of the more important must sufticc here. 
 
532 THE USE OF THE FEMALE CATHETEE. 
 
 Urethral Caruncles, or Vascular Growths. — These growths have 
 been sufficiently described and treated of above (p. 55). All that need 
 here be said in addition is that, partly by obstructing the canal, 
 partly by causing spasm, and partly by leading to voluntary over- 
 retention, they may occasionally give rise to urethral dilatation, to 
 chronic urethritis, or to cystitis. It is surprising, however, how seldom 
 these results are observed. Occasionally, in connection with urethral 
 dilatation, or more rarely without it, the lining membrane of the urethra 
 becomes inverted and bulges through the meatus, and, becoming in 
 time red and swollen, it may very closely resemble a urethral caruncle. 
 Care must therefore be taken to ascertain the existence or non-existence 
 of a pedicle, and the relation of the urethra to the mass. In caruncle 
 it surrounds the growth ; in inversion the swelling wholly or partially 
 surrounds the urethra. The symptoms are very similar. 
 
 Polypi of various kinds sometimes occur in the urethra. First, and 
 most rarely, as occluded glandules ; secondly, and also rarely, as small 
 peduncixlated fibromata ; and thirdly, as vascular growths — the above- 
 mentioned urethral caruncles. 
 
 Varix of the urethral and surrounding veins may cause some disten- 
 tion of the passage, or may give rise to haemorrhage, or to thrombus in 
 its neighbourhood. The blue discoloration of the parts, and the im- 
 mediate, although temporary, reducibility of the swelling on pressure 
 will point to the nature of the affection. 
 
 Cysts, of glandular character, are occasionally found plugging the 
 meatus, or protruding as polypi. 
 
 Treatment. — The various polypoid growths, when near the orifice, are 
 treated as has been recommended with regard to vascular caruncles. 
 Various snares, ligatures, and forceps, similar to those used by aurists, 
 have been devised for the purpose of reaching and removing those 
 lying further within. I must refer the reader to special works for a 
 knowledge and comparative estimate of these. 
 
 Cancer rarely attacks the urethra in a primary form, and even exten- 
 sion is uncommon in this direction. It is chiefly met with, when it does 
 occur, as small nodules, which in time break down either into the 
 canal or into the vestibule. Diagnosis should not be difficult. 
 
 The Use of the Catheter. 
 
 It may not be out of place here if we say one word as to the common 
 operation of passing the catheter, and it will apply also, for the most 
 part, to the passage of the vesical sound. In ordinary retention, and 
 especially if there is any probability of alteration in the direction of the 
 canal, the gum-elastic male instrument, about No. 8, is preferable to the 
 
THE UEETERS. 533 
 
 metal one. The student should learn to use it with equal facility 
 whether the patient is in the lateral or dorsal position. If on her side, 
 the knees and thighs are well flexed, and the more the bod}- is also 
 flexed, with the head away from the operator, the better. The left fore- 
 finger, well-lubricated, is passed within the vagina, and its palm is turned 
 towards the pubic arch. Just vmder the arch lies the urethra, which 
 can almost always be felt as a roimded cord. The finger is now slowly 
 Avithdrawn along this, and will encounter the orifice at the base of the 
 vestibule (fig. 32). No description will, without practice, enable the 
 operator without fail to detect the slightly elevated, soft, perforated 
 point, but this is not difficult to those who possess accurate tactile 
 powers. The orifice being thus found, the catheter, well oiled and car- 
 bolised, is held lightly in the right hand, and is guided into it by the 
 left forefinger. It will slip along in the right direction, upwards and 
 backwards, unless there is some obstacle, in which case the same tenta- 
 tive care is needed as in passing a bougie in the male. If the patient is 
 upon her back, the knees are well flexed, the right forefinger, passed under 
 the right thigh, is used as the guide, and the catheter, held by the left 
 hand, is passed from above, betAveen the thighs, and round the pubes. 
 Although many prefer this latter plan, I have always considered the 
 former as the easier, and the less irksome to the patient, when cir- 
 cumstances peraiit of a choice. 
 
 The Ureters. 
 
 These, the feeding canals of the bladder, should receive a passing 
 notice, not so much on accou.nt of their own maladies as from their ten- 
 dency to be implicated in various way by gynic affections. The pres- 
 sure of ovarian, uterine, or other tumours, or of cancer, may lead to their 
 closure, and so to the production of dilatation of themselves and the 
 kidneys. The extension backwards of inflammation may lead to pyo- 
 nephritis and other fatal diseases of the kidney. They may be involved 
 in adhesions with ovarian tumours, so that it may be impossible to 
 avoid injuring them during operation. In three instances of ureteral 
 fistula thus produced, — one in the practice of a friend, and two in my 
 own, — one patient died from shock before there was time for mischief from 
 this cause, the xireter being fixed to the external wall ; in another, the 
 fistula unexpectedly revealed itself after the separation of a clamp, whicli 
 included a large irremovable portion of a thick-walled ovarian cyst. 
 This patient perfectly recovered from the operation ; after several 
 weeks, the flow of limpid urine began gradually to cease, and finally ceased 
 completely, Avithout any sign of ureteral or renal dilatation. In the third 
 
534 ANATOMICAL EELATIONS OF THE UEETEES. 
 
 case, similarly complete spontaneous recovery also took place, by gradual 
 arrest of the flow, and, it is believed, by atrophy of the corresponding- 
 kidney. The ureters also, although fortunately rarely, may be involved 
 in fistulse due to labour, and it is most essential to bear in mind their 
 position in relation to the bladder in all operations upon the back or lower 
 surface of that organ. But the anatomists do not furnish us with informa- 
 tion on the point, of such exactness as that of which they are apt 
 to bewail the want in practical medicine. According to Garrigues, 
 quoted by Hart and Barbour (073. cit., p. 32), " the ureter does not lie in 
 the broad ligaments, it does not keep the same direction on reaching the 
 wall of the bladder, and it does not lie close up to the wall of the cervix 
 uteri, all of which is taught by anatomical authorities." The most 
 recent researches on the subject are by HoU of Innsbruck ( Wiener Med. 
 Wocliensch., Nos. 45 and 46, 1882). They involve, however, such an 
 amount of anatomical description that I shall best serve the purpose of 
 my readers by inserting a brief description of the relations of the 
 m-eters, after they enter the true pelvis, from the pen of Mr J. Collier, 
 recently demonstrator of anatomy at the Owens College. He has kindly 
 verified this description by several special dissections, some of which 
 were also inspected by my late lamented colleague. Professor Morison 
 Watson. 
 
 COUBSE OP THE UeETER IN THE FeMALE PeLVIS. 
 
 " The ureter enters the pelvis by crossing the termination of the com- 
 mon iliac, or more frequently the commencement of the external iliac 
 artery. It then passes downward and forward, crossing the inner side 
 of the external iliac vein, and lying parallel to and just in front of the in- 
 ternal iliac artery. In this course it reaches to within about half an inch 
 of the upper border of the great sciatic notch. After the splitting of the 
 internal iliac artery into its anterior and posterior divisions, the ureter 
 keeps a position in front of the former until that division splits into its 
 branches. It then crosses on the inner side of the termination of the 
 anterior division or the commencement of its terminal branches, and 
 describes a curve with its convexity backwards. In the middle of the 
 curve it is crossed, on its inner side, by the uterine artery, which is only 
 separated from it by a few veins. The ureter then crosses forward, out- 
 side the cervix uteri, about half an inch from it, and at the level of the 
 external os. It now runs along the lateral aspect of the upper part of 
 the vagina, turns slightly inwards, so as to lie between the junction of 
 the anterior and lateral aspect of the vagina posteriorly, and the posterior 
 wall of the bladder anteriorly. 
 
 " In this part of its course the ureter reaches as low as the middle of 
 
THE FEMALE BLADDER, 535 
 
 the anterior vaginal wall. When piercing the bladder wall the ureter 
 runs downwards, inwards, and forwards. 
 
 " As regards its relation to the peritoneum, in the first part of the 
 above course the ureter lies between the pelvic wall, and the peritoneum 
 forming the lateral boundary of Douglas's pouch. It then comes for- 
 wards opposite the outer inferior angle of the broad ligament, and runs 
 forward and inward in the areolar tissue lying between the peritoneum 
 above and the visceral layer of pelvic fascia below." 
 
 With this description before me, it is a source of considerable wonder 
 that the large exudations of lymph, so common in the peritoneal pouches 
 and cellular interspaces of the pelvis, do not more often produce disastrous 
 results by pressure on, and occlusion of, the ur-eters. 
 
 The Female Bladder. 
 
 The bladder has three ojDenings — those from the ureters and that into 
 the urethra. The entrances of the former lie about 1|- inch from that 
 of the latter, the intervening triangular portion (trigone) (fig, 206) being 
 smooth, while the remainder of the internal surface of the bladder is 
 Avrinkled; The ureteral openings are oblique and very small, while the 
 opening into the urethra is larger. The existence of a true sphincter is 
 very problematical, and the action of one is said to be performed by the 
 surrounding tissues — mucous and connective. The action of the bladder, 
 however, is in the nature of a systole and diastole, dejDendent, like that 
 of the heart, on alternate distention, reflex inhibition, contraction, and 
 flaccidity (Hart and Barbour). The prevention of regurgitation into the 
 ureters, during vesical contraction, is brought about, according to Skene, 
 (1) by their oblique mode of entrance; (2) by two rudimentary muscular 
 slips i-unning from the mouth of the ureters to the point of exit of the 
 urethra; and (3) by an elastic inter-ureteral ligament, which drags upon 
 the openings when they are fully separated by the distention of the 
 bladder. The female bladder is lai-ger, or at any rate more capacious, 
 than the male, flatter, and broader, and it lies lower in the pelvis. Its 
 shape differs at various ages, and its position is liable to constant changes 
 due to pregnancy or other conditions of the female organs. Hallida}- 
 Croom has a most interesting monograph on these changes as affected by 
 and affecting parturition (Edin., Douglas, 1844), The mucous mem- 
 brane is wrinkled, owing to the laxity of the submucous tissue; its 
 epithelium is in part squamous, in part columnar, with transitional 
 forms, and it is very doubtful how far it possesses absorbent powers. 
 
536 METHODS OF EXAMIXING 
 
 Means of Examination and Diagnosis. 
 
 By inspection we leani but little of the condition or affections of the 
 bladder. Great distention is evident to sight, but cannot thus be dif- 
 ferentiated from other swellings of the abdomen, and prolapse of the 
 anterior wall of the vagina, containing a portion of the bladder (cystocele) 
 is also recognised by sight, aided by expulsive efforts on the part of the 
 patient. By vaginal touch the condition of the bladder as to tenderness 
 is made out, and, assisted by the bi-manual method, it is possible to form 
 a tolerably clear idea of the size and general characters of calculi, foreign 
 bodies, or neoplasms of the organ. For the purpose, however, of obtain- 
 ing an accurate notion of some of these affections, it becomes necessary 
 to make use of exploration of the interior of the bladder by the finger — 
 vesical touch. 
 
 We have already spoken of the insertion of the finger into the urethra 
 for the purpose of exploring that organ, but for vesical diagnosis the 
 little finger will not suffice, and in order to introduce the forefinger, 
 it is generally advisable to dilate the urethra by one of the mechanical 
 contrivances about to be mentioned, following up the dilatation imme- 
 diately by the finger. The finger may, however, with full anaesthesia 
 suffice alone. When fully introduced, it is carefully rotated and opposed 
 by the fingers of the other hand above the pubes, and through the 
 vagina or rectum, in turn. The front of the uterus, the vesico- 
 uterine interspace, the broad ligaments, and the Fallopian tubes, can be 
 explored in this way, but sufficiently accurate diagnosis of the con- 
 dition of these parts is nearly always obtainable without the aid of an 
 operation which is never without some danger of producing permanent 
 incontinence of urine, or nipture of the urethra. The dorsal position 
 is always desirable. Neither the vesical touch nor the preliminary 
 dilatation should ever be attempted when there are any traces of recent 
 pelvic inflammation. 
 
 The vesiail sound is familiar as a means of diagnosis to all surgeons, 
 and it is self-evident that we can obtain much assistance by the 
 simultaneous use of vaginal or rectal touch. 
 
 Dilatation of the urethra, for the purpose of vesical diagnosis, may, as 
 we have seen, be accomplished by the finger alone, but both for this and 
 for purposes of treatment, some instrument is commonly used. Simon's 
 dilators or specula (fig. 205) consisting of a series of ^'ulcanite tubes with 
 removable rounded extremities, are the best kno'm.i. They are intro- 
 duced in successive sizes, slowly and cautiously, and Simon maintains 
 that the safe limit in the adult is about 2 j^ inches in circumference. 
 In many cases there is danger considerably short of this limit, and the 
 meatus should be particularly slowly dilated in all cases. Various 
 
THE FEMALE BLADDER. 
 
 537 
 
 Fig. 205.— Simon's Urethral Dilators. 
 
 The catheterisatiou 
 
 branched instruments, the branches separable by screw-action, have been 
 invented for urethral dilatation, but, even when covered with india-rubber 
 sheathing, they are harsh in action. 
 
 It may be as well to specify hei-e the various indications that may 
 occasionally be served by ureth- 
 ral dilatation. These are, the 
 introduction of the finger for 
 the diagnosis of stone, foreign 
 bodies, fistulte, or other pur- 
 poses ; the passage of endo- 
 scopes, and the introduction of 
 instruments, fluids, or caustics 
 for treatment; the removal of 
 calculi, foreign bodies, or mor- 
 bid growths ; the cure of fissure, 
 and the relief of cystitis or 
 irritable bladder. Endoscopic 
 examination of the bladder is as yet in its infancy 
 and examination 
 of the ureteral 
 openings by fin- 
 ger and sound 
 (fig. 206) is one 
 of those diag- 
 nostic curiosi- 
 ties of which I 
 have little per- 
 sonal experience. 
 I have once or 
 twice attempted 
 it, but lament- 
 ably failed. The 
 diagram requires 
 no explanation, 
 and the process 
 looks very sim- 
 ple ; but Winc- 
 kel, from whom 
 it is taken, ad- 
 mits that after 
 himself in findins 
 
 Fig. 206.— Catheterisation of the Ureters (after Winckel). 
 
 many persevering attempts lie liad never succeeded 
 ; the openings with the somul. 
 It is beyond my present limit to describe the various urinary con- 
 ditions whicli may affect the bladder, or be caused by its maladies. 
 
538 IRRITABILITY OF THE BLADDER. 
 
 Congenital Malformations of the Bladder. 
 
 I must again refer my readers for a description of these affections, to 
 Skene, Kussmaul, Schroeder, or other writers on the subject, merely 
 stating that the most common forms are those of fissure or non-closure, 
 with eversion of the walls, and, less frequently, of a duplex condition 
 similar to, and accompanying that of, the vagina. 
 
 Functional Hyperesthesia (Irritability) of the Bladder. 
 
 Hypersesthesia or excessive irritability of the bladder may be, and 
 very frequently is, encountered as a functional affection, independently 
 of any other discoverable disease of the organ ; and, on the other hand, 
 it is often the foremost and only symptom of the most serious diseases in 
 their earlier stages. Its diagnosis as a functional aflFection will therefore 
 always require the probable, if possible the certain, exclusion of organic 
 causes. 
 
 Symptoms. — These may be summed up as, frequent if not constant 
 desire for micturition, with a certain amount of uneasiness, referred 
 sometimes to the Supra-pubic region, but more often to the neck of the 
 bladder ; these symptoms being sometimes accompanied by some ten- 
 dency to either retention or incontinence. 
 
 Causes. — The functional affection has always more or less of a nervous 
 causation— the hereditarily neurotic, the hypersesthetic, and the hysteri- 
 cal are its chief victims. The condition of the urine may conduce to or 
 even solely produce it. Acidity or alkalinity, the presence of oxalates, 
 of albumen, or of sugar, or even the too limpid fluid of the nervous 
 subject, may, each and all, but especially the first and the last, figure as 
 causative agents. Reflex nerve irritation, from irritation of the genital 
 system, including the ovaries, may prove an exciting cause, and most 
 writers mention masturbation as an occasional factor of the kind. 
 Lowering disease of any kind, cold, and pregnancy may be added to the 
 etiological list, — the last acting sometimes mechanically, sometimes by 
 reflex irritation. Habitual constipation has seemed to me to be an 
 occasional caiise. Every uterine or pelvic disease, — displacement, con- 
 gestion, &c., — is occasionally accompanied by hypersesthesia of the 
 •bladder, but these cases stand apart, and can hardly be considered as 
 functional. 
 
 Diagnosis. — The symptoms being present, the diagnosis of functional 
 hypersesthesia can only be arrived at by the exclusion of organic 
 disease. Cystitis will be differentiated by greater accompanying pain 
 on pressure, and by careful examination of the urine, and only 
 a thorough pelvic examination will make sure of the non-existence of 
 
INCONTINENCE OF UEINE. 539 
 
 accompanying, and perhaps causative, disease of organs other than the 
 bladder. The severity of the symptoms and their inamenability to 
 treatment will lead to careful exj^loration of the bladder and urethra, 
 in search of any of the local diseases about to be discussed. In young 
 and neurotic women much may be taken for granted for a time, 
 altliough not indefinite!}', if the ui'ine is carefully examined. In older 
 or post -parous women a careful local examination should precede all 
 treatment. 
 
 Treatment. — Organic disease being excluded, the treatment of the 
 neurotic, hysteric, or otherwise lowered condition of the patient is of 
 the first importance. I need not recapitulate what has already been 
 said on this point. Strychnia is here one of our most valuable tonics, 
 and in small doses exerts a favourable local influence on the vesical 
 muscles. The bromides play also a useful part. The food must be 
 bland, nutritious, and unstimulating. Fluids may be freely allowed if 
 the urine is at all dense, and the following diluents are sometimes ser- 
 viceable in such cases, — barley-water, almond emulsion, triticum repens, 
 buchu, or marsh mallow. When the irritation is great, chloral (gr. xxx. 
 per rectum) and tinct. of belladonna by the mouth, or morphia and bella- 
 donna in suppository, are the most useful calmatives. Ergot of rye in 
 contini^ed doses seems to exert a local tonic influence. The various con- 
 ditions of tu'ine mentioned above must be treated on general principles. 
 In obstinate and distressing cases morphia may be injected into the 
 bladder in rather full doses, the fear of absorption being slight. Carbonic 
 acid gas has been directed into the bladder with good effect, but I have 
 no experience of its use thus. Catheterisation seldom affords permanent 
 relief, but in the most obstinate cases success may occasionally be ob- 
 tained by the retention of a catheter, as after pelvic operations, or by 
 dilatation of the urethra as above described. When ftiilure is persistent, 
 repeated examination may detect hitherto undiscovered organic causes. 
 
 Incontinence of Urine. 
 
 This troublesome affection is most common in young children and 
 adolescents, or in the old and enfeebled, especially the muciparous. In 
 the former it is almost always, like hyperajsthesia, a neurotic aftection, 
 although hyperscsthcsia may or may not be present, and there is gene- 
 rally great laxity of those tissues which play the part of spliinctor to 
 the bladder. In the latter case, that of old or enfeebled subjects, the 
 trouble is almost always associated with displacements of the uterus, 
 vagina, bladder, or urethra, and in these it is also often accompanied by 
 incomplete emptying, leading in some instances to chronic cystitis. The 
 incontinence which is due to vesical or urethral fistula, stands, of course, 
 
540 INCONTINENCE, AND 
 
 in quite a separate category. In middle life, while either the neurotic 
 element or the occurrence of urethral displacement may be present, 
 there is always a considerable probability that uterine flexions or pelvic 
 tumours, or exudations, may, by their pressure, lead to the incontinence ; 
 and even when there is no evident history of these, they must be carefully 
 sought for; urethral growths, vulvar caruncles, or other causes of vaginis- 
 mus or dyspareunia not being forgotten in the search. The incon- 
 tinence of cystitis, hypertrophy, calculus, or foreign bodies and neoplasms 
 of the bladder, is simply due to exaggerated hyperaesthesia of organic 
 origin. 
 
 Diagnosis. — The fact of incontinence is self diagnostic, the degree, 
 the amount of constancy or intermission, the age of the patient, and 
 the other accompanying details, pointing more or less to neurosis alone 
 or to the existence of organic causes, which must be sought for and 
 treated. 
 
 Treatment. — Setting aside all serious diseases of the pelvis, vulva, or 
 bladder itself, and so far as the neurotic cases alone are concerned, there 
 is almost nothing to be added to what has been already said as to the treat- 
 ment of hypersesthesia of the bladder and of general neurasthenia. Mild 
 stimulation of the bladder tissues by strychnia or ergot is not incom- 
 patible with diminution of irritability, and belladonna or the bromides, 
 while fulfilling the latter indication, are not incompatible with the 
 former remedies. Cold bathing, in those who can stand it otherwise, is 
 an effective remedy. The rectum must be freed from the irritating 
 presence of ascarides, scybala, or hsemorrhoids. Quinine is probably a 
 remedy of the same class as ergot and strychnia, as well as a tonic. 
 Common sense, and observation of the urine, will dictate the amount of 
 fluids to be allowed ; the avoidance of these late in the day is desirable 
 in the case of bed-wetting in young persons, and the early formation of 
 good habits is of the same value as in constipation. The dribbling 
 which may accompany spinal or brain aff"ections is only an eff'ect of 
 paralysis. 
 
 Retention op Urine. 
 
 Causation. — Retention in the female may be of nervous character, as 
 is not infrequently the case in hysterical women, or it may be due to 
 paralysis of the bladder, to obstruction within the urethra, or to tumours 
 or exudations pressing upon the bladder or urethra. 
 
 Treatment. — Neurotic retention may occur in a healthy woman, as a 
 result of great bodily or mental shock, and in such cases there need be 
 no hesitation as to the use of the catheter. Occurring in a neurasthenic 
 or hysterical subject, it is but a part of the nerve disorder, which must 
 be treated on general principles, and on no accoiint should the catheter 
 
RETENTION OF URINE. 541 
 
 be used uutil the retention has lasted so long as to compel a local 
 examination. If there is no contra-indication, it is a good plan to use 
 antesthcsia in such cases, to make the examination thorough and once 
 for all, and to insist upon it that catheterisation cannot be repeated. 
 There is no doubt that in many instances a prurient desire for repetition 
 may be established by Avant of firmness on this point. We must 
 depend for immediate relief on hot hip baths, with opium and bella- 
 donna suppositories, or chloral injections (30 to 40 gi-ains) into the 
 rectum. 
 
 Retention of urine, from atrophy of the bladder or prolonged habitual 
 over-filling of the viscus, occurs chiefly in the aged, and will require 
 regular catheterisation until the bladder regains its tone, or perhaps 
 for life. Minor degrees of prolapse must be sought for and remedied by 
 supports, and greater degrees may require plastic narrowing of the 
 vagina ; and by liberal nourishment the system must be supported, while 
 strychnia, ergot, and even digitalis have a fair trial. Meningitis, myel- 
 itis, or other affections of the brain or cord are apt to be followed by 
 paralysis as a part of a general paraplegia, and Skene mentions also 
 inflammation of the lumbar nerves or ganglia, endo-arteritis of the 
 pelvic arteries, lumbar or renal abscess, prolonged use or extreme doses 
 of opiura, and blows on the loins, supra-pubic region, or head, as occa- 
 sional causes of vesical paralysis. All of these may, after a time, as 
 in the male, be accompanied by surface dribbling or incontinentia jxtra- 
 doxa. Fevers or other acute diseases may cause temporary paralysis of 
 a similar kind. The catheter is in all these cases the first remedy. The 
 circumstances of the case will determine how long regular catheterisation 
 must be kept up. The treatment of the cerebral, or spinal lesions 
 belongs to the domain of general therapeutics. Strychnia and ergot 
 may prove locally useful, or galvanism by the introduction of a sound, 
 insulated except at its point, may be tried. I have seen two or three 
 cases greatly improved during the use of the continued current in this 
 way, but there was simultaneous improvement in the accompanying- 
 paraplegia. Cystitis seta in in too many of these cases, requiring ap- 
 propriate treatment. Obstruction of the urethra has been referred to 
 above. Sudden retention is very often the first symptom of a growing- 
 uterine fibroid tumour, and it may occur from the pressure of other 
 displacements, growths, or exudations, in the neighbourhood. The 
 diagnosis and treatment of these are found in their appropriate i^lacetr', 
 but if the obstructing mass can be pushed out of the way, above the 
 pelvic brim, this is the first indication to be fulfilled. 
 
542 VARIOUS AFFECTIOXS OF 
 
 Displacements of the Bladder. 
 This organ may be displaced upwards, backwards, forwards, laterally, 
 or downwards, and the symptoms of such displacement will, according to 
 circumstances, and in varying degree, be hypersesthesia, or retention, or in- 
 continence of urine. Careful examination must determine the exact cause. 
 Uterine tumoui's, pelvic exudations, the contraction of pelvic adhesions, 
 and above all, prolapse of the vaginal wall (cystocele), are the foremost 
 of these, but ovarian tumours, if adherent to the bladder, may drag it 
 upwards, growi:hs deep in the pelvis may push it upwards, the retro- 
 verted, or anteverted, or flexed uterus may push it backwards or forwards, 
 and it may form part of a ventral hernia, after abdominal operations 
 or severe straining of the accessory forces in laboxir, or even of large 
 inguinal protrusions of the ordinary kind. The treatment of all these 
 affections, and consequently of the vesical displacement, is referred to in 
 its appropriate place. 
 
 EVERSION OP THE BLADDER. 
 
 This rare condition of matters may occur congenitally, or as a result 
 of congenital deformity, through the pervious urachus, or through larger 
 ventral fissures, which include the external abdominal wall. It has 
 been met with also in later life as a gradual protrusion through the 
 dilated urethra. 
 
 Exfoliation. 
 
 Exfoliation of the whole, or of a large portion, of the mucous mem- 
 brane, occasionally, though very rarely, occurs during acute cystitis. In 
 nearly every case observed there has been excessive distention of the 
 viscus, probably interfering with the vascular relations of the layers of 
 its walls. For further notice of the two preceding rare complications, I 
 must refer to Skene, or to Barnes {Lancet, Jan. 2, 1875), quoted by him. 
 
 The subjects of Hypertrophy, Atrophy, occasionally wdth rupture, 
 and Perforating Wounds of the bladder, belong also to the domain of 
 general surgery, allowance being made for the preponderance of obstruc- 
 tive forces leading to hypertrophy in the male, and for the greater 
 amount of involutional changes accompanying child-bearing in the 
 female. FiSTULiE have also been discussed in the chapter on vaginal 
 affections as fully as seemed necessary. 
 
 HiEMORRHAGE FROM THE BlADDER. 
 
 In all cases of heemorrhage from the genital passages, it is necessary 
 to make sure that the source is not vesical, a matter of no great diffii- 
 
THE FEMALE BLADDEE. 543 
 
 culty if, ill all doubtful cases, a visual inspection of the parts as Avell as 
 of the discharge is made. It may serve a useful purpose to merely 
 enumerate here the sources of vesical or urethral haemorrhage, apart 
 from renal affections. From the bladder it may be due to (1) hajmor- 
 rhoidal conditions, (2) local congestion, (3) separation of the mucous wall 
 in inflammation, (4) intense general abdominal congestion, (5) fungosities, 
 malignant or otherwise, (6) calculus or foreign bodies, (7) purpura, and 
 the hsemorrhagic diathesis (haemophilia), or (8) zymotic or malarial dis- 
 eases. From the urethra haemorrhage may be due to (1) lacerations, (2) 
 foreign bodies, (3) vascular or polypoid growths, (4) varis, and (5) 
 acute urethritis. 
 
 It is vain to attempt here a differential diagnosis of these varying 
 conditions. For the most part they are common to the male and female, 
 and are nowhere more fully treated of than in the Clinical Lectures on 
 Diseases of the Urinary Organs, and other writings of Sir Henry 
 Thompson. 
 
 Calculi and Foreign Bodies in the Bladder. 
 
 To discuss the chemical nature and origin of calculi forms no part of 
 our programme, and sufficient has already been said as to the occasional 
 introduction of foreign substances from without, or, by perforation, 
 from within the body. Catheters, or portions thereof, hair-pins, bodkins, 
 pencils, and pipe stems, more or less encrusted with calculous material, 
 figure among the list. 
 
 The symptoms of all such cases are similar — hypersesthesia in vary- 
 ing degree, Avith occasional incontinence, tenesmus, and pain before and 
 after urination, but chiefly the latter, and occasionally haemorrhage. 
 Chronic cystitis arises after a time, with its accompanying signs, 
 and, if relief be not obtained within a reasonable time, retrocession of 
 inflammation takes place to the ureters and kidneys, leading to pyelitis, 
 uraemia, and general embolic disease. The symptoms above mentioned 
 lead speedily to a careful examination and inquiry into the history, and 
 these can hardly fail to elicit a correct diagnosis. A neoplastic o-rowth 
 must be distinguished, if there is a doubt, by observing its softer consist- 
 ency and fixed position, and by the introduction of the finger ;:)er %irethram. 
 The endoscope requires great familiarity with its use to be of any service. 
 
 Treatment. — Small calculi or foreign bodies, may be removed ^^e?* 
 urethram after dilatation. There is much room for ingenuity in the 
 use of appropriate forceps. In the case of elongated bodies, the finger 
 in the vagina can do wondci'S in the way of placing them in suitable 
 position for section, or extraction through the urethral canal. Litho- 
 trity is less seldom necessary than in the male, on account of the 
 greater facility of extraction. It should never be performed when a 
 
544 VAEIOUS NEOPLASMS 
 
 calculus becomes an obstacle to labour ; the multiplication of cutting 
 edges might prove fatal if rapid labour ensued. With large calculi or 
 other foreign bodies, removal by vesico-vaginal incision is the most 
 effectual remedy, especially if the case is complicated with persistent 
 cystitis. We shall see that a fistulous opening thus artificially made 
 is one of the remedies for intractable cystitis, and the operation will be 
 more fully noticed under that heading. 
 
 Cancer op the Bladder. 
 
 Sooner or later, if the patient live long enough, cancer of the uterus 
 or vagina involves the walls of the bladder giving rise to incurable 
 fistulse, and thus adding immeasurably to her misery. But primary 
 cancer or sarcoma is very much more rare, although examples of every 
 variety are met with, especially the encephaloid and papillomatous. 
 The syinptoms are in no way pathognomonic, consisting of pain, hgemor- 
 rhage, and constant and difficult urination. The usual seat being about 
 the trigone or base, the mass may be distinguished by vaginal touch, 
 but differentiation from other neoplasms, or non-malignant growths, can 
 only be made by the microscopic examination of the urinary sediment, 
 or of portions scraped away through the speculum by a small curette. 
 The treatment, with the exception of soothing by opiates, and catheterism 
 when necessitated by obstruction, is, I fear, nil. Bearing in mind, how- 
 ever, that several eminent authorities maintain the non-malignant char- 
 acter of, at any rate, a certain number of cases of papillomatous growths, 
 it is permissible, with the intelligent consent of the patient, to attempt 
 extirpation of the mass. This can be satisfactorily accomplished only by 
 vesico-vaginal incision of sufficient extent. Fischer {Centralhlatt fur 
 Gyndkologie, No. 41, 1882) has experimented with some success on 
 partial resection of the bladder in the dog, but all evidence yet obtain- 
 able shows that such comparative surgery is unreliable in its results 
 when applied to the human subject. I have no personal experience on 
 any part of the subject, but the ureters seem to me to present an 
 almost insurmountable obstacle to resection, where alone it could be of 
 service. Of other foreign substances or neoplasms found in the bladder, 
 we can only enumerate — 
 
 Cysts, Polypi, Tubercle, and certain Parasites. 
 
 Cysts or their contents — hair, teeth, sebaceous matter, kc. — when 
 found in the bladder, are almost invariably of outside origin, although it 
 cannot be denied that the vesical mucous follicles may, like those else- 
 where, develop indigenous tumours. 
 
 Polyjn, or polypoid hypei'trophy of the mucous tissue, of varying 
 
OF THE FEMALE BLADDER. 545 
 
 density and bright mulberry-form appearance, and even true fibro- 
 inj^omata, are from time to time encountered and are described in 
 scattered literature, and small tubercular growths, similar to and generally 
 accompanying those in other organs, are also described. In all these the 
 ■symptoms are practically the same as those of cancer or foreign bodies, in 
 varying degree ; they are not differential between the malignant and 
 non-malignant offshoots. To make an accurate diagnosis the growth 
 or tumour must be got at, by endoscope or speculum if possible, by the 
 finger at any rate, and the urinary deposits or scraped portions must 
 be carefully examined microscopically. I cannot quite say with Skene 
 that thu.s " one may be able to tell exactly what kind of a growth you 
 have to deal with," but one should often be able to probably eliminate 
 carcinoma. 
 
 Treatment, in all cases, is by removal through the urethra, or through 
 an artificial vesico-vaginal fistula. Polypi are prone, like cancer, to 
 affect the base of the bladder, and are therefore the more easily got at. If 
 a fine pedicle exists, twisting by forceps may suffice, curetting may be 
 I'equired if the mass is too soft. Tying the pedicle and allowing the 
 tumour to slough off, or separating it by galvanic ecraseur, are 
 measures easy to express on paper, but most difficult of execution, except 
 through an incised bladder, and by a skilled expert. Tubercles, of which 
 I have had no experience, to my knowledge, would, I think, be best left 
 alone. 
 
 As to Parasites, a very considerable number have been known to find 
 their way, either through fistulse or by the ureters or urethra, into the 
 bladder. The Bilharzia hcematohia, the Strongylus gigas, the Penta- 
 stoma denticulatum (probably a larva), and the Distoma hcumotohnim, 
 particularly affect the urinary passages, for the most part in tropical, or 
 sub-tropical regions, however ; and hydatids may appear, as in all other 
 parts of the body. The symptoTois are those of irritation and sometimes 
 of haemorrhage, often j)receded by nephritic colic, due to the passage of 
 the worm through the ureter. The endemic hsematuria of some countries 
 is the result of the presence of Bilharzia hctiinatohia. 
 
 Treatment. — When detected, the offender must be removed, if pos- 
 sible, by forceps, through the dilated urethra. Preliminary poisoning by 
 injection might be advisable, but I am not aware what substances, 
 harmless to the bladder, would suit the case of each of the above 
 parasites. My colleague, Dr William Roberts, has succeeded in de- 
 stroying certain rare bacilli of the bladder by the internal adminis- 
 tration of salicylic acid. Calculi may form around vesical parasites, 
 living or dead. 
 
 2 M 
 
546 ACUTE CYSTITIS. 
 
 Acute Cystitis. 
 
 I have left until the last the important subject of inflammation of the 
 bladder, acute or chronic. 
 
 Acute cystitis is fortunately not of very common occurrence, although 
 sub-acute exacerbations of the chronic form frequently arise. The 
 mucous membrane is for the most part alone attacked, but occasionally 
 the inflammation spreads to the submucous or muscular tissues, or even 
 to the peritoneal covering. 
 
 Causes. — One of the most common of these is gonon'hoeal extension. 
 Next in order we have the occurrence of severe and protracted labour* 
 with retention of urine, direct injuries or blows on the pelvis or abdomen, 
 the use of septic catheters, sounds, or other instruments, decomposing 
 urine, or the purulent discharges of pyelitis acting on an ah'eady con- 
 gested or otherwise unhealthy viscus, calculi or foreign substances, exten- 
 sion from neighbouring organs, as from pelvic cellulitis or acute metritis, 
 and the abuse of certain drugs, especially cantharides or turpentine. 
 Cystitis may occasionally result also solely from long retention of mine. 
 A somewhat more rare cause is the bursting into the bladder of a pelvic 
 abscess, or of an ovarian or other cyst. Cold or exposiu-e seldom excites 
 the strictly acute form, but it may do so. Retroverted gravid uteiTis, 
 with pressure on the urethra and retention of urine, occasionally figures 
 as a cause. 
 
 The symptoms are intense local pain, with constant tenesmus and sen- 
 sation of residual urine. In very acute attacks this symptom may be 
 perfectly agonising. There is always more or less systemic distiu'bance, 
 as shown by pulse and temperature. Slight heemon-hage is common at 
 the commencement, and it may be severe in cases of local injiu-y. The 
 urine may at first be normal in appearance, or of high specific gravity 
 and acid, but it soon tends to become alkahne, and of lower density, as 
 ammonia is evolved in the retained fluid, and the lower specific gTavity 
 is retained in sub-acute recrudescences. Pain is said to be chiefly 
 experienced when pressure is made on the abdominal aspect, and not 
 when made per vaginam, but I have not myself found this distinction 
 hold good to any extent. One of the most serious sequelce is the 
 occurrence of exfoliation of the mucous wall, and this, as above 
 stated, occiu's chiefly in those cases where great distention has pre- 
 ceded or accompanied the attack. The occurrence of nephritis or 
 P3'elitis, due to backward extension of the inflammator}- process or 
 to pressure on the ureters, is a sequel rather of the chronic than of the 
 acute form. 
 
 The diagnosis of acute cystitis can seldom be matter of doubt, but 
 nevertheless a careful examination of the pelvis should always be made. 
 
CHKONIC CYSTITIS. 547 
 
 to ascertain how far it may be part of a general inflammation, or due to 
 local pelvic mischief, uterine displacements, &c. 
 
 Treatment. — The relief of pain and tenesmus is the first object. This 
 can be best effected by the constant use of suppositories of morphia com- 
 bined with belladomia or atropia. External local applications are not of 
 much use, but if the patient can endure the fatigue, a prolonged hot 
 hip-bath affords relief Bland mucilaginous drinks — whey, milk, barley- 
 water, or linseed tea — are indicated. During the acute stage very little, 
 if any other, nutriment is desirable. I have seen a few leeches on the 
 hypogastrium give very immediate relief, explain it as we may. Saline 
 purging is strongly recommended by most authorities, but in the acute 
 stage, at any rate, may easily be overdone. Hyoscyamus is a remedy of 
 considerable value if given in sufficient dose (5ss. to 3i. of the tincture) ; 
 hyoscyamine is dangerous. The urine, if very acid, indicates the use of 
 the alkaline effervescing waters. Catheterisation, often so useful and 
 necessary in the chronic form, is fraught with so much pain that it should 
 only be used if there is positive retention, with great caution, and hardly 
 ever if the urine is acid in reaction and clear. The disease, if there is no 
 general septic poisoning or peritoneal extension, may thus sometimes be 
 rapidly cured, but it more often subsides into the chronic form. Ex- 
 foliation to any great extent will require dilatation of the urethra, and 
 perhaps gentle extraction by forceps. 
 
 Chronic Cystitis. 
 
 This is of but too frequent occurrence, commencing occasionally in the 
 violent and acute form, with pyrexia, &c., but more commonly creeping 
 on gradually. 
 
 The mucous membrane is congested, and the whole wall soon becomes 
 rugose. The epithelium is freely shed, and may even be necrosed and 
 expelled in large patches, as after acute disease. Sir Spencer "Wells and 
 others have nan-ated cases of this kind, and complete regeneration may 
 follow. Ulceration of the wall of the bladder in patches may follow, 
 aggravating and prolonging all the symptoms, and occasionallj', although 
 rarely, this leads to perforation. 
 
 Causes. — These are the same as those of the acute form, acting less 
 violently, and the affection may also, and frequently does, arise from 
 chronic gleet, from the presence in the bladder of calculi or foreign bodies, 
 from cancerous or tubercular disease of the organ, from irritating internal 
 medicines such as turpentine or copaiba, from habitual over-retention of 
 urine, from chronic alcoholism, from paraplegia, complete or partial, from 
 injudicious vaginal injections or manipulations, from the pressure of 
 adjacent tumours or of an anteflexed uterus, from the gouty diathesis, 
 
548 SYMPTOMS AND TREATMENT 
 
 and perhaps from several other causes, seeing that many cases cannot be 
 traced to their real origin. 
 
 The symptoms are those of pain in micturition, irritability, spasm, or 
 pain on moderate retention, and frequency of urination, all in very 
 varying degree. Abundance of toughened mucus, and more or less 
 epithelium, pus, and frequently also blood-cells, are found in the urine, 
 which speedily tends to become alkaline and phosphatic, although the 
 latter condition may for a time exist without the former. The specific 
 gravity is usually low. At first the urine may require to stand some 
 time before the slight deposit of pus takes place, although it will, of 
 course, be albuminous, but afterwards the thick, rojDy, mucous, and 
 gelatinous urine is perfectly characteristic, as is also its foetid ammoniacal 
 smell. Ulceration aggravates all these symptoms. If the bladder is 
 examined digitally under anaesthetics, as becomes necessary in prolonged 
 and aggravated cases, the rugose and contracted state of its walls, and 
 the hypertrophy of its muscles become manifest, dej)Osits of phos- 
 phates give a sensation of roughness or sandiness, and the smooth 
 portions, denuded by exfoliation or ulceration, are thus rendered more 
 apparent. This course of symptoms is apt to be persistent for very 
 long periods, or, in severe cases, the patient may sink into a state of 
 cachexia or chronic septicaemia, or the afifection may terminate in extra- 
 vasation of urine or pelvic abscess. Extension of mischief too frequently 
 occurs upwards, leading either to occlusion of the ureter or pyelitis, 
 and ursemic poisoning leads to the death of the patient in a typhoid 
 condition. These worst symptoms sometimes supervene with painful 
 rapidity on an otherwise apparently slight case. 
 
 The treatment of chronic cystitis is most aggravatingly difiicult. 
 Temporary improvement may easily be effected, but relapse constantly 
 occurs. Yet the disease is so frequent that the practitioner must be 
 provided with many resources. 
 
 The diet must, throughout, be bland and unstimulating, yet nutritious ; 
 milk will always constitute the chief element. For relief of chronic pain, 
 hyoscyamus or belladonna must be chiefly relied upon. Opium is 
 objectionable after the acute stage, both from the dangerous habit, the 
 formation of which is risked, and on account of its tendency to induce 
 constipation. Mild aperients, such as the pulvis glycyrrhizse comp., 
 the electuary of senna, or the various salines, are required. Diluents 
 of the urine, such as are recommended for acute cystitis, must 
 still be freely used, and the decoction or infusion of triticum repens, 
 buchu, and uva ursi have undoubtedly a favourable action in 
 promoting aqueous urination, although the recent infusion of digitalis 
 (3ii. ad. 3iv.) is superior to them all in this respect, and exerts 
 the tonic vascular influence of the drag at the same time. The 
 
OF CHRONIC CYSTITIS. 549 
 
 urine being now almost always alkaline, or verging on alkalinity, 
 must be corrected, as far as internal remedies will do so, in this respect. 
 The mineral acids are most generally relied upon. I have found 
 benzoic acid, as prescribed by Emmet for the preparation of vesico- 
 vaginal fistulse for operation, the most active agent in diminishing the 
 alkalinity of cystitic urine — two drachms of benzoic acid, and three 
 drachms of borate of soda, to twelve ounces of water, a tablespoonful, 
 further diluted, to be given frequently. Slight cases of cystitis will, the 
 cause being removed, sometimes yield to this treatment, if perseveringiy 
 used, but injections into the bladder are generally required, either for 
 the purpose of washing away the tenaceous deposits, or of acting upon 
 the mucous membrane. For this purpose, the double catheter is always 
 required. It is a mistake to trust to the single one. Pure water, at a 
 temperature of 98° or 99°, will fulfil the first indication — for the second, 
 various agents have been used. That which is generally known as 
 boro-giyceride, in the strength of 1 in 40, is one of the most effective. 
 The saturated solution of boracic acid, two or three times diluted, is also 
 very useful. Dilute nitric acid (5i. to the pint), tincture of iodine 
 (3i. to the pint), quinine (1 gr. to the ounce), and carbolic acid (1 in 80 
 to 1 in 60), are also valuable remedies, and it will be seen that they 
 are nearly all agents which counteract the development of septic 
 influences. Before using any of these agents, the bladder should be 
 carefully and gently washed with water alone, by the double catheter, 
 perhaps more than once ; the medicated fluid is then injected slowly, say 
 two or three ounces, and after a short time is either voided or washed 
 ovit again. I have no faith in the use of setons or blisters applied to 
 the hypogastrium, or in the painting of the vaginal Avail Avith iodine ; the 
 latter step may do harm, by adding to the irritation which has led to 
 the cystitis. The question of catheterisation is perhaps the most im- 
 portant one in the treatment of chronic cj'stitis. In some cases the 
 irritation and consequent tendency to ineffective urination are so great 
 that one is impelled to use the catheter with too great frequency. In 
 others, the irritation not being excessive, or the patient being an un- 
 complaining one, viscid alkaline secretions may be allowed to accumulate 
 for the want of it. It is well, therefore, in the slightest cases to make 
 sure occasionally of the perfect emptying of the bladder in this way, 
 but when the urine is distinctly ammoniacal, especially if it is viscid, the 
 catheter should be used at regular intervals — every four, six, eight, or 
 twelve hours, according to the urgency of the symptoms. I prefer this 
 to the permanent retention of any kind of catheter if the patient can 
 have the requisite attention, or can catheterise herself. The character 
 of the urine drawn will indicate the necessity for washing out the 
 bladder. 
 
550 THE fe:\iale kectu:^!. 
 
 There are two methods, of modem introduction and of somewhat 
 heroic character, which have been fonnd useful in the treatment of 
 obstinate cases of cystitis; they are based on the same idea, viz., that of 
 giving rise to temporary incontinence of urine, so that the inflamed or 
 ulcerated surface of the bladder may be free from all irritation by its 
 contents. Thorough dilatation of the m-ethra by Simon's dilators, or 
 even digitally, to such an extent as will not allow of speedy recovery, 
 will have the desired effect, but the danger of permanent incontinence is 
 so great that the remedy seems to me to be almost worse than the dis- 
 ease. The constant wearing of a soft catheter fulfils the same indication, 
 but too often creates an equal amoiuit of irritation itself. The other plan, 
 although it seems more fonxiidable at first sight, is really less dangerous, 
 in skilful hands, to permanent comfort. It consists in making an open- 
 ing through the vesico-vaginal wall, an artificial and voltmtarily produced 
 vesico-vaginal fistxda, which, if it does not close spontaneously, can be 
 closed by operation, after the required results are obtained. Marion Sims, 
 in 1858, advised Emmet to leave open an artificial vesico-vaginal fistula, 
 through which he had extracted a stone, for the purpose of leaving the 
 bladder free to recuperate itself from the effects of chi'onic cystitis. In 
 1861, Emmet made a fistula of the kind for cystitis alone, publicly report- 
 ing the case in 1868. On this side the Atlantic, Mr Lawson Tait de- 
 scribed the practice in the Lancet of 1870, and attributes the knowledge 
 of its value to an operation perfomied by Sir James Simpson many 
 years before. Simon advises a "P-shaped incision of the vagina, the trans- 
 verse part in front of the os uteri, the other extending forwards from it, 
 and through this the bladder is hooked down and incised ; this at any 
 rate is his operation for removing foreign bodies. Emmet makes a direct 
 longitudinal incision, and stitches the edges of the vagina and bladder 
 together, while more recently the actual cautery knife has been used, 
 avoiding haemorrhage and leaving less tendency to too early spontaneous 
 closure. The wound is ultimately treated as an ordinary vesico-vaginal 
 fistula. I can speak from no personal experience, but I should fear danger 
 to the ureters from Simon's plan. Perineal section in the male offers 
 but an imperfect analogy. The good results in the cases I have seen 
 recorded are so far short of expectation that I advise the j)ractitioner to 
 leave the matter yet awhile in the hands of experimenters. 
 
 The Eectum. 
 
 The maladies of the rectum seem to be, in actual practice, less inti- 
 mately connected with the work of the gynaecologist than those of the 
 bladder and urethra, nevertheless it is advisable to advert to some of 
 
METHODS OF EXAMINATION. 
 
 551 
 
 tliem. Anatomically, the rectum is, in its middle portion, connected 
 with the vagina by some loose cellular tissue, for 1|- to 2 inches of its 
 length. Below this it diverges, running backwards to the anus, while 
 the vagina is directed forwards, between them lying the triangular peri- 
 neal body. The upper part is surrounded by peritoneum, and between 
 it and the vagina we have the lower end of the important Douglas's 
 pouch (fig. 5). It is well shown in Hart and Barbour's work, so pro- 
 lific in careful anatomical descriptions, that pressure from the abdomen in 
 the direction of the axis of the pelvic brim is in accord with the axis of the 
 outlet of the rectum, thus facilitating the daily process of defecation, while 
 it is at an angle with that of the vagina, necessitating in labour the 
 various rotating and accommodating processes, and partly accounting 
 for the retention of elongated vaginal pessaries during defecation. The 
 sensitiveness of the lower part of the rectum leads to the necessary calls 
 of nature, and accounts for the pain of many rectal affections, Avhile the 
 insensitiveness of the upper portions allows of much accumulation of 
 fpsces, and sometimes of the existence of organic disease with little dis- 
 comfort. 
 
 Examination op the Rectum. 
 
 On insi^ection we note the existence of external tumours or protrusions 
 — hsemorrhoids, fistulse, and extensive fissures, and we can by the finger 
 discover any surrounding hardness or spasm of the sphincter. This can 
 be quite satisfactorily accomplished, as can any other ordinary examina- 
 tion, in the left lateral position, a position recommended also by Mr 
 Allingham [Diseases of the Rectum) for the male patient. Rectal toucher 
 is practised with the forefinger of either hand, the finger being well 
 lubricated, and the nail coated below with soap. I must confess that 
 I can seldom make much of the plan, so frequently recommended 
 for conjoint ex- 
 amination, of 
 introducing the 
 forefinger into 
 the vagina and 
 the middle one 
 into the rectum. 
 In spite of some 
 inevitable awk- 
 wardness I can 
 
 Fig. 207. — Rectum Siieculum. 
 
 succeed better by the two forefingers, their palmar aspects being 
 opposed. The most satisfactory speculum is a small glass truncated 
 instrument, incomplete on one side (fig. 207), together Avith one of the 
 usual vaginal shape. There are various valvular instruments in occa- 
 
552 PELVIC EXAMIXATIOX THEOUGH THE EECTUM. 
 
 sional use, but they need form no part of an ordinary armamentarium. 
 By passing one or two fingers into the vagina, the anterior wall of the 
 rectum can be easily everted and inspected, in those who have borne 
 children. Sir James Simpson used to lay gi-eat stress on this, which is 
 called in America Storer's method, but I do not know whether he taught 
 it to, or was taught it by, Dr Storer of Boston, who was attending his 
 lectures at the same time as myself I have formerly referred to 
 Simon's method of introducing the whole hand (p. 11). Its dangers 
 are certain, even when the hand is small ; but Allingham has thus suc- 
 cessfully stretched a band which was contracting the gait at the brim of 
 the pelvis, and the method is justifiable in extreme cases of stoppage 
 believed to be of this kind. Under angesthesia, the anus can easily be 
 dilated to a very considerable extent, and this is one of the most satis- 
 factory methods of curing anal fissure. It need hardly be said that 
 before all rectal examinations the bowel should be thoroughly emptied. 
 
 EXAMIXATIOX THEOUGH THE EeCTUM. 
 
 No difficult case of disease of the pelvic organs or tissues can be 
 thoroughly investigated without an examination through the rectum. 
 We can thus sometimes reach higher than by vaginal examination, and 
 get behind many diseased or displaced structures that cannot be other- 
 wise reached. The combination of rectal with abdominal or vaginal 
 touch has already been explained. The student should early famiharise 
 himself with the normal condition of the cervix uteri and other parts 
 when felt through the rectal wall. In atresia vagina and vaginismus, 
 or with young virgins, rectal examination may alone be possible. The 
 state of the posterior wall of the litems, Douglas's pouch, the pelvic 
 ligaments behind the vagina, the broad ligaments and Fallopian tubes, 
 the ovaries, ovarian tumours or their pedicles, and of many other 
 parts which must be investigated, can only be satisfactorily explored in 
 this way. Much assistance may sometimes be given by drawing down 
 the uterus with vidsellum or hook while the rectal examination is made. 
 The diagnosis of elongated cervix from prolapse, of polypus from inver- 
 sion, of retroversion complicated by adhesions, of other impediments to 
 the replacement of retroflexions, of extra-uterine pregnancy, or of hsema- 
 tocele or pelvic exudations, is especially facilitated by rectal examination, 
 pai-ticularly if tense abdominal walls or emhonpoint prevent the ordinary 
 bi-manual examination. 
 
 To illustrate the mutual relations of rectal and utero-vaginal symp- 
 toms or disorders, it may be mentioned that while Emmet lays special 
 stress on fissure of the anus as causing, by reflected irritation, disturb- 
 ance of the pelvic circulation, and so leading to dysmenorrhoea, uterine 
 
DISEASES OF THE KECTUM. 553 
 
 prolapse, leucorrhosa, aud ovarian congestion — Allingham dwells with 
 equal force on the impossibility of curing many cases of rectal fissure 
 while these gynsecological affections are unremedied. Fissure of the anus 
 is a not uncommon source of vaginismus and dyspareunia. Uterine and 
 pelvic disease frequently lead to hsemorrhoids and to otherwise unex- 
 plainable rectal hsemon-hages, and so forth. The rectum has also on rare 
 occasions been utilised for the removal of ovarian tumours. Such an 
 ojieration was successfully performed by my friend Mr Stocks of the 
 Salford Hospital {Brit. Med. Jour., October 1875, p. 487). 
 
 Diseases of the Eectum. 
 
 A very cursory glance at some of these must suffice. 
 
 Rectocele has been already sufficiently noticed. 
 
 Recto-vaginal Fistula has also been mentioned, but I may just state 
 here that in incui-able vesical and urethral fistula, closure of the whole 
 vulva, preceded by an artificial recto-vaginal opening, has succeeded as a 
 useful palliative in the hands of Goodell ; it allowed the rectum, with its 
 strong sphincter, to become part of one large cloaca. 
 
 Constipation. — This symptom constitutes so frequent an element in 
 the causation or resulting consequences of female diseases that some 
 mention of it is here required. It is almost incredible to what an extent 
 fsecal accumulation may amount, and it requires always to be borne in 
 mind that some mucous diarrhoea may coexist, the fluid evacuations 
 finding a way through a channel in the hardened mass (diarrhoea para- 
 doxa). When not due to habitual neglect or to digestive disorders, con- 
 stipation may be the result of pressui-e on the rectum by a retroverted 
 or retroflexed uterus, by fibroid tumours, by exudations of pelvic lymph 
 or blood, or by subsequently contracting bands, all of which should be 
 sought for when ordinary remedies fail. In its turn it may give rise to 
 exacerbations of all the ordinary symptoms of gynic disease, or may be 
 the cavise of rectocele and eventually of uterine prolapse. No uterine 
 disease can be fairly treated while habitual constipation lasts ; it aggi-a- 
 vates pelvic hypersemia and complicates all displacements. Regular 
 injections of tepid water, if not contra-indicated, and the administration 
 (jf the mildest purgatives available, are therefore indicated in many, if not 
 most, chronic uterine affections. The pulvis glycyn-hizsc comp., or still 
 better the pulvis liquirititc comp. of the German Pharmacopoeia, the con- 
 feet, senna;, sulphur, or the milder saline waters, best fulfil this condition. 
 The preparations of aloes, with or without iron or myrrh, are of great 
 value in sluggishness with amenorrhoea, but must be avoided whenever 
 there is local congestion. 
 
 Fissure of the Anus has already been more than once referred to as 
 
554 DISEASES OF THE 
 
 a cause or consequence of uterine disorder, ovarian irritation, or vaginal 
 spasm. Its action on the anus is very similar to that of most of the 
 causes of vaginismus on the vulva. I have met with it as a cause of 
 vaginismus when the intolerable pain at, and long after defecation, was 
 almost absent. It may be divided in its whole length, cutting well into 
 the muscular fibres, or may be treated by forcible dilatation of the rectum 
 by the thumbs. Nitrate of silver and other local applications are seldom 
 of use. 
 
 Pruritus Ani often coexists with pruritus vulvge, or may occur 
 separately. It is sometimes a purely neurotic affection, but many of 
 the causes of pruritus vulvae may conduce to its origin (p. 41). I have 
 seen the symptom localised in the anus when the cause and successful 
 treatment were evidently gynic. There is little to add to the treatment 
 given under pruritus vulvae. The oleum staphisagrise (1 to 7 of vase- 
 line) and white precipitate ointment, I have found of most service as 
 local remedies, but the search for and removal of local or constitutional 
 causes are all-important. 
 
 Hsemorrhoids. — Few women have many children, or suffer from any 
 of their own special ailments Avhich involve pelvic congestion or back- 
 ward uterine pressure, without suffering in some degree from haemor- 
 rhoids, external or internal. The symptoms and signs of these 
 should be familiar to every practitioner. They frequently disappear 
 on the cure of the uterine or other mischief, aided by mild laxatives 
 as above recommended, and by the application of an ointment (acid 
 gallic, gr. XX.; morph. acet., gr. v.; vaseline alb. §i.), this, for obvious 
 reasons, is preferable to the filthy ung. gallse c. opio. For further 
 operative treatment, see Allingham, (pp. cit.), or other works on the 
 rectum. 
 
 Prolapse of the Eectum. — The mucous membrane alone may pro- 
 lapse, or protrusion of the whole thickness may occur. The affec- 
 tion is pre-eminently one of childhood, due for the most part to over- 
 straining, but, owing to the same cause during childbirth, to habitual 
 constipation, and to the numerous causes of relaxation or downward 
 pressure, it is not infrequent in adult women. In severe cases the possi- 
 bility of the inclusion of Douglas's pouch, with hernial contents, is not 
 to be forgotten. Allingham states that the pointing of the opening of 
 the gut towards the sacrum is diagnostic of this complication. If care- 
 ful and constant reposition, attention to the bowels, and the wearing of 
 an anal caoutchouc air-pad, do not ciu-e the disease, as they may at an 
 early stage, the application of pure carbolic acid or of the actual cautery 
 may produce sufficient shrinking of the gut, or plastic operations, some- 
 what similar to those for prolapsus vaginre, may be necessitated. 
 
 Fistula in Ano. — An ordinary fistula of this kind, well removed from 
 
FEMALE KECTUM. 555 
 
 the vulvar and vaginal tissues, is treated in the female as in the male, 
 but, owing to the vascularity of the parts, and the relation of the peri- 
 neum, the treatment by elastic ligature is specially useful when the 
 fistula opens much in front of the anus. I have an impression that 
 spontaneous cure more often occurs in the female than in the male, and 
 also that the affection is much less common in the former. A priori, 
 one would, I think, have expected the reverse. 
 
 I do not think that anything would be gained by referring here to 
 cancer, polt/piis, stricture, rodent ulcer (?), or other affections of the 
 rectum. 
 
556 SYMPTOMS AND SIGNS OF PREGNANCY 
 
 APPENDIX. 
 
 The Symptoms and Signs of Pregnancy, from the Point of View of 
 Diagnosis and Differentiation. 
 
 In considering the various afFections of the female sexual organs, whether 
 in the unimpregnated condition or otherwise, we have so often had occa- 
 sion to refer to the state of pregnancy as influencing oiir diagnosis and 
 consequent treatment, that it seems to be advisable, as has elsewhere 
 been promised, to insert an appendix, giving, in more or less tabular 
 form, the symptoms and signs of pregnancy, from a differential point of 
 view. When the practitioner finds an apparently enlarged uterus, or 
 disordered menstruation, or abdominal distention, or any of the func- 
 tional disturbances which so often accompany pregnancy, it is his duty, 
 no matter what may be the social position of his patient, or her marital 
 relations, to satisfy himself that she is not pregnant, before proceeding 
 to any active treatment, or resorting to the use of some of the methods 
 of physical diagnosis, especially of the uterine sound. 
 
 Symptoms and Signs of Pregnancy. 
 
 1. Suppression of Menstruation. 
 
 In the perfectly normal condition of pregnane}' this is sudden 
 and apparently causeless, lasts during the whole period of gestation, 
 and for some months afterwards during lactation. 
 
 Exceptions. — One or more menstmal periods, generally with a slighter 
 amount of discharge, may occur subsequently to the commencement of 
 pregnancy. Very rare exceptions of menstruation during the whole 
 of pregnancy, of a first pregnancy without previous menstruation, 
 and of other abnormalities in this respect are recorded. 
 
 Diagnostic Value. — As leading to the strongest presumption of preg- 
 nancy this sign is invaluable, but without corroboration by physical 
 signs it is otherwise valueless. It xn-^j be due to any one of the causes 
 mentioned at page 162. Gradual cessation is in favour of disease 
 rather than pregnancy, but the final stoppage may, nevertheless, be due 
 to the latter state. Spurious pregnancy, and pregnancy along with 
 
FROM A DIAGNOSTIC POINT OF VIEW. 557 
 
 disease for which it might be mistaken, must always be borne in mind. 
 When suppression occurs, never use diagnostic or therapeutic means 
 liable to lead to abortion, until physical signs, on their comparison 
 with dates, permit of the exclusion of pregnancy. Beware of inten- 
 tional mis-statements as to the suppression or non-suppression of the 
 catamenia, or even of imitation of the natural discharge. 
 
 2. Sympathetic or Pressure Symptoms op Pregnancy. 
 
 Almost endless in number. The more common affections are dyspepsia, 
 vomiting (especially in the mornings), salivation, tic, shootings in the 
 breast, cephalic congestion, plethora, chlorosis, and insomnia— many of 
 these being due to the hyperinotic and other not yet clearly ascertained 
 changes in the blood of the pregnant woman. From pressure we have 
 the bladder, pelvic vessels, pelvic nerves, rectum, abdominal viscera, dia- 
 phragm, and abdominal walls affected, leading to dysuria, hamon-hoids, 
 varix, sciatica, ciniral and other neuralgias, constipation, tenesmus, 
 dyspnoea, &c. 
 
 Exceptions. — ^Every symptom thus noted may be absent in pregnancy, 
 and the variations in their relative frequency are endless. Their con- 
 nection with successive stages of pregnancy is mainly of importance to 
 the obstetrician. 
 
 Diagnostic Value. — Practically nil. In uterine or ovarian disease we 
 may have, although less frequently, any of the sympathetic symptoms, 
 and those due to pressure may be caused by any form of tumour affecting 
 the pelvis. 
 
 3. Kyestbin. 
 
 On the second or third day after it is passed the urine becomes hazy ; 
 a pellicle, at first thin, but afterwards thicker and opaque, forms on the 
 surface. In twenty-four or forty-eight hours this slowly breaks up and 
 falls to the bottom as a flocculent deposit. The process is again repeated, 
 and decomposition then sets in. The pellicle is a nitrogenous substance, 
 secreted by the kidney, probably in connection with the ha^mic hyperi- 
 nosis above referred to. 
 
 Exceptions.~At the beginning and end (first and last months) of 
 pregnancy, this phenomenon is generally absent, and it may be so 
 during the whole period. It has also been met with in the non- 
 pregnant state, and in the male. 
 
 Diagnostic Value.— Much diminished by the facts just mentioned. In 
 a difficult case of diagnosis the well-marked presence of the sign would 
 so far turn the scale in favour of pregnancy as to lead for a longer time 
 to non-interference in accordance with the presumption. In extra- 
 uterine pregnancy its occurrence would probably be of some con- 
 
55 S SYMPTOMS AjS'D SIGXS OF PEEGNAISTCT 
 
 firraatory diagnostic value, although I can find no special observations 
 on the subject. 
 
 4. ]\Iammaet Appearances. 
 
 From the second month or thereabouts the breasts gradually increase 
 in size, their veins become distended, the nipple increases in prominence 
 and becomes darker, together with a surrounding areola. Later on, 
 watery milk is secreted in small quantities, and still later, silvery streaks 
 appear on the distended skin. A more important characteristic is ths 
 appearance of small soft tubercles in the areola, and the occurrence of a 
 second areolar zone, paler than the inner one, also mottled with still 
 paler spots. 
 
 Exceptions. — In hlondes these changes may be hardly observable, even 
 to the last ; in brunettes the mere darkening of the nipple and areola is 
 common in the absence of pregnancy or disease. 
 
 Diagnostic Value. — In a multipara these signs are of little diagnostic 
 value; they may remain scarcely changed from a former pregnancy. 
 When previous pregnancy can be eliminated, the complete development 
 of all the characteristics mentioned is almost certainly diagnostic of 
 advanced pregnancy. I once saw them well marked in a professed nulli- 
 para, in connection with an ovarian tumour, but discovered afterwards 
 that there had been a previous clandestine miscan-iage. The slighter 
 alterations of the breast must never be rehed on for diagnosis. They 
 may appear in connection with any form of uterine or ovarian disease, 
 and, even when the appearances are typical of pregnancy, there wiU 
 always be the necessity for, and the possibility of, checking fallacies by 
 examination of the utei-us itself. 
 
 •5. Appearance op the Abdomen. 
 
 Dui'ing the first six weeks it sinks rather than rises ; afterwards it 
 becomes gradually distended from below. White silvery cracks from dis- 
 tention may be apparent in the later months. These, however produced, 
 are permanent. Deposits of pigment along the Unea alba, around the 
 umbilicus, and elsewhere, are common. The umbilicus is at first de- 
 pressed, then becomes level, and towards the last is often slightly 
 protruded. 
 
 Exceptions. — None of these symptoms are xuiiversally found in preg- 
 nancy except the gradual distention of the abdomen. 
 
 Diagnostic Value. — This, taking the signs ^:»fr se, is very slight ; in- 
 deed, the distention, the discoloration, and the cracks, may all be exactly 
 simulated in cases of tumour, or even of ascites, although with the last 
 mentioned the distention is usually more prominent in the flanks and 
 flatter in front. 
 
FEOM A DIAGNOSTIC POINT OF VIEW. 559 
 
 Note. — The abdominal distention due to pregnancy is very commonly 
 greater towards the rio'ht side. 
 
 6. Palpation op the Abdomen. 
 
 About the tenth or twelfth week a small rounded swelling is first dis- 
 tinctly felt above the pubes. This increases at a tolerably definite rate 
 It reaches quite to the umbilicus about the sixth month, about two inches 
 higher during the seventh, and finally to the ensiform cartilage. It is 
 central, but often with a distinct tendency to the right. Its consistencj" 
 is firm but not hard, but varies much according to the amount of liquor 
 amnii. After mid-term, distinct contractility may often be felt if it is 
 kneaded or irritated by a cold hand, — a very important sign. Braxton 
 Hicks was the first to demonstrate that these contractions also occur 
 normally, without external irritation, at intervals of five or ten minutes, 
 and may be considered as a regailar physiological phenomenon of preg- 
 nancy. Their perception is therefore of the highest possible positive 
 diagnostic value. But negative evidence is not equally afforded by our 
 inability to detect them. Percussion dulness corresponds with the area 
 of the tumour. Fluctuation is quite apparent when the liquor amnii is 
 excessive. In the last two or three months the limbs of the foetus can 
 generally be clearly made out by the hand. 
 
 Exceptions. — Although the rate of growth of the uterus is gradually 
 progressive, and pretty closely corresponds to the rate just mentioned, yet 
 very sudden apparent increase sometimes occurs, owing to changes of 
 position of the uterus in relation to the other viscera. 
 
 Diagnostic Value. — In very stout women it may be impossible to 
 make out the form of tumour with sufficient accuracy to be of any 
 value. A somewhat soft fibroid tumour, or a resistent multilocular 
 ovarian one, may perfectly simulate the "gravid uterus in form, position, 
 and consistency, therefore no diagnosis can be founded on the considera- 
 tion of these alone. Uterine distention in hsematometra, hydrometra, 
 or pyometra, may also be undistinguishable from pregnancy by palpa- 
 tion alone ; but the discovery of congenital or acquired atresia, and the 
 history of the case, will suffice for differentiation. Careful percussion 
 will eliminate spurious pregnancy, physometra, and ascites. The earlier 
 stages of pregnancy are indistinguishable per abdomineni from enlarge- 
 ments of the uterus due to chronic metritis, sub-involution, or conges- 
 tion. The rate of growth, if it can be ascertained, — and it must 
 sometimes be waited for and watched, — is rarely the same in any form 
 of tumour or uterine enlargement as in pregnancy. It may be laid 
 down, however, as an axiom, that no positive diagnosis, confirming or 
 setting aside the existence of pregnancy, can be based on the manual 
 
560 SYMPTOMS AND SIGNS OF PEEGNANCY 
 
 examination of an abdominal tumour, unless it be confirmed by a careful 
 examination per vaginam, or by stethoscopic signs. 
 
 7. F(ETAL Movements. 
 
 These, when described as felt subjectively by the patient herself, are of 
 very little importance. It is otherwise when they are felt objectively 
 by the practitioner. In advanced pregnancy they may be felt and seen 
 so distinctly, that no possible doubt can arise as to their nature. During 
 the fourth and fifth months they are more indistinct, and may be simu- 
 lated by movements in the intestines or abdominal muscles. Consider- 
 able experience is required to differentiate between these, and the sharp 
 little percussions from within, which follow the application of a rough 
 or cold hand to the tumour in pregnancy. The deliberate rolling over 
 of a more mature child can hardly be mistaken. 
 
 Exceptions. — The child may be dead, when there will, of course, be 
 no movements, and it has periods of sluggishness, when they are very 
 difficult to excite. 
 
 Diagnostic Value. — Clearly felt or seen by an experienced observer, 
 these movements are pathognomonic of pregnancy, but should always be 
 confirmed by vaginal examination. The pregnancy might be extra- 
 uterine. 
 
 8. Uterine Changes discovered per vaginam, or bi-manually. 
 
 These are infinitely more important than the changes observed by 
 mere abdominal examination. In a primapara the uterus at first 
 sinks lower in the pelvis, and is increased in weight ; it is also, 
 or appears to be, more anteverted than normally. To the delicate 
 and experienced touch the o§ and cervix appear very early to be 
 softer and thicker than usual, and the os is more rounded. If 
 carefully examined bi-manually, the enlargement of the uterus will 
 be found to have the following characters : — It is not equal in all 
 directions, but the organ seems to be enlarged antero-posteriorly ; 
 the soft, bulging, anterior wall is easily felt per vaginam, and bi- 
 manually it may give a' not very obscure sense of fluctuation between 
 the two hands. The posterior bulging is most clearly made out pei- 
 rectum. The rounded and smooth fundus is easily felt, but not so 
 distinctly defined as in other forms of moderate uterine enlargement, 
 while the lower portion of the body, above the cervix, is softer than is 
 the case in any form of uterine tumour or hypertrophy. There is no 
 loss of mobility. As the third month is entered on, the uterus is found 
 to have risen again in position ; the cervix uteri often points somewhat 
 to the left, and the cervical softening is greater. In the fourth or fifth 
 
FKOM A DIAGNOSTIC POINT OF VIEW. 561 
 
 mouths, the cervical softening is still more apparent, and some appear- 
 ance of shortening begins to be felt, but the os remains smooth, round, 
 and closed. The globular, lo^yer part of the body is apparent all round 
 the cervix, and is free from the hardness of other enlargements. In the 
 sixth month the so-called shortening and obliteration of the cervix is 
 fairly entered upon. The real nature of this phenomenon is discussed in 
 obstetric works. Henceforth it goes on rapidly and progressively. 
 About the thirty-fourth week the cervix is said to be shortened by one- 
 half, and by the full forty weeks it is abolished altogether, there being 
 nothing but a globular uterine mass to be felt, with a thin circular 
 orifice, representing the os and cervix. 
 
 In the multipara, the changes in the os and cervix uteri are different. 
 The former may be open from the first, admitting the tip of the 
 finger. Later on, its form varies much, according to the amount of 
 laceration or permanent dilatation which may have been produced by 
 former labours, but the internal os remains closed until towards the end of 
 pregiiancy. On the other hand, the walls of the cervix undergo apparent 
 shortening much more slowly towards the end of pregnane}', and may 
 remain quite distinct, and even of cartilaginous hardness, until labour has 
 fairly commenced. 
 
 IJxceptions.— The precise dates at Avhich these phenomena occur are 
 given with too great exactitude in most obstetric Avorks. In my earlier 
 practice I was constantly misled in this way. 
 
 Diagnostic Value.— In order to avoid constant mistakes in diagnosis 
 or treatment, these signs, ascertained by bi-manual examination, are price- 
 less, although they necessitate considerable experience for their correct 
 estimation. The thoroughly investigated history of the case will nearly 
 always give a fairly con-ect idea as to the probability or improbability of 
 pregnancy, and the former must always have the benefit of the doubt. 
 But this probability will amount as nearly as possible to certainty if the 
 changes in the os, cei-vix, and lower segment of the uterine body just 
 mentioned are found to exist. With regard to large tumours, to be 
 differentiated from pregnancy, none can produce any similar condition of 
 the uterine lower segment except intra-uterine tumours, and with 
 tliese the absence of signs of a living foetus, the history of hemorrhages 
 and other usual symptoms, and the rate of growth, will aff"ord the 
 necessary data for correct diff"erentiation. In the case of smaller growths, 
 any approximation to the characteristic signs of pregnancy must lead to 
 prolonged observation, unless the symjitoms of pain, heemorrhage, or 
 constant discharge, are such as to forbid the hope of successful pregnancy 
 and delivery, and to demand procedures for diagnosis or treatment which 
 are incompatible therewith. 
 
 2 N 
 
362 SYMPTOMS AND SIGNS OF PEEGNANCY 
 
 9. Ballottement. 
 
 This sign of pregnancy depends on the fact that the foetus in utero 
 floats in its surrounding liquor amnii, and that, if a sudden fillip be given 
 to any part of the uterus, the foetus recedes and then rebounds, the 
 rebound being conveyed to the percussing finger as a distinct although 
 slight shock. This sign must necessarily be absent during the earlier 
 weeks of pregnancy, when the fcetus is a mere feather-weight, and during 
 the last month or two, when the child generally furnishes such a large 
 proportion of the uterine contents. In women with thin abdominal 
 walls, a sudden jerk being given to one side of the uterine tumour, and 
 the finger being retained in situ, this rebound of the foetus may often be 
 felt. But the sign is more easily produced ^:)er vaginam, the fillip being 
 given to the uterine wall in front of the cervix. This sensation of the 
 rebound of a floating body can never be mistaken if it has been once or 
 twice experienced. 
 
 Exceptions. — A large foetus, with a limited amount of liquor amnii, 
 may prevent the realisation of the sign, and a very large amount of 
 liquor amnii (hydramnion), with a small or blighted foetus, may, less 
 often, have the same result. 
 
 Diagnostic Value. — In the absence of confirmatory signs, ballotte- 
 ment, felt through the abdominal walls, must not be too much relied 
 upon. A pelvi-abdominal tumour, say a pedunculated subserous fibroid, 
 or an ovarian solid tumour with long pedicle, floating in ascitic fluid, 
 may give the same results ; and if the ascites were limited by adhesions 
 or otherwise, the deception would be greater. So also in the case of 
 multilocular ovarian cysts, the parent or larger cyst may contain a float- 
 ing progeny. An examination of the uterus per vaginam should provide 
 against error in this case. But if the tumour to be diagnosed can be 
 clearly traced to the uterus, the occurrence of the sign, felt Y>^f vaginam, 
 is a certain diagnostic of pregnancy. No other intra-uterine products — 
 polypi, fibroids, cancer, or the like — fulfil the conditions required for 
 ballottement. The rebound of an anteflexed uterus, or of a stone in 
 the bladder, are said to have been mistaken for that of an intra-uterine 
 foetus, but this can only have been in the days when bi-manual examin- 
 ation was not practised, or not appreciated. Ballottement has one 
 advantage as a sign, viz., that it may be felt whether the child is alive or 
 dead. 
 
 10. Auscultatory Signs of Pregnancy. 
 
 These are two in number, — 
 
 (a) The sounds of the foetal heart, and 
 
 (5) The uterine, or, as some incorrectly term it, the placental souflfle. 
 
FROM A DIAGNOSTIC POINT OF VIEW. 563 
 
 The former of these, the sound of the foetal heart, when distinctly 
 heard, is absolutely, and by itself, pathognomonic of pregnancy. I do 
 not enter into the details of its characters, which are familiar to all 
 obstetric students ; and, with regard to its exceptions and diagnostic valiie, 
 I need only recall the facts that, a dead child has no foetal heart sounds, 
 and that in a certain small percentage— a very small one at the full 
 term — they are inaudible with a living child. An extra-uterine pregnancy 
 may, of course, afford this sign, but there is no other condition of disease 
 which can deceive the listener, if he will take the trouble to make sure 
 that the maternal heart is not beating at the rate of 130 and upwards, 
 as is that of the foetus. 
 
 The uterine souffle, on the other hand, although very characteristic of 
 pregnancy, is much more apt to lead to error, if relied upon without 
 corroborative signs. It consists of a single murmur, synchronous with the 
 maternal heart-beat, sometimes continuous and sometimes intermittent. 
 It has every conceivable variety of harshness or softness, or pitch of tone. 
 It is usually heard most distinctly towards the lower part of the uterine 
 tumour, but not always at the same point in the same case. Its site is 
 certainly not always over that of the placenta, and as its situation 
 varies in the same case, and as the placenta is more commonly implanted 
 towards the upper part of the uterus, and as the sound may occasionally 
 be heard after the expulsion of that structure, it is certainly not of 
 placental origin. The death of the foetus does not necessarily arrest the 
 sound. I do not enter here into its physiological, or occasionally patho- 
 logical, causation, further than to mention that the uterine curling arteries, 
 the venous dilatations of the organ, and the chlorotic or hyperinotic state 
 of the blood in pregnancy, probably all combine, in varying proportion, 
 to produce a sound which reminds one equally of aneurismal varix, and 
 hsemic, cardiac, or vascular murmurs. 
 
 Exceptions in pitch, site, or positive occurrence are so numerous that 
 they may be considered as possible in every degree. 
 
 Diagnostic Value. — Precisely the same sound is often heard in vascxilar 
 tibroids, and, much more rarely, in the case of ovarian or other tumours. 
 It is clear, therefore, that it cannot be relied on as otherwise than 
 strongly corroborative of other signs of pregnancy. I have often known 
 it render assurance doubly sure, but I have never known it solve a 
 doubtful case which could not be solved without its aid. 
 
 There are a few other signs of pregnancy, very interesting in them- 
 dclves, but which I feel are better left out of account here. The sound 
 of pulsation in the umbilical cord, the supposed differences between 
 the average rate of male and female heart pulsation, the livid con 
 dition of the vagina, and the increased pulsation in that organ, are all 
 subjects which are more fittingly discussed in an obstetric work. I 
 
564 
 
 SYMPTOMS A:N^D SIGNS OF PEEGNANCY. 
 
 never knew any practical good result from attaching importance to them 
 in diagnosis. 
 
 It is often an important matter, in estimating the date of a supposed 
 pregnancy, or in differentiating it from various conditions of disease, to 
 know at what periods some of its signs and symptoms are usually en- 
 countered. 
 
 I have therefore appended a table showing the date at which the 
 various signs or symptoms become developed. All such statements of 
 accurate or even of average dates must be taken, however, as merely 
 approximate. The table is slightly altered from Tanner. 
 
 Table op Signs of Prbgxancy. 
 
 
 
 
 Calendar Months of Pregnancy. 
 
 
 1 
 
 2 
 
 3 4 5 
 
 6 7 8 
 
 9 
 
 Morning sickness, . 
 Suppression of menses, . 
 Mammary areola, . 
 Enlargement of abdomen, 
 Foetal movements, objective, 
 Shortening of cervix, 
 Ballottemeut, . 
 Uterine souffle, 
 Fcetal heart, . 
 
 
 
 X 
 X 
 
 
 X 
 X 
 
 ? 
 
 > 
 > 
 
 ? 
 
 i 
 
 < 
 
 I 
 
 2 
 
 2 
 
 % 
 X 
 X 
 X 
 
 ? 
 
 X 
 X 
 
 ? 
 
 ? 
 
 X 
 X 
 X 
 X 
 
 ? 
 
 X 
 X 
 X 
 
 X 
 X 
 X 
 X 
 
 2 
 
 ■ 
 
 X 
 X 
 X 
 
 X 
 X 
 X 
 X 
 X 
 X 
 X 
 X 
 
 X 
 X 
 X 
 X 
 X 
 
 ? 
 
 X 
 X 
 
 ... 
 
 X 
 X 
 X 
 X 
 X 
 
 ? 
 
 X 
 X 
 
 The mark ( x ) shows the months during which the sign is usually observable. 
 The mark of interrogation shows the more common variations in this respect. 
 
INDEX. 
 
 Abdominal belt, 322. 
 
 gro\\i;lis and exudations, a cause of 
 uterine displacement, 289. 
 
 palpation, 4, 559. 
 
 toilette, 452. 
 Abdominal walls, abscess of the, 434. 
 
 cysts of the, 434. 
 
 Lypertropliy of the, 434. 
 
 oidema of the, 434. 
 
 solid growths in the, 435. 
 Abnormalities of the hymen, 58. 
 
 of the uterine appendages, 135. 
 
 of the uterus, 137. 
 
 behind the vagina, 7. 
 
 of the vagina, 141. 
 
 of the vulva, 143. 
 Abnormal substances anterior to the uterus, 
 305. 
 
 anterior to the vagina, 8. 
 
 posterior to the uterus, 305. 
 
 posterior to the vagina, 7. 
 
 at the side of the vagina, 9. 
 Abrasions of the cervix uteri, 229. 
 Abscess of the abdominal wall, 434. 
 
 of the ovary, 387. 
 
 of the pelvis, 432, 508. 
 treatment, 509. 
 
 of the spine, 439. 
 
 of the vulva, 50. 
 treatment, 51. 
 Absence of menstruation, 160. 
 
 treatment of, 161, 162. 
 Absent uterus, 137. 
 
 vagina, 141, 142. 
 
 vulva, 143. 
 Absorption of pelvic fat and connective 
 
 tissue, 289. 
 Accidents to ovarian tumours, 410. 
 Acne of the vulva, 38. 
 Adhesions of the labia, 57. 
 Amenorrha^a, 160. 
 
 treatment of, 162. 
 Amputation of the cervix uteri, 233. 
 Anaesthesia, 93. 
 Anaesthetics, 93. 
 Anteflexion of the uterus, 303. 
 
 treatment of, 306, 331. 
 Anteversion of the uterus, 307. 
 treatment of, 309, 337. 
 Antiseptics, 89. 
 Anus, fissures of the, 553. 
 Aphthoe of the vulva, 37. 
 " Areolar hyperplasia," 221. 
 Arrested menstruation, 160, 162. 
 
 disease of the ovaries a cause of, 165. 
 l)regnancy a cause of, 166. 
 treatment of, 166. 
 
 Ascites, differential diagnosis of, 424. 
 
 Aspirators, 35, 73. 
 
 Atresia of the genital canal, 146. 
 
 treatment of, 148. 
 Atrophy of the uterus, 128, 199. 
 
 treatment of, 200. 
 Aveling's polyptrite, 283. 
 
 Backward displacements of the uterus, 302. 
 
 Ballottemeut, 562. 
 
 Bathing, 99. 
 
 Battey's operation, 272, 461. 
 
 Belt, abdominal, 322. 
 
 Bichloride of methyline, 455. 
 
 Bi-manual examination, 9. 
 
 Bladder, 535. 
 
 calculi in the, 543. 
 
 cancer of the, 544. 
 
 cysts of the, 544. 
 
 displacements of the, 542. 
 
 distended, differential diagnosis of, 438. 
 
 distension of the, a cause of uterine dis- 
 placement, 289. 
 
 examination of the, 11, 536. 
 
 exfoliation of the, 542. 
 
 e version of the, 542. 
 
 foreign bodies in the, 543. 
 
 hfemorrhage from the, 542. 
 
 hypersesthesia of the, 538. 
 treatment of, 539. 
 
 malformations of the, 538. 
 
 parasites of the, 545. 
 
 polypi of the, 544. 
 treatment of, 545. 
 Boils of the vulva, 40. 
 Bozemann's scissors, 68. 
 Braxton Hicks's ecraseur, 73. 
 Broad ligament, cystic tumours of, 421, 422. 
 
 Cancer of the body of the uterus, 371, 434. 
 treatment, 373. 
 
 of the cervix uteri, 371. 
 treatment, 373. 
 
 of tlie ovary, 391. 
 
 of tlie vagina, 120. 
 
 of tlie vulva, 45. 
 Cancerous nodules of the cervix, 358, 360. 
 Cannula, Atthill's intra-uterine, 220. 
 
 Gooch's, 283. 
 Carcino-saruomata, 375. 
 Caruncuhu niyrtiformes, 57. 
 Caruncles, 55. 
 Catheter, use of the, 532. 
 
 Sims's sigmoid, 93. 
 
 Skene-Goodmau, 93. 
 Catheterism, 93. 
 Cauteries, galvanic, 76. 
 
566 
 
 INDEX. 
 
 Cautery, Paquelin's, 76. 
 
 thermal, 76. 
 Cervical endo-metritis, acute, 206. 
 treatment, 207. 
 chronic, 207. 
 
 treatment, 209. 
 Cervical parenchymatous metritis, chronic, 
 
 227. 
 Cervix uteri, abrasions of the, 229. 
 amputation of the, 233. 
 cancer of the, 357. 
 dilatation of the, 184. 
 hypertrophy of the, 232. 
 inflammatory, 232. 
 non-inflammatory, 237. 
 incision of the, 188. 
 laceration of the, 238. 
 
 treatment, 242. 
 mushroom-like sprouts from the, 358, 
 
 359. 
 nodules of the parenchyma of, 358, 360. 
 scarification of the, 77, 211. 
 soft papillomatous sprouting from the, 
 
 358, 359. 
 stenosis of the, 197. 
 superficial epitheliomatous ulceration of 
 
 the, 358. 
 supra-vaginal hypertrophy of the, 299. 
 ulcerations (?) of the, 229. 
 Chain ecraseur, 73. 
 Chancre of the vulva, 44. 
 Channelled polypus of the uterus, 278. 
 Chassaignac's ecraseur, 75. 
 Chloroform, dangers of, in cystitis and 
 kidney disease, 94. 
 uses of, 94. 
 Chlorosis, 103. 
 
 treatment, 107. 
 Chronic salpingitis, 467. 
 
 cough, a cause of uterine displacement, 
 
 290. 
 hypertrophy of the uterus, 170, 215. 
 
 a cause of displacement, 287. 
 metritis, 207, 215, 221, 227. 
 cervical, 207, 227. 
 corporeal, 215, 221. 
 Clamp, Wells's, 456. 
 Clitoris, hypertrophy of the, 54. 
 Clothing, 94. 
 Coccygodinia, 59. 
 
 treatment of, 59. 
 Colpeurynter, 355. 
 Colpitis, 115. 
 Complications of ovarian tumours, 410, 411, 
 
 412. 
 Condyloma, 44. 
 Congenital atrophy of the iiterus, 140, 194. 
 
 treatment, 196. 
 Congestive dysmenorrhoea, 177. 
 Consistency of ovarian tumours, 405. 
 Constipation, 553. 
 Contents of multilocular ovarian cysts, 401. 
 
 of ovarian tumours, 406. 
 Contracted lymph, a cause of uterine dis- 
 placement, 290. 
 Copper spatulse, 451. 
 Corporeal endo-nietritis, acute, 206. 
 treatment, 207. 
 chronic, 215. 
 
 treatment, 217 
 
 Corporeal parenchymatous metritis, acute, 
 203. 
 treatment, 204. 
 chronic, 221. 
 
 treatment, 223. 
 Corpus luteum, 155. 
 Covering of ovarian tumours, 404. 
 Curette, 35, 76. 
 Cystic ovarian tumours, 394. 
 Cystitis, acute, 545. 
 
 treatment, 546. 
 chronic, 547. 
 Cysts of the abdominal walls, 434. 
 of the broad ligament, 422. 
 of the liver, 436. 
 of the ovary, 394. 
 of the pancreas, 436. 
 of the peritoneum, 436. 
 of the spleen, diflerential diagnosis of, 
 436. 
 
 Dermoid cysts of the ovary, 396. 
 Differential diagnosis of — 
 
 abdominal tumours, solid, 437. 
 abscess of the abdominal walls, 434. 
 
 of the pelvis, 432. 
 
 of the spine, 439. 
 ascites, 424. 
 cysts, abdominal and pelvic, 422, 429, 
 
 434, 435, 436, 477. 
 distended bladder, 438. 
 
 Fallopian tubes, 438, 477. 
 
 stomach, 437. 
 
 ureter, 438. 
 extra-uterine pregnancy, 438, 475. 
 fat in the abdominal walls, 428. 
 fibroid tumours of the uterus, 428, 489. 
 hjematocele, 432, 478, 487, 503. 
 hsematometra, 433. 
 hepatic cysts, 436. 
 hydatids, 436. 
 hydi-amnion, 433. 
 hydrometra, 434. 
 hydronephrosis, 438. 
 hypertrophy of the abdominal wall, 434. 
 cedema of the abdominal wall, 434, 
 omental tumours, 437. 
 ovarian tumours, 419-438, 476. 
 ovary, prolapsed, 489. 
 pancreatic cysts, 436. 
 parametritis, 497. 
 pelvic abscess, 432. 
 
 cancer, 433, 478, 489. 
 
 cellulitis, acute, 488, 495. 
 
 lymph, 432. 
 
 peritonitis, acute, 487. 
 chronic, 488. 
 perimetritis, 497. 
 peritoneal cysts, 436. 
 phantom tumour, 435. 
 physometra, 434. 
 pregnancy, 430, 475, 556. 
 
 bifid uterus in, 476. 
 
 extra-uterine, 438, 475. 
 
 molar, 433. 
 renal cysts, 435. 
 retroversion or retroflexion of a gravid 
 
 uterus, 476. 
 spinal abscess, 439. 
 spina bifida, 432. 
 
INDEX. 
 
 56'; 
 
 Differential clicaguosis of — 
 
 splenic cysts, 436. 
 
 uterine cancer, 434. 
 
 uterine outgrowths, 477. 
 Differentiation of polypus and inverted 
 
 uterus, 281. 
 Digital examination or vaginal '• toucher," 4. 
 
 information obtained by, 6. 
 
 of bladder, 11. 
 
 of rectum, rectal "toucher," 11. 
 Dilatation of the cervix by incision, 188. 
 
 by the sound, 185. 
 
 by tents, 184. 
 Dilators, urethral, 536. 
 
 uterine, 187. 
 
 vaginal, 52, 117. 
 Diphtheria of the vagina, 117. 
 
 of the vulva, 37. 
 Displacements of the uterus, 170, 285. 
 
 backwards, 309. 
 
 causes of, 285. 
 
 chronic hypertrophy, a cause of, 287. 
 
 destruction of pelvic fascia, a cause of, 
 288. 
 
 forwards, 303, 307. 
 
 menstrual engorgement, a cause of, 288. 
 
 pregnancy, a cause of, 287. 
 
 relaxed vagina, a cause of, 288. 
 
 ruptured perineum, a cause of, 288. 
 
 stretching of uterine ligaments, a cause 
 of, 288. 
 
 to the side, 319. 
 
 tumours, a cause of, 287. 
 Distended bladder, dilfei-ential diagnosis of, 
 
 , 438. 
 
 Fallopian tube, difl'erential diagnosis of, 
 438. 
 
 ureter, differential diagnosis of, 438. 
 Distention of the bladder, a cause of uterine 
 displacement, 289. 
 
 of the rectum, a cause of uterine dis- 
 placement, 289. 
 
 of the stomach, 437. 
 Division of the cervix, 188. 
 Douche, vaginal, 81. 
 Drainage-tubes, Keith's glass, 458. 
 
 India-rubbei', 459. 
 Dysmenorrhoea, 160, 174. 
 
 congestive, 177. 
 
 fibrinous casts or polypi, a cause of, 180. 
 
 membranous, 179. 
 
 neuralgic, 176. 
 
 obstructive, 178. 
 
 ovarian, 181. 
 
 treatment, 182.' 
 Dyspareunia, 57, 242, 512. 
 
 ECHASEURS, 73. 
 
 Braxton Hicks's, 75. 
 
 Chassaignac's, 75. 
 
 chain, 73. 
 
 galvanic, 76. 
 
 wire, 73. 
 Eczema of the vulva, 38. 
 
 treatment, 58. 
 Education, 99. 
 
 Elephantiasis of the labia, 55. 
 Elevation of the uterus, 300. 
 Elytrorraphy, 295. 
 Elythritis, 115. 
 
 Emmenagogues, 167. 
 Emmet's curved scissors, 131. 
 double-curved scissors, 131. 
 operation for torn cervix, 245. 
 Endo-metritis, acute, 206. 
 treatment, 207. 
 chronic, 207. 
 
 cervical, 207. 
 
 treatment, 209. 
 corj)oreal, 215. 
 
 treatment, 217. 
 Endoscope, 35. 
 
 urethral, 527. 
 Enterocele, 122, 297. 
 Enucleation of fibroid tumours, 273. 
 Esthiomene, 46. 
 
 E.xamination, instruments for, 12. 
 curette, 35, 76. 
 sound, 22. 
 specula, 12. 
 per rectum, 11. 
 per vaginam, 4. 
 per vesicam, 11. 
 table for, 2. 
 Excision of uterus, 376. 
 Exercise, 98. 
 Extra- uterine fcetation, 156, 438, 471. 
 
 treatment of, 479. 
 Exudation of blood into the pelvis, 421, 432. 
 lymph into the pelvis, 421. 
 
 Facies ovariana, 415. 
 Ffecal accumulation in rectum, 7, 437. 
 Fallopian distension, 421, 438. 
 Fallopian tubes, congenital abnormalities of 
 the, 465. 
 constriction of the, 466. 
 inflammation of the, 466. 
 morbid growths of the, 465. 
 occlusion of the, 465. 
 undue patency of the, 466. 
 Falls, a cause of uterine displacement, 290. 
 Fat in the abdominal walls, differential diag- 
 nosis of, 432. 
 Fibrinous polypi, 279. 
 Fibro-cellular polypus of the uterus, 278. 
 Fibro-cystic fluid, 285. 
 
 tumours of the uterus, 284. 
 treatment, 285. 
 Fibroid polypi of the utenis, 280. 
 
 treatment, 282. 
 Fibroid tumours of the cervix, 277. 
 of the ovary. 390. 
 of the uterus, 256. 
 interstitial, 259. 
 
 submucous, 260. . 
 
 subserous, 260. 
 treatment, 268, 271. 
 differential diagnosis of, 392, 428. 
 Fissures of tlie anus, 553. 
 Fistula in ano, 554. 
 Fistuke, recto-vaginal, 132. 
 vaginal, 124, 126. 
 vesico-vaginal, 128. 
 treatment, 130. 
 Flexions of the uterus, 301. 
 anteflexion, 303. 
 
 treatment, 306. 
 retroflexion, 310. 
 treatment, 313. 
 
568 
 
 INDEX. 
 
 Fluid, fibro-cystic. 285, 430. 
 
 hydatid, 436. ' 
 
 menstrual, 158. 
 
 ovarian, 285, 401. 
 Fcetal movements, 560. 
 Follicular degeneration of the ovary, 394,395. 
 Food-supply, 97. 
 Forceps, Nelaton's, 450. 
 
 speculum, 14. 
 
 torsion, 448. 
 Foreign bodies in the rectum, 7. 
 
 in the vagina, 123. 
 Forward displacements of the uterus, 302. 
 
 Galvanic cauteries, 76. 
 
 ecraseur, 76. 
 Genital canal, atresia of the, 146. 
 
 occlusion of the, 146. 
 Glycerine, use of, in uterine affections, 212. 
 Gonorrhceal warts, 45. 
 Gooch's cannula, 283. 
 Gut sutures, 79. 
 
 Gyua3Cological operations, after-treatment, 
 92. 
 
 anesthetics dming, 93. 
 
 antiseptics in, 89. 
 
 constitutional preparation for, 89. 
 
 local preparation for, 89. 
 
 management of, 88. 
 
 use of catheter after, 93. 
 
 use of spray in, 91. 
 
 HEMATOCELE, 8, 156, 421, 432, 478, 498. 
 
 differential diagnosis of, 432, 478. 
 Hsematokolpos, 147. 
 
 unilateralis, 141. 
 Hasmatometra, 147, 151, 433. 
 
 lateral, 153. 
 
 differential diagnosis of, 433. 
 Hematosalpinx, 151, 470. 
 Hiemorrhoids, 554. 
 Heliotherapy, 105. 
 Hepatic cysts, 436. 
 Hermaphroditism, 144. 
 
 false, 145. 
 Hernia of the ovary, 136. 
 Herpes of the vulva, 37. 
 Higginson's syringe, 80. 
 Hodge's pessary, 123. 
 Holder for knives , 67. 
 
 for needles, 63. 
 
 for sponges, 67. 
 Hydatids, ditl'erential diagnosis of, 436. 
 Hydramnion, 433. 
 Hydrometra, 152. 
 Hydronephrosis, differential diagnosis of, 
 
 438. 
 Hydrosalpinx, 469. 
 Hygienic treatment, 96. 
 Hymen, abnormalities of the, 58. 
 
 forms of the, 58. 
 
 imperforate, 146. 
 Hypertrophy of the abdominal walls, 434. 
 
 of the cervix uteri, 232. 
 
 of the clitoris, 54. 
 
 of the labia majora, 54. 
 
 of the nymphte, 54. 
 Hysteria, 106. 
 Hystero-epilepsy, 106. 
 Hysteropihor, 325. 
 
 Hysteros didelphys, 139. 
 Hysterotome, 188, 199. 
 Hystero-trachelorraphy, 239. 
 
 Ice-Cap, 205. 
 
 Illuminating, methods of, 2. 
 Imperfect development of uterus, 161. 
 Imperforate hymen, 146. 
 Incision of cervix, 188. 
 Incontinence of urine, 539. 
 treatment of, 540. 
 India-rubber drainage tubes, 459. 
 Infantile uterus, 194. 
 
 treatment, 196. 
 Inflammation, of the ovary, 382. 
 treatment, 384, 385. 
 
 pelvic, 484. 
 
 of the uterus, 200. 
 acute, 203. 
 chronic, 207. 
 
 of the vagina, 115. 
 
 of the vulva, 47. 
 Injections, vaginal, 80. 
 Inspection of morbid discharges, 33. 
 Instruments — aspirators, 35, 73. 
 
 catheters, 93. 
 
 cui-ette, 35, 76. 
 
 ecraseurs, 73. 
 
 galvanic cauteries, 76. 
 
 intra-uterine cannula, 220. 
 
 ligatures, 78. 
 
 ointment sjTinge, 218. 
 
 scarificators, 77. 
 
 stem pessaries, 197. 
 
 sutures, 78. 
 
 tampon-extractor, 85. 
 
 tampon-introducer, 85. 
 
 thermal cauteries, 76. 
 
 uterine dilators, 187. 
 Interstitial fibroids of the uterus, 259. 
 Intra-uterine medication, 87. 
 
 stem pessaries, 197. 
 Introduction of hand into rectum, 11, 552. 
 Inversion of uterus, 170. 
 
 acute puerperal, 344. 
 treatment, 348. 
 
 chronic, 349. 
 
 treatment, 352. 
 
 non-puerperal, 349. 
 
 Kidney, floating, 437. 
 
 malignant tumoiu'S of, 437. 
 Keith's glass drainage-tubes, 458. 
 Knife-holder, 67. 
 Kyestein, 557. 
 
 Labia, abscess of the 50. 
 acne of the, 38. 
 adhesions of the, 57. 
 aphthae of the, 37. 
 boils of the, 40. 
 cancer of the, 45. 
 cysts of the, 51. 
 diphtheria of the, 37. 
 eczema of the, 38. 
 elephantiasis of the, 65. 
 herpes of the, 37. 
 hernia of the, 53. 
 hj'drocele of the, 53. 
 hypertrophy of the, 54. 
 
INDEX. 
 
 569 
 
 Labia, iutiauiiuatioii of the, 47. 
 
 licheu of the, 38. 
 
 lupus of the, 46. 
 
 noma of the, 47. 
 
 oedema of the, 40. 
 
 parasites of the, 39. 
 
 pruritus of thp, 40. 
 
 sypliilis of the, 44. 
 
 thrombus of the, 53. 
 
 tumours of the, 54. 
 
 varicocele of the, 52. 
 
 warts of the, 40. 
 Lacerations of the cervi.x; uteri, 170, 238. 
 
 treatment, 242. 
 Lamps, electric, 2. 
 
 reflecting, 2. 
 Lateral displacements of the uterus, 319. 
 Lichen of the vulva, 38. 
 Lipoma of the labia, 54. 
 Liver, cysts of the, 436. 
 
 malignant tumours of the, 437. 
 
 Malformations of the genital tract, con- 
 genital, 135. 
 
 of the uterine appendages, 135. 
 
 of the viterus, 137. 
 
 of the vagina, 141. 
 
 of the vulva, 143. 
 Malignant ovarian tumours of cystic char- 
 acter, 402. 
 Manganese in anajmia, 163. 
 Manual examination, 6. 
 
 of the bladder, 11. 
 
 information obtained by, 6. 
 
 by palliation, 4. 
 
 of the rectum, 11. 
 Medicated pessaries, 86. 
 Membranous dysmeuorrhoea, 179. 
 Menopause, 192. 
 Menorrhagia, 160, 169. 
 
 treatment of, 171. 
 Menstrual fluid, amount of, 158. 
 Menstrual periodicity, influence of, 96. 
 Menstruation, 156. 
 
 absent, 160. 
 
 arrested, 160, 162. 
 
 disorders of, 100. 
 
 excessive, 160, 169. 
 
 iri'egular, 160. 
 
 painful, 160, 174. 
 
 scanty, 160, 168. 
 
 vicarious, 160, 191. 
 Mercury, internal use of, in septic poisoning, 
 
 205. 
 Metal sutures, 78. 
 Metritis, 200. 
 
 acute, 203. 
 
 treatment, 204. 
 
 chronic, 207. 
 Metrorrhagia, 160, 169. 
 treatment, 171. 
 Mobile uterus, 318. 
 Molar pregnancy, 433. 
 Morbid discharges, inspection of, 33. 
 
 uterine, 33. 
 
 vaginal, 33. 
 Mucous polypi of the uterus, 278. 
 
 treatment of, 279. 
 Muscular eftbrts, a cause of uterine displace- 
 ment, 289. 
 
 Mushroom-like sin'outs from the cervix, 
 358, 359. 
 
 Needle-holders, 63. 
 
 Nervous supply of ovarian tumours, 406. 
 
 Neuralgia of the ovary, 381. 
 
 treatment of, 381. 
 Neuralgic dysmeuorrhoea, 176. 
 Neurasthenia, 106. 
 
 treatment of, 110. 
 Nodules in the parenchyma of the cervix, 
 
 358, 360. 
 Noma of the vulva, 47. 
 Nymphaj, hypertrophy of the, 54. 
 
 Obstructive dysmenorrhcea, 178. 
 Occlusion of the uterus, 150. 
 of the vagina, 133, 141. 
 ffidema of the abdominal walls, 434. 
 
 of the vulva, 40. 
 Ointment syringe, 218. 
 Omentum, solid tumours of the, 437. 
 Oophorectomy, 136, 190, 272, 461, 463. 
 Operations, management of, 88. 
 for fibroid tumours, 272. 
 for fistulffi, 130. 
 
 for hypertrophy of the cervix, 232. 
 for laceration of the cervix uteri, 245. 
 for prolapsus uteri, 295. 
 for removal of ovarian tumours, 445. 
 for ruptured perineum, 62, 67. 
 Ovarian apoplexy, 388. 
 cystic tumours, 394. 
 dysmenorrhcea, 181. 
 fluid, 285, 401, 427. 
 follicular degeneration, 394, 395. 
 Ovarian tumours, 389. 
 accidents to, 410. 
 complications of, 410. 
 
 adhesions, 410. 
 
 double tumour, 410. 
 
 gangrene, 412. 
 
 impaction in the pelvis, 411. 
 
 intra-cystic hemorrhage, 412. 
 
 intra-cystic inflammation, 412. 
 
 kidney disease, 413. 
 
 rupture, 412. 
 
 separation of tumour, 412. 
 
 twisting of pedicle, 411. 
 consistency of, 405. 
 contents of, 406. 
 
 chemical charactei-s, 407. 
 
 microscopical ai>pearances, 408. 
 
 physical characters, 407. 
 covering of, 404. 
 cystic, 389. 
 
 diflerential diagnosis of, 392, 419-439. 
 exploration of, 440. 
 nervous supply of, 406. 
 l.cdicle of, 406, 
 physical signs of, 415. 
 ]irogrcss of, 409. 
 size of, 404. 
 .solid, 389, 390, 392. 
 
 treatment, 393. 
 symptomatology of, 413. 
 treatment of, by tlrainage, 445. 
 
 by removal, 445. 
 
 liy tapping, 441. 
 vascular supi)ly, 406. 
 
570 
 
 INDEX. 
 
 Ovariotomy, 393, 445. 
 Ovary, abscess of the, 387. 
 
 adolescent, 155. 
 
 adult, 155. 
 
 arrested development of the, 136. 
 
 dermoid cysts of the, 394, 396. 
 
 follicular degeneration of the, 394, 395. 
 
 hernia of the, 136. 
 
 inflammation of the, 3S2. 
 treatment, 384. 
 
 malignant tumours of cystic charac- 
 ter, of the, 422. 
 
 multUocular cysts of the, 395, 401. 
 
 neuralgia of the, 381 . 
 
 prolapse of the, 136, 380, 489. 
 
 removal of the, 272. 
 
 supplementary, 136. 
 
 unilocular cysts of the, 395. 
 Ovulation, 154. 
 
 disappointed, 156. 
 
 Pad and perineal band for prolapsus uteri, 
 
 322. 
 Painftil sitting, 59. 
 Pancreatic cysts, 436. 
 Papilloma, or cauliflower excrescence of the 
 
 cervix, 389. 
 Paquelin's cautery, 77. 
 Parametritis, 493. 
 
 treatment of, 497. 
 Parasites of the vulva, 39. 
 Parenchymatous metritis, acute corporeal, 
 203. 
 treatment of, 204. 
 chronic cervical, 227. 
 
 treatment of, 228. 
 chronic corporeal, 221. 
 treatment of, 228. 
 Parovarian cysts, 423. 
 Pelvic abscess, 432, 508. 
 treatment, 509. 
 cellulitis, 493. 
 hsematocele, 498. 
 
 intracellular, 503. 
 iutra-peritoneal, 503. 
 treatment, 506. 
 imflammation, 484. 
 peritonitis, 484. 
 acute, 487. 
 chronic, 488. 
 treatment of, 491. 
 Pelvis, abscess of the, 432. 
 
 differential diagnosis of, 432. 
 exudation of blood into the, 421. 
 exudation of lymph into the, 421, 432. 
 peritoneal cancer of the, 433. 
 differential diagnosis of, 538. 
 Perimetritis, 484. 
 Perineorraphy, primary, 62. 
 
 secondary, 67- 
 Perineum, rupture of the, 60. 
 Peri-ovaritis, 387. 
 
 Peritoneal cysts, differential diagnosis of, 436. 
 Peritoneum, solid tumours of the, 437. 
 Peri-uterine cellulitis, 493. 
 
 jDeritonitis, 484. 
 Pessaries, Albert Smith's, 341. 
 for anteflexion, 331. 
 Barnes's stem, 325, 333. 
 Chambers's stem, 333. 
 
 Pessaries, Clay's, 327. 
 
 Cutter's, 326, 332, 343. 
 
 Duffin's, 325. 
 
 elastic ball, 325. 
 
 elastic ring, 324. 
 
 Fowler's anteversion, 332, 333. 
 
 Galabin's, 330, 332, 333. 
 
 Greenhalgh's, 330, 333, 340. 
 
 Hewitt's, 329, 332, 334. 
 
 Hodge, 123, 225, 329, 338. 
 
 hysterophor, 325. 
 
 intra-uterine, 190. 
 
 Meadows's glass stem, 333. 
 
 medicated, 86. 
 
 open lever, 341. 
 
 Playfair's, 330, 331. 
 
 porous, 324. 
 
 for prolapse of the uterus, 322. 
 
 Simpson's stem, 333. 
 
 Skene's, for cystocele, 330, 331. 
 
 Thomas's, 330, 332, 333, 340. 
 
 use and abuse of, 320. 
 
 watch-spring ring, 225. 
 
 Whitehead's, 326. 
 
 Wynn Williams's, 334. 
 
 Zwanck's, 328. 
 Phantom tumours, differential diagnosis of 
 
 435. 
 Physical signs of ovarian tumours, 415. 
 Piston trocar, 456. 
 Placental polypi, 279. 
 Playfair's probe, 14. 
 Plugs, uterine, 28. 
 
 vaginal, 83. 
 Pouch of Douglas, ascitic fluid in the, 8. 
 
 blood in the, 8. 
 
 body of the uterus in the, 7. 
 
 cancer in the, 8. 
 
 extra-uterine foetation in the, 8. 
 
 fibro-myomata in the, 8. 
 
 hernia in the, 7. 
 
 inflammatory products in the, 7. 
 
 ovarian tumours in the, 8. 
 
 tubercular deposits in the, 8. 
 Polypi, a cause of displacement, 290. 
 
 placental or fibrinous, 279. 
 
 treatment, 279. 
 
 of the uterus, channelled, 278. 
 fibro-cellular, 278. 
 hollow, 278. 
 mucous, 278. 
 Polyptrite, Aveling's, 283. 
 Pregnancy, appearance of the abdomen in, 
 558. 
 
 auscultatory signs of, 562. 
 
 ballottement in, 562. 
 
 a cause of arrested menstruation, 166. 
 
 differential diagnosis of, 430, 556. 
 
 extra-uterine, 488. 
 
 fcetal movements in, 560. 
 
 mammary appearances of, 558. 
 
 pressure symptoms of, 557. 
 
 prevention of, 524. 
 
 symptoms and signs of, 556. 
 
 table of signs of, 564. 
 
 uterine changes in, 560. 
 Pressure symptoms of pregnancy, 557. 
 Prevention of pregnancy, 524. 
 Priestley's uterine dilator, 186. 
 Probe, Playfair's, 14. 
 
INDEX. 
 
 571 
 
 Progress of ovarian tumours, 409. 
 Prolapse of the ovary, 136, 380, 489. 
 treatment, 380. 
 of the uterus, 291. 
 
 treatment of, 293, 322. 
 of the vagina, 134, 297. 
 
 a cause of uterine displacement, 
 290. 
 Pruritus ani, 554. 
 vulvae, 40. 
 
 treatment, 41. 
 Pseudo-prolapse of the uterus, 298. 
 
 treatment of, 299. 
 Physometra, 152, 434. 
 Pyosalpinx, 468. 
 
 treatment, 468. 
 
 Rectocele, 122, 297. 
 Recto-vaginal fistula, 132. 
 Rectum, distension of the, a cause of uterine 
 displacement, 289. 
 examination of the, 11, 551. 
 examination through the, 552. 
 fsecal accumirlation in the, 7. 
 fistula of the, 553. 
 foreign bodies in the, 7. 
 haamorrhoids in the, 7. 
 malignant growths in the, 7. 
 polypus in the, 7. 
 prolapse of the, 554. 
 speculum for the, 551. 
 Relaxed vagina, a cause of uterine displace- 
 ment, 288. 
 Removal of the ovaries by abdominal in- 
 cision, 461. 
 through the vagina, 463. 
 Removal of uterine appendages, 272. 
 Renal cysts, diff'erential diagnosis of, 435. 
 Repressor, Sims's, 19. 
 
 vagina], 19. 
 Retention of urine, 540. 
 
 treatment of, 540. 
 Retroriexion of the uterus, 310. 
 
 treatment of, 313, 314, 338. 
 Retroversion of the uterus, 313. 
 treatment of, 314, 338. 
 Ruptured perineum, 60. 
 
 a cause of uterine displacement. 288. 
 operation for cure ol, 62, 67. 
 
 Salicine as an antipyretic, 205. 
 Salpingitis, 466, 467. 
 Sarcoma of the ovary, 391. 
 
 of the uterus, 260. 
 Scanty menstruation, 160, 168. 
 Scarification of tlie cervix uteri, 78, 184. 
 Scarificators, 77, 211. 
 Scissors, Bozemann's, 68. 
 
 Emmet's, 131. 
 
 Kuchenmeister's, 189. 
 
 for vesico-vaginal fistula, 129. 
 Silk sut\ires, 79. 
 Silver wire, twister for, 79. 
 Sims's duck-bill speculum, 18. 
 
 sigmoid catheter, 93. 
 
 uterine dilator, 187. 
 Size of ovarian tumours, 404. 
 Skene-Goodman catheter, 93. 
 Soft papillomatous sprouts from the cervix, 
 358. 
 
 Solid growths of the abdominal waUs, 435. 
 ovarian tumours, 389. 
 tumours of the omentum, 437. 
 of the peritoneal glands, 437. 
 of the i^eritoneum, 437. 
 Sounds, 22. 
 
 danger and use of, 24. 
 facts ascertained by, 25. 
 method of use, 23. 
 uterine, 22. 
 vesical, 536. 
 Spamenorrhffia, 168. 
 Spatulai, cojDper, 451. 
 
 Specrda, duck-bill and vaginal repressor, 20. 
 Emmet's self-retaining, 21 . 
 Neugebauer's, 21. 
 Sims's duck-bill, 18. 
 tubular, 12, 21. 
 valvular, 15. 
 
 Barnes's, 16. 
 bi-valve, 15. 
 Cusco's, 16. 
 Knott's, 16. 
 Meadows's, 16. 
 Reid's, 16. 
 Scanzoni's, 16. 
 Spina bifida, 432. 
 Spinal abscess, 439. 
 Spleen, malignant tumours of, 437. 
 Splenic cysts, 436. 
 Sponge-holders, 67. 
 Spray, uses of, in operations, 91, 454. 
 Stem pessaries, Barnes's, 197. 
 Chambers's, 333. 
 Greenhalgh's, 333. 
 Hewitt's, 334. 
 Meadows's, 333. 
 Simpson's, 197, 333. 
 Wynn Williams's, 334. 
 Stenosis of cervix uteri, 197- 
 
 treatment, 199. 
 Sterility, 517. 
 Stimulants, 97. 
 Stretching of uterine ligaments a cause of 
 
 uterine displacement, 288. 
 Subcutaneous syringe, 73. 
 Sub-involution of the uterus, 170. 
 Sub-serous fibroids of the uterus, 260. 
 Sudden falls a cause of uterine displace- 
 ment, 290. 
 Superficial afi'ections of mucous membrane, 
 37. 
 of skin, 37. 
 Superficial epithelionuitous ulceration of the 
 
 cervix, 358. 
 Super-involution of the uterus after preg- 
 nancy, 164. 
 Suppositories, 86. 
 Supra-vaginalhy pertroiihy of the cervix, 
 
 299. 
 Sutures, 78 79. 
 
 Swelling of the anterior lip of the os iu 
 antefiexion, 305. 
 in retrofiexion, 311. 
 Symiiathetic symptoms of pregnancy, 557. 
 .Symptomatology of ovarian tumours, 413. 
 Syphilis, 44. 
 
 Syringe, Higginson's, 80. 
 for ointments, 218. 
 subcutaneous, 73. 
 
572 
 
 INDEX. 
 
 Tait's uterine dilator, 187. 
 Tampons, 83. 
 
 extractor, 85. 
 
 introducer, 85. 
 . Tenacula, uterine, 19. 
 Tents, 28. 
 
 introducer for, 29. 
 
 use of, 171, 184, 211. 
 Thermal cauteries, 76. 
 Thornton's ice-cap, 205. 
 Thrombus of labia, 53. 
 Tight clothing a cause of uterine displace- 
 ment, 289. 
 Torsion forceps, 448. 
 Trocar, Wells's, 456. 
 Trocar, piston, 456. 
 
 Tubercular deposit in the vaginal walls, 122. 
 Tubular sj^ieculum, 12. 
 
 method of introduction, 13. 
 Tumours of the broad ligament, 421. 
 
 of the labia, 54. 
 fatty, 54. 
 fibrous, 54. 
 
 of the ovary, 389. 
 
 phantom, 435. 
 
 solid or malignant, of kidney, 437. 
 of liver, 437. 
 of spleen, 437. 
 
 of the uterus, 170, 256, 260, 280, 284. 
 
 of the vagina, 120, 122. 
 Twister for silver wire, 79. 
 Tympanites, 437. 
 
 Ulceeatiow of the cervix uteri, 231, 291. 
 
 of the vagina, 124. 
 Unilateral h^matokolpos, 141. 
 Unilocular ovarian cysts, 400. 
 Ureter, distended, differential diagnosis of, 
 
 438. 
 Ureters, 533. 
 Urethra, 526. 
 
 abnormal growths in the, 531. 
 
 cancer of the, 532. 
 
 cysts of the, 532. 
 
 dilatation of the, 529. 
 artificial, 536. 
 treatment of, 530. 
 
 examination of the, 527. 
 
 fistula of the, 530. 
 
 foreign bodies in the, 531. 
 
 functional disorders of the, 528. 
 
 laceration of the, 530. 
 
 malformations of the, 528. 
 
 polypi of the, 532. 
 
 stricture of the, 529. 
 
 varix of the, 532. 
 
 vascular growths of the, 532. 
 Urethral caruncle, 55. 
 
 treatment of, 56. 
 
 dilators, 536. 
 
 endosco^De, 527. 
 Urethritis, 531. 
 Urine, incontinence of, 539. 
 
 retention of, 540. 
 Uterine abscess, 204. 
 
 appendages, malformation of the, 135. 
 
 atrophy, 199. 
 
 dilators, 187. 
 
 discharges, 33. 
 
 displacements, 285. 
 
 Uterine fibroid polypus, 259, 260, 278. 
 medication, 87. 
 pessaries, 197. 
 scissors, 189. 
 sound, 22. 
 tenacula, 19. 
 vulsellum, 20. 
 Uterus, abscess of the, 204. 
 absence of the, 137. 
 anteflexion of the, 303. 
 
 treatment, 306, 331. 
 anteversion of the, 307. 
 
 treatment, 309, 337. 
 atrophy of the, 199. 
 backward displacements of the, 302, 309. 
 bicornis, 140. 
 
 cancer of the body of the, 371 , 433. 
 cancer of the cervix of the, 357. 
 dermoid cysts of the, 284. 
 discharges from the, 33. 
 displacements of the, 170, 286, 289, 802, 
 
 303, 307, 309, 318. 
 duplex, 139. 
 elevation of the, 300. 
 excision of the, 275, 352, 376. 
 fibro-cystic tumours of the, 284. 
 fibro-myomata or fibroid tumours of the, 
 
 170, 256. 
 flexions of the, 300. 
 hypertrophy of the, 250. 
 
 treatment of, 253. 
 imperfect develoj^ment of the, 161. 
 infantile, 140, 194. 
 inflammation of the, 200. 
 
 acute, 20-3. 
 
 chronic, 207. 
 inversion of the, 170, 344, 349. 
 laceration of the cervix of the, 170. 
 malignant disease of the, 170. 
 mobile, 318. 
 occlusion of the, 150. 
 polypi of the, 170, 278. 
 
 channeled, 278. 
 
 fibrinous or placental, 279. 
 
 fibro-cellular, 278. 
 
 fibroid, 260, 280. 
 
 hollow, 278. 
 
 mucous, 278. 
 prolapse of the, 291. 
 
 treatment, 293. 
 pseudo-prolapse of the, 298. 
 
 treatment, 299. 
 retained products in the, 170. 
 retroflexion of the, 310. 
 
 treatment, 313, 314, 338. 
 retroversion of the, 313. 
 
 treatment, 314, 338. 
 sarcoma of the, 374. 
 septus, 140. 
 
 subinvolution of the, 170. 
 unicornis, 138. 
 versions of the, 300. 
 
 Vagina, abnormalities of the, 141. 
 
 abnormal substances anterior to the, 8. 
 
 at the side of the, 9. 
 
 posterior to the, 7. 
 absence of the, 142. 
 acute inflammation of the, 115. 
 cancer of the, 120. 
 
INDEX. 
 
 573 
 
 Vagina, chronic inflammation of the, 118. 
 
 cysts of the, 121. 
 
 dilators for the, 52, 117. 
 
 diphtheria of the, 117. 
 
 discharges from the, 19, 33. 
 
 diseases of the, 114. 
 
 donche for the, 81. 
 
 duplex, 141. 
 
 examination of the, 4. 
 
 fistula? of the, 124. 
 
 foreign bodies in the, 123. 
 
 injections for the, 84. 
 
 occlusion of the, 133, 141. 
 
 plugs for the, 83. 
 
 prolapse of the, 134, 297. 
 
 repressor for the, 19. 
 
 septa, 141. 
 
 specula for the, 12. 
 
 suppositories for the, 86. 
 
 tubercule of the, 122. 
 
 tuQiours of the, 120. 
 
 ulcerations of the, 124. 
 
 unilateralis, 141. 
 
 wounds of the, 123. 
 Vaginal catarrh, 118. 
 
 examination, 4. 
 
 positions for, 4. 
 
 leucorrhcea, 118. 
 
 " toucher," 4. 
 
 points ascertainable by, 6. 
 Vaginitis, acute, 115. 
 
 chronic, 118. 
 
 croupous, 117. 
 
 diphtheritic, 117. 
 
 emphysematosa, 117. 
 
 gangrenous, 116. 
 
 gonorrhceal, 115. 
 
 granular, 116. 
 
 treatment of, 117, 119. 
 Vaginismus, 512, 516. 
 Varicocele of the labia, 52. 
 Vascular caruncle of the urethra, 55, 532. 
 treatment of, 56. 
 
 supply of ovarian tumours, 406. 
 Versions of the uterus, 300, 301. 
 
 anteversion, 307. 
 
 Versions of the uterus — 
 
 anteversion, treatment, 309, 337. 
 
 retroversion, 313. 
 treatment, 314. 
 Vesical sound, 536. 
 Vesico-vaginal fistula, 128. 
 
 scissors for, 129. 
 
 treatment of, 130. 
 Vicarious menstruation, 160. 
 Vulsellum, uterine, 20. 
 Vulva, abscess of the, 50. 
 
 absent, 143. 
 
 acne of the, 38. 
 
 acute inflammation of the, 47. 
 
 aphthae of the. 37. 
 
 boils of the, 40. 
 
 cancer of the, 45. 
 
 chancre of the, 44. 
 
 condyloma of the, 44. 
 
 congenital malformations of the, 143. 
 
 cysts of the, 51. 
 
 diphtheria of the, 37. 
 
 eczema of the, 38. 
 
 fissures of the, 57. 
 
 herpes of the, 37. 
 
 inflammation of the, 47. 
 
 lichen of the, 38. 
 
 lupus of the, 46. 
 
 noma of the, 47. 
 
 oedema of the, 40. 
 
 parasites of the, 39. 
 
 pruritus of the, 40. 
 
 thrombus of the, 53. 
 
 varicocele of the, 52. 
 
 vascular caruncle of the, 56. 
 
 warts of the, 40, 45. 
 Vulvitis, 47. 
 
 follicular, 49. 
 
 treatment of, 49. 
 
 Warts of the vulva, 40, 45. 
 Weir-Mitchell treatment, 111. 
 Wells's trocar, 456. 
 
 clamp, 456. 
 Wire ecraseur, 73. 
 Wounds of the vagina, 123. 
 
LIST OF AUTHORS REFERRED TO 
 
 Alexander, 297, 317. 
 Allingliam, 551, 554. 
 Atlee, 419, 424. 
 Attliill, 220, 270. 
 Aveling, 283, 356. 
 
 Baker Brown. 66, 70, 457. 
 
 Bandl, 472. 
 
 Bantock, 71, 79, 89, 275, 324, 
 
 441, 443. 
 Barber, F., 200. 
 Barbour, 200, 237, 535, 551. 
 Barnes, Fancourt, 157. 
 Barnes, R., 5, 128, 157, 311, 
 
 444, 512, 515, 542. 
 Barwell, 74. 
 Battey, 190, 200, 222, 272, 
 
 463. 
 Bennett, Henry, 239. 
 Bernutz, 464, 483. 
 Bigelow, 277. 
 Biih-oth, 275. 
 Bischoff, 154. 
 BockendaU, 355. 
 Boulton, 368. 
 Bozemann, 125, 530. 
 Bums, 517. 
 
 Cai^eva, 296. 
 
 Chadwick, 1. 
 
 Charcot, 106. 
 
 Chippendale, 295. 
 
 Clarke, 100. 
 
 CoblDold, 436. 
 
 Collier, 534. 
 
 Cook, 28. 
 
 Coste, 156. 
 
 Courty, 359. 
 
 Croora, 535. 
 
 Crosse 344 
 
 Cullingworth, 66, 139, 181, 
 
 389. 
 Cutter, 271. 
 
 De Sinety, 395, 396. 
 
 Dewees, 182. 
 
 Doran, 389, 390, 397, 401, 
 405, 422. 
 
 Drysdale, 408. 
 
 Duncan, Matthews, 48, 59, 
 117, 178, 181, 185, 262, 
 320, 345, 359, 396, 466, 
 483, 485, 498, 514, 518, 
 523. 
 
 Duncan, William, 359. 
 
 Ems, 118, 250. 
 
 Eisner, 389, 396. 
 I Emmet, 21, 71, 80, 81, 89, 
 100, 125, 127, 129, 224, 
 233, 238, 271, 290, 295, 
 329, 330, 336, 355, 360, 
 377, 549, 550. 
 
 Farre, 156, 388, 522. 
 Fischer, 544. 
 Fleisch, 398. 
 Fowlis, 154, 391, 433. 
 Fox Wilson, 389, 396, 401 
 Freund, 376. 
 Fritsch, 237. 
 
 Galabin, 16, 230, 385. 
 G-amgee, A., 178. 
 Garrigues, 285, 389, 407, 
 
 408, 409, 427, 432, 534. 
 Godson, 185. 
 Goodell, 21, 30, 71, 100, 109, 
 
 133, 236, 245, 323, 525. 
 Goupil, 464, 483. 
 Gowers, 107. 
 
 Haddon, 181. 
 Hall, MarshaU, 295. 
 Harris, 389. 
 
 Hart, 114, 237, 535, 551. 
 HavUand, 360. 
 Hegar, 236, 272, 275. 
 Hermann, 47, 176, 287, 311. 
 Hewitt, 97, 176, 287, 289. 
 Hicks, Braxton, 559. 
 Hildebrandt, 270. 
 HoU, 534. 
 Huguier, 22. 
 Hutchinson, 245. 
 
 Jackson, 378. 
 Jacobi, Mary, 157. 
 Jeaks, 69. 
 
 Jenner, Sir W., 436. 
 Jones, Handfield, 157. 
 Jones, Wharton, 217. 
 
 Keith, 89, 275, 433, 446, 
 
 457, 458. 
 Kiwisch, 22. 
 Klein, 389. 
 Kleinwachter, 258. 
 Klob, 136, 257. 
 Kundrat, 157. 
 Kussmaul, 143, 159. 
 
 Leech, 206. 
 Le Fort, 296. 
 
 Leishman, 305. 
 Leopold, 157. 
 
 Lister, Sir J., 79, 89, 90, 
 91. 
 
 M'DowELL, E. . 446. 
 
 Marckwald, 236. 
 
 Martin, 245. 
 
 Mills. 106. 
 
 Mitchell, Weir, 97, 105, 110 
 
 IIL 
 Moricke, 77, 157. 
 Munde, 5, 32, 85, 247, 313 
 
 494, 519. 
 
 noeggerath, 119, 354, 490. 
 
 Oerum, 256. 
 
 Paget, Sir James, 46, 397 
 
 512. 
 PaUen, 85, 234, 241, 245. 
 Parry, 471, 482. 
 Pean, 275. 
 Peaslee, 136, 419. 
 Piorri, 436. 
 Playfair, 112. 
 Pouchet, 156. 
 Priestly, John, 368. 
 Priestley, W. 0., 384, 483. 
 
 Rae, 181. 
 Eanney, 115. 
 Recamier, 76, 214. 
 Ritchie, 396. 
 Roberts, D. L. , 213. 
 Robertson, 510. 
 Rokitansky, 136, 396. 
 Ross, 113. 
 
 ScANZONi, 16, 59, 358, 360. 
 
 Schrceder,"38, 71, 117, 143 
 153, 194, 260, 275. 284, 
 295, 308, 315, 3-36, 364. 
 
 Schultze, 304, 334, 335. 
 
 Simon, 11, 71, 128, 245, 536, 
 550. 
 
 Simpson, A. R., 173, 236, 
 270, 349, 354, 37L 
 
 Simpson, Sir J. Y., 22, 59, 
 136, 144, 188, 239, 279, 
 445, 472, 483, 514, 517. 
 
 Sims, 17, 18, 74, 78, 117, 124 
 127, 128, 130, 186, 236, 
 295, 309, 458, 512, 515 
 519, 547. 
 
 Sinclair, 248. 
 
LIST OF AUTHOKS. 
 
 57( 
 
 Skene, 526, 529, 530, 535, 
 
 541, 542. 
 Smith, Tyler, 156. 
 Spallanzani, 519. 
 Si^iegelberg, 364. 
 Stephenson, 157. 
 Stocks, 553. 
 
 Tait, 37, 71, 89, 100, 136, 137, 
 157, 158, 185, 253, 272, 
 275, 389, 395, 396, 423, 
 441, 458, 461, 464, 465, 
 
 470, 476, 478, 481, 482, 
 
 522, 547, 550. 
 Tnliat'eiTo, 85. 
 Thomas, T. G., 97, 100, 157, 
 
 221, 354, 364, 376, 476, 
 
 480. 
 Thompson, Sir H., 543. 
 Thornton, Knowsley, 89, 275, 
 
 433. 
 Tilt, 9, 96. 
 
 ViRCHDW, 103, 257, 498, 514. 
 
 Watts, 178. 
 
 West, 345. 
 
 Williams, John, lf.7, 174, 
 
 192, 358. 
 Winckel, 536. 
 Windsor, 367. 
 Wells, Sir Speucer, 89, 93, 
 
 275, 389, 395, 415, 419, 
 
 443, 444, 446, 453, 455, 
 
 547. 
 Wliitehea.l, W. , 128. 
 
 I'llINTKH liY NEILL AKD COMPANY, EDINBUIIGH. 
 
By Professors LANDQIS and STIRLING. 
 
 Ill Two A'ols., Royal 8vo, Handsome Cloth. 
 
 HUMAN PHYSIOLOGY 
 
 (A TEXT-BOOK OF): including Histology and Microscopical 
 Anatomy ; with Special Reference to Practical Medicine. 
 
 By De L. LA^'DOIS or aREiFS^'ALD. 
 
 Translated from the Fourth German Edition, Avith Additions. 
 By W^L STIRLIJS'G, M.D., Sc.D., 
 
 KEG. PEOF. IXST. OF MED. , TJXITEKSITT OF ABEEDEEX. 
 
 Witli very Numerous Illustrations. 
 
 GENERAL CONTENTS. 
 
 Vol. I. — Phj-siology of the Blood, Circulation, Eespiration, Digestion, Absorption, 
 Animal Heat, Metabolic Phenomena of the Body. Price ISs.l 
 
 Vol. II. — Secretion of Urine; Structure of the Skin; Physiology of the Motor 
 Apparatus ; the Voice and Speech ; General Physiology" of the Nerres ; Electro- 
 Physiolog}'; the Brain ; Organs of Vision ; Hearing, Smell. Taste, Touch; Physiolog}- 
 of Development. 
 
 *^* Since its Erst appearance in 1880, Prof. Laxdois' Text-Book of 
 Physiology has passed through, four large editions. In the English version 
 win he found man v Annotations hy the Editor, calculated to render the work 
 still more valuable to English Practitioners and Students, while, with the 
 same object in view, the numher of Illustrations has been greatly increased. 
 
 " The characteristic -which has thus commended the work will be found mainly to 
 lie in its eminent 'pradicolity. Prof. Landois never loses sight of the fact that the 
 Student of to-day is the practising Physician of to-morrow. Thus, to every Section 
 is appended — after a full description of the normal processes — a short resume of the 
 pathological variations, the object of this being to direct the attention of the Student 
 from the outset to the field of his future practice, and to show him to what extent 
 pathological processes are a disturbance of the normal activities. 
 
 "In the same way, the work offers to the bus}- Physician in practice a ready means 
 of refreshing his memoiy on the theoretical aspects of Medicine. He can pass haxk- 
 vMTcls from the examination of pathological phenomena to the normal processes, and. 
 in the studj' of these, find new indications and new lights for the appreciation and 
 treatment of the cases under consideration. 
 
 ' ' "With this object in view, all the methods of i>;vestigatiox which may with 
 advantage be used by the Practitioner are carefully and fully described." — Extract 
 from Editor fi Preface. 
 
 OPINIONS OF THE PRESS. 
 
 •'So great are the advantages offered by Prof. lA^■I)0IS' Text-Book from the exhaustive and 
 EiiiNEXTLY PEACTICAL manner in which the subject is treated, that, notiWthstauding it is one of 
 the largest works on Physiology, it has yet passed through four large editions in the same number 
 
 of years. Dr Stirlixg's annotations have materially added to the value of the work 
 
 Admirably adapted for the practitioner With this Text-Book at his command, NO 
 
 Student could fail ix his exajiixatiox." — Lancet. 
 
 "One of the most peactical works on Physiology ever ^mtten, forming a 'bridge' between 
 Physiology and Practical Medicine Its chief merits are its completeness and con- 
 ciseness The additions by the Editor are able and judicious excellently 
 
 clear, attractive, and succinct." — British Medical Journal. 
 
 " One of the best and most practical treatises on Physiology we have ever seen 
 
 Will lielp both Students and Practitioners towards a rational system of treatment Dr 
 
 .Stirling has made large and valuable additions to the original."— Dr Lauder Bruntox in Brain. 
 
 CHARLES GlHFiTX & CO., Exeteii Street, Stkajjd, London. 
 
EROSIONS, GRANULATIONS & FISSURES OF THE CERVIX UTERI 
 after Munde,CrooiiL,8c Savage. 
 
 Watson, 3 ro ' U>aafia,s UJi. 0<- Charles St JJirm. '' 
 
 JWWatSon. dAetllik.. 
 
COLUMBIA UNIVERSITY LIBRARIES (hsi.stxi 
 
 RG 103 .T5 1885 C.I 
 
 ' ''. ■ '■' PS of 
 
 2002355760