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A 
 
 SYSTEM UF GYNECOLOrxY. 
 
 BY AMERICAN AUTHORS. 
 
 EDITED BY 
 
 MATTHEW D. MAXX, A.M., M. D., 
 
 Professor of Obstetrics and Gynecology in the Medical Departjient of 
 THE University of Buffalo, X. Y. 
 
 VOLUME I. 
 
 ILLUSTRATED WITH THREE COLORED PLATES AND TWO HUNDRED 
 AND ONE ENGRAVINGS ON WOOD. 
 
 PHILADELPHIA : 
 
 LEA BROTHEPvJS & CO 
 
Entered nccording to Act of Congress, in the year 1887, by 
 
 LEA BROTHERS & CO., 
 
 in the Office ot the Librarian of Congress at Washington. All rights reserved. 
 
 WnsTcoTT & Thomson, William J. Dornan, 
 
 Slereoiypers and Electrotypers, Philada. Printer, Philada. 
 
PREFACE. 
 
 Ix all departments of science the largest results are to be obtained 
 l>y division of labor and combination of effort. In Medicine this is 
 especially true, and the favor with which the profession has greeted 
 recent systems of Practice and Surgery, concentrating the experience 
 of leading men on each subject, shows that such a plan of composition 
 is more satisfactory than the effort of a single author to treat exhaust- 
 ively all the details of an extensive branch of practice. By a careful 
 preliminary survey of the ground, and the assignment of each sub- 
 division to a practitioner who has made it the special subject of study, 
 omissions are avoided, every article is authoritative, and each is 
 treated with the fuhiess to which its importance entitles it. 
 
 Gynecology has now grown to an extent which requires for its 
 thorough treatment this co-operation of representative men ; and it is 
 eminently fitting that the science which is in so great a degree of 
 American origin should be thus presented by American practitioners. 
 The labors of the Editor have been principally confined to the selec- 
 tion of contributors and the assignment of subjects, and it is with no 
 little pride that he refers to the list of eminent gentlemen whose co- 
 operation has secured in advance the position which the Avork must 
 assume as the leading authority- on its subject. The common effort 
 has been to render each article not only full and complete, but thor- 
 oughly practical, special regard being paid to the needs of the general 
 practitioner as well as to those of the specialist. The responsibilit}-^ 
 for the views presented rests wholly "^ith the contributors ; and if 
 there are occasionally found more or less overlapping and some differ- 
 ences of opinion on certain disputed points, this carries with it the cor- 
 
iv PREFACE. 
 
 relative advantage of enabling readers to compare different views and 
 to value them at their worth. 
 
 In conclusion, the Editor would express his thanks to the contribu- 
 tors for the courtesy and zeal which have characterized their co-opera- 
 tion, and he would further acknowledge his indebtedness to his prede- 
 cessors, Drs. Charles S. Ward and Henry D. Nicoll, not only for their 
 preliminary labors, but for the good-will which they have so generously 
 manifested. 
 
CONTRIBUTORS TO VOLUME I. 
 
 HENRY C. COE, A. I\I., M. D., New York City, 
 
 Pathologist to the Woman's Hospital in the State of New York; Visiting^ Ob- 
 sti'triciaii to the lufant Asylum; Instructor in Gynecology at the New York 
 Polvcliiiic. 
 
 EMILIUS C. DUDLEY, A. B., M. D., Chicago, 
 
 Professor of Gynecology in the Chicago Medical College ; Gynecologist to Mercy 
 Hospital and to Cook County Hospital, and to St. Luke's Hospital. 
 
 HENRY J. GARRIGUES, A. M., M. D., New York City, 
 
 Professor of Practical Obstetrics at the New York Post-graduate School and Hos- 
 pital ; Obstetric Surgeon to the New York Maternity Hospital ; Obstetrician 
 to the New York lufaut Asylum ; Gynecologist to the German Hospital. 
 
 EGBERT H. GRANDIN, A.B., M. D., New York City, 
 
 Instructor in Gynecology at the New York Polyclinic ; Obstetric Surgeon to the 
 New York Maternity Hospital. 
 
 A. REEYES JACKSON, A. M., M. D., Chicago, 
 
 Professor of Gynecology in the College of Physicians and Surgeons of Chicago, 
 and the Chicago Policlinic; Hon. Fellow Boston Gynecological and Detroit 
 Gynecological Societies; Fellow of the American Gynecological, British Gyn- 
 ecological, and Chicago Gynecological Societies; Consulting Surgeon of the Dis- 
 pensary of the Women's Christian Association ; Chief of the Gynecological 
 Department of the West Side Free Dispensary ; formerly Surgeon-iu-chief 
 of the Woman's Hospital of the State of Illinois. 
 
 EDWARD W. JENKS, M. D., LL.D., Detroit, 
 
 Fellow of the American Gynecological Society and the Obstetrical Society of Lon- 
 don; Corresponding Fellow of the Boston Gynecological Society; Honorary 
 Member of the Cincinnati Obstetrical Society and the State Medical Associa- 
 tions of Maine, Ohio, Michigan, etc. ; formerly President and Prnfessor of 
 Gynecology and Obstetrics in Detroit Medical College, and late Professor of 
 Gynecology in Chicago Medical College. 
 
VI • CONTRIBUTORS. 
 
 MATTHEW D. MANN, A. M., M. D., Buffalo, 
 
 Professor of Obstetrics and Gynecology in the Medical Department of the Uni- 
 versity of Buffalo ; Gynecologist to the Buffalo General Hospital. 
 
 RICHARD B. MAURY, M. D., Memphis, 
 
 Professor of Gynecology in the Memphis Hospital Medical College. 
 
 CHAUNCEY D. PALMER, M. D., Cincinnati, 
 
 Professor of Obstetrics and the Medical and Surgical Diseases of Women and Clin- 
 ical Gynecology in the Medical College of Ohio ; Gynecologist to the Cincinnati 
 Hospital. 
 
 THADDEUS A. REAMY, A. M., M. D., Cincinnati, 
 
 Professor of Clinical Gynecology in the Medical College of Ohio ; Gynecologist 
 to the Good Samaritan Hospital; Obstetrician and Gynecologist to the Cin- 
 cinnati Hospital. 
 
 ALPHONSO D. ROCKWELL, M. D., New York City, 
 
 Formerly Electro-therapeutist to the Woman's Hospital in the State of New 
 York ; Member of the American Neurological Association. 
 
 ALEXANDER J. C. SKENE, M.D., Brooklyn, 
 
 Professor of the Medical and Surgical Diseases of Women in the Long Island 
 College Hospital, Brooklyn, N. Y. 
 
 ELY VAN DE WARKER, M. D., Syracuse, N. Y., 
 
 Surgeon to the Central New York Hospital for Women; Fellow of the American 
 Gynecological Society ; Fellow of the New York State Medical Association. 
 
 W. GILL WYLIE, M. D., New York City, 
 
 Professor of Gynecology in the New York Polyclinic; Gynecologist to Bellevue 
 Hospital ; Surgeon to St. Elizabeth's Hospital ; Member of American and Brit- 
 ish Gynecological Societies ; Fellow of New York Academy of Medicine. 
 
CONTENTS OF VOLUME I. 
 
 PAGE 
 
 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. By Edward 
 
 W. Jenks, M. D., LL.D 17 
 
 THE DEVELOPMENT OF THE FEMALE GENITALS. By Henry J. 
 
 Garrigues, a. M., M. D 68 
 
 THE ANATOMY OF THE FEMALE PELVIC ORGANS. By Hexrt C. 
 
 CoE, M. D., M. R. C. S 95 
 
 MALFORMATIONS OF THE FEMALE GENITALS. By Hexry J. 
 
 Garrigues. A. M., M. D 235 
 
 GYNECOLOGICAL DIAGNOSIS. By Egbert H. Graxdin, A. B., M. D. 283 
 
 GENERAL CONSIDERATION OF GYNECOLOGICAL SURGERY. By 
 
 E. C. Dl-dlet, a. B., M. D 328 
 
 GENERAL THERAPEUTICS. By Alexaxder J. C. Skexe, M. D. . . . 363 
 
 ELECTRICITY IN GYNECOLOGY. By Alphoxso D. Rockwell, A. M., 
 
 M. D 383 
 
 MENSTRUATION, AND ITS DISORDERS. By W. Gill Wylie, ]M. D. . 408 
 
 STERILITY. By A. Reeves Jacksox, A. M.. M. D 441 
 
 DISEASES OF THE VULVA. By Matthew D. Maxx, A. M., M. D. . . 477 
 
 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. By C. D. 
 
 Palmer, M. D 541 
 
 SUBINVOLUTION OF THE VAGINA AND UTERUS. By Thaddecs 
 
 A. Reamy, A.m., M.D 637 
 
 PERIUTERINE INFLAMMATION. By Richard B. Maury, M. D. . . . 675 
 
 PELVIC H.EMATOCELE AND H.EMATOMATA. By Ely Vax de 
 
 Warker, M. D 735 
 
 vii 
 
LIST OF WOOD ENGRAVINGS. 
 
 Flo. PAGE 
 
 1. Section ol' Fftftal llalibit 69 
 
 2. Section of Posterior Part of Foetal I\al)bit 69 
 
 3 and 4. Skene's Urethral Glands 70 
 
 5. Cross-section of Urethra 71 
 
 6. Cross-section of Urethra, sliowing Skene's Glands I'l 
 
 7. Skene's Gland laid ojjen 72 
 
 8. Fo?tus of Thirty-five Days 73 
 
 9. Genital Organs of Embryo Cattle 74 
 
 10. Internal (xenitals of Female Human Foetus 75 
 
 11. Internal Genitals of Male liuman Foetus 75 
 
 12. Cross-section of Foetal Ovary 76 
 
 13. Cross-section of Ovary of Bitch of Six Months 77 
 
 14. Cross section of Ovary of Human Foetus 78 
 
 15. Cross-section through Ovarian Region of Foetus 80 
 
 16. Ovary of Human Fffitus at Tenth Week 81 
 
 17. Ovary of Human Foetus at Tenth Week (magnified) 81 
 
 18. Formation of Ova 81 
 
 19. Permanent Epithelium of Ovary 81 
 
 20. Ovary in Thirty-sixth Week , 82 
 
 21. Cross-section of Ovary at Birth 82 
 
 22. Graafian Follicles at Birth 82 
 
 23. Graafian Follicle Seven Months Old 83 
 
 24. Human Ovum 84 
 
 25. Primordial Ova 85 
 
 26. Wolffian Body of Babbit 86 
 
 27. Section of Genital Cord 88 
 
 28 and 29. Ovaries, Tubes, and Uterus at Tenth Week 88 
 
 30. Visceraat Fifth Month 89 
 
 31 and .32. Urogenital Sinus 89 
 
 33. Urogenital Sinus at Different Ages 90 
 
 34 and 35. External Genitals in Foetus 93 
 
 36. Mesial Section of External Genitals . . 96 
 
 37. External Genitals 97 
 
 38. Veins of Vulva and Perineum 103 
 
 39. Veins of Vagina and Vulva 105 
 
 40. Venous Plexuses of Clitoris 106 
 
 41. Perineal Septum 107 
 
 42. Arteries and Veins of Vagina and Uterus 122 
 
 43 and 44. Sections of the Vaginal Wall 123 
 
 45. Section of Mucous Membrane of Uterus 136 
 
 46. Interior of Cervix 137 
 
 47. Utricular Glands 140 
 
 48. Section of Decidua - 141 
 
X LIST OF WOOD ENGRAVINGS. 
 
 Fig. Page 
 
 49. Ovarian and Uterine Arteries 144 
 
 50. Nerves of the Uterus 145 
 
 51. Transverse Section of the Body at Brim of Ti'ue Pelvis 146 
 
 52. Horizontal Section, showing Uterus and Ligaments 15S 
 
 53. Pubic Termination of Round Ligaments 159 
 
 54. Cross-section of Tubes , . 163 
 
 55. Cross-section of Tubes, showing Lymph-spaces 165 
 
 56. Section of Ovary 171 
 
 57. Section of Ovary (low power) 173 
 
 58. Section of Ovary in Infant 174 
 
 59. Frozen Section of Pelvis 184 
 
 60. Section of Vesico- vaginal Septum 187 
 
 61. Muscular Fibres of Bladder 190 
 
 62. Epithelium of Bladder -190 
 
 63. Relation of Ureters 193 
 
 64. Surgical Relations of Uretei'S 195 
 
 65. Rectum Inflated 198 
 
 66. Section of End of Rectum 200 
 
 67. Diagram of Pelvic Peritoneum ^ . . . 205 
 
 68. Cross-section of Pelvis 206 
 
 69. Diagram of Broad Ligaments 208 
 
 70. Diagram of Broad Ligaments 209 
 
 71. Reflections and Pouches of Pelvic Peritoneum . 211 
 
 72. Mesial Section of Pelvis 217 
 
 73. Model of Uterine Supports 221 
 
 74. .Fascia of Pelvic Floor 223 
 
 75. Muscles of Pelvic Floor 224 
 
 76. Section of Pelvis through Vagina 225 
 
 77. Attachments of Muscular Floor of Pelvis 226 
 
 78. Perineal Septum 231 
 
 79. Muscular Floor of Pelvis in Labor 233 
 
 80. Rudimentary Uterus (Nega) 240 
 
 81. Rudimentary LTterus (Langenbeck) 241 
 
 82. Uterus Bipartitus 242 
 
 83. Bipartite Uterus and Ovaries 244 
 
 84. Uterus Didelphys 245 
 
 85. Uterus Unicornis 246 
 
 86. Uterus Bicornis Duplex 247 
 
 87. Uterus Bicornis Duplex 248 
 
 88. Uterus Bicornis Unicollis 249 
 
 89. Uterus Arcuatus 249 
 
 90. Uterus Septus Duplex 250 
 
 91. Uterus Septus Uniforis 251 
 
 92 and 93. Double Vagina 251 
 
 94. Infantile Uterus ' 254 
 
 95. Infantile Uterus, coronal section 255 
 
 96. Uterus Incudiformis 256 
 
 97. Persistent Cloaca 261 
 
 98. Persistent Sinus Urogenitalis 261 
 
 99. The Hymen . . ." 262 
 
 100. Hypospadias 265 
 
 101. Epispadias 266 
 
 102. Lateral Hermaphrodism 271 
 
 103. Internal Genitals of Fig. 102 271 
 
 104. Internal Genitals, left side 272 
 
LIST OF WOOD EXnnAVrXa.S. XI 
 
 Fi<i- I'.\(;k 
 
 lOo and lOG. rienitals of Carl llnlimami 274 
 
 1U7 and 108. Carl llolunaini 'j7o 
 
 109 and 110. .Siipjiosed Section of Iloliriiinin Ii7,j 
 
 111. Chadwick's Table 2!l4 
 
 11 "J. Chadwick's Table -J'.j.j 
 
 11.;. Dagget's Table 2'.J-') 
 
 114. Dagget's Table 290 
 
 1 lo. .Simpson's Somid 30;i 
 
 IK). Fergiisson's Speculum 305 
 
 117. Brewer's S|ieculuni 3(j.O 
 
 lis. Null's Speculum 30(j 
 
 119. Left Lateral Position 309 
 
 120. Sims's Depressor 311 
 
 121. Sims's Speculum 311 
 
 122. Hunter- Erich Speculum 311 
 
 123. Thomas-Mann Speculum 312 
 
 124. Munde's Speculum 313 
 
 125. Emmet's Tenaculum 314 
 
 126. Sims's Tenaculum 314 
 
 127. Emmets Probe 315 
 
 128. Skene's Endoscope 317 
 
 129. Kelsey's Eectal Speculum 318 
 
 130. GoodeU's Dilators 319 
 
 131. Palmer's Dilators 320 
 
 132. Hanks's Dilator 320 
 
 133. Emmet's Water-Dilator 321 
 
 134. Molesworth's Dilator 322 
 
 13o. Tupelo Tents 322 
 
 130. Thomas's Dull Curette • 324 
 
 137. Dieulafoy's Aspirator 320 
 
 138. Emmet's Aspirator 320 
 
 139. Simon's Speculum 342 
 
 140. Emmet's Double Tenaculum Forceps 343 
 
 141. Emmet's Double Tenaculum Forceps 343 
 
 142. Sims's Sponge-holder ,343 
 
 143. Emmet's Scissors 344 
 
 144. Emmet's Scissors, curved 344 
 
 145. Emmet's Scissors, strongly-curved 344 
 
 146. Emmet's Ball-and-Socket Knife 345 
 
 147. Uterine Tenaculum ,345 
 
 148. Method of Denudation 346 
 
 149. Needles 347 
 
 150. Emmet's Needle-Forceps 348 
 
 151. Needles Threaded with Loop ,348 
 
 152. Counter-pressure to Needle 34y 
 
 153. Counter-pressure to Hook 349 
 
 154. Vulsellum Forceps 349 
 
 155. Suture in Position 350 
 
 156. All Sutures in Position 350 
 
 157. Slipknot on Suture 351 
 
 158. Twisting with a Tenaculum 351 
 
 159. Shouldering a Suture 351 
 
 160. Twisting Forceps 352 
 
 161. Sims's Shield 352 
 
 162. Twisting a Suture 352 
 
Xll LIST OF WOOD EXGRAVISOS. 
 
 Fig. page 
 
 163. Bending Twisted Wire 3,52 
 
 164. Removing a Silver Suture 3.53 
 
 165. Sponge Tent 355 
 
 166. Laminaria Tent 356 
 
 167. Introducing a Tent 357 
 
 168. Fritsch's Dilators • 358 
 
 169. Schultze's Dilators 358 
 
 170. Xott's Dilators . 358 
 
 171. Thomas's Dull Wire Curettes 360 
 
 172. Simon's Sharp Spoon - 361 
 
 173. Sims's Curette 418 
 
 174. Sims's Dilator 427 
 
 175. Wylie's Cervical Protector 428 
 
 176. Wylie's Intra-uterine Drainage-tube 429 
 
 176j. Veins of Vulva 479 
 
 177. Anterior Vaginal Hernia 484 
 
 178. Lupus Prominens 522 
 
 179. Palmers Intra-uterine Canula 546 
 
 180. Davidson's Syringe 556 
 
 181. Vaginal Irrigator 556 
 
 182. Peaslee's Dilators 559 
 
 183. Palmei-'s Dilator 560 
 
 184. Conoid Cervix 560 
 
 185. Dilated Canal 561 
 
 186. Hard-rubber Probe Applicator 564 
 
 187. Applicator .577 
 
 188. Self-retaining Tenaculum 577 
 
 189. Palmer's Intra-uterine Medicator 579 
 
 190. Applicator Syringe 580 
 
 191. Sims's Applicator 580 
 
 192. Applicator Syringe 581 
 
 193. Eecamier's Curette 596 
 
 194. Thomas's Curette 596 
 
 195. Sims's Curette 597 
 
 196. Simon's Spoon 597 
 
 197. Emmet's Curette Forceps 597 
 
 198. Buttle's Spear 613 
 
 199. Knife for Intra-uterine Scarification 614 
 
 200. Eetlections of Pelvic Peritoneum 683 
 
 201. Sagittal Section of Pelvis 685 
 
 Plate I. 
 
 Lupus Hypertrophicus 'Duncan I, more properly Fibroma Diffiisum . . . 527 
 
 Plate II. 
 
 1. Erosion of the Cervix (iVreigsi 5-50 
 
 2. Follicular Erosion with Slight Laceration (Munde) 550 
 
 3. Granular Degeneration of an Elongated Cervix (Meigs) 550 
 
 4. Erosion, Cystic Enlargement, Catarrh of Cervix (Meigs) 550 
 
 Plate III. 
 
 1. Chronic Hyperemia. Catarrh, and Enlargement of the Cervix CMeigs) . . 601 
 
 2. Chronic Metritis and Endometritis ' MeigsJ 601 
 
HISTORICAL SKETCH OF AMERICAN 
 GYNECOLOGY. 
 
 By EDWARD W. JENKS, M.D., LL.D., 
 
 DeTKOIT, MiCHKtAN. 
 
 As in the case of most nations, so in that of medicine, of whose his- 
 tory it forms a part, the earliest dawnings are traceable to tradition, 
 and in many instances the historian is obliged to go back of anthen- 
 ticated records for the material with which to construct the foundation 
 of his story. In writing a history of American medicine in any of its 
 divisions this difficulty does not, however, present itself, for, like the 
 American people itself, it arises from a foundation laid in centuries of 
 Transatlantic life. While, therefore, in essaying a history of the achieve- 
 ments of American surgeons in the treatment of diseases peculiar to 
 women I am not obliged to analyze aught which is of doubtfiil authen- 
 ticity as a basis for a starting-point, it has seemed to me that a brief 
 resiune of the historical facts which form the foundation of gynecol- 
 ogy as it exists in America to-day will greatly assist to the clearest con- 
 ception of the superstructure. The explorations of antiquarians of later 
 years into that which has been hidden by the debris of centm-ies has, 
 moreover, unearthed so many of the prototypes of modern discoveries 
 that a consideration of the latter could scarcely be held to be comj)lete 
 without a reference to their predecessors in the remote ages. 
 
 Gynecology is singularly rich in illustrations of the belief that prog- 
 ress is in the direction of a circle rather than in that of a straight 
 line — " that which hath been is, and that which is shall be ;" and manv 
 of the brilliant discoveries with which it has been enriched in modern 
 times, and even in America, were really but rediscoveries of discoveries 
 which the mutations of time have effiiced from the memories and the 
 records of men. 
 
 AYhile the current of gynecology as it has flowed down to us in an 
 ever-widening stream from the past is traceable with definite clearness 
 onlv to the Greeks, there is evidence that it did not have its orig-in 
 among that remarkable people, but that it trickled in rivulets, too small 
 for the attention of the great majority of explorers, from the people living 
 on the Xile. That the stream was clearly recognized in the days of 
 Homer and Herodotus is attested in the writings of those immortal 
 
 Vol. L.—2 17 
 
18 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 Greeks, who wrote in terms of the highest admiration of the skill and 
 the learning of the physicians of Egypt. 
 
 The physicians under the Ptolemies were required to regulate their 
 practice according to certain books, one of which was devoted to diseases 
 peculiar to women. These books were held as sacred, and their authority 
 was thus unquestionable. Doubtless, there existed among a people, evi- 
 dences of whose greatness have of more recent years been so abundantly 
 revealed, other works on this subject, but Saracen fanaticism in the 
 destruction of the Alexandrian Library with its 600,000 volumes blotted 
 out the story of what Egypt once was, and has left us only to conjecture. 
 When the difference in the language and political complexion of Greece 
 and Egypt is considered in connection with the necessarily limited in- 
 tercommunication of the two peoples, it is but reasonable to suppose 
 that comparatively little of the learning of the older civilization found 
 its way to Greece, and that such inkling as we have received through 
 the Greeks of the status of Egyptian medicine is very meagre when 
 compared with the actual advancement which obtained. 
 
 The destruction of the Alexandrian Library has left the writings 
 of Hippocrates, written about 450 B. c, the oldest extant containing 
 anything like a systematic consideration of the diseases of women. 
 Moses, who was versed in " all the learning of the Egyptians," shows 
 a remarkable familiarity with the sexual peculiarities of women, but 
 he treats of them in their physiology, and interests himself in the 
 hygiene of the genitalia rather than in their diseases. 
 
 In the lano-uaoe of Adams, the learned commentator on the works 
 of Hippocrates, " these works furnish the most indubitable proofs that 
 the obstetric art had been cultivated with most extraordinary ability at 
 an early period." Li regard to gynecology proper, these works are, 
 however, disappointing to him who has been led to admire and revere 
 the philosopher of Cos through a study of his works on general med- 
 icine. Hippocrates advised the use of aromatic ftimigations in amenor- 
 rhoea, which fumigations he also recommended as a test of fertility in 
 the female. The woman who did not conceive was T\a'apped in blankets 
 and fumigated from beneath ; if the scent passed through her body to 
 the nostrils and mouth, then it was known that she was not unfruitftil ! 
 "While he recognized a causative relation between the uterus and hys- 
 teria, he maintained that the movement of the womb toward the head 
 caused pain under the eyes and nose, with abundant and frothy saliva ; 
 if it moved toward the hypochondrium, it caused vomiting of an acrid, 
 burning matter ; if it moved toward the liver, it caused loss of speech, 
 clenching of the teeth, and a livid skin. The remedies for these various 
 hysterical symptoms were as ludicrous as their etiology. Nulliparae were 
 held to be more subject to menstrual disorders than women who had 
 borne children, for the veins of the woman ^^^ho has given birth to a 
 
HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 19 
 
 child canv oil" the iiiciistriial discharge more readily, because the lochial 
 discharge improves the eireidation. The views of the " Father of 
 Medicine" on the treatment of uterine hemorrhage were, however, 
 more sensible. Wv discover, indeed, in them some of the fundamental 
 ])rineiples of the advanced metiiods of our own day. His knowledge 
 of the relation of sym[)athy between the uterus and the mannnte is 
 api)arent in his instruction to apjdy a large cupping instrument to the 
 breast as a means of staying uterine hemorrhage. His descriptiiju of 
 leucorrh(oa and the fre(iuent attendant systemic condition is graphic, 
 although his therapy of the aif'ection is crude. The prolapsed uterus, 
 he savs, " hangs down like a scrotum." It should be well washed 
 with iLstringcnt lotions and restored to its place, when the woman must 
 be placed on her back with her legs crossed and tied together. That 
 Hippocrates recognized the fact that a molar pregnancy occurring in an 
 unmarried woman im})eached her virtue is evident from his statement 
 that moles are caused by a superabundance of menstrual blood, together 
 with a bad condition of the semen. He gives a clear differential diag- 
 nosis between molar and true pregnancy. His description of cancer 
 of the uterus is clear, and his gloomy prognosis in such cases has not 
 been much 1)riglitened by the advances made since his day. We recog- 
 nize in the " pliimus " of his day the modern stenosis of the os. He 
 recommends an application containing verdigris for its relief. His 
 remarks on atresia of the vagina and uterus command attention : 
 " Sometimes the vagina becomes obstructed after parturition. I have 
 seen a case where the parts were torn during delivery, causing excoria- 
 tions, after which the parts became seriously inflamed, so that the lips 
 touched and became united as in wounds. After the subsidence of the 
 inflammation the lips, which had reunited, offered an obstacle to the men- 
 strual discharge, preventing its free exit. It is necessary in such a case 
 to dress the lacerated parts and cause cicatrization, but it is also neces- 
 sary that the cicatrix be firm and complete, while it is very difficult 
 to secure this result. In the instance of which I speak all the results 
 took place which occur when the menses are suppressed by malforma- 
 tion of the uterus, but the principal pain was felt in the vagina, which 
 the woman found to be occluded. After suitable treatment the men- 
 strual flow was re-established, the woman recovered her health, and 
 afterward bore children. If the case had been neglected, the wound 
 would have increased in size, and a cancer would have been the final 
 result." It is evident that the subject of sterility received much of 
 his attention, and his views concerning the causation of the same are 
 interesting. He held the cause to be one or several of the following : 
 " 1. Because the os uteri is turned obliquely from the passage to it. 
 2. Because the inside of the uterus, being smooth, either naturally or 
 in consequence of cicatrices and ulcers, does not retain the semen. 
 
20 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 3. When, owing to the suppression of the menses, any obstruction 
 takes j)lace in the os uteri, it is apt to prevent impregnation. 4. When 
 impregnation does not take place, the veins of the uterus become so 
 engorged with blood that they do not retain the semen ; or, on the 
 contrary, the same effect may arise from profuse menstruation, whereby 
 the retentive faculty of the vessels is weakened and a return of the 
 menstrual fluid in too great quantity may wash away the ,semen. 5. 
 Prolapsus uteri, by rendering the mouth of the uterus hard and cal- 
 lous, prevents impregnation." 
 
 Among the Romans there is evidence that the diseases of woman 
 received especial attention. Their knowledge was, however, mainly 
 derived from Greece and Alexandria, their writings revealing none 
 of the originality of thought and boldness of procedure which have 
 always marked progress in this division of medicine. Celsus was a 
 voluminous writer, but it is to be regretted that so much of such parts 
 of his works as treated especially of the diseases of women have been 
 lost as to leave us at best a very disjointed reference to the subject. 
 Enough has, however, been preserved of his ^vritings and of those of 
 Galen to convince us that as early as the first century of the Chris- 
 tian era the speculum, rediscovered by Recamier in 1816, was not 
 unknown ; that the vaginal touch was used as a means of diagnosis ; 
 and that ulceration of the womb and leucorrhoea in its several vari- 
 eties had been recognized. In the excavations of Pompeii and Her- 
 culaneum, overwhelmed with lava from Mount Vesuvius A. D. 79, 
 and remaining buried for nearly eighteen hundred years, there were 
 found among, other surgical instruments, two specula, such as were 
 probably in common use at the time of the catastrophe. 
 
 Following the faint glimmer of light emitted from Rome, we have 
 a period of almost absolute darkness extending over five hundred 
 years, all of such history of the medicine of those years as may 
 have been written having at last become extinct. At the end of 
 this period we find at work in the library at Alexandria one iEtius, 
 a Greek, whom the fame of that wonderfiil collection had probably 
 attracted from his native land, although the fact that he refers occa- 
 sionally in his writings to cases occurring under his own eye gives 
 color to the belief that, besides delving in the accumulated lore, he 
 also engaged in the practice of his profession. The writings of ^tius, 
 compilations chiefly from the Alexandrian collection, having fortu- 
 nately been preserved, we are permitted to know through them some- 
 thing of the status of medicine in Egypt a millennium and a half ago. 
 A study of these writings will open up a wonderful revelation to those 
 who regard gynecology as peculiarly a development of these later 
 times. They consist of four books (tetrabiblus), each of which is in 
 turn subdivided into many chapters. The fourth discourse of the 
 
insTonrcAL sKj'yrcir of AM^nrcAx cysF.coLoaY. 21 
 
 fonrtli book, containimj; one liiiiuli'cd ami twelve (•lia|)t('rs varvinsj:; in 
 loiiiitli fVoni a few lines to several pai^cs, is [)riii('ij)ally devoted to 
 obstetrics ;uid diseases of women. In it the nterns and the ovaries, 
 their strnetnre and fnnetion, are described with a de<i:ree of exactness 
 which both disposes of the assnraption that the ancients were i<>;norant 
 of physioloiiv, and proves that they possessed instrnments for ocular 
 examination of the uterus (their dioptra) and sounds for determining 
 its size in the living subject. The description, too, which is given of 
 the methods in vogue for preventing tlie legitimate consequences of 
 sexual congress and for inducing abortion proves that the nefarious 
 practices by means of which the female of our day would accomplish 
 the same result are not of modern origin. Latero-version, antever- 
 sion, and retroversion of the uterus, and various methods for the relief 
 of these displacements, are discussed, and mention is even made of 
 the sound for correcting malpositions of that organ. Abscess of the 
 uterus was recognized, and the description of the examination for its 
 diairnosis and the methods for its treatment would, barring; certain 
 crudities of expression, pass muster even in the light of our more 
 advanced knowledge of uterine ailments and the means of their 
 relief. The treatment, medical and surgical, laid down for pelvic 
 abscess would do no discredit to the modern gynecologist. The 
 relief of stenosis of the os by means of sponge tents is so graphically 
 described as either to compel the belief that the modern discoverer of 
 this use of these devices derived his knowledge from the writings of 
 iEtius, or to cause the reader to mars^el at the remarkable coincidence. 
 Atresia of the vagina is discussed, and the operation, with instruments 
 therefor, for its relief clearly described. 
 
 The next writer in chronological order whose MTitings are preserved 
 to us is Paul of ^^gina, between whom and JEtiiis there intervenes a 
 century. This writer has been accorded a prominence which he does 
 not merit. Dr. Adams, the translator of the Sydenham series, has 
 shown him much consideration. A study of his writings in connection 
 with those of ^Etius reveal him to have been a plagiarist. He was at 
 most a compiler, and his efforts even in this direction fell far short of 
 those of the industrious and able ^Etius. 
 
 Following Paulus ^Egineta we have a millennium of darkness, the 
 gloom being relieved only by the uncertain glints with which the Sar- 
 acens sought to make amends for their damnable vandalism in the 
 matter of the Alexandrian Library. But an insuperable obstacle to 
 their progress in the knowledge of the diseases of women ])resented 
 itself in the Moslem religion, which forbade visual and digital exami- 
 nation of the female genitalia, even under conditions of the most intol- 
 erable suffering, by male physicians. The ability of the Saracen physi- 
 cians, so abundantly illustrated in other departments of medicine, was 
 
22 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 therefore forbidden an opportunity of manifesting itself in this, and 
 such knowledge as formed the basis of their unsatisfactory practice in 
 gynecology was derived solely from the writings of the Greeks ; and 
 the fact that any treatment of a local nature which might have been 
 deemed necessary must be applied by ignorant mid wives caused this 
 branch of medicine to soon fall into desuetude and consequent decay. 
 Of the Arabian writers, Albucasis, in the fourteenth century, alone 
 seems to have given it any considerable attention, and there is internal 
 evidence in his writings that he was a Jew, and was thus not hindered 
 by any religious scruples of his own from pursuing his studies after 
 the manner proscribed by the Moslem religion. He makes an occa- 
 sional allusion to the speculum, but doubtless the circumstances under 
 which he lived made even his employment of it rare. Although it is 
 apparent from the writings of subsequent authors, and notably Ambrose 
 Pare (1509-90) and Scultetus (1683), that the instrument was not abso- 
 lutely forgotten, it is nevertheless a fact that for a thousand years prior 
 to its rediscovery (if such it really was) by R^camier (1816) it was 
 practically a lost instrument, and gynecology certainly was during this 
 millennium a lost art. 
 
 While, as intimated at the outset, American gynecology, dating from 
 the . earliest attention to this branch of medicine by the profession of 
 this country, is continuous with gynecology as we have traced it in 
 outline from its earliest dawn in the Old World, its achievements prior 
 to the renaissance ushered in by Recamier cannot be said to have been 
 of sufficient importance to entitle it to a distinctive national name. It 
 must not be inferred from this that this division of medicine was more 
 neglected on this side the Atlantic than on the other, or that the Amer- 
 ican woman whose means forbade a visit to the European centres was 
 obliged to suffer from her ailments without having held out to her 
 by native talent as much hope as could be promised abroad. While it 
 may have been true, as charged by Dr. Douglass, that there was in his 
 day (1717) " more danger from the physicians of Boston than from the 
 distemper," this condition of affairs had much improved when the War 
 of Independence was declared. The writings of Joseph Osgood of 
 Andover and Joseph Orne and Augustus Holyoke of Salem evince a 
 knowledge of the diseases of women which was probably quite abreast 
 of that possessed by their European contemporaries. In the year 1790, 
 nine years after its organization, the Medical Society of Massachusetts 
 first published such of the contributions as were presented before that 
 body. Among these publications is found an occasional article on 
 some gynecological subject, but the first which was devoted to a subject 
 unconnected with the puerperal condition was one entitled " The His- 
 tory of a Hemorrhage from a Eupture on the Inside of the Left I^abium 
 Pudendi." This was contributed by Dr. Nathaniel W. Appleton of 
 
HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 23 
 
 Boston, aiul a|)|)('ars in the second [)art of the first volnnic of tin; 
 Trdn-sdvdcius of tlir society, issncd in the year 1<S()(J. 
 
 The inlhicnce of the teachings of 8niellie and linnter very naturally 
 cxtcndeil to tlu' prtiicssion in the colonies, and abundant evidence of it 
 is found in the reports of eases in such literature of the colonial days 
 as is extant. The causes, however, which operated to the repression of 
 progress in gynecology were operative here as in Europe ; and while 
 we believe that the latent energies of the profession of the New World, 
 necessarily thrown ({uite entirely on its own resources, must in course 
 of time have transcended in their results the achievements of the pro- 
 fession abroad, the struggle inaugui-ated by the Declaration of Inde- 
 pendence diverted those energies into channels which were incompat- 
 ible Avith scientific research. For seven long years the struggle for 
 personal and national existence not only forbade the development 
 of the native resources, but it also shut the profession out from the 
 influence of the mysterious awakening from the lethargy of centuries 
 which was going on in Europe. Nor did the cessation of hostilities 
 leave the road to professional progress free and unobstructed. The vic- 
 tory had been achieved, but at a cost of life and energy and treasure 
 which caused a depression from which it required many years to rally. 
 Although the profession of medicine, which has for its object the health 
 of the people — the supreme law — is a very essential factor in national 
 growth, there are other matters which are more immediately pressing 
 in seasons of great national depression — agriculture, manufactures, com- 
 merce. For a couple of decades following the close of the war these 
 were held to be of paramount concern, and it was not until the opening 
 of the present century that the profession of this country found itself 
 in a position to devote even a portion of its energies to the special 
 development of any particular division of the whole field of medicine 
 which commanded its attention. 
 
 It was a happy coincidence that the profession in America found 
 itself sufficiently recovered from the distractions of war to permit of 
 its placing itself in the line of the movement in gynecology inaugurated 
 by Hunter in England, and stimulated to unprecedented activity by the 
 revival of the speculum by Recamier in France. The comparative 
 leisure and wealth which followed in the Avake of the prosperity ensured 
 by the elasticity of our people made it possible for the profession to 
 embrace the opportunity, which, had it presented a decade sooner, would 
 of necessity have been allowed to pass by unimproved. The dawn of 
 the present century found our young men and many of our older prac- 
 titioners repairing to the mother-country and to the various seats of 
 learning in Europe, and drinking in the spirit of the revival, and 
 bringing it back wnth them to these shores. Among these young men 
 was one Ephraim ]\IcDowell, who was born in Virginia in 1771, and 
 
24 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 who moved thence with his father and the rest of the family to settle 
 in Kentucky in the year 1783. Young McDowell was accorded the 
 educational advantages of that early day in that new country. His 
 subsequent writings show that his literary acquirements were not of a 
 much higher order than we could have expected under the unpropitious 
 circumstances. After leaving school he studied medicine for two or 
 three years with a Dr. Humphreys of Staunton, Virginia, a graduate 
 of the University of Edinburgh. When we recall the contempt which 
 the physician educated abroad entertained in those days for American 
 educational institutions, we are not surprised at finding no evidence of 
 McDowell's having attended any lectures in Philadelphia, then the only 
 seat of medical education in this country. At his preceptor's dictation, 
 doubtless, he went to Edinburgh, where during the sessions of 1793 
 and 1794 he attended lectures in the famous university, then in the 
 zenith of its renown. Not fully satisfied, however, with the regular 
 course of the university on the subject of surgery, he took a private 
 course under Mr. John Bell, a surgeon noted alike for his enthusiasm, 
 his eloquence, his skill, and his hold on the affections of his students. 
 We have no evidence that McDowell ever graduated. Mr. Bell is said 
 to have been an enthusiast on the subject of organic diseases of the 
 ovaries, and to have even discussed the possibility of their successful 
 removal, although never himself venturing to practically demonstrate 
 this possibility. Doubtless, the young Kentuckian resolved while under 
 the spell of his teacher's enthusiasm to undertake what that teacher's 
 timidity, perhaps, kept him from attempting, and he returned to his 
 Western home inspired with the high resolve. He settled in Danville 
 in 1795. Although but twenty-four years of age, the fame of his 
 sojourn at foreign seats of learning, and of the fact that he had studied 
 under John Bell, whose reputation had long before crossed the seas, 
 soon secured for him a large clientele. Patients soon flocked from all 
 parts of the South-west, and for hundreds of miles around he had the 
 monopoly of the important operations. He had been in practice four- 
 teen years when he was consulted by a Mrs. Crawford, who sufiered 
 from a large abdominal tumor which a careful examination convinced 
 McDowell was ovarian. Here was the opportunity, and the man was 
 equal to it. The teachings of Bell had fallen in fruitful soil, and the 
 time of their fruition had arrived. Mrs. Crawford was no ordinary 
 woman, and when McDowell declared to her that her only hope lay in 
 the removal of her tumor, explaining to her the fact that such an 
 operation had never before been undertaken, and admonishing her of 
 the dangers which attended it, the brave woman placed herself unre- 
 servedly in the brave man's hands. The consultation was held at Mrs. 
 Crawford's residence, sixty miles from Danville, and Dr. McDowell 
 made it a condition of his operating that his patient come to his home 
 
HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 25 
 
 for the oporation. The h(M'oine travelled thi.s distanee on horseback, 
 wa-^ operated on in Deeend)er, LSOi), she l)ein(j^ then forty-seven years 
 of age, and at the end of twenty-live days returned to her home, where 
 she lived for thirty -two more years, during which she enjoyed for the 
 most part excellent health, and died at length in the seventy-ninth year 
 of her age. \Mien we remember the facts that this first oi)eration for 
 the removal of an ovarian tumor was performed before the days of 
 anrcsthesia, and that Dr. McDowell had none of the advantages of the 
 trained assistants and perfected instruments which are now deemed 
 so essential to the success of this operation, the courage of the woman 
 and the skill and intelligent daring of the surgeon combine to form a 
 picture which is unique for its grandeur in the annals of surgery. 
 Dr. McDowell's delay in reporting this case of ovariotomy was 
 in singular contrast with the more commendable practice of these later 
 days. Instead of immediately giving a description of his wonderful 
 case for the benefit of his contemporaries, he waited for seven years, 
 during which time he successfully performed two other ovariotomies. 
 His report of these three cases appeared in the October (1816) issue 
 of the Eclectic Repertory and Analytical Review. It was a docmnent 
 remarkable for its brevity, that portion of it covering the case which 
 has made his name immortal, and which demonstrated the practicability 
 of a procedure which more than any other has lengthened the average 
 of woman's life and diminished the sum of her sorrow, not occupying 
 more space than a page the size of that on which this sketch appears. 
 The incision was made about three inches from the musculus rectus 
 abdominis on the left side, parallel to the fibres of this muscle, and 
 nine inches in length and extending into the abdomen. The abdominal 
 parietes were found to be very much contused, owing, it was supposed, 
 to the tumor's resting on the horn of the saddle during the journey. 
 A ligature was thrown around the Fallopian tube near the uterus, Avhen 
 the tumor was cut open, and " fifteen pounds of a dirty, gelatinous- 
 looking substance " removed. The sac was afterward amputated at the 
 ligature, and was found to weigh seven pounds and a half. As soon as 
 the external opening was made the intestines rushed out on the table, 
 and so completely was the abdomen filled by the tumor that they could 
 not be replaced during the operation, which was terminated in about 
 tw'enty-five minutes. The woman was then placed on her left side, so 
 as to permit the blood to escape, after which the external opening was 
 closed with the interrupted suture, leaving out at the lower end of the 
 incision the ligature which surrounded the Fallopian tube. Between 
 every two stitches was put a piece of adhesive plaster, which, by keep- 
 ing the parts in contact, hastened the healing of the incision. The 
 usual dressing was then applied, the patient put to bed, and placed on 
 a strict antiphlogistic regimen. On visiting her five days after, Dr. 
 
26 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 McDowell was astonished to find his patient engaged in making up 
 her bed. 
 
 The other two cases occurred in negro women, and the space devoted 
 to the consideration of both of them is less than that taken up by a 
 description of the first operation. The whole report was loosely and 
 carelessly constructed, and poorly calculated to inspire confidence in the 
 author's literary and scientific attainments. Had McDowell been gifted 
 with facility of expression the recognition of his operation would 
 doubtless have been more prompt. At his death, in 1830, it had not 
 yet been looked upon with favor, although he had himself performed 
 it thirteen times in all, with at least eight successes. The report of the 
 first three cases having been sent to Dr. Physick of Philadelphia, "the 
 Father of American Surgery," and at that time the leader of the Amer- 
 ican profession, it failed to interest him, his opinion of the backwoods 
 surgeon being, probably, largely influenced by the display of his literary 
 ability. The report was also sent to the operator's old preceptor, John 
 Bell, but, owing to that gentlemen's ill-health, he was at the time absent 
 on the Continent, and as he died not long afterward at Rome, he never 
 received it. The paper fell into the hands of Mr. Lizars of Edinburgh, 
 by whom it was published in the Edinburgh 3Iedical and SurgicalJour- 
 nal in 1824. Mr. Lizars, with the instinct of a true surgeon, detected 
 its merit, and was the first to perform McDowell's operation in Great 
 Britain. This recognition of the Kentucky surgeon by his eminent 
 Edinburgh contemporary won for the prophet and his operation an 
 honor in his own country which he had previously been denied. 
 
 Dr. McDowell when he operated on Mrs. Crawford had a reputation 
 which was only local, or he was at least known within but compara- 
 tively circumscribed limits from his own home. His name did not 
 appear on the list of the great surgeons of his day, and — such is one 
 of the peculiarities of human nature — when it was discovered that his 
 claims did not deserve the ridicule with which they Avere greeted even 
 in quarters in which one would suppose they would at least have 
 received respectful attention, if not indorsement, envy began to take 
 the place of ridicule. Accordingly, efforts were soon made to rob him 
 of the honor of his great accomplishment, and claims were set up for 
 a number who were alleged to have previously performed the operation. 
 
 It is scarcely necessary in this place to review the nature of these 
 claims or to discuss their validity. Suffice it to say that they were all 
 carefully investigated by the late Dr. Samuel D. Gross, and by him 
 pronounced untenable. 
 
 While the operation by McDowell marked an era in gynecology, 
 two years before he performed it an American, Dr. John Stearns of 
 Saratoga county, New York, had given to medicine the drug ergot, 
 which was destined to become one of the most important agents in both 
 
HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 27 
 
 gynceoloj^v and niidwif'erv. It is true the drut»; had Ion;:; Ix'f'oro been 
 empirically enipKtyetl by European niidwives, but Dr. Stearns was tlie 
 first to reclaim it from such unscientific use by discovering its modus 
 operandi. The publication of" his pa})er in the New York Mediad 
 Repofi'dory in 1807 at once gave the drug a place in the physician's 
 armamentarium, and its judicious employment since then has been the 
 means of relieving perhaps as large a percentage of woman's suffering 
 as any one surgical procedure. 
 
 The next in chronoloo-ical order to jSIcDowell who undertook to 
 remove an ovarian tumor in this country was Dr. Nathan Smith of 
 Yale, who, it is claimed, was not at the time aware of McDowell's 
 achievement. His first operation was performed on July 5, 1821, and 
 was successful, the patient being able to walk about in three weeks. 
 
 On May 23, 1823, Dr. Alban G. Smith of Danville, Ky., success- 
 fully remov^ed an ovarian tumor from a negress thirty years of age. 
 Dr. Smith had made a previous but unsuccessful ovariotomy in 1818. 
 Following this last successful case a number of unsuccessful attempts 
 were made by other surgeons, who in cutting down to the tumor found 
 the adhesions so extensive as to deter them from further attempt at 
 removal of the growth. 
 
 The fourth successful ovariotomist of this country was Dr. David L. 
 Rogers of New York, wdio performed the operation on September 24, 
 1829. The operation lasted two hours, and at the end of two weeks 
 the patient was able to be up and about her room. 
 
 In November, 1 830, Dr. J. C. Warren of Boston made an unsuccess- 
 ful attempt at the removal of an ovarian tumor. In December, 1835, 
 Dr. J. Billinger performed a successful operation, following which there 
 are no records of any cases until 1843, when Dr. A. Dunlap had his 
 first case, an unsuccessful one. In the same year Dr. J. L. Atlee suc- 
 cessfully performed a double ovariotomy. In 1844, Dr. Washington 
 L. Atlee, who did more than any other American surgeon to establish 
 ovariotomy as a legitimate surgical procedure, had his first case, which 
 terminated unsuccessfully. Dr. Atlee took a decided stand in favor of 
 the legitimacy of the operation, and, although he encountered a number 
 of unsuccessful cases, he faithfully reported them in detail as a guide to 
 those who might be induced to study the operation with a view to 
 removing from it the discoverable reasons for its mortality. He 
 encountered violent opposition and much vituperation, but had the 
 satisfaction of living to witness such a general recognition of ovariot- 
 omy as a legitimate surgical procedure that scarcely any surgeon felt 
 deterred from performing it. In 1855 he published a synopsis of 
 his first thirty cases, of which seventeen recovered and thirteen died. 
 Such a percentage of recoveries from a disease in itself necessarily fatal 
 silenced opposition to the operation, and from that time the number 
 
28 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 of ovariotomists in this country has rapidly increased, even up to the 
 present time, while the percentage of mortality attending the operation 
 by competent operators has, under improved methods, antiseptic and 
 mechanical, grown to be quite as small as that attending most other 
 capital operations. 
 
 In 1853, Dr. Washington L. Atlee read before the American Medi- 
 cal Association a paper on fibrous tumors of the uterus which at once 
 became a portion of the classic gynecological literature of this country. 
 It dealt with such of these tumors as had heretofore been supposed to be 
 inaccessible to the knife or not amenable to curative measures. The paper 
 was based wholly on the author's own exjDcrience, and gave important 
 information touching the classification and means of diagnosing these 
 tumors, besides indicating a method of their treatment by enucleation. 
 It divided them into — 1, extra-uterine or surface tumors ; 2, intra-ute- 
 rine or cavity tumors ; and 3, intramural tumors of the uterus. The 
 value of ergot given internally as a remedy was strongly insisted on, 
 and the use of that drug in the removal of these growths through 
 absorption due to pressure from contraction of the non-striated muscu- 
 lar tissue has since been regarded as the most efficacious means of treat- 
 ing such growths as are inaccessible to the knife. 
 
 In 1856 there appeared the prize essay by Dr. George H. Lyman of 
 Boston upon the History and Statistics of Ovariotomy, and the Oircum- 
 stances under which this Oj)eration may be regarded Safe and Expedient. 
 Up to that date Dr. Lyman's monograph was, probably, the most com- 
 plete of any that had appeared, being a complete and careful research 
 of the ovariotomy statistics of all countries. 
 
 In the same year Dr. I. E. Taylor advocated a new operation for the 
 cure of recto-vaginal fistula, reporting two cases in which he had suc- 
 cessfully employed it. This operation consisted in the severing of the 
 sphincter ani in such cases. 
 
 Some remarkable operations for the removal of the extra-uterine 
 foetus were performed in the early history of this country. In 1791, 
 Dr. William Boynham of Virginia successfully removed the tumor by 
 incision of the abdominal parietes. In 1799 he performed a similar 
 operation, and ^ath equally satisfactory results. In 1816, Dr. John 
 King of South Carolina cut through the walls of the vagina and 
 removed through the incision, by means of the forceps and abdom- 
 inal pressure, a living child which had been carried through the full 
 term of gestation in the abdominal cavity outside the uterus. The life 
 of the mother was also saved. This case stands on record as one of the 
 most remarkable ever encountered, and, being without precedent, does 
 all the greater credit to the operator's judgment and resolution. In 
 1874, Dr. T. Gaillard Thomas incised the vaginal wall with the gal- 
 vano-caustic knife and removed a three months' foetus; and in 1875, 
 
HISTOnrCAL SKErCII OF AMERICAN GYSECOLOGY. 29 
 
 Dr. D. Hayes A;^ik'\v of Philadelphia reported a case of vaginal section 
 perK>riiieJ bv himself for the removal of au extra-uterine fa'tiis. 
 
 Simon's method of iutroducinj; the hand into the rectum for diag- 
 nostic and therapeutic purposes is not as new as many are disposed to 
 believe. In 18U(j, Dr. Clark, an American, recorded the fact that he 
 introduced his hand into the bowel, and, putting his finger into the 
 mouth of an extra-uterine foetus, made traction and delivered the head 
 per rectum. The body and secundines were removed spontaneously 
 some time after. On the next day the anus had contracted to its nat- 
 ural size, but on the third day it, as well as the perineum, began to 
 slough. On the ninth day the parts had commenced to heal, but the 
 fourchette was destroyed. 
 
 Although such records as are available show that American surgeons 
 and general practitioners were quite as successful in their treatment of 
 special diseases of the womb as were their contemporaries abroad, nearly 
 half a century had gone bv since McDowell's discovery before anything 
 occurred on this side of the Atlantic of a nature calculated to direct 
 special attention to American gynecology. But the native shrewdness 
 of the American practitioner qualified him for such utilization of exist- 
 ing knowledge as made him the peer of his Transatlantic brother in 
 this special direction. Xot until the year 1852, however — if we except 
 Meigs's discovery of cardiac thrombosis as a cause of sudden death in 
 childbed, and Hodge's improvements in the construction of uterine 
 pessaries — did any of the great Kentuckian's countiymen do aught 
 worthy of giving them marked distinction in the direction of gynecol- 
 ogy. Hodge's pessary was a yer\' decided improvement on instruments 
 heretofore constructed for a similar purpose, being based on more cor- 
 rect physiological principles than any of its predecessors. The descrip- 
 tion of the steps which more immediately preceded the discovery of 
 this pessary is best given in Dr. Hodge's own words, as quoted in a 
 commemorative address by Dr. Penrose of Philadelphia : " He had 
 been contemplating for a long time the subject of new shapes for pes- 
 saries,- and after many experiments had found nothing satisfactory. One 
 evening Avhile sitting alone in the room Avhere the meetings of the med- 
 ical faculty of the university were held his eyes rested on an upright 
 steel support by the fireplace designed to hold the shovel and tongs. 
 The shovel and tongs were kept in position by a steel hook, and as he 
 surveyed the supporting curve of this hook the longed-for lumination 
 came : the shape, apparently so paradoxical, revealed itself in the clear 
 light and flickering volume of the burning grate, and the Hodge lever 
 pessar\" was the result." This was in the year 1830. To him the ])ro- 
 fession is indebted for the origin and development of two ideas which 
 are at this day considered among the most important facts in uterine 
 pathology — namely, that the condition of the uterus characterized by 
 
30 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 enlargement, displacement, congestion, hypersecretion, and tenderness is 
 not inflammation, nor should it be treated as such — that sustaining the 
 uterus, and thus affording an easy and natural means of overcoming 
 congestion and its results, is a prime factor in their relief and cure. 
 
 In 1833, Dr. Walter Channing, professor of obstetrics at Harvard 
 University, wrote an article on " Irritable Uterus." This was the first 
 comprehensive monograph upon a purely gynecological subject in New 
 England, besides being one of the most valuable contributions extant 
 to this division of medicine. 
 
 In 1841, Dr. Gunning S. Bedford, one of the most graceful writers 
 of any age, established the first clinic for diseases of women ever held 
 on this side the Atlantic, in connection with his chair of obstetrics in 
 the University Medical College of New York. In this year also Dr. 
 Alonzo Clark of New York introduced his plan of treating peritonitis 
 with large doses of opium. This plan involves the exhibition of the 
 drug to the limit of profound narcotism. The amount of it which is 
 tolerated by the patient is greatly in excess of that which he will bear 
 in the physiological condition. It requires the close attention of the 
 physician in order that the limit be not inadvertently exceeded. 
 
 In 1844, Dr. J. C. Nott of Mobile, Alabama, published a report of 
 a case of the removal of a carious coccyx, which was followed by relief 
 of a very aggravated coccygodynia. 
 
 During the year 1852 there appeared in the American Journal of 
 Medical iSciences an article by an Alabama doctor which once more 
 directed the eyes of the medical world to this country. If E.6camier's 
 resurrection of the speculum marked the rise of modern gynecology, 
 this article caused it to take a stride unprecedented. Recamier's spec- 
 ulum had exposed the uterus, but it did so quite imperfectly, and was 
 of little or no service in placing the vagina under surgical control. The 
 writer of the paper referred to had solved the problem, and the surgical 
 diseases of the approach to the w^omb became amenable to treatment, 
 while affections of the womb itself ceased very largely to be the oppro- 
 bria of the healing art. If McDowell'fj discovery " has added forty 
 thousand years to the sum of human life," who can compute the sum 
 of happiness to the mind and misery averted through this discovery by 
 J. Marion Sims? The paper by him on vesico-vaginal fistula made 
 his title of " Father of American Gynecology " indisputable, and the 
 discovery which it recorded has made surgery of the uterus and vagina 
 a wellnigh exact science. The discovery of the operation for the cure 
 of a disease previously incurable was in itself a great achievement, but 
 the discovery of a method of so distending the vagina by air as to 
 render this operation and all other necessary operations on the vagina 
 and womb possible was a greater achievement. Gynecology to-day 
 would scarcely deserve the name of a separate branch of medicine but 
 
HISTORICAL SKETCH OF AMIJRICAN CYNECOLOGY. 81 
 
 for Siiiis's dist'overv. It has hccii ;i|)|>i-(i|)ri:i(cly said that " it Ikls hccn 
 to diseases ot" tlic woiul) wliat the priiitinii-prcss is to civilization, what 
 the coinpjLss is to the niariiu'i-, what steam is to navigation, wiiat the 
 teleseope is to astronomy ; and ^rancU'i- than the telescope, because it 
 was the work ot" one man." 
 
 Wliile the grand results to gynecology which the genius of Sims has 
 evolved are the outeonie of that careful study and constant effort which 
 are the essentials to most of such results in science as are destined to 
 live, the discovery of the fact which brought his mind in the line of 
 work which made him famous was (piite purely accidental. Singular 
 as it may appear, his tastes were originally not for gynecological work : 
 he was, indeed, quite averse to treating diseases of the female sexual 
 apparatus, and even to the necessary means of examination for making 
 a diagnosis of such affections. He had, after perhaps more than the 
 usual share of vicissitudes and discouragements which beset the young 
 practitioner, and extending through an unusual length of time, suc- 
 ceeded in gaining the confidence of the community in which he lived 
 and in establishing a reputation as a general surgeon. He was one day 
 called in consultation in a case of labor in which the head had been 
 impacted for nearly three days. He delivered the woman quite readily 
 with the forceps, and she rallied well from the operation. Five days 
 later she was, however, discovered to have an extensive slough of the 
 soft parts, and was discharging both urine and feces through the vagina. 
 He had then been in practice ten years, and this was the first case of 
 vesico- vaginal fistula which he had encountered. After consulting the 
 literature on the subject, he was convinced of the very rebellious nature 
 of the accident to treatment, and in spite of the importunities of the 
 owner of the woman (who was a slave), he refused to undertake an 
 operation for its relief. In one month from that time he was consulted 
 in reference to a vesico-vaginal fistula existing in the case of another 
 negro slave, and again, in about another month, a third case came 
 under his notice. This unusual number of cases presenting within 
 such a short time compelled his attention to the disease, and, as he had 
 established a small hospital, the three cases were placed under his care 
 in the hope that he might devise some means of relief. While per- 
 plexed with these cases he was one morning suddenly called to see a 
 lady who had been thrown from her horse. After due examination he 
 concluded that the distressing pain from which the ^^'oman suffered was 
 caused by a dislocation of the uterus. Recalling a ride for the treat- 
 ment of this accident which had been given him while a student, he 
 placed the patient on her knees and elbows, and, introducing one finger 
 into the rectum and another into the vagina, " pushed up and pulled 
 down" according to directions. Finding that he could just reach the 
 uterus with his index finger, which was not long enough to permit him 
 
32 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 to exert any force on the organ, he introduced also the middle finger ; and 
 in his effort to push the uterus back turned his hand palm upward and 
 then downward, when all at once he could feel neither the womb nor 
 the walls of the vagina. Immediately the woman declared she was 
 relieved. As she turned on her side there was a sudden explosion, as 
 though of air escaping from the bowel. He was satisfied, however, 
 that the air was not from this source, but was from the vagina, and 
 concluded that his traction on the perineum had suddenly created a 
 vacuum into w^hich the air rushed and expanded the vagina to its fullest 
 capacity. Fired with a new idea which had just been forced upon 
 him, he hurried home in order to test it in the case of the unfortunates 
 suffering from vesico-vaginal fistula in his hospital. On his way he 
 had stopped and bought a large pewter spoon, which he bent so as to 
 secure the necessary purchase for retracting the perineum, as he had 
 discovered he had accidentally done in the case of the woman suffering 
 from the dislocation of the womb. Selecting one of his patients, he 
 placed her on a table in the genu-pectoral position, and, placing a 
 student on eacli side, instructed them to lay hold of the nates and pull 
 them open. Before he could get the bent spoon-handle into the vagina 
 the air rushed in with a puffing noise, dilating the cavity to its fullest 
 extent. On making further traction with the spoon he had revealed 
 to him a sight which had never before been seen by any man. The 
 fistula with its edges clearly defined was plainly visible ; the wall of 
 the vagina could be seen closing in every direction ; the neck of the 
 uterus was distinct and well defined, and even the secretions therefrom 
 could be plainly seen. 
 
 He at once devised and had made for him the instruments which he 
 considered to be necessary for closing up the fistula. Among these 
 instruments was the duck-bill speculum, to which his name has been 
 inseparably attached ; and it is a singular fact that the original design 
 of that instrument has never been altered. It took him three months 
 to have the necessary instruments made, and the case which he selected 
 for the operation was an unusually bad one, the whole base of the 
 bladder being destroyed, leaving an opening between the vagina and 
 that viscus at least two inches in diameter. This was in December, 
 1845, and before the discovery of ansesthesia. He succeeded in clos- 
 ing the fistula in about an hour's time. In order to prevent the urine 
 from dripping through into the vagina, he placed a piece of sponge in 
 the neck of the bladder, through which he ran a silk string which 
 he hoped would act as a capillary tube that would serve to turn the 
 course of the urine from the fistula. This latter device proved to be 
 a very unfortunate one. At the end of five days the patient was very 
 ill from what, in more recent times, has come to be known as blood- 
 poisoning. On attempting to remove the sponge, he found that it had 
 
HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 33 
 
 beeomo soliditictl with sabulous matter Iruui the urine, and he had 
 great difficulty in reniovin<j; it. On examining the fistula, he found 
 that it had disap})eared with the exception of two small openings in 
 the line of the union of its edges. Eneoiu-aged by this })ron()uneed 
 success in healing the opening, he was confident that the small remain- 
 ing apertures could be closed by a subsequent operation ; before per- 
 forming which, however, he operated on another of his patients, using 
 in this case a self-retaining catheter instead of the sponge. At the end 
 of seven days he removed the sutures, but discovered that though the 
 original fistula had been greatly changed in character, there still 
 remained three little openings through which the urine escaped. In 
 spite of the repeated operations, having operated some thirty times on 
 one of the cases, extending through a period of three years, he found 
 himself unable to effect a complete closure of the fistula in any case. 
 He finally concluded that he should not perform another operation 
 until he had discovered some method of trying the suture higher up 
 in the body than he could reach. While lying in bed one night the 
 idea occurred to him to run a perforated shot along the suture to the 
 edge of the fistula, and when it was drawn tight to compress it Avith a 
 pair of forceps, thus making the knot perfectly secure. Elated with 
 this idea, he conducted flirther operations, but with scarcely any better 
 success than heretofore. He was now convinced that the cause of the 
 failure lay in the nature of the material employed for sutures — namely, 
 silk thread — and his nest object was to secure some substitute. Mat- 
 tauer of A^irginia had employed lead, and Sims had tried this material 
 as a suture in his cases of vesico-vaginal fistula, and had failed. At 
 this juncture, in walking from his house to his office one day, he picked 
 up a little piece of wire. Taking this to a jeweller, it served as a pat^ 
 tern for some pure silver wire which he ordered. In the next opera- 
 tion the edges of the womb were denuded and brought together with 
 four sutures of wire thus prepared, the suture being closed by means 
 of the shot run upon the wire and pressed with the forceps when run 
 sufficiently far up. In using silk sutures cystitis always resulted in 
 the case of operations at the base of the bladder, the urethra lieing 
 always swollen and the urine loaded with thick, ropy mucus. AVith 
 the use of the silver suture there was a complete change in these con- 
 ditions. After a week had passed the patient M'as removed from the 
 bed and placed upon an operating-table, and with an anxious heart 
 the result of the use of the wire suture was examined. There lay the 
 suture apparatus just exactly as it had been placed, with no inflam- 
 mation, no tumefaction, and perfect union of the fistula. At last the 
 labors of three years had been crowned with success, and vesico-vagi- 
 nal fistula was removed from the list of incurable affections. In the 
 course of two weeks the remaining patients in the hospital were 
 Vol. I.— 3 
 
34 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 operated on, and in every case the results were completely satis- 
 factory. 
 
 While it is manifestly the duty of the historian to select for his nar- 
 rative, without bias or favor, facts which he regards as the most indis- 
 putable, he ought not to be accused of exceeding his duty when he 
 notices claims which, although not disposed to concede them, he may 
 regard as entitled to respectful consideration. The name of Sims will 
 live in the history of medicine as that of the father of American 
 gynecology, but it is only just to state that the claims of priority for 
 some at least of the achievements which have won him this proud 
 title have been disputed. Among those who have contested these 
 claims, his contemporary. Dr. Nathan Bozeman, has been prominent. 
 He was associated with Sims in the early years of their practice, and 
 became his successor at Montgomer}^, Alabama, on Sims's removal to 
 New York. Unfortunately, a dispute as to the authorship of several 
 of the devices, wdiich have made the operation for vesico-vaginal fistula 
 a success, developed in later years, and became tainted with a consider- 
 able degree of acrimony. "With this dispute we have nothing to do, 
 further than to state that while history will endorse Sims's right to all 
 that he claims in connection with the discovery and perfection of the 
 operation, it will not deny to Bozeman an important part in helping 
 to establish the foundation on which American gynecology is erected. 
 Dr. Bozeman subsequently followed Dr. Sims to New York. Among the 
 discoveries with which his name will continue to be associated are his 
 knee-chest support, his self-retaining speculum, his button sutures — 
 instruments and methods now but little used ; also his method of auto- 
 plasty by gradual approaches, and his operation for the cure of chronic 
 cystitis through the establishment of a fistula leading into the vagina. 
 This operation was also independently discovered in the same year by 
 Dr. T. A. Emmet, who was the first to give it to the profession in 1868, 
 Dr. Bozeman's paper not having been published until 1871. 
 
 Dr. Sims's achievements, on which what may be called American 
 gynecology is founded, were wrought out in an obscure Southern town 
 and while engaged in the commonplace duties of the country general 
 practitioner. With no prestige of college connection, and none of the 
 backing which is generally considered necessary to distinction in a spe- 
 cialty, he won for himself the proud distinction, " Father of American 
 Gynecology." It was necessary, however, after having thus laid this 
 essential foundation that it should become known to the profession. 
 To this end Dr. Sims determined to repair to one of the medical 
 centres, and this the precarious state of his health compelled him to 
 do sooner than he would have otherwise done. Being the victim 
 of a chronic diarrhoea, his complaint made it necessary for him in 
 1853 to remove from the scenes of his distinguished labors, and he 
 
HISTORICAL SKETCH OF AMERICAN GYNECOLOCY. 35 
 
 deeicled on New York as his future home. The story of his earlier 
 years in that eity furnishes us a sin<i;ular ilhistration of the jealousy 
 of the obseure praetitioncr on the j)art of the gentlemen eonneeted with 
 the medical schools. An apparently systematic effort was made to 
 ap])vnpriate his work without credit, and the attempts of certain indi- 
 viduals in this direction reflect little credit on their memory. Alter 
 encounterinj»; o])j)osition and sutJering discouragements to which even 
 he, with all his enthusiasm and force of character, would have suc- 
 cumbed but for the support and cheer of an hen^ie wife, he was thrown 
 in the w'ay of a Mr. Henri L. Stuart, who, being a man of great influ- 
 ence in both the financial and social world, and becoming warmly inter- 
 ested in the object of Dr. Sims's ambition — namely, the establishment 
 of a woman's hospital — entered heartily into the project. At Mr. 
 Stuart's suggestion. Dr. Sims sent out notices to the general profession 
 that he would, on a certain day in ^lay, 1854, deliver a lecture in which 
 he would call the attention of all who might attend to the work which 
 he had done. In view of the treatment which he had received at the 
 hands of the gentlemen on whom he had called personally, he was \evy 
 much encouraged at the size of the audience which had responded to his 
 invitation. In spite of his innate diffidence, he succeeded in not only 
 interesting the meetino;, but in arousing it to a verv considerable decree 
 of enthusiasm. The plan of establishing a woman's hospital was 
 broached, and, largely through the influence of Mr. Stuart, the proj- 
 ect found favor Avith the public, and many prominent ladies of the 
 city became actively interested in the work. These ladies formed 
 themselves into an association, and in 1855 the object of Dr. Sims's 
 ambition was realized — the woman's hospital had become a fact. It 
 received very little encouragement from the leaders ; that is, the hospi- 
 tal-men. Dr. Sims w^as called by them a quack and a humbug, and 
 the hospital was pronounced a fraud. But in spite of the formidable 
 opposition from this source the work went on, the wards of the insti- 
 tution were opened to any doctor wdio cared to come, the operations 
 were performed in the presence of leading medical men, and the pro- 
 fession generally was welcomed to the institution. The hospital was 
 inaugurated on the 1st of May, 1855, at 83 ^ladison Avenue, shortly 
 after which Dr. Sims associated with himself Dr. Thomas Addis 
 Emmet, who Avas at that time a young man and unknown, but who 
 has since won for himself a reputation in gynecology second only to 
 that of Sims himself. The woman's hospital in 1857 secured a charter 
 from the State, and has from that time been known as " The Woman's 
 Hospital of the State of Xew York." This institution has been the 
 most important factor in the progress of American gynecology. Here 
 it was that a systematic method of treating the diseases peculiar to 
 women was first adopted. Until Sims's connection with it gynecology 
 
36 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 as a specialty was unknown, he being the first to give attention to it, to 
 the exclusion of all aifections not coming distinctively under its head. 
 Under his direction the facilities afforded by the Woman's Hospital 
 were utilized to the perfection of operations on the perineum, vagina, 
 and uterus, which previous to his immortal discoveries had been 
 unknown, but which, chiefly through the knowledge disseminated 
 from that centre, are now daily performed by even general practitioners 
 in all parts of the world, to the relief of untold suffering. 
 
 In 1861, Dr. Sims visited Europe. His reputation had preceded 
 him, and his reception both by the profession and the pul^lic was in 
 keeping, and he soon found himself with such a large clientele, in 
 nearly all of the European medical centres that he afterward devoted 
 his time about equally between both sides of the Atlantic, In 1865 he 
 published his Clinical Notes on Uterine Surgery, in which he embodied 
 the results of his special work, describing the operations which he had 
 devised and the improvements which he had made on the procedures 
 hitherto in vogue. This work made a very profound impression on 
 the professional mind, and it was soon translated into almost all mod- 
 ern tongues. It was, indeed, the most distinctive work on gynecology 
 which had been published, and may be said to be the basis of the spe- 
 cialty of gynecology as it exists to-day. Written in a style calculated 
 to carry conviction, it at once became the guide and gave impetus to 
 gynecological study. 
 
 On Dr. Sims's retiracy from the Woman's Hospital in 1862, Dr. T. 
 Addis Emmet became surgeon-in-chief, and under his charge the insti- 
 tution continued to grow both in popularity and usefulness. FoUoAving 
 the impetus given by Sims to gynecology as a specialty, a number of 
 American surgeons gave their attention exclusively to this branch of 
 work, and among those who at an early date thus devoted themselves 
 Thomas Addis Emmet, H. R. Storer, Xathan Bozeman, E. E, Peaslee, 
 T, Gaillard Thomas, James P, ^^Hiite, W, H. Byford, William Goodell, 
 and Robert Battey have attained marked distinction, and American 
 gynecology bears the indelible marks of their labors. Some of these 
 gentlemen are dead, and to write of them in terms of the enthusiasm 
 which their valuable work naturally arouses in a contemporary who 
 has closely watched their progress might be in keeping. It is, how- 
 ever, a delicate and very difficult task to write of the living, and it must 
 remain for a future historian to express out of the fulness of his heart 
 his estimate of those who, having done their life-work in this direction, 
 are now in the sere and yellow leaf, A bare record of their work is all 
 that is now permissible, 
 
 Dr, Emmet in 1859 withdrew from general practice, and has since 
 devoted himself exclusively to gynecology. He has been a diligent 
 worker in the field, and has contributed freely to medical periodicals 
 
HISTORICAL SKETCH OF AMh'RICAN GYNECOLOGY. 37 
 
 reports of the nsiilts lie 1i:h ;iclii<'\('(l. 'I'lic iiKtst notable of his coii- 
 tril)iititms |)('rt:iiii to the siibjcct of" laceration ot" the eei'vix uteri, detail- 
 iiit;' the etiology of the alfeetioii, its syiiij)t(»iiis, its oifeets on the consti- 
 tution, and the opei-ation for its I'elief. This operation is now distinct- 
 ively known as " Emmet's ojK'ration." It was first (h'seribed in 1809 
 in a paper road before the JNIedieal Society of the County of New 
 York, and pul)b"shcd in the February mnnber (l<S()t)) of tlie American 
 Joiii-na/ of ()/>sl('trlcs. In 1874 lie j)resented before the same society an 
 article on lacerations of the cervix uteri as a frecjneiit and unreco<j:;nized 
 cause of disease. The writer, not wishing to anticipate the events of 
 later years, nuist dismiss this subject here, but will allude to it at some 
 leuiith when writing of the occurrences of the last-mentioned year. 
 
 In 1854, Dr. E. R. Peaslee made a valuable contribution to the 
 treatment of se])tica?mia following ovariotcmiy. His method consisted 
 in the introduction of a tube into the peritoneal cavity, through ^yllich 
 the serous sac ^^•as freely washed out. Experience with this new method 
 has done much to remove the fear which was before entertained of inter- 
 ference with the peritoneal membrane. After the lapse of a third of a 
 century this method still remains as the most reliable for the treatment 
 of one of the gravest consequences to the operation for the removal of 
 ovarian tumors. In one of Peaslee's cases, reported at the time of his 
 introduction of this new method, intraperitoneal injections were kept 
 up for fifty-nine days, and in another for seventy-eight days, recovery 
 following in each case. 
 
 In 1856, Sims added another to his long list of brilliant achieve- 
 ments by publishing his operation for narrowing the vagina as a means 
 of curing prolapsus of the uterus. This advice was not strictly original 
 with him, although we have no evidence to show that he had imitated 
 any of his predecessors. The operation had been performed in Europe 
 many years previously, but had fallen into desuetude. 
 
 Dr. James P. White of Buffalo during the same year reported the 
 successful reduction by taxis of an inverted uterus of eight davs' stand- 
 ing: Dr. White was a pioneer in taking the position that chronic inver- 
 sion of the uterus is, as a rule, always reducible. He is distinguished as 
 the first successful operator in the country to reduce a chronic inverted 
 uterus. E. Noeggerath in 1862 practised reduction of inverted uterus 
 by digital compression of both horns ; and in 1868, Dr. T. Addis Emmet 
 reported that he had retained partial repositi<jn of the organ by closing 
 the OS externum with silver sutures. By means of this operation the 
 advance made at one sitting is not lost, and the case is thus all the 
 better prepared for future effort. 
 
 In 1861, Sims described the disease kno"\^Ti as vaginismus, and recom- 
 mended, as a means for its relief, the removal of the remains of the 
 hymen and the section of the tissues at the perineal extremity of the 
 
38 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 ostium vaginae. This aifection had been previously known to European 
 authorities, and forcible distension of the ostium vaginae, together with 
 alterative applications with a view to the modification of the local 
 nervous hypersesthesia, recommended for its relief. The operation pro- 
 posed by Dr. Sims was, however, an advance on the latter. 
 
 Prior to 1862 but one case of pelvic hsematocele had been published. 
 In this year this subject was brought prominently to the notice of the 
 profession by the appearance of three essays, written respectively by 
 John Byrne of Brooklyn, Fordyce Barker and Emil Noeggerath of 
 New York. 
 
 In 1866 appeared an excellent treatise on " Vesico-vaginal Fistula," 
 by M. Schuppert of New Orleans. It contained the history and 
 exhaustive summary of the operation, was illustrated, and embodied 
 the extensive . experience of a successful operator in this department 
 of surgery. 
 
 Dr. Theophilus Parvin reported in 1867 a case of uretro-vaginal 
 fistula in which he operated by turning the displaced distal extremity 
 of the ureter into the bladder, and then closing the vaginal opening. 
 The operation proved entirely successful, and was original with Dr. 
 Parvin. 
 
 In 1869, H. P. Storer published a "Method of Exploring and Ope- 
 rating upon the Female Rectum by Eversion of the Anterior Rectal 
 Wall by a Finger in the Vagina." Since then this " method " has 
 been quite generally adopted by gynecologists in certain cases. 
 
 In the same year V. A. Taliaferro of Georgia published an essay 
 on " Pathological Sympathies of the Uterus," which attracted some 
 attention. 
 
 In 1869, Dr. Julius F. Miner of Buifalo recommended, as an 
 improvement in the management of the pedicle after the removal of 
 an ovarian tumor, the stripping off from the tumor the expansion of 
 the pedicle instead of ligating and severing it. This mode of treat- 
 ing the pedicle was called by Miner " enucleating the pedicle." This 
 method is applicable in many cases, and when it can be applied is 
 much to be preferred to the ordinary methods of securing the pedicle 
 by clamp or ligature. 
 
 In 1870, Dr. T. Gaillard Thomas of New York removed an ovarian 
 cyst of the size of a large orange through an opening made through the 
 vagina and the cul-de-sac of Douglas. This was the first time that this 
 procedure had been deliberately adopted for this purpose. It has been 
 successfully practised since by Dr. Davis of Pennsylvania, Dr. Gilmour 
 of Alabama, Dr. Battey of Georgia, and others. In the same year an 
 important contribution to the current gynecological literature appeared 
 from the ready pen of H. R. Storer entitled " Anal Fissure in Women." 
 In the same year appeared an article entitled " Sudden Enlargement of 
 
HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 39 
 
 Ovarian (_'vst.s from llt'm()rrliajj;e into them," by the late brilliant and 
 lamcntecl John 8. Parrv, who afterward (187G) wrote so learnedly and 
 exhaustively on " E.\ti'a-iitei-ine Preii'nancy." Dr. F. D. Lente has 
 made many valuable contributions to gyneeologieal literature, his prin- 
 cipal article being " Intra-uteriue Medication" (1870), of which he was 
 a prominent advocate. Lente's silver probe and platinum cup were 
 devised tor the purpose of applying fusible substances, more particu- 
 larly nitrate of silver, to the uterine cavity. His method was a 
 marked improvement upcjn many of the other modes of intra-uterine 
 medication. It was considered very valuable when caustics were more 
 freely and more frequently used within the cavity of the uterus than is 
 customary at the present time. 
 
 In 1871, through the energetic efforts of Dr. A. Reeves Jackson, the 
 Woman's Hospital of the State of Illinois was founded. For a number 
 of years he was the surgeon-in-chief, but latterly a full staff of medical 
 officers has been in charge. Dr. M. S. Buttles claims to have been the first 
 (1871) to apply the actual cautery to the uterine cavity in the treatment 
 of submucous fibroids, and to be, therefore, the originator of that 
 operation. 
 
 In 1872, Dr. Robert Battey of Atlanta, Ga., reported a case of extir- 
 pation of the ovaries, the results of which justified him in recommend- 
 ing this operation for the relief of dysmenorrhoea due to imperfect 
 ovulation and accompanied by an excessive menstrual molimen, the 
 object of the operation being to establish at once the change of life, and 
 thus prove an effectual remedy for diseases otherwise incurable and 
 dependent upon ovarian irritation. He termed the operation " normal 
 ovariotomy." This name is not strictly applicable, inasmuch as it 
 implies a normal condition of the ovaries, and is thus nothing more or 
 less than spaying — an operation which has been practised from time 
 immemorial for the production of sterility. The important points con- 
 nected with this subject are best described in Dr. Battey 's o\\u words : 
 " I have operated in widely different circumstances. In one case the 
 patient had amenorrhoea, convulsions, recurrent hpematocele, repeated 
 pelvic abscesses, incipient tuberculosis from pulmonar}^ congestion, etc. 
 Several of the cases passed under the head of ovarian neuralgia ; several 
 had intractable dysmenorrhoea with pelvic deposits of old lymph ; one 
 had ovarian insanity, etc. All had exhausted the available resources 
 to no useful purpose. I operate upon no case that any other respectable 
 medical man proposes to cure. In most of my cases the full results 
 of the operation have not yet been developed. This is the work of 
 many months, and sometimes two or three years are necessary to its 
 full and perfect realization. In no case has the patient failed to realize 
 such a degree of relief and benefit following the operation as to amply 
 compensate her for the pains and dangers incident thereto, to say 
 
40 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 nothing of the promise of full and ample recovery at the completion of 
 the physiological change. In two of my cases this change has seemed 
 to occur at once in all its comjileteness, but it is always my expectation 
 that it will occur gradually, extending through two or even three years 
 to its final completion. In my first case, now nearly three years ago, 
 the restoration to health is eminently satisfactory. It is true that she 
 is not absolutely and perfectly well, but she is fully relieved of the con- 
 vulsions, the ovarian periodical congestions, the hsematoceles, the pelvic 
 abscesses, etc. for which I operated. I submit the question in all sin- 
 cerity : If I confine myself to cases where life is in danger or where 
 health and happiness are destroyed — cases which are utterly hopeless 
 of other remedy this side of the grave — ought the profession to demand 
 at my hands the restoration of these forlorn invalids to complete and 
 absolute health in every particular?" 
 
 The operation was originally performed by Dr. Battey in most cases 
 with the patient on the left side and by the aid of Sims's speculum. 
 " The cervix was drawn down to the pubes by means of a strong hook, 
 where it was held while Douglas's cul-de-sac was opened from the vagina, 
 by means of a pair of scissors. On reaching the ovary with the finger 
 as a guide it was seized by forceps or tenaculum and drawn into the 
 vagina. It was then separated by the ^craseur, or, being secured by 
 a silk ligature, it was cut oiF and the stump returned into the cavity, 
 the opening being left to close gradually, so as to admit of drainage." 
 Dr. Battey does not, however, confine himself to this method of opera- 
 tion, but removes the ovaries by abdominal section as well. Battey's 
 operation has been successfully performed by a number of practitioners 
 since his introduction of it, and a sufficient time has now elapsed to 
 permit a just estimate of its merits ; and there no longer remains any 
 doubt as to the propriety of its performance in cases which have resisted 
 all other means of treatment. The principal danger consists in its 
 performance at the hands of unskilled persons, and in the improper 
 selection of cases, which is very apt to occur in the practice of those 
 of limited experience in the treatment of diseases peculiar to women. 
 Dr. Sims's inferences from his experience in the performance of the 
 operation are as follows, and they are generally endorsed by those 
 qualified to pass an opinion : " 1st. Remove both ovaries in every case; 
 2d. As a rule operate by abdominal section, because if the ovaries are 
 bound down by adhesions it is possible to remove them entire, whereas 
 by vaginal incision it is not possible ; 3d. If we are sure that there has 
 been no pelvic inflammation, no cellulitis, no hsematocele, no adhesions 
 of the ovaries to the neighboring parts, then the operation may be made 
 through the vagina or otherwise." Dr. Goodell of Philadelphia formerly 
 preferred the vaginal method, and if he found it impossible to remove 
 the ovaries in that direction on account of adhesions or other causes, he 
 
IIISTOIilCAL SKF.TCII OF AMElllCAN GYNECOLOay. 41 
 
 woukl rosort to t\\v alMloiiiiiial .section, Icuvini; the Vii<i;iiial incision I'oi' 
 (Ici'p (lniina<;('. The timely \varnin<5 of" tlie experiencctl gyncolot>,'i,st u iio 
 ori*;-inatc(l it innst never be forgotten by those who essay the proceihire. 
 Dr. Emmet wonkl limit the operation to the cxtir])ation of Ixjth ovaries 
 for the arrest of hemorrha<;'e from a fibrous tumor and in cases of threat- 
 ened insanitv, ejiilepsy, or j)hthisis. For nervous disturbances which 
 j)rescnt more of tlie iiysterical element he maintains that th(! <jj)eration 
 should never be th()ui:;ht of. The operation, he thinks, may be more fre- 
 quently necessary in the present generation than it ought to be in the 
 future, since a large number of cases calling for it have, under inju- 
 dicious management, been already rendered incurable by other means. 
 He holds that in the future this ought not to be so, for our enlarged 
 opportunities for acquiring skill in the treatment of uterine and ovarian 
 diseases ought to enable us to raise our patients above the necessity of 
 such a terrible ordeal. This operation has of late come into very gen- 
 eral use, and has been performed by many operators both at home and 
 abroad. 
 
 During the year 1873 was published the eminently practical treatise 
 of Dr. D. Hayes Agnew of Philadelphia on " Laceration of the Female 
 Perineum and Vesico- vaginal Fistula, History and Treatment." The 
 profession is much indebted to this author for his earnest and valuable 
 labors in the branches of surgery of which this volume treats. 
 
 In the year above mentioned was published by the Government a 
 quarto volume entitled A Report of the Columbia Hospital for Women. 
 This was written by Dr. J. H. Thompson, the surgeon-in-chief of the 
 hospital. The book was very widely distributed throughout the coun- 
 try. It contains much valuable matter, but it encountered a great deal 
 of adverse criticism on the part of medical editors and reviewers fol- 
 lowing its publication. 
 
 In 1873, Dr. John Ball of Brooklyn described a plan of treating 
 constrictions and irregularities of the canal of the cervix uteri from 
 flexions and versions by rapid dilatation by expanding instruments of 
 steel. His method is to first evacuate the bowels very thoroughly, so as 
 to prevent all effort in that direction for two or three days. The patient 
 is then placed on her back with her hips near the edge of the bed 
 and profoundly anaesthetized. A three-bladed, self-retaining speculum 
 is introduced to bring the os uteri into full view. The os is then 
 seized with a double-hook tenaculum and drawn toward the vulva, 
 when an ample bougie, as large as the canal will admit, is introduced, 
 and followed in rapid succession by others until tlie canal is dilated to 
 admit of a Xo. 7, which represents the size of his dilator. With this 
 instrument the cervix is stretched in every direction until it is enlarged 
 sufficiently to admit of a No. 16 bougie. A hollow gum-elastic uterine 
 pessary of that size is then introduced, and retained in position by a 
 
42 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 stem secured outside of the vulva for about a week, in which time it 
 will have done its work and is ready to be removed. The patient dur- 
 ing this time is kept perfectly quiet, usually upon her back, which is 
 generally found to be the most comfortable position. Out of between 
 twenty and thirty cases in which Dr. Ball had to resort to this pro- 
 cedure he has met with but one fatal issue. Lately, Dr. Goodell of 
 Philadelphia has published a large number of cases operated on by 
 forcible divulsion with very gratifying results. The method has come 
 into very general use. 
 
 Early in this year Emmet published an account of the cause of fail- 
 ure and a new mode of operating for complete laceration of the peri- 
 neum. Heretofore, operators had not taken into account the fact that 
 the muscular fibres of the sphincter retract more than the others. Con- 
 sequently, only the external fibres were brought together, resulting 
 often in entire or partial failure to restore the retentive powers of the 
 anus, and frequently, while the external parts would be united and the 
 operator thought he had been successful, it was common to find that a fis- 
 tula resulted. By diagrams and descriptions he showed in his written 
 articles the manner in which the denudation must be made and sutures 
 placed in order to secure apposition of the inner as well as the outer 
 fibres of the sphincter : " If we examine careftilly the extremities of 
 the lacerated muscle, we shall find a slight pit or depression at each end 
 which has been caused by contraction of a portion of its fibres. At the 
 commencement of the operation a portion of the tissues at this point 
 must be seized with a tenaculum and removed with a pair of scissors, 
 together with a narro^v strip entirely around the laceration to the oppo- 
 site end of the muscle. After the edges of the muscles have been prop- 
 erly denuded the most important part of the operation is to introduce 
 the first suture in its proper relation to the edges of the divided muscle. 
 The manner in which these sutures should be introduced can only be 
 shown by diagrams, and is not essential in this connection. These 
 sutures are so adjusted that the divided edges of the sphincter are 
 turned up and appear in perfect apposition." 
 
 But he also taught the profession the importance of adjusting the 
 sutures in order to make this operation a success ; and as a result of 
 the teachings of this distinguished gynecologist his mode of operating in 
 these cases has become generally known, and is now the common prop- 
 erty of the profession. In his very latest writings he announces that he 
 has but little to add as the result of further experience to the paper 
 which was published during this year. He states that to unravel the 
 cause of failure in this operation and to devise means of obviating it 
 have occupied his attention for many years, and that they have cost 
 him more thought than he has ever devoted to any other professional 
 subject. 
 
HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 43 
 
 In IST.") nlso \)r. 'I'lidiims M. Drysilalc of IMiilndclpliia described a 
 j)0('uliar {•orpiisck' as characteristic of ovarian lliiid, and i'or a time it 
 was believed that a [)erl"ect means of diagnosis of the existence of cystic 
 ovarian tumors by microscopical examination of their contents could 
 be tleterniined ; but while Dr. Drysdale se;'ms to have been very suc- 
 cessful in diaj;'uosticatiug- ovarian tumors, others have not been so suc- 
 cessful. 'Pile late Dr. Atlee attached great importtmce to this method 
 of Dr. Drvsdale's, whose views U])on this matter may be sunuued uj) in 
 the fallowing words : " I claim, then, that a granular cell has been dis- 
 covered by me in ovarian fluid which differs in its behavior with acetic 
 acid and ether from any other known granular cell found in the abdom- 
 inal cavity, antl which by means of these reagents can be readily recog- 
 nized as the cell which has been described ; and further, that by the 
 use of the microscope and assisted by these tests we may distinguish 
 the fluid removed from ovarian cysts from other abdominal dropsical 
 fluids." 
 
 In this same year (1873) a paper which has been designated as a 
 remarkable one, and which excited much adverse criticism, was pub- 
 lished by Joseph R. Beck of Indiana, entitled " How did the Sperma- 
 tozoa Enter the Uterus ?" The patient of the doctor in whom sexual 
 orgasm could be produced by digital examination was the subject upon 
 whom his observations were made, which are reported as follow^s : " The 
 cervix uteri had been firm, hard, and generally in a normal condition, 
 with the OS closed so as not to admit the uterine probe without difficulty ; 
 but immediately the os opened to the extent of fully an inch, made five 
 or six successive gasps, drawing the external os into the cervix each 
 time powerfully, and at the same time becoming quite soft to the touch. 
 All these phenomena occurred within the space of twelve seconds' time 
 certainly, and in an instant all 'svas as before — the os was closed, the 
 cervix hardened, and the relation of the parts had become as before the 
 orgasm." According to Flint, Jr., Sitzmann of Germany published 
 similar observations in 1846. 
 
 In 1874 one of the most important contributions to the pathology 
 and treatment of diseases of the neck of the uterus was published by 
 Dr. T. Addis Emmet. It had long been known that childbirth caused 
 lacerations of the muscular portion of the neck of the uterus, but pre- 
 vious to his description no one had seemed to recognize how uniformly 
 such lacerations had been confounded with so-called ulceration of the neck 
 of the uterus, or how commonly the ectropion at the neck of the lip 
 resulting from such tears had been mistaken for hypertrophy of the 
 tissues. Emmet, recognizing these conditions, began to devise some 
 method for their cure, and he advocated for this condition the paring 
 of the edges of the ulcerated part and the bringing of them together 
 bv means of sutures. 
 
44 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 The mode of operating, as first laid down by Emmet, is to place the 
 patient on the left side, in the Sims position, and by means of a Sims 
 speculum bring the parts into view. Tlie first step is to bring the flaps 
 together in apposition, and while they are lifted up by means of a double 
 tenaculum in the hands of an assistant a uterine tourniquet is slipped 
 over the cervix below the point of vaginal junction, and tightened, 
 the object of this being to control hemorrhage during the operation. 
 The surfaces of the laceration are then freshened either with scissors 
 or scalpel, after which they are brought together by means of silver 
 sutures. One of the essentials to the success of the operation consists 
 in the complete removal of cicatricial or other adventitious tissue during 
 the freshening of the parts. 
 
 Since the introduction of Emmet's operation and the publication 
 by its author of the technique of the operation, other gynecologists 
 have adopted different means to accomplish the same results. The 
 uterine tourniquet is not deemed requisite to control hemorrhage, nor 
 is it the universal custom to place the patient in either the left or right 
 semi-prone position. It is no longer deemed a prerequisite to success 
 that silver wire must be invariably used, or that no other speculum 
 than Sims's will suffice. Hot water will control hemorrhage. The 
 dorsal— or, more commonly, the exaggerated lithotomy position, or 
 the position of Simon — is chosen by many. Silk, or catgut properly 
 prepared, is more easily introduced than silver, and is less liable to 
 cut tissues. The silkworm-gut suture is preferred by some. Some 
 of those who have used Simon's speculum a number of times prefer 
 it to Sims's. This procedure is now generally known as " Emmet's 
 operation." It is the belief of most American gynecologists — in 
 which the writer fully concurs — that this operation marks one of the 
 greatest advances in modern gynecology. At the same time, it is an 
 operation which is liable to many and great abuses. Owing to the fact 
 that so many neurasthenic women, as well as those suffering from neur- 
 algias from the imprisonment of nervules in the cicatricial tissue of the 
 torn uterine neck, have been relieved by this operation, many superficial 
 observers have resorted to it with such frequency as to often bring it into 
 disrepute. Many of our foreign brethren have also attempted to ridi- 
 cule the operation, but, in spite of all, the fact still remains that no one 
 operation or procedure of equal importance for the relief of suffering 
 women has been devised in the last quarter of a century. 
 
 In March of this same year (1874) Emmet, during an operation for 
 a submucous fibroid tumor of the uterus, discovered the value of trac- 
 tion during enucleation in producing a denuded pedicle. His mode 
 of operating was with scissors around the base of the tumor, and to his 
 surprise the raw surface thus left seemed much smaller than the orig- 
 inal base of the tumor. The value of traction was several years before 
 
HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 45 
 
 insisted upon by him, but not until Mai-ch, 1874, was he able to 
 demonstrate clearly that the attenuated pedicle was the eif'ect of the 
 traction, and not an accident. In a case operated upon at that time he 
 was able to encircle the broad basis of the tumor with his lingers and 
 feel tlie process of pedunculation fj^oinj^ on, as strong contraction was 
 produced bv traction, the contraction beginning at the fundus and run- 
 ning down in an oblique direction. On this account the traction should 
 be made as near the fundus as possible. In this case a base of three 
 inches in diameter became a pedicle of the size of a common lead-pencil, 
 and the point of attachment after removal was reduced to a small pit, 
 thus leaving an almost infinitesimal surface, comparatively speaking, 
 for the possible absorption of septic matter. 
 
 In the year 1874 there were two papers in the Boston Medical Jour- 
 nal upon pelvic drainage after ovariotomy, by Dr. Gilman Kimball of 
 Lowell, Mass., a distinguished pioneer in ovariotomy. Dr. Montrose 
 A. Fallen of New York published a description of the operation as a 
 substitute for amputation of the neck of the uterus in certain forms of 
 intravaginal elongation, which he termed vaginal cervi plasti. 
 
 In the same year Dr. Marion Sims contributed a valuable paper to 
 the JVew York Medical Journal upon the enucleation of intra-uterine 
 fibroids. 
 
 In this year also appeared a small work, written in a powerful style 
 by Dr. Edward H. Clark of Boston, entitled Sex in Education. No 
 work upon medical topics or any kindred subject in modern times suc- 
 ceeded better in attracting the attention of the people for whose benefit 
 it was written to the influence of the habits of modern life on the 
 sexual organs. 
 
 In 1875 a valuable and interesting paper appeared by Dr. J. R. 
 Chad wick of Boston in the American Journal of Obstetrics upon injec- 
 tion of nutritious or cathartic fluid into the intestines through the 
 abdominal walls by means of an aspirator needle when the stomach 
 proves entirely intolerant. 
 
 In this year Dr. Noeggerath of New York published in the Ameri- 
 can Journal of Obstetrics an interesting paper upon " Vesico- vaginal 
 and Vesico-reetal Touch — a New Method of Examining the Uterus 
 and Appendages." 
 
 In the Transactions for 1875 of the American Medical Association 
 is a paper by Dr. Byford of Chicago upon " The Treatment of Uterine 
 Fibroids by Ergot." This method, for the purpose of causing atrophy 
 of uterine fibroids, was first suggested by Hildebrandt, but Byfoi'd seems 
 to have been the first to advocate the use of this remedy in sufficiently 
 large doses to cause expulsion in addition to the atrophy. 
 
 In this same year was published a valuable and very interesting 
 paper by Dr. H. F. Campbell of Georgia upon " Position, Pneumatic 
 
46 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 Pressure, and Mechanical Appliance in Uterine Displacements." This 
 gentleman has from time to time written several papers bearing upon 
 the same subject. He advocated replacement of uteri, if posteriorly 
 displaced, by the patient assuming the knee-chest position, and the 
 introduction of a glass tube into the vagina while this jDOsition is 
 maintained. This position, by favoring the gravitation of the viscera 
 forward, together with the introduction of air into the vagina through 
 the glass tube, will often effect reposition of the displaced organ. 
 
 In this same year an interesting paper was contributed to iYie Rich- 
 mond and Louisville Medical Journal by Dr. Goodman of Louisville 
 upon "" Menstruation and the Law of Monthly Periodicity." Dr. 
 Brickell of New Orleans contributed also an article upon " Rupture 
 of the Perineum, with a Description of a New Operation." 
 
 In 1875, Alexander Skene of Brooklyn performed the operation of 
 laparo-elytrotomy, with a result never before attained. The patient was 
 a dwarf with a rachitic pelvis, who had been three times delivered — 
 twice by premature delivery and once by craniotomy. In her fourth 
 pregnancy Dr. Skene allowed it to advance to the full term, and then, 
 after labor had begun, he performed the operation, saving the mother 
 and a healthy child of ten pounds' weight. This operation might more 
 properly be designated as one pertaining to obstetrics, and yet we cannot 
 forbear alluding to it here. It is one that had attracted the attention 
 of obstetricians in our own country and in Europe at different times, 
 and had been essayed by Skene in 1874, but first by T. Gaillard 
 Thomas in 1870, who states that he did it without a knowledge of the 
 fact that he been anticipated in the procedure by Baudeloque. In Dr. 
 Thomas's case the patient died in one hour, and the child, premature 
 and imperfectly developed, also almost simultaneously. 
 
 The year 1876, being termed the "Centennial year," as it was the 
 year in which this country celebrated its hundredth anniversary as an 
 independent nation, was rich in gynecological work. It also marks 
 the beginning of a very important epoch in American gynecology — 
 namely, the formation of the American Gynecological Society. In 
 response to a summons issued May 24th a number of gynecologists 
 from various parts of the United States came together at the hall of 
 the Academy of Medicine in the city of New York for the purpose of 
 forming a society for the advancement of the special department of 
 medicine in which they were chiefly interested. The meeting was 
 called to order by Dr. Chadwick of Boston, who had taken the most 
 active part in the formation of the society, and was organized by the 
 election of Dr. E. R. Peaslee of New York as chairman and Dr. 
 Chadwick as clerk. Remarks was made by Dr. Peaslee upon the 
 importance of such a society, and by Dr. Chadwick, who said that 
 " the call to which vou have responded by your presence here to-day 
 
HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 47 
 
 was acklrossod to a liiuitcd miinlKT of rwoi^iiizeil fi;vnc('()l()<>i.st.s after 
 consultation witli several of the [)r(>niinent men of IJoston, xSew York, 
 riiihulelpliia, and the West. It was not intended to include all those 
 whose labors in this field of medicine would fully entitle them to an 
 honored place in our ranks, but simply to form a nucleus around which 
 o'vnecologists of the country should cliLstcr. It seems a most fitting 
 tribute to our national <>reatness that those who have striven to advance 
 the noble cause of humanity, of science, of art in any of their depart- 
 ments should take ste[)s in this Centennial year to prosecute their labors 
 in the coming century with reucAved vigor and under more favorable 
 circumstances." These remarks apply with more than common force 
 to the branch of medicine in which America can justly claim to stand 
 pre-eminent. Tiiere were at this inaugural meeting the following gen- 
 tlemen : Drs. Fordyce Barker, E. R. Peaslee, T. A. Emmet, T. G. 
 Thomas, J. M. Sims, I. E. Taylor, E. Noeggerath, W. T. Lusk, P. 
 F. Munde, of New York ; John Bvrne, A. J. C. Skene, of Brooklyn ; 
 A. D. Sinclair, G. H. Bixby, J. R.'Chadwick, of Boston; W. Goodell 
 of Philadelphia; J. D. Trask of Astoria, N. Y.; T. Parvin of Indian- 
 apolis ; W. H. Byford of Chicago ; and Ed. W. Jenks of Detroit, Mich. 
 
 Letters were read from Drs. D. H. Storer, C. E. Buckingham, G. 
 H. Lyman, AV. L. Richardson, of Boston ; W. L. Atlee, R. A. F. 
 Penrose, E. Wallace, A. H. Smith, T. M. Drysdale, J. Y. Ingham, 
 of Philadelphia ; S. C. Busey of Washington ; E. Van de Warker 
 of Syracuse ; J. P. White, of Buffalo ; R. Battey, of Rome, Ga. ; 
 J. C. Reeve, of Dayton, O. ; and G. J. Engelmann, of St. Louis. On 
 motion these gentlemen were added to the list of Fellows, and were 
 considered as founders of the society. 
 
 A committee consisting of Drs. Trask, Sinclair, Jenks, Noeggerath, 
 and Lusk Avas appointed by the chair to nominate a list of officers for 
 the first annual meeting. The following list of officers was reported, 
 and the gentlemen unanimously elected : President, Fordyce Barker ; 
 Vice-Presidents, W. L. Atlee, W. H. Byford ; Council, J. M. Sims, W. 
 Goodell, T. Parvin, G. H. Lyman; Secretary, J. R. Chadwick; Treas- 
 urer, P. F. Mund6. 
 
 The first annual meeting of the society was held in the same place 
 Sept. 13, 14, and 15, 1876, at which twenty-eight Fellows were pres- 
 ent. This society has since its organization, although not numbering 
 among its Fellows all of the able gynecologists of our country, reallv 
 represented the progress of American gynecology. Its annual volumes 
 of Transactions have shown the rapid progress made in this specialty, 
 and have given evidence of much original work, and each year its list 
 of Fellows has been augmented by the election of new members, and, 
 although many of its founders have passed away, the character of the 
 societs^'s work has continued to be of the highest. 
 
48 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 Dr. Lyman of Boston published a paper on the theory entitled " A 
 Theory of the Cause of Menorrhagia/' with a list of cases treated with 
 success by dilatation, which reads substantially as follows : '^ Dilatation 
 of the cervix for surgical and diagnostic purposes is an old procedure, 
 but that it should be followed by arrest of hemorrhage, although 
 observed by some, was not publicly noticed until 1869 by Dr, Sims." 
 In 1876, Dr. Lyman of Boston reported a short list of cases in which 
 he had used dilatation with success in menorrhagia, and advanced the 
 following theory : " In menorrhagia there is constriction of the vessels 
 at the internal os, giving rise to congestion of the tissues above : such 
 constriction doubtless is due to some morbid condition beneath the 
 mucous membrane. Hence this operation is beneficial, although the 
 opening through the canal be apparently sufficiently large. Precaution 
 is to be taken that the hemorrhage is not due to malignant disease, and 
 that there is no cellulitis nor peritonitis." 
 
 In this same year a valuable paper was published by Dr. Skene on 
 the principles of gynecology as applied to obstetrical operations. 
 Although not wholly original or the first time that many of his 
 theories were enunciated, it is well worthy of mention in a history 
 of American gynecology. Dr. Skene advocated the use of Sims's 
 speculum in performing craniotomy and in using the cephalotribe, 
 perforation being recommended to precede the use of that instrument. 
 The use of Sims's speculum also facilitates the carrying out of Thom- 
 as's method of replacing a prolapsed cord ; also the introduction of 
 Barnes's dilators. He also recommended the use of the speculum in 
 applying the tampon for arrest of hemorrhage and in the use of the 
 curette or the scoop in removing the ovum. 
 
 In 1876, also. Dr. Noeggerath of New York read a paper at the 
 American Gynecological Society upon latent gonorrhoea, especially with 
 regard to its influence on fertility in woman. This was his first paper 
 in the English language upon the subject, as the one in 1872 was pub- 
 lished in the German language in Bonn. This paper has given rise to 
 much discussion, favorable and unfavorable, and frequent allusion to it 
 has been made in home and foreign journals. The jjaper and the 
 author's conclusions are certainly unique, and we cannot forbear to 
 allude to the latter, which he summarizes as follows : 
 
 " 1st. Gonorrhoea in the male, as well as in the female, persists for 
 life in certain sections of the organs of generation, notwithstanding its 
 apparent cure in many instances. 
 
 " 2d. There is a form of gonorrhoea which may be called latent gon- 
 orrhoea, in the male as well as the female. 
 
 " 3d. Latent gonorrhoea in the male, as well as in the female, may 
 infect a healthy person either with acute gonorrhoea or gleet. 
 
 " 4th, Latent gonorrhoea in the female, either the consequence of an 
 
HISTORICAL SKETCH OF AM ERICA X GYNECOLOGY. 49 
 
 acute li'onorrhti'al invasion (»r not, iC it j)a>scs I'roni tlic latent into the 
 apparent condition manifests itself iis uciite, chronic, ro(;urrcnt peri- 
 metritis or ovaritis, or catarrh of certain sections of the genital or^^ans. 
 
 *' 5th. Latent gonorrha'a in becoming apparent in the male does so 
 by attacks of gleet or epididymitis. 
 
 '' Gth. Abont J)0 percent, of sterile women are married to husbands who 
 have suifercd from gonorrhoea, j)revionsly to or during marrietl life." 
 
 In 187G, Dr. Jenks of Detroit i)ublishcd the result of his observa- 
 tions ou the use of Vibunxam pruni/oliain in the treatment of disea-ses 
 of women. This remedy had a limited use for some years as a preven- 
 tive of abortion, it having been iirst introduced by Dr. Phares of Mis- 
 sissippi. The writer advocated the use of this remedy in all forms of 
 dysmenorrhwa attended Avitli profuse menstruation. It is not sufficiently 
 stnlative, if given alone, to fully relieve the sufferings of spasmodic 
 dysmenorrJKpa. It is, however, a valuable adjuvant to sedative and 
 antispasmodic remedies. In dysmenorrhoea with menorrhagia caused 
 by fibroid gro^^i:hs viburnum, in combination "with ergot, has proved 
 much more valuable than either remedy given without the other. The 
 writer gave, as a general statement concerning the uses of viburnum, 
 *' that it is serviceable in all uterine disorders characterized Iiy loss of 
 blood." Since Dr. Jenks's paper was published the remedy has come 
 into more general use, and the results have shown that too much was 
 not said in its praise. 
 
 In this year also the first ten cases of Battey's operation by Dr. 
 Battey were published, the following results being claimed for the 
 operation in the cases reported : Complete relief, 3 ; temporary relief, 2 ; 
 life prolonged, 1 ; no benefit, 2 ; death, 2. 
 
 In the same year there was published by Henry C Lea of Philadel- 
 phia a small volume entitled A Century of American Medicine, Dr. T. 
 G. Thomas contributing the chapter on obstetrics and gynecology. Xo 
 one except those who have had occasion to search through the volumes 
 and periodicals for historical matter can flilly appreciate the labor 
 which such an able paper must have cost its author. It contains a 
 summary of ever}i:hing of importance that had been previously done 
 in these departments by the profession of this country. 
 
 In 1877 a paper was published by Dr. Brickell of Xew Orleans on 
 the diagnosis and treatment of pelvic effusions. Three cases are 
 reported by Dr. George H. Bixby, one by Dr. Byford, treated by 
 aspiration either through the abdominal walls or per var/inam, the 
 latter site being preferred. The history of these cases is valuable as 
 showing the progress in the diagnosis of pelvic effusions and the relief 
 afforded by this mode of treatment. Dr. Brickell considers the removal 
 of a collection of serum in the cellular tissue as necessar}' as the removal 
 of a collection of pus. 
 
 Vol. I.— 4 
 
50 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 A paper was read before the American Gynecological Society by Dr. 
 Goodell on the subject of vaginal ovariotomy. This operation was 
 first performed by Washington L. Atlee, but the first premeditated 
 vaginal ovariotomy was, as previously stated, performed by Dr. T. G. 
 Thomas in 1870. Dr. Goodell, in discussing the subject, concludes 
 that while this operation can never rival the ordinary operation, it is 
 preferable in rare cases — namely, where a small polycyst lodges in 
 Douglas's pouch or an unadherent monocyst protrudes into the pelvic 
 cavity. The difficulties met with in this operation are from prolapsus 
 of the intestines and unforeseen adhesions. In this same year Dr. Paul 
 r. Munde made a valuable reports on the treatment of ovarian tumors 
 by electrolysis. Dr. Von Ehrenstein claims to be the originator of this 
 method, and, although this claim is disputed, he has at least had a 
 larger experience than any other in its use. It was brought more 
 prominently into notice by an announcement in 1875 of Dr. Semelleder 
 of Mexico. Dr. Mund^, from his own experience and that of others, 
 draws the following conclusions regarding the operation : That this 
 method is most apt to be beneficial in cases where the tumor is mono- 
 cystic, and yet so small as not to demand the radical operation ; or a 
 polycyst with thin walls and fluid contents, and absence of large and 
 solid masses ; or a large unilocular or multilocular tumor, in which 
 adhesions are so extensive as to render ovariotomy dangerous. 
 
 Although it has long been known that mental aberrations may be 
 caused by the sexual disturbance occurring at the time of puberty, 
 menopause, during pregnancy, the puerperal state, and lactation, the 
 idea of connecting this abnormal mental state with disease of a non- 
 gravid uterus is modern. The first in this country to call attention to 
 the causative relations of uterine and ovarian disease to mental dis- 
 turbances in women were Dr. Fordyce Barker of New York and Dr. 
 H. R. Storer of Boston. The former published an article upon this 
 subject in 1872, and the latter a monograph upon the same subject in 
 1871, while both had promulgated their ideas by lectures some years 
 previously. 
 
 In 1877, Dr. George J. Engelmann made a valuable collection of 
 facts concerning hystero-neurosis. These show that neuroses of the 
 brain, pharynx, larynx, eye, stomach, intestines, bronchii, and joints 
 of severe and misleading character are frequently produced by non- 
 development or disease of the uterus or ovaries, or both, or by peri- 
 uterine disease. That the apparent disease of the organs named was a 
 neurosis was proved by its disappearance upon removal of the abnor- 
 mal condition of the uterus. 
 
 In 1878 there appeared a paper on the causes of vesico-vaginal fis- 
 tula by Dr. T. A. Emmet, in which he exonerated the forceps from 
 the charge that has been laid to them of frequently causing such lesions, 
 
HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 51 
 
 ami attributed the l'iv(|uciicy ol' tistiilii rather to delay in delivery and 
 the neglect to use the catheter before instrumental delivery. 
 
 In this same year appeared in the Ncio York Medical Journal a very 
 valuable contribution from tiie facile pen of Dr. T. G. Thomas on the 
 most eti'ectual method for controlling the high temperature occurring 
 during ovariotomy. Dr. Thomas's method is as follows : Upon a 
 Kibbee fever-cot a folded blanket is laid, so as to protect the patient's 
 body from cutting by the cords of the netting. At one end is placed 
 a pillow covered with india-rubber cloth, and a folded sheet is laid 
 across the middle of the cot to -about two-thirds of its extent. Ujjon 
 this the patient is now laid : her clothing is lifted up to the armi)its 
 and the body enveloped by the folded sheet, which extends from the 
 axillffi to a little below the trochanters. The legs are covered by flan- 
 nel drawers and the feet by warm woollen stockings, and against the 
 soles of the latter bottles of warm water are apj^lied. Two blankets 
 are then placed over the patient and the application of water is made. 
 Turning the blankets down below the pelvis, the physician now takes a 
 large pitcher of water at from 70° to 80° F., and pours it gently over the 
 sheet. This it saturates, and, percolating the network of the cot, it is 
 caught by the india-rubber cloth beneath, and, running down the gutter 
 formed by this, is received in a tub placed at its extremity for that pur- 
 pose. Water at a higher or lower temperature than this may be used. 
 As a rule, it is better to begin with a high temperature, 85° to 90°, and 
 gradually diminish it. The patient now lies in a thoroughly soaked sheet 
 with warm bottles to her feet, and is covered up carefully with dry blank- 
 ets. Neither the portion of the thorax above the shoulders nor the infe- 
 rior extremities are wet at all. The water is applied only to the trunk. 
 The first effect of the affusion is to elevate the temperature, but the 
 next, wdien the application is practised for an hour, usually brings it 
 down. The water collected in the tub at the foot of the bed, having 
 passed over the body, is usually eight or ten degrees warmer than 
 when poured from the pitcher. This mode of procedure has been 
 modified by others, but still it is to Dr. Thomas that we are indebted 
 for this effective means of reducing the temperature. 
 
 In this same year Dr. E. Van de Warker of Syracuse, N. Y., con- 
 tributed a valuable paper containing some original opinions upon the 
 treatment of adhesions and indurations. The objects of treatment in 
 this case are — 1st, to allay pain ; 2d, to produce absorption. For the 
 first object anodynes — namely, opium or opium combined with Vibur- 
 num prunifolium — are valuable. JNIore important, however, though act- 
 ing less quickly, are rest, postural treatment, hot fomentations, and an 
 occasional blister. Swinging in a hammock admirably combines a 
 soothing feeling, from the gentle motion, with relaxation of the abdom- 
 inal muscles and elevation of the hips. The continuous current, ten 
 
52 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 to sixteen cells, indirectly through the system and through the indura- 
 tion, is also important. The agents for producing absorption are less 
 direct, but still more valuable — ^viz. the galvanic current directly 
 through the mass, one electrode being placed in the vagina and one on 
 the abdomen. The internal us,e of ammonium chloride markedly less- 
 ens the size of the mass, producing absorption, probably by its eifect 
 upon the portal circulation. Careful handling at a later stage not only 
 hastens absorption, but also tends to reduce the tenderness. The best 
 method is by bimanual manipulation, a gentle to-and-fro motion given 
 the mass by rolling it between the hands, one of which is placed against 
 the vaginal and the other against the abdominal side. If the mass is 
 situated in the iliac fossa, then the bone aifords sufficient internal sup- 
 port, and but one hand is used. 
 
 In 1878, Dr. Henry J. Bigelow of Boston reported a number of 
 cases operated upon by a method which he had devised for crush- 
 ing and removing the fragments of stone in the male bladder. He 
 demonstrated that tolerance by the bladder of protracted manipula- 
 tion is greater than heretofore recognized, and that the operation of 
 lithotrity can be done at one sitting. The article of Dr. Bigelow is of 
 great importance, and even more applicable to the female bladder when 
 no cystitis or thickening exists. 
 
 In 1879, Dr. Edward W. Jenks of Detroit published, in the Amer- 
 ican Journal of Obstetrics, a paper upon perineorrhaphy, in which he 
 described a method devised by himself for denuding the mucous sur- 
 faces with but little loss of blood. His method, given in his own 
 words, is as follows : 
 
 " The patient being etherized, I begin by cutting with a scissors the 
 anterior margin of surface to be denuded at the juncture of integument 
 and mucous membrane. Next I introduce two fingers of the left hand 
 into the rectum, while assistants hold the labia apart, it being important 
 that they are held uniformly tense. I use scissors slightly curved and 
 sharp-pointed to denude the mucous membrane. I use neither tenacu- 
 lum nor tissue-forceps, but with the parts tense snip a hole in the 
 mucous membrane in the median line close to the integument, and 
 then, inserting the scissors with a cutting motion into the small hole 
 made, I continue to dissect the mucous membrane away from adjacent 
 tissues without removing the scissors, first going up the septum as far 
 as desired, and then laterally, first on one side and then on the other, 
 without removing the scissors or once bringing their points out from 
 beneath the mucous membrane. Then with blunt-pointed scissors I 
 cut away the dissected flaps. The advantages of this method are — a, 
 the rapidity with which it can be done ; h, the absence of hemorrhage 
 in the vagina, as no blood escapes at the locality where the scissors enter 
 beneath the mucous membrane ; c, the ability with which the operator 
 
HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 53 
 
 can make cuinplcte (Icmidaliuii, its tlie disculoratiuii hciicatli the luiu-ou.s 
 nionibraiie marks tlie route the scissors have taken. This mode of 
 operating is only applieahle where tliere is redundancy of tlie tissues, 
 autl not where there lias been great loss of substance, as in cases where 
 the septum has been torn to any great extent." 
 
 The same author describes also in the same paper a new method of 
 securing the sutures in the operation of kolpo-perineorrliai)hy. 
 
 In this same year there was a valuable contribution on the subject 
 of ovarian diseases made by Dr. Munde, entitled " Prolajisus of the 
 Ovaries." In this paper he gave points in diagnosis and modes of 
 treatment. INIention, however, had been made of this subject in the 
 Journal of the Gynecological Society of Boston in 1872 by Storer, 
 Warner, and Blake. In this publication, covering the results of his 
 observations, ]SIunde calls attention to the fact that uncongested ovaries 
 may become prolapsed, and in turn prolapsus leads to congestion. He 
 calls attention to points now well known, that many of these cases were 
 undetected, and directs attention to the physical and mental derange- 
 ments to which they lead. He also directs attention to the value of 
 the genu-pectoral position and Sims's speculum as aids in their replace- 
 ment. In the discussion which followed this paper, which was read 
 before the American Gynecological Society, Dr. Barker recommended 
 suppositories of iodide of lead if painting the vaginal roof with iodine 
 produced too much irritation. Drs. Bozeman and Munde had found 
 iodoform useful in these cases for the relief of the hyperaesthesia. Dr. 
 Albert H. Smith advised examination by rectum for diagnostic pur- 
 poses, and Dr. Skene alluded to the pain during and after defecation as 
 a diagnostic symptom. Dr. Taliaferro of Atlanta, Ga., was the first to 
 suggest packing the vagina with cotton tampons to support prolapsed 
 ovaries. In April, 1878, Dr. Taliaferro, in a paper read before the 
 Medical Association of Georgia, advocated pressure by the tampon as a 
 therapeutic in the treatment of uterine and periuterine diseases. 
 
 In 1880 a paper was written by Dr. Chadwick advocating the use 
 of hot rectal douches in the treatment of pelvic inflammations. 
 
 At the meeting of the American Gynecological Society in 1880, 
 C. D. Palmer of Cincinnati read a full and instructive paper entitled 
 " Laparotomy and Laparo-hysterotomy, their Indication and Statistics 
 for Fibroid Tumors of the Uterus." 
 
 In this year also a paper was read by Dr. A. Reeves Jackson of 
 Chicago, at a meeting of the American Gynecological Society, on 
 " Uterine Massage " as a means of treating certain forms of enlarge- 
 ment of the womb, which, although not wholly original with the writer, 
 gave rise to some considerable discussion in home and foreign medical 
 journals. 
 
 In 1881 an interesting paper was published by Dr. Van de Warker 
 
54 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY, 
 
 in which he recommends forcible elongation of pelvic adhesions in cases 
 where they cause pain during defecation or other straining eiforts. 
 
 In this year Dr. Thomas published a paper Upon " Laparotomy com- 
 plicated by Expansion of the Bladder over the Surface of Abdominal 
 Tumors, and its Attachment to them or to the Abdominal Walls." He 
 made a collection of reports and cases, and offered the following mode 
 of procedure : "As diagnosis even by the sound is difficult, if it is not 
 impossible, this complication is not perceived until the abdominal 
 incision is made or the bladder laid open. If it happens to be 
 attached to the abdominal parietes, the bladder should be separated 
 by digital detachment. If adliesion is too close, then incise the ante- 
 rior wall of the bladder ; if incision has not already been made, with 
 two fingers in the bladder as a guide the adhesions can be cut. Then 
 clamp the edges of incision between the lips of the abdominal wound, 
 and close by silver sutures." 
 
 An interesting paper by Dr. William Goodell of Philadelphia was 
 published on " Bursting Cysts of the Abdomen," in which the author 
 alludes to the great difference, as far as danger is concerned, between 
 parovarian and ovarian cysts, the contents of the former usually being 
 limpid and innocuous, and the fluid eliminated frequently by the kid- 
 neys, intestines, or skin, and is usually rapidly taken out. In case of 
 the bursting of ovarian cysts the danger is much greater. He alludes 
 to a case seen by Dr. Sims in 1856 which burst three times, the fluid 
 being eliminated by each of the three channels mentioned — one entirely 
 by the kidneys, another entirely by the intestines, and the remaining 
 one wholly by the skin. 
 
 In 1882, Dr. Emmet brought to the notice of the profession his new 
 method of exploration and treatment of the urethra by the " button- 
 hole incision," as he designates it. He first essayed this method in 
 1879. It consists of a buttonhole incision in the urethra extending 
 from near the meatus to a short distance from the neck of the bladder, 
 the greatest length being on the vaginal mucous membrane. Retention 
 is not impaired, and diagnosis and treatment are greatly facilitated. The 
 special advantage of this method is the facility which it offers to the 
 diagnosis and treatment of polypi or other growths about the neck of 
 the bladder. After the cure is effected the opening is easily closed. 
 
 In this year Dr. J. C Warren of Boston offered a new method of 
 operation for laceration of the perineum involving the sphincter and 
 rectal wall. The operation consists in dissecting a butterfly flap from the 
 posterior vaginal wall above the rent, and a similar flap from above down- 
 ward, leaving plenty of attachment around the entire edge of the rup- 
 tured rectal wall and sphincter. The flap is turned downward, cover- 
 ing the rectal rent. The freshened edges of the sphincter are brought 
 together over the flap, which hangs out of the anus like a small hemor- 
 
HISTORICAL SKETCH OF AMERICAN GVy ECOLOGY. 55 
 
 rlioid. All iV('sli('iu'<l surfaces arc then hnmj^ht in coaptation, the flap 
 being; laid in folds. The i)art hanging- troni the anus if not too long 
 will draw up as cicatrization takes place. 
 
 In Januarv of this year Dr. Christian Fen<i;er of Chieajro recorded 
 the first successful operation of kolpo-hysterectoniy for uterine cancer, 
 at which time he also advocated the operation as a justifiable one. Dr. 
 (). Stroinskv of C'hicairo in this year reported a novel operati<tn for 
 traumatic rupture of the bladder : while removing a fibroid jxtlypus 
 from the bladder by twisting he made a rent into the anterior wall, 
 inverted the whole bladder through the dilated urethra, repaired the 
 rent by three sutures, and replaced the bladder. The result wa.s 
 recovery. 
 
 In 1883, Dr. C. C. Lee read before the American Gynecological 
 Society a paper on the injiu-ies of the gravid uterus as a complication 
 of laparotomv. From a study of a necessarily small collection of cases 
 both at home and abroad, the first occurring in 1856, Dr. Lee con- 
 cludes that — 1st, the gravid uterus may be wounded without neces- 
 sarily producing abortion ; 2d, abortion seems to depend upon opening 
 the ovisac ; 3d, if the uterine contents are injured Csesarean section is 
 indicated, after which drainage may be maintained through the dilated 
 cervix ; 4th, if the uterine contents are uninjured, the wound is to be 
 treated on general principles — namely,* exact coaptation by carbolized 
 sutures. 
 
 In this year, too, Emmet describes a new operation for so-called 
 laceration of the perineum. It is considered particularly useful where 
 there are large rectoceles. In this paper he holds that the loss of sup- 
 port following the laceration produced by childbirth is not due to the 
 injury of the perineal body. In fact, he denies the existence of any 
 such body, and claims that the injury is due rather to the detachment 
 of perineal muscles and the perineal fascia. The description of this 
 operation by the author is by no means lucid, but it substantially con- 
 sists in a semilunar form of denudation, wholly within the vagina, 
 of such extent that when the edges are brought together by means 
 of sutures the " slack " in the posterior M-all is entirely taken up or 
 made to disappear, and yet the ostium vaginae is in no way denuded or 
 directly interfered M'ith. The advantages claimed are — great diminu- 
 tion in the discomfort following immediately after the oj^eration, and 
 the perfect juxtaposition of the anterior and posterior vaginal walls, as 
 in the non-parous woman. 
 
 In the Transactions of the American Gynecological Society for 1883 
 appears a paper by Dr. E. W. Jenks describing a new mode for operat- 
 ing for fistula in ano. In the same volume is a paper of Dr. Emmet's, 
 in which he alludes to having performed the operation in the same 
 manner, neither <rentleman havino- been aware of the fact that the other 
 
56 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 had performed the operation. Dr. Jenks's first operation was on March 
 31, 1881. The operation consists in incising the fistulous tracts after 
 the usual method, dissecting out the so-called pyogenic membrane and 
 all lardaceous and cartilaginous substances along the route of the fistula, 
 and also cutting away all portions of thin livid skin of low vitality. The 
 incised parts are maintained in perfect apposition by means of deep and 
 superficial sutures until adhesion is effected. 
 
 In this year Dr. W. H. Byford published an interesting paper upon 
 chronic abscesses of the pelvis, and the following jDoints are made 
 prominent : When the surface of a pelvic abscess is identical with that 
 of an external ulcer, granulations may be exuberant or freely movable 
 and flabby or firm and vigorous. When the granulations are exuberant, 
 forming large projections into the abscess-cavity, its surfaces should be 
 curetted. The same operation is also indicated when early suppuration 
 takes place in pelvic hsematoceles, in order to remove the clots which 
 suppuration cannot dispose of. As granulations disappear and cicatri- 
 zation takes place the contents of the abscess undergo changes. Serum 
 exudes, macerating and finally disintegrating the pus-corpuscles and 
 causing them to disappear. Osmosis going on through the cicatricial 
 membrane converts the contents into simple serum. There then results 
 an encysted tumor containing serum-like fluid. 
 
 It is believed that Dr. Charles K. Briddon was the first in the United 
 States to perform laparotomy after rupture of the foetal sac in tubal 
 pregnancy. This he did in October, 1883. 
 
 Dr. Matthew D. Mann was the first to publish a successful operation, 
 performed in February, 1883, in which he removed a small subperitoneal 
 fibroid tumor of the uterus through the anterior wall of the vagina. 
 
 In this year an operation for the cure of retroversion of the uterus 
 was described by J. B. Hunter of New York. Dr. O. E. Herrick of 
 Michigan had also performed and reported the same operation, each 
 gentleman working independently. The latter, however, it is believed, 
 is entitled to the credit of being the first to perform the operation. 
 The operation consists of a denuded surface upon the posterior lap of 
 the uterus which is united by sutures to a similarly denuded surface 
 upon the posterior vaginal wall. 
 
 In the January number of the American Journal of Obstetrics of this 
 year Dr. Garrigues of New York published a paper upon laparo- 
 elytrotomy. In this paper he alluded to the place of incision and the 
 position of the ureters, and pointed out how they might be avoided 
 during operations. Dr. Polk of New York had written upon the sub- 
 ject the previous year, and Dr. Garrigues had himself investigated it 
 in 1878. Drs. Polk and Garrigues agree, from experiments made upon 
 the cadaver, that in the operation of laparo-elytrotomy the ureter is 
 safer from injury if it remains below rather than above the incision. 
 
HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. .07 
 
 In November of" this year Dr. B. Bernard Brown of Baltimore per- 
 formed a new operation for the rediietion of an inverted uterus. An 
 ineision was made in the fundus of the uterus, tlirough whieh he passed 
 one of Sims's hirge dilators up through the cervix, expanding the lat- 
 ter to the fullest extent. He then passed through hard-rubber dila- 
 tors, and having assured himself, by means of the linger, that no 
 adhesions existed, the incision of the fundus was sutured, and with 
 some manipulation the fundus was easily pushed up through the now 
 dilated cervix, and the operation was complete. 
 
 In 1884 a valuable paper was published by Dr. Palmer of Cincin- 
 nati, entitled "Abdominal Section, its Value and Range of Application 
 a.s a Means of Exploration and Treatment." This paper was read 
 before the American Gynecological Society, and gave rise to much 
 valuable discussion. In this year an instructive paper by Dr. Thomas 
 appeared, entitled " Management of the Placenta after Laparotomy in 
 Abdominal Pregnancy at Full Term or Beyond." 
 
 An unique and interesting article from Dr. Isaac E. Taylor of Xcav 
 York M'as published upon physiognomy of the vulva following anal 
 diseases. Dr. Taylor had made observations in this connection which 
 may be considered as very useful in diagnosis. He directs attention to 
 anal diseases causing changes in the appearance of the vulva as painful 
 affections, coming under the head of — 1st, spasmodic contractioiLS of 
 the anus ; 2d, neuralgia or hysterical hj-peraesthesia ; 3d, irritability or 
 indolent fissure in that localit}^ 
 
 An interesting article was published in the American Journal of 
 Obstetrics of November, 1883, to March, 1884, by Dr. H. R. Bigelow, 
 entitled " Gastrotomy for Myo-fibromata of the Uterus." It is one of 
 the most valuable contributions to om- knowledge of the subject up to 
 that time. He alludes to the publication in 1853, by AY. L. Atlee, of 
 a paper entitled " Surgical Treatment of Certain Fil^rous Tumors of 
 the Uterus " as the beginning of a movement in the treatment of ute- 
 rine fibroids. Until 1863 a few surgeons at home and abroad, like 
 Atlee, Burnham, and Kimball, on opening the abdomen for ovarian 
 tumors, having found a uterine tiunor, ventured to remove it. Burnham 
 made a supravaginal hysterectomy June 26, 1853, and the patient recov- 
 ered. This was the first successful case in America. Afterward Koeberle 
 of Strasburg was the first to deliberately open the abdomen for the purpose 
 of removing uterine fibroids and fibrous cysts, which he did by ligature 
 if pedunculated, or by the performance of hysterectomy if they were 
 intramural or sessile. Dr. Storer was among the first in America to 
 deliberately follow in his footsteps. Dr. Kimball of Lowell with equal 
 boldness operated about the same time as Koeberle. 
 
 In writing of early operators Bigelow states that "Kimball and 
 Koeberle seem to be the only ones whose operations were based upon a 
 
58 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 correct diagnosis." The present status of such a treatment of myo- 
 fibromata of the uterus was concisely set forth in this year by Dr. 
 R. S. Sutton of Pittsburg in an article on "Non-malignant Tumors 
 of the Uterus ;" and several American writers on uterine fibroids give 
 Dr. Goodell the credit of being the first in the United States to remove 
 ovaries to prevent further growth in uterine fibroids, but the date of his 
 operation we are unable to state. 
 
 Dr. H. A. Kelly of Philadelphia reports a successfiil operation for 
 sessile cervical fibroids above the vaginal roof by abdominal incision. 
 Free hemorrhage was checked by the use of Paquelin's cautery apj)lied 
 deep in the j)eritoneal cavity. The first successfiil case of laparotomy 
 for pelvic abscess in this country was made by Dr. R. S. Sutton in 
 June, 1884. 
 
 A very interesting address was made at the meeting of the American 
 Gynecological Society in 1885 by Dr. Wm. T. Howard upon encysted 
 tubercular peritonitis. He had collected from various sources six cases 
 in which there was interference : one of these was aspirated, three tap- 
 ped, two operated upon as in ovariotomy, and all died. One case was 
 simply treated by hygienic and therapeutic measures, and recovered. 
 Some of his clinical conclusions are that tubercular peritonitis appears 
 in early life. Its development is rapid, varying from six weeks to 
 eight months. Being rarely a local affection, we should search for 
 indications of the disease in other parts of the body. A number have 
 observed that a red blush of the central anterior part of the abdom- 
 inal wall is characteristic of tubercular peritonitis. 
 
 At the meeting of the Gynecological Society of this year (1885) quite 
 a lengthy discussion was held upon modifications of Emmet's operation 
 upon the cervix uteri, called forth by a paper of Dr. Sutton's. The 
 majority of the members participated in this discussion, and the fact 
 was clearly demonstrated that the mechanical ingenuity of the different 
 gynecologists is of the highest order. 
 
 Dr. Goodell reported this year having observed a form of parotitis 
 following operations upon the female genital organs which was not of 
 septic origin. That such diseases might occur is owing to the relation- 
 ship which is known to exist between the sexual organs of the adult 
 and the cervical and salivary glands. The inflammation observed by 
 Goodell closely resembles mumps, and usually ends in resolution unat- 
 tended with any of the signs of septicaemia, such as frequency of the 
 pulse or glassy apearance of the eye. This variety of parotitis lasts 
 longer than mumps. Instead of the patient failing as in septic inflam- 
 mation, she gains pari passu with the continued enlargement of the 
 glands. His first case was reported to the Obstetrical Society of Phil- 
 adelphia in October, 1884. 
 
 In this same year Dr. Alfred C. Post of New York reported a new 
 
HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 59 
 
 form ol' operation lor lacerated ju'riiieuiii, wliidi may be briefly described 
 as follows : An ineisjon ol" liallaii inch in de|)tli is made upon each side 
 of the vagina in sneh a manner as to make upper and lower segments. 
 The upper segments are turned up to form the floor of the vagina and 
 secured by a row of catgut sutures passed through the subcutaneous tis- 
 sues. A row of silver sutures is passed beneath the bottom of the 
 incision. The lower edges are also united by fine sutures. 
 
 In the New York Medical Jomiial of this year Dr. John Scott of 
 San Francisco reports a case of chronic pelvic abscess treated by 
 abdominal incision. After the abscess-cavity was Avashed out a drain- 
 age-tube Avas passed through the incision into Douglas's cul-de-sac and 
 through into the vagina. The abdominal incision was then closed ; 
 recovery. 
 
 In June of this year Dr. B. E. Hadra of San Antonio, Texas, read 
 a paper before the section of Diseases of Women at the American 
 Medical Association, entitled " Intraperitoneal Adhesions in Relation 
 to Tait's Operation." He calls attention to the marked relief in some 
 cases after Tait's operation in which disease of the tubes and ovaries 
 was not extensive. This fact he considers due rather to the breaking 
 up of adhesions — namely, of the intestines to the fundus or sides of the 
 uterus ; also extra-pelvic adhesions, especially adhesions between the 
 omentum and parietal or visceral peritoneum. He advocates laparot- 
 omy for a new purpose — namely, to free the peritoneum throughout its 
 entire area. 
 
 In a paper on vulvar and vaginal enterocele, read before the New 
 York Academy of Medicine in 1885, Dr. T. G. Thomas advocated a 
 ne^v method of treatment for vaginal enterocele in cases not amenable 
 to the ordinary measures — namely, laparotomy and dragging up the 
 hernial sac and fastening it to the abdominal wound. He reports one 
 case in which this plan was partially pursued with successful result. 
 
 In a series of articles in the American Journal of Obstetrics in 1885, 
 entitled " Studies in Endometritis," Dr. Mary Putnam-Jacobi further 
 develops the cyclical theory of menstruation which was first enunciated 
 in 1878 by Dr. Goodman of Louisville. The theory which she sets 
 forth is substantially as follows : The endometrium above the os inter- 
 num, the mucosa of the Fallopian tubes, and the cortex of the ovaries 
 are designated a^ the " gerrninative membrane.^' "The epithelium and 
 subepithelial cells of this membrane are directly derived from the ger- 
 minal epithelium of the embr^^onic hypoblast which covers the repro- 
 ductive eminences of the pleuro-peritoneal cavity." . ..." In all the 
 elements of germinative membranes persists the embryonic property 
 of indefinite groMi:h." This process is changed from continuous to 
 cyclical through the mechanical obstructions which are encountered 
 after a certain point in groAvth is reached. Dr. Jacobi, like Dr. Good- 
 
60 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 man, separates ovulation and menstruation as far as cause and effect are 
 concerned. Ovulation and menstruation are usually synchronous. The 
 former does not cause the latter, but both are produced by the same 
 cause — namely, growth of embryonic tissue. 
 
 In 1885, Dr. Baird of Texas advocated a new method for the treat- 
 ment of pelvic cellulitis for arresting exudation and pain, and applies 
 the galvanic current. He reports a case also where pus had formed, 
 which he evacuated by asjDiration, and then injected the cavity with 
 salt water, and applied a galvanic current to the cavity, with the result 
 of speedy contraction of the abscess and radical cure. 
 
 In 1886, Dr. Sarah E. Post published in the Ameriean Journal of 
 the Medical Sciences an exhaustive resum^ upon the subject of kolpo- 
 hysterectomy, which comprises a collection of all cases on record, with 
 a short history and description of each of the various modes of ope- 
 rating. 
 
 Dr. H. Marion Sims of New York read this same year, before 
 the New York Obstetrical Society, a paper on ventral hernia following 
 ovariotomy, in which he advocates a radical operation for its cure. In 
 a patient who suffered very much pain on account of the hernia, the 
 hernial ring being ten inches in diameter, he excised an elliptical piece 
 of skin, and then united the peritoneum by Lembert sutures. Then 
 the muscles and fascia were united separately with catgut and silver 
 wire. The result was a perfect recovery. 
 
 Dr. Polk of New York reported to the Obstetrical Society of New 
 York a case of pelvic abscess which was operated upon outside of the 
 peritoneum by means of an incision made as in that for ligating the 
 iliac artery, the patient recovering. 
 
 January 20th of this year the first annual meeting of the Alumni As- 
 sociation of the Woman's Hospital of the State of New York, composed 
 of former medical officers and house-surgeons, was held. A permanent 
 organization was effected, and Dr. J. B. Hunter was chosen president. 
 At this meeting many interesting papers were read and discussed, most 
 of which have been published in medical journals ; a history of the 
 institution was also read, it being altogether a meeting of the alumni. 
 
 In mentioning the historical points heretofore the writer has aimed 
 to pursue a chronological order, but there are some items relating to 
 gynecological history which, being matters of development, can hardly 
 be spoken of as pertaining wholly to any one year, and therefore will 
 now be alluded to. 
 
 In this connection attention is directed to the use of electricity in 
 the treatment of uterine fibroids. Among those who have investigated 
 this subject and experimented and published their results may be men- 
 tioned Dr. J. N. Freeman of Brooklyn, Dr. Engelmann of St. Louis, 
 Dr. Everett of Clyde, O., Dr. Martin of Chicago. These gentlemen 
 
HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 01 
 
 have writtru upon I'k'ctrolysi.s in the treatment of" .sub])eritoneal ;ui(l 
 intramural fibroids. Drs. Thomas, Muntl6, Vanderveer, and Semelloder 
 of Mexico have exj)erimented and written n])on electrolysis in the treat- 
 ment of ovarian tumors. Dr. INIiuide ^ives a report of fifty-one cases 
 which he has collected from various sources, of which there were nine 
 deaths and fourteen failures, the remainder beinjr benefited or cured. 
 
 In 1874, Dr. Gihuan Kimball published in the Boston Medical 
 Journal a paper entitled " Treatment of Uterine Fibroids by Electrol- 
 ysis or Galvanism." In 1878, Ej)hraim Cutter reported fifty cases of 
 uterine fibn)ids treated by electrolysis by Kimball and himself. These 
 cases were treated during the period extending from 1871 to 1877, with 
 the following results : Non-arrests, 7 ; death, 4 ; arrests, 32 ; relieved, 
 3; cured, 4. Writing of these cases nine years later (in 1887), Cutter 
 shows that time has served to strengthen rather than weaken the posi- 
 tion which he and Kimball took as pioneers of this method, for the 
 present resume of those same fifty cases now stands thus : Non-arrests, 
 7; fatal, 4; arrests, 25; relieved, 3; cured, 11. 
 
 Dr. Robert Ne\vman of New York is the veteran advocate in America 
 of the electrolytic treatment. He reported the results of some of his 
 labors in this direction as early as 1867. Reports of successful cases 
 of electrolysis in extra-uterine pregnancy have been made by Drs. A. 
 D. RockAvell, T. G. Thomas, E. G. Landis, N. Bozeman, Garrigues, J. 
 C Reeve, William T. Lusk, and others. 
 
 Hot water, which is so generally made use of in the treatment of 
 diseases peculiar to women, and has had such an ardent advocate in 
 Dr. Emmet, w^os first brought to the attention of the profession as a 
 hnemostatic during surgical operations by the late Dr. Pitcher of Detroit 
 in 1859. 
 
 A valuable contribution to gynecology has been made by Dr. H. 
 Coe, the pathologist of the Woman's Hospital of New York. His 
 published observations of certain conditions of the ovaries have been 
 revelations to many who believed that an}i;hing appearing like a cyst 
 upon the ovary indicates disease demanding removal. Some of his 
 conclusions are as follows : Laparotomists often judge of ovarian dis- 
 eases by — 1st, thickening of the cortex of ovaries : such thickening is 
 perfectly normal in the senile organ or after frequent ovulation; 2d, by 
 the appearance of a " cystic " degeneration, which is often only hydrops 
 folliculorum, and, according to Olshausen, "the stroma of the ovary 
 in these cases is intact and most of the vesicles are normal." This con- 
 dition seldom attains any clinical importance, because the changes pro- 
 duce no symptoms. Dr. Coe states the case of a perfect ovum found 
 within a Graafian vesicle as large as a marble. Of a large number of 
 tubes removed by different operatoj's which Coe has examined, only one- 
 fifth had true pyosalpinx. A less number were affected with hydro- 
 
62 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 salpinx, and only one with lisematosalpinx. An acute catarrhal sal- 
 pingitis had been found in women who had died from acute peritonitis 
 following extension of acute purulent endometritis. Chronic catarrhal 
 salpingitis he has not found. Thickening of the fibroid muscular tis- 
 sue without evidence of inflammation is rare. This condition has been 
 designated pachysalpingitis. Coe gives this as a rule : Unless pus is 
 found there is no pyosalpinx. 
 
 In 1882, Dr. Baker of Boston originated the cone-shaped excision 
 of the neck of the uterus for cancer, the apex of the cone being carried 
 far above the os internum. Dr. Baker has also cured a case of con- 
 genital malposition of the ureter. The ureter opened into the vagina 
 near the meatus urinarius. He dissected up a portion of the misjjlaced 
 ureter, made an opening in the original bed near the neck of the blad- 
 der, and turned the stump through it and closed the vaginal wall over 
 it. About a year after he was obliged to open the bladder and remove 
 a stone which had probably formed as the result of leaving a raw sur- 
 face in the bladder. Phosphates are often deposited upon such surfaces. 
 In 1886, at a meeting of the American Medical Association, Dr. A. 
 F. Pattee reported great success for many years with potassium chloride 
 in the treatment of anaemia, exudations from pelvic cellulitis in ovarian 
 neuralgia, menstrual headache with wakefulness, he having found the rem- 
 edy more advantageous than potassium bromide or ammonium chloride. 
 Dr. Byrne of Brooklyn in the October and December numbers of the 
 New York Medical Journal for 1878 published a new method of redu- 
 cino- inversion of the uterus bv means of an instrument consisting of a 
 curved stem, to the end of which is attached a cup for receiving the 
 inverted uterus. The stem is traversed by a rod which is affixed to 
 a disk forming a false bottom of the cup. Counter-pressure upon the 
 abdomen is maintained by means of an open bell-shaped cup, through 
 the centre of which passes a screw provided at the lower end with a 
 conical plug of hard rubber, and on the opposite or lower extremity a 
 flat knob for a handle. 
 
 Heretofore, in speaking of the mechanical treatment of uterine dis- 
 placements, credit has been given to Dr. Hodge for his ingenuity, but 
 American ingenuity has been taxed to its utmost in the invention of 
 pessaries, the most valuable of which are some form or modification of 
 the one originally invented by Hodge. Among those most worthy of 
 mention are the pessaries of Thomas, Emmet, and Albert H. Smith. 
 Gehrung of St. Louis has devised various forms — one particularly 
 useful in anteversion or procidentia accompanied by anteversion or 
 cystocele — and so has Cutter. All forms of gynecological instru- 
 ments have been devised, and there is scarcely an operator but has 
 originated or modified some form of instrument, to which his name 
 is attached. 
 
HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 63 
 
 One of the improved pessaries is tlie bloelv-tin jK'ssarv devised by 
 Sims about 185!). lie reeoL>,iu/ed tlie neeessity of" liaving a pessary fit 
 the eanal in which it was to be phieed, and devised pessaries from that 
 material to aeeomplish this j)urpose. 
 
 Prior to Dr. Siius's book most of the works piiljlislied in this coun- 
 try upon diseases of women were either foreign works edited by Ameri- 
 can physicians or were treatises chiefly u[)on diseases of the puerperal 
 state. In 182(j was published the treatise on Diseases of Females, by 
 William P. Dew'ees. This book reached its tenth edition. From 1852 
 to 1855 the clinical lectures of Dr. G. S. Bedford were publislied in 
 medical journals, after which they were published in book form. The 
 work of Dr. C. D. Meigs, published in 1850, which ran through several 
 editions and was written in the most charming manner, was in no degree 
 a representative of modern gynecology. In 1860 was published Z)t.s-- 
 eases Peculiar to Women, including Displacements of the Uterus, by Hugh 
 L. Hodge. The first edition of Byford's work upon medical and sur- 
 gical treatment of women was in 1865. Dr. Marion Sims's book, en- 
 titled Clinical Notes on Uterine Surgery, was published in 1866. In 
 1868 a treatise upon vesico-vaginal and vesico-rectal fistula, by T. A. 
 Emmet, was published. In 1868 was published a book by T. Gail- 
 lard Thomas entitled Practical Treatise upon the Diseases of Women. 
 This work was the fullest and most systematic treatise that had ever 
 emanated from an American author. As early as 1880, so great had 
 been the demand for this book, it had run through four editions, and 
 the fifth was published, much revised and enlarged. Especially note- 
 worthy are the chapters entitled respectively "An Historical Sketch 
 of Gynecology " and " The Anatomy, Physiology, and Pathology of 
 the Female Perineum." The former is a concise and most interesting 
 article on gynecology, dating back to ancient times. The latter, an 
 ably-written chapter, has especial reference to the functions of the 
 perineal body and the necessity of restoring it afber rupture, even 
 though incomplete. 
 
 The first journal devoted to obstetrics and gynecology appeared in 
 1868, edited by Dr. B. F. Daw^son, to whose energy and untiring efforts 
 chiefly this journal owes its origin. It first appeared as a quarterly. 
 After some years Dr. Dawson was succeeded by its present able editor. 
 Dr. ]\Iunde. The first journal devoted especially to gynecology was 
 the Journal of the Gynecological Society of Boston, edited by Drs. H. 
 R. Storer, G. H. Bixby, and W. Lewis. It first appeared in 1869, 
 and exercised no inconsiderable amount of influence. 
 
 In 1872, Dr. E. N. Chapman, a former professor of obstetrics 
 and diseases of women in the Long Island College Hospital, pub- 
 lished his work on Diseases and Displacements of the Uterus, which 
 met with rather rough usage at the hands of reviewers, although 
 
64 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 possessing considerable merit. The book never reached its second 
 edition. 
 
 In 1872^ Dr. John Byrne's (of Brooklyn) monograph, entitled Clin- 
 ical Notes on the Elective Cautery in Uterine Swgery, was published. 
 Notwithstanding this gentleman's enthusiastic advocacy of the electric 
 cautery and the good showing of his clinical reports, this mode of 
 treatment is not at the present time held in the high esteem it once 
 was by leading American gynecologists. 
 
 In 1872 was published by Appletons the truly classical Avork On 
 Ovarian Tumo'^s, by Edmund R. Peaslee, which was dedicated " To 
 the memory of Ephraim McDowell, M. D., the father of ovariotomy, 
 and to Thomas Spencer Wells, Esq., the greatest of ovariotomists." 
 Of this great work his friend and biographer. Professor Fordyce 
 Barker, writes for the third volume of the Transactions of the Amer- 
 ican Gynecological Society: "No work has been published in this coun- 
 try on any special subject of medical science of higher merit than his, 
 as regards its plan of arrangement, its artistic excellence of execution, 
 its literary finish, its learned, impartial, historical research, its sound- 
 ness in pathology, its keen analytical teaching of diagnosis, its wise, 
 prudent, practical, and thorough directions as regards treatment, both 
 in the medical and surgical aspects of the subject." This M'ork will be 
 " an imperishable monument to his name." 
 
 Soon after Peaslee's book was published appeared another work (in 
 1873) on Ovarian Tumors, which had been announced, and the publi- 
 cation of which had been eagerly anticipated by all interested in the 
 operation of ovariotomy in the United States. The work referred to 
 was written by Washington L. Atlee, who up to this date had made 
 more ovariotomies than any other American. This truly valuable book 
 differs widely from Peaslee's, as it is more purely clinical and personal, 
 showing as it does the many years of its author's labors as a pioneer 
 ovariotomist. The twenty-fourth chapter of this volume, entitled 
 " Dropsical Fluids of the Abdomen, their Physical Properties, Chem- 
 ical Analysis, Microscopic Appearance, and Diagnostic Value, based on 
 the Examination of Several Hundred Specimens," was contributed by 
 Dr. Thomas M. Drysdale. 
 
 In 1876 appeared the first volume of the Transactions of the Ameri- 
 can Gynecological Society, which have appeared from year to year since 
 that time. Allusion has herein before been made to the organization 
 of this society and the influence which it has exerted on the progress 
 of gynecology in this country. Nor has this influence been confined to 
 the United States alone, but has been felt in foreign countries. After 
 the appearance of the sixth volume of the Transactions the following 
 introduction to a translation of one of its articles by the distinguished 
 Prof. Kleinwachter appeared in the Deutsches Archiv fiir Geschichte der 
 
HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 65 
 
 Med. ic Jli'd. (icog., in which the translation was published. Ai'tor 
 writing- at sumo length in a eonuncndatorv maimer of the foundation 
 of the society and its founders and Tntn.sdclioiis, lie says: " Uj) to the 
 present time six vohimcs have appeared, \\ hich are an ornament to our 
 libraries of special sciences and contain an abundance of highly inter- 
 esting and valuable contributions, a.s would be expected, Ibr amongst 
 the co-workers may be enumerated such men as Washington Atlee, 
 Fordyce Barker, William Byford, Thomas Addis Emmet, George En- 
 gelmann, William Goodell, Charles Carroll Lee, William Lusk, Paul 
 Mund6, Emil Noeggerath, Randolph Peaslee, the universally-kno\vn 
 and celebrated Dr. J. INIarion Sims, T. Gaillard Thomas, and others 
 whose scientific reputation is everywhere known and recognized." 
 Aside from the scientific interest which the Transactions possess, 
 Kleinwiichter considers the medico-historical characteristics note- 
 worthy : " The previous volumes contain full biographies of Simon 
 (of Heidelberg), Charles Buckingham, Randolph Peaslee, Marmaduke 
 B. Wright, and others. The fifth volume contains an extensive paper, 
 illustrated with numerous cuts, upon midwifery among the various 
 peoples of the globe, by Engelmann, and in the sixth is a noticeable 
 contribution from the pen of Edward W. Jenks entitled ' The Prac- 
 tice of Gynecology in Ancient Times.' "...." If the English and 
 French cultivate the history of medicine, we need be less surprised, for 
 both of these nations possess a famous history of more than a thousand 
 years, and such a one doubtless stimulates historical research. The 
 Americans are without an ancient national culture, and therefore with- 
 out an ancient history, and yet we see them fostering the history of 
 medicine. With this people xo.t £^oyrjV of the present, necessity has 
 compelled it to make a path for itself, in order to learn what the 
 ancients knew and did, in order not to be too one-sided — in other 
 words, more fully to comprehend the spirit of medicine than it is 
 possible by the modern methods of so-called exact investigation." 
 
 In 1878 was established the Obstetric Gazette, published in Cincin- 
 nati and edited by Edward B. Stevens ; it has also a department 
 devoted to diseases of women. 
 
 Dr. Skene's book, entitled Diseases of the Bladder and ZTrethra of 
 Women, first came out in 1878. This volume is the only one of its 
 kind which has been published in this country, and its intrinsic value 
 has greatly served to establish and extend the justly-deserved reputa- 
 tion of its author as an authority on the disorders of ^\hich it treats. 
 
 In 1879, Emmet published his work entitled Principles and Practice 
 of Gyna'colngii. This work is a clinical work, and is tqtally unlike the 
 systematic treatise of Thomas. Owing to the author's long connection 
 with the Woman's Hospital of the State of New York, first as assistant 
 to Dr. Sims, next as surgeon-in-chief for many years, and later as one 
 Vol. I.— 5 
 
66 HISTORICAL SKETCH OF AMERICAN GYNECOLOGY. 
 
 of the surgeons of the staif, his experience has given him great advan- 
 tages in the way of clinical observation, of which his book bears an 
 abundant evidence. This book has passed through several editions, 
 the last one being practically a new book, so much has been rewritten 
 and added since the first edition appeared. 
 
 In 1879 was published the clinical lectures of Dr. Wm. Goodell of 
 Philadelphia, entitled Lessons in Gynaecology. 
 
 In 1881 a new edition of By ford's work was published on the dis- 
 eases of women, but so changed from the first edition as to be practi- 
 cally a new work, fully abreast of the times and worthy of its indus- 
 trious author. 
 
 In 1880, Mund6 published a work entitled Minor Surgical Gyne- 
 cology, The second edition appeared in 1885 — a work of great use 
 to the younger members of the profession, for whom chiefly it is 
 written. 
 
 Obstetrical societies were formed many years ago in a few of the larger 
 cities, but the first gynecological society organized was the Gynecolog- 
 ical Society of Boston, established in 1869. Its Transactions, pub- 
 lished monthly, exerted a widespread influence on the interests of 
 gynecology, which was due chiefly to the labors of Dr. H. R. Storer 
 and a few of his colleagues. Although the journal has been discon- 
 tinued. Dr. Storer having been compelled to withdraw from active 
 work by reason of his illness, the society continues to hold its stated 
 meetings. 
 
 Other obstetrical and gynecological societies have been established 
 quite universally. Where obstetrical societies exist, gynecology shares 
 with obstetrics in the attention which is devoted to it. Gynecological 
 societies exist in Washington, Chicago, Detroit, Baltimore, and sev- 
 eral other cities, while the principal part of the work of the obstetri- 
 cal societies of New York, Philadelphia, and some other cities seems 
 to be gynecological. 
 
 In 1870 the American Medical Association passed resolutions recom- 
 mending that the establishment of chairs of gynecology separate from 
 that of obstetrics be more generally adopted by medical colleges and 
 schools throughout the country. The direct cause of these resolutions 
 was a memorial presented to the association by the Boston Gynecolog- 
 ical Society. The Medical College at Castleton, Vt., was the first one 
 in which special attention was given to the diseases of women, Dr. 
 Woodward lecturing upon gynecology as well as upon obstetrics. Prob- 
 ably the first college to found a full professorship of gynecology was 
 Dartmouth, Dr. Peaslee being its incumbent. About the same time Dr. 
 H. R. Storer gave a full course of lectures on gynecology in Berkshire 
 Medical College, Massachusetts, of which institution he was professor 
 of obstetrics and diseases of women. 
 
HISTOIilCAL SKI:T('II OF AMERICAN GYSICCOLOdY. 07 
 
 As early as ls71 tlicrc wwv. thirteen inctlical (-(tlle^es in the United 
 States in wliieli there were f"nll professorships of gyneeoloj^y and of 
 obsti'tries. Of this ninnber, there were seven schools with fnll profes- 
 soi-ships of the diseases of women, incumbents teaching nothing else — 
 namely, the Albany Medical College, K. K. Peaslee ; Long Island Hos- 
 pital College, A. J. C. Skene; St, Louis College of Physicians and 
 Surgeons, M. A. Fallen ; University of Louisville, T. Parvin ; the 
 Medical College of Ohio, C. D. Palmer; I'nivcrsity of Pennsylvania, 
 AVm. Goodell ; Detroit Medical College, Edward AV. Jenks ; and there 
 were eight professoi'ships of gynecology and the diseases of children 
 combined — namely, University of Xew York, F. D, Lcnte ; Mcflical 
 College of Virginia, J. 8. D. Cullen ; University of Maryland, W. D. 
 Howard ; Washington University, Baltimore, M. P. Scott ; Miami 
 INIedieal College, B. F. Richardson ; Indiana Medical College, T. B. 
 Harvey ; Medical College of Evansville, D, ]\Iorgan ; Louisville Med- 
 ical College, J. A. Ireland. Since then the authorities governing 
 medical schools and colleges, realizing the importance of gynecology, 
 have in almost every instance added a separate professorship of that 
 specialty. 
 
 The foregoing historical sketch of the rise and progress of gynecology 
 in America, imperfect though it necessarily be, can scarcely fail to 
 impress the reader with a sense of the important part which this 
 country has borne in the development of this division of medicine. 
 The profession of America has, in what it has already accomplished, 
 both demonstrated a peculiar aptness in this particular field and given 
 a guarantee for the future. With the increasing facilities which 
 increasing wealth, and its accompaniment of growing freedom from 
 the mere money-getting obligations resting on physicians, and the 
 enthusiasm, in their work which seems to an extent to be peculiar to 
 workers in this field, the future of gynecology in this country is big 
 with hope and promise. It is but fitting that the land which furnished 
 the pioneers should furnish also those who shall carry on to its fullest 
 possible perfection the work so auspiciously begun. The mantles of 
 ^IcDowell and Sims and Peaslee and the Atlees have fallen on worthy 
 shoulders, and coming generations will accord to many now living 
 places beside the pioneers who have rested from their labors. 
 
THE DEVELOPMENT OF THE FEMALE 
 GENITALS. 
 
 By henry J. GARRIGUES, A. M., M. D., 
 
 New York. 
 
 As in other departments of the history of the development of the 
 human body, so our knowledge of the earliest stages of development 
 of the female genitals is chiefly derived from the study of the develop- 
 ment of the corresponding parts in animals, especially the chicken and 
 the rabbit. 
 
 The Wolffian Ducts.' 
 
 The first organs belonging to the genital sphere which appear in 
 the male and female are the Wolffian ducts. In the chicken embryo 
 they appear during the latter half of the second day. There is one 
 on either side. It begins at the level of the fourth or fifth protover- 
 tebra, and extends rapidly backward, so that at the beginning of the 
 third day it reaches the last proto vertebra. At first it is a solid column, 
 which later, by the formation of a cavity in its interior, is transformed 
 to a tube. On cross-section of embryos it makes its first appearance 
 as a small protuberance from the lateral plates where they come together 
 with the protovertebral columns. 
 
 The posterior end of the Wolffian duct opens into that part of the 
 allantois which is situated within the body of the embryo, and com- 
 municates with the cloaca, and later, after the separation between the 
 intestinal and urogenital canal has taken place, into the urogenital 
 sinus described below. 
 
 In the rabbit the Wolffian duct appears at the end of the eighth or 
 the beginning of the ninth day, and is developed in the same way as 
 in the chicken. On the eleventh day it opens into the urogenital sinus. 
 Fig. 1 shows its situation between the protovertebral column, the lat- 
 eral plate, and the descending aorta. On one side it is yet a solid 
 string, on the other it has begun to be changed into a canal. In Fig. 
 2 we see it open into the urogenital sinus. Its lower end lies on either 
 side of the body, imbedded in a ridge which Waldeyer has denominated 
 "plica urogenitalis. According to the same author, the Wolffian duct is 
 
 ^ Casper Friedrich Wolff, Theoria Generafinvix, Berlin, 1759; "On the Development 
 of the Intestine," in Nov. Comment. Acad. PetropoL, 17GS-69. 
 68 
 
THE WOLFFTAN DUCTS. 
 
 69 
 
 not formed by the porfnration of a solid column, but by tho application 
 of tiie above-mentioned ])rotuberancc to the lateral plates, whereby first 
 u channel, and then a closed tube, is formed. 
 
 Transverse Section through the Median Part of the Body of the Embryo of a Rabbit of nine 
 days and two hours (enlarged 158 times) : dd, hypoblast ; dr, intestinal groove ; ch, noto- 
 chord; ao, descending aorta:; ww, protovertebra ; mr, medullary tube; wn^, Wolffian duct; 
 dfp, visceral division of the mesoblast ; g, vessels in the deeper parts of the visceral meso- 
 blast; hp, parietal mesoblast; h, epiblast; pp, pleuro-peritoneal cavity (KoUiker). 
 
 In the female embryo of a calf which measured one and a half 
 inches in length Kolliker found the Wolffian duct composed of flat 
 epithelium and a very thin fi- 
 brous membrane not yet quite 
 separated from the surrounding 
 tissue. It lay imbedded in a 
 thick layer of blastema, which 
 may be looked upon as the fu- 
 ture peritoneal covering of the 
 A^"olffian body. 
 
 His found it as a cylindrical 
 duct in a very young human 
 embryo, the total length of 
 whose body was only 2.4 milli- 
 meters. 
 
 AVhile in the male sex the 
 ^Yolffian duct is destined to 
 play an important part in the 
 adult animal, since in course 
 of time it forms the tail of the 
 epididymis and the vas defer- 
 ens, in the female sex of man 
 and most animals it disappears 
 more or less completely, yet 
 
 Sagittal Section through the Posterior Part of the 
 Body of the Embryo of a Rabbit of eleven days 
 and ten hours (enlarged 45 times) : wy, Wolffian 
 duct; n, ureter; n', beginning formation of the 
 kidney; ug, urogenital sinus; cl, cloaca; hg, re- 
 gion in which, in the mesial plane, the hind gut 
 opens into the cloaca ; ed, postaual gut ; a, anus 
 or fissure of the cloaca ; «, tail ; r, perineal fold 
 (Kolliker). 
 
 perhaps not to such an extent as was formerly thought. In the swine 
 
70 
 
 THE DEVELOPMENT OF THE FEMALE GENITALS. 
 
 and the cow the Wolffian ducts persist as Gartner's^ canals, so called 
 after the Danish physician Herman Treschow Gartner, who discovered 
 and described them in 1822 as a glandular organ, but Malpighi had 
 already described them in the cow in 1681 in his Bissertatio ad Jaco- 
 bum Sponium. The identity of Gartner's canals with the Wolffian 
 ducts was first shown by Jacobson. According to Chevau, these canals 
 run in the cow in the lateral parts of the vagina and extend six or 
 eight centimeters beyond the os uteri. Their posterior end opens in 
 the vulva at the side of the urethral orifice. They are not known to 
 be of any particular use, and nothing similar is found in the goat and 
 the sheep. K5lliker found them as two fine tubules in the anterior 
 wall of the uterus of the female embryo of a cow which measured three 
 inches and four lines. 
 
 Milne-Edwards thinks that Gartner's ducts are analogous to the peri- 
 toneal tubes of crocodiles. In these animals the upper end opens into 
 the peritoneal cavity ; the lower is either closed or opens with a small 
 opening furnished with a valve in the vulva. 
 
 Beigel found Gartner's ducts in a female human foetus of seven 
 months' utero-gestation as small epithelial ducts situated laterally and 
 anteriorly in the superficial layers of the uterus. K5lliker found yet 
 distinct remnants of them in the broad lio-aments of full-^rown human 
 fcetuses. Fischel has described a case of a newborn child in which 
 
 Fig. 4. 
 
 The Urethra laid open by division 
 of its posterior or vaginal wall ; 
 the tubules distended by probes 
 (Skene). 
 
 The Urethra laid open by division 
 of its anterior wall ; probes passed 
 into the tubules (Skene). 
 
 one of these ducts was found in the vaginal portion. Geigel found 
 remnants of them in the wall of the vagina of a four months' foetus, but 
 not in the uterus, and in two foetuses of six months they had totally 
 
 ^ The name is almost everywhere erroneously spelt Gartner or Gaertner. 
 
THE WOLFFIAN DUCTS. 71 
 
 (Hsajipinired. Of late these duets seem even to have been fbuud quite 
 f'i'e(|uently, by different observers, in the adult woman. 
 
 Dr. Skene of l^rooklyn, N. Y., deseribed in the year 1880 Avhat 
 he ealls "two important jilands of the female urethra," which by tlieir 
 position and structure seem to correspond with Gartner's ducts. He 
 says that they are found on each side, near the floor of the female 
 urethra, admit a No. 1 probe of the French scale, and extend upward, 
 parallel to the long axis of the urethra, from three-eighths to three- 
 fourths of an inch in the muscular tissue below the mucous membrane. 
 The mouths of these tubules are found upon the mucous membrane 
 of the urethra, according to the condition of the meatus, either one- 
 eighth of an inch inside, or, if the mucous membrane is everted — which 
 is not uncommon in those who have borne children — exposed to view on 
 either side of the entrance to the urethra. The upper ends of the 
 tubules terminate in a number of divisions which branch off into the 
 
 Fig. 0. 
 
 \mrethra 
 
 XUBULE 
 
 TUBULE. 
 
 Transverse Section of the Urethra about a quarter of an inch from the meatus, showing the 
 cross-cut of the tubules (Skene). 
 
 muscular walls of the urethra. Skene says he has investigated these 
 tubules in more than a hundred different subjects, and found them con- 
 stantly present and uniform in size aud location. 
 
 Observations in most respects similar to those of Skene have been 
 made by J. Kocks of Bonn. According to him, these remnants of 
 Gartner's ducts are found in 80 per cent, of women. In newborn 
 children they are relatively larger, but absolutely smaller, than in 
 the adult. In old women they very frequently disappear. Micro- 
 
72 
 
 THE DEVELOPMENT OF THE FEMALE GENITALS. 
 
 A, Vestibule of Vulva, with meatus urinarius, 
 the everted mucous membrane showing the 
 entrance to the tubules. 
 
 B, Meatus Urinarius, with everted mucous mem- 
 brane and entrance to the tubules (Skene). 
 
 scopical examination has failed to discover any glandular substance in 
 them. 
 
 The observations regarding the persistency of Gartner's ducts have 
 A Fig. 6. B lost somewhat of their apparent 
 
 reliability by Dohrn's investi- 
 gations. He has for years ex- 
 amined human embryos with 
 special regard to these ducts, 
 and has come to the conclusion 
 that, as a rule, they soon disap- 
 pear. According to this author, 
 they are only found, exception- 
 ally, in embryos from the latter 
 half of pregnancy. They reach 
 the uterus at a point which later 
 corresponds to the internal os, 
 and become imbedded in the 
 outer edge of the womb. In the vagina they are found in the tissue 
 which surrounds the mucous membrane, but lower down they become 
 indistinct, and they disappear totally before they reach the orifice of 
 the urethra. Dohrn thinks that what has been described as persistent 
 Gartner's ducts are only folds of the m^ethra. At 
 the posterior part of the urethral orifice are normally 
 found two such invaginations of the urethra, which 
 extend upward as more or less deep pockets. 
 
 Wassilieif, who has described the two tubuliform 
 glandular formations at the entrance of the female 
 urethra in a Russian work in the same year as Skene 
 — that is, two years before the article of Kocks — does 
 not admit the correctness of Dohrn's criticisms. He 
 has repeatedly examined these tubules on sections made 
 after injection with Berlin blue, and found them lined 
 with an epithelium very much like that of the prostate, 
 and entirely diiferent from that in the adjoining part 
 of the urethra. 
 
 Carl Rieder found Gartner's ducts only persisting 
 in eight out of forty cases. 
 
 From the results of these various investigations 
 we may conclude that Gartner's ducts, as a rule, dis- 
 appear in the second half of pregnancy, but that they exceptionally per- 
 sist even in the adult woman. 
 
 That the upper parts of these ducts occasionally persist, and may 
 give rise to vaginal cysts, there is scarcely any doubt. I have myself 
 examined a cyst of this kind extirpated by Dr. R. Watts of this city, 
 
 Fig. 7. 
 
 A Tubule laid open, 
 and showing the 
 branches at the up- 
 per end (Skene). 
 
TIIK WOLFFIAN BODIES. 
 
 73 
 
 and both the clinical observation that the cyst at its upper end liad a 
 tubulit(»rm continuation throuijh which a uterine sound went uj) to the 
 iliac I'nssa, and tlie liistological composition of the sac, which cor- 
 respondci^l with that of the vas deferens, determined me to tai<c it to he 
 a dilated Gartner's duct.^ 
 
 The Wokffian Bodies. 
 Shortly after the Wolffian ducts — in the chicken at the end of the 
 second and the beginning of the third day, in the rabbit on the ninth 
 
 and tenth day — appear the so-called Wolff- 
 ian bodies. His found them in a human 
 foetus of the first month whose body was 
 2.6 millimeters long. Like the ducts, they 
 are placed symmetrically one on either side 
 of the vertebral column. At the period 
 of their highest development they extend 
 as two long prismatic ])odies from the level 
 of the rudimentaiy diaphragm Iom* down 
 into the pelvis. At their upper end they 
 are bound to the lower surface of the dia- 
 phragm by a small filament which Kol- 
 liker calls their " diaphragmatic ligament," 
 and which Waldeyer explains to be the 
 upper end of ^liiller's ducts, of which we 
 soon shall speak. At their lower end they 
 are fastened to the inguinal region bv a 
 filament which Kolliker calls their " in- 
 guinal ligament," and which in the course 
 of time becomes the gubemaculum testis 
 in the male and the round ligament in the 
 female sex. The bodies are bound to the 
 posterior wall of the abdominal cavity- by 
 a broad and low mesenterv. They are so 
 large that they fill the whole hollow of the 
 posterior wall, leaving only a narrow fissure 
 
 Human Embryo of thirty-five days rfront vie-n-)-. 3. left external nasal process ; 4, superior max- 
 illarj- process ; 5. lower maxillary process ; s, tongrue ; 6, aortic bulb ; 6', lirst permanent aortic 
 arch ; h", second aortic arch ; h", third aortic arch, or ductus Botalli ; ij. the 1r\vo filaments to 
 the right and the left of this letter are the pulmonary arteries, which begin to be developed ; 
 c. the stem of the superior cava and right azygos vein : c', the common venous sinus of the 
 heart : c", the common stem of the left vena cava and left azygos : o'. left auricle of the heart ; 
 I', right, r', left ventricle ; ae. lungs ; e, stomach : j. left omphalo-mesenteric vein ; s, contin- 
 uation of the same behind the pylorus, which becomes afterward the vena porta; x, vitello- 
 intestinal duct : a, right omphalo-mesenteric artery ; m. Wolffian body ; i, gut ; n, umbilical 
 artery ; w. umbilical vein : 8. tail ; 9, anterior, 10. posterior limb. The liver has been removed. 
 The white band at the inner side of the Wolffian body is the genital gland, and the two 
 white bands at its outer side are the Miillerian and the Wolffian ducts (Kolliker, after Coste). 
 
 ^ "Trans, ^*ew York Obst. Soc," Am. Journ. of OhsL, October, 1881. 
 
74 
 
 THE DEVELOPMENT OF THE FEMALE GENITALS. 
 
 on either side. In the inner one of these fissures is later developed the 
 genital gland ; in the outer one runs the Wolffian duct, and later like- 
 wise the Miillerian duct. Their posterior surface rests on the blastema 
 (in which later the kidneys are developed), on the aorta, and on a large 
 vein which takes up the blood coming from the bodies. 
 
 The Wolffian bodies are formed from the lateral plates — or, more 
 precisely, from the cellular lining of the peritoneal cavity — as a long 
 row of small pear-shaped, solid bodies, which soon become separated 
 from the endothelium of the peritoneum and become hollow, in which 
 stage they are called segmental vesicles. These vesicles are in contact 
 with the Wolffian duct, and soon the thin layer which separates the two 
 
 Fig. 9. 
 
 
 
 III , \ y'l d 
 
 ''^/ /, . "f"u 
 
 
 \\ fill ^,,1^^. 
 
 The Genital and Urinary Organs of the Embryos of Cattle : 1, from a female embryo V/, inches 
 long (double size) : w. Wolffian body ; wg, the Wolflfian and the Miillerian ducts ; i. Inguinal 
 ligament of the Wolffian body; o, ovary with an upper and lower peritoneal fold; n, kid- 
 ney ; nn, suprarenal body ; g, genital cord, composed of the united Wolffian and Mullerian 
 ducts. 2, from a male embryo 2]4 inches long (nearly three times natural size) : one of the 
 testicles has been removed. Letters as in fig. 1, and, besides, m, Mliller's duct; m', upper 
 end of the same ; h, testicle ; h', lower ligament of the testicle : h", upper ligament of the 
 testicle ; d, diaphragmatic ligament of the Wolffian body ; a, umbilical artery ; v, bladder. 
 3, from a female embryo (enlarged nearly three times) : letters as in figs. 1 and 2, and, be- 
 sides, t, opening at the upper end of Miiller's duct; o', lower ovarian ligament; m, thickened 
 part of the Mullerian duct, which later becomes the uterine horn (Kolliker). 
 
 cavities is absorbed, so that henceforth the vesicles appear as invagina- 
 tions from the duct, which as to origin they are not. These grow rapidly, 
 and are transformed into long convoluted tubes, which in the inner part 
 of the Wolffian bodies connect with arterial tufts in a similar way as 
 the uriniferous ducts of the permanent kidneys combine with arterial 
 convolutions to form the Malpighian tufts. 
 
 The Wolffian body is in the male developed into the epididymis and 
 
Tllh' WOLFFIAN BODIES. 
 
 76 
 
 Giralclez's' body (Fiji". 10). In the f'cinalc sex these two parts are less 
 prominent. Corres])on(lin^' to tlie epididymis we have Roseniniiller's^ 
 
 Fio. 10. 
 
 <!«?«« 
 
 Fig. 11. 
 
 ....JT 
 
 Fig. 10.— Internal Genital Organs of a Female Human Foetus zy, inches long (enlarged 10 
 times): O, ovary; Z, Fallopian tube; O.abcl, abdominal opening of the tube; E, epo- 
 ophoron (upper part of the Wolflian body) ; U, paroophoron (lower part of the Wolffian 
 body) ; Y, Wolffian duct, the lower part of which disappears, but its place is marked by 
 thickened tissue that combines with the thickened connective tissue surrounding the 
 tube; 3Tp, Malpighian bodies (Waldeyer). 
 
 Fig. 11.— Internal Genital Organs of a Male Human Foetus 2]4 inches long (enlarged 8 times) : 
 //, testicle ; E, epididymis (the upper part of the Wolffian body) ; U, paradidymis, or Giral- 
 dez's organ (the lower part of the Wolffian body) ; O, bundle of connective tissue with blood- 
 vessels; y, vas deferens (Wolffian duct) (Waldeyer). 
 
 organ, or the parovarium, and Giraldez's organ is represented by stray 
 tubes found in the broad ligament between the parovarium and the 
 uterus (Fig. 11). They are filled with epithelial cells and detritus, and 
 often give rise to the formation of cysts. I have frequently seen small 
 cysts situated between the parovarium and the uterus. It is therefore 
 not an improvement when of late years some authors substitute the 
 term " parovarian cyst " for the older term " cyst of the broad liga- 
 ment." When a cyst forms in any part of the broad ligament and 
 acquires surgical proportions, it will scarcely be possible to prove that 
 it has been developed in the parovarium. The term **cyst of the 
 Wolffian body," on the other hand, would probably be more correct, 
 although there is a possibility that any small agglomeration of cells 
 belonging to the native germ -epithelium, which will be described later, 
 may become the starting-point of an extra-ovarian cyst. 
 
 In order to sho^v the homology between the named organs in the two 
 sexes, Waldeyer has proposed to call Giraldez's organ " parepididymis," 
 
 ^Giraklez, " Recherche? anatomiqnes snr le corps innoniine," in BrowH' S^quard's 
 Journ. de I'Anat. el de la Pln/iiioL, 1861. 
 
 ^Eosenmiiller, Qucedam de ovariis embryonum etfoetimm humanorum, Lipzire, 1802. 
 
76 
 
 THE DEVELOPJiUENT OF THE FEMALE GENITALS. 
 
 or, shorter, " paradidymis," Rosenmiiller's organ " epoophoron," ^ and 
 the tubules between this organ and the uterus " paroophoron." ^ 
 
 The Ovaries. ^ 
 
 The sexual glands are originally entirely alike in the two sexes. 
 They make their first appearance very soon after the Wolffian bodies — 
 in the chicken on the fifth day, in the rabbit on the twelfth or thirteenth, 
 in man in the fifth or sixth week. In the latter they begin as a white 
 streak, called "the genital ridge," on the inner side of the Wolffian 
 bodies. This streak extends almost as far as the bodies themselves, 
 and is in close contact with them. How it is formed in man is not 
 known, but in chickens the process has been studied step by step. In 
 these animals the genital glands originate as a thickening of the epi- 
 thelium of the inner part of the Wolffian bodies. This part of the 
 peritoneal epithelium diifers from the other by being composed of 
 columnar cells, and as it forms the substance of which the Fallopian 
 tubes, the ovaries, and the ova are formed, Waldeyer has designated it 
 as the " germ-epithelium " (Keimepithel). 
 
 It is not before the end of the second month that the ovaries begin 
 to differ from the testicles in man, the latter becoming broader and 
 
 Fig. 12. 
 
 Perpendicular Section through the Ovary of a Human Foetus of thirty-two weeks (Hartnack, s) : 
 a, epithelium ; b, b, cells in the epithelium which become primordial ova ; c, prolongations 
 of connective tissue growing into the epithelial layer; d, d, cluster of epithelial cells in the 
 process of being imbedded ; e, e, primordial follicles with a wall formed of narrow connec- 
 tive-tissue cells ; /, groups of imbedded epithelial cells, some of which are larger than the 
 others (primordial ova); g, granular cells (His). 
 
 shorter, while the former retain their lengthy shape, and in the ninth 
 or tenth Aveek take a more oblique direction. 
 
 Another earlv sim of distinction between the testicles and the 
 
 1 'E-i, upon ; 'wov, egg ; 0£pw, I carry. 
 ^ Latin, ovum, egg. 
 
 Ilapd, beside. 
 
THE OVARIES. 
 
 11 
 
 ovaries i.s that the latter liave a imich more developed eoliimnar 
 epithelium. In the ehicl^en this diflereiice is j)resent as early as the 
 end of the lirst wfek. 
 
 Even before the distinetion between the sexual glands takes place 
 they are fastened to the Wolffian bodies by means of a small fold of 
 the peritoneum, which, according to the sex, is called " mesorchium " 
 or " mesoarium." From the upper end of the reproductive gland a 
 small ligament runs to the diaphragmatic ligament of the Wolffian 
 body, and the lower end is bound by another ligament to the Wolffian 
 duct opposite the starting-point of the inguinal ligament of the Wollf- 
 ian body (Fig. 12). 
 
 Fig. 13. 
 
 Perpendicular Section through the Ovary of a Bitch of six months (Hartnack, ?): a, epithe- 
 lium; 6, epithelial pouch, opening on the surface; c, larger group of follicles; d, ovarian 
 tube containing ova ; e, oblique and transverse sections of ovarian tubes (Waldeyerj. 
 
 Originally both ovaries have about the same size, but from about the 
 ififth month of gestation the left ovary is left considerably behind as to 
 development. In the eighth week their length is 2.5 to 3 millimeters 
 (Puech). Meyer furnishes the following figures as indicating the length 
 of both ovaries of human foetuses at different periods, the figures being 
 the average of several measurements : 
 
 Age in weeks. 
 
 10. 
 
 15. 
 
 20. 
 
 24. 
 
 28. 
 
 .32. 
 
 35. 
 
 40. 
 
 Length of the ovaries / right .... 
 in millimeters (^ left .... 
 
 3.8 
 3.7 
 
 5.0 
 5.0 
 
 Ill 
 
 12 
 
 12J 
 11 
 
 12f 
 
 16| 
 13^ 
 
 16J 
 
 m 
 
 111 
 
 Puech mentions likewise the greater length of the right ovary, but 
 the average difference in forty cases was only about one and a half 
 millimeters, the average length of the right being 19.8 millimeters; 
 of the left, 18.2. 
 
 During the first two-thirds of gestation the uterus and the ovary 
 keep almost equal pace as to size, but from the end of the seventh 
 
78 
 
 THE DEVELOPMENT OF THE FEMALE GENITALS. 
 
 month the uterus increases much more rapidly. In the following list^ 
 taken from Meyer, the length only is considered, and that of the ova- 
 ries is the average found for the two : 
 
 uterus. Ovaries. 
 
 10th week — mm. 3.8 mm. 
 
 15th " 5J 5 
 
 20th " ^ 12 
 
 24th " llj llf 
 
 28th " 12J 13J 
 
 32d " 19 15J 
 
 36th " .24 15 
 
 40th " 28 19 
 
 The shape of the ovary varies very much at different periods. At 
 first it is a long flat body ; later it grows, especially at the edges, so that 
 a cross-section presents the figure of a bean or a mushroom, as in Fig. 
 
 Fig. 14. 
 
 Transverse Section through the Ovary of a Human Embryo of three months (enlarged 43 
 times) : a, mesoarium ; a', stroma of the hilus (medullary substance) ; 6, glandular tissue 
 (cortical substance) (KoUiker). 
 
 14. About the middle of gestation the lips at the hilus disappear, and 
 the line of insertion of the mesoarium approaches the lower and pos- 
 terior edge, so that a cross-section presents a pear-shaped appearance. 
 In the foetus as well as in the infant the surface of the ovaries shows 
 impressions of the surrounding organs. It is first at the end of the 
 second year that the organ has become resistant enough to maintain 
 an even surface independent of the contiguous pails. 
 
 The ovary is subject to a descent similar to that of the testicle. It 
 takes place soon after the tenth or eleventh week, so that the ovary at 
 the end of the fifteenth week is found almost in the same place as later.. 
 
THE OVARIES. 79 
 
 Yet even in newborn children and shortly .liter hirtli we find the ovaries 
 sitnatc'd above the ile()-[)eetineal line. As a I'ule, tlie ovaries descend 
 into the trne j)elvis dnrinji; the first two or three months after the birth 
 of the child (Kolliker), The descent consists chiefly in a change of 
 diriH-tion, and not in a trne change of the distance between the ovaries 
 and the nterns. At the earliest period the lower end of the ovary is 
 fonnd oi)])osite the starting-point of the ronnd ligament of the nterns. 
 JNIost of the api)arent descent is dne to a disproportion in the growth 
 of the parts sitnated above and below the ovaries. The shrinking 
 of the ronnd ligaments, which are composed of cellular elements 
 and much fibrillar tissue — a shrinking analogous to that which takes 
 place in cicatricial tissue — seems likewise to be at work, but to be of 
 subordinate importance. By the change in direction referred to the 
 upper end turns outward and sinks considerably downward ; the lateral 
 edge becomes the superior or free edge ; the mesial edge becomes the 
 lower ; the ventral or anterior surface is turned inward to the mesial 
 line ; the dorsal or posterior surface is turned outward to the side of 
 the pelvis (Kolliker). 
 
 The relations to the Fallopian tubes are changed in such a way that 
 the ovary, instead of being situated on the inner or mesial side of the 
 Miillerian duet, finally lies behind and below the Fallopian tube. The 
 rio-ht ovary is from the tenth week of gestation placed lower and nearer 
 the uterus than the left. 
 
 At the upper end of the foetal mesoarium enter the ovarian vessels 
 from the posterior abdominal wall, and extend downward, enclosed in a 
 particular fold of the peritoneum, which exhibits a free lateral edge and 
 in course of time becomes the infundibulo-pelvic ligament, extending 
 from the fimbriated end of the Fallopian tube to the side wall of the 
 
 pelvis. 
 
 To the lateral side of the mesoarium is attached the mesosalpinx, 
 or mesentery of the Fallopian tube. In older embryos it is stretched 
 out behind the ovary as a fine membrane, the free outer edge of which 
 surrounds the Fallopian tube. In a previous stage this membrane 
 formed the peritoneal covering of the Wolffian body, and contains the 
 remnants of this body, especially the parovarium. 
 
 The inner (lower, anterior) end of the ovaries is bound tc the uterus 
 by means of the ovarian ligament, which is a continuation of the meso- 
 arium. At the middle of gestation these inner ends lie pretty near one 
 another. They rest on the ureters and the umblical arteries, while the 
 outer (up]3er, posterior) part of the ovaries is placed in front of the ex- 
 ternal iliac vessels. The broad ligament cannot be said to exist yet, the 
 uterus filling the whole cavity of the true pelvis. AVhat starts from its 
 sides is nothing but the already-mentioned formations — namely, the 
 mesoarium, the mesosalpinx, and the round ligament ; which latter, as 
 
80 
 
 THE DEVELOPMENT OF THE FEMALE GENITALS. 
 
 we have seen above, is originally a ligament belonging to the Wolffian 
 body, and only enters into connection with the uterus after the destruc- 
 tion of those bodies, 
 
 "While the tubes, and likewise that part of the uterus which is situ- 
 ated in the peritoneal cavity, are covered all over with peritoneum, the 
 
 Fig. 15. 
 
 Transverse Section through the Ovarian Region of a Human Embryo of five months, lower 
 surface seen from above (enlarged 3 times) : oi, os ilium ; s, sacrum ; mo. mesoarium and 
 the hilus of the ovary, bounded by two lips; o, cut surface of the ovary; r, free ventral 
 surface of the ovary or lateral part of the ventral surface ; t, tube ; mt, mesentery of the 
 tube (later the ala vespertilionis) ; r, rectum ; lu; ureter ; au, umbilical artery ; ie, external 
 iliac vessels ; nc, anterior crural nerve (KoUiker). 
 
 ovaries are, as it were, lodged in two holes of the peritoneum. Only 
 quite near the hilus have they a sheath of that membrane. 
 
 The formation of the ova and Graafian follicles ^ has especially been 
 elucidated by Waldeyer, and his views have with slight modifications 
 been corroborated by H. jSIeyer, the most recent investigator of the 
 subject, and by Allen Thomson. At the earliest stage we have seen 
 the ovary to be represented by a streak composed of cells developed 
 from the peritoneal covering of the Wolffian body. Very soon a pro- 
 tuberance of connective tissue makes its way from behind into this 
 cell-heap. These two different parts are the beginning of the two 
 substances which go to build up the ovarv^, the connective tissue form- 
 ing the stroma ; the cells, the parenchyma or glandular part ; but in 
 the ensuing development these two elements become most intimately 
 interwoven. The stroma sends out between the cells prolongations 
 which separate them into groups, and grow together over them, so as 
 
 ^ Begnier de Graaf, De Mulkrum organis generationi inservientibus, Leyden, 1672. 
 
THE OVARIES. 
 
 81 
 
 to form a layer of connective tissue above them ; but simultaneously 
 new layers of cells are formed outsitlc (»f the first border-line, wliich 
 
 Fig. 1G. 
 
 Y\<:. 1 
 
 ^f^. 
 
 & n 
 
 Fig. 16.— Ovary of a Human Foetus of ten or eleven weeks : a, superficial stratum of cells ; b, 
 layer of connective tissue; c, trabecule of connective tissue, the cells having been removed; 
 d, mesoarium (Meyer). 
 
 Fig. 17.— Part of the same Ovary, near the surface, seen -with higher power: v, natural size 
 of the ovary. 
 
 again l^ecome divided into groups by new prolongations of the stroma. 
 The chief direction of the,se prohjugations is a radial one from the hilus 
 
 Fig. 18. 
 
 From a Fcetus of sixteen weeks. The formation and separation of ova (Meyer). 
 
 to the surface. At an earlier stage they are entirely irregular, and do 
 not form closed cavities, but an irregular system of meshes and anas- 
 
 FiG. 19. 
 
 From a Foetus of twenty-eight weeks. In some places is already seen the permanent epithe- 
 lium, composed of a single layer (Meyer). 
 
 tomosing tubes, much like those seen in a sponge. At the surface is a 
 particular zone composed of several layers of cells, between which are 
 
 Vol. I.— 6 
 
82 
 
 THE DEYELOPMENT OF THE FEMALE GENITALS. 
 
 Fig. 20. 
 
 From a Foetus of thirty-six weeks. The single epithelial layer is interrupted by the intercala- 
 tion of a belated primordial ovum with its follicular epithelial cells (Meyer). 
 
 Fig. 21. Fig. 22. 
 
 Three Graafian Follicles from the Ovary 
 of a Newborn Girl (enlarged 350 times) : 
 1, natural condition; 2, treated with 
 acetic acid: a, structureless mem.brane 
 of follicles; 6, epithelium (membrana 
 granulosa) ; c, yolk ; d, germinal vesicle, 
 with germinal macula; e, nuclei of the 
 epithelial cells; /, vitelline membrane 
 (very fine) (Kolliker). 
 
 found fine prolongations from 
 the stroma ; and this zone is 
 separated from the rest of the 
 parenchyma by a fine layer of 
 connective tissue (Fig. 16). 
 
 From the end of the sixth 
 month the surface begins, in 
 some places, to form a single 
 layer of epithelial cells (Fig. 
 19), and in the newborn girl 
 the whole ovary is covered with 
 such a single layer of low col- 
 umnar cells, under which lies a 
 more or less thick layer of con- 
 nective tissue, the so-called albu- 
 
 Part of Section from surface to hilus of Ovary from Girl three days old : single layer of epithe- 
 lium yet in connection with a cluster of primordial ova. All ova have disappeared from 
 the surface. A broad layer of stroma separates in most places the epithelium from the fol- 
 licular zone. The farther we go from the surface toward the hilus, the fewer ova are there 
 in one nest, until finally there is only one in its primary follicle, n, natural size of the 
 whole ovary (Meyer). 
 
THE OVARIES. 83 
 
 ginoa (I^'it!;. -1). This is by no moans a separate membrane, but only 
 a sonu'w hat dcnsor ])art of tiu' ovarian stroma. (Figs. 18-20 show the 
 gratUial cliaiige of the surface.) 
 
 In the mean time the prolongations extending from the hihis to the 
 surface have grown in thickness, length, and width, and new prolonga- 
 tions have grown from the walls of the older meshes, dividing the ceil-, 
 groups into smaller and smaller compartments, until finally one large 
 cell with one or m<jro smaller ones is entirely enclosed in a cavity formed 
 by the stroma (Fig. 20). These large cells, containing a large nucleus, 
 are the future ova, and are called primordial ova. The compartment 
 in which they are found imbedded with the small epithelial cells are 
 called primary follicles (Figs. 18, 19). The smaller cells increase in 
 number and form several layers. A fissure appears between these 
 layers, and a liquid accumulates in the interstice, forming the begin- 
 ning of the liquor folliculi. The outer layers form the epithelium of 
 the Graafian follicles, the so-called membrana granulosa; the inner 
 continue to surround the ovum and form the discus proligerus, or, as 
 
 Fig. 23. 
 
 Graafian Follicle from a Girl seven months old (enlarged 220 times ; natural size, 0.351 mm.) : 
 a, epithelium (membrana granulosa i detached from the fibrous membrane ; h, discus prolig- 
 erus or cumulus ovigerus, situated far away from the surface. It contains the ovum, on 
 which the zona pellucida and the germinal vesicle are visible. The surrounding fibrous 
 membrane of the follicle is not yet separated into two layers, and there is no distinct line 
 of demarkation between it and the stroma (KoUiker). 
 
 Kolliker more graphically designates it, the cumulus ovigerus — i. e. the 
 heap containing the ovum (Fig. 23). At what time this formation of 
 the true Graafian follicles normally takes place is not yet decided. Some 
 have found them in the newborn child, others only after the age of two 
 years and a half. 
 
84 THE DEVELOPMENT OF THE FEMALE GENITALS. 
 
 At first the primordial ovum is a simple protoplasmic body without 
 any membrane, the zona pellucida (Fig. 24) appearing after the forma- 
 tion of the Graafian follicle is completed. 
 
 The fibrous membrane of the follicle is formed by a differentiation 
 
 of the surrounding stroma. After the completion of the follicles they 
 
 can easily be enucleated from the surrounding stroma, showing that the 
 
 connection with the latter has been loosened. This 
 
 Fig. 24. seems to be due to the formation of numerous 
 
 lymph-spaces in .the connective tissue surrounding 
 
 the fibrous membrane of the follicles. 
 
 As here described, the ova, the surface epithelium 
 of the ovaries, and the epithelium lining the inside 
 of the Graafian follicles have all one and the same 
 origin ; but it might be proper to add that while 
 Human Ovum from a me- ^H observers havc Corroborated Waldeyer's doctrine 
 
 dium-sized Follicle (en- i r> • r> i i • 
 
 larged 250 times) : a, as to the formation 01 the ova, there obtams some 
 I™SSTrnmTt difference of opinion as to the origin of the epithe- 
 between the yolk and Hum of the folliclcs, the so-callcd membraua granu- 
 
 the zona pellucida; c, i -ttti -i -ttt- it • -x x1 • ■ 
 
 germinal vesicle with ^osa. VVhile Waldeyer gives it the same origin as 
 germinal spot (K61- the ova — namely, the germ-epithelium covering the 
 surface of the ovaries — Foulis believes it is formed 
 from the stroma of these glands. According to Kdlliker, the process 
 is much more complicated. In that part of the ovary which is situated 
 nearest to the hilus are found cords composed of small cells and canals 
 lined with columnar epithelium, which, like several other microscopists, 
 Kolliker takes to be remnants of the Wolffian body. But he has found 
 that these so-called medullary cords come in contact with the primordial 
 ova which are exclusively found in the more superficial layers of the 
 ovary, and, according to him, they surround these ova and furnish the 
 membrana granulosa of the Graafian follicle. 
 
 The great simplicity of Waldeyer's theory, and new observations in 
 lower animals by other embryologists, would seem to give that theory 
 the preference, according to which the epithelium of the follicle and 
 the ovum which it encompasses are derived from the same source ; and 
 recently this view has been corroborated by the investigations of Meyer 
 in human embryos. 
 
 It is very likely, although not yet positively proved, that the cells 
 which are destined to become ova after being surrounded by stroma 
 multiply by division. This would constitute a second source of the 
 enormous number of ova contained in the ovaries, which has been 
 evaluated by Henle to thirty-six thousand in each gland (Fig. 25). 
 The formation of ova on the surface of the ovaries ceases almost 
 entirely from the time they are covered with a single layer of epi- 
 thelium — that is to say, about the end of the seventh month — but it is 
 
THE MVLLERIAN DUCTS. 
 
 85 
 
 not unlikely that the formation of new ova by division may go on much 
 longer. 
 
 From the time of the birth of the eliild to that of puberty the ovaries 
 simply grow in size and beeome 
 smoothed and rounded off. In 
 children from six to eleven years 
 old the average measures of the 
 rio'ht ovarv are — length, 26.7 
 millimeters ; height, 9.0 ; thick- 
 ness, 4.4 ; the left, length, 24.0 ; 
 height, 8.4 ; thieloiess, 4.6. In 
 girls of thirteen to fourteen 
 years the average measures are 
 — right ovary, length, 29.6 ; 
 height, 15; thickness, 10; left, 
 length, 25 ; height, 14 ; thick- 
 ness, 9.3 (Puech). At the age 
 of puberty a new life begins in 
 
 the organs by the periodical development and rupture of the Graafian 
 follicles, by which the ova are set free. (For the particulars of this 
 process we refer the readers to works on physiology and anatomy.) 
 
 From a Human Embrj-o of six months (enlarged 
 400 times) ; 1, two primordial ova surrounded by a 
 common layer of epithelium, one of which has a 
 prolongation by means of which it probably was 
 attached to another ovum, as in 2, where two pri- 
 mordial ova are linked together by means of a 
 band of protoplasm, the whole surrounded by one 
 epithelial layer. 3, primordial ovum with two 
 nuclei (germinal vesicles) (Kolliker). 
 
 The Mullerian ^ Ducts. 
 
 In no part of our study of the development of the female genitals 
 are we more forcibly reminded of the yet unsettled condition of 
 embryology than in regard to the JMiillerian ducts — an uncertainty 
 which is explainable when we remember that these investigations are 
 of a comparatively recent date, that different observers sometimes have 
 worked on the embryos of different animals, and that gradually new 
 and improved methods have been adopted in the preparation of the 
 specimens. As heretofore, we will chiefly follow Kolliker, the author 
 of the most complete work on human embryology in any lan- 
 guage. According to this authority, jSIiiller's ducts appear shortly 
 after the Wolffian bodies — in chickens on the sixth day, in rab- 
 bits on the twelfth or the thirteenth day. They begin as a ftinnel- 
 shaped invagination from tlie germ-epithelium at the inner side of the 
 upper end of the Wolffian bodies, on a level with the fifth protovertebra 
 (Fig. 26). From this locality the ]Mullerian duct extends behind the 
 Wolffian body to its outer part, where it lies close uj:» to the Wolffian 
 duct, outside of this latter duct ; but gradually the JMiillerian duct turns 
 spirally round the Wolffian duct, so as to come in front of it, then 
 inside of it, and finally behind it. The lower end is in young embryos 
 
 * Johannes Miiller, Handbueh der Physiologie der 3fenschen, Coblenz, 1834 et seq. 
 
86 
 
 THE DEVELOPMENT OF THE FEMALE GENITALS. 
 
 formed of a solid mass of cells, in which subsequently a canal appears. 
 In the chicken this whole development is finished in the course of two 
 days, when the duct opens into the cloaca. In the rabbit the develop- 
 ment takes considerably longer time, probably nineteen or twenty days. 
 In human embryos the perforation takes place in the seventh week. 
 This Ls the origin of the Miillerian ducts as observed by Bornhaupt, 
 Egli, and Kolliker in the chick and the rabbit. 
 
 Waldeyer, on the other hand, who has investigated the matter in 
 chickens, pretends that the duct is formed from the germ-epithelium as 
 
 Fig. 26. 
 
 u 
 
 u 
 
 \ 
 
 ^N 
 
 'TIUJ 
 
 Transverse Section througli the upper end of the Wolffian Body of the Embryo of a Rahhit 
 of 14 days (enlarged 140 times) : ivg, Wolffian duct ; ni, connection between a tubule of the 
 Wolffian body with a Malpighian body ; t, entrance to the Miillerian duet (later the abdominal 
 ostium of the Fallopian tube) ; g, g, mesentery of the Wolffian body, containing a glandular 
 tubule ; I, I, surface of the liver ; lib, posterior abdominal wall ; mg', lateral pjart of the 
 Miillerian duct (Kolliker). 
 
 a canal which, at first open, becomes gradually closed by the fusion of 
 the borders, so as to form a closed tube. 
 
 A third view is that put forth by Balfour and Sedgwick. Accord- 
 ing to these authors, Miiller's duct is at first a solid string of cells 
 which becomes detached from the outer wall of the Wolffian duct. 
 
 The Miillerian duct has a mesentery of its own, which is first attached 
 to the AYolflfian body. After the absorption of that organ it is fastened 
 to the posterior abdominal wall, and at a still later stage we find it 
 starting from the outer surface of the mesoarium, as described above 
 in speaking of the ovars^. 
 
 If thus the origin of the Miillerian ducts is still somewhat uncertain, 
 their further development and ultimate fate are well known. In the 
 male sex they disappear very soon almost entirely. In the male 
 
THE UTERUS AND THE K 167X1. 87 
 
 (Muhrvi. of a ral.l.it ..I" twcntv-lhnr dnvs' jicstation Kolliker fouixl no 
 trace of tlu'iu. In tlic cliicUcn they disappeared likewise eomi)letely 
 atter the twelfth <lay. In some animals, siieli as the niminaiils and the 
 Caniivora, some remnaiils oi" them are iWiind as vesicular lormations at 
 the fundus of the bladder. In man the whole central i)art of them is 
 absorbed. The upper end is left, and forms the small vesicle attached 
 to the epididymis which is called Morgagni's hydatid. The lower end 
 likewise remains, and forms the vesicida prostatica, which corresponds 
 to the uterus and vagina. AVhile in the male sex only vestiges, without 
 any physiological importance, are left of the Mullerian ducts, in the 
 feinale'they become the ducts through which the ovum passes from the 
 ovary, the' receptaculura in which the fjetus is developed, and the tube 
 in which sexual connection takes place, and through which the off- 
 spring is brought out to separate existence. 
 
 The Fallopian' Tubes. 
 These organs are a development of that part of the Mullerian ducts 
 which is situated above the round ligament. In the course of time 
 it increases in size ; it changes direction in follo^^'ing the ovary down, 
 and comes to occupv a position above and in front of the latter organ ; 
 the muscular coat and mucous membrane are developed, and around 
 the opening at the upper outer end sprouts out the row of tongue-like 
 prolongations constituting the fimbriae. 
 
 The Uterus'^ and the Vagina.^ 
 That part of the Mullerian ducts which is situated below the inser- 
 tion of the round ligament and the lower ends of the Wolffian ducts 
 enter into close connection and form a quadrilateral cord with rounded- 
 off edcres, the so-called genital cord. (See Fig. 27.) Cross-cuts through 
 this co^rd show that at the upper and louver ends there are four epithelial 
 tubules, the Mullerian ducts Iving behind the Wolffian ducts; but in 
 the intermediate part the two Mullerian ducts are seen growing or 
 o-rown together, so as to form one single tube, which is the first appear- 
 ance of the uterine cavitv. From pathological specimens Schatz has 
 inferred that the fusion begins just below the place where later the 
 vaginal portion will be situated. This fusion of the Aliillerian ducts 
 takes place in the human embrvo at the end of the second month. As the 
 whole of the genital cord is used to build up the uterus and the vagina, 
 
 ^ G&hriele FaWo^io, Obs€rvationesanatomkre,\enet.,1r,CA. , , , 
 
 ^ Classic Latin name for the womb, but in ancient times comprising the whole gem- 
 
 tal tract. 
 
 3 Classic Latin, meaning a slieath. 
 
THE DEVELOPMENT OF THE FEMALE GENITALS. 
 
 Fig. 27. 
 
 Transverse Section through the Genital Cord from the Embryo of a Cow 1}4 inches long (en- 
 larged 14 times) : 1, from the upper end of the cord (the ducts have been cut somewhat 
 obliquely) ; 2, somewhat lower down; 3 and 4, from the middle of the cord, showing incom- 
 plete and complete fusion of Mtiller's ducts ; 5, from the lower end, showing the two Miiller- 
 ian ducts separated; o, anterior; p, posterior side of the genital cord; m, Mtiller's duct; wg, 
 Wolffian duct (Kolliker). 
 
 Fig. 28. 
 
 Fig. 29. 
 
 the lower parts of the Wolffian ducts contribute their share to the for- 
 mation of these organs. In the third month the uterus is still two- 
 horned ; that is to say, those parts of the Miillerian ducts which lie nearer 
 
 the round ligaments are not yet united. 
 (See Figs. 28 and 29.) As just stated, 
 the fusion begins in the middle, while 
 the ducts are still separated above and be- 
 low. The upper parts constitute the horns 
 of the uterus, which persist in many ani- 
 mals, but in woman gradually grow to- 
 gether, the partition between them becom- 
 ing absorbed, until finally, about the 
 middle of pregnancy, the uterus forms 
 one sac without horns, as seen in Fig. 30, 
 and containing a single cavity. The lower 
 parts later become fused together, except 
 when, by an arrest of development, they persist as two and form a 
 double vagina — a point to which we will come back in treating of mal- 
 formations. 
 
 The Miillerian ducts open into the lower part of the urachus — i. e. 
 that part of the allantois which is comprised in the body of the embryo 
 and forms the bladder (Fig. 31). This lower part-, from the openings 
 of the Wolffian and Miillerian ducts downward, is called the sinus uro- 
 genifalis (Fig. 2, p. 69). Originally, it opens into the cloaca, a com- 
 mon vault, in which end the urogenital system and the intestine (Fig. 
 31), and which communicates with the surface through the cloacal 
 opening formed by an invagination from the epiblast and thinning 
 
 Ovaries, Tubes, and Uterus from a 
 Human Foetus from the tenth 
 week, 26 mm. long (Fig. 28 natural 
 size ; Fig. 29, enlarged four times) : 
 a, the round ligament ; h, rectum 
 (Meyer). 
 
THE UTERUS AM) THE VAGLYA. 
 
 89 
 
 of" tlio tissue intervening between it and the gut. TliLs perforation 
 takes place in the human embno in the fourth week. In the course 
 
 Fig. 30. 
 
 Abdominal and Pelvic Viscera of a Female Embryo of five months (length, from vertex to sole, 
 19 centimeters— natural size) : t, tube ; r, round ligament ; v, bladder ; «, umbilical artery ; 
 ur, urachus ; c, cfecum ; pa, vermiform appendix (KoUiker). 
 
 of the sixth and seventh vreeks the common orifice is seen to become 
 divided into two parts — ^viz. the longer slit of the genito-urinary 
 aperture anteriorly, and the narroAver and more rounded anal open- 
 ing posteriorly. This separation 
 of the single cloacal opening into 
 two is probably mainly effected 
 by the groAvth of ti.ssue from the 
 
 Fig. 31. 
 
 Fig. 32. 
 
 I'ti 
 
 sides of the cloaca and downward 
 from the point where the rectum 
 and the urachus unite. By the 
 formation of this septum the sinus 
 urogenitalis is separated from the 
 rectum (Fig. 32). This partition 
 unites with the posterior end of 
 the genital folds (see Fig. 34), and thus the separation between the 
 genito-urinary and the anal openings is completed by "the formation of 
 the perineum, which takes place in the tenth week. 
 
 Fig. 01.— c/, cloaca; all, allantois; m, Miiller's 
 duct; r, rectum 'Schroeder). 
 
 Fig. 32. — sti, sinus urogenitalis ; r, rectum, sepa- 
 rated by the perineum ; v, vagina, lower part 
 of Miiller's duct; b, bladder; u, urethra 
 (Schroeder). 
 
90 THE DEVELOPMENT OF THE FEMALE GENITALS. 
 
 The sinus urogenitalis lags behind in growth, while the urethra is 
 being formed as a distinct part, different from the bladder, with which 
 it hitherto has been blended into one organ, the urachus, and the uterus 
 and vagina are being developed from the lower part of the Milllerian 
 ducts. (See Fig. 33, 2.) Actual measurements at different stages of devel- 
 opment prove that the sinus urogenitalis increases in size, so that its 
 apparent diminution is only due to the comparatively greater devel- 
 opment of the surrounding parts. In consequence of the considerable 
 
 Fig. 33. 
 
 LL C/.' 
 
 Sinus Urogenitalis and its Appendages from Human Embryos (in life-size) : 1, from a three 
 months' fcetus ; 2, from a four months' ; 3, from a sixth months' ; b, bladder ; h, urethra ; iig, 
 sinus urogenitalis; g, genital canal, common rudiment of vagina and uterus; s, vagina; 
 M, uterus (Kolliker). 
 
 growth of the vagina the sinus urogenitalis, which at an earlier stage 
 appeared to be the continuation of the bladder, becomes the direct con- 
 tinuation of the vagina and forms the vestibule. 
 
 At first the uterus and the vagina form only one organ, without any 
 line of demarkation between the two, as seen in Fig. 33, 1 and 2, repre- 
 senting embryos of the third and the fourth month. In the fifth, and 
 still more distinctly in the sixth month, the uterus becomes separated 
 from the vagina by the formation of a ring protruding from the inner 
 surface at the level of the future external os (see Fig. 33, 3) ; which 
 ring, by further development during the remaining months of preg- 
 nancy, becomes the vaginal portion. 
 
 In the fifth month the uterine wall is scarcely thicker than that of 
 the vao;ina, but from the sixth month it increases considerablv in 
 thickness. Transverse folds appear in the fifth month, designating 
 the cervix. 
 
 In the newborn child the cervix constitutes about two-thirds of the 
 whole length of the organ, and its walls are much thicker than those 
 of the body. In a specimen lying before me the exact outer measures 
 are — cervix, 2.2 centimeters; body, 1.0; wall of cervix, 0.3. On 
 the outer surface there is no distinct line of demarkation between the 
 cervix and the body. The lower part forms a cone the base of which 
 points down toward the vagina, and the shape of which is such that a 
 cross-cut made perpendicularly on the long axis almost forms a circle. 
 The body, on the other hand, has the shape of a flattened cone, the basis 
 
THE UTERUS AND THE VAGINA. 91 
 
 of which is turned iipwanl to the alxldiiiiiial cuNily ; hut this triaiif^iilar 
 fiat part cxtciids soiiu'wiiat lower dcnvu tlum tlie internal line of 
 deniarkation hetween the cervix and the hody, and on tlic anterior sur- 
 face the peritoneum descends almost as iar down below the internal lino 
 of deniarl<ation (nine millimeters) as ihe whole len<rth of the hodv. On 
 the internal surface the line of demarkation is very sharp on the anterior 
 surface. The anterior column, from which numerous rn^ae ^o off to 
 both sides under acute angles tending outward and upward, ends 
 abruptly at a deep transverse furrow which separates it from the cav- 
 ity of the body. The whole anterior surface of the cavity of the body, 
 from this furrow up to the fundus, is occujiied by two large bundles of 
 longitudinal furrows, each of which forms a lengthy, narrow triangle, 
 touching the fundus with their base. A similar formation is found on 
 the posterior wall, but here the line of demarkation between the trans- 
 verse folds of the cervix and the longitudinal folds of the body is less 
 distinct. In both edges of the cavity of the body is found a fine lon- 
 gitudinal ridge from Avhich start to both sides fine transverse folds end- 
 ing at the longitudinal folds on the anterior and posterior surfaces. They 
 are a direct continuation of the transverse folds found in the cervix.^ 
 
 Later in life all these folds of the cavity of the body disappear. In 
 a figure in Courty's treatise of the diseases of the uterus, representing 
 the normal uterus of a girl of seven years, the folds are already limited 
 to the cervix. The fundus in the newborn forms a straight line from 
 one tube to the other. The whole organ is slightly curved forward, 
 but there is no anteflexion ; that is to say, the axis of the organ does 
 not form any angle. According to Kolliker, some uteri from the end 
 of embryonic life, and during childhood up to the age of pubertv, 
 present a slight degree of anteflexion. After that time the normal 
 uterus is straight. 
 
 The mucous membrane of newborn children has no true glands, but 
 only follicular depressions.^ The formation of glands begins much 
 earlier in the cervix than in the body. Thus in the body of the uterus 
 of a girl of six or seven years there are barely found at long intervals 
 some epithelial invaginations which only penetrate to a short distance 
 into the stroma of the mucous membrane, constituting rudimentary 
 glands. At the same time, those of the cervix are jicrfectly developed, 
 and have even almost acquired the size they obtain in the adult (De 
 Sinety). It is true that even in the newborn child we find the cervical 
 canal filled with a thick colorless mucus, as in the adult, but this is 
 
 ' This description of the cavity of the uterus with lonrjihicUrKtl folds differs entirely 
 from the common one, according to which the transverse folds of the cervix should be 
 continued on the anterior and posterior wall up to the fundus ; but on the other hand, 
 it comes pretty near to the description, and especially the drawiufr. of Hagemann, 
 who injected the cavity with a soft metallic composition or paraffin. 
 
 ■■* Cornil, Journal de I'Anatomie, 1874, quoted by Imbert. 
 
92 THE DEVELOPMENT OF THE FEMALE GENITALS. 
 
 merely a secretion from the calciform or cup-shaped epithelial cells 
 found on the folds of the cervix. During the years elapsing between 
 the birth of the child and its arrival at puberty the uterus stays much 
 behind the rest of the body in development — so much so that in a girl 
 of ten or twelve years it scarcely diifers in external appearance from 
 that of a newborn child (Puech). But at the time of approaching 
 menstruation the organ increases much in size — an increase which goes 
 on till the general gro^vth of the body reaches its maximum. 
 
 The vagina, after the diiferentiation between it and the uterus has 
 taken place in the fifth month, becomes much wider than the uterus, 
 and about the middle of utero-gestation its folds make their appearance. 
 
 The hymen^ is not, as stated in most books, a mere fold of the 
 mucous membrane of the vagina, but, as demonstrated by dissections 
 made by Budin, the whole lower end of this canal dipping into the 
 vestibule. It is only a further development of the ring-shaped swell- 
 ing with which the Miillerian ducts are surrounded where they open 
 into the sinus urogenitalis. This development does not begin before 
 the nineteenth week. As a rule, a larger part of the posterior wall 
 protrudes than of the anterior. The internal or upper surface shows a 
 continuation of the vaginal columns and folds. The vagina in young 
 individuals has the shape of the finger of a glove, with a small round 
 opening or lengthy slit at the end, which is the true entrance of the 
 
 The Vulva.'' 
 
 As stated above, at an early stage of embryonic development the 
 intestine and the bladder open into a common space called the cloaca, 
 which from the fourth week communicates with the outer surface by 
 means of an aperture called the primitive anal or cloaca! opening. In 
 front of this opening there aj)pears in the sixth week a protuberance 
 called the genital eminence, and soon thereafter two lateral folds called 
 the genital folds (Fig. 34). The genital eminence protrudes more and 
 more, and toward the end of the second month a furrow appears on its 
 lower surface extending to the outlet of the cloaca, the so-called geni- 
 tal furrow. From the fifth to the tenth week the cloaca becomes sepa- 
 rated, as described above, into an anterior or urogenital part, the sinus 
 m'ogenitalis, and a posterior or rectal part. Up to the tenth week the 
 sexes cannot be distinguished, but henceforth the peculiarities of each 
 appear. The genital folds grow to be the labia majora;^ the edges of 
 
 ^ Although it would he gratifying to the aesthetic and moral sense to put this word 
 in a particular relation to Hymen, the god of marriage, it simply means a membrane 
 
 '^ Classic Latin, but in ancient times often comprising the whole genital canal. 
 ^ Latin, labium, lip. 
 
LITERATURE. 
 
 93 
 
 tht' liciiital furrow arc develnpc'd as the labia minora; and the <r<'iiital 
 eniineiK-e bccuiuos tlio clitoris/ round which is thrown a fold i'roni the 
 labia minora formini; its prcpiico.^ The sinus urogenitulis rcmaias in 
 the shaj)c of the vestibule. The jxjsterior part of the genital fjlds 
 
 Fig. 34. 
 
 Fig. 35. 
 
 hi 
 
 Fig. 34.— Fonnation of the External (jenitals in Mankind. 1, lower portion of tiie trunk of an 
 embryo from the eighth week, double .size : e, gland or point of the genital eminence ; /, gen- 
 ital furrow leading back to an aperture which at this period communicates with the rectum, 
 and consequently is a cloacal o[iening; W, genital folds; s, caudal extremity of the body ; 
 II, umbilical cord. 2, from a Female Embryo about 10 weeks old and 1 inch and 2 lines 
 long: a, anus; vg, entrance to sinus urogenitalis ; n, edges of genital furrow or labia 
 minora. The other letters as in 1 (Kolliker). 
 
 Fig. 35.— 1, from an Embryo 1 inch long, double size, representing a stage that precedes Fig. 34; 
 2, the sex is not yet distinguishable. 2. from a Male Embryo from the end of the third 
 month, 2 inches and V/, lines long. Letters as in Fig. 34. In 2 the genital furrow is closed, 
 forming the raph6 (r) of the penis, scrotum, and perineum (Kolliker). 
 
 groM' together, forming the perineum,^ which above unites A\ith tiie 
 partition which ha.s divided the cloaca into two di.stinct cavities. 
 
 Literature Referred to. 
 
 BoEHM, C. : "Ueber Erkrankung der Gartnerschen Giinge" (Arch.f. Gyndk., 1883, vol. 
 
 xxi. p. 176). 
 BuDix, P.: "Eecherches sur I'llymen et TOuverture du Vagin" [Progrts medical, 
 
 1879, Nos. 35, 36, 37, and 38). 
 Chatty AU: Anatomie comparee desAnirrumx domestiques, 3d ed., Paris, 1879. 
 CouRTY, A. : Tmite pratique des Maladies de V Uterus et de ces Annexes, Paris, 1866. 
 DoHRN, E.: "Ein Fall von Atresia vaginalis" [Archiv fixr Gyndk., x. p. 544). 
 : "Die Gartnerschen Kaniile beim "VVeibe" {Arch. fixr Gyndk., 1883, vol. xxi. 
 
 p. 328). 
 FiscHEL, W. : " Ueber das Vorkommen von Resten des Wolffschen Ganges in der 
 
 Vaginal portion" {Arch. Jur Gyndk., 1884, vol. xxiv. p. 119). 
 FouLis: "Cancer of the Ovary" (Edinburcjh Med. Journ., March, 1875). 
 Gartner, H. T. : '' Anatomisk Beskrivelse over et ved nogle Dyrearters Uterus un- 
 
 dersogt glandulost Organ" (Konyl. Dansk. Vidensk. Sehk. Skri/ter, Copenhagen, 
 
 1822). 
 Geigei., R. : Ueber Variabilitdt in der Enlmckelung der Geschlechtsorgane, Wiirzburg. 
 
 1883. 
 Hagemaxn : "Ueber die Form der Hohlung des Uterus" {Arch. fixr Gyndk., 1873, 
 
 vol. V. p. 295), 
 Hedexius, p. : " Ett fall af uterus septus nied en ensidig kongenital atresi " ( Upsala 
 
 Ldkareforenings Fdrhandlingar, 1882, vol. xvii. p. 530). 
 
 ^ Classic Greek, K?eiropic. 
 
 ^ Classic Greek, •zepivenv or ~epivaiov. 
 
 Classic Latin, prccputium. 
 
94 THE DEVELOPMENT OF THE FEMALE GENITALS. 
 
 His, Wilhelm: Anatomie menschlicher Embryonen, i.-iii., Leipzig, 1880-85. 
 Imbert, G. : Developpement de I' Uterus el du Vagin, Paris, 1883. 
 Jacobson, L. : Die Okenschen Korper oder die Primordicdnieren, Kopenhagen, 1830. 
 KocKS, J. : " Die Gartnerschen Giinge beim Weibe " {Archiv fur Gyndkologie, 1882, 
 
 vol. XX. p. 485). 
 KoLLiKER, A. : Entivickelungsgeschichte des Menschenund der hoheren Thieve, 2te Auflage, 
 
 Leipzig, 1879. 
 
 : Ueber die Lage der iveiblichen innern Gesehlechtsorgane, Bonn, 1882. 
 
 : "Organejunger menschlicher Embryonen" [Centralbl. fur Gyndk., 1884, vol. 
 
 viii. p. 585). 
 Meyer, H. : " Ueber die Entwickelung der menschlichen Eierstocke" {Arch, filr 
 
 Gyndk., 1884, vol. xxiii. No. 2, p. 226). 
 Milne-Edwards, H. : I^egons de Physiologie et d^ Anatomie coniparee, vols. viii. and ix., 
 
 Paris, 1870. 
 Puech, a. : Des Ovaires, de leurs Anomalies, Paris, 1873. 
 QuAiN : Elements of Anatomy, edited by Allen Thomson, E. A. Shiifer, and G. D. 
 
 Thane, 9th ed., Islew York, 1882. 
 EiEDER, Carl: "Ueber die Gartnerschen (Wolffschen) Kanale beim menschlichen 
 
 Weibe" {Virdiovfs Arch., vol. xcvi. p. 100). 
 Schatz, F. : Vier neue Falle von unvoUkommener Theilung des weiblichen Genital- 
 
 kanals [Arch, filr Gyndk., 1870, vol. i. p. 12). 
 SiNETY, L. De: Manuel pratique de Gynecologic, Paris, 1879. 
 Skene, A. : " The Anatomy and Pathology of Two Important Glands of the Female 
 
 Urethra" (Am. Journ. Obst., 1880, vol. xiii. p. 265). 
 Waldeyer, W. : Eierstock und Ei, Leipzig, 1 870. 
 Wassilieff, M. : " Betreffend die Eudimente der Wolffschen Gange beim Weibe " 
 
 {Arch.f Gyndk., 1884, vol. xxii. p. 346). 
 WiNCKEL,, T. : " Die Krankheiten der weiblichen Harnrohre und Blase," Stuttgart, 
 
 1877 {Billroth's Handbuch der Frauenkr., vol. iii. part ix.). 
 
THE ANATOMY OF THE FEMALE PELVIC 
 
 ORGANS. 
 
 By henry C. COE, M. D., 31. R. C. S., 
 
 New Yurk. 
 
 Introductory. — lu venturing upon ground which has been so fre- 
 quently trodden the writer would disclaim, at the outset, such an amount 
 of original research as would entitle him to speak authoritatively upon 
 any one of the many disputed questions which will arise in the course of 
 the following studies. If, then, some mooted points are left undecided, 
 it may be assumed, without further exjjlanation, that the writer feels 
 himself incompetent to settle them. 
 
 It is intended in this article to avoid such details as would be interest- 
 ing only to the anatomist, and to present a brief and fairly accurate 
 review of the pelvic organs as regarded from the standpoint of practical 
 gynecology. The general reader, who has hitherto been content to 
 limit his knowledge of pelvic anatomy to the half-dozen introductory 
 pages in a textbook on obstetrics or diseases of women, will be sur- 
 prised, on looking deeper into the subject, not so much at the unsolved 
 problems that confront him on eveiy side, as at the number of erroneous 
 statements that have long received the sanction of the highest authorities. 
 
 In describing in detail the organs of generation there are several 
 orders in which they may be considered. Thus they may be studied — 
 1, in the order of their development; 2, according to their relative 
 importance, or from within outward ; 3, from without inward. The 
 latter sequence, which is the one usually followed, is the most natural 
 one, since Ave not only begin with the study of simpler structures and 
 ascend gradually to those of greater complexity, but we observe the 
 same order as in a systematic examination of the organs in the living 
 subject. 
 
 It is customary to speak of the external and the internal genitals. 
 The vagina is commonly included among the former, although not 
 properly. It is better to describe it by itself as a connecting-link 
 between the external, or visible, and the internal, or deep-seated, 
 organs. The hymen is invariably described with the pudenda, when, 
 
 95 
 
96 
 
 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 as will be shov^Ti later, it is strictly a part of the vagina, and should 
 be considered with that canal. 
 
 THE EXTERNAL GENITALS. 
 
 Synonyms. — ^^^ulva^ ; Led., pudenda, cunnus ; Fr., vulve, parties 
 genitales externes ; Ger., Schamritze, Schamtheile ; It, vulva, pudende ; 
 8p., vulva, pudendum. 
 
 Defixitiox. — Under this term is included that portion of the genital 
 tract which is visible externally.^ 
 
 It should be added that this definition implies that the subject is 
 placed in the recumbent posture, with the thighs abducted and the labia 
 majora separated. In the nude erect female the mons Veneris alone Ls 
 
 Fig. 36. 
 
 The External Genitals, as seen in mesial section (Henle) : a, anus ; h, perineal body ; c, vagina ; 
 d, urethra ; e, lahium minus ; /, clitoris ; g, fossa naTicularis, in front of which is the hymen. 
 
 visible (Fig. 36). The external genitals include the greater and lesser 
 labia and the clitoris, with the jDarts immediately adjacent to them. 
 The meatus urinariiis belongs to the urinaiy tract, with which it will 
 be described. Certain accessory structures, such as the bulbs of the 
 vagina and the glands of Bartholin, may be regarded as common to 
 both the \Tilva and vagina, while the pad of fat over the s}Tnphysis 
 pubis, kno^m as the mons Veneris, has no ftmction whatever in connec- 
 tion with generation,^ but will be mentioned first on account of its 
 architectural prominence. 
 
 ^ " Le vulve est 1' ensemble des parties genitales externes de la femme ;" so Quain's 
 Anatoray, last ed. : " All the parts perceptible externally." 
 
 ^The term "vulva" is not sufficiently exact, since it has been applied by some 
 writers to the rima pudendi. by others to all the parts surrounding the entrance to 
 the vagina and situated anterior to the hym.en or caruncles. Etymologically, the 
 vulva fvalvula) includes the greater labia only; and this was its original meaning, 
 according to ancient writers. 
 
 ^ Comp. Tarnier, Charpentier, and Tillaus. 
 
Moys \'j:\Erj.s. 
 
 97 
 
 MoNS Veneris. 
 
 Synonyms. — " Mount ot" love ;" Fr., niont de Venus, penil, emi- 
 nence .sus-j)ubienne ; Ger., Sehaiuhutrel ; It., monte di Venere ; *S/^., 
 monte de Venus. 
 
 Definition. — The nions is a somewlmt triangular area or projection 
 
 Fig. 37. 
 
 The External Organs of Generation (Liischka) : 1, 1, labia majora ; 2, glans clitoridis ; 3, the 
 nymphse; 4, pra?putiuni clitoridis; 5, frseniilum clitoridis; C, frenulum nympharum; 6, 
 hymen; 8, orifice of the glands of Duverney; 9, tuberculum vaginae, 10, meatus urethrte. 
 
 situated in front of the symphysis pubis. It is covered with a thick 
 gro^\i:h of coarse hair. 
 
 The triangular area mentioned is continuous at its apex with the 
 upper extremities of the labia majora, while its base is defined by a 
 groove at the lower limit of the hypogastrium, which is more or less 
 shaqjly defined according to the amount of adipose tissue in the ab- 
 dominal wall. Ijaterally, the elevation' melts away gradually toward 
 the ino;uinal folds, which form its extreme lateral boundaries. The 
 mans cannot be regarded as in any sense an independent structure, 
 since it is merely an imperfectly circumscribed collection of fat, sup- 
 ported by connective tissue, varying in prominence in diiferent subjects. 
 The inteofument over this region is thicker than that coveriuo; the rest 
 of the abdomen, while the hair is coarser and more crisp than that 
 found elsewhere in the body, and has a decided tendency to curl. Its 
 color will be found to correspond quite closely with that which is nat- 
 ural to the peculiar type of individual in which it is observed, but it is 
 
 Vol. I.— 7 
 
98 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 frequently several shades darker than the hair of the head, especially 
 in brunettes. Appearing at puberty, this hair reaches a certain stage of 
 development, at which it persists through life. It is rather late in under- 
 going the senile change. It may be stated as a curious, rather than an 
 important, fact that the upper limit of the hairy growth on the external 
 genitals of the female is rather sharply defined by the groove before 
 mentioned. It is rare to find a line of hair following the course of the 
 linea alba as high as the umbilicus, a distribution commonly observed 
 in the male. Among five or six hundred women in the lying-in wards 
 of the Vienna General Hospital, whose abdomens the writer inspected 
 with the view of collecting data bearing on this point, not over half a 
 dozen presented the hirsute development described, and these were sub- 
 jects of a decidedly masculine type. 
 
 Anatomy. — a. Gross. — This projection, as before stated, is essen- 
 tially a cushion of adipose tissue traversed by interlacing fibrous and 
 elastic bands, and covered by the skin and superficial fasciae which are 
 common to the abdominal wall. The skin is thick and has an oily 
 feel, the latter peculiarity being due to the presence in it of numerous 
 sebaceous glands. On removing the integument a delicate layer of 
 fascia is seen, which is continuous Avith the superficial fascise of both 
 the abdomen and thighs. This layer is separated with difficulty, since 
 it is traversed by elastic fibres which come from the subjacent tissue, 
 where they form a close network. Certain bundles of these fibres have 
 a definite direction, and have been differentiated by Broca in his descrip- 
 tion of the sac dartdique ("pudendal sac" of Savage^). Thus, some 
 extend laterally as far as the borders of the external inguinal rings ; 
 another set enter the suspensory ligament of the clitoris, and others 
 blend with the elastic tissue of the labia majora. The terminal fibrils 
 of the round ligaments may be traced by careful dissection into the 
 midst of the fibro-lipomatous tissue of the mons. As will be inferred 
 from the above description, the fat composing the mons is arranged 
 in the form of lobules, separated by fibrous trabeculge, and it does not 
 appear as a diffuse mass. 
 
 B. Minute. — The microscopic anatomy of the suprapubic region may 
 be dismissed in a few words, since it is identical with that of any other 
 portion of the skin, plus an extra amount of adipose. Hair-bulbs, 
 sebaceous, and sweat-glands will be seen in a cross-section ; the exist- 
 ence of the latter structures has been questioned, though without suf- 
 ficient reason. 
 
 Labia Majora. 
 Synonyms. — Greater, or external labia, lips of the vulva; Lat, labia 
 externa, seu cunni, sen pudendi, alaj majores, etc. ; Fr., grandes Ifevres, 
 
 ^ Anatomy of Female Pelvic Organs. 
 
LABIA MAJOR A. 99 
 
 l^vres di' la \iilvi' ; Ger., grosse SclKuiilippcii ; //., ^raiidi lal)l)ra; -S^;., 
 lal)i()s luavdi'is. 
 
 Definition. — riic labia niajui-u are two cutaneous folds which begin 
 at the lower part of the moas Veneris, extend downward and hack- 
 ward on either side of the vulvar cleft, and terminate bv blendin<r with 
 the integument of the perineum. Luschka' ha.s shown that there is no 
 well-marked line of separation between the opposite labia, and hence 
 that the expressions "anterior" and "posterior" commissures, so far as 
 they convey the idea of connecting bands, are incorrect.^ By the anterior 
 commissure we understand simply a median projection situated from 
 one to one and a half centimeters above the clitoris; it represents the 
 point of fusion of the labia ^vitl^ the mons Veneris, and forms the 
 anterior or npper extremity of the rima. The posterior commissure is 
 still less distinct, and only appears as a band when the labia are widely 
 separated. It is a region, rather than a well-defined brklge of shin; it 
 is not possible to identify the exact point at which either labium ends 
 and the perineum begins. The prevailing inaccuracy in the description 
 of the posterior commissure has led to a similar looseness of expression 
 with regard to the antero-posterior extent of the perineum, which is 
 commonly represented as stretching from the anus to the posterior 
 commissure, instead of to the lower edge of the vulvar orifice.^ 
 
 Gross Appearance, — The cross-section of a labium is somewhat tri- 
 angular in shape, so that we may regard each labium as possessing 
 three sides — a base, which rests upon (but is not attached to) the 
 ramus of the pubes, and two surfaces, an external and an internal. 
 The external surface is convex, rugose, and bears a resemblance to the 
 scrotum, of which it is considered the analogue. The integument is 
 similar to that covering the mons, and has a growth of hair continuous 
 with that of the pubic eminence, while its sebaceous glands are so large 
 that their openings are visible to the naked eye. This surface is limited 
 externally by the genito-crural fold. 
 
 The inner surfaces of well-rounded labia, especiallv in the virgin, are 
 always in contact, except Avhen" the thighs are strongly abducted. They 
 are normally smooth, soft, and of a reddish color, offering a decided 
 contrast to the outer surfaces. Scattered hairs of a fine, downy cha- 
 racter are apparent on close inspection. 
 
 The labia are subject to variations both in size and in degree of 
 approximation. In young, well-developed subjects they are firm, 
 plump, and are so closely in contact as to entirely conceal the parts 
 
 ^ Anatomie des menschlichen Beckens, p. 407. 
 
 ^ Equally questionable is the statement of Hart and Barbour, that "they form by 
 their junction — the anterior commissure — the structure known as the mons Veneris'' 
 {Gyinecolorjy, p. 46). 
 
 * Comp. Savage's definition of the perineal body, Female Pelvic Orrjans, pi. i., text. 
 
100 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 behind them (vulva connivens). With the disappearance of their 
 adipose tissue, a change which occurs normally in old age, they become 
 flabby and pendulous and no longer cover the nymphse. The appear- 
 ance presented by such gaping labia, as observed with the subject in the 
 dorsal position, was designated by the older anatomists as the vulva 
 hians. It should be added that the vulvar cleft is equally exposed in 
 the fcetus, but the condition here is to be ascribed to the incomplete 
 development of the greater labia. 
 
 Anatomy. — a. Gh^oss. — The structure of the labia is similar to that 
 of the mons, so far as regards their integument, adipose, and elastic 
 tissue ; but the latter assumes more importance here, and deserves our 
 careful consideration. A layer of fat, of variable thickness, lies just 
 beneath the skin. It is most abundant near the mons and toward the 
 external surface, but fades away toward the posterior commissure and 
 internal surface. The elastic fibres may be divided into superficial and 
 deep bundles, the former appearing as a thin stratum continuous with 
 the deep layer of the superficial perineal fascia. Sappey describes in it 
 smooth muscular fibres, and compares it to the dartos. The deeper 
 bundles of elastic tissue were originally described by Broca, who dis- 
 tinguished four main groups, one of which, he says, comes from the 
 mons, and others from the borders of the external ring and from the 
 pubic rami. The disposition of the elastic tissue of each labium in the 
 form of a sac, having its neck at the external ring and its fundus just 
 above the posterior commissure, . was described by the same author. 
 This structure, which practically includes the entire labium except the 
 integument, is, as Savage admits, rarely defined save in cases of labial 
 hernia. It is really formed by the superficial layer of elastic tissue 
 (that continuous with the perineal fascia) which is attached around the 
 margin of the ring. Within the sac are the deeper fibres, forming a 
 network in the midst of a quantity of adipose tissue, as in the mons. 
 If this is followed up to its junction with the mons, the lower terminal 
 fibres of the round ligament will be found. In the neck of the sac 
 will occasionally be seen the persistent' process of peritoneum known 
 as the canal of Nuck. The labia derive their arterial supply from the 
 superficial perineal branch of the internal pudic. The veins form rich 
 plexuses in the subcutaneous tissue, finally communicating with the 
 vaginal bulbs, and accompany the arteries : the lymphatics enter the 
 superficial inguinal glands, following the course of the external pudic 
 artery, as do those of the scrotum. The nerves are the superficial peri- 
 neal branches of the internal pudic and the inferior branch of the small 
 sciatic. 
 
 B. Minute. — The skin of the labia is distinguished by the unusual 
 size of its hair-bulbs and sebaceous glands. Sweat-glands are also 
 present. The hair-follicles gradually disappear toward the inner sur- 
 
LABIA MfXORA. 101 
 
 face, but the glands persist. For a description of the })apilUe, the dis- 
 tribution of the blood-vessels, and the ultimate terminations of the 
 nerves the reader is referred to the chapter on the skin in any work on 
 normal histology. There is nothing peculiar in the minute anatomy of 
 the Hbrous and adipose tissue. 
 
 It is difficult to conceive how any writer can alhrm of the labia that 
 " the inner surface is in all respects like a mucous membrane, except 
 that it poasesses sebaceous glands in jilace of mucous fjUicles." ^ 
 
 Labia Minora. 
 
 Synonyms. — Lesser labia, nymplue ; LaL, labia pudendi minora, 
 sen interna, alee minores ; Fr., petites levres, nymphes ; Ger., kleiue 
 Schamlippcn ; It., piccole labbra ; Sp., pequenos labios. 
 
 Definition. — The labia minora are two muco-cutaneous folds or 
 flaps which are situated between the labia majora, from the inner sur- 
 faces of which they appear to spring. The nymphse are ordinarily 
 described as " two reddish folds of mucous membrane." ^ Hart asserts, 
 confidently, that " they are skin, thin and fine, and not mucous mem- 
 brane, as often alleged." ^ The writer is not prepared to accept this 
 latter statement without qualification, at least with regard to the labia 
 minora in the virgin, which are always covered by the external parts. 
 Their outer surfaces may indeed be regarded as true skin, but the inter- 
 nal approach so closely to the character of mucous membrane that the 
 difi'erence between the two is inappreciable. It is only when the nym- 
 phae have been long exposed by the separation of the labia majora that 
 their imier surfaces assume the appearance of integument. The writer 
 suggests the adjective " muco-cutaneous " as a compromise. The sub- 
 ject will become more intelligible after the reader has studied the 
 minute structure of the tissues. 
 
 Gross Appearance. — These folds are usually symmetrical, although 
 one is sometimes a little larger than the other. They are of a rose-red 
 hue in the virgin, but may become of a dark-blue or slat^^ color during 
 pregnancy or after they have been long exposed. Their general appear- 
 ance has been aptly compared to that of a cock's comb. Beginning 
 just below the anterior commissure, the nymphre appear as double folds 
 which meet above and below the clitoris, forming respectively the pre- 
 puce and fraenulum of the clitoris ; they then descend on each side of 
 the vestibule, along the base of the inner surface of the labium, with 
 whicli they apparently blend at about its middle. They are not lost 
 
 ^ Lusk, Science and Art of Midwifery, 1st ed. p. 3 — corrected in last edition. 
 ^ Op. cif., p. 4; Ranney, Topographical Relations of Female Pelvic Organs, p. 67. 
 ' Hart and Barbour, Gynecology, p. 6 ; also, Hart, in Edinburgh Med. Journal for 
 Sept., 1882. 
 
102 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 here, however, but reappear at the lower extremity of the vulva, where 
 they are united by a thin muco-cutaneous commissure known as the 
 fourchette, or fraenulum vulvae ; ^ in fact, they are sometimes prolonged 
 so as to encircle the entire orifice. These folds are entirely concealed 
 in the virgin, being only exposed when the external labia are widely 
 separated. They are quite prominent in the foetus, because of their 
 relatively advanced development, and in the aged by reason of the 
 gaping vulva. 
 
 Fourchette. — This is a delicate fold of skin (or skin and mucous 
 membrane ?) which unites the posterior extremities of the nymphse. It 
 is situated in front of the posterior commissure, being distant from the 
 anus 2.7 cm. in nulliparae, and 2.5 cm. in women who have borne 
 children.^ Its persistence in the latter is by no means so uncommon 
 as most writers affirm. The fourchette occupies a different position 
 according as the nymphse are in contact or are artificially separated. 
 Under the former conditions it is but faintly marked as a loose fold 
 between the hymen and the posterior commissure; but when the 
 nymphse are drawn apart it appears as a tense band, separated from 
 the posterior border of the ostium vaginae (or, more properly, from the 
 lower portion of the hymen) by a depression which, from a fancied re- 
 , semblance, has been termed the fossa navicularis. It should be clearly 
 understood that this fossa is not a natural depression, but is produced 
 artificially when the fourchette is put on the stretch by lateral traction.^ 
 The subject being supine, it is bounded in front by the inner surface 
 of the fourchette, behind by the anterior surface of the hymen, while 
 its base rests upon the perineal body. 
 
 The writer has frequently identified the line mentioned by Hart and 
 Barbour, which, according to these writers, forms as sharp a limit 
 between skin and mucous membrane as the well-known " white line " 
 at the anal orifice. This line of separation is described as running 
 along the bases of the internal aspects of the nymphse, and crossing 
 between the two below the prepuce of the clitoris in front and at the 
 base of the outer aspect of the hymen posteriorly. 
 
 Anatomy. — a. Gross. — Without attempting to discuss this disputed 
 subject at length, we shall assume that the labia minora consist essen- 
 tially of delicate skin, which on their inner surfaces passes over insen- 
 sibly into a sort of transitional tissue, the character of which differs 
 
 ^ Luschka was the first who called attention to the fact that the fourchette unites 
 the lesser, and not the greater, labia {op. cit, p. 403). Hart and Barbour are, strangely 
 enough, at variance with him {op. cit., p. 6). 
 
 ^Foster, "Topographical Anatomy of the Uterus and its Surroundings," Am. Journ. 
 Obsiet., vol. xiii., Jan., 1880. 
 
 ^Ranney is correct in his criticism of the statement made by Hart and Barbour, 
 that " when the fourchette is pulled doivn by the finger a boat-shaped cavity is made — 
 the fossa navicularis" {op. cit., p. 66). 
 
LA HI A MfNORA. 
 
 103 
 
 in (liffcM'ont subjects. While it may sometimes be regarded as true skin, 
 tlie limit ol' which is dciiucd by tlic line before described, it can, on the 
 other liand, rarciv be c()iisi(hM-cd as true unicous mcndjrane, sucli as tliat 
 uhicli hues the iiciiital cauals. The writer believes that it will even- 
 
 The Superficial Veins of the Perineum (Savage) : h, g, crura clitoridis ; C, corpus clitoridis ; 1, 2, 3, 
 corpus eavernosum urethrse; 5, superior perineal and obturator veins; 6, veins of com- 
 munication witli superficial epigastric veins; 8, 9, 10, pudic vein and primary branches; 
 M, urethral meatus ; V, vaginal aperture : A. anus; T, tuberosity of ischium ; 0, coccyx; G, 
 vulvo-vaginal gland ; a, anterior border of gluteus maximus muscle ; b, superficial sphincter 
 ani nauscle ; c, c, pubo- and obturator coccygeus muscle, closing upward the posterior 
 perineal space bounded by the coccyx, 0: lower border of gluteus, a; larger sciatic lig- 
 ament, L; tuberosity of the ischium, T; superficial muscles, r!, d; and inferior border of 
 perineal septum, /; e, bulbo-cavernosus muscle: i, anterior aponeurosis, and k, posterior 
 aponeurosis, of perineal septum; {/, erector clitoridis muscle; /(, left crus clitoridis. 
 
 tually be shown that the Edinburgh anatomist is correct in his state- 
 ment, but as vet the evidence is not whollv conclusive. We are at 
 
104 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 least justified in affirming tliat the nympli^ are not '' folds of mucous 
 membrane." ^ 
 
 The subcutaneous tissue of the nymphse is entirely devoid of that fat 
 which forms such a prominent part of the labia majora. It consists 
 almost entirely of a iibro-elastic framework supporting a rich venous 
 plexus, in the meshes of which are bundles of smooth muscular fibres. 
 It is questionable if we are justified in regarding this, with Gassenbaur, 
 as a variety of cavernous tissue. Kobelt^ excludes the nymphse from 
 the class of erectile structures. 
 
 The arterial supply of the lesser is derived from the same source as 
 that of the greater labia (internal pudic). The large venous plexuses 
 not only empty into affluent vessels which enter the pudic vein, but 
 communicate freely with the vaginal bulbs and with the perineal veins,^ 
 thus forming a link between the pelvic and perineal systems. The 
 nerves and lymphatics are common to both the labia majora and 
 minora. 
 
 B. Ilinute. — A cross-section of one of the nympliEe presents the fol- 
 lowing appearances : The free surface is covered with several layers of 
 stratified epithelium, the lowermost cells containing pigment-granules. 
 Beneath the epithelium is the connective-tissue basis, which consists of 
 interlacing fibres, some of which are elastic. Bundles of smooth mus- 
 cular fibres will be recognized by their large fusiform cells ; the latter 
 will be found in greatest numbers along the course of the vessels. The 
 fibrous tissue forms numerous papillae, which project into the epithelial 
 layer and are provided with vascular loops, the veinlets returning from 
 which enter the plexuses before alluded to. A superficial capillary net- 
 work immediately below the epithelium has also been described. The 
 peculiar nerve-termination described by Krause as "end-bulbs" are 
 also seen in the papillae. One striking feature in the minute anat- 
 omy of the nymphse is the presence in them of large sebaceous glands, 
 which open upon the free surface. According to some authorities, 
 these are confined to the outer aspect of the labium ;* they are said 
 to be absent at birth. It is generally agreed that hairs are entirely 
 absent from the labia minora : this is rather a curious fact when taken 
 
 ' There is no profit in pursuing this discussion farther here, since it resolves itself 
 merely into an expression of personal opinion. Most authorities in histology, it must 
 be admitted, describe the labia minora (when they describe them at all) as genuine 
 mucous folds. Klein characterizes them somewhat vaguely as " fibrous connective- 
 tissue mucous membrane" {Elements of Histology, p. 270). 
 
 ^ Die Mdnnlichen ii. Weiblichen Wollust-Organe des Menschev. 
 
 ■''No description can convey any idea of the vascular richness of these parts wliich 
 can compare with Savage's plates fpls. vi., vii.). The reader must bear in mind that 
 it is only in very successful special injections that the venous plexuses can be traced 
 continuously. 
 
 * Satterthwaite, Manual of Histology, chap. xvi. 
 
L.miA MisoiiA. in.j 
 
 in connection with the j)rosen('c' of the glands, since the two are usually 
 inseparahk'.' Tiie latter fiirni.sli a strong argument in I'avor ol" the 
 tegnnientarv character of the labia. 
 
 As to the venous plexuses, it may be added that, in spite of their 
 free coninuuiication and the elastic tissue in which they run, we can 
 
 Fig. 39. 
 
 C . -^JfjXG^ 
 
 3 
 
 The Venous Plexuses of the Vagina and Vulva, as seen in mesial section (Savage) : B, bladder, 
 partially inflated ; 6, ureter; V, vagina; P, section of puhis; R. rectum; C. clitoris; 1. bulb; 
 2, its urethral venous process; 3, lower efferent veins: 4, dorsal vein of the clitoris : 5, urethral 
 venous plexus; 6, commencement of vaginal venous plexus; 7, 8, 9, 10, sciatic and gluteal 
 veins; 11, uterine veins ; 12, obturator vein : 13, internal iliac vein; a. pyriformis muscle; 
 5, larger sciatic ligament ; c, puho- and obturato- and ischio-coccygeal muscles ; e. suspen- 
 sory' ligament of the clitoris ; F, bulbo-vaginal gland ; g, g, g, g, roots of sacral plexus 
 of nerves. 
 
 hardly regard them as sufficiently large and intimately connected with 
 the terminal arteries to justify the application of the term " erectile " 
 to this tissue.^ 
 
 The minute anatomy of the fourchette is similar to that of the 
 nymphse. Ranney^ states confidently that its inner surface, "since 
 it possesses minute hairs, is considered as properly belonging to integ- 
 unientar\' structures :" the latter clause may he true, although the 
 former is questionable. 
 
 ' Quain's Anatomy, 9th ed.. vol. ii. p. 256. 
 
 2 Compare the definition of " erectile tissue " in Quain's Anatomy, Sth ed., vol. ii. 
 p. 180. 
 
 ^ Top. Relations of Female Pelr. Orrjan.^. p. 65. 
 
106 THE AS ATOMY OF THE FEMALE PELVIC ORG ASS. 
 
 Clitoris. 
 
 Syxoxy^is. — Gr., Kh'-opi- ; Led., penis muliebris, memlDrum 
 muliebre ; Fr., clitoris ; Ger., Kitzler ; It, clitoride ; Sp., clitoris. 
 
 Definition. — A small, curved, oblong organ, the analogue of the 
 penis in the male, situated at the apex of the vestibule just below the 
 anterior commissure. 
 
 As ordinarily seen, the clitoris (or rather its giaus) appears as a small 
 pea-shaped projection hidden between the diverging folds of the labia 
 minora. It is only when the latter are widely separated that the end 
 of the organ is seen. The reader whose attention has not l^een spe- 
 cially directed to the subject will be somewhat suri^rised at the actual 
 size of the clitoris in the living female, since many of the descriptions 
 and drawings in the textbooks must have led him to suppose that it 
 actually resembles a small penis. Nothing could be more erroneoiLS 
 than this notion. The glans clitoridis, which is the only portion of the 
 organ that we ever see normally, except in dissections, is in its most 
 turgid condition merely a small projection, rarely larger than a small 
 pea, and more often smaller. In some women it cannot even be dis- 
 covered without a search. By bearing this fact in 
 Fig. 40. mind the relative .insignificance of the clitoris when 
 
 compared with the male organ will be intelligently 
 appreciated. Of course, the apparent variations in 
 the size and prominence of the former are explained 
 to some extent by the thickness of the nymphfe. Al- 
 though it has but a limited range of motion, during 
 erection it becomes distinctly arched, the glans pro- 
 trudes sensibly, while the iDody may be felt as a firm 
 cord curving upward and backAvard until it is lost be- 
 neath the pubic arch. 
 
 Gross Appearance. — The comj^onent parts of the 
 The Venous Plexuses of clitoris, as considered from before backward, are the 
 the Clitoris (Savage) : glans, bodv, and crura. The attached folds of the 
 o'nThrbiunr^n'd ^of nymphse, known as the prepuce and frtenulum, should 
 the clitoris ; 2, dorsal pj-Qperlv be described in connection \dx\\ the glans. 
 
 vein of clitoris ; 3, ure- -C^i- -, • t • ^ i- 
 
 thrai venous process The glans clitoridis, which IS the oniv portion 
 I'ratiti'htncS; of the organ ^nsible without dissection, is a small 
 5, pars intermedia; 6, mass of erectile tissue covercd by mucous membrane 
 ruspTnSry°^i£ment (or skin ?), which is partially enveloped by a sort. 
 of clitoris : 9, section ^f ^^^^ formed bv the upper of the two folds into 
 
 of rislitcrus clitoridis. , ^ -,..-, / • t • t \ rni 
 
 which the nymphse divide (preputmm clitoridis). i lie 
 lower folds bend sharply inward to meet in the median line beneath the 
 glans, to which they are attached, forming its fr^nidimi ^ (Fig. 40). 
 1 Hart and Barbour describe the fraenulum as if it was the same as the suspensory 
 
CLITORIS. 
 
 107 
 
 If the ivailor will rcnu-nibt'r the difference of opinion concerning the 
 true character of the tissue covering the nymphae, he will rightly infer 
 that the same doubt exists as to whether the glans, with its fra^nulum 
 and prepuce, is clothed with skin or with mucous membrane.^ 
 
 The corpus clitoridis is a firm, cord-like body, seldom exceeding an 
 inch - in length even when turgescent. It is situated in the median 
 line in front of and below the symphysis pubis, and may be traced 
 upward beneath the prepuce, and then backward to a point immediately 
 under the anterior edge of the pubic arch, where it divides into the two 
 crura (Fig. 41.) It is partly attached and partly dependent, the limit 
 
 Fig. 41. 
 
 Front View of Perineal Septum, showing entire clitoris (Savage) : 1, clitoris ; 2, suspensory liga- 
 ment; 3, crura of clitoris; 4. subpubic ligament: 5, dorsal vein of clitoris; 6. perineal sep- 
 tum; 7, superficial transverse muscle: U, urethra; V, rectum and vagina; P, site of 
 perineal body. 
 
 between the fixed and movable portions being defined by the point of 
 insertion of the suspensory ligament. The latter is a small, but per- 
 fectly distinct, band of fibres which extends from the anterior aspect of 
 
 ligament of the clitoris ( Gj/no'colof/}/, p. 4i. Eanney says that tlie lower folds of the 
 nymphre '"help to complete tlie suspensory ligament of the clitoris" {op. cit., p. 67). 
 This is certainly an error. In Qnain's Anatomj (9th. ed., p. 700) we read : "There is 
 a small suspensory ligament attached to the upper border, like tliat of the penis." 
 Tliis agrees with Savage's plate (pi. vi. Fig. 3) and with tlie writer's own dissections. 
 
 ' Lusk (p. 3) speaks of the "cuticular covering of the glans "—an apparent incon- 
 sistency, as he considers the ]ire]mce as a mucous fold. 
 
 ^ Quain says an inch and a half. 
 
108 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 the symphysis (above its middle point) to the upper border of the pos- 
 terior half of the corpus clitoridis. In front of its point of attachment 
 the clitoris is somewhat dependent, like the penis, although its move- 
 ments are further restrained by the frsenulum. 
 
 The crura are two long, fusiform processes of spongy tissue, less than 
 half an inch in diameter, which arise from the anterior borders and 
 inner surfaces of the pubic and ischiatic rami, to ^^^hich they are 
 attached by firm connective tissue : they extend upward along the 
 anterior edges of the ascending rami until they almost reach the 
 symphysis, when they turn forward and coalesce beneath the arch to 
 form the body. The inner side of each crus is covered by the slender 
 erector clitoridis muscle (erector penis or ischio-cavernosus), wliich has 
 its origin on the front of the tuber ischii, and its insertion by two sep- 
 arate tendinous expansions,^' one above, where the crura join to form 
 the clitoris — one in front and somewhat below." ^ 
 
 Anatomy. — a. Gross. — The clitoris consists essentially of cavernous 
 tissue surrounded by a firm, fibrous covering (tunica albuginea), over 
 which is an extremely sensitive tissue. Its gross resemblance to the 
 penis, which is only partially apparent in the glans, is borne out in 
 a longitudinal section of the body, which shows that it is composed of 
 symmetrical halves (corpora cavernosa) separated by an imperfect or 
 rudimentary septum pectiniforme. These corpora cavernosa are clearly 
 the prolongations of the crura, which they resemble both in their gross 
 and in their microscopic anatomy. 
 
 The spongy character of the tissue is apparent even to the naked eye : 
 the trabecule look much finer than those of the male organ. The crura 
 resemble unyielding fibrous cords, so that the presence in them of erectile 
 tissue would never be susjpected from an external examination. On sec- 
 tion this tissue is found to occupy the central portion of each crus, and 
 to disappear gradually toward the point of origin. It is covered by a 
 thick fibrous layer of almost cartilaginous firmness, which gives to the 
 body its cord-like feel. 
 
 At their origin the crura are entirely fibrous (or ligamentous ?) in 
 their structure (Fig. 41). 
 
 Vascular Sujjpli/. — In studying this we enter upon the subject of the 
 erectile organs of the female,^ which should first be considered in detail, 
 and then in their relations to one another and to the general circulation. 
 The clitoris is the most important link in the chain that may be said to 
 
 ^ Savage, op.cit, p. 6 and pi. i. 
 
 2 Ranney (op. cit., p. 98), after Savage, divides the pelvic structures rather arbitrarilj 
 into three classes— the "erectile," " erecto-turgescent," and " turgescent." The former 
 includes the clitoris and its crura ; the latter the urethra and vagina ; while the body 
 of the uterus and the ovarian and vaginal bulbs belong to the second class. ^ As this 
 idea rests upon physiological rather than upon anatomical facts, we can give only 
 this passing reference to it. 
 
CLITORIS. 109 
 
 begin at the vat«;inal bulbs and to end at the ovary. It receives its 
 arterial supply from the two terminal branches of the pudic, which run 
 between the point of junction of the criiia and the arch of the pubic 
 bones, pierce the suspensory ligament, and follow along the din'sum of 
 the organ on either side of the vein. One of these vessels supplies the 
 body of the clitoris, corresponding to the artery of the coqjus cavcrno- 
 suni in the male ; it is called the profunda. The otlier* larger branch 
 is the analogue of the dorsal artery of the penis, and divides at its ter- 
 mination into twigs ^vhich sujjply the glans and prepuce (dorsal artery).' 
 These two ai'teries have a free intercomnumication b}' means of their 
 small branches. Their jweuliar ultimate terminations will be described 
 Avitli the minute anatomy of the ])art. The blood is returned from 
 the clitoris by the dorsal vein, which begins by the union of efferent 
 branches from the glans, around the end of which is a small plexus, 
 and receives numerous tributaries as it passes backward along the dor- 
 sum between the two arteries before mentioned, and reaches the pelvis 
 by ascending to the space between the arch and the subpubic ligament. 
 It terminates in the vesical plexus.^ The upper ends of the vaginal 
 bulbs are so intimately related to the veins of the clitoris that Hart 
 and Barbour regard the pars intermedia as almost a portion of the 
 organ. " The glans clitoridis," they affirm (p. 4), " is not directly 
 continuous with the body, but joins it through the pars intermedia of 
 the hulb." The writer has never been able to verify this statement.'^ 
 Besides their connection with the pars intermedia, the veins of the 
 clitoris communicate with the urethral, perineal, pelvic, and, indirectlv, 
 with the obturator veins, as will be readily understood by a glance at 
 Savage's plates (pi. vi.). The difference between the vas<^lar supplv 
 of the penis and clitoris is greater than appears at first (sight, that of 
 the latter being both richer and more complex in its relations. The 
 difference may be roughly stated by saying that the penis has a richer 
 infernal, the clitoris a more extensive external, supplv. 
 
 The clitoris is surrounded by a plexus of lymphatics which receive 
 numerous branches from the deep tissues, the whole terminating in the 
 superficial inguinal glands. 
 
 The nerves of the clitoris are unusually numerous, considering its 
 size. "■ Small as this organ is compared mth the penis," says Savage, 
 *' it has in proportion four or five times the nervous supply of the lat- 
 ter." Numbers of fibres belonging to the sympathetic system accom- 
 
 ^ Kobelt (op. cif.) mentions several small unnamed branches which run to the cor- 
 pora cavernosa. 
 
 ^ For an elaborate description of the venous plexuses of this region see Gussen- 
 bauer's paper, " Ueber das Gefass-System der iiusseren Weiblichen Genitalien,'' Siiz- 
 unr/sb. der Wiss., July, 1869. 
 
 ^ Savage refers to the pars intermedia as " a double row of veins issuing from a 
 double series of apertures at the under surface of the clitoris." 
 
110 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 pany the arteries and enter with them the erectile tissue. The pudic 
 nerve, after giving off muscular branches, terminates in a twig of much 
 larger relative size than the corresponding one in the penis, which 
 accompanies the artery between the layers of the deep perineal fascia, 
 pierces the suspensory ligament, and runs along the dorsum as far as 
 the glans, where it terminates in a network which has been aptly 
 described as " a true nervous sheath." It gives oif several branches to 
 the body and prepuce, and one of considerable size to the interior of 
 the organ. There is a free communication between the sympathetic 
 and spinal nerves of the clitoris. 
 
 B. Jlinute. — The minute structure of the organ resembles so closely 
 that of the penis that it will be unnecessary to repeat a description with 
 which the reader is doubtless somewhat familiar. The glans has an 
 external covering w^iich is similar to that of the nymphge as regards 
 the presence of papillae, covered by layers of stratified epithelium and 
 containing capillary loops and nerve-terminations (end-bulbs). There 
 are j)resent iii addition a special variety of end-bulbs known as " the 
 genital corpuscles of Krause," which are also found in the mucous cov- 
 ering of the glans penis. The erectile tissue of both the glans and 
 body does not need a separate description. As before stated, the tra- 
 beculse are more delicate than in the penis, and the tissue is rather a 
 collection of venous plexuses than of cavernous spaces. The opposite 
 halves of the corpus are j)ractically one, since the septum between them 
 offers no barrier to the free intercommunication of the plexuses. If a 
 number of cross-sections of the corpus and crura are examined, the 
 fibrous covering (tunica albuginea) will be seen to increase in thickness 
 from before backward at the expense of the spongy tissue, until the 
 latter dwindles away at the origin of the crura. 
 
 Vestibule.^ 
 
 SYisroisrYMS. — Lat, vestibulum, atrium vaginae ; F7\, vestibule, canal 
 vulvaire ; Ger., Vorhof ; It. and 8p., vestibulo. 
 
 Definition. — The vestibule is a triangular area, the sides of which 
 are formed by the inner edges of the nymphse, while its base corresponds 
 Avith the upper margin of the vaginal orifice. Its apex lies immediately 
 below the clitoris. 
 
 The vestibule is ordinarily included among the structures forming 
 the vulva, although it is simply a surface covered by mucous mem- 
 brane, which is of importance only because of the structures contained 
 
 ^ As its name implies, the vestibule has been regarded as the entrance to the vagina. 
 Thus Dunglison defines it as "a smooth cavity between the perineum and nymphse in 
 the female, which leads to two passages — to the urethra above and to the vagina 
 below." French anatomists have termed it the canal vulvaire. It is better to regard 
 it as entirely independent of the vaginal orifice. 
 
VESTniri.i:. ni 
 
 within it. lli'iilc aj>[)li('s tlu' ikuiic to (lie l:il)i:i |ni(lcii<li and tlic space 
 botwtrn tiirni. 
 
 Grosn Appearance. — Tho vcstilnili' is covered hy nincons nienibraiie, 
 wliieh presents a corrugated apiK'aranee. Tlie color of this nienibrane 
 is retlder and its texture finer than that of the nynipliie. The line 
 of separation between sUin (or transitional tissue?) and mucous mem- 
 brane is not so well defined here as it is at the ed";e of the vay-inal 
 orifice. Several depressions or crvpts (glandidie vestibulares minorcs) 
 will be observed on the floor of the vestibule : most of these are ranged 
 about the uretiiral opening, which appears as a small dimple or pucker 
 in the mucous membrane at the middle of the base of the triangle, 
 three-fourths of an inch below the clitoris and about an inch frcjm 
 the fourchettc. The meatus will be described with the urinary tract. 
 
 The dimensions of the vestibide, as well as the appearance of its 
 mucous membrane, are quite variable, especially in multiparte. More- 
 over, the crypts are sometimes of minute size, while they may be one- 
 third as large as the meatus. They vary in number ; there are generally 
 five or six. 
 
 AxATOMY. — A. Gross. — On dissecting off the mucous membrane 
 of the vestibule an intricate venous plexus will be observed, which can 
 only be studied satisfactorily by means of special injections. When 
 fully injected these veins are seen to have a general transverse direc- 
 tion both above and below the urethral orifice ; they constitute the 
 pars intermedia, and serve both to unite the opposite \'^stibular bulbs 
 (hence the name " isthmus ") and to establish a free communication 
 between these bodies and the vessels of the corpora cavernosa of the 
 clitoris. 
 
 Much confusion has arisen on account of the vague description of the 
 bulbs in most textbooks. A study of the best plates, supplemented by 
 careful dissections of this region, will convince the reader that the 
 bulbs are situated not 'svithin, but at the sides of, the vestibular area, 
 that space being occupied only by the connecting plexuses above men- 
 tioned. Moreover, the expression " glandulse vestibulares majores," as 
 applied to the vulvo-vaginal glands, is misleading, since it gives the 
 impression that these structures are related to the vestibule, which is 
 incori'ect. 
 
 B. Minute. — Microscopically, the vestibule presents nothing of special 
 interest : as viewed in a cross-section its superficial covering consists of 
 several layers of pavement epithelium. The mucous glands, the diam- 
 eters of which vary from 0.5 to 2.5 mm., are of the compound racemose 
 type, consisting of numerous acini which open into branching ducts ; 
 these latter terminate in single short ducts which open on the free sur- 
 face by large orifices. The acini are lined with a single layer of cohmi- 
 nar epithelium, which is continued into the ducts as far as their orifices, 
 
112 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 where it passes gradually into the pavement variety. Beneath the 
 mucous membrane is a rich network of fine capillaries, which may 
 be traced into papillse to form loops, in the manner already mentioned. 
 Sebaceous glands are entirely absent. There are no special features 
 about the nerve-supply of this region ; it is not so rich as that of the 
 surrounding parts. Beneath the mucous layer is a layer of connective 
 tissue in which is the venous plexus constituting the pars intermedia. 
 The veins are immediately surrounded by a layer of fibro-muscular 
 tissue, so that this region may be included among the turgescent bodies 
 in Savage's classification. 
 
 Before describing the vagina it is necessary to refer to two pairs of 
 bodies which are in immediate relation with the vulvo-vaginal orifice, 
 although, as has been stated, they are more commonly described in con- 
 nection with the vestibule. These are the vaginal bulbs and the vulvo- 
 vaginal glands. These structures are quite dissimilar in their character 
 and functions, since the former are essentially erectile masses belonging 
 to the chain which terminates with the bulbs of the ovaries, while the 
 latter are simply mucous glands of unusual size. 
 
 The bulbs of the vagina (bulbi vestibuli vaginse, bulbs of the vesti- 
 bule) are two oval masses of veins situated on either side of the base of 
 the vestibule and the upper two-thirds of the vulvo-vaginal outlet. 
 They have been described as '' leech-shaped masses of reticulated 
 veins." They are somewhat conical in shape, their bases, which are 
 rounded and measure half an inch in diameter, being opposite the 
 lower third of the ostium, while their apices (not sharply defined) 
 extend as high as the level of the meatus urinarius, where they are 
 prolonged by the pars intermedia as high as the root of the clitoris.^ 
 Their length is about an inch and a half It should be stated, in 
 explanation, that this description of the bulbs applies to these bodies 
 when distended by injection. The reader who attempts to dissect 
 them out in their collapsed state will be greatly disappointed at the 
 discrepancy that will exist between his dissections and the classical plate 
 of Kobelt.^ Hence Hart and Barbour (p. 10) describe them as "small 
 masses of erectile tissue about the size of a bean." When distended 
 they fill the spaces between the vestibule and edges of the ostium and 
 the pubic arch. Their relations have already been partly described. 
 They surround the ostium vaginse, their inner surfaces being just 
 beneath the mucous membrane of the vagina, while posteriorly they 
 are in contact with the anterior layer of the triangular ligament. They 
 
 1 Quain {Anatomy, last ed.) makes the doubtful statement that "their upper pointed 
 extremities are attached to the crura of the clitoris." 
 
 ■^ It is difficult to escape the impression that Kobelt's drawing is exaggerated, since 
 he figures the lower ends of the bulbs as actually on a level with the anterior edge 
 of the perineum. Savage's plate (pi. vi.) corresponds more nearly with the results of 
 most dissections. 
 
VESTIBULE. 113 
 
 arc j)artially covorod on llicir anterior and ontor asjiocts by the hullio- 
 oavornosi niiii^cles. lichind their lower ends are the vulvo-vajrinal 
 ghinds. 
 
 Thi' hnlhs, wliieh are retiarded as tlie analoirues of the bidl) of the 
 urethra in the male, consist anatomically of complicated venous plex- 
 uses enclosed in tibrons sheaths. The expression "masses of erectile 
 tissue" ^ freijnently applied to them is not strictly correct. Savaj^e is 
 more exact in referring- these bodies to the class of erccto-turgescent 
 structures. The chief feature about their gross anatomy is the free 
 comnnniication of their veins Avitli neighboring ])lexuses. Xot only 
 are they intimately connected with each other by the veins of the isth- 
 mus, and with the vessels of the clitoris by the pars intermedia, but 
 they comnuuiicate freely Avith the veins of the labia, perineum, and 
 vagina, and even with the plexuses which unite to form the obturator 
 vein, as well as with the epigastric veins. Their arterial supply is 
 derived from branches of the internal pndic. Their nervous twigs 
 are largely derived from the sympathetic system, the nerves accom- 
 panying the arteries. 
 
 A microscopical section of a bulb will not add much to the infor- 
 mation gained by a gross inspection. Externally there is a layer 
 of firm connective tissue, beneath which is a dense mass of veins 
 and tortuous arteries surrounded by fibro-muscular tissue, the his- 
 tological structure being analogous to that of the erectile tissue of 
 the clitoris, except that the trabeculse are largely replaced by actual 
 veins. 
 
 The vulvo-vao;inal elands (glands of Bartholin or Duvernev) are 
 small oval bodies, of a reddish-yellow color, varying in size from a 
 bean to an almond, situated on each side of the vaginal orifice near 
 the lower extremities of the bulbs. They lie, as a rule, behind the 
 anterior layer of the triangular ligament^ (like CoAvper's glands in 
 the male, to which they are analogous), and hence behind the rounded 
 ends of the bulbs. They are situated beneath the superficial perineal 
 fascia, in front of the transversus perinei muscles, and between the 
 lower edo;e of the orificium vaginse and the erectores clitoridis mus- 
 cles. The glands vary in size in diiferent subjects : they are largest 
 in young women, while in the aged they become atrophied, and may 
 even disappear. Huguier thought that he succeeded in establishing 
 some relation between the size of a gland and that of the ovary on 
 the same side. During; sexual excitement these bodies share in the 
 general tm^gescence of the vulvo-vaginal region. Each gland has a 
 
 ' Eanney, Annals of Anatomy and Surgery, April, 1883, p. 4. 
 
 ^Eannev, N. Y. Medical Journal, July, 1882; a\s>o Annals of Anatomy and Surgery, 
 April, 1883. He admits that they may lie either in front of or behind the posterior 
 layer. 
 
 Vol. I.— 8 
 
114 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 duct, from a half to three-quarters of an inch in length, and less than 
 one-fifth of an inch in diameter, which runs along the inner margin 
 of the rounded extremity of the bulb, and opens into the fossa navicu- 
 laris on the inner surface of the nymphse, just in front of the base of 
 the hymen. 
 
 Microscopically, the vulvo-vaginal glands belong to the compound 
 racemose variety, their acini, secondary, and discharging ducts being 
 lined by columnar ejDithelium. Their secretion is a yellowish, tena- 
 cious mucus, Avhich acts simply as a lubricant to the parts ; its expul- 
 sion is favored by the reflex contraction of the surrounding perineal 
 muscles, 
 
 Peactical Deductions. — Bearing in mind the tegumentary cha- 
 racter of the external genitals, the reader will naturally infer that they 
 are subject to many of the same affections as the skin in other portions 
 of the body, and that these are to be referred to essentially the same 
 causes. It is hardly necessary to refer to the risk incurred by the 
 physician wliile practising the vaginal touch in infected females : there 
 is no more dangerous — because unsuspected — source of infection. 
 
 The comparative frequency of hypertrophy of the external genitals is 
 readily explained by reference to their structure : thus, an excessive 
 development of adipose may result in enormous enlargement of the 
 mons or labia, so as to interfere with locomotion or sexual intercourse, 
 while hypertrophy of the skin and fibrous tissue may be still more 
 marked, as in elephantiasis. The contractile character of the tissues 
 not only renders healing difficult after extensive loss of substance from 
 wounds, sloughing, the ravages of rodent ulcer, etc., but leads to the 
 formation of large, ugly cicatrices. Hence the danger (aside from that 
 of hemorrhage) which follows the excision of large tumors. 
 
 Inflammatory affections of the vulva are seldom confined strictly to 
 this region, but involve the lower end of the vagina, and frequently the 
 urethra, because of the direct continuity of the mucous membrane ; con- 
 versely, inflammation of the vagina, especially when of a specific cha- 
 racter, generally extends to the nymphse. The extreme pain and hyper- 
 sesthesia which attend eruptions and inflammation of these parts, fre- 
 quently out of proportion to the local trouble, afford a striking clinical 
 proof of their rich nerve-supply, while the reflex symptoms that some- 
 times result from an insignificant eruption would be inexplicable did we 
 not recall the intimate relation between the cerebro-spinal and sympa- 
 thetic nerves, which is by no means confined to the internal genitals. 
 Burning and itching sensations about the vulva may thus cause a con- 
 siderable amount of general disturbance. A familiar illustration of 
 this is offered in the sensitive red patches which are seen on the inner 
 surfaces of the nymi^hse in women who have passed the climacteric, 
 especially in connection with urethral caruncle. 
 
VESTIBULE. 115 
 
 TIk' extensive aiiasloim iscs of the piuk'ndul veins with the ])elvi(5 
 plexuses, as well as their eoimeetioii with the ereetih; system, e\[)laiii 
 the alai-iuiug heni()rrha<;es whieh Deeasioiially follow wounds ol' the 
 labia, the excision of eysts and tumors, operations on the perineum, 
 ete. The sur<!;eon need not antlei[)ate any ecmsideral^le arterial bleed- 
 in"- in this region, although secondary vencHis oozing is by no means 
 uncommon, especially if one of the vaginal bulbs be wounded. Most 
 of the fatal cases rei)orted resulted from the rupture of dilated veins. 
 This dilatation is best observed during pregnancy, when the labial 
 plexuses are mapped out more clearly than in the most carefully 
 injected anatomical preparations. A rupture of one of these varicose 
 vessels, either by an injury from without or by the pressure of the 
 child's head during parturition, results in the formation of a labial 
 thrombus which may attain a large size. The rapid development of 
 oedema of the external genitals in connection with general venous 
 obstruction and anasarca is another striking evidence both of the 
 vascularity of the parts and of the free communication of the veins 
 with the deeper vessels. 
 
 The possibility that a tumor of the labium may be a hydrocele or 
 hernia (even of the ovary) will be evident to the reader who recalls 
 the relation which the part bears to the inguinal canal as the analogue 
 of the scrotum. It is often difficult to apply the ordinary rules of dif- 
 ferential diagnosis because of the thickness of the adipose tissue cover- 
 ing the tumor. 
 
 It has been stated that the vestibule is entirely concealed by the 
 apposition of the labia majora when the thighs are closely approxi- 
 mated. In order to examine this region, then, it is necessary to sep- 
 arate the knees widely and to hold the labia apart. The inexperienced 
 examiner will be disappointed not only at the small size of the clitoris, 
 but at the indistinctness of the meatus urinarius. The small " tuber- 
 cle " which is said to form a sure guide to the meatus is quite as often 
 absent as present, while prolapse of the mucous membrane of the canal, 
 polypi, etc. may cause a complete alteration in the usual feel of this 
 region. In passing a catheter by the sense of touch the physician will 
 do well to disregard the rule laid down in most of the textbooks on 
 obstetrics, and, instead of searching the vestibular area for a " guide " 
 to the meatus, to look for it at once in the median line immediately 
 above the vaginal outlet. Introduce the fore finger into the vagina, 
 with the volar surface uppermost, locate the meatus, and pass the 
 catheter along the finger as a guide. In this way we not only avoid 
 entrance into the vagina, but can feel and direct the instrument as it 
 glides along the urethra. It should not be forgotten that the glandulse 
 vestibulse minores, which lie one on either side of the urethral opening, 
 mav become enlarged, forming culs-de-sac admitting the tip of a catheter. 
 
116 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 Although the sensitiveness of the cHtoris has undoubtedly been exag- 
 gerated, it is desirable to avoid fingering it during a vaginal examina- 
 tion : this may always be accomplished by sweeping the finger over the 
 perineum to reach the vulvar orifice, instead of beginning at the ves- 
 tibule and passing it downward. The clitoris may become the seat of 
 epithelioma or hypertrophy, so that excision of the organ is indicated : 
 as a smart hemorrhage may follow a wound of the dorsal artery, the 
 galvanic 6craseur is usually preferable to the knife. 
 
 The surgical anatomy of the vulvo-vaginal glands is not without 
 interest. They may become enlarged from simple cystic dilatation, or as 
 the result of inflammation extending from the vaginal mucosa, which 
 is continuous with the lining membrane of the gland and its duct. 
 Under the latter circumstances the presence of gonorrhoea should be 
 strongly susj^ected. The danger of severing the duct of the gland in 
 the minor obstetric operation known as " episiotomy " has been exag- 
 gerated : the accident could only occur through carelessness or want of 
 skill on the part of the accoucheur. The same remark will apply to the 
 operation of perineorrhaphy. 
 
 Having considered the external genitals, we shall next preceed to the 
 description of the vagina, which forms a connecting link between these 
 and the internal generative organs. 
 
 Vagina. 
 
 Syistois^yms. — Vulvo-uterine canal ; Grr., iXuzpov ; Lat., vagina, sinus 
 muliebris ; Fr., vagin ; Ger., Scheide ; It. and Sp., vagina. 
 
 Defixitiox. — The vagina is a musculo-membranous canal of variable 
 dimensions, situated between the bladder and rectum, extending from 
 the uterus to the vulva. It is attached below to the ischio-j)ubic rami ; 
 above, it surrounds the cervix uteri, with which it is continuous. 
 
 The direction of the vaginal canal varies in different subjects accord- 
 ing to the position (especially the degree of inclination) of the sym- 
 physis pubis. Its normal axis, as obtained with the bladder empty, 
 forms with the long axis of the uterus an angle described by some an- 
 atomists as a right angle, by others as an obtuse, the degree of obtuse- 
 ness being determined by the amount of distension of the bladder. 
 AVhen the woman is in the recumbent posture the direction of the 
 vaginal axis is nearly horizontal, while in the lithotomy position it 
 forms an inclined plane extending downward and backward from the 
 \'^dva. De Sinety claims that the axis of the vagina is rectilinear, and 
 that it is not correct to represent it by a curved line corresponding with 
 the axis of the pelvis, as is done in most works on obstetrics. 
 
 The vagina has been aptly termed " a mucous slit in the pelvic floor," 
 since, when it is not artificially distended, its anterior and posterior 
 
IIYMKX. 117 
 
 walls an- in dose contact, and it ai)[)('ars in a mesial section of the 
 pelvis as a line convex anteriorly. On cnjss-section it is represented 
 by a slit, transverse or ereseentic in an infant, bnt H-shapecl in an adnlt, 
 the lonjjjitndinal limbs of the H bcin*^ convex on their inner asj)ects, the 
 horizontal lind) i)rojectin;2;a little anteriorly. The canal when distended 
 shows a o-radual increase in size from the hymen to the uterine junction, 
 so that a [)ULstcr cast of a nulliparous vagina bears a certain resem- 
 blance to a truncated cone. In multipara? it is capable of great disten- 
 sion and its shape is extremely variable. The length of the canal varies 
 from seven to eleven centimeters, the average being seven and a half. 
 The posterior wall is from one to tvvo and a half centimeters longer 
 than the anterior. The transverse (and antero-posterior) diameter varies 
 in nulliparae from three to four centimeters, in multipara from six to 
 seven. Before entering upon the anatomy of the vagina it is desirable 
 to glance at the structure which forms its lower boundary. 
 
 Hymen. 
 
 Synonyihs. — Virginal membrane ; Gr., bivr^v ; Led., claustrum vir- 
 ginale, valvula vaginae, zona castitatis, etc. etc. ; Fr., hymen ; Ger.y 
 Hymen ; It., imene ; Sp., himen. 
 
 Definition. — The hymen is a circular or ereseentic fold of connect- 
 ive tissue, covered by mucous membrane, which immediately surrounds 
 the orifice of the vagina and forms the lower extremity of that tube. 
 
 The hymen is almost invariably spoken of as " a fold of mucous 
 membrane " which partially closes the orifice. Budin proved conclu- 
 sively that it is anatomically a folding in of the entire vaginal wall.^ 
 His arguments may be stated briefly as follows : 1 . After removing 
 entire the genital organs of an infant, if the vulva is detached and 
 the labia minora are divided transversely the hymen disappears, but it 
 reappears on restoring the parts to their original condition ; that is, the 
 vagina is like a glove-finger which has a circular opening at its lower 
 extremity ; 2, the ridges and columns of the vagina are continued on 
 to the hymen as far as its free edge ; 3, the histology of the hymen, 
 which has been carefully studied by De Sinety, shows clearly that it is 
 not an independent fold of mucous membrane ; 4, in the foetus there 
 is an interval of several millimeters between the vulvar and vaginal 
 openings. The hymen surrounds the latter at as early a period as the 
 end of the fourth month. As the foetus develops the vaginal orifice 
 appr(jaches the vulvar, until the hymen finally reaches the inner border 
 of the nymphse. It is interesting to note the fact that the first trace 
 of this fold in the embryo is represented by minute excrescences on the 
 posterior vaginal Avail." 
 
 ' ProgrH med., Aug. 1879, p. 677 ; also Ledru, These de Paris, 1855. 
 ^ Am. Journ. ObsteL, 1878, vol. xii. p. 205. 
 
118 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 Gh'oss Appearance. — The hymen ordinarily appears as a crescentic 
 fold situated at the posterior jDart of the introitus. It lies loosely 
 against the posterior vaginal wall, " like a jib bellied by the wind," ^ 
 and does not assume the appearance of a tense membrane stretched 
 across the orifice unless the thighs are widely abducted so as to sepa- 
 rate the sides of the canal. So little obstruction does this variety of 
 hymen offer to the introduction of a foreign body into the vagina that 
 it frequently persists after repeated acts of coitus. Budin ^ states that 
 in the course of a single year he found this structure intact in no less 
 than seventy-five primiparse who were examined during labor, so that 
 he goes so far as to say, " Ce n'est pas le mari, mais I'enfant, qui a 
 enleve a sa mere ce quon consid6re comme les marques physiques de la 
 virginity." On the other hand, the hymen is by no means constant. 
 Mauriceau and Buifon deny its existence. 
 
 Several forms of hymen have been described, the most common 
 being the crescentic ; the annular, which forms a complete ring 
 around the vaginal outlet, with a central aperture; the cribriform, 
 which is perforated by several small holes ; and the fimbriated type, 
 which has a fringed edge. The imperforate variety is of course 
 pathological. 
 
 It is unnecessary to refer to the medico-legal importance of this 
 structure, since it is an accepted fact that neither is its presence an abso- 
 lute proof of chastity in its possessor, nor, on the other hand, does its 
 rupture imply that sexual intercourse has taken place.^ Schroeder has 
 made a careful study of the appearance presented by the hymen after 
 rupture. (For a detailed account of these, accompanied by drawings, 
 the reader is referred to his original article.*) The important fact to 
 remember in this connection is that the so-called carunculse myrtiformes 
 do not represent the remains of the hymen after its rupture. It would 
 seem superfluous to refer to this error were it not still retained in popu- 
 lar textbooks. A superficial examination of the hymen in a married 
 woman Avho has never borne children will invariably reveal the fact 
 that this structure persists just as truly as in the virgin. The caruncles 
 are irregular, fleshy protuberances skirting the vaginal orifice, and are 
 the remains of the sloughing and cicatrizing processes that result from 
 childbirth. A careful examination of these masses will show that they 
 vary greatly in their size and shape, appearing sometimes as mere tags 
 of tissue, sometimes as distinct polypi, which result from injury to 
 the vaginal wall as well as the hymen. As a consequence of labor the 
 line of demarkation between the vulva and vagina is obliterated, the 
 latter being really " unfolded," to use Budin's expression, so that its 
 
 ^ Foster, op. cit. ^ Des Lesions traumatiques chezla Femme, etc., 1878. 
 
 3 Comp. Thomas, N. Y. Med. Journ., 1859, vol. vi. p. 196. 
 
 * See Edinburgh Med. Journ., 1877-78, vol. xxiii. pp. 906-910, for translation. 
 
VAGrXA. 110 
 
 lower extremity (the liynien), instead of f'onuinjr a ])roinineiit fold five 
 or six niilliiiietei's in width, is Ihish with the wall <»!" the vulva. 
 
 Anatomy. — a. dross. — AlthouLih it |)resents the appearaiux; of a 
 thin niemhrane when viewed iVoni the front, a eross-scetion of the 
 hymen has a somewhat trian«inlar ontline, the base of the triangle rest- 
 ing upon the vaginal wall, while its apex corre.spond.s with the free 
 vih^c. As will he seen even with the naked eye, the hymen eonsists of 
 a double fold of nuieous membrane, between whieh is a delicate layer 
 of connective tissue that is directly continuous with that of the vaginal 
 Avail. Numerous blood-vessels may also be traced from the vaginal 
 ])lexuses into the hymen, in which they ramify as far as its free edge. 
 
 B. 3Ii)U(f('. — The mucous membrane is covered by a layer of pave- 
 ment e])ithelium, that on the upper surface of the hymen being contin- 
 uous with the vaginal epithelium, on its lower surface with that of the 
 vulva. Beneath the epithelial layer is a dense network of fibrous tissue, 
 in which are numerous clastic and a few smooth muscular (?) fibres. 
 jSIany papillae extend upward into the epithelial layer. Xot only is 
 there a rich capillary plexus in the midst of this tissue, but numerous 
 fine nerve-fibrils Avill be seen under the microscope, the ultimate termi- 
 nations of Avhich are not certainly known. All of these structures may 
 be traced from the vaginal wall.^ 
 
 Walls of the Yagixa. — There are two, the anterior and the pos- 
 terior : both have a somewhat triangular shape, the bases of the triangles 
 being uppermost. The former extends from the upper edge of the ori- 
 ficium vaginse to the cervix, in front of which it expands to form the 
 anterior cul-de-sac. Its length averages five centimeters, the lower three 
 centimeters being intimately united Avith the urethra and neck of the 
 bladder, forming the urethro-A'aginal septum. The anterior cul-de-sac 
 is a shalloAV pouch in front of the cervix Avhich varies in depth accord- 
 ing to the amount of inclination of the uterus. The mucous membrane 
 coA'ering the anterior Avail is throAvn into numerous folds or projections, 
 which are most marked near the A^ulva and gradually disappear toward 
 the upper end of the canal. These folds are distinguished as temporary 
 and permanent, the former disappearing AA'hen the vagina is distended. 
 The latter consist of series of transA^erse ridges that extend obliquely 
 upAvard and outAvard from a median longitudinal ridge knoAvn as the 
 anterior column. The transA'erse cristse are themseh'es composed of 
 still smaller secondary ridges, AA'hich are covered with papillfe. The 
 anterior column may begin immediately behind the meatus or at the 
 
 ' Budin's view of the origin of the hymen is not universally accepted. Pozzi (Gaz. 
 med. de Paris, Feb. 23, 1884, p. 86) believes that it is an outgrowth from the fo?tal 
 sinus urogenitalis, and hence that it is really a part of the vulva. He regards the 
 hvinen as the analogue of the bulb of the urethra in the male. 
 
120 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 small tubercle below it, and it generally disappears at the upper third 
 of the vagina. It is not infrequently divided into two parts by a 
 median longitudinal groove ; the opposite halves may reunite. This 
 column may be situated laterally. The ridges are most prominent in 
 the newborn and in virgins ; in the latter they are remarkably firm to 
 the touch. They disappear to some extent after childbirth, especially at 
 the upper part of the canal, but they may persist near its lower end in 
 the form of prominent papillae. 
 
 The posterior vaginal wall extends from the lower edge of the orifice 
 to the cervix, behind which it forms the deep pouch known as the pos- 
 terior cul-de-sac. Its average length is seven and a half centimeters. 
 The lower four-fifths of this wall is loosely connected with the rectum, 
 forming the recto-vaginal septum. There is a posterior column with 
 transverse ridges extending outward from it, but these are not so prom- 
 inent as those on the anterior wall. 
 
 The roof, or fornix, of the vagina is the upper part of the tube 
 where it surrounds the cervix. Its extent and peculiar dome-like 
 appearance are only seen when the canal is dilated, the anterior and 
 posterior walls being normally in contact with the cervix. The pos- 
 terior cul-de-sac, or fornix, has at least twice the depth of the anterior, 
 on account of the higher attachment of the vagina behind the cervix. 
 This difference is not ajjpreciated on viewing the vagina and uterus 
 externally, because of the intimate union between the two organs. The 
 lateral fornices are simply the portions of the vaginal roof which lie on 
 either side of the cervix ; they have no appreciable depth, and serve to 
 connect the anterior and posterior culs-de-sac. The important relations 
 of the latter will be mentioned subsequently. 
 
 It is unnecessary to give more than a passing reference to the changes 
 in the vagina which ensue from senile involution — shortening of the 
 longitudinal and transverse diameters, narrowing of the entire canal, 
 atrophy of the mucous membrane, with obliteration of the rugse — or to 
 the general hyperplasia which results from pregnancy. It shares in 
 the changes which occur in all of the pelvic organs under the conditions 
 mentioned. 
 
 AiSrATo:MY. — a. Gross. — The wall of the vagina consists of three layers 
 — an external, composed of connective tissue ; a middle, of unstriated 
 muscle ; and an inner mucous layer. The connective tissue serves to 
 unite the vagina firmly to adjacent organs ; in fact, Cruveilhier does 
 not regard it as belonging properly to the wall of the canal. It serves 
 also to support the external plexus of veins. The fibres of the mus- 
 cular layer do not form distinct strata, but interlace ; they have, how- 
 ever, been divided into two sets, those having a general longitudinal 
 direction, and those which are circular or oblique. Authorities differ 
 as to the relative position of the fibres, some stating that the innermost 
 
VAGiyA. 121 
 
 ones aiv loiioltudiiial/ while Ureisky- alliriiis tliat they are usually cir- 
 cular. He admits that in the anterioi- eolininis the I'oriner aiTanuenient 
 prevails. Luschka' describes a hinidle of" striated nni.-cidar fibres 
 wlilcli suiToiinds the lower end of the va<i;ina and also encii-clcs the 
 urethral oi'iliee (sphincter va<;-ina'). 
 
 'V\\o nuicons nicinbrane of" the vaj^ina varies in thickness from one 
 to one and a hall" millimeters, and extends l"i'om the free edge of" tiie 
 hymen to the cervix uteri, over which it is rellected. Its color is nor- 
 mally rosy red, but it may vary from a light pink to a dark pui'ple or 
 slate color, the latter hue fre([uently appearing- during ])regnancy. It 
 is closely united to the subjacent nuiscular layer, and is disj)osed in the 
 form of columns and transverse ridges, as before mentioned : a section 
 through one of the colunuis shows that the nnicous meml)rane is nnich 
 thicker here than it is in the hollow between the ridges, and that it is 
 also more vascular. Numerous papillje cover the mucous surface ; these 
 increase in size during pregnancy. A small amount of acid mucus is 
 normally present on the walls of the vagina. The secretion is aug- 
 mented during pregnancy and the menstrual period. The vaginal wall 
 has not the same thickness throughout. At the upper part of the canal 
 it measures from two to three lines, A\hile near the outlet it is from five 
 to six lines thick. This difference is due to the variation in thickness 
 of the muscular layer. 
 
 Vascular Supply. — The vagina receives arterial branches from sev- 
 eral sources. Besides the vaginal arteries, which spring generally from 
 the anterior divisions of the internal iliacs below the origin of the ute- 
 rine arteries, and give oif several parallel twigs which ramify ujDon the 
 lateral wall of the tube, branches from the uterine supply its upper end, 
 while the pudendal arteries send branches to its lower extremitv. All 
 of these vessels anastomose freely with one another, with those of the 
 opposite side, and with the uterine, vesical, and rectal arteries. H}'rtl 
 figures an azygos branch which has a longitudinal course along the 
 anterior vaginal wall and empties into the circular arter}^ of the cervix. 
 
 The vaginal veins are disposed in the form of plexuses that form 
 complete vascular sheaths around the canal, one being external to the 
 muscular layer, while the other lies just beneath the mucous membrane. 
 These communicate freely with the pudendal, vesical, and hemorrhoidal 
 plexuses below, and with the plexuses of the broad ligament above. 
 Some of these communicating networks have received special names. 
 Thus a collection of veins situated on either side of the fornix has been 
 called the utero-vaginal plexus ; another in the vesico- or urethro-vagi- 
 nal septum, the vagi no- vesical plexus.* All of these veins are without 
 valves. 
 
 ' Henle, Klein, and Frey. 2 Kranl;h. der Vagina, 1879, p. 7. 
 
 3 Op. cil., p. 387. * Ravage, op. cil., pi. ix. fig. 1. 
 
122 
 
 THE ANATOMY OF THE FEMALE PELVIC OBGASS. 
 
 Lymphatics. — The lymphatics which oome from the lower end of the 
 vagina unite with those from the external genitals and enter the ingui- 
 
 ■ •* — K F^G. 42. ^^ 
 
 Arteries and Veins of Vagina and Uterus fSa\^5^;. j^, ^x..v.^er cut at urachus and turned 
 forward ; R, rectum ; L, round ligament ; U, uterus : 0, ovary : T', vagina ; S, sacro-iliac 
 articulation; K, kidney; F, Fallopian tube; P, pubic symphysis; o. pyriformis muscle; 
 h, gluteal muscles ; c, ischio-coccygeus muscle ; d, internal obturator muscle ; e, e, psoas 
 muscle ; /, linea alba ; g, g. ureters ; h, obturator nerve : i, internal inguinal ring : 1, abdom- 
 inal aorta ; 2, inferior mesenteric artery ; 3, S, common iliac arteries ; 4. external iliac artery ; 
 5, vena cava ; 6, renal veins ; 7, 7, common iliac veins ; 8, external iliac vein ; 9, internal 
 iliac artery ; 10, gluteal ; 11, ileo-lumbar ; 12, sciatic ; 13, pudic ; 14, obturator ; 15, epigastric 
 veins ; 17, uterine veins ; 18, vagino-vesical venous rete ; 19, spermatic veins ; 20, bulb of 
 ovary; 21, vein to round ligament; 22, Fallopian veins. 
 
 nal glands. The vessels from the upper three-fourths of the vagina 
 are joined by branches from the cervix uteri and bladder, and termi- 
 
F.167X1. 
 
 123 
 
 nato in tlio internal iliao o;lan(ls.' The nervous supply of the vajxina 
 is (IcrJNrd almost entirely Ironi the synipallietie system; branches irom 
 the interioi- hypogastric plexuses form a network around the canal, 
 ^vhieh is eoutimious with that M'hieh surrounds the uterus. 
 
 Fig. 4 1. 
 
 Longitudinal Section of the Vaginal Wall. 
 
 Transverse Section of the same i Breisky). 
 
 a, mucous membrane ; b, muscular layer, including a, circular, and p, longitudinal fibres ; c, 
 fibrous layer, containing fat. 
 
 B. 3Iinufe. — A cross-section through the vaginal wall presents the 
 following appearance under the microscope : There is an external layer 
 of fibrous tissue, in the midst of which will be seen numerous large 
 veins belonging to the so-called plexus venosus vaginalis. Around 
 
 ^ Accordin,? to Le Bee (Gaz. hehdom., April 15, 1881), the united lymphatics of the 
 cervix and upper part of the vagina rtin beneath the base of the broad ligament, and 
 open into some small glands around the obturator foramen. 
 
124 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 these are bundles of smooth muscular fibres, the presence of which 
 suggests a resemblance to true cavernous tissue. Running with the 
 veins are large lymphatics, some of which are dilated so as to form 
 sinuses. More internal to the fibrous layer is the muscular stratum, in 
 w^hich the outer fibres will be divided more or less transverselv, while 
 the inner have a longitudinal course. Between and among these are 
 other fibres that cross one another in all directions. Lymphatic plexuses 
 are distributed between the bundles. Internal to the muscular coat is 
 the submucous layer of loose areolar tissue which supports a second 
 venous network, the vessels appearing to be much smaller than those 
 forming the external plexus, and having a general course parallel to 
 the course of the canal. Another set of lymphatics is present in this 
 tissue, the vessels being relatively of large size and having valves. The 
 mucous membrane of the vagina consists of dense fibrous tissue, in the 
 midst of which are numerous elastic fibres, over which are several layers 
 of stratified pavement epithelium. This mucosa with its epithelium is 
 not only thrown into large folds, but forms secondary elevations or 
 papillae, in each of w^hich is a capillary loop. In sections of the mucous 
 membrane of the fornix these loops are single, but in the large papillae 
 that cover the rugse near the introitus there is quite a complicated vas- 
 cular network. The rugae have a different structure from the general 
 mucosa, since they contain large venous plexuses sm-rounded by bun- 
 dles of muscular fibres, as in cavernous tissue. 
 
 The mucous membrane is richly supplied with lymphatics : L5w- 
 enstein has described lymph-follicles similar to those in the large 
 intestine.^ 
 
 The existence of true secreting glands in the vaginal mucous mem- 
 brane has not been postively determined. Von Preuschin^ has de- 
 scribed tubular crypts or glands in the region of the fornix which are 
 lined with columnar (ciliated?) epithelium. Robin, Cadiat, Sappey, 
 De Sin6t}^, and many others deny the existence of glands in the 
 vagina, and believe that the vaginal mucus is an exudation from the 
 free surface of the mucosa, and not a true secretion. 
 
 Nerves ramify throughout the muscular coat and communicate vv^ith 
 one another and with the ganglia that are present in considerable num- 
 bers. There is a plexus beneath the epithelial layer, the terminal fila- 
 ments from which enter structures known as end-bulbs. 
 
 Relatioxs. — Anteriorly, the vagina is connected with the bas fond 
 and neck of the bladder by means of a quantity of dense areolar tissue. 
 This union, which occurs over the upper half of the vagina, is not as 
 intimate as that between the vagina and urethra, yet the term " vesico- 
 vaginal septum " is applied to the entire thickness of the tissues sepa- 
 rating the two cavities. It is formed by the anterior wall of the vagina, 
 
 ^ Centralbl.f. Tried. Wissenschaft, 1871, p. 546. ^ Virch. Arch., Bd. Ixx. p. 6. 
 
VAGIXA. 125 
 
 the jiostcrior wall of" the hhuUlor, and the layer ol" (•(inneetive tissue 
 between thcni, in which is the va,ii;inu-vesical plexus of veins. The hjwer 
 halt" of the anterior va<i;inal wall is so firmly united to the urethra that the 
 latter is literally " imbedded in it," as Quain describes it, the vmion re- 
 sultin*!: in the f"ormation of the " urethro-vaginal septum," Mhieh includes 
 the anterior three-fourths of the urethra. The posterior vaginal wall 
 is looselv connected over the middle two-fourths of its extent with the 
 rectum, one or more layers of connective tissue being interposed. The 
 correctness of the term " recto-vaginal septum " as applied to this union 
 has been properly questioned, since the connection is hardly close enough 
 to warrant it. Over its upper fourth the vagina is separated from the 
 rectum by the cul-de-sac of Douglas,^ while below the level of the pel- 
 vic floor the perineal body intervenes between the two canals. 
 
 Laterally, the vagina receives the attachment of the pelvic diaphragm 
 — that is, the levatores aui muscles and the fascia covering them — while 
 it is in immediate relation with the large venous plexuses already men- 
 tioned. 
 
 The relations of the fornix are so important as to deserve a separate 
 description. The anterior cul-de-sac is at least an inch and a half from 
 the vesico-uterine peritoneal fold. Above and well to its outer sides 
 are the ureters, which here bend downward and inward to enter the 
 bladder. The lateral fornices are in relation with the bases of the 
 broad ligaments and the vessels that pass along and below them. The 
 posterior cul-de-sac is covered by the anterior fold of peritoneum which 
 forms the pouch of Douglas,^ some areolar tissue being interposed, and 
 descends for an inch or more on the posterior vaginal wall. AVhen the 
 bladder is empt^' a coil of intestine may rest against the peritoneum 
 covering the fornix. 
 
 Peactical Deductions. — The hymen presents numerous varia- 
 tions as regards shape, thickness, distensibilit^-, etc. The diagnosis of 
 imperforate hymen should not be made too hastily, since there may be 
 a minute opening sufficient to permit the escape of the menstrual blood, 
 vet so small as to be readily overlooked. It is difficult to form a cor- 
 rect idea of the true size of the hymeneal opening in virgins unless the 
 parts are relaxed by an anaesthetic : such patients should be examined 
 under ether, when the finger may be easily introduced through a vulvo- 
 vaginal outlet which before appeared to be hermetically sealed. The 
 presence or absence of the hymen is now regarded as of small medico- 
 legal importance, except in cases of rape, where evidences of recent 
 
 ^ The depth of Douglas's pouch is subject to wide variations within normal limits. 
 De Sinety states that the peritoneum descends on the posterior vaginal wall only to a 
 distance of 12-15 mm. Tillaux assigns 3 cm. as the average depth of the pouch. 
 
 ^ According to Hart and Barbour, only one-third of an inch of tissue separates the 
 posterior fornix from the peritoneum. 
 
126 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 rupture may be significant. It should not be forgotten that an intact 
 fimbriated hymen may simulate rupture. The carunculse myrtiformes, 
 on the contrary, are of value as pointing to a previous parturition ; it 
 is impossible to conceal this sign of childbirth. From its position the 
 hymen shares in inflammatory conditions of the vagina and vulva. 
 When inflamed it is extremely sensitive, as might be inferred from its 
 nerve-supply. 
 
 The anatomical relations of the vaginal canal are of extreme import- 
 ance clinically : it is impossible for the physician to make an intelligent 
 digital examination unless he has them constantly before his mind, 
 while the surgeon will find it necessary to keep his regional anatomy 
 ever fresh. This remark applies particularly to the fornices, which lie 
 in such close proximity to the internal pelvic organs. 
 
 The fusion of the urethral and vaginal walls to form the urethro- 
 vaginal septum is interesting surgically. Because of this close union, 
 as well as of the firm connections of the urethra, pure urethrocele, a& 
 compared with cystocele, is not common ; redundancy of the vaginal 
 tissue is often mistaken for this condition. The thickness of the sep- 
 tum, as well as its vascularity, will be apparent during the performance 
 of the " buttonhole " operation. The looser connection of the bladder 
 with the upper part of the anterior vaginal wall explains the greater 
 range of mobility of the former organ, while the union between the 
 two is sufficiently intimate to render cystocele a common aifection. It 
 is important clinically to distinguish prolapsus vaginse (or descent of 
 the vaginal wall loithout the bladder) from cystocele : the former usually 
 accompanies prolapsus uteri, and, as the reader must infer from his 
 knowledge of the anatomical relations, is a rare condition. In many 
 cases of supposed prolapsus uteri in old women the displacement is 
 really a cystocele vaginalis due to loss of tone of the tissues, which 
 will not be corrected by simply elevating the uterus with tampons or 
 pessaries. 
 
 The surgeon finds a convenient access to the base of the bladder 
 through the vagina, cystotomy and lithotomy being simple operations 
 in the female : the hemorrhage is insignificant, and there is no danger 
 of wounding important structures as long as the incision is made ver- 
 tically and in the median line. 
 
 The anterior fornix is a region of far less importance than the pos- 
 terior. Through it the body of the uterus is distinctly felt when that 
 organ is in a position of physiological anteversion, while the angle in 
 cases of anteflexion is apparent to the least practised touch. Fibroids 
 on the anterior aspect of the uterus, enlargement of the organ from 
 various causes (especially pregnancy), the presence of the foetal head, — 
 all these objects are accessible through the anterior fornix, especially 
 with the patient in Sims' s position. Surgically, we may be called upon 
 
VAOINA. 127 
 
 to n|)cii the aiiti'fior poiicli in the tipiTatiuiis ol" >ii|)r;i\';i^iii;il cxcir-ioii 
 (il'tlic ccfsix and \auiiial liystercctoiiiy — a pi'dccilurc rc(|iiin'ii^- >(,|||(. 
 can', not so imicli Iroiii the (laiiiici" of |H"fiiiatur<'ly opciiiii;;- (he jiciMto- 
 nonl cavitv ami iiijuriiii;- (he intotiiic, as iVoiii tlic liahilitv of" ciitcriii;^- 
 the hiadilcr. The pcritoiiciiiii lies \i'\<^\[ ii|) oiil of (he \va\', hut the 
 hlatldiT is so near to tUv I'nw of incision tliat the only safety lies in 
 kcepinji" close to the ntorns, while the exact jiosition of the hladder is 
 iiuliciited hy introdueint;- a sound into it. 'IMie readei" who witnesses 
 for the first time this staj;eof a kolpo-hysterectoniy will he snrjirised at 
 the comparative ease with which the hladder can he separated from its 
 utero-vajijinal ct)nncctions, as well as at the slight amonnt of hlcedintj!;. 
 The ])eritoneal cavitv has heen opened thron^h the anterior fornix for 
 the removal of a small snhperitoneal fihroid/ 
 
 The bases of the hroad ligaments are directly accessible to the exam- 
 ining finger through the lateral fornices — a point of importance clinical- 
 ly, since it enables the gynecologist to determine the presence of inflam- 
 matoiy processes or their results (adhesions) extending outward from a 
 lacerated or cjiitheliomatous cervix. The pulsations of the uterine 
 artery can often be felt through the vaginal roof, especially during preg- 
 nancy, while it is not difficult to reach and control both vessels by liga- 
 ture or forceps as a })reliminary step in vaginal hysterectomy : on the 
 other hand, the venous oozing may be copious and impossible to check 
 except by continued ])ressure. 
 
 The anatomical importance of the posterior fornix is evident at a 
 glance. It lies in close proximity to the peritoneal cavity. Remem- 
 ber that the depth of Douglas's pouch is variable, and that the perito- 
 neum may rarely dip down between the rectum and vagina so low as 
 to be wounded in operations on the posterior vaginal Avail. On the 
 <^ther hand, the lowest point in the pouch may barely reach the level 
 of the fornix. It is hardly necessary to call attention to the various 
 objects Avhich may be touched through the post(>rior fornix, since this 
 subject belongs to the section on diagnosis. The distinctness with 
 which prolapsed ovaries may sometimes he felt is quite startling to 
 the tyro, so that he almost forgets that they are separated from his 
 finger by a septum composed of several distinct layers of tissue. 
 The beginner should become perfectly fiimiliar with the feel of 
 the sacro-uterine ligaments, so that he will not infer the presence of 
 inflammation in them simply because they happen to be better devel- 
 oped than usual. As to the question of the presence or absence of coils 
 of small intestine in Douglas's pouch, the reader need only observe that 
 if the posterior cul-de-sac be opened through the vaginal roof, the 
 patient being on her back, the proximity of the intestine will frequ(>ntly 
 be demonstrated in a maimer unpleasant to the operator. Practically, 
 
 ' Mann, Am. Journ. Obstet., June, 1885. 
 
128 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 then, vaginal hysterectomy is best performed ^vith the woman in the 
 left lateral posture, so that the intestines may gravitate away from the 
 cul-de-sac. The nearness of the gut to the vaginal roof is proved by 
 the occasional occurrence of enterocele. The frequency of suppuration 
 in the subperitoneal sj)ace adjacent to the posterior fornix, and the tend- 
 ency of abscesss to point in this region, are well known. Not only a 
 pelvic abscess, but a peritoneal efPnsion or an intrapelvic cyst, is easily 
 reached by the aspirator-needle through the vaginal roof. Vaginal 
 ovariotomy or salpingotomy is a tempting operation in many cases, but 
 its difficulties are much greater than they appear : the operator can 
 never be sure that in allowing the stumps to retract into the cavity 
 he has not released some bleeding vessels which cannot be secured. 
 Theoretically, drainage through the vaginal vault should be perfect; 
 practically, it is not, and the danger of sepsis is great. Abscesses and 
 suppurating adherent cysts are not always opened with impunity 
 tlirough the fornix : severe hemorrhage occasionally follows the use 
 of the knife ; hence the thermo- or galvano-cauter}- is preferred by 
 careful operators. 
 
 The ■ posterior vaginal wall is more liable to become prolapsed than 
 the anterior, since it is connected with the rectum, as low as the apex 
 of the perineal body, by the recto-vaginal process of the pelvic cellular 
 tissue : that this process is hardly thick enough to constitute a distinct 
 septum will be evident on passing the finger into the rectum. 
 
 The attachments of the vaginal tube are important. By reason of 
 its union with the cervix uteri any pressure or traction exerted upon 
 either fornix is transmitted directly to the cervix and indirectly to the 
 body of the uterus. Hence pressure upon the posterior fornix (by 
 tampons or pessaries) fends to draw the cervix backward and to throw 
 the body foru^ard, and, conversely, distension of the anterior fornix by 
 a foreign body will tend to lift the anteverted fundus to a slight extent 
 as the cervix is drawn forward. The practical application of this gen- 
 erally accepted fact is this : A movable uterus (ante- or retroverted) is 
 affected by a pessary or tampon, while T^-ith an ante- or reflexed organ 
 the angle of flexion is simply increased by distending either fornix. 
 
 It is well to bear in mind the level at which the vaginal roof is 
 attached to the cersax, and the fact that, as the result of contraction 
 following old lesions, the infra- and supravaginal portions of the cervix 
 may be practically continuous. In repairing a laceration of the cervix 
 which has involved the vaginal roof, a careless operator might readily 
 open into the subperitoneal cellular tissue and expose his patient to the 
 chance of septic absor^^tion. AA^ien the cervix is atrophied and the 
 laceration has been deep, resulting in the formation of an extensive 
 cicatrix, the accident is not an uncommon one. Fortunately, compli- 
 cations are rare if the sutures are carefiillv inserted and antiseptic injec- 
 
VAGINA. 129 
 
 tidiis tire (liorniiiihly u^cd. in ;iiii|)iit:iti(tii ol" tlic ccrx'i.x (Inv lixpcr- 
 tropliy or cpitliclioiMa) it is easy to R'liiovc at the same time a puilioii 
 ol" the va<i;iiial rool", and thus to open into the subperitoneal or perito- 
 neal cavity — an accident which is ibrtunately not followed by fatal 
 conseciuences so often as mi<;ht be supposed. 
 
 The relations of the vagina to the pelvic diaj)lnagni will be con- 
 sidered in another place. 
 
 A few of the general features of the canal deserve mention. W'c 
 have seen that it is normally a slit, not an open tube; it assumes the 
 latter character only \\1umi its walls are artificially separated. The 
 phenomena observed on retracting the jiosterior wall by tiie finger or 
 a speculum, an well as the influence of i)osture on the size and direction 
 of the vagina, are familiar to every one through the classical description 
 of Sims. Some idea of the resistance offered by the pubo-coccygeus 
 muscle may be gained by endeavoring to examine a patient with vagi- 
 nismus before and after an anesthetic has been administered. The 
 great distensibility of the vagina is seen during parturition ; but it 
 should not be forgotten that in distending it encroaches upon both the 
 rectum and nrinary tract. In tamponing for uterine hemorrhage, there- 
 fore, the tampons should be so arranged that pressure is exerted upon 
 the former rather than upon the latter canal. Advantage is taken of 
 the distensibility of the posterior fornix in the treatment of retroflexion 
 of the uterus Avitli fixation and prolapse of the ovaries. Crude and 
 mechanical as this method is, no better way of gradually stretching 
 (or causing the absorption of?) old adhesions has yet been devised than 
 the application of pressure through the vaginal roof by means of tam- 
 pons. Doubtless some brilliant results are obtained in this way, but 
 careful observations at the examining-table, as well as experiments in 
 the dead-house, have convinced the writer that it is frequently impossi- 
 ble to dislodge an imprisoned uterus or ovary by pressure exerted from 
 below through the posterior fornix. AVhoever devises a safe and scien- 
 tific method of overcoming this difficulty will deserve a place only a 
 little lower than that of the pioneers of abdominal surgery. 
 
 It is surprising how the posterior fornix may be " ballooned out " 
 as the result of long-continued packing : a pouch so shallow that it 
 will not retain a pessary may in this way be deepened to the extent of 
 from one to two inches. A slight amount of reflection will convince 
 the reader that by introducing the plug with the patient in the knee- 
 chest position he will obtain the assistance of gravity, both in replacing 
 the pelvic viscera and in deepening the posterior fornix. 
 
 The thinness of the vaginal walls (two or three lines) should not be 
 forgotten during operations for rectocele and cystoc^le. It is a fact of 
 common observation that in denuding, as soon as the mucous membrane 
 has been removed, the surgeon reaches immediately the large submucous 
 
 Vol. I.— 9 
 
130 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 venous plexus, which it is desirable not to wound. Whether, as Dr. 
 Emmet believes, it is possible to penetrate the entire thickness of the 
 vaginal wall with a needle in posterior colporrhaphy, and to catch up 
 the torn fascia outside, it is impossible to decide, since no dissections 
 have been made for the purpose of proving this statement. In spite 
 of the instructions which are given in descriptions of this operation, it 
 is probable that in most instances it consists essentially in merely tak- 
 ing a reef in the redundant vaginal mucous membrane. The marked 
 tendency of the tissues to stretch proves a source of annoyance to the 
 surgeon, who frequently finds that a few months after the performance 
 of plastic operations, undertaken with the view of narrowing the canal, 
 its calibre is nearly the same as before. 
 
 The continuity of the vaginal mucosa with that of the uterus and 
 Fallopian tubes is an anatomical fact of extreme practical importance. 
 Gonorrhoea is a serious aifection in the female : the physician who, in the 
 light of our present knowledge of tubal pathology, continues to regard 
 it as an insignificant local inflammation is certainly not abreast of 
 modern ideas. One of the chief reasons why gonorrhoea in the female 
 is such a chronic afiection is because there are so many folds in the 
 vagina which are not reached by the local applications and injections. 
 
 The normal rugosities of the vagina are sometimes so marked that 
 they may be regarded as pathological : the distribution of the papillae 
 and follicles is well shown in granular vaginitis, a condition often 
 present during pregnancy. Cysts, resulting from dilatation of the 
 mucous follicles, are not very common : they are usually found near 
 the ostium, and should not be confounded with enlargements of the 
 \'Tilvo- vaginal glands. They may be incised and the lining mem- 
 brane touched with a caustic, or the cysts may be dissected out entire : 
 in the latter case the caution with regard to the thinness of the vaginal 
 wall will not be unheeded. The same applies to operations for the 
 removal of polypoid tumors, to curetting for primary and secondary 
 epithelioma, etc. 
 
 The remarks concerning the nerves and vessels of the external 
 genitals apply also to those of the vagina. The reflex symptoms 
 observed in vaginismus furnish sufficient evidence of the continuity 
 of the pelvic nerve-plexuses. The phenomena may be due to some 
 cause entirely outside of the vagina. There being two sets of valveless 
 veins in the vaginal wall, which communicate freely with the deeper 
 plexuses, any obstruction to the pelvic circulation or general engorge- 
 ment will at once affect the former. The blueness of the mucous mem- 
 brane of the vagina during early pregnancy is sufficiently familiar, yet 
 ovarian and uterine tumors or prolapsus may cause the same appear- 
 ance. During operations on the perineum and posterior wall, when 
 the patient is profoundly etherized the submucous plexuses appear 
 
UTERUS. 131 
 
 o-rcativ (listciidcd as (he imicuiis iiiniihraiic is rciiioxcd. \\'(»iiii(ls ol 
 the va<;iiia (»rt('ii nivc rise to |)n»fiiso venous lu'inorrliaj^c, tsju-cially 
 (liiriiiij; |)r('i;iiaiicy and pai-tiirition.' It is bettor to pass a suture 
 under (he Wlccdin;;- vessel than t<t endeavor to isolate it or to lijrate 
 en inawr. Hot water is an excellent styptie durin<^ i)lasti(; ojjera- 
 tions. On the same principle, copious injeetions of water at a liij^li 
 teini)erature (110° F.), the hips beiuji;- elevated in order to favor the 
 i-eturn of the venous blood, frequently cut short an attack of acute 
 vaginitis. Even those who question the antiphlogistic action of hot 
 water in deep intrapelvie inHanmiation will not doubt its value in 
 cases wher(> it can be applied so directly to the affected spot. 
 
 The union of the lymphatics of the lower fourth of the vagina with 
 those of the external genitals Iuls already been mentioned. Le Bee's 
 statement that the lymphatics of the upper three-fourths of the canal 
 unite with those of the cervix and pass below the broad ligaments to 
 the obturator glands, and that they eommunicatc freely with the ingui- 
 nal glands, seems to be borne out clinically by the fact that the latter 
 are commonly involved in malignant disease of the upper portion of 
 the canal. The hopelessness of eifccting a radical cure in such cases is 
 sufficiently evident. The blood- and lymphatic-supply of the cervix 
 and upper part of the vagina being practically the same, it is evident 
 that the prognosis in malignant disease, as regards its extension to sur- 
 rounding tissues, Avill be nearly identical for both regions. 
 
 Uterus. 
 
 Synoxyjvis. — Eng., womb ; Gr., uazipa ; Lat., matrix ; Fr., ma- 
 trice ; Ger., GebJirmutter ; It., matrice ; Sp., matriz. 
 
 Defixitox. — The uterus is a hollow, thick-walled organ, shaped 
 like an inverted truncated cone, occupying the middle of the pelvic 
 ca\nty between the bladder and rectum. 
 
 PosiTiox. — The normal position of the uterus has long proved a 
 fruitful subject for discussion among both pure anatomists and gyne- 
 cologists. It wall be impossible to rehearse in such a brief paper as 
 this the results of the many investigations that have been made in order 
 to determine a point ^vhich at the first glance appears so simple.^ 
 
 Much of the difference of opinion on this subject has arisen from the 
 fact that observers have sought to assign arbitrarily a certain definite 
 position to the uterus, and have not made due allowance for the influ- 
 ences exerted upon it by neighboring organs. It must be evident to 
 
 ' Compare paper by Dr. Mann on "Surgical Operations on the Pelvic Organs of 
 Pregnant Women," Gi/nnrrdoffiml Transadion.", vol. vii. 
 
 ^ For the literatnre of the snbject the reader is referred to Hart and Barbour's Gj/nce- 
 coJofpj, chap, ii., and to the list of authors appended to Ranney's Topog. Relations of the 
 Female Pelvic Organs. 
 
132 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 any one who has studied the pelvic organs in the cadaver that no dis- 
 sections or frozen sections, however carefully they may be made, can 
 ever present a perfect picture of the relation of these organs as they 
 appear in the living subject. The elasticity of the tissues is lost, and 
 the uterus, deprived of its natural supports, which are so nicely l^alanced 
 during life, must necessarily assume a position far different from that 
 which it once occupied. In short, such results as those obtained by 
 Schultze and Kohlrausch, as proved by their figures,^ will go far to con- 
 vince the reader that clinical observations are more likely to give a 
 satisfactory solution of this question than are pure anatomical studies. 
 Still more reliable are those results which are obtained by a judicious 
 combination of both methods. It is sufficient for practical purposes to 
 state that, with the bladder and rectum empty, the uterus is normally in 
 a position of slight anteflexion, the os externum being directed down- 
 ward and backward, and the entire organ having an inclination toward 
 the right side.^ To what extent its anterior surface is in contact with 
 the posterior aspect of the bladder (as affirmed by Hart and Barbour) 
 is not clear, nor is it of any practical importance. It is well known 
 that the uterus possesses a considerable range of mobility, its position 
 varying according to the amount of distension of the bladder.^ 
 
 When viewed from above the uterus appears as a pear-shaped body, 
 somewhat flattened from before backward, so that its anterior surface 
 is nearly plane, the posterior being distinctly convex. It tapers gradu- 
 ally to a point near its middle, where there is a slight depression (most 
 marked on the posterior aspect) that represents the line of demarkation 
 between the body and the cervix. This sulcus is not seen when the 
 uterus is observed m siht in the living body or when it is injected after 
 its removal. The fundus uteri lies either just below or on a level with 
 the plane of the pelvic brim : the tip of the cervix, according to Savage, 
 " marks nearly the centre of the pelvic cavity — the centre of a general 
 radius of about two inches." 
 
 Dimensions. — The entire length of the unimpregnated uterus is 
 about three inches, the cavity of the organ measuring between two and 
 two and a half; a little less than two inches belong to the body. The 
 transverse measurement at the level of the Fallopian tubes varies from 
 one and a half to two inches ; that at the constricted portion, or isthmus, 
 from one-half to one inch. The average antero-posterior diameter of 
 the organ is about an inch. The weight of the virgin uterus varies 
 from seven to twelve drachms. The sulcus before alluded to separates 
 
 ^ Hart and Barbour's Gyncecology, figs. 50, 51. 
 
 ^ There is doubtless truth in Luschka's idea, that muscular fibres in the utero-sacral 
 ligaments (called by him the retractores uteri) assist by their contraction in maintain- 
 ing the uterus in a position of anteversion (Anatomic der WeibUchen Beckens, p. 361). 
 
 •^ Compare Van de Warker's papers, N. Y. Med. Journ.^ vol. xxi. p. 337 ; Am. Journ. 
 Obstetrics, vol. xi. p. 314. 
 
tlic iiicnis into two jioitiofis — tlir tipjx'r, pyrifonn mass Itciiij:; called tlic 
 l)o<lv ; the lowci", s|)iii(lli-.-li:i|»c(| |)oitioii, tlic cervix. Tliat part of the 
 l)o(|\' wliicli lies alio\-e a line joiiiiiiu' llie proximal v\\d> ol"tlie I''alloj)iaii 
 tiiUc- is known as the fnndns. The cervix has been thrther snixlivided 
 l)V Sehroeder into three se^nnents, the ni)per and lower ol" which arc 
 calletl, iVoni their relation to the point ol" attachment of the fornix 
 vaiiina', the supra- and inlravajiinal portions, while an intermediate 
 zone ol" rather indelinite si/e is assnmed as existinj^ between them. 
 It is sullieient for practical purposes to consider the cervix as con- 
 sistintr of two i)arts — an nj)per, which lies al)ove the va<;inal vanlt, 
 and a lower, which is below it. The snpravaginal portion of the cervix 
 extends from the istlunns to the roof of the vagina ; its transverse diam- 
 eter is a little less than an inch, its antero-posterior half as great. The 
 relations of this se<;;ment of the uterns are important, and will be 
 described later. The infra vaginal segment of the cervix is most 
 interestinii' to the gynecologist, because it is the only jxirt of the uterns 
 which is directly accessible to the eye and finger. Its size and appear- 
 ance are extremely variable, according to the age and sexual activity of 
 the subject. In the virgin the cervix appears as a small conical projec- 
 tion about one-third of an inch in length, having a smooth, firm feel. 
 Its apex measures seven or eight lines transversely and five in its ante- 
 ro-posterior diameter. At its centre is the external os (os tincae), a 
 small opening or slit one or tsvo lines in width, situated between 
 the anterior and posterior lips and directed backward. The anterior 
 lip is considerably longer than the posterior, although from the depth 
 of the posterior cul-de-sac and the greater distance of the posterior lip 
 from the ostium the reverse seems to the true. 
 
 The cervix in nulliparous married women is usually larger than in 
 virgins ; its conical shape is less marked, the os is more open, and the 
 lips have a softer feel. It is a question as to what changes may occur 
 in the cervix within strictly normal limits as the result of parturition. 
 In multipara the lips are softened and increased in size, and the os is 
 an irregular opening, around the edges of which are small irregularities 
 and cicatrices, even where no actual laceration has occurred. It should 
 not be forgotten that certain pathological conditions, such as cervical 
 endometritis, may lead to eversion of the lips and an irregular, gaping 
 OS — appearances which closely simulate the results of childbearing. 
 In consequence of senile atrophy the lips may become so shortened that 
 they seem to be almost flush with the vault of the vagina. 
 
 The body of the uterus includes that portion of the organ which lies 
 above the isthmus. Its form and dimensions have already been referred 
 to. It has t^vo surfaces and three borders. Of the former, the anterior 
 surface is flattened, the ])osterior convex. The upper border, which is 
 convex, is continuous with the upper surfaces of the Fallopian tubes. 
 
134 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 The lateral borders are convex at the upper portions^ but become con- 
 cave at the isthmus. At the superior angles of the uteriLS (where the 
 lateral pass into the upper border) are the origins of the tubes ; just 
 below these are the attachments of the ovarian ligaments, while still 
 lower the round ligaments arise. Besides their relations to these struc- 
 tures, the lateral borders are intimately connected with the broad liga- 
 ments, and especially with the vascular plexuses that lie bet^veen their 
 folds. The arteries, veins, and lymphatics enter and leave the uterus 
 at these borders. The body of the nulliparous uterus is smaller than 
 that of the multiparous, and is more distinctly flattened antero-poste- 
 riorly, while the triangular outline is more apparent. 
 
 The uterine cavity is not strictly a cavity at all in the normal organ, 
 since its anterior and posterior walls are in contact. As studied in a 
 coronal section, it consists of two portions, between which is a constric- 
 tion (the isthmus). The cavity of the body has a triangular shape, the 
 apex of the triangle being at the isthmus, while at each end of the base 
 is the opening of a Fallopian tube. A third opening (os internum) 
 leads from the cavity of the uterus into that of the cervix. The latter 
 is fusiform before childbirth, conical aftenvard ; at its upper end is the 
 OS internum, while the os externum forms its lower limit. The lenoth 
 of the entire uterine cavit}' averages two and a half inches, its width 
 one and a half, the antero-posterior diameter of the corporeal cavity 
 nine-tenths of an inch, while that of the os internum is three-eighths 
 of an inch. The entire capacity of the uterine cavity is tv\"0 or three 
 cubic centimeters (Sappey). The internal lining of the corporeal cavity 
 is smooth, that of the cervix is corrugated. As in the vagina, there is 
 a longitudinal ridge on both the anterior and posterior walls, from 
 which oblique processes (arbor vitse uterina) are given off. 
 
 AxATO]MY. — A. Gross. — The uterine wall consists essentially of two 
 layers, the muscular strata and the mucous membrane. The peritoneal 
 covering of the organ, although intimately connected with it, is not 
 really a constituent part of the wall, and will be considered Avith the 
 peritoneum. The muscular tissue of the uterus is best developed after 
 impregnation, when it may be separated into three fairly distinct layers ; 
 hence a minute study of the musculature is more interesting from an 
 obstetrical than from a gynecological point of view. Of the three 
 layers, the external or superficial is most distinct over the anterior and 
 posterior surfaces of the organ, where it is seen as a thin layer (closely 
 adherent to the peritoneum), which sends off prolongations that may be 
 traced bet^veen the folds of the broad ligaments (as the ovarian liga- 
 ments) and along the round ligaments to their termination in the mons 
 "Veneris. Both of these ligaments deserve a separate description. 
 
 The former fibres are derived from the posterior surface of the uterus, 
 the latter from that portion of the " j)latysma " (as it has been appro- 
 
UTERUS. 135 
 
 priatcly naninl) wliidi covits its anterior siirracc. The siijH'rficial 
 muscular layor oi' the Fallopian tubus is als(j derived larj^-ely Injui tho 
 latter souree. The lateral asjjeets of the uterus are entirely dev(jid of 
 this sui)erli('ial stratum.' The middle layer, which is hy far the thick- 
 est, consists ol" interlacing fibres, transverse antl longitudinal, which are 
 coutimious with those of the vagina, having a similar coiu-se. Many 
 of the longitudinal fd)rcs, however, cannot be traced beyond the cervix, 
 wliere thev terminate in the connective tissue. This layer constitutes 
 the principal ])ortion of the uterine wall, and is of importance beeause 
 of the fact that it contains the vessels. These are enclosed within the 
 network of libres, and may be studied with the naked eye in cross-sec- 
 tions, their intimate relation to the tissue in which they are imbedded 
 being shown by the fact that their walls do not collapse Avheu they are 
 divided transversely. 
 
 The thin nuiseular fasciculi of the internal layer have a general cir- 
 cular direction, which is best marked around the os internum, where 
 they form a so-called "sphincter."^ This annular arrangement is also 
 seen around the horns of the uterus, where the circular fibres are 
 directly continuous with those of the Fallopian tubes, and in the cer- 
 vix at the point of attacliment of the vagina. Among the muscu- 
 lar bundles in the latter situation are numerous blood-vessels and 
 lym])h-si)aces, that run transversely. According to Chrobak, the cir- 
 cular fibres enter the mucous layer, so that the union between the two 
 layers is an intimate one.^ 
 
 The connective tissue of the uterus is not distributed in the form of 
 definite layers, but appears as irregular masses of fibres which separate 
 the muscular fasciculi and surround the vessels. It is especially rich 
 ill the cervix, as will be inferred from its extensive hypertrophy as the 
 result of pathological conditions (laceration).^ In the body of the 
 organ a loose areolar tissue is present in considerable quantity in the 
 external muscular layer, where it extends longitudinally, accompanying 
 the bundles of fibres. In the middle layer the individual fibres become 
 finer, while their distribution is circular ; they are found almost exclu- 
 sively around the vessels. The connective tissue of the inner layer is 
 
 ' Vkk Savage {op. cit., p. 47) for a minute description of the external layer, which, 
 togetiier with its serous covering, he denominates the " sero-ihuscular platysma." He 
 appears to regard it as derived almost entirely from the prolongations of the longitu- 
 dinal fibres of the vaginal wall, which simply pass over the surface of the uterus to enter 
 the utero-sacral, round, and broad ligaments and the Fallopian tubes. 
 
 '^ Helie, Itecherches sur la Di.^pos. des Fib. muse, de I' Utc'nt.% Paris, 1869. 
 
 ^Savage {op. cit., p. 45) is almost alone in his positive statement that "the uterine 
 walls are absolutely inseparable into layers or coats, and no sort of formula of 
 arrangement of fibre, as in the case of the heart, is conceivable in respect to them." 
 His observations must have been confined entirely to the unimpreguated organ. 
 
 *Comp. Wylie, '"Observations on Laceration of the Cervix Uteri," Atn. Jounu 
 Obstetrici, vol. xv., No. 1, Jan., 1S82, p. 20 (reprint). 
 
136 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 
 
 dlM^ 
 
 /y/;c: 
 
 'z^i^.m'i^'^i>- 
 
 Section of the Mucous Membrane of the 
 Uterus from near the Fundus (Schafer) : 
 a, epithelium of inner surface ; 6, 6', ute- 
 rine glands; c, interglandular connective 
 tissue ; d, muscular tissue. 
 
 more abundant than that of the 
 median, akhough the fibrillse are 
 so delicate that they are not readily- 
 appreciable with the naked eye. 
 There is still some difference of 
 opinion among anatomists as to 
 whether these fibres can be traced 
 directly into the mucous membrane 
 or not. We have not the space in 
 which to enter upon a discussion of 
 this question. The fact that there 
 is such a firm attachment of the 
 mucous and submucous strata to 
 the subjacent parts, aside from care- 
 ful studies of the normal and patho- 
 logical histology of the uterus, leads 
 the writer to believe that both the 
 muscular and connective-tissue fibres 
 do penetrate the mucous membrane ^ 
 (Fig. 45). 
 
 The mucous lining of the uterine 
 cavity varies in thickness from half 
 a line at the fundus (or less in the 
 vicinity of the cornua) to one-eighth 
 or one-quarter of the entire depth of 
 the wall near the centre of the body. 
 It is so intimately united to the mus- 
 cular tissue, at least in the body of 
 the organ, that the existence of a dis- 
 tinct mucosa has long been denied by 
 many competent observers. In the 
 cervical cavity, on the contrary, 
 where the mucous membrane is 
 much thicker, its attachment to the 
 muscle is not so firm, a layer of 
 areolar tissue intervening. 
 
 On account of the marked differ- 
 ence between the mucosa of the body 
 and that of the cervix, it is desirable 
 that they should be considered sepa- 
 rately. That of the body is smooth 
 and velvety, of a grayish or grayish- 
 
 1 Qnain's Anal. (9tli ed.), vol. ii., fig. 610, 
 p. 709. 
 
UTKRUS. 
 
 1.^7 
 
 rod color, mikI ;iii :i\('i:i^c lliicUncss oC oiio-tAVOiity-fif'tli of an iiidi. 
 Tlicrc is a coiiiiilctc ahsciicc of folds or (•orrii<:;ations, oxcopt in tlic; 
 iimiu'diatc viciiiily ol" the (iil)al oimI'iccs, wlicrc a fow Hiiiall plica; 
 inav sometimes he distin^iiislicd, according;- to Ilciiiiij^. The cervical 
 mucous mcmhraue, as was pi'cvioiisly statc<l, dilVcrs from that of tlu; 
 hodv ill hciii^' disj)()seil in prominent I'olds or rid<;-cs. It is less dis- 
 tinctly red' in color, and is thicker and firmer to the touch. Allusion 
 has heen made to the arranjijement of the arhor vitse uterina or plicaj 
 palmatjie. (luyon states that the Ion»j;itudinal rid<^cs arc not exactly 
 opposal, but that the anterior one fits into a depression in the posterior 
 wall of the cervix, so that its canal is practically obliterated. This is 
 best marked near the os internum, where there is a sharp line of sep- 
 aration between the nuicosie of the cervix and body (Fig. 46). The 
 
 Fui. 46. 
 
 Interior of the Cervix, showing the arboreseent appearanec of the mucous membrane 
 
 'Playfair). 
 
 arborescent appearance of the cervical lining membrane is best observed 
 in a virgin uterus ; after parturition it becomes less distinct. 
 
 B. Minute. — In a section including the entire thickness of the uterine 
 wall there are presented fin- study several distinct varieties of tissues. 
 It is well to caution the inexperienced reader that many of the familiar 
 drawings representing the histological structure of the uterus are largely 
 diagrammatic, having been constructed by the comparison of a number 
 of different sections. It is extremely difficult to obtain perfect sections 
 
 ' Yellnwisli-re^il. acconlinii to iiidst writers. 
 
138 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 of the mucous membrane, since this structure is very delicate and soon 
 becomes disorganized. The writer has always placed more confidence 
 in the examination of fresh scrapings from the interior of the uterus 
 than in the specimens obtained from frozen or hardened organs. The 
 peritoneal covering of the organ, like other serous membranes, is 
 most intelligently studied by staining it in the fresh state. 
 
 Proceeding from without inward, the following tissues are presented 
 for consideration : (1) A delicate serous layer ; (2) a dense mass of 
 fibro-muscular tissue, in which are three different varieties of fibres, 
 blood-vessels, and lymphatics, and finally numerous nerve-filaments ; 
 (3) a mucous layer, the structure of which differs in different regions. 
 
 (1) The relations of its serous covering to the uterus will be described 
 in the paragraphs on the pelvic peritoneum : it is sufficient to remind 
 the reader that, while this membrane is so intimately united to the 
 muscular tissue over the anterior and upper aspect of the uterus that it 
 can hardly be separated by careful dissection, posteriorly a layer of 
 loose areolar tissue is interposed. When stained with nitrate of silver 
 it presents the ordinary appearance of serous surfaces — i. e. a basis of 
 delicate fibrous and elastic tissue supporting large endothelial cells. 
 The capillary and lymphatic plexuses are unusually rich, and may be 
 traced directly into those of the muscular wall ; the lymphatic vessels 
 are provided with valves. 
 
 (2) The distribution of the muscular substance of the uterus in the 
 fi^rm of strata has been described. Under the microscope the longitu- 
 dinal fibres will be identified by their long fusiform cells arranged in 
 parallel rows. In the centre of each cell is a large oblong nucleus 
 that takes a deeper staining than the surrounding protoplasm. The 
 transverse and oblique fasciculi will be represented by round or oval 
 bodies, cross-sections af the same cells. It is important for the 
 beginner to become perfectly familiar with the appearance of smooth 
 muscular fibres in whatever plane they may be divided, since when 
 stained they are easily mistaken for collections of leucocytes, from the 
 presence of which the incautious observer might infer that some patho- 
 logical condition was present. It should be remembered that the fibre- 
 cells become hypertrophied during pregnancy, and are a long time in 
 returning to their original size.' 
 
 Among the separate fusiform cells, and between the different groups, 
 there will be seen, in addition to the usual structureless cementing sub- 
 stance, numerous fine connective-tissue fibres : if the latter tissue is 
 treated when fresh with acetic acid, it will be found to contain a con- 
 siderable number of elastic fibres. These are recognized, in sections 
 stained with carmine or hsematoxylin, by their failure to retain the dye. 
 
 ^ Vide Helie, op. cit. ; also Kreitzer, St. Petersb. Med. Zeitschrift, 1871, Heft ii. 
 p. 113. 
 
VTERUS. 139 
 
 111 tracint; the fihroiis tissue from without inward it will he scfii that 
 it «;ra(hiallv hccoincs (iiicr and more ('(tiidciiscd, chaiiiiiiii; its direction 
 tVoni a lou^iitudinal couisc in thr cxtcnial muscular hiycr to a circular 
 one in the inner, where it represents at some points the so-ealled *'siih- 
 mueosa " o<" mueoiis memhraues. In the median layer the (ihres inter- 
 laee in a eoiiiplieated mauuei- among the umstidar huudles, and also 
 aei'ompanv the blood-vessels, which they surround in the fnim of 
 riiii;s : the latter arrangement can be observed in u eroti.s-seeti(jn oi" a 
 nietl i 1 1 Ill-sized artery. 
 
 The middle musetilar layer, as before stated, contains a large jjart of 
 the vessels of the uterus. The arteries, which are readily recognized 
 hy their thick w^alls and convoluted intima, are especially abundant 
 just beneath the mucous membrane, wdiere they form a ca|)illary net- 
 work. The veins are unusually large and thin-walled, and are with- 
 out valves. Their walls are closely adherent to the surrounding ves- 
 sels, so that the latter remain patulous when divided. These veins, 
 wliicli form dense plexuses in each of the three muscular layers, become 
 .dilated in the middle layer of the pregnant uterus to form irregular 
 spaces known as "sinuses."^ Rouget^ has described a peculiar mode 
 of communication between the terminations of the arteries and the 
 veins, in which the former are connected with the venous sinuses by 
 means of minute branches, instead of by tlie usual capillary plexuses. 
 
 The lymphatics contained within the muscular substance of the 
 uterus can only be traced by means of special injections. Their 
 extent is best appreciated in pathological preparations, especially in 
 sections of interstitial fibroids that are undergoing the first stage of 
 cyst-formation (" geodes "). In addition to the lymphatic plexus that 
 was mentioned as existing just beneath the serous covering, two vari- 
 eties of lymphatics may be demonstrated within the muscular sub- 
 stance — a vascular netw^ork which accompanies the arteries, and a 
 widespread system of intercommunicating spaces, M'liich not only fill 
 the intermuscular connective tissue, but surround the arteries and veins 
 in the form of perivascular sheaths.'^ According to Leopold, these 
 spaces are lined by a single layer of endothelium. Tlie writer has 
 never been so fortunate as to observe this. The lymphatics of the 
 muscular and serous coats (as w^ell as of those of the mucous mem- 
 brane, to be mentioned subsequently) may be traced to large vessels 
 in the external muscular layer that empty into the efferent trunks at 
 
 ' Klein {op. cit., p. 268) says that the venous sinuses of the middle stratum rei)resent 
 " a sort of cavernous tissue." 
 
 '^ " Recherches sur les Organes erectile de la Femme," Joum. de la Phys., 1858, 
 p. 320. 
 
 ^ Comp. Leopold's exhaustive article, " Die Lymphgefasse der norraalar nicbt 
 Schwangern Uterus," Arch. f. Gi/n., Bd. vi. lift. 1, p. ]. 
 
140 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 the lateral borders of the uterus ; the latter unite with the lymphatics 
 of the Fallopian tube and ovary and terminate in the lumbar glands. 
 The minute anatomy of the nerves of the uterus has been most 
 carefully studied by Frankenhauser. They are derived from the sym- 
 pathetic system, and their fine filaments may be seen, in fortunate 
 -p^^ ^„ preparations, ramifying among the muscular bun- 
 
 d dies. According to the above author, they termi- 
 
 ^^ '^ ^,, nate in the nuclei of the fibre-cells. 
 
 |> ^ (3) The mucous lining of the body of the uterus 
 
 <^ "^ \s, directly continuous with the internal muscular 
 
 jt - stratum, the usual submucous layer being w^ant- 
 
 '•^1 ^ ing. It consists of a loose plexus of connective- 
 
 rr^-' ^ tissue fibres, among which may be seen groups of 
 
 _r fusiform cells that are derived from the subjacent 
 ^ muscular tissue.^ In the interstices of the fibres 
 ^, are frequently observed collections of leucocytes : 
 ^ in special preparations these spaces are found to 
 - be lined with small endothelial cells, each of which 
 contains an oval flattened nucleus.^ From its his- 
 tological appearance the mucosa has been com- 
 pared, not inaptly, to the " stroma of lymphoid 
 ^r organs." ^ Leopold * calls it " a lymphatic sur- 
 
 ^^ ^ face which contains no special lymphatic vessels, 
 
 f^^-— "^'=s?s^ |)ut consists of lymph-sinuses covered with en- 
 utricuiar Glands, as seen in dothclium." The free surface of the membrane 
 IbepSd of commencing i^ covcrcd by a single layer of columnar epithelial 
 pregnancy, twice the nat- cclls, wliicli are SO easily detached that they are 
 
 ural size, shiowing the , , ... . -\ r^ i* t 
 
 arrangement and other Seldom sccu m S'ltu in scctions made Irom hard- 
 pecuiiarities of the glands, gned Specimens. The presence of cilia on the free 
 
 a, a, a, with their orifices, ^ ^ 
 
 a, a, a, on the internal sur- surfacc of thcse cells, although denied by a few 
 face of the organ. observers,Ms well established.^ The writer has 
 
 found them in fresh scrapings of the uterine cavity, removed by means 
 of the curette, although they were never in motion when seen. 
 
 The mucous membrane is filled with glands (glandulse uterinse) of 
 the tubular variety, which penetrate through its entire thickness, their 
 
 ^ Savage (Female Pelvie Organs, Wood's ed., p. 45) says that the tissue composing tlie 
 framework of the mucous membrane " is permeated by protoplasmic amoeboid mole- 
 cules, which by cell-evolution take the place of effete fixed cells, amongst others the 
 gland-cells, which are dying incessantly in the act of giving out their secretion." This 
 is a very plausible theory, but it is doubtful if it rests upon any positive anatomical 
 basis. 
 
 ^ Leopold, quoted by Klein {op. ciL, p. 266). 
 
 ^ Satterthwaite's Manual of Histology, p. 243. ■* Op. cit, p. 31. 
 
 * Garrigues, De Sin^ty. 
 
 ^ Strieker, Die Lehre der Geweben, Leipzig, 1871, p. 1173. 
 
UTKll US. 
 
 li 
 
 ciils-dc-sac occMsioiially l)ciiiL;' imlicdilrd in flic iiiiicr iiiusculiir layer. As 
 'runu'i- has shown, the (lircctidii ol" the inlands is not perpendicular to 
 tlu' surface (as lOnji'ehnaun lij^ures them'), hut is nioi'e or less ohli(juo.^ 
 Thev Miav exist as single tuhes, sinuous or sj)iral, hut uiore often they 
 <livide into t\\t> or three hrauehes near their lower ends, where they 
 hei'ouie souiewhat dilated. In htnjxitudiual section they present a 
 delicate hasenient niend)rano, which, acc(jrding to Leopold, is " coni- 
 j)oscd of spindle-shaped cells, which dovetail into one another like the 
 endothelium of the cajjillaries and lymjihatics."'' The existence of this 
 
 ¥\(i. IS. 
 
 Vertical Section through the Uterine Mucous Membrane (Turner): e, columnar epithelium; 
 g, g, utricular glands ; ct, connective tissue surrounding glands ; v, v, blood-vessels ; mm, 
 submucous layer. 
 
 merabrana propria in the iinimprcgnated uterus is denied bv some 
 authorities ; others state that it is only found near the orifice of the 
 gland. It is well marked in the pregnant uterus. Upon this mem- 
 brane rests a single layer of prismatic cells, with single large nuclei 
 near their bases. It is now generally allowed that these cells are 
 ciliated.^ The uterine glands increase largely in number at puberty, 
 
 ' Am. Joum, of Obstetrics, vol. viii. p. 40. 
 
 "^ Ranney, Annals of Anat. and Surgery, April, 1883. rontra. 
 
 ^ Leopold, quoted by Lusk (op. cit., p. 17). See also Ercolani, Utricular Glands of 
 the Ulcnis, trans, by Marcy. 
 
 *Comp. Chrobak in Strieker's Hnndbuch ; Nylander {MiUler's Archiv, 1852, p. 375) ; 
 Lott {Rolleifs Unter.fuch.. Leipzig, 1871); Willi.ims (Structure of the Mucous Membrane 
 of the Uterus) ; Friedliinder ( Untersuch. iiber d. U^lcru.% 1870). 
 
142 THE ANATOMY OF THE FEMALE PELVIO ORGANS. 
 
 being formed by a simple folcling-in of the general mucous surface : 
 during menstruation there is a perceptible increase in their length, 
 which becomes much more evident during pregnancy. 
 
 The mucous membrane possesses its own vessels and nerves. The 
 glands are surrounded with rich capillary networks, which communi- 
 cate with the plexuses in the muscular tissue ; the lymph-spaces are 
 directly connected with the lymph-sinuses and vessels in the inner layer. 
 The ultimate ending of the nerves in the mucous membrane is not cer- 
 tain. Some of them enter small ganglia ; others form plexuses of non- 
 meduUated fibres, the primitive fibrils of which are seen immediately 
 below (or within?) the epithelial cells.^ 
 
 The principal diiferences between the minute anatomy of the cervix 
 and that of the body of the uterus lie in the structure of the mucous 
 membrane. There is no serous investment to the cervix. Its infra- 
 vaginal portion is covered externally by vaginal mucous membrane, 
 the appearance of which under the microscope has already been 
 described. A section through the muscular substance of the cervix 
 shows a preponderance of firm connective tissue as compared with that 
 in the body of the organ. The muscular interlacement is so intricate 
 that a separation into layers is not possible. " In the cervix," says 
 Savage, "the uterus at once loses the characters of an erectile organ" — 
 by which statement he evidently refers to the firmer condition of the 
 cervical tissue and the absence of the large venous sinuses. The blood- 
 vessels of the cervix differ from those of the body in possessing small 
 lumina with extremely thick walls,^ the thickness being most marked 
 in the circular layer of muscular fibres. Within the tissue of the labia 
 the small arteries and veins run in parallel rows to and from the mucous 
 membrane : this disposition is also apparent in the arbor vitse, where 
 the vessels run at right angles to the free surface. 
 
 The mucous lining to the cervical cavity is considerably thicker than 
 that of the body. In a cross-section it will be noted that there is a 
 layer of connective tissue separating the epithelium from the muscular 
 coat. The parallel rows of vessels just alluded to form capillary plex- 
 uses beneath the epithelial layer. The papillae that have been described 
 by so many writers, and in which the capillaries have been said to form 
 loops,^ are in reality appearances presented in sections that have been 
 made through the plica palmatse.* The latter are due simply to increase 
 in the connective-tissue framework. 
 
 The basis of the cervical mucosa is a firm, fibrous, and not a lym- 
 phoid, tissue, upon which rests a layer of ciliated cylindrical epithelial 
 
 ^ Lindgren. quoted by Klein (op. cit, p. 2fi8). 
 
 ^According to Henle (Handbuch der Eingeweidelekre), the diameter of the lumen 
 averages only one-third of that of the entire vessel. 
 =* Lusk, quoting from Henle {op. cU., p. 25). * Klein {op. at., p. 266). 
 
UTEIWS. \V.\ 
 
 colls. Acconliiiti- (<» sonic aiillinrilics, llic cilia ari' |(i(scii( iinivcfsally 
 over the ii[»|»cr (\\(t-iliii-(ls nl" ihc cervical canal ;' the most rwciit inves- 
 tigations, however (e>|tceially those ol' I )e Sinety"j, have estal)lishe<l the 
 faet that eiliate<l epithelinni exists throughout tlu; entire cavity, hut 
 onl\- u|)()n the suinniit ot" the ridges, the colls covering the depressions 
 being non-ciliated.^ The glandular structures of the inend)ran(! are of 
 the rai'oniosc varietv, consisting of branching ducts with dilate<I ends. 
 These are surrounded by capillary plexuses, and consist histologically 
 of simple inversions of the mucous membrane. They are line<l by a 
 single layer of non-ciliated ' cid)ical epithelium, which is supported by a 
 structureless basement membrane. These glands open upon the free 
 surface by minute apertures that are both upon the ridges of the plica? 
 and in the depressions between them. They secrete a clear mucus hav- 
 ing an alkaline reaction. The well-known ovula Nabothi are patho- 
 logical appearances due to the occlusion of the follicles and the for- 
 mation of simple retention-cysts. 
 
 In sections of the cervix at the level of the os externum a well- 
 marked line of separation will be observed between the ciliated colum- 
 nar epithelium of the canal and the vasculse papillae and squamous epi- 
 thelium derived from the reflexion of the vaginal mucous membrane. 
 The latter have been previously described. There has been much dis- 
 cussion as to the presence or absence of glands on the vaginal surface 
 of the normal cervix. It would not be profitable to enlarge upon this 
 topic here. The writer's observations have led him to believe that De 
 Sinety and Ruge and Veit are correct in denying their existence, except 
 under pathological conditions.^ 
 
 Vessels and Nerves. — The uterine arteiy is a most important 
 vessel surgically. It arises from the anterior division of the internal 
 iliac, and takes a course downward and inward between the folds of the 
 broad ligament, until it arrives at a point below the level of the os exter- 
 num, just above the lateral fornix of the vagina. Here it makes a sharp 
 turn upward, and runs along the lateral border of the uterus to unite 
 at about the centre of the orQ-an with the descendino- branch of the 
 ovarian artery. It gives off numerous horizontal branches, Avhich run 
 in spirals (hence their name, "curling arteries of the uterus") and sup- 
 ply the various segments of the organ, anastomosing with the corre- 
 sponding branches of the opposite vessel. A branch of considerable 
 size opposite to the os internum unites with its fellow to form a ring 
 
 " ' The lower limit is stated by some as within one-sixth of an inch from the os 
 externum. 
 
 ^ Also Klein, op. dt., p. 266. 
 
 ' In children, according to Lott {Znr Anat. u. Ph}/.<f. der Cenr'x Uteri, p. 17), the epi- 
 thelium in the upper half of the cervix is not ciliated. 
 
 * The gland-cells are probably ciliated in the newborn, but not after puberty. 
 
 * See Ruge and Veit, Zur Patholorjk der Va'jinalpordon, Stuttgart, 1878. 
 
144 TEE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 around the cervix, known as "the circular artery." This vessel is fre- 
 quently found at a lower level. Other branches run over the fornix 
 vaginee, anastomosing with offsets of the vaginal artery. The latter 
 
 Fig. 49. 
 
 The Ovarian, Uterine, and Vaginal Arteries (Hyrtl) : a, ovarian artery ; a' and V, branches to 
 tube ; 6, branch to round ligament ; c, uterine artery ; c', branches to ovary ; g, vaginal 
 artery ; h, azygos artery of vagina. 
 
 vessel may arise directly from the uterine. AYilliams has called par- 
 ticular attention to the fact that each horizontal segment of the uterus 
 has to some extent an independent vascular supply, so that flexions of 
 
UTERUS. 
 
 Ho 
 
 the oruaii caimnt roiilt in :iii\ Liiiicral (»l)stru<'ti<>n to the Mfxxl-flow. 
 The t'mulus ivtvivcs ;nMitinii;il l)r:iiiclics ihtm tlii' ovarian arteries. 
 TIk' uttTUs is c'onipli'trly >iiiroiin«l('(l hy intricate vcnou.s plexuses 
 
 Vui. .-,(1 
 
 The Nen-es of the Uterus (Fraukenhiiuser) : A, plexus uterinus magnus; B, plesrus hypo- 
 gastricuis; 1, sacrum; 2, rectum; 3, bladder; 4, uterus; 5, ovary; 6, fimbriated extremity of 
 tube. 
 
 (that lie beneath tlie peritoneum), which receive the blood from the 
 veins and sinuses within the walls of the oro;an. These plexuses com- 
 municate freely with the va_iz:inal and vesical plexuses below, and with the 
 pampiniform above, and terminate directly in the internal iliac vein, 
 indirectly in the ovarian. The " utero-vaujinal " plexns, as fiirured by 
 Savage, surrounds the lower part of the uterus and the vaginal fornix. 
 The ureters run directly through this mass of veins to reach the bladder. 
 The lymphatics coining from the body of the uterus unite on each 
 
 Vol. I.— lu 
 
146 
 
 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 side with those from the ovary and tube, and form a dense network 
 within the broad ligament around the pampiniform plexus, the eiferent 
 branches of which ascend in company with the ovarian artery and ter- 
 minate in the lumbar glands. The lymphatics from the cervix and 
 upper extremity of the vagina form a plexus at the level of the os 
 internum, and descend on each side to the base of the broad ligament, 
 beneath which they pass to enter the hypogastric glands around the 
 iliac vessels : here they are joined by the vesical lymphatics.^ 
 
 The main nerve-supply of the uterus is derived from the pelvic or 
 inferior hypogastric plexuses, which surround the rectum and send fila- 
 ments to the uterus and vagina. These are prolongations of the ute- 
 rine plexus that lies over the bifurcation of the aorta. The uterine 
 branches spring from the sides of the pelvic plexuses, run inward 
 between the folds of the broad ligaments until they reach the cervix, 
 when they turn upward, accompanying the branches of the uterine 
 artery and entering the substance of the organ with them. A large 
 nervous mass, situated bet^veen the cervix and rectum, arises from the 
 
 Fig. 51. 
 
 Transverse Section of the Body, showing relations of fundus uteri (Savage) : M, pubes ; A, A, 
 hypogastric arteries in front, spermatic vessels and nerves behind ; B, bladder ; L, L, round 
 ligaments; U, fundus uteri; T, T, Fallopian tubes; 0,0, ovaries; S, rectum; G, right 
 ureter ; C, utero-sacral ligaments ; T', last lumbar vertebra. 
 
 union of branches of the upper sacral nerves and ganglia, and a num- 
 ber of sympathetic twigs from the hypogastric plexus : it supplies the 
 cervix chiefly, and is enormously enlarged during pregnancy. 
 
 The ultimate termination of the uterine nerves is either in the 
 nuclei of the fibre-cells or in submucous g^anglia.^ 
 
 ^ Le Bee ("Contributions a I'Etude des Ligaments larges," Gaz 
 says that they terminate in the obturator gland. 
 
 ^ Frankenhauser, Hie Nerven der Gebdnnutter, etc., Jena, 1867. 
 
 ., Apr. 15, 1881) 
 
UTERUS. I 17 
 
 Relations and Connections. — Thoso have alnmly Itccn hkh- 
 tioiu'd, or will iu' in tho course of the .siux'xrdiii'r pap'S. For con- 
 vonioMcc tlu'V may be brieHy rejieated. As has been statetl, when the 
 bladder and rwtiim are empty the uterus lies normally in a j)ositioii of" 
 sli«i:lit anteHexion. At some distanee behnv the fundus uteri, and sep- 
 arated from it by a double fold of peritoneum and a (piantity of cellular 
 tissue (below the vesieo-uterine pouch), is the fundus of the bladder. 
 The writer cannot accept the statement that the fundus rests upon the 
 bladder, as tiijured by Schultze, Pirogotf, and others. Behind the 
 uterus is Doui][:las's pouch, which separates the p<jsterior a.spect of the 
 ort^an from the rectum. When the bladder is empty, coils of small 
 intestine till the upper part of this pouch and rest against the fundus and 
 posterior aspect of the uterus. Laterally are the broad ligaments, in the 
 u])per edges of which are the Fallopian tubes, while below their prox- 
 imal extremities are the origins of the ovarian and round ligaments. 
 Below is the vault of the vagina, which surrounds and is firmly 
 attached to the uterus. Just above the line of attachment (utero- 
 vaginal) is the portion of the supravaginal segment of the cervix 
 which lies in the subperitoneal space and is surrounded by areolar 
 tissue containing venous plexuses. The relations of the pelvic perito- 
 neum and connective tissue to the uterus Avill be described under the 
 subdivisions which treat of those subjects. The so-called false and true 
 ligaments of the uterus (except the round ligaments) will be included 
 under the same topics. 
 
 Practical Deductions. — Allusion has been made to the range of 
 mobility of the uterus in an antero-posterior plane. It is important 
 that the physician should learn to recognize not only the phvsiologi- 
 cal changes of position produced by a full rectum or bladder, but those 
 caused by posture. For example, if an old multipara is examined 
 upon the back, the uterus, by reason of the weight of the organ and 
 the relaxation of its ligaments, may be felt through the posterior fornix ; 
 with the patient semi-prone the uterus falls forward, and the fimdus is 
 distinctly touched through the anterior fornix. Two different examiners 
 may thus diagnosticate ante- and retroversion in the same patient. 
 
 The normal uterus may be elevated on the finger to the extent of 
 between one and two inches without doing injury to the surrounding 
 parts.* The reader should be cautioned against accejiting unhesitatingly 
 the statement that " artificial prolajysus " is an entirely harmless pro- 
 cedure. Experiments made upon the cadaver are not conclusive ; the 
 inexperienced will ac-t ^^^sely in distrusting the teaching that the uterus 
 
 ' A clear idea of the mobility of the uterus in a vertical direction can be gained by 
 observing (during an examination with the speculum i the manner in which the respi- 
 ratory movements are transmitted to the organ. This is still nn)re marked in singing, 
 defecation, etc. 
 
148 THE ANATOMY OF TEE FEMALE PELVIC ORGANS. 
 
 '■'■ can be drawn downward by the volsella to the ostium vaginae without 
 endangering its return to its proper position in the pelvis " (Ranney). 
 Practical gynecologists are apt to be cautious in resorting to such 
 aids to diagnosis. As our knowledge of the frequency of tubal 
 disease and localized peritonitis becomes more certain, we hesitate 
 about exerting much traction upon the appendages by dragging down 
 the uterus in the manner described. It is necessar}^ to be on one's 
 guard during operations or examinations under ether, because when 
 the parts are thoroughly relaxed by an anaesthetic a uterus which pre- 
 viously possessed a limited range of mobility can be pushed upward 
 or depressed to an extent which did not seem possible. IS^ot having 
 the patient's expressions of pain as an index, we may easily rupture 
 recent peritonitic adhesions and do incalculable harm without being 
 aware of it. The cardinal principle in gynecology should be not to 
 do the woman any harm : the question of actually benefiting her is 
 often of secondary importance. The reader will avoid one, by no 
 means imaginary, source of danger if he learns to make a diagnosis 
 and to practise the ordinary operations while displacing the uterus just 
 as little as possible, either with or without instruments. 
 
 While we become familiar with the normal mobility of the uterus, 
 we should be equally prompt to recognize impairment of the same, 
 either partial or complete : moreover, if this information can be gained 
 without the use of the sound, so much the better. The diagnosis of 
 retroflexion with fixation Avill be discussed elseAvhere. 
 
 Ascension of the uterus — a normal condition in pregnancy — should 
 be viewed with sus2:)icion when the organ is not thus enlarged, since it 
 points to the probable presence of adhesions or morbid growths. Xote 
 that it does not follow that the organ is thus displaced because the 
 examiner finds it difficult to reach the cervix : the vagina may be 
 unusually long, or the cervix short. By examining the patient upon 
 the side the mechanical difficult}^ may be overcome. The extent to 
 which the uterus can be elevated is best appreciated during the per- 
 formance of Alexander's operation : the limit is found to depend not 
 upon the mobility of the organ, l)ut upon the length of cord which 
 can be drawn through the inguinal ring. The operator can hardly 
 raise the uterus too high. 
 
 As the uterus is capable of motion laterally as w^ell as antero-poste- 
 riorlv, so it may be fixed in a position of lateroflexion by cicatrices in 
 either broad ligament — a displacement which it is particularly difficult 
 to correct by means of tampons. 
 
 Lateral deviation of the muciparous uterus is frequently observed 
 when the patient is in Sims's position; the normal mobilit}' in this 
 direction is limited, but distinct. Lateroflexion, with fixation, it is 
 hardly necessary to add, is a more serious displacement, pointing to a 
 
VTKIiVS. 1 JO 
 
 f'oniici" iiill;iiiiiii;itii>ii in niir of tlir IhumiI li;^;iiiu'iits in \vlii<li the corrf'- 
 sjxhkIImj^ ovarv ami tiihc arc doiihtli'ss iiivolvcd ; it >li(nil«l IcaW the 
 snpot'oii to be on his ii;iiar<l a<:;aiiist any ron<rli inaiiipulalioiis. 
 
 Tlio (•haM«j:('s ill j)ositioii consoijiU'iit iijMtn the iiicn'asin<; size (»!" tlic 
 ortjaii (prctiiiaiicy, suliiiivnhition) are sclf-cvidciit : the tciidciicy to pro- 
 lapsus ohservc'd in old suhjcrts is often exj)lained by j;eneral atrophy 
 and loss of tone in its supports, the or^an itself beinj; really of small 
 size. It is only necessary to allude to the ])hysiolon;ical changes in the 
 shape and size of the uterus. It is not always an easy matter to recog- 
 nize these by bimanual paljjation or to assign them to their proper cause. 
 The diagnosis of early pregnancy from the sha})e and consistence of the 
 organ, as suggested by Hegar, deserves the careful consideration of 
 every gynecologist. He relies upon the presence of softening and 
 thinning of the inferior segment of the uterus, as well as the pyramidal 
 shape assumed by the body.' There is a peculiar bulging of the ante- 
 rior Avail and an elasticity of the fundus, as felt through the anterior 
 fornix, which may be recognized as early as the fifth f»r sixth Aveek of 
 pregnancy, even when the cervix docs not show any marked changes. 
 
 The anatomy of the cervix uteri and its surroundings should 
 be carefully studied by the gynecologist. He who forms his con- 
 ception of its a})pcarance entirely from descriptions of the nulliparous 
 cervix will be sadly puzzled when he comes to touch, or to observe 
 through the speculum, the results of an extensive laceration. It is 
 necessary for one to examine a large number of multiparas before he 
 can be in a position to appreciate the fact that no two cervices are alike. 
 To the various changes in shape, size, etc. to which this portion of the 
 uterus is subject as the result of pathological conditions (especially lace- 
 ration) we need not refer, since these are touched upon elsewhere ; the 
 eifect of pregnancy upon the size and consistence of the part is described 
 in works on obstetrics. It was stated that Schroeder's division of the 
 cervix into three distinct zones is more or less artificial ; the " portio 
 intermedia " is often wanting in multipara. In old subjects the cervix 
 is represented by a small nodule projecting from the vaginal roof. In 
 cases of extensive bilateral laceration with e version it appears to be 
 flush with the roof, until the opposite lips are approximated, according 
 to Emmet's direction, by means of tenacula. 
 
 The long axis of the uterus forms such an angle with that of the 
 vagina that the reader must not be surprised at times to find the cer- 
 vix high up against the posterior fornix, with the os externum resting 
 against the rectum : this position is of course modified as the rectum 
 and bladder become distended. AVhen the vagina is unusually deep 
 and the cervix long, it may be impossible for a tyro to either touch the 
 OS or to bring it into view with the speculum. By applying the prin- 
 
 ^ Comp. Prafjcr Med. Wochenschrij't, "So. 26, 1884 ; Annaies de Gynecologie, Sept., 1884. 
 
150 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 ciple already stated, he will succeed in exposing it by slipping the long- 
 est blade of the instrument behind the cervix and gently jurying the 
 latter forward, while with the depressor he exerts traction upon it by 
 making pressure in the anterior fornix. The introduction of a retro- 
 version pessary may be rendered difficult by the same condition of the 
 parts. In inserting such an instrument the upper bar has a tendency 
 to slip in front of the cervix and to glide into the anterior cul-de-sac : 
 when this occurs the beginner should remove the pessary and repeat 
 the manoeuvre, instead of trying to carry the bar backward over the cer- 
 vix into position. The same rule should be followed as in introducing 
 the speculum — i. e. to hug the rectal wall closely until the tip of the cer- 
 vix is passed. 
 
 A few brief practical points may be mentioned in connection with 
 operations on the cervix, suggested by its structure and relations. The 
 height of the vaginal attachment varies ; the posterior wall of the 
 vagina meets the cervix at a point above the junction of the anterior. 
 It is evident that a laceration of the cervix through the vaginal junc- 
 tion must be an extensive one, and liable to be followed by parametri- 
 tis and subsequent cicatrization. Amputation of an hypertrophied cer- 
 vix may be compared with circumcision ; if the uterus is drawn down 
 and due provision is not made for the retraction of the vaginal tissue, 
 nearly the entire fornix may be excised, leaving an unsightly wound. 
 In high amputation for cancer, if firm traction is made on the uterus 
 while the vaginal attachment is separated, the os internum will be 
 opposite to the line of incision, so that it will only be necessary to 
 divide the cervix straight across. If the disease has invaded the body 
 of the organ, it is easy to remove a wedge-shaped piece ; when the parts 
 are allowed to retract, the operator is frequently surprised at the depth 
 of the excavation. 
 
 The intimate relation of the cervix to the broad ligaments, with their 
 labyrinth of blood-vessels and lymphatics, renders it easy for us to 
 understand the reason why lacerations may be followed by inflamma- 
 tory processes. The frequency of so-called cellulitis has been ques- 
 tioned, but the occurrence of inflammation in the tissues adjacent to 
 a lacerated cervix as the result of septic absortion (whether we term it 
 lymphangitis, periphlebitis, or cellulitis) can certainly not be denied in 
 toto} At the same time, the direct continuity of the cervical and cor- 
 poreal endometrium points to a certain source of tubal and peritoneal 
 trouble originating in lesions of the cervix. In all of the autopsies 
 performed by the writer in fatal cases of hystero-trachelorrhaphy and 
 posterior section (five or six) death was due to an extension of inflam- 
 mation from the wound iqncard along the mucous membrane, not out- 
 
 ^Comp. paper by the writer in Trans, of Alumni Association of the Woman's Hospital, 
 vol. i. p. 67. 
 
UTERUS. \')\ 
 
 tnird iilniii;- tlic l)ii>;ii| li^;^-:imriils. Iiccalliiio- (he ;iii:iti)iiiy <il" lln- utcro- 
 sacnil ligaments, it is iiol always easy tn iiinlcr.-taml liuw |iararin'tritis 
 postci'ioi- can be a tV('(|iiciit acc()mj)aniiiicnt <»1" cci'vii-al lesions. 
 
 'I'liat iiicisiuii ol' the cci-vix lor stenosis is not an entirely liarnilcss 
 j)ro('etliire is e\i(lent anatoniicallv as well as elinieally. The |)roximity 
 of tlie peritoneum and the rich network ol' veins which lie in the mns- 
 cular coat ot" the ntei'us render the daniicr of" |)eritonitis and septic 
 ahsorplion no iniaiiinarv one. The indications are clearly to make the 
 incision as liniiled in leiiLith and depth as j)ossil)l<', and to ])ractise i'i<;id 
 antisepsis. 
 
 The corpus uteri is only indirectly accessible through the medium of 
 the himanual touch ; in fat subjects it is frofjuontly impossible to feel it 
 at all. Kxtreme deviations from its normal size and ])ositioii arc easily 
 recognized by the most inexperienced, but to detect moderate enlarge- 
 ments, small fibroids in the anterior or posterior wall, unusual softness 
 of the muscular tissue, etc., requires long practice and a thorough famil- 
 iarity with the feel of the normal organ. It is a matter of daily experi- 
 ence among laparotomists to find on opening the abdomen that the size 
 and position of the uterus do not correspond to the impressions derived 
 at the examining-table. The fundus, as touched through the fornix, 
 usually appears larger than it really is, the normal protrusion of the 
 anterior surface being often mistaken for an interstitial fibroid. Some 
 gynecologists diagnosticate anteflexion whenever they feel the fundus 
 uteri through the anterior fornix, while others rarely make this diag- 
 nosis. If the reader will bear in mind the range of mobility of the 
 organ, he will doubtless meet with fewer displacements. As regards 
 the difference between anteversion and anteflexion, the reader should 
 remember that there is normally a distinct, though large, angle between 
 the cervix and the body, which is increased when the uterus is enlarged 
 and of softer consistence than usual. 
 
 It does not belong to this place to enter at length into a consideration 
 of the variations in the shape and size of the corpus uteri. The possi- 
 bility of an enlargement being due to pregnancy should always be kept 
 in view, even when there are no symptoms pointing to that condition, 
 especially when an operation is meditated. In the absence of this con- 
 dition, it will remain to determine whether the enlargement is general, 
 and is caused either bv some growth in the intra-uterine eavitv or bv a 
 hypertrophy of the muscular substance, or is of an irregular character, 
 due to growths on its exterior. Tiie normal changes in old age — atrophy, 
 decrease in depth, etc. — must not be mistaken for disease. 
 
 Variations in the consistency of the uterine wall are not easily recog- 
 nized mdess marked. The normal fundus has a Arm, elastic feel as 
 touched through the fornix ; it is claimed tliat the ]ieculiar softness of 
 the pregnant organ can be recognized as early as the sixth week. In 
 
152 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 subinvolution, in malignant disease of the body, etc., the tissue is soft- 
 ened. The recognition of this condition of the muscle should lead 
 the surgeon to be cautious in using the sound, sharp curette, spoon- 
 saw, and other similar instruments, since he might easily perforate the 
 uterine wall. 
 
 There are many points in regard to the anatomy of the uterus, both 
 gross and microscopic, which are of direct surgical interest. The depth 
 of the cavity in the unimpregnated organ is usually given as two and a 
 half inches, but it frequently exceeds this measurement in the living 
 female by reason of the elasticity of the wall. Most of the cases in 
 which a probe is supposed to enter one of the Fallopian tubes, because 
 it can be introduced to the depth of four or five inches, should be viewed 
 with suspicion. The cavity in such instances is doubtless really elon- 
 gated ; sometimes the wall itself is perforated without serious conse- 
 quences, as in a case observed by the writer. It is important for the 
 physician to become thoroughly familiar with the depth, direction, and 
 size of the normal cavity as indicated by the probe or sound, as well 
 as with the peculiar spongy, elastic sensation communicated through 
 the instrument as it touches the fundal mucous membrane, before he 
 can expect to recognize deviations from the normal at the examining- 
 table or undertake manipulations within the cavity. These are mat- 
 ters not of description, but of practice. Beginners invariably forget 
 that the uterine canal forms a decided curve, and that any instrument 
 designed to enter it must either have a corresponding curve, or in intro- 
 ducing it its handle must be carried well backward to a line parallel 
 with the uterine axis ; this applies particularly to tents. A glance at 
 a median section of the pelvis will show that to endeavor to push a 
 tent straight upward in the axis of the os externum is to lose sight 
 of the first principles of common sense, still more those of anatomy ; 
 in fact, the writer has known of the posterior uterine wall being per- 
 forated in this way. The cavity of the nulliparous uterus appears 
 in a vertical section as little more than a slit; even in the interior 
 of the multiparous organ that has undergone subinvolution there is 
 scanty room for manipulation with instruments. Consequently, in 
 using the curette we are limited mainly to a scraping motion in a 
 vertical direction. Considering the large arc described with the 
 handle of a sharp curette or spoon-saw, as compared with the small 
 space in which the blade revolves, it is evident that some care must 
 be exercised in sweeping the latter about in a circular direction. 
 
 The normal constriction at the os internum is often mistaken for a 
 pathological condition. The existence of an angle at this point is to be 
 remembered in introducing the sound, which is often arrested at this 
 point when it is not properly curved ; a temporary constriction is fre- 
 quently caused by a contraction of the sphincter muscle. An internal 
 
UTEIIVS. lo,'] 
 
 OS wliirli Icirclv :i<liiiit> nf the |»:i->;iLi«' 'it" :i jirolx' will ca.-ily allnw tin- 
 iiiti'diliictiiiii of a lai'iic sniiiitl wlicii the patient i-. aiia'.>tli('ti/f(l. Another 
 practical hint derived Ironi tlieaMi;le l)et\veen the cervix and IxmIv i.~ this: 
 It" an instrument or tent i> arrested at the (ts iiiterniiin, draw tiie cervix 
 downward and backward with a tcnacidnni, tliiis rt'iideriiif^ the canal 
 more neai'ly straight. 
 
 Our opj)oi-tnnitii's lor stndyinj;' tiie normal liiiin;^ membrane ot" the 
 utei lis are few, ondcwcopy not havin<^ achieved many satisfactory results 
 in this direction. In cases of" deep laceration of the cervix with 
 marked eversion the nmeoiis membrane is visible nearly as high up 
 as the OS internum, but its angry, florid appearance is far from being 
 that of health. It is a mistake tosupj)ose that the lining of the corj)or- 
 eal cavity luus normally a s(jft, spongy feel ; it is ratlier elastic. The 
 rugae in the cervical canal oflen render the introduction of a probe dif- 
 ficult when a sound will not be arrestcKl. The normal endometrium 
 being poorly sup})Iietl with sentient nerves, no pain should be experi- 
 enced in the passage of an instrument. Extreme sensitivenass is proof 
 ])()sitive of the existence of disease. The uterine wall is of consider- 
 able interest surgically. In the non-parous organ, when removed from 
 the body, it appears to be semi-cartillaginons and almost non-vascular, 
 yet few structures bleed more obstinately when wounded. From the 
 thickness of the wall, as seen in mesial section, as well as from its inhe- 
 rent toughness, it would seem as if a blunt instrament could not be forced 
 through it except by the exercise of great violence ; but when it is soft- 
 ened by pregnancy or disease (subinvolution, carcinoma) the accident 
 might easily occur. 
 
 Divulsion of the cervix — a procedure which is frequently practised at 
 the present day to the exclusion of the cutting operation — owes its suc- 
 cess to the complete stretching, or even tearing, of the fibres of the 
 sphincter muscle. Unless this is thoroughly effected, the benefit will 
 only be temporary. In incision of the cervix the surgeon aims rather 
 at straightening, than at enlarging, the canal. The idea that a flexion 
 can be ])ermanently eliminated by the use of an intra-uterine stem is 
 hardly founded on anatomical principles. 
 
 Some idea of the extreme vascularity of the wall will be gained 
 during operations wliich involve direct injury to it, as in the enuclea- 
 tion of interstitial fibroids, myomotomy by Schroeder's method, etc. ; 
 fortunately, the contractility of the muscular substance is sufficient to 
 overcome to some extent the tendency to bleeding. Hemorrhage from 
 the external muscular layer is difficult to control ; the peritoneal covering 
 of the uterus is sometimes torn while separating adherent ovarian tumors, 
 when the venous oozing is almost uncontrollable. Styptics, the actual 
 cautery, etc. are often useless, and it is impossible to surround the bleed- 
 ing points with ligatures. During an ovariotomy the writer was obliged 
 
154 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 to seize the bleeding surfaces en masse with two pairs of long forceps, 
 and to leave these in the abdomen for forty-eight hours. In the intra- 
 peritoneal method of treating the stump after hysterectomy it is import- 
 ant to secure all of the vessels on its surface, other^vise a dangerous 
 oozing may occur beneath the peritoneal flaps. 
 
 Although the peritoneal covering of the uterus is no longer regarded 
 as inviolable, and subserous fibroids are now removed with impunity, it 
 should not be forgotten that this covering belongs to the general peri- 
 toneal lining of the pelvis, in which inflammation extends rapidly. The 
 close proximity of coils of small intestine to the uterus favors the forma- 
 tion of adhesions between their serous surfaces in peritonitis. If the 
 patient recovers with permanent adhesions, she will be subject to dis- 
 tressing symptoms referable both to the uterus and the imprisoned gut. 
 Doubtless this complication would be less frequent if the bowels were 
 moved earlier in the course of the disease, instead of being paralyzed 
 with opium. 
 
 The minute anatomy of the uterus does not concern the surgeon so 
 much as it does the pathologist. A study of its vast network of veins 
 and lymphatics, and their connection with the mucous membrane, cannot 
 fail to suggest some practical lessons in regard to the strict use of anti- 
 septics in all operations within the cavity. Although this article does 
 not deal with obstetrics, the writer cannot avoid the temptation to reit- 
 erate the trite maxim that an intelligent appreciation of the absorbent 
 power of the uterine vessels would lead accoucheurs to view with appre- 
 hension the smallest puerperal lesion, and by their careful use of anti- 
 septics to render subsequent attention on the part of the gynecologist 
 unnecessar\\ The normal histology 'of" the cervix possesses no small 
 degree of practical interest. Attention has been called to the tran- 
 sition from the columnar epithelium lining the cervical canal to the 
 squamous variet}^ that covers the portio vaginalis beyond the os exter- 
 num. The importance of this distinction becomes evident in study- 
 ing the pathology of cervical ectropium resulting from laceration. 
 This subject is discussed elsewhere. We can only emphasize here the 
 fact that " ulceration " of the cervix does not exist — that the raw everted 
 surface seen in these cases is really " a neidy -formed glandular secret- 
 inr/ surface resembling in structure the cervical mucous membrane." ^ 
 The importance of the cervical glands in this connection, as well as 
 in relation to the development of epithelioma, cannot be over-estimated. 
 The cervix during pregnancy has been called by Fritsch a " glandular 
 organ," and the pathological hypertrophy of the glands both explains 
 the causation of cervical catarrh and furnishes a hint for its successftil 
 treatment. The glands, being the seat of the disease, must be thor- 
 oughly destroyed by means of strong caustics, thorough scraping with 
 ' Hart and Barbour, op. cit., p. 279. 
 
UTERUS. \-)-) 
 
 the sluirp curctto, or even In' coiiiplctt' excision (jf the iiiiicous nioiu- 
 brane tu'c^orclinjr to Scliroecler's iiu'tliod. 
 
 The cervix is coiiiposcd essentially of connective tissue, wliich is 
 normally toiii;h and resistant ; in okl a<:;e it may assume a semi-carti- 
 laginous consistence. It is anatomically and clinically one of tiie least 
 sensitive ])ortions of the genital tract; ojierations have frequently been 
 performed uj)on it without the use of an aniesthetic, the patient experi- 
 encing com})aratively little pain. For this reason it is difficult to esti- 
 mate to what extent cocaine acts as a local anaesthetic in hystero-trach- 
 elorrhaphy. 
 
 This portion of the uterus is not particularly rich in nerve-filaments, 
 nor does it abound in those terminal i)ulbs that are found in the exter- 
 nal genitals. The explanation of various reflex neuroses in cases c^f 
 lacerated cervix by reference to the inclusion of nerve-filaments within 
 the " cicatricial plug " at the angle of the tear does not, therefore, 
 rest on a positive anatomical basis. 
 
 There is no time to study the anatomy of the uterus \nt\\ reference 
 to the origin of morbid growths from its tissues. This opens up an 
 interesting subject which has been fully treated by Gusserow.' 
 
 Some familiarity with the distribution of the uterine vessels is indis- 
 pensable for one who aspires to a scientific knowledge of gynecologv. 
 Probably not one medical student out of twenty ever takes the trouble 
 to inject and dissect them out in the cadaver ; fortunately, a study of 
 plates and museum-specimens vnW enable him to sup])ly his deficient 
 practical knowledge to some extent. Writers on pelvic pathologv have 
 unfortunately shown a disposition to distort anatomical facts to suit 
 their individual theories. If the reader will glance at any plate show- 
 ing the pelvic circulation (Hyrtl's, for example), he will recognize the 
 justness of Dr. Williams's criticism of the theory that uterine 
 "■ engorgement " is a necessary result of displacements, especiallv 
 flexions. The uterine artery gives off a large number of parallel 
 branches w^hich run at right angles to the main trunk, and anas- 
 tomose freely with the corresponding branches on the opposite side, 
 so that the uteriLS may be regarded as composed of numerous seg- 
 ments, each of w'hich has its independent vascular supply. It is 
 obvious, without argument, that no flexion, however sharp, can cause 
 any considerable interruption of the circulation either above or below 
 the point of flexion. The same principle maybe extended to supposed 
 obstructions in the periuterine tissues from localized inflammatorv foci 
 (peri- or parametritis) ; the pelvic vessels anastomose too freely to admit 
 of an unquestioned acceptance of the theory of general obstruction and 
 engorgement. 
 
 The uterine vessels are of importance principally from a surgical 
 ^ Nevbildungen de.s Z^tenui. 
 
156 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 standpoint. In vaginal extirpation of the uterus it is important to 
 control the vessels in the broad ligaments before separating the uterine 
 attachments. Some difficulty may be experienced in passing a ligature 
 around the ovarian artery from below. A recent writer has suggested 
 that the operation might be shortened by compressing each broad liga- 
 ment, with its contained vessels, with a pair of long forceps, detaching 
 the uterus, and afterward securing the vessels at leisure. There is some 
 danger in this method that one or more of them may slip, when it will 
 be a difficult matter to pick them up again. The defect in the plan of 
 starving a malignant growth of the uterus by cutting oflP a portion of 
 the blood-supply of the organ, or of preventing the hemorrhage in sub- 
 peritoneal myomotomy by ligating one or two of the arteries, will be 
 evident from what has already been said of the free anastomosis of the 
 pelvic vessels. It should be noted that the uterine artery runs near the 
 base of the broad ligament, so that its pulsation can often be felt through 
 the lateral fornix. Some of its large vaginal branches may be divided 
 in the incision for gastro-elytrotomy. The circular artery of the cer- 
 vix, formed by the union of opposite branches from the main trunks, 
 is a bugbear that is constantly held up before the inexperienced ope- 
 rator. The fact is, this vessel, which lies opposite to the cervix, is 
 rarely divided in Emmet's operation, and when it is the hemorrhage 
 can be readily controlled by passing a wire suture beneath it and 
 twisting the same. In cases of extensive laceration in which the 
 denudation is carried deep into the angles a small arterial branch is 
 often cut, but the hemorrhage is by no means as alarming as we 
 have been taught to expect. 
 
 It should be noted that in certain morbid conditions of the uterus 
 (especially fibro-cystic disease) the vessels are enormously enlarged, so 
 that a venous hemorrhage would be fatal in a short time. 
 
 Our knowledge of the functional nervous affections of the pelvic 
 organs is as fragmentary as the study of their nerve-distribution is dif- 
 ficult. Pain as a subjective symptom of pelvic disease is seldom local- 
 ized in any single organ : the relation between the plexuses is too inti- 
 mate to admit of the application to them of Hilton's ingenious theories. 
 Doubtless, many supposed ovarian pains are really due to disease of 
 the uterus, and vice versa. When we advance a step farther and con- 
 sider the relation of the uterine nerves to those of the general sympa- 
 thetic system, and the various reflex disturbances which result from 
 this intercommunication, we begin to deal with psychical phenomena 
 which have little to do Avith the sober facts of pelvic anatomy. 
 
 We cannot conclude these rambling remarks on uterine surgery more 
 fitly than by quoting from a writer of the old school, whose caution is 
 too often disregarded by the modern gynecologist : " No surgical pro- 
 ceeding whatever, touching any part of the uterine system, should be 
 
ROUSl) IJCAMKSTS. Uu 
 
 iniatt('ii(lc(l l)y the ])i\'caiitioiis ohscrvcd in operations of a {rravc dia- 
 ractcr (licrc i»r cIscwIktc : in cri'tain states of" the }i;('n('ral system, unlore- 
 sliadoweil l»v anv recunni/.altle peculiarity, the most trivial o|H'ration has 
 been speedily followed by i'atal |)eritonitis." ' 
 
 The round lijiaments are pi'o|>erly (leserii)e<l in couneetion with the 
 uterus, sinee they are ically otU^rowths iVom the superficial nuiseular 
 hiyer. 
 
 Round Ligaments. 
 
 Synonyms. — Susj)ensory lijraments; Lat., liframenta rotunda, lifra- 
 menta tereta uteri; Fr., litjaments rouds de la matrice; GVr., runde 
 ISIutterhander ; //., Icgamenti rotonde ; 8p., ligamentos redondos. 
 
 Definition. — The round litiaments are two fibro-museular cords 
 which spring Injm the sujierior angles of the uterus, extend forward 
 and outward to the internal inguinal ring, and pa.ss through the inguinal 
 canal to reach the anterior aspect of the symphysis pubis, where they 
 terminate in fibrous expansions which are lost in the substance of the 
 mons Veneris. 
 
 These structures, the anatomy of which is commonly dismissed in 
 a few words, deserve a careful description, because of the importance 
 that they have recently assumed in connection with Alexander's ope- 
 ration. 
 
 Each ligament appears as a somewhat flattened cord, which remains 
 of quite constant size in the same subject (and, in fact, in different 
 subjects) until after it has entered the inguinal canal, when it tapei*s 
 gradually, and at its point of exit varies greatly in size and distinctness. 
 Its length varies from four to five inches.^ 
 
 For convenience of description, the ligament may be divided into 
 three portions — that part which lies within the pelvic cavity, that 
 within the inguinal canal, and the terminal portion. The pelvic 
 division of the ligament is attached to the anterior aspect of the 
 upper angle of tlie uterus, in front of, and imme<liately below, the 
 origin of the Fallopian tube. Lying at first in the anterior fold of 
 the broad ligament, it curves upward and outward, then forward and 
 inward, to reach the internal ring. In the latter part of its course it 
 leaves the broad ligament, and, enveloped in a fold of peritoneum, runs 
 near the lateral wall of the pelvis, lying well to the outer side of tlie 
 bladder even when that organ is distended ; it crosses the external 
 iliac and obliterated hypogastric arteries, and at the internal ring has 
 the same relations as the spermatic cord in the male, the epigastric artery 
 curving around it on its inner side. At its orijrin the lio;ament is larire 
 
 ' Savage, np ciL, p. 92. 
 
 '-' Madame Boivin has stated that the right ligament is slightly sliorter and tliicker 
 tlian tlie left. 
 
158 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 and fleshy, and has a somewhat triangular shape on cross-section ; before 
 leaving the broad ligament it becomes smaller and more cylindrical. 
 Within the inguinal canal (the length of which is one and a half 
 inches) it is nearly round, and tapers gradually toward the external 
 ring. Its relations within the canal are identical with those of the 
 spermatic cord. The fold of peritoneum that envelops the intrapelvic 
 portion of the ligament forms a slight depression at the internal ring, 
 but does not usually extend beyond this point in the adult, although in 
 the foetns after the fifth month it regularly accompanies the ligament 
 throughout the canal, like the processus vaginalis in the male. This 
 
 Fig. 52. 
 
 ^M 
 
 Horizontal Section of Body, showing uterus and round ligaments (Savage): B, bladder; U, 
 uterus ; C, C, utero-sacral ligaments ; L, L, round ligaments : 0, 0, ovaries ; T, T, tubes ; R, 
 rectum. 
 
 tube of peritoneum is occasionally persistent in the adult, when it is 
 known as the canal of jN^uck.^ 
 
 On emerging from the external ring the ligament lies close to the 
 outer side of the pubic spine, which forms the surgical guide to it in 
 Alexander's operation. On reaching the anterior aspect of the sym- 
 physis it breaks up into a number of fine strands, which are lost in the 
 fibrous tissue of the mons and upper portion of the corresponding labium 
 majus. At the edge of the ring fibres are often given oif which are 
 attached to surrounding parts. Three sets have been described and 
 figured — an external, an internal, and a median, the former of which 
 
 ^The importance of tins persistence of the peritoneal sheath in connection with the 
 operation of shortening the round ligaments is at once evident. 
 
J^ol'M) Lie AM J:\TS. 
 
 i:.:i 
 
 l)l('ii(l with the outer pillar <»!' tlic I'iiiji' close to ( JiiiilKTiiat's li;^aiiieiit , 
 the lattei' (eniiiiiate in ihi' ii|)|>er |)oi"tioii olthe external i-iiiu", wliile th(- 
 iiitenial teniiiiial lihi'cs enter (he euiijoiiieil temlon. IJainey ' in liis 
 (h'seription of the i-onnd lijianient regards 1 1 lat slrnetnre as l()i"ine(l by 
 till' eoalesei'uee of" these tlii'ei' sets oi' libres. It seems luore correct to 
 
 Fig. r,:i. 
 
 \ 
 
 u-- 
 
 -4- 
 
 Pubic Termiiintinii of the Round Ligaments : P, pubis where covered by pubic portion of apon- 
 eurosis of interior (jblique nmscle; U, fundus uteri; L, uterine extremity of round liga- 
 ment ; JB, aponeurosis of external oblique muscle ; /, internal oblique muscle ; t, transversalis 
 muscle; r, rectus muscle; i\', genital brancli of genito-crural nerve; 1. external terminating 
 fibres of round ligament into outer pillar uf internal ring near Gimbernat's ligament ; 2, 
 internal terminating fibres into conjoined tendons of internal oblique muscle and transver- 
 salis muscle, near pubis; 3, middle terminating fibres into upper part of external ring; 4, 
 internal i)illar of external ring; 5, vessels of round ligament, nervous filaments, and middle 
 terminal libres of round ligament descending into pudendal sac. (Savage.) 
 
 reverse this order. As it emerges from the external rino; the Umamentiim 
 rotuiidiim has the same coverings as the cord in the male, with the 
 exception of the cremaster muscle — viz. the integument, superficial 
 fascia, intercolumnar fliscia, transversalis fa.scia, and, lastly, the sub- 
 peritoneal fat. In fat subjects the areolar tissue around the ring may 
 be so loaded with adipose that it is difficult to distinguish the ligament ; 
 moreover, its size, color, consistency, strength, the point at which it 
 splits up into its terminal fibres, — all of these are subject to normal 
 variations, as the writer has satisfied himself by dissections and opera- 
 tions on the cadaver. 
 
 The genital l)raneh of the genito-crural nerve lies first to the outer 
 side, and then in front of the ligament on its emergence from the 
 canal ; a little lower down is a plexus of small arteries and veins, 
 among Avhich are several nerve-filaments. The va.scular supply of 
 the cord is derived from several sources. Near the uterus it receives 
 
 ' " On the Structure and Use of the Ligamentiim Hotundum Uteri," London Philo- 
 soph. Trans., 1880, p. 515. 
 
160 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 a branch from the ovarian artery that enters the muscular substance 
 and extends in it along the inguinal canal ; at the internal ring it has 
 a branch from the deep epigastric which supplies the exterior of the 
 ligament and runs upward to reach the uterus, where it anastomoses 
 with a branch of the uterine artery. A corresponding vein runs with 
 the artery (Fig. 42). In addition, a plexus of veins from the pampini- 
 form surrounds the pelvic portion of the ligament and sends branches 
 along the canal. The lymphatics are derived from the uterine plexuses : 
 they surround the cord throughout its entire extent and terminate in the 
 superficial inguinal glands. The upper portion of the ligament receives 
 sympathetic nerve-filaments from the same plexuses that supply the 
 muscular substance of the uterus, while the genital branch of the 
 genito-crural sends filaments to its terminal portion. 
 
 Steuctube. — The basis of the ligament is a firm fibrous tissue 
 which we may trace either from the uterus downward^ or from the 
 mons and borders of the external ring upward. Xear the uterus the 
 ligament has a well-marked covering of smooth muscular tissue, 
 derived from the superficial uterine layer. This covering persists as 
 far as the internal inguinal ring, beyond which point it is not easily 
 distinguishable. Rouget claims to have found striated muscular fibres 
 in the areolar tissue covering the lower end of. the ligament ; he says 
 that they are derived from the transversalis muscle. Sappey says that 
 " striated fibres come from the lower part of the inguinal canal and from 
 the pubic spine, and ascend to the uterus, but generally disappear at the 
 level of the superior strait." These, he affirms, are surrounded by the 
 layer of smooth muscle derived from the uterus, " like the sleeve of a 
 coat." The peritoneal envelope of the ligament, as was stated, is 
 usually wanting below the internal ring. 
 
 The anatomy of these cords has attracted considerable attention in 
 connection with Alexander's operation. They are more developed in 
 multiparse, as they increase in size during pregnancy and do not return 
 to their original size after delivery. The amount of " slack " of the 
 ligament — if it may be so expressed — allows it to be drawn out of the 
 external ring to the extent of three or four inches. The relations of 
 the intrapelvic portion of the ligament to the peritoneum are import- 
 ant ; the latter envelops the cord as far as the internal ring, or forms 
 a sheath for it throughout the canal (as the canal of Xuck). Fortu- 
 nately, this peritoneal sheath can be stripped off quite readily if it is 
 drawn throug'h the external rino; with the cord. 
 
 The appearance of the round ligament, as exposed in the incision for 
 Alexander's operation, varies greatly, being sometimes a prominent red- 
 dish cord, at others a bundle of indistinct, scattered fibres. In ver\' fat 
 subjects, in whom the external ring is filled with a mass of adipose 
 tissue, the difficulty is obvious. It should be observ^ed that the guide 
 
I'ALLoi'iAS rrnics. li;i 
 
 to tilt' li^aiiicnt is tlic (■xtciiiiil riii^-, wliidi is fiiiiiid afcmdiii^- to tin- 
 usual uictliod, tlu' j)ul)ic s|)iu(' scrviuji; as the sur;j:ical laudiuark. Tlic 
 l)lo(«l-V('ss('ls wliicli acconi|)auy tlic ('»)r(l may lead to its idcntilic^ation 
 in caaes of" doubt. 
 
 The Uterine Appendages. 
 
 ITiidor the term "uterine a|)j)endau('s " most writers include both 
 the tubes and the ovaries. A\'e shall adopt the ordinary .surjxical 
 phraseology, reminding the reader, however, that the relations of the 
 two organs to the uterus arc essentially diiferent. The tubes are the 
 true " appi'udages," in the sense that they are originally develojied 
 from the uterus and represent the continuation of that organ ; the 
 ovaries, on the contrary, are developed inde])endently of the womb, and 
 have no direct connection with it. 
 
 Fallopian Tubes. 
 
 Synonyms. — Oviducts, uterine tubes ; Gr. uazspoad/.-r/yzz ; Lat., 
 tub?e Fallopianoe, oviductus muliebres, cornua uteri, vasa dcferentia 
 mulicris, etc. ; Fr., trompes Fallopiennes, on uterines ; Ger., Eileiter, 
 Muttertrompete ; It., trombe di Fallopio ; Sp., trompas dc Falopio. 
 
 Defixitiox. — Two sinuous tubes, of varying dimensions, which 
 extend outward from the superior angles of the uterus along the upper 
 borders of the broad ligaments, almost to the edges of the pelvic brim. 
 
 The tubes vary in length from three to five inches, the right being 
 slightly longer than the left and lying a little lower in the pelvis. 
 Their general direction is first directly outward, then backward and 
 inward, so that each tube has been compared to a shepherd's crook. 
 Three portions are presented for study — the isthmus, ampulla, and 
 fimbriated extremity. The isthmus is the narrowest ])art of the tube, 
 immediately adjacent to the uterus, and is about an inch in length ; it 
 extends from the ostium intermuu through the uterine wall at the 
 cornu, and then directly outward to the ampulla. It is of a firm, cord- 
 like consistency, and has a diameter of about three millimeters. The 
 lumen is extremely small, only admitting the finest bristle. The ampulla 
 is the outer dilated portion of the tube, its direction being outward, then 
 forward and downward. The diameter varies from six to eight milli- 
 meters, while the lumen expands to a diameter of two or two and a 
 half millimeters. The fimbriated extremity (infundibukmi, pavilion) 
 is a funnel-shaped expansion surrounded by a fringe of peculiar fleshy 
 processes (fimbri;^), which recall in a striking manner the tentacles 
 of a sea-anemone. The larger processes (four or five in number) 
 are known as " primary " fimbrife ; others, which arise from the 
 
 Vol. I.— 11 
 
162 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 primary, are called "secondary" fimbriae, and vary in number from 
 eight to ten. The longest of the former lies to the inner side of the 
 ostium, and is attached to the outer end of the ovary (fimbria ovarica). 
 It forms a groove terminating at the ostium. A small fibrous band, 
 stretching from the infundibulum to the lateral wall of the pelvis, i& 
 known as the infundibulo-pelvic ligament. 
 
 The tube has two openings — an internal or uterine, which is found 
 at the superior angle of the uterine cavity, and is of very small size ;: 
 and a distal opening, the ostium abdominale, already described. Quain 
 states that " a second smaller fimbriated opening not unfrequently 
 occurs at a short distance from the main one." ^ 
 
 By making numerous transverse sections of the tube the lumen will 
 be seen to vary in diameter at different points, the narrowest part being 
 at, or near, the uterine opening. Remaining of nearly constant size as 
 far as the middle of the isthmus, it then expands suddenly toward the 
 ampulla, where it becomes large enough to admit an average uterine 
 sound. The distal opening is only apparently larger because of the 
 distensibility of the tube at this point. 
 
 Anatomy. — ^a. Gi^oss. — The tube is essentially muscular in its 
 structure, resembling closely the uterus, from which it is an out- 
 growth. Beneath the serous covering is an outer longitudinal layer, 
 derived from the external muscular stratum of the uterus, and an inner 
 layer of circular fibres which forms the direct continuation of the 
 inner uterine layer. Lining the interior of the tube is a thick layer 
 of mucous membrane, which, being very vascular, is normally of a 
 rosy-red (?) color. After a careful examination of many healthy 
 and diseased tubes immediately after their removal, with a view ta 
 determining the normal appearance of their lining membrane, the 
 writer has come to the conclusion that it is extremely difficult to 
 decide this question. In every case in which a ligature is placed 
 around the proximal end of the tube the mucous membrane of the 
 excised portion beyond the ligature is so congested that it appears of 
 a dark-red or bluish color ; the same hue is observed in the tubes of 
 women who have died suddenly during menstruation. On the other 
 hand, in specimens removed from the cadaver the membrane is cer- 
 tainly much paler than it is during life. This fact is of importance 
 in connection with the diagnosis of " catarrhal salpingitis," one which 
 is frequently made at the present day by laparotomists. 
 
 The membrane is disposed in the isthmus in the form of single 
 longitudinal folds, which in the ampulla assume a more complex 
 structure that is best studied in a cross-section of the tube, observed 
 under a low power of the microscope. Springing from the primary 
 rugse are numerous secondary and tertiary folds, which present an 
 1 Anatomy (9th ed.), P- 713. The writer has never observed this anomaly. 
 
FA LI. on A. \ rrni'js. 
 
 163 
 
 a|)|)<:ii;iiicr aliiiost idciit ir:il with that of a scH-timi made tlii-(»ii;xl> ''"' 
 wall t»t' a |)r(ilircratiii!j,- ovarian cyst, ircmiiii^^ says tiiat lie has 
 CDuntcd iVoin thiVL- to li\<' primary I'olds and from ei^ht to ten 
 smaller j)li<';e "between cadi pair of the foi'nici-." This statement is 
 somewhat obscure, but the aiithoi- probably means that these smaller 
 folds sprin<i; from the surface of tlie uuicous mend)i'ane, and not from 
 
 Fi(i. 54. 
 
 Section through Ampulla (Luschka), under low power: a, submucous layer; b, muscular layer; 
 c. serous coat ; d, mucous membrane ; e, e, vessels ; 1, 1, small xjriinary folds ; 2, 2, larger 
 longitudinal and accessory folds ; 3, 3. small folds united, forming canaliculi. 
 
 the larger projections. There are no rugae in the intramural tract of 
 the tube. The dendritic arraug-ement becomes less marked toward 
 the fimbriated extremity, where the longitudinal folds are quite dis- 
 tinet to the naked eye. 
 
 The surface of the mucosa is covered normally by a thin layer of 
 grayish mucus, Avhich has a distinct alkaline reaction. The variations 
 in the amount, color, and viscidity of this mucus cannot be definitely 
 stated, and constantly give rise to loose diagnoses of " catarrhal salpin- 
 gitis." In spite of Bandl's assertion, that he had found catarrh of the 
 tubes in more than half of the specimens that he had examined, the 
 writer believes that one is unwarranted in assuming the presence of a 
 pathological condition of the tubes because of a slight congestion and 
 ^ Krankheiten der Eileiter und die Tubarschwangerschaft, Stuttgart, 1876. 
 
164 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 increase in the amount of mucus, both of which occurrences are nor- 
 mal during menstruation. Certainly, no one is justified in making 
 the diagnosis of catarrhal salpingitis simply from a gross inspection 
 of the organs.^ 
 
 B. Minute. — By a comparison of cross-sections of the tube made at 
 different points it will be apparent that its wall is not of the same thick- 
 ness throughout. The serous covering extends over the entire tube, 
 ceasing at the ostium abdominale, where it is directly continuous with 
 the mucous lining of the fimbrise ; the transition from the flat cells of 
 the peritoneum to the ciliated columnar epithelium of the mucosa is 
 quite abrupt. The peritoneal covering of the tube is strengthened by 
 an increase in the usual amount of fibrous and elastic tissue, and con- 
 tains a rich capillary network, which can readily be demonstrated with- 
 out special injections. 
 
 The muscular coat of the tube is much thicker in the proximal than 
 in the distal half. The internal, or circular, layer is especially devel- 
 oped at the uterine opening, Avhere a collection of fibres has been 
 described under the name sphincter tubse.^ In a cross-section the 
 outer muscular stratum will be recognized by the presence of the divided 
 spindle-cells, the inner by the groups of cells that are arranged in rows 
 parallel with the circumference of the tube. As in the uterine wall, the 
 circular layer contains the principal vascular plexuses ; the divided ends 
 of the arteries and the large gaping veins, surrounded by their zones of 
 fibrous and muscular tissue, present appearances quite similar to those 
 in the uterus. In addition to the smooth muscle, there is a consider- 
 able amount of connective tissue in the tubal wall, which is distrib- 
 uted between the bundles of muscular fibres around the vessels and 
 beneath, as w^ell as in, the mucosa. Klein appears to regard the long- 
 itudinal stratum as essentially fibrous in character, with a few scat- 
 tered bundles of smooth muscles. 
 
 The mucous membrane of the tube resembles that of the uterus in 
 possessing no well-marked submucosa. Its relation to the subjacent 
 muscle is not so intimate as in the body of that organ, but is more 
 like that of the cervical canal. Although they contain a considerable 
 amount of fibrous tissue, the plic£e in the tube are not so essentially 
 fibrous in their structure as are those forming the arbor vitae. Under 
 the microscope the membrane is seen to be covered by a single layer 
 of ciliated columnar cells, beneath which are two or three supporting 
 layers of cells round and pyriform in shape. The cilia are best 
 observed in fresh scrapings of the interior of the tube. They 
 are frequently observed moving (although slowly) four or five 
 hours after the removal of the tube from the living subject. Their 
 limited vitality in these cases is perhaps due to the effects of the 
 1 Comp. Bandl [op. ciL), p. 8. ^ Ibid. {op. dt), p. 2. 
 
rALLoi'iAS rrnKS. lOo 
 
 etlu'r-nart'osis, -iiicc that (lni<: is well kiidwii to Iw liarnif'iil to tlu'tu.' 
 The |)i-t'S('iict' ol' its intact liiiiiijr cjiitlicliiiiii, and tlic )Ki*sist<'iH'(' an<l 
 inotioii (»r tlu' jH'i"islial>Ic cilia, arc prool' |)(>>itivc that no inflainniatory 
 process is present in a tiilic. Moreover, the proj^cnoe ol* small collec- 
 tions ol" nuicns-corpnscles on the i'vw siirlace of the mucosa d(x*s not 
 justitV the inference that :i catarrhal condition is present. The 
 mucous menihrane is (piite vascular. Sections through the plica? 
 show that they contain loops of" vessels as well as large lymj)h- 
 spaces. 
 
 The arterial su] »]ily is derive<l from the spermatic (ovarian) arter}', 
 the distribution <»f the branches l)eing as follows : As the arterj' enters 
 
 Fig. 55. 
 
 Section of the Tube, showing Lymph-spaces (Savage). 
 
 the broad ligament, it gives off a special branch to the fimbriated 
 extremity and the outer end of the ampulla ; from the ovarian plexus 
 several small twigs run to the middle third of the tube ; while the 
 isthmus receives its supply by branches of the main artery and that 
 division of it which runs to the fundus uteri. The veins of the tube 
 enter the pampiniform plexus. The lymphatics unite with those from 
 the ovar}'. Xen'e-filaments reach the tube from the inferior hypogastric 
 plexuses : they have been traced into the mu.scular tissue, but the man- 
 ner of their ultimate termination is unknown. 
 
 The minute anatomy of the fimbriae is identical with that of the rest 
 of the tube, and does not require a separate description. The peritoneal 
 connections of the tube (mesosalpinx) will be described with the pelvic 
 peritoneum. 
 
 Practical Deductioxs. — The anatomical relations of the tube 
 enable us to explain the changes which take place as the result of 
 disea.se. Lying above the ovar}- and surrounding it, when the tube 
 becomes dilated (as in hydro, pyo-, ha?matosalpinx, or tubal preg- 
 nancy), it sinks, together with the former, to which it is adherent, to a 
 position behind and near the base of the broad ligament, where the 
 
 * This was first demonstrated by Lister i Laudois's Manual of Human PhysifAoyy, trans. 
 by Stirling, 1885, p. 614j. 
 
166 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 two form the characteristic sausage-shaped mass which is felt through 
 the vaginal fornix. The shape of this body and its position at the 
 side of the uterus serve to distinguish it to some extent from a pro- 
 lapsed ovary. The proximity of the small intestine explains the con- 
 dition which is commonly found on opening the abdomen in the per- 
 formance of Tait's operation, the tube, ovary, and intestine being 
 matted together by peritonitic adhesions firmly attached to the pos- 
 terior surface of the uterus or broad ligament. But the tube may 
 not be occluded ; its fimbriated extremity may be merely agglutinated 
 to the ovary as the result of a localized peritonitis. In that case there 
 will be no displacement, except of the distal extremity, which will be 
 drawn inward. The relations of the tube to the ovary are not altered 
 even when the latter becomes the seat of cystic degeneration. As is 
 well known, the tube and mesosalpinx are always found on the exte- 
 rior of the cyst. When the latter is intraligamentous — i. e. has grown 
 inward between the folds of the broad ligament — the tube will be 
 closely applied to the surface of the growth, no mesosalpinx being 
 present. If the cyst is parovarian, both tube and ovary will be 
 attached to the cyst. 
 
 The tube forms the principal portion of the pedicle, which is tied 
 before the removal of the aj)pendages, for whatever cause the operation 
 may be performed, hence its proximal portion possesses no little inter- 
 est for the laparotomist. It is usually tied about half an inch from 
 the uterus. There is no advantage in ligating closer to that organ ; in 
 fact, the ligature is liable to slip if the latter course is adopted. The 
 needle transfixes the mesosalpinx midway between the tube and the 
 ovarian ligament, the pedicle being tied in two parts, the upper con- 
 sisting of the tube, the lower of the ligament and the ovarian 
 vessels. 
 
 The continuity of the mucous lining of the uterus and tubes, and 
 of the latter with the peritoneum, suggests a direct channel for the 
 transmission of septic and specific infection, to which it is only neces- 
 sary to allude. The proximal opening of the tube is rarely much 
 dilated, even when the latter is greatly distended. Cases are on record 
 in which fluid injected into the uterus was supposed to have passed 
 through the tubes and into the peritoneal cavity, with fatal results. 
 It is difficult to see how this could occur during the use of a vaginal 
 injection ; and even supposing a fluid was injected into the uterine 
 cavity, and its exit through the cervix was prevented, it would require 
 a tremendous pressure to force it through the minute openings of the 
 tubes. In order to be on the safe side, the reader is advised to inject 
 fluids into the uterus only when he is sure that there is a free return- 
 flow. But the fear of an accident, which is certainly exceedingly rare, 
 should never deter us from the judicious use of intra-uterine injections 
 
OVARIES. 1G7 
 
 wlicii tlic-c ai'f indicatcil. ( 'ntlictcri/.iitioii ;iii<l cMiiIcri/atioii of llic tiihcs, 
 as j)rn|»(>si'<l l»v Tyler Smith and l''r(>ric|), arc dl" course of no practical 
 value, not to spcaU of the (lilliciihy and danger of the procedure. 
 
 Tiic auatoni\- of the I'^illopian liihes is not iininiporlant ])raclicall\'. 
 The muscular coat may hecome the seat ot" hypci'trophy (i'or which 
 condition Munde has su;;i>;ested the term " pachysalj)in^itis "), or it 
 may i)e u;rcatly thimicd when the tube is dilated by aoeumulatioiis (»f 
 lluid or the urowth of a misplaced ovum. Rupture in the latter case is 
 atti'uded by hemorrliai;e irom the vessels at the })lacental site, -which 
 is ofiten i'atal. 
 
 The dominant influence over menstruation claimed for the tubes by 
 Ml'. Tait gives them a far more important })osition physiologically 
 than they held a few years ago. Their highly congested appearance 
 during menstruation (especially marked in the mucous lining) must 
 not be mistaken for dlsca.se. The diagnosis of "catarrhal salpingitis/' 
 as before stated, is sometimes made on insufficient grounds, since the 
 mucous mendn'ane is normally quite vascular and is covered with a 
 layer of mucus. If moving cilia are found in a tube soon after its 
 removal, there can be no extensive inflammation of the mucosa. 
 
 Ovaries. 
 
 Synonyms. — Gr. wdpioa', Lett., ovaria, testes mnliebres ; Fr., 
 ovaires ; Ger., Eierstocke ; It., ovaje ; Sj)., ovarios. 
 
 Definition. — The ovaries are a pair of small oval bodies situated 
 on either side of the uterus, in the posterior folds of the broad liga- 
 ments, below the distal extremities <tf the tubes.^ 
 
 Position. — The ovaries are situated normally either inmiediately 
 below the plane of the pelvic brim or partly above and partlv below.- 
 The true position of the vertical axis of the ovaiy has formed the sub- 
 ject of no little controversy. Olshausen maintains that it extends out- 
 ward and backward, forming with the transverse axis of the uterus an 
 angle that opens backward. Hasse, on the contrary, believes that the 
 direction of the axis is outward and forward. Kolliker describes the 
 axis as parallel with tlie iliac vessels, and figures the ovary as not only 
 occupying an oblique position with regard to the uterine axis, but as 
 being also tilted in such a manner that its surfiices look inward and 
 outward and its rounded border iipward and fonvard. Scludtze fig- 
 ures the ovarv with its long axis at right angles to the transverse axis 
 
 ^ Small accessory ovaries have been observed bv Hermann, Beisl, De Sincty, and 
 othei-s. These are probably not separate organs, but rather detached portions of 
 •ovaries, the anomaly bein.c: explained by irregularities of development. 
 
 - One-half of the ovary is above the plane of the brim, according to Hart and 
 Barbour. 
 
168 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 of the j)elvis, while His even insists that it occupies normally a vertical 
 position, its rounded border looking directly backward. The writer 
 has never been able to satisfy himself that the normal position of the 
 organ is the one last mentioned, and that it is not the result of some 
 previous localized inflammation resulting in the formation of slight 
 adhesions, such as are more often present than absent in subjects exam- 
 ined at the autopsy-table. In fact, it is hardly possible to affirm dog- 
 matically that a certain position of the ovary is normal, and that all 
 other positions are abnormal, any more than this can be urged of the 
 uterus. The ovaries are certainly not fixed organs, and are subject to 
 normal variations in their position, although within circumscribed limits. 
 The reader may content himself with the statement that the axes of the 
 organs do not lie exactly in the transverse axis of the pelvis, but slightly 
 oblique to it, while at the same time there is a nutation, or inclination 
 forward. 
 
 Relations and Attachments. — The ovary may be regarded as 
 lying in the plane of the pelvic brim. It is described by Spencer 
 Wells as situated in a depression in the posterior fold of the broad 
 ligament ; perhaps it would be more correct to say that it lies in front 
 of it, being attached by its anterior border or hilum to the anterior 
 fold. In front is the anterior fold of the broad ligament, separated 
 from the ovary, except at the hilum, by a plexus of vessels and nerves. 
 The round ligament also crosses in front of the organ. Above and 
 somewhat in front is the Fallopian tube, separated from the ovary by 
 the mesosalpinx above and by the parovarium on the outer side. The 
 tube encircles the outer extremity of the organ, so that the fimbriated 
 portion finally lies below the convex border. The left ovary is in 
 contact with coils of small intestine (at least when the bladder is 
 empty) ; the right is in close relation to the rectum, especially when 
 the latter is distended. The inner extremity of the ovary is connected 
 with the cornu of the uterus by the ovarian ligament, a small fibro- 
 muscular cord about an inch in length, which springs from the lateral 
 border of the uterus immediately below the origin of the Fallopian 
 tube, and receives unstriped muscular fibres from the external laj-er of 
 the uterus, and fibrous tissue from the tunica albuginea of the ovary. 
 It lies in the posterior fold of the broad ligament, and receives a com- 
 plete peritoneal investment. Hart and Barbour regard it as simply a 
 " longitudinal fold of the peritoneum, into which the unstriped mus- 
 cular fibre of the uterus is prolonged." The upper border is continu- 
 ous externally with the ovarian fimbria which connects the ovary with 
 the infundibulum. The lower border is continuous with the infun- 
 dibulo-pelvic ligament. 
 
 The ovary is usually designated as an oval body. It is more 
 properly described as a ''flattened ovoid," one-third of one lateral 
 
OVMUKS. !<;!> 
 
 S^iiu'iit <»t" wliicli i> rcphifcd hy :i >lr:iiL:lit side (S|)(ii(rr Wells), the 
 l)rt)a(l, roiiiidi'il cikI Ix'iiij:,- dinctiMl oiitwai'd, w Idle tlic siiiallcr, j»(»iiitc<| 
 t'Xtremity oxtcud.s toward the iitt'ius. Both tlic antrridi- and j)(»tcri<jr 
 .surfui-os are convex, the latter beinj^ the hroadci- and more rounded of 
 the two. The nru-au is siihject to many variations in shape. It may 
 he tusitorm, «i;lobnlar (like an oI)I;it<' spheroid), di-f<»id. or dl" a --frictlv 
 oval form. 
 
 The size varies with the a«2;e of the subject, the lunctional a<tivity 
 of the or«::an, the; <x-eurrence of menstruation, pregnancy, etc Accord- 
 injs: to Hennino;, the ovary attains its largest size six weeks after par- 
 turition, when its ordinary dimensions (especially its length) may l>e 
 doubled, and it never returns to its original size after involution. After 
 the menopause the organ shrinks to one-half, or one-third, of its dimen- 
 sions during sexual activity, and assumes a somewhat fusiform shape; 
 The average measurements given by Farrc are : Length, 1^ inches, 
 width, \%i\\^ of an inch, thickness, 1 inch. Luschka states that the 
 average is : Length, 4 centimeters, width, 2.2 centimeters, thickness, 
 L3 centimeters. The weight of the normal ovar^^ varies from 60 to 
 135 grains, the average weight in a healthy nullipara being 87 grains. 
 
 The color of the ovary is well described by Tait as '^ a pinkish, 
 pearly hue, with here and there a hazy blueness showing through the 
 tissue, when a follicle is either getting ready for the discharge of its 
 nucleas or is disappearing after having fulfilled its function."^ This 
 description applies rather to the quiescent organ in the virgin or young 
 nullipara. During menstruation it appears of a darker hue, w^hile the 
 ripe Graafian vesicles assume a purple color, which changes to a dark- 
 red or brown after the discharge of their contents ; yellowish spots rep- 
 resent so-called corpora lutea. After the menopause the ovary becomes 
 of a whitish color and almost cartilaginous consistence. Before puberty 
 its surface is uniformly smooth, but as menstruation occurs it becomes 
 covered w'ith depressions and cicatrices, marking the sites of the ruptured 
 vesicles, until the senile organ is transformed into a hard, irregular mass 
 of scars and nodules. 
 
 Anatdmy. — A. Gross. — In approaching this subject, it may be well 
 to remind the reader that much confusion exists at the present time with 
 regard to Nvhat constitutes a perfectly normal ovar}'. Judged by the 
 ordinary standards of anatomical normality, such an organ is rarely 
 found either in the dead-house or at the operating-table. Even when 
 it appears on gross inspec-tion to offer no departure from the normal, 
 histologically there may be found in an ovars' changes that would be 
 regarded as j^athological if fi)nnd in other organs. On the other hand, 
 ovaries that are apparently the seats of degenerative changes may dis- 
 charge their functions so ]>erfectly as to satisfv the demands of all except 
 
 ' Discfises of the Ovaries (4th ed.), p. 5. 
 
170 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 the ardent laparotomist. In other words, the boundary between the 
 normal and pathological is not a fixed one, and in spite of numerous 
 careful studies of the subject there yet remain many mooted jDoints. 
 Many of the classical drawings that have been copied by several gen- 
 erations of writers are largely diagrammatic, having been constructed 
 as the result of careful comparisons instituted between sections of the 
 human ovary and those of the lower animals, especially the cat. This 
 caution may serve to soften the disappointment experienced by the 
 student after his repeated failures to hit upon sections that correspond 
 exactly with the familiar illustrations of the textbooks. The micro- 
 scopist who succeeds in determining to what extent an ovary may con- 
 tain cysts without being " cystic," and just how much fibrous tissue 
 must exist in its stroma before the diagnosis of " cirrhosis " is justi- 
 ciable, will deserve no little praise. 
 
 In describing an ovary we may consider its extremities, borders, and 
 surfaces, -two of each. The inner extremity, which is distant about an 
 inch from the uterus, is long and pointed, and tapers gradually into the 
 ovarian ligament. The outer is thickened and rounded, and is situated 
 more posterior, with reference to the transverse axis of the pelvis, than 
 the inner ; to it is attached the fimbria ovarica before mentioned, which 
 is sometimes regarded as one of the ovarian ligaments. 
 
 The borders of the ovary are designated " upper " and " lower," and 
 its surfaces "anterior" and "posterior." Considering the true position 
 of the organ, it is more correct to reverse the terms, the surfaces being 
 termed upper and lower. The posterior border is convex, and is free, 
 or not covered by peritoneum ; the anterior is straight, somewhat flat- 
 tened, and is attached to the posterior fold of the broad ligament. It is 
 known as the hilum, and is the portal through which the vessels and 
 nerves of the organ enter. The superior surface is nearly flat, and 
 looks upward and forsvard, while the posterior is decidedly convex 
 and is directed downward and backward. 
 
 On making a longitudinal section of an ovary from a healthy adult 
 there will be presented two zones of tissue — a central and a peripheral. 
 The former has a jjinkish-gray or even rosy hue, is of soft consistence, 
 and has a moist, glistening appearance. The peripheral zone is white 
 or grayish-Avhite, and has a firm, semi-cartilaginous (or, more properly, 
 ligamentous) structure. The former is evidently well supplied with 
 vessels, especially near its margin, while the latter seems to be non- 
 vascular. A closer examination of the cut surface will reveal the 
 presence of numbers of small pits and vesicles of variable size, those 
 near the periphery being the smallest as well as the most numerous ; 
 imbedded in the central portion of the surface are several of these 
 cystic bodies of much larger size, while in the peripheral zone are a 
 few vesicles, the size of small peas, which are filled with clear fluid. 
 
OVMllES. 
 
 171 
 
 The latter hodics piMJcct iiutrc (ir less :il)ov(' the lire stirfiuT of tli<" 
 ovary, and (Hic oi- two of tliciii will f^cnerally l)e ho (liHtcnd('<I with 
 lluid and tliiii walls tliat tlicy rnptun' on tlio application of sli;;lit 
 pre.ssurc. In tlio }K'riplu'rv will also he seen the remains of" rnj)tnre<l 
 ovisacs in all stages of retrogiiule metamorphosis, from a hlood-clot 
 to a firm, hloodloss cicatrix. The general disposition of the hands (»f 
 fibrous tissue in the stroma are also evident to the naked eve, although 
 
 Fig. 56. 
 
 Section of the Ovaiy of an Adult Bitch : a, germ-epithelium ; h, egg-tubes ; c, c, small follicles ; 
 d, more advanced follicles; e, discus proligerus and ovum; /, second ovum in the same 
 follicle (this occurs but rarely; ; g, outer tunic of the follicle ; h, inner tunic; i, membrana 
 granulosa ; k, collapsed retrograded follicle ; I, blood-vessels ; m, m, longitudinal and trans- 
 verse sections of tubes of the parovarium; y, involuted portion of the gcrm-cpithelium 
 of the surface ; z, place of the transition from peritoneal to germinal or ovarian epithelium- 
 (Waldeyer.) 
 
 the more complex interlacement i.? only apparent under the microscope. 
 These fibres not only radiate in all directions from the hilus, hut also 
 surround the ovisacs and vessels. The vascular richness of the organ 
 is best appreciated in injected specimens, but the divided ends of 
 
172 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 numerous arteries will be seen on the cut surface of the ovary even 
 in its natural state. 
 
 B. Minute. — The microscopical anatomy is so important that the 
 writer feels justified in devoting to it what may seem like a dis- 
 proportionate amount of the limited space at his disposal. 
 
 Three points are presented for study — the exterior of the ovaiy, the 
 fibrous (or fibro-muscular) tissue, and the Graafian vesicles. The exter- 
 nal covering is best observed in fresh preparations that have been 
 specially stained. Contrary to the opinion of Waldeyer, Leopold, 
 Klein, and many other microscopists Avho have carefully investiga- 
 ted the matter, Mr, Tait confidently affirms that " the posterior sur- 
 face, when treated by silver and other staining methods, displays 
 the same stomata and stigmata as does the anterior surface" — in 
 short, that the ovary is entirely covered by a layer of peritoneum, 
 the presence of which on the posterior surface can be recognized by 
 finding the scpiamous epithelium which is characteristic of that 
 membrane.^ 
 
 Without entering into a discussion in which the weight of evidence 
 is decidedly against the writer just quoted, it may be stated that most 
 authorities are in accord in the belief that the free surface of the organ 
 (i. e. the posterior surface, which projects beyond the hinder fold of 
 the broad ligament) is covered by a single layer of short columnar 
 epithelia, which has received from Waldeyer the name '' germinal epi- 
 thelium," because, in his opinion, the primitive ova are developed from 
 it, the young ova themselves being represented by the occasional 
 large spheroidal cells with prominent nuclei which are observed 
 amonff the columnar cells.^ These are most numerous in the ovaries 
 of young girls, in which ingroT\i:hs of the germ-epithelium into the 
 miderlying stroma are sometimes seen (ovarial tubes of Pfliiger). 
 At the attached border of the ovary (the so-called " white line ") there 
 is an abrupt transition from the columnar to the squamous epithelium 
 of the peritoneum. 
 
 The epithelial layer rests directly upon the tunica albuginea, a thin 
 layer of condensed fibrous tissue containing a small number of smooth 
 muscular fibres ; although this capsule is quite sharply diffi?rentiated 
 from the underlying stroma, the two are inseparable. The albuginea 
 does not become completely developed until the third year. It under- 
 goes changes corresponding with the age of the subject, becoming, 
 as the result of prolonged" ovulation and senile atrophy, so dense as 
 to resemble fibro-cartilage. This physiological change is undoubtedly 
 often regarded as pathological by superficial observers. Henle ^ states 
 
 ' Op. eif., p. 6. 
 
 nValdever, EierstocJc u. Ei, Leipzig, 1870; also Sirickei^s Hmidhuch, p. 545. 
 
 ^ Handhuch der Eingeiceidelehre. 
 
OVA III KS. 
 
 17:; 
 
 that ill man tlirt'c separate layi'rs arc (listiii'^uisliahlc in the allniirinca, 
 tlic til)n's of tin- oiitci- and inner li('in;j; lontiitndinal, wliilt- tliii.-c (»t' tlic 
 inidtllc lavcr have a circnlar direction. 
 
 Tlic ovarian stroma oi" |»arcncli\ ma i> <lividi'd into two zones — an 
 outer ""ravisli i-ortical (|iai"cncli\ iiial zone), and an inner pinki-li niediil- 
 
 Tn; 07. 
 
 Longitudinal Section of the Ovary, under a low power (Henle) : 1, albuglnea ; 2, fibrous layer of 
 cortical portion ; 3, cellular layer of cortical portion ; 4, medullary substance ; 5, loose con- 
 nective tis.sue between the firm medullary layers. 
 
 larv (zona vasculo.sa). There is no essential diiference between the 
 structure of the two, except that the latter is softer and more vascular. 
 The cortex is composed of bundles of connective ti.ssue, among 
 which are scattered ela.stic and mu.scular fibres ; imbedded in the ti.s- 
 sue are numbers of Graafian vesicles of the smallest size. Under tlic 
 micro.scope the cortical zone presents an outer layer (called l)y Henle 
 the "fibrous" layer), in which the fibrous tissue is firmer than in the 
 deeper portion, the bundles of fibres forming; a dense network. In 
 the deejier ]iart of the cortical zone the connective tissue is looser and 
 has a radiating appearance from the centre toward the periphery'. A 
 curious feature of the tissue here is the presence in it (especially in the 
 vicinity of the vesicle.*) of numbers of cells, both round and fusiform. 
 
174 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 some of the latter possibly representing bundles of smooth muscle- 
 fibres. There was formerly much difference of opinion as to the sig- 
 nificance of these spindle-cells, many authorities denying that they 
 were fibre-cells. There is little doubt that the stroma contains a con- 
 siderable amount of muscular tissue, which is most abundant in the 
 neighborhood of the larger vessels. The majority of these fusiform 
 cells, which have prominent oval nuclei, doubtless belong to connective 
 tissue in an early stage of development. This inference is justified, 
 1, by the fact that the cells are, as a rule, shorter and broader than 
 the fibre-cells in the muscular strata of the uterine wall ; 2, by the 
 variable size of the cells, some of which are short and nearly oval in 
 shape, while others are long and tapering, showing that there is some 
 process of growth or development going on among them ; 3, the 
 cells are seldom arranged in groups, as in smooth muscle, but are 
 scattered throughout the connective tissue, to w^hich they bear an 
 intimate relation. Some authorities go so far as to say that all of 
 the spindle-cells in the stroma represent muscular tissue. Of the 
 round and polyhedral cells scattered throughout the stroma, some are 
 leucocytes, Avhile others come from the foetal Wolffian body and are 
 analogous to the interstitial cells of the testicle ; some of the round 
 
 Vertical Section through the Ovary of a newborn Infant (Waldeyer) : a, germinal epithelium -■ 
 6, ovarial tube; c, primitive ova; d, longer tubes becoming constricted to form Graafian, 
 vesicles ; e, large cell-nests ; /, isolated ovisacs ; g, g, blood-vessels. 
 
 cells, as well as the fusiform, undoubtedly belong to the young con- 
 nective tissue type. Into the cortical zone (in the ovaries of young 
 subjects) project those curious cell-columns before alluded to under the 
 name " ovarial tubes." They are simply ingrowths from the layer of 
 germ-epithelium, with which they are directly continuous. A detailed 
 
ov.mih's. 17-> 
 
 ilcscriptiiiii 111" tlioc Ix-luii^s ralliiT lo tlic |)i'<tviiicc of f'iiil)r\-((l(t;j;v.' 
 From tlic lai'uc inmilx'r ol" small ovisacs lliat cxi.-l in the <oi-tical 
 lavcr it lias Ih'cii called hy Sappc v roiir/ic oi'nji'ne. Hut not all of tlicsc 
 hodics (IcstTvc tlif name oliliaaHan vesicles, si m-c man\' ol'tiii'm irj»r»- 
 st'Mt miMviy collections of embryonal cells that have not yet reached 
 the diiiiiitv ol" Ihlly-rornied vesicles, while othei's an; p;ronj)s of f'attv 
 dejjenei'atcd cj)ithelial cells. The Nc^icles will he dcscrilKHl se|)aratcl\-. 
 The vascular supply ot'the cortex is not so rich as that ol' the medulla. 
 The lar<:-er and nie(lium-sized arteries are surrounded hy I'ascicidi of 
 elastic and muscular lihi'cs. Kach of the ovisacs is surrounded hv a 
 tine nctwoi'k of capillariis. 
 
 In the medullary portion of" the ovary the character of the stroma 
 iinderii;t)es a chan*>e ; it becomes looser and more vascular. Although 
 the tissue contains the same elements as in the parenchyma, the bundles 
 (»f liijrous and elastic tissue and smooth muscle-fibres are not so close 
 together, but interlace in all directions. The non-striped muscle may 
 be traced directly through the liilum (with the blood-vessels) into the 
 broad ligament. The bands of fibrous tissue also radiate from the 
 hilum, as well as the nerves and vessels. The blood-vessels of the 
 parenchyma are large and numerous. Entering the ovary at the 
 hilum, the arteries pursue a spiral course through the stroma, their 
 branches terminating in ca])illary networks around the vesicles. The 
 veins, which begin in small efferent twigs from the above-mentioned 
 plexuses, are tortuous like the arteries, and may be traced to the hilum, 
 M'here they leave the ovary to enter the bulb. The lymphatic supply 
 of the ])arenchyma is particularly rich. By means of j^'ojier injec- 
 tions the distribution is seen to be similar to that of the arteries and 
 veins. Each vesicle is surrounded by a fine network of lymphatics, 
 while the ultimate termination of the system is in the plexuses of the 
 broad ligament. As was stated before, both the arteries and veins 
 present an appearance on cross-section similar to that of the uterine 
 vessels. The lumina of the arteries are small in comparison with 
 their diameters, their fibrous and muscular coats being quite thick, 
 while the veins are imbedded in the fibrous stroma with which they 
 are surrounded. The smooth muscle-fibres are especially distinct 
 around the larger arteries. 
 
 The nerve-fil)res can be traced from the hilum into the stroma in 
 the vicinity of the larger vessels, but their ultimate endings in 
 man have not yet been described. Elischer of Buda-Pesth has 
 studied the ovaries of the lower animals with a view to settling the 
 question of the termination of the nerves. He states as the result 
 of his observations that medullated fibres after entering the hilum 
 
 ' Vidp F. M. Balfour, Treatise on Comp. Embryology. Quaiu {Anat., 9lh ed.) gives a 
 full bibliography. 
 
176 THE ANATOMY OF THE FE3IALE PELVIC ORGANS. 
 
 brauch iu a dichotomoiis manner, and lose their medullary sheath 
 when they reach the neighborhood of the vesicles, around which they 
 form looiJS. The larger the vesicle, the more distinct is its nervous 
 plexus ; a fine secondary network arises from the primar}'- filament and 
 rests upon the outer layer of the membrana granulosa. The same 
 observer claims that he has traced the terminal fibrils to the cells of 
 the granular layer, where they probably end in the nuclei. The larger 
 vessels, he says, are also surrounded by plexuses of nerves. 
 
 Graafian Vesicles. — The stroma of .the ovary constitutes merely the 
 framework or bed in Avhich rest the ovisacs. The former may be said to 
 exist simply for the nourishment of the latter. In order to under- 
 stand properly the nature of these important bodies, it will be necessary 
 to trace briefly their development and ultimate fate. For details the 
 reader is referred to works on embryology. 
 
 Whether the vesicles are formed from ingrowths of the germ-epithe- 
 liiun, according to Pfliiger's theory, or, per contra, by outgrowths of 
 the stroma into the epithelial layer, as Balfour believes, or, as Klein 
 suggests, by " mutual ingro^^i:h " of both epithelium and stroma, cer- 
 tain it is that at an early stage in foetal life groups of cells undergo a 
 special differentiation. Some of these cells become enlarged and their 
 nuclei prominent, forming the primitive ova, while others of the same 
 group remain as the membrana granulosa. In the ovary of an infant 
 there is seen immediately beneath the tunica albuginea a granular 
 layer which, when examined under a low power, appears to be filled 
 with minute bodies that represent immature vesicles ; still deeper in the 
 substance of the organ are larger vesicles containing ova. Toward 
 the time of puberty these latter vesicles increase in size and advance 
 from the deeper part of the stroma into the cortical zone. They con- 
 tinue to enlarge, make their way through the albuginea (the tissue of 
 the latter becoming atrophied), and form small projections on the sur- 
 face of the ovary. The fluid contents of the vesicle increase, its wall 
 becomes thinned, especially at one point, toward which the vessels run 
 (stigma), and ultimately rupture takes place. 
 
 The mature vesicles vary greatly in size, the largest being about 
 2^th of an inch in diameter, while the smallest may not exceed yo¥*^^ 
 of an inch. Each vesicle has an external covering of connective tissue 
 (tunica fibrosa, theca folliculi externa of Heule) which may be sep- 
 arated into tw^o layers — an outer, containing the vascular plexuses 
 before alluded to, and an inner, in which are the delicate capillaries 
 that supply nourishment to the ovum. The external stratum is merely 
 a condensation of the stroma, and hence in it are seen numbers of the 
 spindle-cells that fill the tissue of the former ; the inner is more com- 
 plex in its stracture, and contains a variety of cells, round, polygonal, 
 stellate, and fusiform. The round cells possess the amoeboid propeiiy 
 
OVARIES. 177 
 
 (tl' li'iicoc'vtes. The iiiiiucdiatc lining- dI" the vesicle is a laver of Hal 
 eells witli siiiirle oval iiiielei, external to wliidi is a layer ttl' enlmmiar 
 epitlielia. The latter rest ii|)()n a delicate stratum lA' c<jmieetiv<' tis>iio 
 known as the menibraiui pr()j)ria. The interior of the ovisac is mostly 
 filled l)V a clear alhuiniiiuiis lluid, in which float a few fatty particles 
 and eells (liijnor f'oUieidi), while at one side of the cavity (<j:enerally 
 that most removeil from the surface of the ovary) there will he seen 
 a delicate transparent body — sometimes two, rarely three — snrroinide<l 
 by a collection of cells from the membrana granulosa, called the discus 
 proligerus. The cells forming the latter have been divided into two 
 layers — the "eg<i-ei)ithelium," that lies adjacent to the ovum, and the 
 " follicular epithelium," which is external to the former. 
 
 The ovum itself has been aptly called " a typical cell." It is a yel- 
 low, spherical body having a diameter of about ^^jyth of an inch, sur- 
 rounding which is a thin hyaline membrane (vitelline membrane, zona 
 pellucida), which is doubtless formed from the innermost cells of the 
 discus proligerus. Within the zona pellucida (in which fine pores 
 have been described) is the vitellus, a mass of granular fibrillated 
 protoplasm containing numerous fat-globules, the central portion of the 
 protoplasm being less opaque than the peripheral. Somewhere on the 
 outer edge of the central zone of the vitellus is a light spot, which 
 under a high power appears as a delicate network of fibrillated proto- 
 plasm, in the meshes of which is a quantity of finely granular material, 
 the whole being enclosed in a distinct membrane (nucleus or germinal 
 vesicle). AVithin the latter is a small, highly-refracting granular 
 body (nucleolus or germinal spot), not over g-g^g-jjth of an inch in 
 diameter, which occupies the same relative position to the contents of 
 the vesicle that the latter does to the interior of the ovum. A\"hen 
 strongly magnified the nucleolus appears only as a mass of finely 
 granular material. This brief description applies to a mature ovisac, 
 such is as seen at the periphery or on the surface of the ovar\\ 
 Between these and the undeveloped vesicles (ytoT^^^ ^^ ^° ^^^^^ "^ 
 diameter) there are ovisacs of various sizes and forms. In the small 
 and medium-sized ones the cavity is entirely filled by the o\'um. As 
 the vesicles increase in size the latter becomes larger and occupies a 
 relatively smaller portion of their interior, while the zona pellucida 
 becomes thicker. 
 
 It is impossible in this place to study the interesting subject of the 
 degeneration, or arreste<l development, of the ovisacs. Doubtless the 
 small, irregidar collections of epithelial cells scattered about in the 
 stroma, the localized thickenings of the latter (not unlike cicatrices in 
 their microscopical structure), and other anomalous appearances fre- 
 quently described as pathological, all represent the remains of Graaf- 
 ian bodies that have perished, as it were, in the midst of the stroma, 
 
 Vol. I.— 12 
 
178 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 without ever coming to maturity or being able to reach the surface. 
 The mere mention of these facts will serve to indicate to the reader 
 the possibilities that lie before the original worker.^ 
 
 In considering the unruptured vesicle and its contents we have 
 referred only to the initial period in its history. If such a vesicle be 
 examined just as it is on the point of rupturing, it will be found to be 
 distended to its utmost capacity, while over its thin, transparent wall 
 run engorged capillaries. Immediately after rupture the cavity is filled 
 with coagulated blood derived from the torn vessels. A few weeks 
 later the periphery of the clot has become of a yellowish color, while 
 its centre has more of a reddish-gray hue. The walls of the cavity 
 contract, compress the clot, and thus throw the yellow zone into the 
 convolutions which are so familiar to every one. The mass is now 
 known as the corpus luteum. The yellow ring increases in width, 
 gradually encroaching upon the central portion, until almost the entire 
 mass becomes yellow. As viewed under the microscope the change 
 may be briefly explained as follows : The original peripheral zone of the 
 corpus luteum consists of fatty degenerated cells from the membrana 
 granulosa, into the midst of which penetrate offshoots of fibrous tissue 
 and capillary vessels derived from the wall of the ovisac. In the centre 
 of the clot there will be seen many large pigmented cells and crystals 
 of hfematoiclin, together with newly-formed blood-vessels. Ultimately 
 the pigment disappears, and the fatty cells (which give the yellow tinge 
 to the mass) encroach upon the central zone until it loses its original 
 appearance entirely, and is represented by a small quantity of mucoid 
 tissue. The final stage of retrogression is the transformation of the 
 cells into a mass of fat-globules, the vessels disappearing. The fat is 
 then absorbed, the surrounding fibrous tissue contracts, and a white 
 depressed cicatrix (corpus albicans) alone remains to mark the site of 
 the former vesicle. If the ovum from the vesicle in question becomes 
 impregnated, the degenerative changes are retarded, and the corpus 
 luteum is nourished for some time by the rich development and per- 
 sistence of the newly-formed vessels ; hence it becomes larger than the 
 one just described, while the convoluted appearance of its yellow border 
 is much more striking.^ 
 
 It will be evident to the reader, even after this superficial view of 
 the minute anatomy of the ovary, that its structure is not only a com- 
 plex .one, but that it is not always easy to state when the organ is 
 entirely normal and when it is not. The fact that it is the seat of 
 constant changes, beginning in foetal life and continuing till after the 
 menopause, should lead us to be cautious in giving an opinion as to 
 
 ^ For an ingenious essay on the fate of the ova see Dr. Creighton's paper in the 
 
 Journal of Anat. and Physiol., vol. xiii. 
 
 ^ Refer to Dalton's Physiology for details and illustrations. 
 
OVA in lis. 179 
 
 tlic pi'cx'iicc III" ;il)ii(iriii;il cniidii i(iii>. Wlicllicr wr f.XMiiiiiic crit ical l\' 
 the sti'oiiia oi" the Dvisacs, the (•<tiirliisioii is unavoidnWlc that the Ixjiind- 
 arv-Iinc Itciwccii the iioiMiial and |iath()l()<:;ical is not a fixed one. Thus 
 the de;j,'enei'ative ehanjics eonse(|Ucnt upon the senile state may easily 
 he nii>tak(ii I'oi" cii'i'littsis, while (lie dia^jjnosis of cystic defjjeneratioii 
 may In- made heeansc of the presence of a few vesicles that are some- 
 what ahove the usual >i/.c, tliouiih lliey may contain perf"eet ova. 
 The j)i-ac(ical deduction is self-evident. Tlic (lia}z;nosis of ovarian 
 disease rccpiircs for its support the aid of the microscope, as well as a 
 ihorouiih acipiaintance on the part of the observer with all of the pos- 
 sible variations in the a])pearance of the normal organ. 
 
 The ovai'y receives a portion of its blood from the ovarian artery (Fig. 
 49), which arises directly from the aorta, like the spermatic in the male, 
 and has a course similar to that vessel until it reaches the pelvis. 
 Having reached a point near the pelvic brim, the ovarian artery makes 
 a bend inward, enters the broad ligament, and runs between the folds 
 of pcritoneun upward and inw^ard to the upper angle of the uterus. 
 In its tortuous course and in the manner of distribution of its branches 
 it resembles the sj)leuic artery. On reaching the uterus, or just before, it 
 divides into two branches, one of which supplies the fundus and joins 
 the vessel of the opposite side, while the lower and larger branch 
 descends along the lateral border of the uterus, giving oif numerous 
 parellel twigs of a curious spiral form, and finally anastomoses with 
 the uterine artery. Soon after entering the broad ligament, the ovarian 
 vessel sends three or four large branches to the distal end of the tu1)e, 
 then a group of extremely tortuous vessels which ramify over the sur- 
 face of the ovary and cuter the hilum. Near the point of division 
 other tw^igs are given off, whicli run to the proximal end of the tube, 
 Avhilc there is a special branch to the round ligament. It is impossi- 
 ble to give a clear view of the richness of the vascular supply of the 
 pelvic organs and of the intricate anastomosis which takes jilace 
 between the vessels that run in the broad ligaments. A glance at 
 one of Hyrtl's or Savage's plates will teach more than pages of 
 description. The reader is referred to these as the best substitutes 
 for actual dissections, wliich latter arc not only very difficult, but 
 require careful ])reliminary injections. xVttention should be called to 
 the most marked peculiarity of the ovarian artery, Avhich extends to its 
 minutest branches — its extreme tortuosity. It is hardly necessary to 
 remind the reader of the physiological fact that this peculiarity is one 
 observed in many arteries which sujiply organs of the turgescent tvjie.^ 
 
 The ovarian capillaries tei'minate in veins that emerge from the 
 hilum and enter a mass of veins which is situated along the lower 
 
 ' Sappey ( Traite cV Anntomir, Paris, 1S74, tome iv. p. 691 ) denies tlie truth of Kouget's 
 assertion that the ovarv is an erectile bodv. 
 
180 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 edge of the organ and is known as the " bulb." Savage describes it 
 as a " chib-shaped venous body in which the ovary and utero-ovarian 
 ligament are partly imbedded," It communicates freely with the veins 
 from the upper part of the uterus and from the tube (as well as with 
 the uterine plexus), forming with them an intricate network, known as 
 the ovarian or pampiniform plexus. This plexus terminates in the 
 ovarian or sjjermatic vein, which on the right side empties directly 
 into the vena cava inferior, but on the left joins the corresponding 
 renal vein. There is a well-marked valve at the termination of the 
 right, but not of the left, spermatic vein.^ 
 
 Reference has been made to the distribution of the nerves and lym- 
 phatics. The lymphatics of the ovary unite with those from the tube 
 and upper portion of the uterus, and enter the hmibar glands. The 
 nerves arise from the spermatic plexus and accompany the arteries. 
 
 Parovarium. 
 
 Definition. — A triangular group of small tubules situated in that 
 portion of the broad ligament which intervenes between the outer end 
 of the ovary and the distal extremity of the Fallopian tube. The 
 apex of the triangle touches the upper border of the ovary. 
 
 This curious body, analogous in its structure to the epididymis, is 
 usually dismissed by anatomists in a few words as the " remains of the 
 Wolffian body." Doran^ deplores the general want of interest that 
 prevails with reference to a structure that ought to be regarded by 
 gynecologists as of no little importance, because of its relation to 
 certain morbid growths. The tubes or fibrils forming the parovarium 
 vary considerably in number. There may be only half a dozen, or as 
 many as twenty-five or thirty. They lie in the midst of the delicate 
 cellular tissue which exists between the folds of the broad ligaments, 
 and have no close attachment to any of the surrounding parts. Begin- 
 ning at or near the hilum of the ovary, they ascend in parallel rows 
 and enter a transverse tube or canal which terminates in a cul-de-sac 
 — sometimes in a cystic dilatation — near the fimbriated extremity of the 
 tube. Beyond the point at which the lumen of this transverse tube 
 disappears, the latter can still be traced as a delicate cord which extends 
 inward toward the uterus, but is lost before it reaches that organ. This 
 is the persistent duct of Gartner, which Doran found in upward of one- 
 fifth of the specimens examined by him. Attempts have been made to 
 trace a direct connection between these ducts and the so-called ^'Skene's 
 glands" at the meatus urinarius, but Dr. Schiiller^ of Berlin has dis- 
 
 ^ For a discussion of the practical significance of this fact, vide Tait, op. cit., pp. 7-9. 
 ^ Tumors of the Ovary and Broad Ligament, London, 1885. 
 ^ Beitrdge zur Anatomie der Weibl. Harnrohre, Berlin, 1883. 
 
pMiovMnrM. 181 
 
 proved tlic tlicoiMcs ol" liis |»i'ct|cc('ss(»rs. 'I'hc \(i-iic,il ihIks arc ol' dil- 
 I'crciit si/i'S and show \ari(iiis decrees of (l('\('li>|»iiniil, those wliifli arc 
 most iiitiTiial hciiii;- ticiicrally iiici-cly threads oi' lil»i'(tiis tissue, while 
 a hair dozen of more of the external t nlmlo >lio\\ nnder the miero- 
 seope a well-mai'ked himen, which is lined hy a single layef of cili- 
 ated columnar epithelium resting- upon a line memhrana j)ro|)ria. The 
 latt<'i' consists ol" lihrons tissue containing' a small (jiiantity ol* snioot Ji 
 mnscle : two layers have been desei'ihed, the onter consistiiiji; ol" circii- 
 lai' lihres, while the inner rnn in a loniiitndinal direction. This de- 
 scription aj)plies to an c\eej)tionally pei'lect tnhiile. As a I'nie, the 
 Inmen, it' it exists at all, is Idled with a mass ol' deji'enerated ej)itiie- 
 lial cells ind)ed(k'd in a mucoid Hnid. The duct of (Jartner is sel- 
 dom anythinti' more than a lihrons cord. Cystic dilatations avc fre- 
 (piently observed in the course of the tubides, the most common bein*^ 
 the j)e<lunculated vesicle known as the "hydatid of Morj^agni," the 
 j)e<licle of which s|)l•in^'s from a ])oint in the mesosalpinx to the innci" 
 side of the limbria ovariea. It is generally regarded as the result of 
 dilatation of the up])er extremity of the frctal duet of Miiller. The 
 other eysts around and within the ])arovariuni are really pathological 
 ai)pea ranees. 
 
 PiJACTiCAL Deductions. — Can the normal ovaries be detected by 
 the bimanual touch? Opinions on this subject vary. In thin snb- 
 jeets the ])raetised examiner may be able to feel them, but we ven- 
 ture to affirm that it is only under the most favorable circumstances 
 that they can be felt through the abdominal Avail. By practising the 
 rectal or vesical touch, the uterus and its appendages being at the 
 same time depressed from above or draAvn down from below, the 
 gland may often be distinctly recognized. According to Munde, the 
 normal ovary is not so insensitive as has been claimed, but a peculiar 
 sickening pain can be produced by deep pressure upon it. The mobil- 
 ity of the normal organ, as well as its situation in the pelvis, prevents 
 it from being reached through the vaginal fornix ; hence A\hen it is 
 readily felt by the vaginal touch alone, the inference is that it has 
 sunk below its normal ])lane. 
 
 Rememl)ering the rather loose attachments of the ovary, and the 
 fact that it " floats at a certain level " in the pelvis, the etiology of 
 prolapsus becomes almost self-evident. Stretching of the ovarian lig- 
 ament or increase in weight of the organ (both conditions being a nor- 
 mal accompaniment of pregnancy) will naturally destroy its adjustment 
 and cause it to sink downward. Traction, from displacement of the 
 uterus, adhesions, enlargement and ]u-ola})se of the tube, etc., is a com- 
 mon cause. As the ovaries sink downward and backward (the usual 
 course), they rest at first uj)on the "retro-ovarian shelves," as Polk has 
 called the two sections of the posterior fossa of the pelvis that lie above 
 
182 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 the level of the sacro-uterine ligaments ; subsequently they may descend 
 into Douglas's pouch. Every reader must have noticed the greater 
 frequency with which the left ovary is thus displaced. This diifer- 
 ence is explained by reference to the fact that the left ovary is more 
 often diseased — a fact which depends upon a chain of anatomical causes, 
 not the least of which is the valveless condition of the left spermatic 
 vein, so that this vessel is readily affected by any obstruction to the 
 general circulation. The rectum encroaches on the left retro-ovarian 
 shelf, so that the corresponding ovary tends to glide off" from it into the 
 true pouch of Douglas. The anatomical relations of the displaced organ 
 explain the pains which attend defecation, as well as coitus ; these are 
 especially aggravated when the organ is fixed in its abnormal position. 
 From the brief statements which were made regarding displacement 
 of a diseased tube, with or without the corresponding ovary, it will be 
 inferred that not only the shape, but the position of a tender body behind 
 the uterus, may give some clue as to whether it is an ovary or a tube. 
 A positive differential diagnosis is seldom possible at the examining- 
 table. Although the circulation in the ovarian vessels is doubtless 
 interfered with when the gland is much displaced, there is probably 
 less obstruction than there would be if they were not so long and 
 tortuous. 
 
 When the ovary becomes the seat of tumors, its relations to neighbor- 
 ing organs are greatly changed ; still, by remembering them, we are 
 often enabled not only to make a correct diagnosis, but to explain cer- 
 tain complications. Among the points to be borne in mind, the most 
 important is the position of an ovarian tumor (at least before it has 
 grown so large as to fill the abdomen) with reference to the uterus — 
 i. e. at the side of that organ. The attachment of the tube and meso- 
 salpinx to a pelvic tumor always gives a clue to its origin, even when 
 its nature is not clear at the time of the operation. 
 
 The relations of the ovary to the broad ligament, as well as to the 
 'Fallopian tube, indicate frviitful sources of disease; the well-known 
 frequency of localized peritonitis around the distal extremity of the 
 tube requires no comment. 05phoritis and perioophoritis are hardly 
 separable ; how many of the symptoms observed in these cases are due 
 to disease of the ovary, and how many to the surrounding peritonitis, it 
 is not often possible to decide. 
 
 The normal anatomy of the gland should be thoroughly studied at 
 the present day when so many ovaries are removed for real, or sup- 
 posed, disease. From what has been said regarding the variations in 
 shape, size, and external appearance, it may be inferred that there are 
 many opportunities for error when we attempt to decide delicate shades 
 of difference bet^veen the normal and pathological by a hasty inspection 
 of the organ. The normal histology of the ovary is a key to the know- 
 
UREruiiA. is;; 
 
 Icd^c of till' I'tiolo^v of its (lisciisi's. \\v must he tlHtmiijflily liiiniliar 
 with tlic MpiM'iiniMcc (iltlic stroma in order to dclrct liypci-tropliy ol'llic 
 liliroiis tissue; with the (iranliaii vesicles in order to reeojrni/c small 
 patlioloii'ieal evsts; while a study (»!" the e|»ithelial eoNerill)^ is a licccs- 
 sarv introduction to that of cyst-formation. The ehanjics in the cortex 
 resultinu,' from the ru]»ture of ovisacs or from senility must he carefully 
 distiniiuished from the thickeiiin<;s due to chronic inilammation. 
 
 The remarks conc<'rning- the <;('neral pelvic circulation c<iver that of 
 the ovary. The a r ran foment of its vessels is such as to i:i\or sud<len 
 and excessive euii-ori:'ement, whicli niifrlit easily become ])atholo;iieal. 
 Suhperitoneal ha'matoma, the I'csult of hemorrhaue from the ovarian 
 vessels, is readily eoncei\al)le, and donhtless uocurs at the time of the 
 menstrual period more fretpiently than wo ima<:;ine. Hemorrhage into 
 Graafian vesicles, and tlienec into the peritoneal cavity, has often been 
 recorded, and Savage has shown by a series of interesting cases how- the 
 snbovarian plexuses may ru])ture and fatal hemorrhage ensue. The sud- 
 den appearanee of acute abdominal pain and collapse during menstrua- 
 tion should at once a\vaken the snspicion that this accident may luue 
 occnrred, even when no information can be derived from a physical 
 examination. The treatment, with onr modern views on abdominal 
 surgery, is evident. The intimate relation between the vessels sup- 
 plying the pelvic organs precludes the possibihty of engorgement in 
 one without at least some disturbance in the rest. Thus the ovary- 
 sympathizes with uterine affections. It is the centre of reflex neuroses 
 which are not always explicable by reference to anatomical facts ; 
 mammary pain (generally on the same side as a diseased ovary) is 
 a familiar example. 
 
 To the various neoplasms and their origin we can only refer ; that 
 they are formed from pre-existing elements will be evident to the 
 student of normal histology. 
 
 THE URINARY TRACT. 
 That portion of the tract which is usually described with the genital 
 organs includes the urethra, the bladder, and the termination of the 
 ureters. These will be considered in the same order as were the 
 genital organs — that is, from below upward. 
 
 Urethra. 
 
 Syxonyms. — Gr., obprjdpa ; Laf., canalis urinarius, urethra, iter uri- 
 narium ; Ft:, urethre, uretre ; Ger., Harnrohre ; Sp. and //., uretra. 
 
 Definition. — The female urethra is a short canal imbedded in the 
 anterior vaginal wall, extending from the meatus urinarius to the neck 
 of the bladder. 
 
184 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 In a mesial section of the pelvis the urethra appears as a slit nearly- 
 straight, or, as some authors describe it, with a slight sigmoid curve 
 corresponding to that of the posterior vaginal wall.^ Its course is 
 
 Fig. 59. 
 
 Frozen Section of the Pelvis, sliowing contracted bladder and relations of urethra : a, anuS; 
 b, vagina ; c, bladder ; d, uterus ; e, bottom of Douglas s pouch ; /, symphysis pubis (Fiirst). 
 
 upward and backward, being " parallel with the plane of the pelvic 
 brim." Henle states that in cross-sections the canal is represented by 
 a transverse slit near its vesical end, while at other points, except at 
 the meatus, the section has a stellate appearance. The average length 
 of the urethra is one and three-eighths inches, the average diameter a 
 quarter of an inch. For the sake of convenience we may consider 
 first the beginning of the canal, then the portion that lies between its 
 two openings, and lastly the vesical extremity. 
 
 "When in a state of rest the meatus appears as a small dimple, 
 
 or puckering, of the mucous membrane, situated in the median line 
 
 at the lower edge of the vestibule, from three-fourths to four-fifths 
 
 of an inch below the clitoris and an inch in front of the four- 
 
 ' Winckel, Krankheiten der Weibl. Harnrohre u. Bkm, S. 5. 
 
vniyniiiA. 185 
 
 chette, A cross-sect ion of tlw canal at this iioiiit is rcprosentccl l»y a 
 vertical slit. The corrn<;ati()n of (he nnicoiis nicinhrane is not coiilincd 
 to the nieatns, hut exists thi'on<;;hont the whole c(Mirse of the urethi'a 
 when it is not ilistendi'd. The pnckerinji' nl'thc nuicosa at the external 
 opening:; is dne to the sphincter action of the nniscnlar Hbres w'hich 
 siu'roiMid it. Around the nii-atus there will be observed on close inspec- 
 tion several little (le[)ressi()ns, which are the openin<i;s of the glandnlie 
 vestibnlares niinores, already alluded to in connection with the vestibuh;. 
 Just within the meatus are the orifices of a })air of <>;lands described by 
 Dr. Skene.' These are simply two of I^ittre's glands of large size, 
 corresponding to the lacuna major in the fossa navicularis of the 
 penis. They are not always easy to find in the healthy urethra, but 
 in cases of prolapse of the mucous membrane they often stand out 
 prominently. J^r. Skene describes them as tubules, situated just 
 beneath the mucous membrane near the floor of the urethra, and 
 extending nj)ward from the meatus parallel with the canal for a dis- 
 tance of three-quarters of an inch ; their function is unknown. They 
 derive a certain patlK)l()gical interest from the fact that they are some- 
 times the seat of an inflammatory process, Avhich may hjng resist treat- 
 ment until its true site is discovered. 
 
 The mucous membrane of the meatus, as well as that of the lower 
 portion of the urinary tract, is covered Avith pavement epithelium sim- 
 ilar to that of the vestibule. The glands (like those near the end <jf 
 the penis) arc lined at their nujiiths with squamous epithelium, Avhich 
 soon passes into the columnar variety. The venous plexuses around 
 the meatus are apparent even on superficial inspection. The distri- 
 bution of the vessels and nerves is the same as in other parts of the ves- 
 tibular area. 
 
 The urethra lies beneath the pubic arch, suspended by the pubo- 
 vesical ligament, and pierces the triangular ligament, to the tw'O layers 
 of wdiich it bears the same relations as the canal in the male. In its 
 anterior three-fourths it is literally imbedded in the anterior vaginal 
 wall, while the upper fourth is intimately connected with the vagina bv 
 an intermediate layer of cellular tissue. The fusion of the walls of the 
 two canals results in the formation of the urethro-vaginal septum, Avhich 
 is nearly half an inch in thickness. 
 
 Anatomy. — a. Gross. — Three layers of tissue are present in the 
 urethral wall, two of which are muscular and the third nnicous. An 
 external layer of cellular tissue is sometimes described, but it is well 
 marked only over the upper portion of the canal. The outer muscular 
 layer consists of smooth fibres disposed in a circular manner around the 
 tube, while those of the internal layer run longitudinallv. Uffleman 
 
 ' For details and drawings consult vSkene's original article in the Am. Jouni. of 
 Obstetrics, vol. xiii. 
 
186 THE AXATOMY OF THE FEMALE PELVIC ORGANS. 
 
 describes a double layer of voluntary muscle (the inner fibres being 
 transverse, the outer longitudinal) which extends from the neck of the 
 bladder to a point halfway to the meatus, below which point it invests 
 only the anterior half of the canal. Tliis muscle is regarded by the 
 writer quoted as a voluntary sphincter. His observations have not 
 been generally confirmed, although WinckeP appears to regard them 
 as reliable. Luschka^ describes a sphincter muscle common to both the 
 lower end of the urethra and the vaginal orifice. It is a tliin muscular 
 band, about six millimeters in breadth, surrounding both the introitus 
 vaginae and the urethra, and continuous behind mth the deep trans- 
 versus perinei. It serves to compress the urinary canal against the firm 
 urethro- vaginal septum. Another urethral sphincter, known as " Guth- 
 rie's muscle," is described by Savage as existing just in front of the 
 sphincter vesicae, of which it is probably the prolongation.^ By fol- 
 lowing the circular layers of smooth muscle throughout their entire 
 course, it "svill be found that it is incomplete over the lower half of the 
 tube, where the fibres blend with those of the vaginal wall. The long- 
 itudinal fibres are continuous above with the inner longitudinal layer 
 of the bladder. The mucous membrane, when in a state of rest, is of 
 a pinkish color, and is thrown into longitudinal folds by reason of the 
 large amount of elastic tissue that is contained within it. 
 
 B. Minute. — In a cross-section of the urethra the following points are 
 to be noted : Exterior to the canal is a plexus of large veins, which are 
 especially abundant at the sides. These are situated in the midst of a 
 mass of loose cellular tissue, which is seen in its true relation to the 
 urethra within the urethro-vaginal septum, Avhere it appears under the 
 microscope as forming a line of separation between the two portions 
 of the septum. Over the anterior wall of the canal its connection is 
 less intimate. The fibres have both a circular and a longitudinal 
 course. Internal to the cellular layer are the longitudinal muscular 
 fibres, which are recognized by the fact that their spindle-cells are 
 divided longitudinally. Between the two muscular layers, and serv- 
 ing to unite them, is a venous plexus enclosed in loose connective tis- 
 sue. In the transverse muscular layer the fibres run in several direc- 
 tions, not all of them being disposed in a circular manner, so that the 
 fibre-cells will be divided in different planes. Internal to the muscular 
 coat is a thick submucous layer consisting of fibrous and elastic tissue, and 
 containing a plexus of large veins, some of which are really sinuses ; so 
 that this tissue may be regarded as analogous in its character to the cor- 
 pus cavernosum of the penis. From the submucosa elastic fibres extend 
 into the mucous membrane, and numerous papillae are formed, as in other 
 mucous tracts, by projections of fibrous tissue from the subjacent layer,, 
 
 ■* Op. cit., p. 6. ^ Anat des MenscM: Beckens. 
 
 "* See Guthrie, Anatomy and Diseases of the Geiiito^irinary Orgasm. 
 
URETIin. 
 
 187 
 
 Fk;. (10. 
 
 which tiro covered hy epithelium ami contain h)r»j)s ol' capilhiries. The 
 mucous linino- of the urethra is rich in ehistie lihrcs, and is (piitc vascu- 
 hu*. Tlie epithelium ex)verin>:; its upper portion is ut" the sit-ealled transi- 
 tional tyj)e, liUe that of the hhuMer; 
 that is, it consists of a superficial 
 layer t)f coluiunar cells restin<< upon 
 a layer of cuhical epithelium, and 
 this on one of round cells. Near 
 the orifice the cells become squam- 
 ous, closely resemhliui;' those of the 
 vagina, except that they are some- 
 what smaller. At the meatus they 
 pass into the larger squamous va- 
 riety. In addition to the papillae 
 numerous glands are scattered 
 throughout the mucous membrane, 
 as well as lacunae, the latter being- 
 surrounded near the meatus by 
 villous tufts. The glands are lined 
 by columnar epithelium, while the 
 lacunte have a partial lining of 
 squamous cells near their mouths ; 
 the latter become columnar at a 
 short distance from the free sur- 
 face. Attention should be called 
 to the presence of collections of 
 lymph-corpuscles ^\'ithin the mu- 
 cous membrane, which give to it 
 in some places almost the appear- 
 ance of adenoid tissue.^ 
 
 A separate description of the 
 minute anatomy of the septum is 
 hardly necessary. The intimate 
 relation between the walls of the 
 two canals can be better appreciated by a study of the accompanying 
 figure than by a detailed statement of the anatomy of the parts, to 
 which reference has already been made. 
 
 The vesical opening of the urethra is situated about four-fifths of an 
 inch below, or behind, the middle of the symphysis pubis and an inch 
 and a quarter from the cervix uteri, and will be described in connection 
 with the bladder. Hcnle states that a cross-section of the canal at this 
 point presents the appearance of a transverse slit, Simon and "SVinekel 
 claim that it is diagonal, Holden tliat the opening is infundibular, 
 
 ' Satterthwaite, op. ciL, p. 242. 
 
 Horizontal Section of the Vesico-vaginal 
 Septum (Henle) : a, vesical epithelium; 6, 
 submucosa; c, layer of circular fibres; d, 
 layer of longitudinal fibres ; e, loose cellu- 
 lar tissue ; /, layer of circular fibres ; g^ 
 longitudinal layer; /(.submucosa; /.vagi- 
 nal epithelium. 
 
188 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 while Savage figures the same as triangular. The determination of 
 this point in. the living subject is obviously extremely difficult, if not 
 impossible, and is of no consequence from a practical standpoint. The 
 longitudinal folds in the mucous membrane are especially marked at 
 this extremity of the canal.^ 
 
 Bladder. 
 
 Syxonyms. — 6rr., xuarcQ', Lot., vesica urinaria; Fr., vessie; Ger., 
 Harnblase ; It, vescica ; Sp., vejiga. 
 
 Definition. — A hollow muscular organ, situated in the anterior 
 part of the pelvis, between the symphysis pubis in front and the 
 vagina and uterus behind. 
 
 In the living subject the shape of the bladder is constantly changing 
 as it is filled and emptied, so that it is not easy to state what its normal 
 dimensions are. Its shape and size vary at different ages. In infancy 
 it aj)proaches the masculine type, the vertical diameter being the longer, 
 in the mature female the transverse diameter is the greater, while in the 
 senile state there is a return to the infantile condition. When empty the 
 viscus appears as a collapsed sac, which lies behind the pubes and is par- 
 tially concealed by the fundus uteri. As it becomes distended with urine 
 it gradually rises from behind the symphysis, appearing as an ovoidal 
 body, that pushes upward the fundus of the uterus and fills the anterior 
 pelvic segment. The usual shape of the empty bladder, as viewed in 
 mesial sections of frozen bodies, is that of the letter Y, the vertical leg 
 of which is formed by the urethra, while the oblique legs may be of 
 equal length, or the posterior one the longer (Hart). Hart and Bar- 
 bour have also figured a mesial section of the empty bladder in which 
 that viscus is represented as of an oval shape, the latter probably repre- 
 senting the bladder in a condition of systole. In the living subject the 
 contracted organ is more nearly round : this is ascribed by Savage to its 
 inherent tonicity. Except during the act of urination the bladder is 
 flaccid and possesses no definite shape. When moderately distended it 
 becomes round ; when fully distended, transversely oval. According 
 to Henle and Luschka, the bladder of the female is smaller than that 
 of the male, though others affirm that it is capable of greater disten- 
 sion. Unlike the male organ, its transverse diameter is larger than the 
 vertical (Fig. 61). 
 
 Anatomy. — a. Gross. — The bladder is divided into three regions — 
 the body, base or fundus, and neck. The former is defined by Skene 
 as " all that portion of the organ lying above an imaginary line drawn 
 from the ureteric openings to the centre of the symphysis pubis." 
 
 1 For other details vide Blum, " Des Affections de I'Urethre chez la Femme," Arch, 
 gen. de Med., 1877, vol. ii. 
 
llLAUDKll. l.SO 
 
 'riic jturlidii below this phiiic is the I'iiikIiis or Ikisc, wliidi iiiclii<lcs 
 the triu'ono, or tlic triaiiii'iilar s|»:uv Ix'twccii the iii'ctliral and iii'ctcric 
 opeuinjis, and tlu' has loud, or pai't o(" the iiiiidiis hcliind tlic oj)cii- 
 ings of tlu' uri'ttTs. Tlii' latter may even hi- a dee|) |M»neli, especially 
 in old snbjeet.s. The thickened portion aronnd the nrethral orilico is 
 the iieeU; it is the must dependent part oi" the organ when the body 
 is ereet. 
 
 The bonndaries of the different reuions are clearly reeogni/.ed only 
 by exaniinini;' the interior of the bladder. The most prominent land- 
 mark is the vesical orifice, which forms the apex of the trigone, where 
 the nuicons membrane is thrown into longitudinal folds. The uvula, 
 a distinct elevation at the a})ex of the triangle in the male bladder, is 
 only faintly marked in the female. The base of this area is formed by 
 an imaginary line joining the o])enings of the ureters, M'hieh appear as 
 small slits distant from eaeh other and from the urethral orifiee about 
 an inch and a half, so that the triangle is equilateral. It is smaller 
 than the corresponding region in the male bladder, and is not so clearly 
 defined. 
 
 The bladder is essentially a muscular organ. Its wall, Mhich varies 
 in thickness from one-sixth to one-half an inch, according to the de- 
 gree of distension (Savage), consists of two layers of muscle with the 
 usual mucous lining. The exterior of the viscus is partially covered 
 by peritoneum, as will be explained subsequently. This muscular coat 
 consists of an outer longitudinal and an inner circular stratum, but a 
 distinct separation of the two is not possible, as the fibres interlace in 
 an intricate manner. The longitudinal fibres (of the unstripcd variety), 
 which are beautifully shown when the fully-distended bladder is held 
 before a light, are mostly confined to the anterior and posterior aspects. 
 They may be traced from the vesical neck and pubes in front (where 
 they are called the musculi pubo-vesicales) over the anterior surface of 
 the organ to the summit, whence a few fibres extend over the urachus, 
 and then downward over the posterior to the under surface of the neck, 
 where they blend with the anterior vaginal wall. At the sides this layer 
 is represented by a few pale interlacing fibres (Fig. 61). 
 
 The circular fibres are best developed around the vesical orifice, where 
 they form the sphincter vesicae. ^ Their transverse direction is only 
 maintained in the region of the fundus, especially at the trigone, while 
 above this point they cross one another in an oblique manner. Ellis^ 
 describes and " figures a submucous stratum," consisting of a thin layer 
 of smooth muscle, the fibres of which run in a longitudinal direction 
 over the lower third of the bladder, and extend for some distance along 
 the urethra. In the upper two-thirds this layer is represented by a few 
 
 ^ Henle (op. eii). denies this function to these fibres. 
 ^Demonstrations of Anatomy, p. 574. 
 
190 
 
 THE A]s\iTOMY OF THE FEMALE PELVIC ORGANS. 
 
 oblique fibres^ Between the muscular and mucous coats there is a layer 
 
 of fibrous and elastic tissue. 
 
 The mucous membrane of the emptv^ bladder is thrown into numerous 
 
 folds by reason of its loose attachment to the underlying tissue, except 
 
 at the trigone, where it is thinner 
 than at other points, and is more 
 intimately connected with the sub- 
 mucous layer. Its color has been 
 variously described. As viewed 
 through the endoscope in the liv- 
 ing subject, it has always appeared 
 to the writer to present a pinkish 
 or rosy hue. Shortly after death it 
 assumes a slatv' color, with here and 
 there pinkish areas due to localized 
 hyperemia. The mucosa is directly 
 
 continuous wath that lining the ure- 
 thra and ureters ; around the open- 
 ings of these canals it is more firmly 
 adherent than elsewhere. 
 
 B. Minute. — The mucous mem- 
 brane is the chief object of interest 
 microscopically, the muscular layers presenting the same appearances 
 as in other hollow organs, except that their division into separate strata 
 is less distinct than usual. Klein ^ instances the bladder as an organ in 
 
 Muscular Fibres of the Bladder, lateral view 
 (Allen Thompson) : a, a', a", decussating 
 longitudinal fibres; 6, b', diverging fibres; 
 b", divergent fibres surrounding entrance 
 of ureter ; c, deep layer of circular fibres. 
 
 Fig. 62. 
 
 Epithelium of the Bladder (Obersteiner) : a, cell from the second layer : b, cell from the super- 
 ficial layer ; c, the three layers as seen in vertical section. 
 
 which the bundles of fibres form plexuses. This membrane is sup- 
 ported by the submucous stratum, which is composed of bundles of 
 '■ For further details vide Boyd Med.-Chir. Transactions for 1856. ^ Op. cif., p. 64. 
 
i;lai>1)i:i:. Hil 
 
 fild'uiis ami clastic ti->uc, in tlic nicslics of wliidi arc networks of ves- 
 sels ami a limited ninnlxT ot" l\ in|)liatics and nerve-|)lexu,s(?H, iiiclii<liii^ 
 lianvilia. .Ner\'e-lil)res are also visible tliroMuliont the niiisciilar coat and 
 jnst lu'iieatli the |)eritoiienm. The epithelial lining- «jt" the bladder con- 
 sists of thi'ee or nioic layers ot" cells resting upon a nienibrana propria, 
 and presentin^• a typical exani))le of the "transitional " typ(.' (Fig. 02). 
 Tiie superficial cells ai'e S([uaiuous (but smaller than those of the 
 vagina) ; the inferior layer consists of eolunuiar epithelia with long 
 pr(»eesses, and the middle of pyriform cells. Over the trigone the 
 mucosa is thinner and luore intimately related to the submucous 
 stratum. The nuicous membrane contains a rich plexus of fine capil- 
 laries and nerve-iibres, the latter being most numerous in the region 
 of the trigone ; they have been traced as far as the cells, but the exact 
 manner of their termination is obscure. The lymphatic supply of the 
 tissue is poor. Sections of the vesical wall in the region of the ure- 
 thral opening show that the mucosa is thicker here than at other points, 
 so that it may form, as Hart and Barbour suggest, the real barrier to 
 the escape of urine. The uvula is formed by a localized thickening of 
 the submucosa. Savage maintained that there are neither villi nor 
 glands in the lining membrane of the bladder. The former are cer- 
 tainly absent, but later investigations have demonstrated beyond a 
 doubt the existence of small lacunre and racemose mucous glands lined 
 with cylindrical epithelium, the latter being most numerous near the 
 neck of the bladder. 
 
 The organ derives its vascular supply from the anterior division of 
 the internal iliac artery, through the medium of the three vesical branches 
 and a branch from the uterine. These vessels anastomose freely. 
 
 The arterial supply of the urethra is received from the branches that 
 are distributed to the anterior vaginal ^vall. The vaginal artery sends 
 a twig to the region around the vesical neck. The venous plexuses are 
 large and intricate ; they cover the exterior of the organ lying outside 
 of the muscular coat, and are largest around the base and neck. The 
 latter plexuses communicate with those of the uterus, vagina, nymphse, 
 and rectum, and empty into the internal iliac vein. The urethra has 
 its own venous plexus, which is intimately related to the vaginal veins. 
 
 The lymphatics from the submucous stratum and exterior of the 
 bladder accompany the veins, and finally enter the glands near the 
 internal iliac artery. The nerves belong to both the sympathetic and 
 cerebro-spinal systems, the former being derived from the hypogastric 
 plexus, and supplying the bladder in common with the other pelvic 
 organs. The latter nerves are branches of the third and fourth sacral, 
 and are distributed mainly around the base and neck. 
 
 Relations axd Attach:mexts. — Anteriorly the bladder is sepa- 
 rated from the posterior surface of the symphysis pubis by the retro- 
 
192 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 pubic fat, which latter tissue assumes a triangular shape when the viscus 
 is empty. The anterior surface of the organ is entirely devoid of peri- 
 toneum ; as it rises above the pubes it approaches closely to the anterior 
 abdominal wall. The summit of the bladder and a portion of the pos- 
 terior wall are covered by peritoneum. The former is only in contact 
 with coils of small intestine when the organ rises out of the pelvis ; 
 under normal conditions the vesico-uterine pouch does not contain 
 intestine. As the bladder becomes empty the uterus inclines forward, 
 resting upon — or, more correctly, over — the summit, w^hile the coils of 
 small intestine ghde backward. Below the level of the os internum 
 the peritoneal investment of the posterior wall is wanting, and the 
 latter is united to the upper part of the anterior vaginal wall by means 
 of an intervening layer of dense fibrous tissue. 
 
 The neck of the bladder and the upper fourth of the urethra have 
 the same attachment to the vaginal wall, the entire thickness of the 
 tissue separating the cavities of the bladder and vagina being knoAvn as 
 the vesico-vaginal septum. Above the upper limit of the septum is a 
 subperitoneal space, intervening betAveen the posterior vesical wall and 
 the cervix uteri ; this is filled with a small quantity of loose cellular 
 tissue. The round ligaments cross the lateral walls of the bladder, 
 while above and behind the summit are the broad ligaments with 
 their contents. 
 
 The relations of the ureters will be described later. The so-called 
 true and false ligaments will be mentioned under the sections treating 
 of the pelvic connective tissue and peritoneum, of which they .form 
 parts. The attachments of the urachus and obliterated hypogastric 
 arteries are the same as in the male bladder. 
 
 Ureters. — Their course previous to entering the pelvis is the same as 
 in the male. Their relations within the pelvis have been studied with 
 great care in connection with the obstetrical operation known as gastro- 
 elytrotomy.^ In the non-pregnant woman they are nearly parallel in 
 the upper part of their course until they cross the iliac arteries (the left 
 ureter lying behind the sigmoid flexure, the right behind the lower end 
 of the ileum), when they extend downward, backward, and outward 
 along the lateral walls of the pelvis until near the spine of the 
 ischium, where they bend downward, forward, and inward behind 
 the uterine vessels. Passing beneath the bases of the broad liga- 
 ments, they converge behind the cendx uteri, and enter the bladder 
 from one-half to three-quarters of an inch in front of, and below, it. 
 The distance between the two ureters just as they reach the bladder 
 is about two inches. They run in the muscular coat of that organ 
 
 ^ Garrigues and Polk have investigated this subject quite thoroughly. Comp. Gar- 
 rigues's papers in Am. Journ. ObsteL, Jan., 1883 ; N. Y. Med. Journ., Oct. and Nov., 
 1878 ; and Polk's in the N. Y. Med. Journ., May, 1882, and Am. Journ. ObsteL, Jan., 1883. 
 
nL.innhi:. 
 
 1 \m 
 
 Vui. (j:i. 
 
 r 
 
 |i»r ;i (li-taiiff of a little iin'iv than half an inch, still cmvorpnjj:, so 
 that their internal (•luninjis are .-«e|)arate<l from each <ither hy only an 
 inch or an inch and a hail", and irom the anterior lip of the eervix 
 bv a space of tliree-(|narters of ;ui inch. .Inst before enterin); the 
 bladder they lie in the mass of 
 cellular tissue which is iinme- 
 tliately above the lateral walls 
 of the vauina. As each ureter 
 pierees the muscidar coat of 
 the bladder its circular fibres 
 blend with those of the iiuier 
 or eireular layer, while the 
 lono;itudinal are prolonged in- 
 ward to meet those of the op- 
 posite side, forming the " inter- 
 ureteric ligament " of Juerie, 
 which is represented by a 
 transverse ridge extending be- 
 tween the ureteric openings and 
 constituting the base of the 
 vesical triangle. The slit-like 
 
 orifices of the ureters are pro- Relations of the ureters at the level of the OS inter- 
 tceted bv valvidar f(^>lds of num as seen from above (Polk): U, uterus: B. 
 
 , rp bladder; if. rectum ; ^,.4, uterine arteries; C C, 
 
 mucous membrane. iWO ureters ; L, L, mero-sacralligaments. 
 
 faintly-marked bundles of 
 
 smooth muscular fibres (rudimentary in the female) have been 
 described as arising from the so-called vesical sphincter, and passing 
 beneath the base, to be attached near the terminations of the ureters. 
 The function of these muscles, as well as of the interureteric band, 
 seems to be to close the orifices of those tubes by drawing upon them, 
 thus preventing regurgitation during the act of urination. 
 
 The relations of the ureters in the pregnant Avoman are slightly 
 different from those in the non-pregnant, the differences being thus 
 summarized by Polk,' who has made a special study of the sub- 
 ject : "As a whole, the tubes in the pelvis are situated upon a 
 higher plane than in the non-pregnant condition, having been carried 
 slightly upward, Avhile being separated from their close relations with 
 the pelvic wall by the ascending uterus."^ The gross and microscopical 
 anatomy of these canals does not require a separate description. 
 
 Practical Deductions. — The condition of the bladder is too 
 of\en disregarded during an examination of the female pelvic organs, 
 
 ' X r. Med. Jnvrn., May. 1S82. 
 
 ^ See also Liisclika, "Topograjjliie d. Ilarnleiter d. Weibes," Arch, fur Gi/n.,ih. 1S72, 
 p. 37.3. 
 
 Vol.. I.— 13 
 
194 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 although the symptoms referable to this organ are among the most 
 common and distressing of which women complain. There is such 
 a radical difference between the urethro-vesical tract in the sexes, as 
 regards both its anatomy and pathology, that the reader should not 
 seek to draw comparisons. To infer that a woman has acute cystitis 
 because she has symptoms ordinarily accompanying that disease in the 
 male would imply a complete ignorance of the anatomy and physics 
 of the pelvis. 
 
 Let the reader bear in mind the cardinal fact that "the uterus and 
 bladder behave practically as one organ," so far as concerns changes in 
 position ; in other words, that the base of the bladder is so firmly 
 united to the uterus that any displacement of the latter will cause trac- 
 tion upon the former at its point of attachment to the pubes — i. e. the 
 neck. Thus is explained the vesical irritation (frequent and painful 
 micturition) so common in acquired anteflexion, where the traction 
 exerted along the line of the utero-sacral ligaments is transmitted 
 from their uterine attachment to the neck of the bladder. In this 
 way a remote retro-uterine inflammation may directly eifect the blad- 
 der, causing a permanent disturbance of its functions, while the organ 
 itself remains free from disease. This is more in accord with anatomi- 
 cal facts than the theory that frequent micturition in cases of ante-dis- 
 placement is due to the pressure of the fiuidus uteri on the bladder. 
 The effects of backward displacement upon the bladder are best 
 observed in retroflexion of the gravid uterus, when the neck of the 
 former organ may be so compressed between the cervix and the pubes 
 that retention and all its serious consequences may result. 
 
 Aside from the physiological elevation of the bladder during preg- 
 nancy, the organ is .sometimes drawn upward by a fibroid uterus, or 
 ovarian cyst, in such a manner that it might easily be wounded by the 
 laparotomist. The introduction of a sound as a guide is the only safe- 
 guard. This precaution is indispensable during the separation of the 
 bladder from the uterus in vaginal extirpation, a delicate procedure 
 requiring both time and patience. Perforation of the vesical wall can 
 only be avoided by keeping close to the uterus. The proximity of the 
 bladder to the organs occupying the anterior pelvic fossa has suggested 
 the practice of the vesical touch, in which the finger is introduced 
 through the dilated urethra. 
 
 That portion of the posterior wall of the viscus which enters into 
 the formation of the vesico-vaginal septum is most interesting surgi- 
 cally, since it is the usual site of fistula and is the region in which arti- 
 ficial openings are made into the bladder for the removal of calculi, 
 foreign bodies, or morbid growths, the relief of chronic cystitis, etc. 
 This portion of the bladder is, of course, not covered by peritoneum. 
 Cystocele also occurs in this locality from obvious causes. Retention 
 
liLAimhJi. 
 
 ]u: 
 
 of iirino in tlie pouch thus formed may lead to cyf^titis or to the forma- 
 tion of t-iUi'iili. It will occur to the reader that, l»y a<lvi>in^ a j>atieut 
 to urinate <tn the hands and knees, jrravity will assist in em[)tyinj; thi.- 
 |M)neh. There can \)v no I'xeu.se for dragginj^ a larj^e ealeulus through a 
 dilated urethra, at the risk of causini; permanent inc<mtinencv, when 
 it can he removed so easily and safely throuj^h an incision in the h'|>- 
 tiim. Surgical wounds of the septum heal so rapidly that it is difficult 
 to maintain a permanent opening atlcr cystotomy, unless the opening 
 is madi' with the thermo-cautery or by Emmet's meth<Ml. 
 
 From what has; been said regarding the course of the ureters just 
 before entering the bladder, it will be inferred that transverse incisions 
 through the septum should be avoided, median longitudinal ones being 
 safer. As the mucous membrane of the vagina is loose and movable, 
 we can only avoid making an irregular or valvular opening by cutting 
 down directly upon the end of a sound, which presses forward the sep- 
 tum at the exact point at which it is proposed to establish the fistula. 
 The ureters may be included in a large fistula, and one or both of their 
 openings can be seen in the everted vesical mucosa ; it must then be 
 exceedinglv difficult to avoid including them in the sutures at the time 
 of operation. Uretero-vaginal fistulte are rarely formed in the fornix ; 
 communications between a ureter and the uterine cavity are still more 
 uncommon. 
 
 The operation of catheteri- ^^' 
 
 zation ot the ureters possesses ^^ ^ ' ^ 
 
 no practical interest for the 
 general reader. In complete 
 extirpation of the uterus the 
 operator avoids these ducts 
 by keeping close to the cervix ; 
 in gastro-elytrotomy it is gen- 
 erally acknowledged that the 
 vagina should be opened above 
 the line at which it is crossed 
 by the ureter. From the 
 limited space which exists for 
 the incision in the latter ope- 
 ration, it is evident that the 
 tear may readily involve the 
 bladder ; which is, in fact, a 
 common accident. Fortu- ^""^^^ ^^^T.f '^^ ^''^'''"^ (Oamgues): u 
 
 uterus: B, bladder: ur, ureter: «, urethra: V, 
 nately, wounds of this visCUS vagina, with x, showing line of incision in gastro- 
 / '• 11 ^ -^ f ^ \ ] 1 elyirotomy: r, Fallopian tube ; O, ovary ; 6, broad 
 
 ^^especiauy ar its lunmisj neal ligament; r, round ligament; ct, connective tis- 
 
 quickly. sue. 
 
 Since endoscopy has become popular we have been able t(» studv 
 
196 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 thoroughly the normal mucous membrane of the bladder, and conse- 
 quently to distinguish more definitely the changes in its color due to 
 disease. It may be stated in general, with regard to inflammation of 
 the female bladder, that it is capable of being diagnosticated more 
 directly (by palpation through the vagina, etc.), and that local treat- 
 ment by means of irrigation, permanent catheterization, and surgical 
 interference is more practicable, than in the male. Intractable as are 
 many cases of chronic cystitis, it would seem as if suppuration and 
 renal complications should be of rare occurrence when the gyne- 
 cologist can at any time establish perfect drainage through an artificial 
 fistula, and thus also apply his remedies directly to the diseased mucosa. 
 Our study of the pelvic nerves has shown us that the innervation of 
 the genital and urinary tracts is practically the same. We have seen 
 that certain affections of the other pelvic organs may cause irritation 
 of the bladder, and conversely. The sphincter vesicae being especially 
 sensitive to these reflex influences, we need not wonder that inconti- 
 nence and retention may result from distant causes. 
 
 The frequent extension of malignant disease of the cervix to the 
 bladder, and the ultimate ursemic complications which may result, are 
 well known. 
 
 The female urethra differs from that of the male in its shortness, its 
 dilatability, and its comparative immobility. The first two peculiarities 
 tempt the gynecologist to enlarge the canal for the convenient practice 
 of manipulations within the bladder, while the last suggests a danger 
 from over-dilatation, which is not imaginary. Although there is a 
 wide difference of opinion as to the liability to persistent incontinence 
 after dilatation of this canal, for the purpose either of introducing the 
 fingers or of extracting a foreign body, a careful study of its anatomy 
 must convince the reader that this procedure is not so harmless as it 
 has been represented. Emmet, in the light of his great clinical 
 experience, strongly condemns it. In some instances clumsy efforts 
 to extract calculi have resulted in laceration of the urethra. Dr. 
 Emmet believes that this laceration is usually transverse, and is situated 
 in front of the subpubic ligament ; to repair the injury requires excep- 
 tional skill in plastic surgery. Urethrocele is believed by the same 
 writer to be also due to mechanical injury to the canal, whereby its 
 natural supports are weakened. The prolonged compression of the 
 urethral tissues between the pubes and the impacted foetal head is no 
 slight cause of lesions. The most important surgical operation in this 
 region is the formation of a " buttonhole," after Emmet's method. 
 
 At the meatus Skene's glands possess a practical interest, from the 
 inflammation to which they are subject; this inflammation, though 
 localized, is very obstinate, and can be cured only by treatment directed - 
 to the glands themselves. 
 
RECTUM. 107 
 
 We iic<'<l not dwell il|inii tlic little o|)cr;iti(m of ]»:i.-.-iii;r tin- <"i( lictcr, 
 Easv as it aitpcars tVuin tlic (k'Scni)ti(»M, wlieii the l)la<l(l('r is drawn 
 U[)\vard, or comin-csscd l)y iiiorl)id growths, or the urethra is encroaelied 
 upon l)v a larjic fetal head, it often tests botli the skill and tlie anatomical 
 Uno\vle<l<;c of the physician. Xothintr ^vill he grained hy force; the 
 len-ith aiitl direction of the canal must he renieinlx'retl, and the catheter 
 must he guided accordingly. It woidd hardly seem necessary to add 
 the caution that the female bladder is pectdiarly liable to receive infec- 
 tion froiu unclean instnmicnts, and that the resulting cystitis is often 
 extremely intractable. 
 
 Rectum. 
 
 Synonyms. — ia/., rectum ; F/-., rectum ; Ger., Ma.stdarm ; It., retto; 
 Sp., recto. 
 
 Dkfixitiox. — The rectum is the lower extremity of the large intes- 
 tine and the termination of the intestinal tract. 
 
 The rectum of the female, although it is not so intimately connected 
 with the genital organs as the urinary tract, and is not the seat of as 
 many atiections which directly concern the gynecologist, nevertheless 
 deserves careful mention because of the relation which it bears to the 
 pelvic c(jntents. It is nr)t enough for the specialist and general prac- 
 titioner to become thoroughly acquainted with these relations from 
 an anatomical standpoint ; he must also be familiar \y\ih. the " feel " 
 of those organs which can be touched through the anterior rectal 
 wall. 
 
 The rectum begins near the left sacro-ihac synchrondrosis, extends 
 downward and Ijackward, and at the same time toward the median line 
 of the body, until it reaches a point opposite to the third sacral vertebra, 
 ^vhen it curves downward and forAA'ard behind the cervix uteri to meet 
 the vagina, the course of which canal it follows, finally making a sharp 
 bend Ijackward to its termination. It thus appears that the rectum pre- 
 sents three separate curves, the first being from left to right, the second 
 forward, and the third directly backward.^ 
 
 The reader must be cautioned against regarding the rectum as an 
 open canal, as it is figuretl in many textbooks. A careful study of 
 frozen sections, as well as observations made on the living subject, 
 jirove that, unless distended by the presence of some foreign body, it is, 
 like the canals of the genito-urinar}- system, simply a slit, and, more- 
 over, that during life the amis is never patent under normal conditions, 
 except when by the relaxation of the sphincter it opens to allow the 
 passage of feces. 
 
 ^ Tlie direction of the anal canal is thus given by Hart and Barbour {op. cil.), who 
 base their statement upon studies of frozen sections. The writer is inclined to believe, 
 with Kannev, that this direction is more nearlv vertical. 
 
198 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 Fig. 65. 
 
 Anatomy. — a. Gross. — The rectum in the female is about eight 
 inches in length, and is somewhat less curved than in the male, its 
 
 calibre being usually greater. Externally it 
 is smooth, non-sacculated, and is destitute of 
 the longitudinal muscular bands which are 
 the prominent characteristics of the colon. 
 Although the lower four inches of the canal 
 are usually empty, the portion just above the 
 anus is capable of great distension, and has 
 in consequence been called the "ampulla." 
 Wlien hyper-distended by artificial means 
 the rectum appears to taper gradually from 
 the ampulla to the upper end, which is the 
 narrowest part next to the anus ^ (Fig. 65). 
 The anal orifice is very dilatable ; the anus 
 itself is not a mere apertm-e, but a canal, ex- 
 tending through the entire thickness of the 
 integument and muscles forming the pelvic 
 floor. The skin around the external opening 
 is thrown into a number of radiating folds, 
 caused by the contraction of the sphincter, 
 is deeply pigmented, and is covered with hair 
 
 Rectum Inflated (Chadwick) : a,b, j cphaopmics crlnnrlt; 
 sphincter tertius; c, ampulla. ^^'^ SCDaceOUS gianQS. 
 
 On exposing the interior of the rectum 
 by an incision carried through the entire length of the anterior wall, a 
 number of folds will be observed in the mucous lining. Those near 
 the anus have mostly a longitudinal direction, and are known as the 
 "columns of Morgagni," the depressions between them being called 
 the "sinuses of Morgagni;" they are said to be corrugations of the 
 mucous membrane due to the contraction of the sjDhincter, and they 
 nearly all disappear when the gut is distended. Higher up • in the 
 bowel are various circular and oblique folds. Three of the latter 
 variety are permanent ; they include a portion of the muscular as well 
 as the mucous stratum, and are about half an inch in dejDth. One of 
 these projects from the anterior wall at a distance of an inch and a half 
 from the anus,^ another is on the right side of the canal, on a level with 
 the sacral promontory, while a third is situated midway between the 
 two on the left side. 
 
 The lowest fold has been called " the valve of Houston," while Hyrtl 
 has described it under the name of sphincter ani tertius. The so-called 
 
 ^ Vide Chadwick, ''The Function of the Anal Sphincters," Trans. Am. Gyn. Soc, 
 vol. ii. p. 43. 
 
 '^ Ellis {op. dt., p. 583) says that it is " three inches from the anus, on the front of 
 the rectum, opposite the base of the bladder." 
 
RECTUM. \\yj 
 
 ^' third sj)hiii('t('r of the n-ctiiin " is a stnirtiirc wliidi \\:\s n'c«'ivc<l no 
 small aiiiuiiut ol" attcntidii — iiir»rc, in lact,llian it <|nitc drsrrvfs. Tln're 
 has hccn much cont rovcrsv n'}j;ar(linji: its location, a|»|»c:iranr(', an<l func- 
 tion. All authorities ai^rcc that folds and constrictions do exist within 
 the rirtum, but they dill'cr widely as to the numixr ol" fohls and the 
 exact situation of those which iiirm the thii-d sphincter, CliadwieU ' 
 describes and fiirures it as eonsistinjx ot" two en'scentic rupo, one of 
 which is in the anterior wall (oorresjKindinji; with the lowest valve of 
 Houston), while the other is an inch higher uj) in the posterior wall. 
 The writer has seen the tipj>er fold so ])rominent that it was mistaken 
 for a stricture. On the other hand, he has met with folds in the 
 mucous membrane at a distance of three or four inches from the anus 
 so larii;e that they arrested a rectal tube, but when the patient was 
 exaiuinal under ether, the canal being exposed with a Sims speculum, 
 thev had entirely disappeared.^ An extended discussion of this matter 
 Woidd he out of place here. It is enough to state that the sphincter in 
 question is not, as its name suggests, a band encircling the gut, but a 
 succession of valve-like folds situated at diiferent levels and acting 
 together to cause a certain amount of constriction of the canal. 
 
 The coats of the rectum are three in number. Like the bladder, it 
 has only a partial peritoneal invastment, the disposition of which will 
 be mentioned subsequently. The muscular coat includes tAvo layers of 
 unstriped muscle — a superficial, which coasists of longitudinal fibres 
 similar to those in the colon, but distributed uniformly around the gut 
 instead of being collected in separate bands, and a deep layer of cir- 
 cular fibres. The latter are best marked -immediately above the anus, 
 where they form a di.stinct ring nearly half an inch in width (internal 
 sphincter). The submucous layer is common to the intestine. The 
 mucous lining is thicker and more movable than that of the colon, and, 
 by reason of its vascularity, generally appears of a bright pink, or even 
 red, color. 
 
 Certain muscles are attached to the lower end of the rectum. Of 
 these the levatores ani are especially important, as forming an essential 
 part of the pelvic floor ; they will be described in connection Avith that 
 structure. The external sphincter is a thin, pale, elliptical voluntar}' 
 muscle which surrounds the anal canal, having posteriorly a fibrous 
 attachment to the coccyx, while anteriorly it is inserted into the peri- 
 neal centre, where it appears to blend with the sphincter vaginae. Dr. 
 Emmet has recently stated that the opposite fibres of the sphincter do 
 not interlace in front of the anus, but run parallel to each other up to 
 their point of insertion, being simply kept in apposition by transverse 
 
 ' Op. cit. 
 
 * For an able article on this subject by Kelsey the reader is referred to the X Y. 
 Merf. Journal for March, 1881. 
 
200 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 bands of fibrous tissue.^ Although this opinion seems to be supported 
 by many of the figures in anatomical works, the writer has not been 
 able to satisfy himself by his own dissections of its absolute correctness. 
 The relations of the sphincter to the perineal body belong properly to 
 the section which treats of that subject. Ellis also describes a delicate 
 
 Fig. 66. 
 
 Vertical Section through Lower Enrl of Rectuui (Ruedinger) : 1, rectal mucous membrane ; 2, 
 line of separation between mucous membrane and skin of buttock; S, fat; 4, levator ani; 
 5, 6, external sphincter; 7, internal sphincter; 8, 9, longitudinal muscular fibres interlacing 
 with those of sphincter ; 10, terminations of longitudinal fibres ; 11, circular fibres ; 12, 13, 
 longitudinal fibres of muscularis mucosae. 
 
 subcutaneous layer of involuntary muscle that "surrounds the anus 
 with radiating fibres" (corrugator cutis ani). 
 
 B. Minute. — The muscular coat offers nothing of particular interest 
 microscopically, except near the anus, where the longitudinal fibres 
 
 ^ A laceration of the perineum through the sphincter involves, according to some 
 writers, simply a separation of the opposite halves of the muscle, and not an actual 
 laceration of its fibres. 
 
RECTUM. liOl 
 
 iiUcrlacc with those i^i' the >|ihiii(tcis mikI end just Ix'iifuth the iiit<'j:;- 
 imient of the anal region. 
 
 Tlie ininuti' anatomy of the inucotis nicnild-anc is similar to that of 
 the eoUm, It is lined by eolnmnar epithelinm and contains nnmhers 
 of Lieheikiihn's I'ollieU's. Hermann and Desfossos liuve described 
 cduvoliited glands which open on llie live surface near the amis.' 
 There is a liansition at the amis from cohimnar to stratifie<l pavement 
 epitheliniu. The so-eaili'd "white liiu'" marks the lower limit of the 
 luneons mendn'ane. 
 
 The vascidar supply of the rectnm is very abnndant. The Ijranches 
 of the three hemorrhoidal arteries (of which the sin)erior arises from 
 the inferior mesenteric, the middle iicncrally from the internal iliac, 
 and the interior from the pudie) penetrate tlie muscular coat in the 
 upper half of the canal, and form a network in the submucous layer ; 
 over the lower half they run downward parallel to one another, and to 
 the long axis of the bowel, as far as the anus, where they are united in- 
 transverse branches.^ The veins form a dense plexus (hemorrhoidal 
 plexus) in the submucosa, which communicates with another plexus 
 exterior to the gut, and empties into those veins that accompany the 
 corresponding arteries. These enter both the portal and general venous 
 systems, the superior hemorrhoidal being a branch of the inferior 
 mesenteric vein, while the middle and inferior hemorrhoidal veins 
 empty into the internal iliac. The lymphatics form two intercommu- 
 nicating plexuses, one in the submucosa, and the other beneath the 
 peritoneum and in the superficial muscular stratum. In the anal region 
 they communicate with those of the integument. They all pass through 
 the "lands of the mesorectum to terminate in the sacral o;lands. The 
 sympathetic nerves are derived mostly from the hypogastric plexuses, 
 those of the cerebro-spinal system from the sacral plexus. 
 
 Relations axd Attachments. — The upper portion of the rectum, 
 which is covered by peritoneum, is in direct relation anteriorly with the 
 pouch of Douglas ; the utero-sacral folds, that form the lateral bound- 
 aries of the ]iouch, pass on each side of the rectum to reach the sacrum. 
 When the bladder is empty and the uterus inclines forward, the ante- 
 rior rectal wall ^vill be in contact with tlie loops of small intestine 
 which fill the fi^ssa. As the uterus rises toward the vertical the small 
 intestine is displaced upward, and the rectum and uterus are only sepa- 
 rated by a narrow space, in which is a double fold of peritoneum. If 
 the rectum is much distended, or the uterus lias a considerable range 
 of mobility, the two may be in contact, especially when the woman is 
 in the recumbent posture. On tlie left side of this portion of the rectum 
 lie the ureter and some branches of the internal iliac artery. Behind it 
 is a fold of peritoneum (mesorectum) which attaches it to the sacrum, 
 
 * Compl. rend., xc, 1880. 'Quain's Anatomy (9th ed.), vol. ii. p. 010. 
 
202 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 against which bone it lies ; it rests also upon the left pyriformis muscle 
 and sacral plexus. 
 
 The sacral portion of the rectum, or that part which lies within the 
 hollow of the sacrum, gradually loses its peritoneal covering, first behind, 
 then at the sides, and finally in front. It is in relation anteriorly at 
 first with the bottom of Douglas's pouch, which intervenes between 
 it and the upper end of the posterior vaginal wall ; but at a point 
 about three inches from the ostium the peritoneum is reflected from the 
 rectum, and the latter becomes loosely attached to the vagina as low as 
 an inch and a half from the anus. Here the rectum bends backward 
 and the vagina somewhat forward, so that a triangular interval is left 
 between the lower extremities of the two canals, which is occupied by 
 the perineal body. The septum separating the rectum and vagina 
 where they lie in contact (recto-vaginal septum) is formed by their 
 walls and a quantity of loose areolar tissue enclosing some venous 
 plexuses that serves to connect them. The rectum is attached to the 
 sacrum and coccyx by bands of fibrous tissue containing a quantity of 
 fat. Laterally, it receives the insertions of the levatores ani. The anal 
 canal is in immediate relation anteriorly with the base of the perineal 
 body, and is surrounded above by the external sphincter, and at its ter- 
 mination by integument, beneath which is a layer of adipose tissue. 
 
 Practical Deductions. — The principal point of practical interest 
 in the rectum of the female is its relation to the genital organs. By the 
 rectal touch we are enabled to distinguish, more clearly than by the 
 vaginal, retro-uterine tumors, inflammatory conditions of the utero- 
 sacral ligaments, etc. Prolapsed tubes and ovaries and indurations 
 in the broad ligaments can also be touched through the rectal wall. 
 It is often possible to replace a retroverted uterus (and especially 
 the retro-displaced pregnant organ) by pressure exerted through 
 the rectum. 
 
 That gynecologists emphasize the fact that habitual constipation is a 
 fruitful source and aggravation of uterine disease, especially of dis- 
 placements, cannot surprise the reader who considers the relations of 
 the rectum to the genital tract, and the changes in size and position of 
 the latter which result from constant over-distension of the gut. The 
 pain occasioned by the pressure of hardened feces against a sensitive 
 ovary or an acute inflammatory focus can readily be conceived. Rec- 
 tocele as a result of fecal accumulation is easily understood. The rec- 
 tum is closely connected with the vagina, so that the two canals share 
 some affections in common ; in fact, disease of the former is sometimes 
 referred by the patient to the latter. Thus rectocele is not, as its name 
 would seem to imply, a prolapse of the rectum alone, but of the ante- 
 rior rectal and posterior vaginal walls, which have been deprived of 
 their natural support by a tear of the perineal body (and injury to the 
 
RECTUM. 203 
 
 jM'Ivii' lldiirV). A rnimUc i-ccto-vaiiiiial li.-tiila may <'aii.-c an anioimt of 
 (liscoinlort to the patient entirely ont ol" j>ropoi-tion to its size. 
 
 On aeeoiint of its proximity to tlic vajrina, the lower end of tlie re<> 
 tiim can readily be examined by intr<Klueing one or two fingers into the 
 former eanal and everting the rectal mneons membrane thn»ngh the 
 sphincter. The lower third of the recto-vaginal septnm generally 
 shares in laceration of the perineum extending through the sphincter; 
 the hemorrhage at the time of the accident, wlien the circulation has 
 been obstructed by prolonged pressure of the child's head, is sometimes 
 quite alarming. The reader need only recall the train of consequences 
 which ultimately follows this lesion in order to rwxjgnize the propriety 
 of the primary operation for its repair, although it is not always suc- 
 cessful. The secondar}- operation for laceration through the sphincter 
 recjuires as much skill and judgment as any in gynecology ; the diffi- 
 culty of maintaining perfect apposition of the parts and rest during 
 healing is obvious. From the anatomical structure of the torn sphinc- 
 ter and its constant tendency to contract, it ofiten fails to unite per- 
 fectly. The method of closing the tear in the recto-vaginal septum 
 by suturing the rectal and vaginal mucosa separately, and then repair- 
 ing the perineal rupture, including the sphincter, seems to provide 
 against most of the chances of failure. 
 
 Constipation not only favors the development and persistence of 
 uterine disease, but it renders common certain affections that result 
 from obstruction to the, venous circulation, esjiecially hemorrhoids. It 
 LS in vain to treat these latter until the cause has been sought for and 
 removed. Referring again to the oft-mentioned continuity of the 
 pelvic venous plexuses, the writer need only call attention to the fact 
 that the obstruction of the circulation through the rectal vessels may 
 be situatcMl in some remote portion of the pelvis. If ablation is 
 necessary, the operation is easier than in the male, since the piles are 
 rendered easily accessible by everting them by pressure through the 
 vagina. 
 
 The reflex symptoms resulting from rectal disease in the female are 
 best obser\'ed in cases of anal fissure. Besides the characteristic pain 
 experienced after defecation, the patient may suffer from vaginismus or 
 vesical disturbance, or may describe symptoms A\hich point to some 
 affections of the internal genital organs. Thorough dilatation of the 
 sphincter will remove a train of evils which appeared as formidable as 
 they were inexplicable. From the close proximity of the anus to the 
 \'ulva, it follows that certain affections of the latter may readily extend 
 to the former. Thus, pruritus ani, although it may exist independently, 
 oflen accompanies pruritus vulvse, while acrid and irritating vaginal 
 discharges, specific or non-specific, flowing downward over the anus 
 while the patient lies upon the back, may cause troubles which are 
 
204 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 rarely found in that region in the male (chancroids, plaques, mu- 
 quenses, etc.). 
 
 Pelvic abscesses sometimes rupture into the lower bowel, and con- 
 tinue to discharge their contents for months, or even years, especially 
 during defecation. It is manifest that it is not only next to impossible 
 to discover the opening of such an abscess, but to promote healing of 
 the sac, since it is subject to constant disturbance from the passage of 
 the feces. This fact is sufficient to prevent the surgeon from tapping 
 an abscess, ovarian cyst, or hsematocele through the rectal wall, or from 
 removing a diseased ovary through this channel, the latter being an 
 operation that has never enjoyed much favor. 
 
 In addition to the organs contained within the female pelvis, there 
 are certain tissues that invest and supj^ort those organs, with the anatomy 
 and relations of which it is important for the gynecologist to be thoroughly 
 acquainted. These are arranged to some extent in layers, and include, 
 as viewed from above downward, the peritoneum^ the connective tissue^ 
 and the pelvic floor. Each of these will be studied first as a whole, 
 and then in its relations to individual organs. It is assumed that the 
 reader is sufficiently familiar with the bony pelvis through his obstetri- 
 cal reading to obviate the necessity of introducing even a brief descrip- 
 tion of it here. 
 
 Pelvic Peritoneum. 
 
 As its name implies, this includes that portion of the serous lining 
 of the abdomen which covers the floor of the pelvis and invests more 
 or less completely the contained organs. The peritoneum covering the 
 anterior abdominal wall, as traced in a vertical mesial section at a point 
 an inch or an inch and a half above the upj^er border of the symphysis 
 pubis, is reflected backward to the fundus of the bladder. Covering 
 the posterior surface of that viscus as low as the level of the internal 
 OS (and as much of the lateral surfaces as lies behind the obliterated 
 hypogastric arteries), it crosses over to the anterior surface of the uterus, 
 which it invests, while laterally it extends outw^ard in a plane perpen- 
 dicular to that of the pelvic brim, to be attached to the lateral wall of 
 the cavity, forming the anterior fold of the broad ligament : having 
 covered the fundus uteri, it descends on the posterior surface of the 
 organ to a point on the vaginal wall about an inch below the utero- 
 vaginal junction, at the same time extending laterally as the posterior 
 lamina of the broad ligament. Finally, it is reflected from the vagina 
 to the anterior surface of the second portion of the rectum, and ascends 
 to the third part, which it surrounds completely (Fig. 67). Above this 
 point it leaves the pelvis, and need not be traced farther. 
 
 Besides investing the organs in the manner described, the membrane 
 
THE PKLVIC PERITOSKrM. 
 
 205 
 
 liiu's the lateral walls nf tlii' jx'lvis and tlij)s dnwii to cover the ]>elvie 
 floor, forming the anterior ami posterior ioss<e, which are sc])arate<l by 
 the broad ligaments. The anterior is not so deep as the j)osterior, sinee 
 the ])eritonciiiii at the sides of" the bladder only descends as low its the 
 base of the broad ligament, while behind the uterus it forms the pouch 
 
 Diagrrammatic Representation of the Pelvic Peritoneum, as seen in a mesial section fRanney) : 
 P, P, peritoneum ; li, rectum ; U, uterus ; B, bladder, distended ; S, symphysis pubis. 
 
 of Douglas, the bottom of which is considerably below this level. Fol- 
 lowing Luschka's teaching, we may regard the peritoneum as a sort of 
 diaphragm dividing the pelvic cavit}- into two portions : the one above 
 the peritoneum may be called the peritoneal space, while that which is 
 situated below it (/. e. between the peritoneum and the upper surfaee 
 of the levator ani mu.scle) is the subperitoneal. The latter contains 
 most of the connective ti.ssue of the pelvis (Fig. 68). 
 
 From what has already been said, it will be inferred that portions 
 of the pelvic organs are devoid of a peritoneal investment ; all of the 
 organs are really situatetl in the " ca\'nra pelvis subperitoneale," although 
 the anterior surface of the bladder, the anterior aspect of the cervix, 
 the anterior fornix vaginre, and the lower two-thirds of the rectum are 
 
206 
 
 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 the uncovered portions that lie in this space. The peritoneum is capa- 
 ble of a considerable amount of distension, so as to accommodate itself 
 to the variable size and position of each organ to which it is attached. 
 Thus it is affirmed by some writers that the lining of the anterior 
 abdominal wall immediately above the symphysis is actually " stripped 
 olf " by the bladder as it rises in extreme distension. Less probable 
 is the theory of Josephs, that, as the viscus fills, it deprives the ante- 
 rior surface of the uterus of a portion of its serous covering.^ 
 
 Polk has studied the changes in the relative position of the pelvic 
 peritoneum occasioned by pregnancy.^ The principal alteration seems 
 to consist in the elevation of the broad ligaments above the level which 
 
 Cross-section of the Pelvis, showing the Peritoneal and Subperitoneal Cavities (Luschka). 
 
 they occupy in the nulliparous woman. Hart and Barbour, reasoning 
 from the appearances seen in frozen sections, maintain that "during 
 parturition the peritoneum is drawn oif from the bladder." Savage is 
 sceptical on this point. Without stopping to discuss a matter which is 
 still sub judice, it may at least be said that the attachment of the 
 serous membrane to the lower part of the anterior abdominal wall 
 and to the fundus and posterior surface of the bladder is less inti- 
 
 ^ " Beitrag zur iEtiologie der Uterns-flexionen auf Grund anatomisclier TJnter- 
 suchung. u. Klin. Beobachtung," Beitrag zur Geburtsh. und GyndJcologie, Bd. ii., 1879. 
 
 ^ " Observations upon the Anatomy of the Female Pelvis," N. Y. Med. Journ., Dec, 
 1882. 
 
77//; I'l'.LVic ri:iUT()M:vM. 207 
 
 mate than ('Isc'wlicrc, so tliat il" a separation or slri|i|)ii);:; oil' o(;ciirrc(l 
 it would (loiil)tlcss !)(• at tlicsc; j)oiiits. 'I'lial (lie litems is over 
 depi'ive<l of its periloncal coveriiii;' is iniprdlniMc. 
 
 Tlie various attaeliineiits and folds of tlie pelvic j»eritoneiini have? been 
 described separately under the name of " litranients" and "pouches." 
 The forraor term is not a liap|)y one, since the delicate meniWrune in 
 (piestion seldom if evei- has a true lia,amentons function, this heinj^ 
 assumed l)v the subperitoneal layer of fibro-nniscular tissiu; which 
 Savajic has described as a platysma muscle. The expression "false 
 liii'aments," commonly emi)loyed by anatomists in descri])in^ the ])elvi(' 
 ortians, is in itself an evidence that the peritoneum is not regartled as 
 atfordino- much support to the structures beneath it, 
 
 l^ciiiuuino; anteriorly as beibre, we notice in the median line a narrow 
 fold of peritoneum which extends from the lunbilicus along- the anterior 
 abdominal wall, and is then reflected along the urachus to the fundus 
 of the bladder. This is known as the ligamcntum snspensorium, or 
 superior false ligament. The folds which extend outward from the 
 sides of the organ constitute the lateral false ligaments. Tlu^ utero- 
 vesieal ligament (or ligaments) includes that portion of the membrane 
 which stretches between the uterus and bladder. 
 
 The broad ligaments are the double folds of peritoneum before men- 
 tioned, which extend from the sides of the uterus to the lateral walls of 
 the pelvis, dividing that cavity into two parts. They contain the 
 uterine appendages with their vessels and nerves, the vessels and nerves 
 of the uterus, and other important structures, all of wdiich have been 
 described. In order to gain an intelligent idea of the formation and 
 contents of the broad ligaments, the reader should forget for a time the 
 unfortunate term " ligament," and recall the appearance of the mesentery 
 \vith its t^vo laminoe, between which are the vessels and nerves. The 
 conditions are similar : let the Fallopian tube represent a loop of small 
 intestine, and the corresponding broad ligament wnll be its mesentery. 
 Again : imagine that there is a double layer of membrane stretching 
 across the pelvis, and that the uterus has pushed its -way up from 
 beneath and separated the laminte, Avhich are elsewhere closely approx- 
 imated. And when we remember that each layer of peritoneum, as it 
 becomes folded, carries with it its subperitoneal layer of fibro-muscular 
 tissue, the subject becomes greatly simplified. It is now^ easy to under- 
 stand that there must be a space between the laminae in which run the 
 vessels and nerves, so that these are subperitoneal as well as the organs 
 which they supply. When the bladder is empty and the uterus is inclined 
 forward, the broad ligaments run outward and backward, while their 
 planes are tipped in such a manner that their anterior surfaces look 
 downward and forward. The base of each ligament will be rc]>resented 
 approximately by a wavy line, convex over its external half, drawn 
 
208 
 
 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 from the lateral border of the uterus at the level of the os internum 
 outward to a point just in front of the sacro-iliac synchrondrosis (Fig. 69). 
 Its upper margin, corresponding \\dth that of the tube, is slightly 
 concave near the uterus, from the superior angle of which it extends to 
 "a point on the pectineal line, situated in the virgin about midway 
 between the sacro-iliac synchondrosis and the ilio-pectineal eminence.^' 
 Its inner attachment is along the lateral border of tlie uterus from 
 the superior angle almost to the lateral fornix of the vagina, from 
 which it is separated Ijy a quantity' of loose connec-tive tissue enclosing 
 a venous plexus. The outer edge of the ligament is attached to the 
 pelvic wall " along a line which is situated betsveen the great sacro- 
 
 FiG. 69. 
 
 Diagram showing the Attachments and Relations of the Broad Ligaments rRanney) : P, P, pel- 
 vic bones ; Z7, uterus ; V, vagina ; 0, ovarj' ; F, FaUopian tube ; B. L, broad ligaments. 
 
 sciatic notch and the margin of the obturator foramen, as far doAvn as 
 the level of the ischial spine." According to Polk, as the uterus 
 enlarges during pregnancy the bases of the broad ligaments are car- 
 ried upward until at term they are almost on a level with the pectineal 
 line; their upper borders are simultaneously moved backT^-ard. They 
 return to their former positions after deliverv. 
 
 The following objects are suspended \\'ithin the folds of the liga- 
 ments : Along the upper margins are the Fallopian tubes, enclosed 
 betw^een the two folds which are attached around their distal extremites, 
 where the serous passes into the mucous membrane. The strip of peri- 
 toneum between the tube and the ovary is the mesosalpinx. As the 
 fimbriated extremities do not reach the pelvic walls, the gaps are filled 
 
Till-: I'KLVIC I'EIUTOSIJUM. 
 
 209 
 
 bv tlu'so-calkHl inf'iiu(lil)iil<»-|)tlvic lij^anionts, which arc sini])ly the dis- 
 tal portions of the upjtcr inarjiiiis ot" tlic hroad lijiaiiiciits. lidow the 
 proximal vmU i»l" the tubes are the ovarian ligaments, at the outer ends 
 of which arc the ovaries. These orfrans arc includetl Ix'tween the two 
 lavcrs, but arc attached to the anterior and project throuj^h the j)os- 
 terior.' The term raesovarium is sometimes applied to a j)ortioii 
 of the broad liirament just below the attached border of the ovary. A 
 space between the Ibkls of the mesosalpinx, between the distal end oi' 
 
 Diagram showing the Three Minor Folds of the Broad Ligament (Ranney) : 1. 2. 3. anterior, 
 middle, and posterior folds; if, round ligament: F, Fallopian tube: O. ovary: V. vagina: 
 JJ. pouch of Douglas: A, anterior layer of broad ligament; P, posterior layer: 7>. reflection 
 of peritoneum to bladder: B, reflection to rectum; S, space containing muscular and con- 
 nective tissue, enclosing vessels and nerves. 
 
 the ovar}- and the infundibulum, is called bv Olshausen ^ the bursa 
 ovarica. In the mesosalpinx beloAv the middle portion of the tube is 
 the parovarium. The round ligaments are still lower down, more 
 
 ^ Reference has already been made to the assertion of some writers that there is no 
 peritoneum on the posterior surface of the ovary. 
 ^ Krankheiten der Ovarkn, Stuttgart, 1S77, p. 7. 
 Vol. I.— 14 
 
210 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 internal than the ovaries, and lie in a plane more anterior than the 
 organs already mentioned ; the view that the ovary is situated in a 
 separate posterior fold of the broad ligament, the tube in a middle 
 fold, and the roimd ligament in an anterior, introduces, in the wri- 
 ter's opinion, an unnecessary complication (Fig. 70). 
 
 In the space bounded above by the tube and below by the round 
 ligament are the ovarian artery with its branches, the pampiniform 
 plexus, and a dense network of nerves and lymj)hatics; below this 
 region is one quite free from large vessels. Near the base of the liga- 
 ment are the uterine artery and venous plexus, and nerves and lym- 
 phatics as above. The position of the ureters with reference to the 
 broad ligaments has been made the subject of much discussion. Savage 
 affirming that they are normally found between the laminse, which is' 
 denied by Garrigues. As Polk has shown, in nulliparae they extend 
 downward along the lateral walls of the pelvis, passing behind the pos- 
 terior layers of the ligaments at their points of attachment, and dip- 
 ping down beneath the bases of the same ; during pregnancy the liga- 
 ments may change their positions and their folds become expanded, 
 while the ureters are but little disturbed, so that the latter may 
 come to be included within them.' 
 
 After covering the posterior surface of the uterus, the peritoneum dips 
 downward to cover the posterior vaginal fornix and a small portion of 
 the upper extremity of the posterior wall, and then it ascends to the 
 rectum. Two folds, however, cross over directly from the uterus, 
 extending backward and outward in the shape of a letter V, surround 
 the middle part of the rectum, and are attached to the second sacral 
 vertebra.^ These are known as the utero-sacral ligaments, or folds of 
 Douglas, and from their structure as well as their function they 
 approach more nearly to the character of true ligaments than do any 
 of the peritoneal processes thus far mentioned. They contain a con- 
 siderable amount of fibrous and smooth muscular tissue, so that they 
 possess a firm, cord-like feel. They may be described as fibro-mus- 
 cular bands enveloped by peritoneum. 
 
 Several well-marked pouches exist in the pelvic peritoneum. The 
 most important of these, as noted in order from before backward, are 
 the pubo-vesical, vesico-abdominal, utero-vesical, and the recto-uterine, 
 or pouch of Douglas. When the empty bladder is in systole the peri- 
 
 ' A consideration of the supporting function of the broad ligaments belongs properly 
 to the article on Displacements. The writer does not believe that they offer much 
 resistance to either antero-posterior displacements or prolapsus of the uterus. When 
 normal, they doubtless oppose to some degree lateral dislocation, just as they may cause 
 lateroflexion when contracted. 
 
 2 We have Polk's statement to the effect that during gestation the utero-sacral liga- 
 ments are elevated en masse — not only their uterine origins, but also their points of 
 attachment to the bony pelvis, so that they meet the sacrum near the promontory. 
 
Tin-: I'l.Lvic I'F.inroM'j'M. 
 
 211 
 
 toiiciiiii ;i[)|)t'ai> to lie rcllcctftl diicctly iVnin tlir anterior nlxloiniiial wall 
 to llii' iitcnis, while a (liprc.-.-ioii exists over tiie .site of the Madder whieh 
 has Ihvii called the iiteru-ahdoiuiiial ixnieh. This cavity, when it exists, 
 is Hlk'tl witii coils of small intestine, which are j^rraduully displaced 
 
 Fiu. 71. 
 
 The Reflectiniis and I'mirhes of the Pelvic Peritoneum > Hodge). 
 
 upward a.s the bladder becorae.s distended. The vesico-abdorainal 
 pouch is only observed during di.stension of the bladder ; its depth 
 varies according; to the point at which the .serous lining of the ab- 
 dominal wall is reflected. It is always empty. The vesico-uterine 
 pouch is bounded in front by the posterior surface of the bladder, 
 and behind l)y the anterior surface of the corpus uteri. The actual 
 depth of this fxssa varies less than that of the others, because of the 
 firm attacliment of the peritoneum to the uterus. When the blad- 
 der is empty the bottom of this pouch is .separated by about an inch 
 from the anterior cul-de-.«ac of the vagina; the entire pouch ri.ses .some- 
 what as the bladder fills. (See Fig. 71). 
 
 The pouch of Dougla.s is the most important, as well as the largest, 
 of the serous culs-de-sac of the pelvis. Its shape and extent are not 
 con.stant. It is bounded in front by tlie posterior vaginal wall to 
 the extent of an inch, and by the po.sterior surface of the supra- 
 
212 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 vaginal portion of the cervix, behind by the anterior surface of the 
 middle third of the rectum, and laterally by the utero-sacral folds. In 
 spite of opposing statements, the writer has satisfied himself by repeated 
 observations in both dead and living subjects that Hart and Barbour 
 are correct in asserting that, " v^hen the bladder is empty and the unim- 
 jji'egnated uterus to the front, there is small intestine in Douglas's 
 'pouch, excepjt at its very lowest part." The normal depth of the pouch, 
 as well as its precise relation to the posterior cul-de-sac, has been vari- 
 ously estimated. The variations in depth may range between twelve 
 millimeters and three centimeters. The bottom of the pouch (which 
 is the lowest limit of the pelvic peritoneum) may encroach so far upon 
 the space between the rectum and vagina as to reach the apex of the 
 perineal body.^ 
 
 Other pouches of less importance might be mentioned. A depres- 
 sion on each side of the bladder is called the paravesical pouch ; these 
 pouches may contain loops of small intestine when the bladder is 
 emptied and the uterus lies well forward. The external and internal 
 inguinal pouches, which lie one on each side of the obliterated hypo- 
 gastric artery, are more properly described in connection with the sur- 
 gical anatomy of inguinal hernia. The reflection of the peritoneum 
 along; the round ligament to form the canal of Nuck has been alluded 
 to in the section on the round ligaments. 
 
 Besides the disposition of the pelvic peritoneum in the form of small 
 pouches, we may regard the cavity as divided into two fossae — an anterior, 
 lying in front of the uterus and broad ligaments, and a posterior, which 
 is situated behind them. From ^^'hat has already been said, it will be 
 remarked that the peritoneum covering the anterior fossa is not so 
 firmly attached as that in the posterior : this fact is interesting in 
 connection with the theory of the pelvic segments, as will be shown 
 subsequently. The posterior fossa has been further subdivided by 
 Polk into two portions — an upper, which lies above the level of the 
 utero-sacral ligaments, and includes two triangular surfaces called by 
 him the "retro-ovarian shelves,"^ and a lower, which is Douglas's 
 pouch. The boundaries of each shelf are : in front, the base of the 
 corresponding broad ligament, internally, the utero-sacral ligament 
 of the same side, and externally, the wall of the pelvis. The upper 
 portion of the posterior fossa communicates with the lower through 
 the space which exists between the utero-sacral ligaments. In 
 nulliparge the most dependent point in the peritoneal lining of 
 the pelvis (excepting, of course, the bottom of Douglas's pouch) 
 nearly always lies above a horizontal plane intersecting the middle of 
 
 1 Pirogoff figures a section of a pelvis in which it descends as low as the ostium 
 vaginfe. 
 
 ^ So named because the prolapsed ovaries frequently rest upon them. 
 
Tin: I'Ki.vic ri:nrr<>si:rM. '21 M 
 
 the .<vin|>liysis in iVoiit and tiic |>i>iiit of tlic iinioii of the tliii'(l aii<l 
 tuiirtli saiTiil vcrtcltra- Ix-liiiid. In tlic |»rctiiiaii( woiiiaii, liowcvcr, llic 
 fldiii's ol' l)ittli lo.vsa' arc lai.-cd (tlic jtostcrini- nid.-t iioticcaMy), until at 
 tlu' st'vciitli nidiitli tlic rctiM-ovariaii .-^licivcs occupy a liif^iicr level than 
 the pelvic hrini, wliile at th(^ same lime the posterior fossa is contracted 
 l)V rca--on of the ehan}>"e in the external attaelim<nt.- of the liroad liga- 
 iiients. I'A-eii Doiiiilas's jumicIi is slightly elevated above its ordinary 
 level (l*olU). Till' chanj;es in the anterior fossa arc less strikinu'. 
 
 PiJAtTlcAL Dkductions. — The |)eritoiieum possesses a jiceuliar 
 interest for the s;ynec()lo<:;ist, because it not only clothes the peKic 
 oriians, but from its sensitiveness to irritation receives and transmits 
 iiiHnm Illations Irom them, h'atal j)eritonitis has ceased to be regarded 
 iLS the natural eonseinienee of injury to the serous lining of the ]«']- 
 vis, but localized iuHanimation is sutKeiently common and tlei>lorable 
 in its ultimate consequences. These limited inflammatory foci are 
 most common in two localities, and for different reasons — around 
 the distal extremities of the tubes and ovaries, through the direct 
 extension of inflammation of the lining of the genital tract, and 
 along the bases of the broad ligaments, as the concomitant (or result) 
 of so-called cellulitis. Remembering how the coils of small intestine 
 descend into the pelvis, so that their serous covering is in direct con- 
 tact with that of the pelvic cavity, it is evident that a peritonitis may 
 remain strictly localized, and yet may result in the formation of 
 adhesions which will impair the functions of several organs. When 
 the la|)arotomist boasts at the i)resent day that peritonitis is a rare 
 complication, he refers to a general affection of the serous membrane. 
 Some organs are only loosely covered by peritoneimi ; to others it 
 is closely adherent. This distinction is not unimportant, since injury 
 to the serous coat of the uterus, for example, is a more serious matter 
 than if a tear in the peritoneal covering of the bladder is involved, 
 both as regards hemorrhage and subsequent inflammation. 
 
 It is desirable that the reader should rid his mind of the idea that 
 the so-called broad ligaments are " ligaments " in the sense that they 
 furnish much sujiport to the uterus : they rather serve to steady it and 
 ojjpose lateral deviation of the organ. Doubtless their most important 
 function is to suspend the uterine appendages and to support the net- 
 work of vessels that ramifv between its folds. Cicatrices in either lig- 
 ament produce lateroflexion, a form of displacement exceedingly resist- 
 ant to treatment. Tearing of the folds — an accident which is not un- 
 common in separating adhesions during laparotomy or as a result of 
 too great traction upon the pedicle of an ovarian or tubal tumor — is 
 followed by an obstinate hemorrhage, wdiicli it is difficult to control 
 Ijccause of the situation of the l)leeding ]ioints at the bottom of the 
 pelvis. Temporary compression by means of long forceps, or pres- 
 
214 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 sure exerted through the vaginal fornix by means of a firm tampon, 
 is sometimes useful when it is impossible to ligate the oozing sur- 
 faces. 
 
 It is impossible to discuss the subject of sub- and intraperitoneal 
 hsematocele here ; contrary to the opinion advanced by Savage, the 
 peritoneum is capable of being separated from the subjacent tissues to 
 such an extent as to allow of the formation of large extravasations 
 beneath it. This is particularly noticeable during pregnancy ; hence 
 the possibility of making gastro-elytrotomy a strictly subperitoneal 
 operation. Recent writers have expressed doubt as to whether pelvic 
 abscess is ever confined to the cellular tissue — i. e. they believe that it 
 is, nearly always, of tubal origin. The fact that such abscesses often 
 lie wholly beneath the peritoneum should negative this theory. 
 
 The pouches formed by the pelvic peritoneum possess much prac- 
 tical interest. The bottom of the vesico-uterine pouch lies so far above 
 the anterior vaginal fornix that it is not exposed to injury during 
 operations in this region ; the distance of the peritoneum from the 
 fornix will be appreciated during the preliminary steps of vaginal 
 extirpation of the uterus, as it is necessary to separate the bladder 
 entirely from the uterus before the serous membrane is reached. It 
 is accordingly advised to open Douglas's pouch and to retrovert the 
 uterus through it before dividing its peritoneal attachments anteriorly. 
 Unless there is an unusually low dip of the vesico-uterine fold, it will 
 not be endangered in any ordinarv" operation on the cervix, short of high 
 amputation. The bottom of Douglas's pouch, on the contrary, lies 
 normally only one-third of an inch above the tip of the examining 
 finger when introduced into the posterior fornix ; this distance may be 
 diminished, not only by the pressure of morbid growths, the fundus of 
 a retroverted uterus, exudations, etc., but by the existence of an abnor- 
 mally deep dip of the membrane, as in the condition described by 
 Pirogoif, where it covered the posterior vaginal wall almost as low as 
 the vulvo-vaginal outlet. Less significance is attached to the opening 
 of the peritoneal cavity through the posterior fornix now that the 
 principles of drainage are better understood. Note that the middle por- 
 tion of the rectum is only partially covered by peritoneum (anteriorly), 
 although sufficiently to be affected by inflammations and adhesions of 
 that membrane. 
 
 The utero-sacral ligaments are, as before stated, essentially folds of 
 peritoneum strengthened by fibro-muscular tissue ; whether peritonitis 
 or cellulitis is the inflammation most common in them is an open 
 question. Probably both the serous and fibrous tissues are involved 
 in nearly every case of so-called " parametritis posterior." They are 
 commonly contracted in epithelioma of the cervix, even where the 
 broad ligaments are not involved, and complicate the final steps of 
 
I'lu.vic ciiSM-jTivi-: Tissvi:. 215 
 
 va<;inal hystiTt'ctoiny. Tlic siipixirtin;^- fiiiKlion of llic-i- IuuhIs will 
 1)1' (list'iisscd later. 
 
 As rcji'ards the iiiiicli-vcxctl ([iic-tinii nf the iTl;iti\c l'rci|iiciicv of" 
 peri- and parametntis, it may be addcnl that tlie aiiatomieal evidences 
 ail' ;;i"eatly in fiivor of tlie former, as will a])pear to the reader who 
 eoiisiders tin- various sources (»f infection to which the peritoneum is 
 exposed. The results of recent .studies in tidjal ])atholojiv have led to 
 a ('hauLic of vii'ws on the subject of pelvic inHainiaation.' 
 
 Pelvic Connective Tissue. 
 
 There are few subjects in the whole range of normal and pathological 
 anatomy about which so much has been written — and blindly ^^•ritten 
 — as that of the cellular tissue of the female pelvis. It is the bete 
 noire of the student and the stumbling-block of the more mature. 
 Instead of taking a rational view of the matter and remembering that 
 connective tissue possesses exactly the same structure, appearance, and 
 functions in whatever region of the body it may be found, nine men 
 out of ten approach the study of the pelvic areolar tissue in somewhat 
 the same .spirit as they begin that of the brain — with the idea that they 
 are about to grapple with a thing sui generis, the thorough ma.stery of 
 which will be a formidable task. Doubtless writers on gynecology are 
 responsible partly for this notion, since they have been somewhat dis- 
 posed to adapt anatomical facts to pathological theories, instead of 
 taking that broader view of the subject which can alone prevent one 
 from falling into error, Avhether of theory or of practice. 
 
 The pelvis is not an independent region of the body, neither do its 
 various tissues exist nnder different conditions from the same tis.sues 
 in other portions of the body. In considering the pelvic areolar tissue 
 as a whole instead of referring to it under the description of each 
 organ, we not only gain a clear idea of its relations to the separate 
 organs, but are able to appreciate better its close continuity with the 
 entire fibrous framework of the body.^ Although this continuitv 
 may not always be as clearly marked as in the case of the mem- 
 brane which has just been studied, it is none the less present, as will 
 be seen. 
 
 Connective tissue, whether it appears in the form of areolar or 
 lymphoid tissue, cartilage, or bone, always has the same office — " to con- 
 nect and support the other tissues, performing thus a passive mechanical 
 
 ^ Comp. paper by the ■writer on "The Exaggerated Importance of Minor Pelvic 
 Inflammations" ( X. Y. Med. Joiirn., May 15, 1886 1 ; also paper by Prof. W. M. Polk 
 in the X Y. Med. Record, Sept., 1886. 
 
 - Freund ( G>/na/:nlof/ii)rhe Klinil:. Strasbur?, 1885) ha.s complicated the subject by 
 describing the connective tissue around the various organs by separate names. He 
 refers to the '" paracystium," " paracolpium," " paraproctium," etc. 
 
216 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 function." ^ As viewed in the pelvis, it appears under tv\^o varieties or 
 systems •? 1. As a loose tissue which is distributed apparently in a most 
 irregular manner around and between organs, and between the layers 
 of the broad ligaments, where it serves to support the blood-vessels, 
 the folds of peritoneum, etc. ; 2. As firm, well-defined laminae or 
 planes which enter into the formation of the pelvic floor, and together 
 constitute the " pelvic fascia." The latter will be described with the 
 pelvic floor. 
 
 Considered in its entirety, all of this connective tissue forms the 
 middle layer of the three, which begins above with the peritoneum; it 
 may be traced from before backward in a vertical median section, just 
 as was done with the peritoneal layer, beneath which it lies throughout. 
 Passing down the anterior abdominal wall below (that is, anterior to) the 
 peritoneum, as low as the posterior aspect of the pubic symphysis, it. 
 stretches across to the anterior surface of the bladder, as the pubo- 
 vesical, or anterior true ligaments of that organ. Immediately behind 
 the pubes it contains a quantity of adipose tissue (retro-j)ubic fat), 
 which has a triangular outline in mesial sections of the pelvis, the 
 bladder being empty. The position of this pad of fat varies in different 
 attitudes of the body : when the patient is in the genn-pectoral posture 
 it sinks downward and forward, so as to be below {i. e. above) the 
 symphysis. There is a certain amount of areolar tissue in the space 
 bounded by the lower part of the posterior vesical wall in front and 
 the cervix uteri and upper third of the anterior vaginal w^all behind. 
 This tissue contains a venous plexus, and serves to unite the vagina to 
 the base of the bladder.^ When the latter is empty this " vagino- 
 vesical process " is all that intervenes between the peritoneum and the 
 anterior cul-de-sac. 
 
 The lower two-thirds of the anterior vaginal wall are so firmly 
 attached to the urethra by an intermediate layer of connective tissue 
 that it is possible to separate them only by careful dissection. While 
 the supravaginal portion of the cervix is surrounded by a quantity of 
 loose fibrous tissue, on the fundus and anterior surface of the uterus, 
 as well as beneath the vesico-uterine fold, there exists only the delicate 
 subperitoneal layer before described (the "platysma" of Savage). 
 Laterally, however, the tissue is again well marked, where it extends 
 outward between the folds of the broad ligaments. This same pla- 
 tysma, composed as it is of fibrous, elastic, and smooth muscular tis- 
 
 1 Schiifer, Essentials of Histolor/j/, p. 30. 
 
 2 The loose cellular tissue of the pelvis has been divided by some authorities into 
 two "processes"— a "pubo-sacral," including the median portion of the layer, extend- 
 ing from the symphysis pubis to the sacrum, and a " utero-iliac," which comprises the 
 fibres extending outward from the lateral borders of the uterus to the pelvic wall 
 between the folds of the broad ligaments. 
 
 ^ It is the " parametric" tissue of Virchow. 
 
rF.LVir royyFJTivr. tissue. 
 
 217 
 
 sue, is ivricctoil on !<» llii- liilxs, roiiiid liji,aiM(.'iits, iit('r(i-s;i<'r:il, ami 
 ovarian liiiuincnts, loi-miiii; tlicii" siipcrlicial layer. 
 
 It is cliilicnlt to understand how some authorities can deny the |»res- 
 eueo of lihro-inuseuhn* tissue in the hroad lli^anieuts. Reasoniuj^- IVoui 
 analo^ry, tiie [)rosenco of such a rich \aseular area as that which lies 
 between these folds of peritoneum |)resu])p()ses the existence of no 
 inconsiderable ([uantity of such tissue iu (he iuuuediate neighborhood 
 
 I'lc. 7-2. 
 
 Mesial Section of the Pelvis, cutting at junction of Broad Ligament and Uterus : a, vagina, with 
 its walls separated; b. bladder; c, symphysis; d, broad ligament; e, ovary;/. Fallopian 
 tube. (Hart and Barbour). 
 
 of the blood-vessels.^ This alone Mould be a convincing proof, even 
 if it were not possible to trace Avith ease distinct bands of fibres which 
 are continuous with the general connective ti.-^sue of the pelvis. Gue- 
 rin's^ idea, that the ti.ssuc between the folds of the ligaments has no 
 connection with the rest, is not tenable, any more than if it Avas 
 affirmed that the included vessels M-ere independent of the general 
 
 ^ The reader will also remember that each fold of peritoneum lias its own platvs- 
 ma layer. 
 
 '^ rhierin, '" Sur la Structure des Liuaiiients larges,"' (/iiinptes n')t(lii)>, 1879, p. 13G4. 
 
218 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 pelvic circulation. In point of fact, the application of the term '' liga- 
 ments " to these reduplications of the peritoneum is only justified by 
 the presence in them of a strong fibrous and muscular framework, as 
 was shown in the case of the sacro-uterine bands. Without such a 
 framework they could not even furnish proper support to the vessels 
 and nerves, not to speak of the uterine appendages. In short, the 
 connective tissue of each broad ligament is the ligament itself ; the 
 peritoneal folds constitute simply a thin veil which is thrown over 
 the former, but which does not increase its strength.^ The tissue in 
 question enters the broad ligament from various sources. The super- 
 ficial muscular stratum of the uterus contributes numerous delicate 
 fibro-elastic bands ; others are reflected from the external layers of the 
 tubes and round ligaments. The vessels carry with them their own sup- 
 porting tissue and the peritoneal folds have their thin elastic substra- 
 tum. The areolar tissue seems to be most abundant at the bases of the 
 ligaments, where it blends ^vith the mass already referred to, which sur- 
 rounds the cervix uteri and roof of the vagina, filling the interval 
 between these and the neck of the bladder. The richness of the blood- 
 and lymph-supply of these parts was noted in another place. The 
 practical importance of these facts will be evident in connection with 
 the pathology of cellulitis. 
 
 Proceeding backward from the broad ligaments, we observe a thin 
 subperitoneal layer on the posterior surface of the uterus ; it is not so 
 intimately united to the subjacent muscle as it is over the fundus and 
 anterior aspect of the organ, so that a certain amount of separation 
 of the peritoneum is possible. Between the rectum and the posterior 
 vaginal wall there is a stratum of areolar tissue which extends down- 
 ward as low as the apex of the perineal body, establishing a loose 
 connection between the two canals (recto-vaginal process). The 
 upper portion of this tissue surrounds the supravaginal portion of the 
 cervix and the posterior fornix. As in the vesico-uterine pouch, it 
 separates the fornix from the peritoneal cavity. The entire thick- 
 ness of the tissues intervening between the latter cavity and the 
 vagina is estimated at not over a third of an inch. The opinion 
 has already been expressed that the " folds of Douglas," or utero- 
 sacral ligaments, are true ligaments, consisting of bands of fibrous 
 tissue enclosing elastic and muscular fibres, the latter being derived 
 from both the uterine and the vaginal walls. Their direction is such 
 (upward and backward) that they would lie almost in a line with the 
 
 ^ The unstriped muscular tissue of the broad ligaments is thickest near the borders 
 of the uterus. As we trace them outward both the fibrous and muscular bundles 
 decrease in number and size, until, on reaching the pelvic wall, they have almost 
 entirely disappeared. Note that the bases of the broad ligaments are in contact with 
 the lateral culs-de-sac of the vagina, except when the former are elevated during 
 pregnancy (Eanney). 
 
PELVIC COXM-CTIVJ-: TISSUE. 219 
 
 anterior wall oi" the vaiiiiia if it wi-re exteiideil iKiekward (Fi^. 7."J).' 
 Luselika" well described liolli the sti'iietiire and the innetions of these 
 tolds w hi'n he applied to them the name nuiscii/it.s retractor uteri. The 
 " pnl)o-saeral " [»i-oeess ol" eonneetive tissne terminates in a thin layer 
 which separates the rectnni from the saernm. 
 
 A description of Konig's method ol" dcmonstratinti' the coiitimiitv 
 of the suhjieritoneal eonneetive tissne by means of injections of air or 
 fluids belongs more properly to the snbjeet of ex})erimental patholo;i,y. 
 His results, as snnunarized by IJandl, were briefly as follows : On inject- 
 ing- water into the space between the folds of one broad li<rament, the 
 site of the injection being near the upper edge of the ligament, it flrst 
 extended i^)ut\\ard to the pelvic wall, then entered the iliac fossa beneath 
 the peritoneum ; from this ])oint it made its way both upward along the 
 anterior abdominal wall, and downward along the wall of the true pel- 
 vis. If injected below the base of the ligament, however, anterior to, 
 and a little to one side of, the utero-eervieal junction, it first spread in 
 a lateral direction, and later distended the vcsico-utcrine subperitoneal 
 space ; it then made its "svay beneath the peritoneum covering the 
 anterior surface of the supravaginal cervical segment and the poste- 
 rior aspect of the bladder, and ran along the round ligament to the 
 internal ring, turned to the left to follow the line of Poupart's liga- 
 ment, and terminated in the iliac fossa. If fluid is introduced pos- 
 terior to the base of the ligament, it first infiltrates the corresponding 
 half of the posterior fossa, then extends to the iliac fossa, and event- 
 ually reaches the anterior abdominal wall as before.^ 
 
 Practical Deductions. — Great importance has been attached to 
 the manner of distribution of the pelvic cellular tissue in connection 
 with the study of ])arametritis and abscess-formation. For details the 
 reader must consult special works. In some localities it is evident 
 that an inflammatory process may be limited to this tissue ; in others 
 (notably in the broad ligaments) it is difficult to conceive how the 
 peritoneum can fail to be involved. The experiments of Konig and 
 Bandl, in w'hich fluid or air was injected into the cellular tissue of 
 the pelvis in order to determine the course taken by collections of pus, 
 explain the "pointing" of abscesses in the perineum, in the inguinal 
 region, or even as high up as the umbilicus. Konig holds, briefly, that 
 an exudation between the folds of the broad ligament eventually makes 
 its way to the floor of the pelvis along the ilio-psoas muscle, M-hile 
 
 ^ F(ir an ingenious explanation of the action of these ligaments, consult Fosters 
 paper on "The Mechanical Action of Pessaries,"' Am. Gyn. Tt-ans., 1881. Comp. Fos- 
 ter's diagram, reproduced by Ranney {op. cit., fig. 6). 
 
 - Op. cit., p. o()l. 
 
 'Elaborate experiments of the above character have been reported by Schlesinger 
 (Med. Jahrb. der K. K. Geselkchaft d. Aei-zte in Wien, Heft 1-2, 1878). See also Bandl, 
 op. cit.. pp. 109-1] 4. 
 
220 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 a collection of pus forming near the side of the cervix follows the 
 course of the cellular tissue at the lateral borders of the uterus, 
 then passes beneath the inguinal canal along the round ligament, 
 and, reaching Poupart's ligament, turns backward and outward to 
 reach the iliac fossa. Rupture of a pelvic abscess into the peritoneal 
 cavity is fortunately rare, spontaneous perforation into the vagina, 
 rectum, or bladder being much more common. The danger of hem- 
 orrhage in incising an abscess through the fornix is not imaginary, 
 and should render the thermo- or galvano-cautery preferable to the 
 knife. 
 
 Subacute inflammation of the cellular tissue is a common result of 
 puerperal lesions, especially laceration of the cervix. However we 
 may difPer in regard to the character and significance of the indura- 
 tions which are found at the bases of the broad ligaments in cases of 
 deep laceration of the cervix, we must admit that they do exist, and 
 that they radiate directly outward from the angle of the tear. Dr. 
 Emmet has attached great importance to their detection by palpation 
 through the vaginal fornix, and to the advisability of endeavoring to 
 promote their absorption by means of hot-water injections and local 
 applications before the operator can safely or successfully repair the 
 lacerated cervix. He is also inclined to regard utero-sacral cellulitis 
 as a consequence of injury to the cervix — a sequence which, from the 
 indirect relation of the parts involved, is by no means clear. 
 
 While the writer has no desire to dwell upon his personal views 
 regarding the treatment of chronic cellulitis, he cannot avoid the 
 temptation to propose to the reader the consideration of the follow- 
 ing questions in the light of the foregoing anatomical studies : Are 
 small cicatrices or strictly localized thickenings in the serous or 
 cellular tissue of the pelvis capable of obstructing the circulation 
 over a sufficient area to cause chronic engorgement of the uterus and 
 its appendages? Does the constricting action of hot vaginal injec- 
 tions directly affect the vessels not contiguous to the fornix ? Does 
 the entire pelvic circulation feel their influence, or is ansemia produced 
 in one locality at the expense of hypersemia in another? Let the 
 reader recall what has been said regarding the extent and continuity 
 of the venous plexuses, and answer for himself.^ 
 
 One more question may be permitted : Is it in the power of hot- 
 water injections, iodine, and glycerin-tampons to act through the 
 vaginal fornix in such a manner as to cause the absorption and dis- 
 appearance of firm, non-vascular cicatricial bands, which may be situ- 
 ated w^ithin the pelvis from a third to half an inch from the spot 
 
 ^ It is claimed that in these questions we are dealing with known clinical facts. No 
 one denies the local hsemostatic and astringent action of hot water ; reference is 
 made to its power to modify the circulation at distant points. 
 
PELVIC CONNECTIVE TISSUE. 
 
 roaclicti l)y the inicrtiuii ov ;i|i|>li<':i(iim ? Whatever dircciioii our 
 anat<»mi("il speculations may take, eliiiieally we shall never re<rret 
 the atlo|>tion ol' the routine ])raetiee of renardinji; with suspicion all 
 evidenei'S, whetlier sul)jeetive ol" ohjeetivi', (»t" f'orniel" periuterine 
 indaniMiatioii, and oi" resti-ainiutr our ardor operandi aeeordin<:lv. 
 
 Sinee the utero-saeral folds of peritoneum are, bv reason (jf their 
 contained connective tissue and mode of attachment, true ligaments, it 
 seems advisable to studv their 
 
 normal and pathological action '"''■ 
 
 here. This V-shaped process, 
 which can usually be distinctly 
 felt through the posterior for- 
 nix, is attached to the uterus 
 just above the isthmus, in such 
 a line that it forms with the 
 anterior vaginal wall \\hat Fos- 
 ter has ai)tly called a " support- 
 ing beam " — the two structures 
 opposing each other and retain- 
 ing the uterus (which lies in the 
 middle of the beam) in its nor- 
 mal position. That the liga- 
 ments contain a sufficient 
 amount of muscular fibre to 
 justify Luschka in calling 
 them the *' rctractores uteri " 
 is proved clinically, not only 
 bv the state of tension which 
 is observed in them during a 
 vaginal examination, but also 
 by the fact that they often dis- 
 tinctly relax under the influence of an antesthetic. The writer has 
 affirmed, as the result of clinical and anatomical observations, that 
 the diagnosis of " thickening of the utero-sacral ligaments " (para- 
 metritis posterior) is often ba.sed ujjon a supposed prominence or 
 tension of these cords which is entirely normal. Every gynecologist 
 must have noticed how moderate anteflexion, due to apparent shorten- 
 ing of the ligaments, has been practically eliminated after the ])atient 
 was anfesthctized. 
 
 True cicatricial contraction of the utero-sacral folds (whether as the 
 result of cellulitis or peritonitis, or of a combination of the two con- 
 ditions) leads to anteflexion and vesical irritation, the latter symptom 
 being one of the most trying with which the gynecologist has to deal. 
 The futility of expecting to accomplish much l)y the use of anteflexion 
 
 iJiagram of Model designed to show the suiif.ort- 
 ing action of the Anterior Vaginal Wall and 
 the Utero-sacral Ligaments (Foster* : A, B, C, 
 D, two elastic bands intersecting at the point 
 of attachment of the uterus {U), which is fast- 
 ened to them by a pivot (P) ; S, s>'mphysis pnbis 
 fastened fh-mly tn block, as is also the sacrum 
 (.S) : r, uterus rendered movable in all direc- 
 tions by the elastic bands; T'. vagina, repre- 
 sented by a piece of rubber tubing: L, rubber 
 bantl representing utero-sacral ligaments. 
 
222 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 pessaries will be apparent to any one who views the displacement even 
 from a purely mechanical standpoint, since the problem is not to ele- 
 vate the fundus, but to relieve backward traction on the organ. 
 Neither does dilatation of the cervical canal for the purpose of 
 overcoming the mechanical obstruction (with or without the intro- 
 duction of a stem pessary) fulfil the main indication, which is to 
 stretch the shortened ligaments. How far it is possible to accomplish 
 this clinically by means of tampons, massage, etc, we shall not 
 attempt to decide here. 
 
 Pelvic Floor. 
 
 Synonyms. — Pelvic diaphragm ; Lot., diaphragma pelvis ; Fr., 
 plancher pelvien ; Ger., Beckenboden. 
 
 Definition. — By the pelvic floor we understand the ensemble of the 
 soft parts which close the outlet of the pelvis. Strictly speaking, this 
 definition includes several of the organs already described (the rectum, 
 vagina, and bladder), as well as the serous and fibrous layers which 
 have just been mentioned. We shall limit it to the actual diaphragma 
 pelvis^ — i. e. the levatores ani muscles, with the layers of fascia above 
 and below them, the perineal body, with the muscles and fascise enter- 
 ing into its composition, the ischio-rectal fossse, and the integument cov- 
 ering the whole. 
 
 In order to possess a clear idea of the diaphragm we may imagine 
 that we are looking down upon it from above, after having removed 
 the uterus and broad ligaments, together with the peritoneum, and 
 cleared away as much of the loose connective tissue as suffices to expose 
 the underlying fascia. We have now to consider from above down- 
 ward — that is, from within outward — the following distinct lamiuse : 
 Two layers of fascia, a superior (recto-vesical) and an inferior (anal), 
 between which are the levatores ani ; below these is a space occu- 
 pied posteriorly by the lower end of the rectum, with its muscles, 
 and a quantity of fat (ischio-rectal fossa), and corresponding anterior- 
 ly to the cavity between the two layers of the triangular ligament. 
 Still lower are the inferior boundaries of these spaces — behind, the 
 obturator fascia; in front, the anterior layer of the triangular liga- 
 ment. Next comes the deep layer of the superficial perineal fascia ; 
 and lastly, the superficial layer and the integument. 
 
 We may group the component parts of the pelvic floor into a superior 
 and an inferior layer, the latter including the parts ordinarily exposed 
 in a dissection of the perineum, which may be studied best from below. 
 The superior or deeper parts will first be considered. 
 
 ^For exhaustive details refer to Hart's monograph, " The Structural Anatomy of 
 the Female Pelvic Floor," Edinburgh, 18S1. 
 
 '■^ Under this term German writers refer, as a rule, to tlie levatores ani alone. 
 
THE PEI.VK' FiJtOi:. 
 
 09:^ 
 
 Altlioiiiili till' :iii:iii;:ciiitiif of tin- pt-lvic liiscia is <'X|)Iaiiic(l in all <>!' 
 the staiulani works mi general aiiatmiiy, tlic <l('scri|>tiniis nearly always 
 liave rctrn'iicc to tlic male pelvis, in which the relatimis oC the |)arts 
 are ciiiiipai-atiNclv sini|)le. In the female the Moor ix pierced hy tlie 
 vauiiia, so that a i'iini|)licati<»n i- tinis introduced which renders a sep- 
 arate description of the |»arts necessary. The pelvic I'u-seia, a.s viewed 
 
 Fid. 74. 
 
 Fascia of Pelvic Floor (Savage): B. bladder: T'. vagina; B, rectum; P, pubic symphysis; S, 
 sacrum ; a, fascia covering psoas muscle ; b, obturator fascia ; c, ilio-pubic line ; d, reflection 
 of fascia on to the rectum, vagina, and bladder: e, posterior portion of pelvic fascia cover- 
 ing sacral vessels and nerves; /, iliac fascia, covering iliac vessels; ^, gluteal vessels; h, 
 ischiatic vessels; i, internal pudic vessels; k, obturator vessels. 
 
 from above, is seen to be attached laterally to the ]K'lvic brim ; ante- 
 riorly, its line of attachment extends downward, following: the oritjin 
 of the obturator muscles, and terminates near the lower border of the 
 symphysis pubis. As it crosses the obturator foramen the fascia becomes 
 attached to the membrane which covers that openintr. Posteriorly, it 
 is adherent to the spine of the i.sehium, beJiind which point it is con- 
 tinuous with a thin lamina that covers the pyriformis mu.scle and sacral 
 plexus (fascia of the pyriformi.s) ; the latter separates the sacral plexus 
 
224 
 
 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 from the iliac vessels, branches of the latter piercing the pelvic fascia.^ 
 The attachment of the pelvic fascia is clearly indicated by a tendinous 
 band ("white line") which extends from the spine of the ischium to 
 the lower portion of the symphysis. From this line springs the recto- 
 vesical fascia, which is now regarded as the direct continuation of the 
 pelvic, instead of the obturator, fascia, as is still affirmed by many 
 anatomists.^ The recto-vesical process arises as above mentioned, ex- 
 tends downward and in^vard, lying upon the upper surface of the cor- 
 
 Muscles of Pelvic Floor (Savage; : B, neck of bladder; T, vagint^'^ It, rectum; P, symphysis 
 pubis; C, coccyx; S, sacrum: A, acetabulum; 1, anterior vesical ligaments; 2, pubo-coccyg- 
 eal portion of levator ani; 3, obturator-coccygeal portion ; 4, ilio-pubic line of the latter; 
 5, ischio-coccygeal portion ; 7, pyriform.is muscle ; 8, obturator muscle. 
 
 responding levator ani, and unites in the median line with the fascia of 
 the opposite side. The fascial diaphragm thus formed, Avhich separates 
 the pelvic from the perineal space, is perforated by two slits, the vagina 
 and the rectum. It is firmly attached to the walls of these canals, and 
 
 1 Comp. Quain's Anatomy, vol. i. p. 326 ; Ellis, Dissections, p. 546 ; Carrington, Dis- 
 sections, pp. 145 and 160-167 ; Heath, Practical Anatomy, '^p. 266-268. 
 ^Carrington, op. cit, p. 161 ; also Quain, op. cit., p. 326. 
 
Tin: rKLVic FLonn. 
 
 22o 
 
 sends off from its iiiidcr >iirliic(' lihrmis >li(:itlis wliidi >nn-<»iiii<l ;iinl 
 follow the tiilx'S (jowinviirtl. 
 
 The rt'ctal ,-licatli cuvcrs the lower three iiielie~ of the l»o\vcl, j^rad- 
 uallv disapiK-ariiii; toward the amis; it lies immediately over the 
 superior hemorrhoidal vessels. The vairiiia also has an eiiveloj)e, 
 whieh mav he traeed alonjj; the 1iil)e lo it> lower end, w iiei'e it ix'oomcs 
 lost in the deep j)erineal fascia {'.'). It 
 covers the va<>iiial plexuses and con- 
 stitutes the external layer (tf tiie va- 
 ginal wall. 
 
 The bladdi'r also receives su]>port 
 from the same source, the anterior 
 true ligaments being formed by two 
 processes which extend from the back 
 of the pubes (the anterior attachment 
 of the fa.scia) to the neck of the blad- 
 der ; between these special processes 
 the recto-vcsical fascia is said by El- 
 lis to descend to the triangular liga- 
 ment of the urethra, of which it forms 
 the posterior layer.^ The lateral liga- 
 ments of the bladder are formed by 
 fascial bands which arc attached to 
 the postero-latcral border of the vesi- 
 cal base. The rectum has also two 
 lateral ligaments derived from the 
 same fascia, which are attached ex- 
 ternally to the ischial spines, and op- 
 pose lateral displacement of the gut. 
 
 '- , . J^ transverse perineal muscle: 3, bulb of 
 
 On removing that portion of the vagina; 4, muscle of perineal septum. 
 
 recto-vesical fascia of both sides 
 
 which covers the floor of the pelvis, bv detaching it along the entire 
 length of the white line externally and from its attachments to the 
 pelvic organs internally, the subjacent muscular stratum will come 
 into view (Fig. 75). This consists of two pairs of muscles, the 
 coccygei and the levatores ani, the former being comparatively 
 unimportant in this connection. The coccygei (levatores coccygis, 
 ischio-coccygei of Savage) are two thin, triangular muscles which 
 spring from the upper portions of the ischial spines, and by a few 
 slips from the lesser sacro-sciatic ligaments, and pass inward, gradually 
 expanding into broad, thin laminte that are attached to the lateral bor- 
 ders of the lower segment of the sacrum and to the anterior surface and 
 
 ' Denied by Carrington (Manwd of Dissections, p. 165), who intiists that the deep layer 
 is formed by the obturator fascia. 
 Vol. I. — 16 
 
 2 PW4- S 
 
 Perpendicular tran.-verse Section of Pelvis 
 through middle of Vagina (Savage): V, 
 vagina, showing posterior wall : O, ischio- 
 rectal fossa, filled with fat; T, ischial tube- 
 rosity; i?, inferior pelvic space; />, recto- 
 vesical fascia, covering upper surface of 
 levator ani; C, fascia covering lower sur- 
 face of levator ani ; X, olnurator fascia ; P, 
 posterior aponeurosis of perineal septum; 
 .1/, anterior aponeurosis of same ; S, deep 
 layer of superficial perineal fascia; 1, 
 cross-section of right crus clitoridis, in- 
 cluding erector muscle : 2, superficial 
 
226 
 
 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 borders of the coccyx. Their inner (pelvic) surfaces are covered by- 
 special layers of fascia continuous with the recto- vesical. The upper 
 surface of the left coccygeus is in contact with the rectum, which it 
 partially supports. The lower surfaces rest upon the glutei maximi 
 and the lesser sacro-sciatic ligaments ; in front are the posterior borders 
 of the levatores ; behind, the pyriformis muscles, separated from the 
 pair under consideration by vessels and nerves. 
 
 The levatores ani have such extensive origins and insertions that 
 each muscle is divided by Savage into t^vo separate portions, pubo- 
 and obturato-coccygeal. The coccygeus muscle he includes with the 
 levator under the name of the ischio-coccygeus. Each levator arises 
 in front from the posterior aspect of the pubes near the symphysis 
 (pubo-coccygeus), behind, from the lower and inner surface of the 
 
 Fig. 77. 
 
 - v.. 7 
 
 lis, / I - 
 
 "A lii 
 
 :-^*il tli'ikt^ 
 
 ''WiiiJ'fii''' 
 
 / 
 
 5 6 
 
 Attachment of the Muscular Floor of the Pelvis to the Bladder, Vagina, and Rectum (Savage) : 
 B, bladder; V, vagina; It, rectum; 1, pubo-coccygeus; 2, otaturato-coccygeus ; 3, ischio- 
 coccygeus; 4, ilio-pubic attachment of muscle; 5. coccygeal attachment; 6, median raphe ; 
 7, Arcus tendineus of Luschka, aponeurotic fibres reflected to bladder. 
 
 ischial spine, and between these origins from the " white line " that 
 represents the point of division of the pelvic fascia. It is also con- 
 nected by fleshy slips with the obturator fascia and the posterior layer 
 of the triangular ligament. The anterior fibres may form a separate 
 bundle, an interval existing between them and the rest of the muscle ; 
 these extend downward and inward contiguous to the posterior layer 
 
77//; I'l.l.Vir FLnon. L'-J7 
 
 of the tri:iii^iil:ii' li^Miiiciit, :iiiil unite in the niediiiu line nf the |ie|\'is 
 with tlie ••<>nc-|Kiii(|iiiii |»()ii inn ol' the o|i|(u~ite muM-le. 'Ihe iM-ethi:il 
 and vaii;iiial slips perforate the inns<Mihir ilia|>hra;j;in hei-e, and feeeivo 
 .sli|)s tVoin it ; Ix-hind the vagina the internal Hl»fes of ojtpo.-ite nins<'le.s 
 meet and Mend with the deep tran>\'er-e p<iineal inn>ele~ in the peri- 
 neal body. The |)f(»lnn<iati(>ns ot" the pnl)u-eoee\ j^^ens nti the sides of 
 the vajfiiia and ni'ethra convspoud to Santorini's iniiseles ( levatorcs 
 prostatjo) in the male.' The j)o.sterior ]»ortion (I''ii:. 77) of the piiho- 
 c<Hvvireiis (eorrespoiidin<i; with the middle portion of other anatomists) 
 unites with its fellow to surround the lower end of the rectum, whieh 
 it suspends as it' in a sliuu", and Mends with the external (and, to 
 Some extent also, with the internal) sphinet<'r. The most posterior 
 of the fibres unite behind the rectum in a median raphe whicii termi- 
 nates at the end of the coccyx. The posterior part of the levator (the 
 obturator coccviii-eus of Savaire) meets its fellow in the raj)he behind 
 the rectum, and I)oth are inserted into the sides of the la.st two eoe- 
 cvgeal vertebne, below tlu- insertions of the eoecygei (i.schio-coccygei). 
 
 From the ahove it will Ik' evident that the levatores ani form a thick 
 septum across the jK'lvic outlet, the general shape of whicli is concave ; 
 this septum at its }>eripherv has bony attachments extending around 
 the brim of the pelvis, while its centre has no fixed su])port. In the 
 median line it is weakened by the presence of the vaginal slit, which 
 defect is obviated to some extent l)y the fact that the vaginal walls are 
 normally in close apposition, and that the canal cuts the ])elvic floor at 
 an angle of al)out sixty degrees (Hart and Barbour). The firm attach- 
 ment of the muscular diaphragm to the genit< (-urinary organs is an 
 important factor in connection with the maintenance of their proper 
 positions. 
 
 A thin layer of fascia covers the under surface of the levator; it 
 arises from the pelvic brim below the origin of the muscle, and is 
 attached to the obturator fascia, while in the median lifie it blends Avith 
 the opposite lamina and is attached to the rectum and vagina in the 
 same maimer as the recto-vesical fascia, although it is much less devel- 
 oped than the latter. Anteriorly, it is attached to the posterior laver 
 of the triangular ligament. It is in immediate relation below Mith 
 the fat which fills the iscliio-rectal fossa. A description of the obtu- 
 rator iascia does not really belong here, since it merely covers the inner 
 surface of the <jbturator muscle, and thus forms the outer wall of the 
 ischio-rectal space. 
 
 After removing the layers above mentioned there remain onlv 
 the superficial structures which chtse the pelvic outlet. The ischio- 
 
 ' Note that Savage's description of the insertion of the pnbo-coccvgeus is pecnliar, 
 in that he represents the fibres as running downward and backward, rather tlian down- 
 ward and inward. 
 
228 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 rectal fossse do not need a special description, since their anatomy is 
 the same as in the male. The perineal body, on the contrary, is a 
 structure peculiar to the female. 
 
 The Perineal Body.^ 
 
 Synonyms. — dr., Tzepi'uacov -, Led., perinseum; Fr., perinee ; Ger., 
 Damm ; It. and -S)^., perineo. 
 
 Between the lower ends of the rectum and vagina is a somewhat 
 pyramidal space, formed by the divergence of the two canals that have 
 been described as lying in close contact as low as an inch and a half 
 above the anus. This space is filled by a mass of fibro-muscular tissue, 
 which is attached not only to the anterior wall of the rectum and the 
 posterior wall of the vagina, but also to the pelvic floor. Its dimen- 
 sions are variable, depending not only upon the muscular development 
 of the individual, but upon the amount of adipose. It is common to 
 represent it in mesial sections as a perfect triangle. It is highly 
 desirable that these diagrammatical figures should cease to be repro- 
 duced in modern textbooks, to mislead the inexperienced reader and to 
 give him false ideas of the aims of gynecological surgery. IS^ow that 
 the " keystone" theory of the perineum has been rejected by all thought- 
 ful men, the inaccurate representations of the supposed keystone should 
 not be retained as the exuvice of a discarded error. The perineal body 
 is neither a triangle nor a pyramid, but, as we learn from a careful 
 study of the region both in the living female and in frozen sections, 
 it is irregularly quadrilateral in form ; ^ sometimes it has almost the 
 shape of a gourd, the neck of which corresponds to the " apex " of 
 the triangle, as formerly described.^ 
 
 The quadrilateral shape of the perineum is, as Foster has shown by 
 careful measurement, largely the result of muscular action, which draws 
 the body forward, causing a prominence near the ostium vaginse that 
 forms the anterior angle of the square. T^vo sides of the square rest 
 thus against the vaccinal wall, a third looks toward the rectnm, and 
 the fourth represents the space between the posterior vulvar commis- 
 sure and the edge of the anus. If, as the same writer states, through 
 weakness of the muscles attached to the perineal body, it is not drawn 
 forward in the usual manner, it may present but a single surface ante- 
 riorlv, and then it has the triangular shape usually figured. As before 
 stated, its dimensions are variable. Its upper limit — or rather the 
 point at which the rectum and vagina begin to diverge — is about an 
 
 ^ For literature refer to Hart and Barbour, and to Eanney's paper on " The Female 
 Perineum " (N. Y. Med. Journ., July and Aug., 1882). 
 
 - Foster, "Topograp. Anat. of Uterus, etc.," Am. Journ. Obstet.,vo]. xiii., 1880. 
 ^ "The cucurbit of an alembic" (Garrigues, Am. Journ. Obst, April, 1880). 
 
THE J'i:i:im:al nonv. 229 
 
 inch ;iii(l a hall' trmii the aiiii~. Vlir prc-ciicr of :i thick JaNcr nf 
 adipost' ill a liit siihjci-t will nf" cDursc increase the distaiK-e hetweeii 
 its ajji'x ami the surl'acc ol' the intetiiinient. The transvei>>e nieas- 
 urenient is an incli and a hall", the antero-po.sterior from three-quar- 
 ters ot" an inch to an ineJi. Its relations have already been mentioned. 
 Ant(M-it)r to it lie the vaj2;ina, i)eliiiid, the rectum and anus, laterally, 
 fat ; lu'low, the intei;unient of the perineal space, above, the lower end 
 of the lihrous sej)tuiii iinitiui;' the vaii;inal and rectal walls. The entire 
 body lies below a horizontal plaue passing; through the subpubie liga- 
 ment in front and the tip of the coccyx behind. 
 
 Hitherto we have i'ollowed the dissection of the pelvic floor from 
 above. The })erineal body is best understood by adopting the usual 
 order described in manuals of dissection. Unfortunately, there is 
 much confusion as to the exact meaning of the term " perineum," 
 nearly all of the works on anatomy defining it as the entire lozenge- 
 shaped space which corresponds to the pelvic outlet. Others divide 
 this space into an anterior and a posterior perineum, the latter includ- 
 ing the anus and the ischio-rcetal fosste, the former, the parts included 
 between the symphysis and pubic rami as far backward as an imagi- 
 nary transverse line joining the tuberosities of the ischium. " The true 
 perineum of the female," adds a writer, after making the above divis- 
 ion, " is between the posterior commissure of the labia and the anal 
 orifice." ^ The only satisfactory way out of the difficulty is, as Hart 
 and Barbour suggest, to keep always before the mind the idea of a 
 perineal body, of Avhich the " perineum " of the anatomists is merely 
 the ''skin over the base."^ 
 
 In reviewing briefly the anatomy of this region reference will be 
 made to certain structures closely related to it which have already been 
 mentioned in connection with the external genitals. Having removed 
 the integument, not only over the perineum proper, but over the entire 
 urethral triangle, the snjjerficial fascia w'ill be exposed. This may be 
 separated intc* two layers — a subcutaneous, Avhich consists of fine trabec- 
 ulae of fibrous tissue enclosing masses of fat and branches of the super- 
 ficial perineal and hemorrhoidal vessels and nerves, and a deep layer, 
 which is of considerable importance. The latter is attached along the 
 anterior edges of the pubic and ischiatic rami ^ almost as far back as 
 the tuberosities. It is limited posteriorly by the transversus perinei 
 muscles, around Avhich it turns to become continuous with the subpubic 
 fascia (anterior layer of the triangular ligament, perineal septum of 
 Savage). The lower edge of the perineal septum, which is strengthened 
 by the attachment of the deep layer of fascia, is called the ischio-jiori- 
 
 ' Heath, Practical Anatomi/, p. 173. ^ Hart and Barbour, op. cit., p. 38. 
 
 ' Savage describes an " abdominal portion," which is attached to Poupart's ligament 
 (op. cit., p. 13). 
 
230 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 neal ligament by Savage, who describes it as " an extremely resisting 
 aponeurotic band attached by its outer ends to the rami of the ischi- 
 um, somewhat in front of their tuberosities. They are confounded," he 
 adds, " in the structure of the perineal body." The perineal septum, 
 as described and figured by Savage, is best understood by a reference to 
 the figures. This fascia can be traced directly into the labia majora, 
 and through them to the external inguinal rings, to the edges of 
 which it is attached, forming on each side the '' pudendal sac" {sao 
 darto'ique) before described, in which the terminal fibrils of the round 
 ligaments are found. 
 
 On clearing away the tissue above mentioned, which, with the integ- 
 ument and superficial fascia, is intimately related to the base of the 
 perineal body, the so-called perineal muscles will be exposed, as well 
 as the " perineal septum," or anterior layer of the triangular lig- 
 ament, in recent nomenclature. The latter is comparatively a weak 
 structure in the female, because of the manner in which it is en- 
 croached upon by the urethra and vagina. The muscles which are 
 immediately connected with the perineal centre, as it is sometimes 
 called, are the bulbo-cavernosi, transversus perinei, sphincter, and 
 levatores ani (pubo-coccygeal portions). The transverse perineal ves- 
 sels and venous plexuses will be exposed with the muscles. 
 
 The bulbo-cavernosi blend posteriorly with the perineal body ; encir- 
 cling the vaginal bulbs and vestibule, each divides, according to Henle, 
 into three slips, one of which may be traced to the posterior surface 
 of the bulb, another to the lower surface of the corpus cavernosum 
 clitoridis, while the third is lost in the mucous membrane of the ves- 
 tibule. The function of these muscles is not, as is frequently stated, 
 to contract the vaginal outlet (which office is performed by the anterior 
 portion of the levator ani), but to compress the bulbs. The trans- 
 versus perinei are sometimes divided into two layers, a superficial 
 and a deep, separated hf the anterior layer of the triangular liga- 
 ment. They appear almost invariably in actual dissections as pale, 
 indistinct slips, which spring from the rami of the ischium and ante- 
 rior layer of the triangular ligament, and are lost in the perineal body. 
 The anal sphincter, which has been described, blends anteriorly with 
 the muscles above mentioned ; some of its peripheral fibres are appa- 
 rently continuous with those of the bulbo-cavernosi. The pubo- 
 coccygeus (anterior portion of the levator ani), as viewed from below, 
 lies deeper than the preceding muscles (i. e. above them), as it is behind 
 the perineal septum (Fig. 78). It encircles the vagina, and its inner 
 fibres curve inward behind that canal to enter the perineal body behind 
 the lower edge of the septum. When traced farther backward they sur- 
 round the rectum in a similar manner between the two sphincters, and 
 blend with the terminal fibres of the longitudinal layer of the rectum. 
 
77//; i'i:i:/.\i:a/, iuidy 
 
 TM 
 
 The crcctnrcs cliidfidis arc iii>t j)i-()|)crl\ iiK-liidcd in tlii- (lisscftinii 
 ami arc dcscrilx'd with the clitoris. 
 
 Ivcmoviiin' the hiilltn-cavcnutsi and the vaiiinal hnlli.-, which rest 
 M|)(ti» llic antcrinr hncr of the t I'ianiiidar litzanicnt, the latter is seen 
 to he [>ci'l(>ratcd lt\ lnanche- ol" the piidie aileric- and nerves an<l 1)V 
 
 Fifi. 78. 
 
 Perineal Septum, posterior view (Savage): S, posterior surface of .symphysis: U. urethra; 7, 
 vagina; 1, jiubic attachment of bladder; 2, pubic attachment of levator ani (pubo-coccyg- 
 eus): 3, line of attachment of obturato-coccygeus; -1, pudic vein; .'». urethro-pubic plexus 
 of veins; 6, posterior surface of .septum ; 7, median portion of pubo-coccygeus, entering 
 perineal body at lower edge of septum. 
 
 the coaimunicatiiijr veins wliieh extend from the bulbs and clitoris 
 to the vesical plexuses. When the layer itself is detached, the follow- 
 intr structures are exposed : The urethra, surrounded l)y tlie conijiressor 
 urethras ^ of Guthrie, the constrictor vagintc of some authors;^ the deep 
 transversus perinei, the vulvo- vaginal glands, internal pudic vessels 
 and nerves, dorsal vein and nerve of the clitoris, and artery of the 
 bulb. The two former muscles are described by Pleatli as forming a 
 fignre-of-8 around the urethra and vagina, being attached anteriorly to 
 tlie posterior aspect of tlie pubic arch, and entering the perineal body 
 behind. Behind the above structures lies the deep layer of the tri- 
 
 ' Ellis. Trans. Roy. Med.-Chlr. Soc, vnl. xxxix., ISoG. 
 
 ^ Why not include these two nmscles in one as ihe sjdiinoter vaginse of Liischka? 
 
232 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 angular ligament, belonging to the pelvic fascia, which was studied 
 from above. 
 
 The vascular and nervous supply of the urethral triangle may be dis- 
 missed in a few words, since it presents no special points of difference 
 in the two sexes. We are most concerned here with the vessels and 
 nerves of the perineal region. The arteries spring from the internal 
 pudics, which, after re-entering the pelvis through the lesser sacro- 
 sciatic foramina (each artery being accompanied by two veins and a 
 nerve), skirt the outer edges of the ischio-rectal fossse, ascend the pnbic 
 rami, perforate the posterior layer of the triangular ligament, and con- 
 tinue to ascend between the two layers until within a short distance of 
 the symphysis, where each terminates in the artery of the corpus caver- 
 nosum and the dorsal artery of the clitoris. The inferior or external 
 hemorrhoidal arteries of the pubic are tw^o or more small branches 
 which leave the main vessel in front of the tuberosity, cross the 
 ischio-rectal fossa, supply the external sphincter and the posterior 
 part of the levator ani, and terminate by anastomosing with the 
 vessels of the opposite side beneath the skin around the anus and 
 in the superficial perineal fascia. The superficial perineal branch 
 arises in front of the hemorrhoidal, pierces the deep perineal fascia, 
 crosses the transversus perinei muscle, and extends forward beneath the 
 superficial fascia to the vulva. It sends deep branches to the surround- 
 ing muscles, and superficial twigs to anastomose with those from the 
 hemorrhoidal arteries. The transverse perineal branch perforates the 
 posterior layer of the triangular ligament, and follows the course of 
 the transversus perinei muscle inward, where it divides into branches 
 that anastomose with those of the opposite side at the perineal centre 
 beneath the deep layer of the superficial fascia. It may send branches 
 to the corresponding vaginal bulb and gland of Bartholin. The veins 
 of the perineal region communicate freely with one another and with 
 the hemorrhoidal and labial plexuses, as well as with the bulbs; they 
 accompany their respective arteries and terminate in the pudic veins. 
 The lymphatics unite w^ith the vessels from the external gejiitals to 
 enter the inguinal glands. 
 
 The perineal body is supplied exclusively by branches of the pudic 
 nerve; the pudendal branch of the small sciatic may send a twig 
 which enters the superficial perineal fascia. The inferior hemorrhoidal 
 branch of the pudic accompanies the vessels of the same name and has 
 a similar distribution ; the superficial perineal branches supply the 
 vestibular area, the labia, and integument covering the base of the 
 perineal body, communicating with the hemorrhoidal branch. The 
 deep perineal nerve accompanies the superficial vessels and supplies 
 the labia, vaginal bulbs, and glands, sending special twigs to the 
 perineal and urethral muscles. 
 
Till'. rh/UXh'AL lloDY. 
 
 233 
 
 I'^'oiii this hricf accniiiil of 1 lie ,-ti'iicliircs ill iiniiicdiatc rdalioii with 
 
 the periii(':ii Ixidy it will he seen that, aside i'v the support wliich it 
 
 pves to the anterior rectal wall, its principal otlice si'cins t<» be to i()i"ni 
 a point (Tapj)!!/ for the niusclcs and fascia- which have hccn iiicntioncd 
 as constitutinji; the siipcrlicial jxn'tioii of the jx-lvic fioitr, and tliat tlie 
 oidy way in which it can be said to fnrnisii support to the internal 
 litMiital oriians is tiiroiii!;li its connection with the flooi-. 'J'hat its 
 relation with the deeper strnetures is not pai'ticiilarly intimate will be 
 inferred iroin the fact that it receives only a few of the more internal 
 fibres of the ])nbo-eoccy*>ei. Its base, on the other hand, is closelv 
 connected with the snperfieial portion of tiie floor, espeeially with the 
 stronu; ischio-perineal ]ii;ament, which in parturition bears the brunt of 
 the expulsive force during- the emerirenee of the child's head (Fig. 79). 
 
 Fig. 79. 
 
 — -.— 3 
 
 Relations of the Muscular Floor of the Pelvis to the Presentation at the Last Stage of Parturi- 
 tion : 1. upper margin of vuf^'iiial ring; 2, isehio-pcrincal ligament and superficial trans- 
 verse mu<cle : :i. their attachments to the tuberosities of the ischium ; 4, lower part of the 
 pubo- and obturato-coccygeus muscles ; p, perineal body ; a, anus. 
 
 ^^"ant of .space forbids our entering upon a discussion of tlie interest- 
 ing suljject of the structural anatomy and physics of the pelvic floor, 
 which have been so admirably treated by the Edinburgh authors, from 
 whom we have borrow^ed freely. It may be stated, briefly, that, accord- 
 ing to Dr. Hart's theory,^ the floor may be divided into two segments, 
 a pubic, including the bladder, urethra, anterior vaginal wall, and peri- 
 toneum covering the bladder, and a sacral, made up of the rectum, 
 perineal body, and posterior vaginal wall. Ranney, following a sug- 
 gestion of Foster's," offers a different division, which is rather better. 
 He includes in the pubic segment the parts above mentioned plus the 
 uterus and utero-sacral ligaments. The pubic segment is then attached 
 
 1 The Structural Anatomy of the Femah- Peine Floor, ISSl. 
 
 ^ Made in a paper on '' The Mechanical Action of Pessaries." Am. Gyn. Trains., 1881, 
 
234 THE ANATOMY OF THE FEMALE PELVIC ORGANS. 
 
 somewhat loosely to the symphysis, more firmly to the sacrum. Parallel 
 with the former is the sacral segment, which is " firmly dovetailed into 
 the sacrum and coccyx." Without going into details, it will at once be 
 evident that the sacral segment, as a whole (including the perineal body), 
 acts as a support to the pubic, and thus (acting with the utero-sacral lig- 
 aments) maintains the uterus in its normal position. 
 
 The writer can subscribe only in part to Foster's positive statement, 
 that " except to resist extreme displacements of the organ the broad 
 ligaments, the round ligaments, the bladder, the rectum, and the peri- 
 neum take no part among the supports of the uterus." It seems better 
 to regard the uterus, as well as the vagina, as upheld by the " compact, 
 unbroken pelvic floor," the perineum being "only a small, though 
 strong, part of the sacral segment." 
 
 Another point which ought not to be overlooked in this hasty glance 
 at the architectural anatomy of the pelvic floor has reference to its pro- 
 jection beyond the conjugate of the outlet. This has been studied by 
 several, especially by Foster, to whose paper the reader is referred for 
 details on this subject, as well as for careful measurements of the bony 
 pelvis.^ His average estimate of this projection is 2.5 cm., the patient 
 being semi-prone. 
 
 Regarding the perineal body as simply a portion of the sacral seg- 
 ment of the pelvic floor, we shall be disposed to attach less importance to 
 lacerations of the body which do not involve the sphincter. The mechan- 
 ism of prolapsus becomes much more satisfactory when viewed in con- 
 nection with the theory that '' the chief support (of the uterus) is the com- 
 pact, unbroken pelvic floor," while the gynecologist now regards the use- 
 ful rather than the beautiful in the performance of perineorrhaphy. 
 
 Although Dr. Emmet was not the first to aflirm the insignificance 
 of the perineal body as a support, he has deduced the practical lesson that 
 laceration of the perineum alone impairs but little the integrity of the 
 uterine support, whereas overstretching, or tearing of, the fascia or mus- 
 cles (levatores ani) of the floor at their attachment to the vagina, as 
 the result of parturition, at once disturbs the delicate adjustment of the 
 pelvic organs. This theory, so correct logically, has, unfortunately, not 
 yet received confirmation through careful dissections. Assuming that 
 the injury in such cases involves the deeper tissues, and that it is not 
 repaired by closing the perineum alone, it remains to inquire if the new 
 operation proposed by Dr. Emmet does fulfil the indications. Granting 
 that the tissues of the pelvic floor are lacerated, does the operator reunite 
 the torn ends by passing his sutures blindly through the posterior vagi- 
 nal wall, or is the operation simply a modified posterior colporrhaphy, 
 the ultimate result of which is simply to narrow the vagina by the 
 removal of redundant tissue?^ 
 
 1 Am. Journ. Obstetrics, vol. xiii. p. 30. ^ Comp. Emmet, op. cit., ch. xx. 
 
MALFORMATIONS OF THE FEMALE 
 GENITALS. 
 
 Bv iiKNiiv J. (;auki<;l:ks, a. m., m. d., 
 
 Ni;\v YoKK. 
 
 All malformations are rof"eral)lo to one of two lar^e classes. The 
 first of these com j)risos those eases wliieh are due to an c.rc<'.s-« of growth, 
 wiiieh a^iun may he a mere liypci'jjlaski or uncommon size of an organ 
 brought on by an increase in the number of constituent histological 
 elements, or hi/perfj'ophi/, by which is designated the condition in 
 which the elements themselves are enlarged ; or, on the other hand, 
 the excess may be characterized by a multiplication of organs. To the 
 other much more numerous and important class belong all those cases 
 which are referable to an arrest of development. 
 
 Why an organ should increase in size beyond the ordinary limits, or 
 wiiy it should appear in a larger number than usual, is not clear. We 
 must be satisfied with stating the fact that sometimes organs do obtain 
 larger dimensions than in the majority of cases. Still less can we 
 understand in most cases how a multiplication of organs is brought 
 about, apart from those cases where there evidently is a double fa?tiLs, 
 parts of which have not been developed, while the two foetuses have 
 grown together. We do not know by what process sometimes a child 
 has six fingers instead of five, four breasts, etc. 
 
 In the second cla.ss our intellect finds more satisfaction. W^liat 
 formerly was a chaotic mass of different freaks of Nature has, to a 
 great extent, become a system of well-connected links which are easily 
 underst(jod as soon as we study them in the light of embr^-ological 
 development as described in the preceding article. 
 
 The Ovaries. 
 
 Sometimes the ovaries in newborn children are found twice as large 
 as normal. In some cases it is a simple hyperplasia, with an even 
 increase of all the constituent parts, but oftener we find a preponder- 
 ance of connective tissue and a more or less complete disappearance of 
 Graafian follicles — a condition which may be looked upon as the result 
 of a fcetal inflammation. 
 
 235 
 
236 MALFORMATIONS OF THE FEMALE GENITALS. 
 
 Supernumerary ovaries are, according to Beigel, not rare. He found 
 them 23 times in 500 autopsies of adult women. They were only small 
 bodies, of the size of a pea or a hazelnut, but showed on microscopical 
 examination the complete structure of the ovarian tissue, especially 
 follicles, the characteristic element of an ovary. They had thin 
 pedicles, and were found near the peritoneal border of the normal 
 ovary, and once on the surface of the broad ligament. 
 
 Sometimes the ovaries present more or less deep fissures. In other 
 cases two parts have been found bound together with a ligament, and 
 in a case of Grohe there was a large ovary on one side and two small 
 ones on the other, the inner one of which was bound to the uterus by 
 an ovarian ligament, the outer one not (Puech). This is probably only 
 a further division of one ovary. 
 
 Olshausen removed a large multilocular ovarian cyst which was 
 bound by a pedicle to the uterus, and yet two normal ovaries were 
 found in tlieir places imbedded in a mass of inflammatory adhesions. 
 
 Winckel has photographed a somewhat similar case to Grohe's, and 
 an unique case in Avhich a supernumerary ovary as large as a n6rmal 
 ovary was bound to the uterus by a separate ovarian ligament.^ 
 
 The possibility of the presence of a supernumerary ovary must be 
 borne in mind as one explanation of the occurrence of pregnancy after 
 double ovariotomy, a case of which occurred in Norway some years ago 
 (Leopold Meyer). 
 
 Both ovaries may be absent — a condition commonly only found in 
 the rare cases of total absence of the uterus. The congenital absence 
 of the ovaries entails absence of menstruation, but the female type 
 and sexual appetite have been found normal. One ovary may be 
 totally absent in an individual with a one-horned uterus. 
 
 That the ovaries are not found in their usual place is not a sufficient 
 proof of their absence. In consequence of a deficient descent they may 
 be found in the lumbar region — a condition which, however, is very 
 rare, and has only been found in connection with great arrest of devel- 
 opment in other respects. 
 
 Sometimes the ovary is found in the inguinal canal, or even in the 
 corresponding labium majus. This may be due to a faulty development. 
 If the round ligament, instead of acquiring its normal length, stays 
 short, it drags the tube and ovarv and sometimes the horn of a bicor- 
 nous uterus through Nuck's canal ; that is, the prolongation from the 
 peritoneum which surrounds the round ligament during its passage 
 down throug-h the inguinal canal to its attachment to the mons Veneris 
 and the large labia. 
 
 More rarely, the ovary alone, without the tube, is found in such a 
 congenital hernia. That it can come down during intra-uterine life is 
 1 Winckel's Pathologie der Weiblichen Semalorgane, p. 28 and table xxxiv. fig. 7. 
 
THE FALLol'lAS Tl'IiES. 2:57 
 
 easily iiiidcrsttuKl wlicii we cxainiiic the relative size of" tlie ovar\' and 
 tlie canal. I'^'oni the titnrtli t<i tlii' sixtli ninntli (»!" f'retal life the latter 
 is () niillinieters wide (rnrcii), and in the lilih month the o\ar\- is 
 l.<! inillimeti-rs thick and 'lA inillinu'ter> hi^h ( Kc'iliiker). It is of so 
 UHich <::reater ifn|>ortance to hear in mind that the ovarv can he found 
 ill these imusiial localities, as it lias here hccoinc the seat oi' diseases, 
 such as cystic or cancerons de^■eneration, re<jnirin;^- snr<:ical intei-t'creiice. 
 
 Sometimes one oi- Ix.th ovaries hecoine severed from thej^enita! aj»j)a- 
 ratns hy foetal inflammation, and may either l)e found adherent to some 
 other part or floatinii; free in the ahdominal cavity. 
 
 More comm(»n than the total ahscnce of ovaries is a rnfllmrnftirij 
 clevclopiiicitf of these or<::ans, either with ])re-ei-vation of Graafian fol- 
 licles or with total loss of these latter, in which ease the ovary is onlv 
 formed by a mass of connective tissue. As a rule, the rndimentarv 
 development of the ovaries is combined with a similar deficiency in the 
 formation of the litems; but sometimes well-developed ovaries are 
 fonnd toiicther witli the arrest of develo})ment of the uterus; and, on 
 the other han<l, the atro])liy of the ovaries may i)e found in women 
 with well-devcloj)ed uterus and external *ienitals. Sexual desire mav 
 be ])resent, but such women do not menstruate. 
 
 A'irchow has shown that the ruiliuientarv develo])ment of the ovaries 
 is sometimes combined with conuenital faults in the larue blood-vessels, 
 especially stenosis of the aorta ; and ]Morel has pointed out the frequent 
 combination of a rudinicutarv development of the ovaries with a sim- 
 ilar deficient development of the nerve-centres, especially in cretins and 
 idiots. 
 
 The Fallopian Tubes. 
 
 The oviducts are sometimes unusually large. In most cases this 
 increase is the consequence of the presence of a tumor with which 
 the tube is more or less intimately connected. But even in the aljsence 
 of all other abnormities the tubes have been found 16 or 17 centimeters 
 (about 6J inches) long. 
 
 Another kind of excessive formation is constituted hy .wpeniumcrary 
 osiia surrounded by fimbriae. These openings may be found on one 
 or both tubes. They are ahvays situated at the upper surface and near 
 the a1)dorainal end. How they are produced is not yet known. If 
 Waldeyer's views about the formation of the Fallopian tube as an 
 originally open canal (see p. 68) were true, these openings might be 
 looked upon as the result of an arrested development ; but the forma- 
 tion of the fimbriae which surround them would still place them among 
 malformations by excess. 
 
 The tubes mav be ah.<tenf — a condition which is usually coml)ined 
 with a defect of the uterus, or at leiist with a solid, untunnelled uterus. 
 
238 MALFORMATIONS OF THE FEMALE GENITALS. 
 
 The absence of one oviduct is found in cases of a one-horned uterus. 
 In one case the tube on one side was absent, although the uterus was 
 well developed. 
 
 All these varieties are easily understood when we remember that the 
 tubes are only the upper part of the Miillerian ducts, a malformation 
 or destruction of which must result in corresponding deficiencies in the 
 Fallopian tubes. 
 
 Sometimes the tubes are only represented by feeble streaks of con- 
 nective or muscular tissue at the upper edge of the broad ligaments. 
 At other times the tubes, in their whole course or in some part of it, 
 are represented by solid strings. This condition is explainable when 
 we remember that according to the generally accepted doctrine the 
 Miillerian tubes begin as solid filaments, in which there subsequently 
 appears a bore. 
 
 At the fimbriated end of the tube is often found a pea-shaped cyst 
 called Iforgagni's hydatid. Its interior is lined Avith ciliated epithe- 
 lium like that of the tube, and it contains a clear fluid. Formerly this 
 cyst was taken to be the upper end of Miiller's duct, but, as we have 
 seen, this is never closed. Besides, this cyst is only found in one out 
 of five women (De Sinety). It is therefore now looked upon as a jjatho- 
 logical formation. Occasionally it becomes enlarged : I have myself 
 seen it the size of an English walnut. 
 
 The Uterus. 
 
 In studying the malformations of the uterus, more than in any other 
 part of this disquisition, it is of the greatest importance to keep in mind 
 the teachings of the history of foetal development. If we remember 
 that this organ is formed by the fusion and further development of the 
 middle parts of the Miillerian ducts, which themselves are originally 
 solid filaments, we will easily understand that that part of those ducts 
 which should form the womb may have originally been absent or may 
 have been destroyed, or that the filaments continue to be solid columns 
 without bore, or that the muscular tissue which in the course of time 
 should surround these tubes fails to be produced, or that fusion between 
 the tubes does not take place at all or does so only imperfectly, or that 
 one tube undergoes its regular development while the other lags behind 
 or is altogether absent. On the other hand, an excess of development 
 may take place. Thus we will have to consider the following con- 
 ditions : 
 
 A. Excessive development. 
 
 B. Arrest of development during the first half of intra-uterine life : 
 
 I. Absence of uterus. 
 II. Rudimentary uterus. 
 
EXCEii^'ilVJ-: DEVKUJl'MKyr ASD I'liEVUVITY. 2;i'J 
 
 III. Uterus duplex s('j)anitus. 
 
 IV. Uterus uuicoruis. 
 V. Uterus hiconiis. 
 
 VI. Uterus septus. 
 VI r. Uterus suhseptus. 
 VII I. At resin uteri. 
 
 C Arri'st of (leveli>piueut duriutr the seeoiid half" of" iutra-uteriue 
 lifl': 
 I. Uterus fa?talis aud uterus iufairtilis. 
 II. Uterus puheset'us. 
 
 III. Uti'rus iueudiforuiis. 
 
 IV. Uterus j)arvieollis or aef)llis. 
 V. Auteflexion. 
 
 D. Irre«2:ular development : 
 I. Obliquity. 
 II. Later()})(>siti()U, 
 
 III. Anteposition. 
 
 IV. Postposition, 
 \. Hernia uteri. 
 
 VI. Abnormal eommunications. 
 
 A. Excessive Development and Precocity. 
 
 Sometimes the uterus of newborn children has been found to equal 
 that of a "irl near puberty, not only in size and mass, but in the pro- 
 portions between the neck and the body. (See p. 90.) In many eases 
 menstruation has begun in early childhood. Kerkring saw it appear at 
 the birth of the child and continue regularly. Langlade and Cummen 
 observed it between the eighth and the twentieth day of the child's life 
 (Klob). Bouchut has published the history of a child four years old 
 who had well-developed breasts, pubes, and external genitals, and Avho 
 had menstruated regularly since it was twenty-two months old.' 
 
 Proehownick has proved by post-mortem and microscopical examina- 
 tion that such a case of precocious menstruation was combined with, not 
 to say depended on, a precocious development of the uterus and the 
 ovaries. The child was scrofulous and rickety, three years old, and had 
 menstruated regularly, for the last two years, three days in every four 
 weeks. The child died immediately after a menstruation. The breasts 
 were only a little developed, but on either side a small movable lump 
 of glandular tissue was found. The hair-growth was somewhat more 
 abundant than normal. The vagina measured o centimeters, the uterus 
 4 cm., two of which belonged to the body ; that is, twice the normal 
 depth. The inside had a greenish color and was covered with a thin 
 » Paris Medical, Dec 22, 1876. 
 
240 
 
 MALFORMATIONS OF THE FEMALE GESITALS. 
 
 greenish-yellow mucus, although the parts were entirely fresh. JNIicro- 
 scopical examination showed that the superficial layer and the mucous 
 were composed of glandular tubules, epithelial lining, and detritus mixed 
 with numerous red blood-corpuscles, innumerable leucocytes, and a few 
 pus-corpuscles. The right ovary measured 2 cm. in length, 1,3 cm. in 
 height, and 0.3 in thickness; the left was 3.5 long, 1.5 high, and 0.25 
 thick. These long and high but thin ovaries showed notches and 
 puckerings, as those of a senile woman. In the left was found a freshly- 
 ruptured follicle in the first stage of transition into a corpus luteum. 
 Microscopical examination showed nearest the surface a zone of young 
 follicles, and in the deeper layers much larger follicles, while the 
 stroma was remarkable for its richness in blood-vessels compared 
 with that of another child of the same age. 
 
 B. Arrest of Development during the First Half of 
 Intra-uterine Life. 
 I. Absence of the UxEErs. — It has often been claimed that the 
 uterus was absent in cases in which such an assertion was not warranted 
 
 Fig 
 
 ^^ 
 
 a, ribbon-shaped rudiment of the uterus : 6, 6, the round ligaments ; c, e, Fallopian tubes; d, d, 
 ovaries. (From Kussmaul, after Nega.) 
 
 by the examination. All observations which regard living persons must 
 be eliminated, as the womb may be so rudimentary as to escape detec- 
 tion even bv the most skilful examiner. The total absence of the womb 
 
ARREST OF DEVELOPMENT. 
 
 241 
 
 (•;m oiilv lie |»ru\c(l 1)\- :i caicriil |i(ist-iii(ii'lfiii cxaiiiiiiatioii ; ainl even 
 then tlu' (iWscrvtT is lial)l(' t<» Ix' led astray. IK- iimsl cspcc-iallv tliiiik 
 of the |u)ssil)ilify that the supposed woman be really a man with female 
 external <;enitals and hidden testicles. He must furthermore distin- 
 ii-iiisii a nidiiiu'iitarv uterus from a Fallopian tuhe, the limit hctween 
 the two being the point of insertion of the round ligament. The eom- 
 
 Fio. 81. 
 
 A, External View : a, a, the labia majora, tbat lay in close contact, but here are drawn apart: 
 6, b. the labia minora ; c, the opening of the urogenital sinus ; d, anus, with normal rectum : 
 €, flap of skin ; /. the external opening of the left iliac canal, from which protrudes the 
 round ligament, which spreads in the adipose tissue. B, Sagittal Section : a, urogenital 
 canal, which here almost exclusively represents the urethra; 6, bladder; c, small blind 
 pouch at the upper end of the urogenital canal; d, fine ridge detaching itself on both -sides 
 from the wall of the urogenital canal, and forming a rudimentary partition of the same 
 into an urethra and a vagina; e, peritoneal covering of bladder; /, section of the flat uterus, 
 over which the peritoneum is extended without forming any deep pouch between it and 
 the bladder : it is bound to the bladder by means of loose connective tissue : (i, symphysis 
 pubis; h, labia minora; (, labia majora. C, View from the Peritoneal Cavity, behind the 
 Uterus: a, bladder, incised; b, b, ureters; c, c, umbilical arteries; d, rectum; e. very flat 
 uterus, the lower part of which has not been developed ; /,/. the round ligaments, or rather 
 horns, of the uterus; p. internal opening of the inguinal canal, through which the round 
 ligaments go to the adipose tissue of the labia minora; /), h, very small and flat ovaries; k, 
 peritoneal fold in which the ovaries are imbedded. (From Kussmaul, after Langenbeck.) 
 
 plete absence of even a rudimentary uterus is rare. In our own litera- 
 ture we have two cases examined post-mortem by Dr. I. E. Taylor, and 
 there are a few other authentic cases on record. 
 
 The absence of the uterus may be found alone, but is more commonly 
 
 Vol. I.— 16 
 
242 
 
 MALFORMATIONS OF THE FEMALE GENITALS. 
 
 combined with other developmental faults of the genitals or other parts 
 of the body. Thus in J. T, Whittaker's case, in which utero-gestation 
 had progressed six months, the external genitals were only represented 
 by a rudimentary clitoris ; the urethra and the anus were absent, the 
 ovaries atrophic, and the tubes devoid of fringes. In a recent case, 
 reported by Coen of Bologna, of a girl born at eight months' gesta- 
 tion, the absence of uterus and vagina was combined with absence of 
 the kidneys and deficient development of the eyeballs, while the exter- 
 nal genitals, the tubes, and ovaries were normal. 
 
 II. Rudimentary Uteeus.— The subject of the malformations of 
 the uterus has become considerably complicated by the fact that dif- 
 ferent authors use the same term for different things or designate the 
 same conditions by different expressions. In the following pages we 
 will use KussmauFs names, his work being by far the most important, 
 
 Fig. 82. 
 
 a 
 
 uterus Bipartitus of a servant-girl sixty years of age : a, vagina, about one inch deep, and end- 
 ing at the anterior wall of the rectum, above the internal sphincter; 6, connective tissue 
 interspersed with muscular fibres, simulating the shape of a uterus ; c, c, fleshy strings rep- 
 resenting the horns of the uterus ; d, d, swellings of the size of a bean, one cut open and 
 showing a cavity of the size of a lentil and lined with mucous membrane ; e, e, rudiment- 
 ary ovaries ; /, /, Fallopian tubes ; g, round ligaments ; h, broad ligaments. (From Kuss- 
 maul, after Mayer.) 
 
 but at the same time add those used by others, and indicate when 
 Kussmaul's terms are used by others in a different sense. 
 
 1. In some cases in the place of the uterus there has only been found 
 a globular, solid, fibrous mass of the size of a hazelnut. 
 
 2. In Nega's case (Fig. 80) the uterus was reduced to a narrow flat 
 muscular band, without any cavity, forming a transverse arch in the 
 pelvis. 
 
 3. In a case described by Langenbeck (Fig. 81) the uterus is like- 
 wise formed by a solid flat, muscular mass, as in Nega's, but the mass 
 
AliRKST OF l)i:vi:i.nrMi:ST. lAW 
 
 lias tlic >lia|)t' III the 1)im|\ nl' the iKcni-, and lioiii it> cfiriicrs starts uii 
 eitluT side a nuiml striiii;- wliidi ciitci-s llic injriiiiial canal, and wliidi 
 (•(msc(jiiciitly ri'|»i'cs('nts partly the li<>i-ii dl" tli<' iitcni> and |)artl\- the 
 round ligament. Tlu'rc is no neck. 
 
 4. A transition Ix'twcvn the solid and iinjluw I'orins oi' rudiniciitarv 
 \vond)s is f"oriuo<l by what was first described by l*rof. Mayer of Bonn 
 under tlu' name nt' uterus hipdrtitus^ (1''^- ^^)' This kind of rudiment- 
 ary uterus is not so extremely rare as those hitherto consideretl, which 
 arc only represented by one or two cases. It is characterized by the 
 presence, between tlie bladder and the rectum, of" a body which has 
 somewhat the shape of a uterus, and which is composed of connective 
 tissue with interspersed muscular fibres. At the uj)per end it sends off 
 to both sides a cord of similar composition, which, at the point of 
 insertiim of the round ligament, forms a small muscular swelling, 
 which either is solid or contains a small cavity lined with a mucous 
 membrane. These cords represent the horns of the uterus. With its 
 lower end the fibro-muscular body rests on the cul-de-sac of a short 
 vagina or on the solid fibrous column which replaces that organ. 
 
 The late E. R. Peaslee has described a solid uterus in the first 
 volume of the Transactions of the American Gynecological Society 
 (Fig. 83).- It was taken from the body of a woman twenty-four 
 vears old. " A hard conical nodule was found on introducino; the 
 hand through the abdominal incision on each side, the two meet- 
 ing behind the bladder at their apices in a pretty firm mass of 
 tissue. The finger introduced into the vagina was arrested at about 
 three inches, and above this point to the union of the nodules above, 
 a distance of about one and a half inches, nothing existed in the wav 
 of fibrous cords, nor the slightest canal except some blood-vessels. 
 From the outer and anterior portion of the nodules the round liga- 
 ments were seen to be given off and to take their normal course to 
 the internal abdominal ring." The nodules showed no cavitv. The 
 figure which accompanies the description shows that the tissue which 
 formed the connection between the two nodules had the form of the 
 intermediate part of a uterus, and it is stated that that likewise was 
 solid. 
 
 The uterus hiparfitus may have a neck. Then there are three more 
 
 ^ Lefort applies the name uterm bipnrdtus to any kind of double uterus, lUeriis didiic- 
 tiis (i.e. flidclph'/.f), ntent.^ bicorni.'^, and ulerus globulari.-i \\.e.septii.<). Uterus bipartitus 
 (Mayer. Knssmaul) is by others designated as u(erii.< bijidns. On the other hand, the 
 term bijid is by Playfair (Science and Practice of Midwifenj, London, 1876, vol. i. p. 43) 
 used as a synonym of doMe, and applied to a uterus bicornis unic/)!li.i. 
 
 The term double uterus is used in very different senses, and does not designate any 
 particular kind of malformation. It ought only to be used as a general term, compris- 
 ing the uterus didelphys, the uterus bicornis duplex, and the uterus septus. 
 
 * Am. Gyn. Trans., 1876, i. 347. 
 
244 
 
 MALFORMATIONS OF THE FEMALE GENITALS. 
 
 developed muscular, perhaps hollow, parts united by more membranous 
 or cord-like parts. 
 
 5. On the other hand, there may be two well-developed horns sep- 
 arated by an incomplete septum, without neck {uterus bicornis acollis). 
 
 6. Vesicular Uterus. — The rudimentary uterus may only consist of a 
 membranous vesicle with or without neck. In none of the cases of 
 
 A, the two unequal solid masses representing the cornua and part of the corpus of the bipartite 
 uterus; E, the remainder of the organ, also solid, the fundus of the empty bladder lying on 
 a level with its lower border ; C, C, the commencement of the two round ligaments ; B, the 
 right Fallopian tube, the left being crossed by the line ascending from the left round liga- 
 ment; D, stump whence the left ovary had been removed, that of the right side being 
 behind the convolutions of the Fallopian tube; F, pavilion of the left tube, below the lat- 
 ter: the right pavilion is seen to be higher than the left, the left ovary having been one 
 inch lower in the pelvis and farther back than usual; O, right ovary laid open, showing 
 gray spots of colloid degeneration, ovisacs, and colloid cysts ; H, left ovarj% showing cysts 
 filled with colloid, and the polypoid mass on its lower extremity— namely, a colloid cyst 
 into which hemorrhage had occurred. (From Peaslee.) 
 
 rudimentary uterus, the authenticity of which has been proved by 
 autopsy, did the women menstruate, but they suffered often from 
 monthly molimina, and in some few cases, in which it was impos- 
 sible on the living to find any uterus, there was a periodic discharge 
 of blood from the genitals. 
 
 III. Uterus duplex sepaeatus, s. didelphys (o;c, twice ; oeX(phi^, 
 womb ; Uterus diductus, Lefort). — This is the type produced when the 
 Miillerian tubes do not even come in contact with one another in that 
 part of their course in which they ought to melt together and form the 
 
AIiJ:KST OF UEVKLorMKyT. 
 
 24; 
 
 iitcnis. C()iisc<|ii('iitly, we have two entirely separate iit<'ri, hut eaeli 
 ot" tlieiii repit'seiits uulv oiie-lialt" ol" tlie orj^au. Alxtve, it joins a J''al- 
 I(»i)iaii tiilx' ; l)t'l<i\v, eacli cervix may npeii into a separate vagina, or 
 the hitter or^an may he more or k'ss (h-feetive. The uteniH dnjjlr.r 
 neiHirnhts has mostly i)een fitnnd in stillhorn ehildren or sueh as <lie<l 
 SfK^n alter l»irth, Imt ( )lli\ier's s|)ecim('n, w liich we reproduce here (Fig. 
 <S4), came iVoni a woman wiio was torty-two years old and had heen 
 pregnant five times. Dirner's patient was twenty-seven years (jld and 
 had had (»ne miscarriage. 
 
 In t\iQ Ainirlcdii Joiinidl of Ohsfetrirs (187(5, vol. ix. ]>. Ool) is i'ound 
 a report ot" a ea.se relateil to the Xew York Ohstetrieal Society by the 
 
 Fig. 84. 
 
 Uterus Didelphys : a. right cavity ; b, left ca^^ty ; c, right ovary : d, right round ligament : e, 
 left round ligament ; /, left tube ; </. left vaginal portion ; /(. right vaginal portion : /. right 
 vagina ; j, left vagina : /:. partition between the two vaginte. ( From De .Sinety, after OUivier.) 
 
 late Dr. E. R. Peaslee, under the heading " Uterus didelphys septus 
 and Vagina septa ;" but since it is stated that " the septum ran through 
 up to the fundus uteri," and that " the uterus was not bieornis," it is 
 evident that this was not a uterus didelphys, but a uterus septus duplex, 
 which will be described below. 
 
 Xear the uterus didelphys stands the uterus described by Cooper 
 Rose :^ On either side of the pelvis, resting on the rami of the isehia, 
 were two bodies three-quarters of an inch in length, broad below and 
 tapering above, separated from one another by a space of more than an 
 inch, not connecting with one another or externally. The body on the 
 left side, being cut open, was found to be one lateral portion of the 
 uterus, having a central cavity lined with rnucous membrane, and com- 
 
 1 Lond. Obst. Tram., 1874, vol. xv. p. 128. 
 
246 
 
 MALFORMATIONS OF THE FEMALE GENITALS. 
 
 mimicating at its upper end with a pervious Fallopian tube having 
 attached to it a small ovary and terminating in a fimbriated extremity. 
 There was no cervix or vagina to this portion. On the body on the 
 right side existed a cervix and vagina, the latter without any external 
 opening. This side had a Fallopian tube and ovary like the other. 
 In this case, then, the Mlillerian ducts have remained separate ; the 
 right remained imperforate at its lower end ; of the left, the lower part, 
 which should have formed the cervix and vagina, had not been formed 
 or had been destroyed. 
 
 IV. Uterus unicornis. — The one-horned uterus (Fig. 85) is formed 
 by the development of one of the Miillerian tubes, while the other is 
 absent or rudimentary. The one-horned uterus is always very long in 
 
 Fig. 85. 
 
 Uterus Unicornis : iiT, left horn ; ir, left tube; io, left ovary; £Lr, left round ligament; RH, 
 right horn ; RT, right tuhe ; Ro, right ovary ; RLr, right round ligament. (From Schroeder.) 
 
 proportion to its width, forms a curve with the concavity turned out- 
 ward, and ends in a point from which start a Fallopian tube, an ovarian 
 ligament, and a round ligament. It has no fundus. 
 
 Pregnancy in a strictly one-horned uterus does not vary materially 
 from that in a normal one. If there be a rudimentary horn, both 
 horns develop a decidua, and a foetus may be formed in both or in either 
 of them. If the development takes place in the rudimentary horn, 
 there is great danger that it will not be able to develop muscular sub- 
 stance enough for sheltering the icetus through the whole normal period 
 of utero-gestation. As a rule, the rudimentary horn is ruptured by 
 the increasing bulk of the foetus. Such cases may be taken for a rup- 
 ture of the Fallopian tube if the observer does not bear in mind that 
 the round ligament offers a safe landmark. If the foetal sac is situated 
 inside of the ligament, it belongs to the uterus ; if developed outside 
 of it, it is tubal. In very rare cases menstrual blood has been found 
 to collect in the rudimentary horn, so as to form a unilateral hemato- 
 metra. 
 
 V. Uterus bicornis. — When the Mtillerian ducts stay more or 
 
AIUU'ST or DF.VELOI'MF.Sr. 
 
 247 
 
 less soparatcd fVoin otic aiiotlicr in that |)arl <»1" tlicir course whieli 
 <'orr('S|)oii(ls to tilt' ii|t|>(i' part ot" the uterus, this oriiaii is at its upper 
 rntl tlividcd iiittt two horus. As to the lower pai"t ol" the uterus, it 
 may varv in (levclopincnt. In some easi-s there are two eavitie^s 
 entirely separat<'(l <r<tm one another hy a partition an<l havinj^ each 
 a eervix {uterus fiicornis <liij)lex, Fi<>:s. 80 and 87). In other easc^ the 
 separation is oiilv I'ouiid in the hody of the ut<'riis, while heh»w the 
 
 Fr;. ««. 
 
 Uterus Bicornis Duplex, from a virgin thirty yours old: «, left horn; 6, cavity of right horn; 
 c, right cervical canal; d, d, external orifices; e, e, the two vaginal canals; /, partition 
 between the vaginal canals; (/,.';, tubes ; A, /i, ovaries; «, i, cysts of the ovaries ; t, it, round 
 ligaments; /, suspensory ligament of uterus or recto-vesical ligament. (.From Kussmaul, 
 after Cassan.) 
 
 Miillerian tubes have been fused together in the normal way, so as to 
 form a single cervix {utei'us bicornis unicoUis, s. infra simplex, s. semi- 
 duple.v, Fig. 88). 
 
 A still smaller degree of separation is found in the form of uterus 
 which Kussmaul calls uterus arcuatus [uterus corrJifoi-mis, uterus echan- 
 cre cordiforme, Barth). On the outer surface (Fig. 89) there is only 
 a shallow notch between the two horns, as in some forms of uterus 
 bicornis duplex, and inside the se])tuni is reduced to a ridge running 
 over the fundus in an antero-posterior direction. It looks as if the 
 
248 
 
 3IALF0R3IATI0NS OF THE FEMALE GENITALS. 
 
 fundus had been bent inward toward the cavity in the median line, by 
 which disposition both the whole uterus and its cavity acquire a shape 
 somewhat Hke the heart on playing-cards. 
 
 Fig. 87. 
 
 a 
 
 Uterus Bicomis Duplex: a, double entrance to vagina; 6, meatus urinarius; c, clitoris; d, 
 urethra; e,e, double vagina; /,/, external orifices of uterus; g,g, double cervix; h. h, 
 bodies and horns of uterus; i, i, ovaries; 7;, k, tubes; I, I, round ligaments; m,'m, broad 
 ligaments. (From Kussmaul, after Eisenmann.) 
 
 VI. Uterus septus ( Uterus cloisonne, Cruveilhier ; Uterus bilocv^ 
 laris, Eokitansky ; U. glohularis, Lefort). — Much rarer than the bicor- 
 nuted uteri are those which in consequence of the normal development 
 of the fundus outwardly present the appearance of a single uterus^ but 
 in which the cavity is divided by a more or less complete longitudinal 
 septum into two halves. 
 
 If the partition is complete, this kind is called uterus septus, or by 
 redundancy utei%is septus duplex (Fig. 90) ; if it is incomplete, we have 
 a uterus suhseptus. 
 
ARREST OF DEVELOPMENT. 
 
 249 
 
 Fici. 88, 
 
 Uterus Bicornis UnicoUis of a virgin : a, vagina ; 6, single neck ; c, c horns ; d, d, tubes ; e, e, 
 ovaries; /,/, round ligaments. (From Kussmaul.) 
 
 YII. Uterus subseptus ( TJ. semipartitus, Lefort) is a uterus which 
 looks outside like a single uterus, but is divided interually by an iucom- 
 
 Utcrua Arcuatus : a, indented fundus ; b, 6, tubes ; c, c, round ligaments : d, central longitudinal 
 ridge on the posterior wall of the cavity of the body : e, e, lateral ridges of the same ; /, 
 internal os; g,g, neck of the womb. (From Kussmaul.) 
 
 plete longitudinal partition (Fig. 91). If the partition extends do^vn 
 through the body and part of the cervix, so as to leave only one open- 
 
250 
 
 MALFORMATIONS OF THE FEMALE GENITALS. 
 
 ing at the os externum, the variety is called uterus subseptus uriiforis. 
 If it stops at the os internum, we have the variety called uterus sub- 
 septus unicollis. If it extends only partially down from the fundus 
 through the body, that variety is called uterus subseptus unicorporem. 
 On the other hand, the septum may only be found near the os exter- 
 num, thus forming a uterus biforis supra simjjlex. 
 
 A peculiar variety standing very near the last one is that observed 
 by " a Western physician," and reported to the New York Obstetrical 
 
 Fig. 90. 
 
 Uterus Septus Duplex (natural size), completely double uterus and incompletely double vagina 
 of a girl twenty -two years old : a, a, tubes ; 6, b, fundus of the double uterus ; c, c, c, parti- 
 tion of uterus; d, d, cavities of the uterine bodies; e, e, internal orifices; /,/, external walls 
 of the two necks ; g, g. external orifices ; h, h, vaginal canals ; i, partition which divided the 
 upper third of the vagina into two halves. (From Kussmaul.) 
 
 Society by Dr. P. F. Munde. The patient was a woman of middle 
 age who had been married ten years. She was treated for leucorrhoea, 
 and a discrepancy between her statement about the continuance of the 
 discharge and the doctor's own observation that the cervix got well 
 under appropriate treatment, led to the discovery of a second and nar- 
 rower vagina leading to another cervix. By meaps of two sounds the 
 doctor convinced himself that the septum in the vagina was complete, 
 and that it extended somewhat into the cervix, while there was no trace 
 
Ai:ni:s'r of devkiju'MEST. 
 
 251 
 
 Vu,. ',11 
 
 Uterus Septus Uniforis: a, vagina: h, single os uteri; e, partition of uterus, tliick above, tiiin 
 below ; d, d, right and left uterine cavities ; e, e, two ridges on the posterior wall of the cer- 
 vix. (From Kussmaul, after Gravel.) 
 
 of a septum in the body of the uterus (Figs. 92 and 93). This form 
 differs from the uteriLS subseptus biforis by the presence of t^vo vaginal 
 
 Fig. 93. 
 
 Fig. 92. 
 
 '-—A 
 
 Fig. 92. — a, left vaginal entrance ; 6, right vaginal entrance. 
 
 Fig. 93.— Ideal Section, showing double vagina and neck, single body : -■1, left vagina ; B, right 
 vagina; C, partition dividing the neck of the womb. 
 
 portions. As the woman had borne a child by a premature birth at the 
 sixtli month, there may possibly have been a complete septum which 
 
252 MALFORMATIONS OF THE FEMALE GENITALS. 
 
 was destroyed during labor. In M. Duncan's case of uterus subseptus 
 the cervix was single, and the " firm septum of the uterine cavity ended 
 at its upper part in a smooth, broad-edged end." Thus there must have 
 been a free space between the septum and the fundus ; and since its end 
 was smooth and broad, that means, probably, that it had not been torn 
 during the preceding delivery. 
 
 In all forms of double uterus, be it horned or not, the vagina mav 
 be single or double. If there is a double vagina, there commonly is a 
 vaginal portion in each half. Exceptionally, there is only one prom- 
 inence, divided internally by a septum. Sometimes there is one cervi- 
 cal portion opening with two openings into one-half of the vagina, the 
 other half ending blind superiorly ; which cannot be explained as a 
 simjjle arrest of development, but constitutes an irregularity. In a case 
 described by Cruveilhier there was a single vagina with a single vaginal 
 portion. 
 
 In women with double uterus the menstrual flow comes sometimes from 
 both halves of the uterus, sometimes from one only ; and if it comes from 
 both, it may come at different times from the two halves (Kussmaul). 
 In the case of the '' Western physician " mentioned above a specular 
 examination performed during menstruation showed that the discharge 
 came from both orifices of the uterus at the same time. Dr. T. A. 
 Emmet ^ has reported a case of double uterus and double vagina, with 
 imperforate hymen on one side, in which there never was a show at less 
 than two months' interval. The doctor, therefore, thought it likely that 
 the patient menstruated from the two uteri alternately. Dr. H. F. Walker 
 has described ^ the case of a woman with uterus septus, double vagina, and 
 double vaginal portion. In this case menstruation recurred eveiy two 
 weeks. It is therefore possible, although not proven, that both halves 
 had a monthly period, but at different times. Dr. John Aikman's case is 
 conclusive, since it afforded the opportunity of a post-mortem examina- 
 tion. The patient died at the end of menstruation. She had a double 
 uterus and vagina. The mucous membrane of the left cavity was cov- 
 ered with a grayish shreddy structure and opaque mucus, but the mem- 
 brane itself was firmly adherent and in no part absent. That of the 
 right was quite unaltered. In the left ovary was found a dark-colored 
 granular clot, which had evidently been a Graafian " vesicle ;" that is 
 to say, it was a ruptured Graafian follicle filled with a blood-clot. In 
 this case, then, evidently only one half of the uterus was implicated in 
 the menstrual process. 
 
 Pregnancy occurs in a double uterus as easily as in a single. One 
 or both halves may become the seat of development of a foetus. Even 
 if the pregnancy is limited to one side, as a rule the other side partici- 
 pates more or less in the development during gestation, increasing in 
 
 ^ Trans. Am. Gyn. <Sbc., vol. ii. p. 444. '^ Am. Journ. Obstetrics, vol. viii. p. 515. 
 
ARREST OF Dh'Vh'l.OlWfhWT. 253 
 
 si/f, protliiciiiij,' new iiiiisciilai' tissue, ;iii<l roniiiii^- a dccidiia. In mhhc 
 cases tlie <is opens t»ii Itntli sides diii'inu lalmi', in <>tliei"s not. The fol- 
 
 Idwiiiij; case came under my lu'i'sona! (»l)>ervati<fn : ( '. Y , iut. 20, 
 
 ])riini|)ara. Tlic Hrst mcnstruatinn (lecnrrcd when she was thirteen 
 veai's old. She had a comph'te septum ot" the \'a^ina exteniHuL:- in tlie 
 median line from tlic vulva uj) to the ntei-us. The two halves ot" the 
 va;^ina were of the same size, and led each to a vaginal portion. Siie 
 was delivered at term ol" a male child weighing six pounds eight 
 oimces. The child ))reseuted hy the hreech in the left os. In the 
 he-rinning of labor both mouths dilated, that of the empty right side 
 even more than the other, but latci- in labor the right stayed at a dila- 
 tation of an inch in diameter, while the l(>ft became fully dilated. The 
 labor lasteil seventeen hours and three-(piarters, fifteen of which came on 
 the first stage, two and a (piarter on the second, and half an hour on the 
 third. The scrotum having become discolored, the child was easily 
 extracted mamially. During parturition the vaginal septum was torn 
 up to a quarter of an inch from the uterus, and ten days after con- 
 finement nothing could be felt of it. The interior of the womb was 
 not examined ; the external configuration was that of a normal single 
 uterus. 
 
 The much-vexed question of superfcetaiion lies beyond the scope of 
 this work. Suffice it here to say that the presence of a double uterus 
 M'ould materially facilitate such an occurrence, for the idea prevailing 
 until quite recently, that ovulation ceased during pregnancy, has been 
 jM'oved to be erroneous, and the conditions of the unimpregnated side 
 of the uterus are such that even after the third month, at which 
 period superfoetation is absolutely impossible, in a single uterus on 
 account of the development of the ovum, such an event might occur 
 in it. 
 
 It has been noticed in several instances that women with a double 
 uterus were uncommonly broad of face and body, showing a similar 
 disposition to lateral extension in the rest of the body as in the 
 uterus. 
 
 VIII. Atresia uteri. — In very rare cases the utei-us has been 
 found closed at its lower end. The occlusion may be seated at the os, 
 and be due to the mucous membrane of the vagina, which covers the 
 vaginal portion totally, without leaving any hole open. In other 
 instances the occlusion is found in the cervix itself, which may be 
 totally impermeable, a muscular tissue identical Avith that of the sur- 
 rounding parts being found where normally the canal is situated. In 
 the latter case the vaginal portion is small or absent. Atresia has been 
 found in a tv/o-horned uterus. 
 
 Menstruation and conception are of course impossible. By being 
 pent up the menstrual flow gives rise to a distension of the womb 
 
254 
 
 MALFOBMATIONS OF THE FEMALE GENITALS. 
 
 formed of blood (Jicematometra^), which may be changed to pus {pyo- 
 metra^), or instead of blood a mucous fluid may collect (hydrometra^). 
 If the atresia affects a two-horned uterus, one or both horns may be 
 occluded, and consequently the fluid collect in both sides or only 
 in one. 
 
 The explanation of the occurrence of congenital atresia of the cervix 
 as a malformation presents no difliculty when we remember that the 
 uterus is formed by the fusion of the Miillerian ducts, and that these 
 at their first appearance are solid. 
 
 0. Arrest of Development durestg Second Half of Intra- 
 uterine Life, or After Birth. 
 
 All the forms of arrested development hitherto considered are refer- 
 able to the first half of gestation. An arrest at a later period gives 
 rise to less marked variations from the normal type. To this group 
 belong the foetal, the infantile, and the pubescent uterus. 
 
 I. Uterus fcetalis and Uterus infantilis. — Several observations 
 at post-mortem examinations of adult women have revealed the pres- 
 
 lufantile' uterus of a girl twenty-one years old: A, Uterus and Appendages diminished: a, 
 body; &, neck ; c, c, tubes; d, d, ovaries; e, e, round ligaments; /, /, broad ligaments. B, 
 right ovary cut open longitudinally, showing large Graafian follicles. C, left ovary with 
 smaller follicles. (From Kussmaul.) 
 
 ence of a uterus which not only in size, but in configuration, corresponded 
 to that normally found in the foetus toward the end of pregnancy or in 
 young children (Figs. 94, 95). Sometimes it measured only an inch 
 or an inch and a half in length. In other cases it attained the length 
 
 ^ aJfia, blood ; fJ-vrpa^ womb. 
 ^ vdup, water ; {J^VTpa., womb. 
 
 ■ "Kvov, pus ; firjTpa^ v;omb. 
 
AJiRKST OF DKVELOI'MKST. 
 
 255 
 
 Fig. 95. 
 
 (tl";i virgin iitt-rii-.. Imt cluiractiTi.^tic wcic the |)i(|M)iMlcr;iii(c nl' the ii<'<-k 
 over the body and tlic tliiniu'ss of the walls. liittTiially the folds of the 
 arlxir vitiO were cither eoiifmed to the cervix or extcnd(Hl more ur k*ss up 
 into the body of the woiiih (Fi;:;. !'•'»). Women with .such a uterus rarely 
 menstruate, and cannot conceive, altlKtu^h 
 thev may have sexual aj)|)etite and he well 
 fit for copulation. 
 
 The uteriiK fcetalia may at the same time 
 he hironiiH as the residt of a double arrest 
 of development. 
 
 The following; case of infantile uterus ha.s 
 come under my personal observation. It 
 concerned a woman thirty-six years of age 
 who had been marriefl six years and never 
 been prefrnant. Her courses had begun 
 when she was twenty years old, and had 
 been painfid and very scant. She had 
 never felt any sexual appetite, although 
 coition did not cause pain, except when 
 performed shortly after menstruation. 
 Before marriaije she was chlorotic and had coronal Section of the same uterus 
 
 , , , _^ . , . . as in Fig. W, natural size: a, va- 
 
 nnich leucorrhcea. \ aginal examination gina; 6, neck with arbor vitse; c, 
 revealed a somewhat smaller and rounder 
 OS than normal. The cervix was thin, but 
 about of normal length, whereas the body was only represented by a 
 small swelling like a little finger w^hich could be felt both in front and 
 behind. The depth of the whole uterine cavity from os to fundus 
 measured only 4 centimeters (If inches), leaving about 1 centimeter 
 for the cavity of the body, 
 
 II, Uterus pubescexs. — Puecli gave this name to a class of uteri 
 which are conformed like that of the young girl immediately before 
 puberty, and especially characterized by their small weight, which does 
 not exceed an ounce, whereas the normal uterus averages an ounce and 
 a half. The cervix and the body have about the same length.^ Men- 
 struation is absent or scanty and irregular, and women with so small 
 a uterus are commonly sterile. Still, a late development may take 
 place, and they may bear children. 
 
 III. Uterus incudiformis,^ s. biaxgularis. — The anvil-shaped 
 
 'Even in the arlnlt nulliparons woman the cavity of the neck is. according to 
 Sapiiey 'vol. iii. p. 664 1. longer tlian that of the hody, the dimensions being, on an 
 average, in nulliparons women, the whole cavity. 52 millimeters: the neck, 2o ; the 
 isthmii<. 5; the body, 22; in miiltipnroiis women, the whole cavity, 57 millimeters; the 
 neck, 24; the i,sthmns, 5; and the body, 28. Others, throwing the isthmus together 
 with the body, come to the opposite conclusion (Kussmaul, p. 18). 
 
 ' Inam. Latin, anvil. 
 
 bfjdy; d. fundus: e, e, internal 
 ends of the tubes. 
 
256 
 
 MALFORMATIONS OF THE FEMALE GENITALS. 
 
 Fig. 96. 
 
 uterus (Fig. 96) is well developed in other respects, but the deficient 
 
 bulging of the fundus, which 
 forms almost a straight line from 
 one Fallopian tube to the other, 
 and the abrupt transition from 
 the neck to the body of the womb, 
 give it the shape of an anvil, 
 and reminds us of a uterus from 
 the fourth or fifth month of 
 gestation. 
 
 IV. Uteeus parvicollis and 
 ACOLLis. — The body of the uterus 
 may be well shaped, but the neck, 
 or at least the vaginal portion, 
 rudimentary or absent. 
 In othei' cases there obtains smallness of the uterus, with specially 
 
 defective development of the neck. 
 
 V. Anteflexion is often congenital, and as long as there is only 
 
 an even and moderate curvature it may be regarded as a continuation 
 
 of the shape of the uterus in the foetus and in young children. 
 
 uterus Incudiformis. (From Kussmaul, after 
 Oldham.) 
 
 D. Irregular Development. 
 
 The forms so far considered were all reducible to an arrest of devel- 
 opment. In others we must admit a true divergence from the normal 
 type. 
 
 I. Obliquity. — There may be a congenital crookedness of the 
 womb itself, or an otherwise Avell-shapecl uterus may be misplaced. 
 The former condition is attributable to an uneven development of the 
 two Miillerian ducts, which combined go to form the uterus. Thus a 
 GongenUal lateroflexion is produced. A similar result may be due to 
 foetal peritonitis, with cicatricial shrinkage of the broad ligament on 
 one side. 
 
 A well-shaped uterus may be tilted over to one side, especially where 
 there is a beginning ovarian hernia. 
 
 II. Lateroposition. — It is not rare to find in the adult the womb 
 well shaped, but placed with its axis parallel to the median line instead 
 of lying in the same. This lateroposition, when it is not due to pre- 
 vious inflammation and cicatricial shrinkage, is referable to an uneven 
 development of the broad ligaments. 
 
 III. Anteposition, and IV. Postposition — that is, the place- 
 ment of an otherwise normal womb too far forward to the symphy- 
 sis or too far back toward the sacrum — are probably due to similar 
 irregularities in the development of the surrounding parts. 
 
THE VAC! IN A. 257 
 
 V. TIkrnia rTF:i{i. — The uterus has been found in a con^^cuital 
 in<j:;uiiial licruia. Tliis irr('<!;ular position is due to a cornpk'ti! descent 
 of tlie (t\ai-y like that whieh is normal lor the fijenital gland of the 
 other sex. The womb is then |)idled alonj^ until it enters the hernial 
 sac. In this unwonted ])laee it has even become impregnated, and 
 been subjected to Ctesarean section. 
 
 VI. Abnormal Communications. — The uterus has been found 
 forming one sac together with the bladder and the vagina. It has 
 likewise been found communicating with the bladder or the colon 
 ascendens or the rectum. In a case described by Doran the right 
 side of a uterus bipartitus opened on the outer surfac'c of the body. 
 
 The Vagina. 
 
 The vagina being originally one with the uterus, its malformations 
 are in many respects similar. It may be more or less completely closed 
 by a transverse septum ; it may be divided by a longitudinal septum ; 
 it may be too narrow, or it may have faulty communications with other 
 cavities. 
 
 Atresia vagin.e. — The word " atresia " is often used by authors 
 in a loose way in speaking of cases in which the vagina was closed by 
 a septum with a narrow opening. The etymology of the word, from 
 a privative, and rpdco, to bore, teaches that it ought only to be apjilied 
 to an unbored — that is, absolutely closed — vagina. Where the men- 
 strual flow can find an outlet and spermatozoids an entrance the term 
 atresia is not appropriate, but ought to be replaced by stenosis} 
 
 Sometimes the atresia is only produced by a membrane forming a 
 transverse partition in the vaginal canal. The most common kind of 
 this deformity is that in Avhich the hymen closes the whole entrance 
 (atresia hymenalis). It is commonly stated that the hymen is formed 
 about the end of the fifth month of gestation. If that is correct, the 
 atresia hymenalis would be an overgro-wth ending in the transforma- 
 tion of the hymen ial valve to a complete circle ; but perhaps atresia 
 might be due to a fusion of the originally solid Miillerian ducts at 
 their lower end, and the persistence of this solid membrane -without 
 the formation of an opening. 
 
 Breisky has found the vagina closed in newborn children by a 
 tliin membrane situated just above the hymen {septum rctrohyme- 
 nale). 
 
 A more solid transverse septum is found in adults about an inch 
 above the entrance of the vagina or nearer the upper end. Sometimes 
 a more extensive atresia has been found in the middle between a nor- 
 mal upper and lower part of the vagina. As many as three or four 
 
 1 Srfvor, narrow. 
 Vol. I.— 17 
 
258 MALFORMATIONS OF THE FEMALE GENITALS. 
 
 transverse septa have been found placed one above the other and sep- 
 arated by different kinds of retained fluid. 
 
 Finally, the whole canal may be absent — a condition which com- 
 monly is combined with absence of the uterus ; but in other cases a 
 normal uterus is found beyond the closed vagina. A case in which the 
 former condition seemed to obtain has come under my personal obser- 
 vation, and was reported to the ISTew York Obstetrical Society (Octo- 
 ber 7, 1884). The patient was twenty-one years old and had been 
 married ten months. She had never menstruated, but had had monthly 
 molimina for the last two or three years. She had sexual desire, but 
 had never had any satisfaction. She complained of headache every 
 few days, general weakness, and slight constipation. She was strongly 
 built, had well-developed breasts, an uncommon abundance of black 
 pubic hair blending with a rich growth of hair around the anus. The 
 urethra and the rectum were perfectly normal. So were the large and 
 small labia ; but there was no vagina. In its place, just behind the 
 meatus urinarius, close up to the median line, were found two round 
 depressions, one on either side. The left admitted a probe to the dis- 
 tance of one-quarter of an inch ; the right one was imperviable. These 
 two recesses were evidently remnants of the Miillerian ducts. Behind 
 them the fossa navicularis yielded easily to pressure, so as to admit 
 a finger to the depth of one and a half inches. This pouch was the 
 place in which coition took place, and had probably been expanded con- 
 siderably by the act itself. There was no tumor over the symphysis. 
 In spite of a very careful examination with the index in the rectum, 
 a sound in the bladder, and the other hand on the abdomen, no trace 
 of a uterus or ovaries could be felt. 
 
 In Gomer Davies's case atresia of the vagina was combined with a 
 cyst formed by distension of its upper part. It was found in a newly- 
 born child, in whom it occupied most of the abdomen. It contained 
 about six ounces of a clear fluid, with grumous deposit at the bottom. 
 The uterus sat at the upper part of the cyst, communicating with it. 
 
 Complete atresia excludes menstruation, and may give rise to the 
 accumulation of blood (Jicematooolpos) or pus (pyocolpos) in the vagina 
 above the septum or in the uterus. Atresia prevents impregnation, 
 and renders a normal connection difiicult or impossible. If there is 
 only a transverse septum in the upper part of the vagina, the relations 
 approach the normal condition. If it is situated near the lower end or 
 at the entrance, the pouch may in course of time become considerably 
 deeper. Sometimes connection takes place in one of the neighboring 
 openings, the urethra or the anus, especially the former. The urethra 
 is in some women very easily dilatable. I examined once an intact 
 virgin in whom the entrance had not been made easy by masturbation, 
 as often is the case, and I was much surprised to find that my index, 
 
Tin-: ^.l^7.v.l. 250 
 
 ;iltlittiii:li Mot cxcrclsiiii;- more than a \(iy iiHMlcratc prt'ssiirc, had pciic- 
 tratctl into the l)la(l«l('i\ Rctraciiin- my steps, I f'oimil iimch more n-sist- 
 aiict' ill I'litci'iiin' the vauina, ahhoii^h this oruaii |)rov('(l to he ciitii'dv 
 normal. This is |>rol>al»ly a rare condition: I at lra>t have oidy met 
 with tliis sinii'lc case. lint l)y rc|)catc»l attcm|)ts at coition in cases (jf 
 ocrhision of tlie vaiiina the nrethra Ix'comes ol'tcn <:r:i<hially dihited, so 
 as to admit the male meml)er; and, strant;'e enoniih, this considerable 
 dihitation ivsnlts only exceptionally in incontinence ut" nrine. As a 
 rnle. it does not uive rise to any snch troui)le. 
 
 Much moi'c common tlian complete atresia are the cases of nteiw.sis 
 produced l)v a more or less complete septum with one or more oj)en- 
 iugs. Such an opeiiinii; is sometimes so small that it can only he dis- 
 covered at the time of menstruation, when perhaps softeninjr takes 
 place; and, at all events, the blood trickliui;- tlirouuh the openin<; leads 
 to its discovery. Even under so unfavorable circumstances spermata- 
 zoids may work their way into the interior of the womb and pregnancy 
 take place. The membrane will then, of course, form an obstruction 
 to delivery, and re([uire operative interference, as in the cases of I, E. 
 Taylor, J. S. Coleman, F. Barnes, Heywood Smith, and others. 
 
 Different theories have l)een proposed for explaining the occurrence 
 of a transverse septum in the vagina. One is that after the ^liillerian 
 ducts had been perforated, and had been fused together into one canal, 
 an agglutination and coalescence took place between the two walls. 
 According to another, the septum is looked upon as a remnant of the 
 originally solid filaments, which have coalesced, but failed to be tun- 
 nelled at the seat of the membrane. Finally, where there is only one 
 more or less thick septum, it may be that the canal above the septum 
 belongs to one Miillerian duct, and that below to the other. 
 
 Double Vagina. — Like the uterus, so the vagina may be divided 
 into two halves by a longitudinal partition. It is composed of two 
 layers of mucous membrane and intervening muscular tissue. It may 
 be complete or inc(jmplete. In the latter case it may be found in the 
 upper part or in the lower or in the middle, or be perforated by one or 
 more holes. 
 
 When the vagina is double the uterus is commonly so too, but in 
 rarer cases a double vagina may correspond to a single uterus. One- 
 half of the vagina is often more developetl than the other. Where 
 there is a one-horned uterus combined with a double vagina, that side 
 which corresponds to the atrophied or absent uterine horn remains 
 rudimentar}^ Sometimes there corresponds only one-half of the 
 vagina to a one-horned uterus, the other half being absent altogether. 
 In tliis case the vagina is very narrow. 
 
 When a double vagina corresponds to an entirely double uterus 
 (bicoi'nis duplex or septus), as a rule there is a separate vaginal portion 
 
260 MALFORMATIONS OF THE FEMALE GENITALS. 
 
 in each half of the vagina. As we have seen above, there has excep- 
 tionally been found a single cervical portion with two openings in one 
 half of the vagina and none in the other. One-half of the vagina 
 may be too narrow for coition, and the one that is used may end as a 
 cul-de-sac without communication with the womb. 
 
 Instead of a more or less complete vaginal septum, there may only 
 be found a band uniting the anterior with the posterior wall in the 
 median line. I have seen such a case myself, in which there was a 
 fleshy band as thick as a finger just below the vaginal portion. As it 
 obstructed labor, I cut it with scissors. There was no bleeding. In 
 another case under my care the husband complained of some obstruc- 
 tion to the introduction of the penis. On examination I found on the 
 left side of the upper half of the vagina a septum one and a half inches 
 high and three-quarters of an inch wide. Between it and the vaginal 
 wall there was a free passage. This septum was likewise cut with scis- 
 sors, which gave rise to some little hemorrhage. As the lady had borne 
 a large child before, and the dyspareunia had appeared after the birth 
 of the child, it is not unlikely that this septum was only a remnant 
 of a more complete one which had been partially destroyed during 
 parturition. 
 
 Double vagina may be combined with atresia on one or both sides, 
 and thus unilateral or bilateral hsematocolpos or pyocolpos may be 
 produced. 
 
 Stenosis, or narrowness of the vagina, may, as we have seen above, 
 be due to the presence of an incomplete transverse septum, or to the 
 vagina being really only half a vagina. By an arrest of development 
 in childhood and later it may likewise stay narrow — a condition which 
 sometimes is combined. with the insufficient development of the uterus 
 described above as uterus fcetalis and uterus infantilis. 
 
 Blind Canals. — Immediately above the entrance to ihe vagina, on 
 one side of the columna rugarum, are sometimes found openings leading 
 into canals lined with mucous membrane, but with smooth walls extend- 
 ing upward parallel to the vaginal wall or deviating into the peri- 
 vaginal connective tissue. They may be an inch and a half long and 
 thick enough to admit the little finger. The upper end is closed. These 
 canals are supposed to be uncommonly-developed lacunae of the mucous 
 membrane. They differ from a secondary vagina by their thin and 
 smooth wall, and sometimes by their direction (Breisky). 
 
 Faulty Communications. — When we remember that at an early 
 stage of foetal development there is a common cloaca in which end the 
 urinary and genital canals, as well as the rectum (see Fig. 2, p. 69 ; 
 Figs. 31 and 32, p. 89), it is easy to understand how by an arrest of 
 development faulty communications may be found between the differ- 
 ent passages. 
 
Tiir. VAciyA. 
 
 2(n 
 
 Normally, the rectum is scpai'atcil \'vuu\ the simis iiroM^cnitalis hv tlic 
 formation oi' u st'ptum wliidi is <'oiii|)l(t('(l in tlic tnitii week. Il" this 
 is not formed, tlie rectum will a|»|»ar<iitly open into the vajjina, ami 
 tlicrc will be atresia arii — a eouditioii wliicli lias hccii dcsiirnatcd hv tlie 
 stranjije name of atresia ani-raf/hia/i.s. What ha.s l>een taken for tlie 
 vau;ina is really the cloaca, which has not been 
 divided into a rectal and a urou;('nital |)art (|K'r- 
 sistent cloaca, Fig. 97). Sometimes the opening 
 of the rectum has a sphincter, so that the individual 
 may retain the feces voluntarily. This apparent 
 communiciition with the vagina is not very rare. Persistent (;ioa< a: r. <io- 
 Dr. J. H. Pooley of this city ha.s compiled 38 cases, ougiit to have forme<i 
 
 the r>erineuin ; ]i, ree- 
 tum ; y, vagina; //, 
 bladder, U, urethra. 
 (From Schroeder.) 
 
 She menstruatwl 
 
 In other cases it is the genital canal which seems 
 to open into the normally-formed rectum. The 
 celebrated French surgeon Louis has reported the 
 case of a girl whose genitals were imperforate, 
 through the anus, and through the same opening coition took place, 
 and, finally, a child at full term was born that way. In this case 
 either the vagina or the uterus must have opened into the rectum. It 
 is not stated where the urethra opened, but there can scarcely be anv 
 doubt that that organ likewise opened inside of the only opening 
 present. 
 
 A similar faulty communication may take place between the vagina 
 and the bladder or the urethra. At first the sinus urogenitalis appears 
 a.s a continuation of the bladder, but in consequence of the growth of 
 the uterus and the vagina in the sixth month, and the comparatively 
 slow development of the sinus urogenitalis, it appears finallv as the 
 continuation of the vagina, forming the vestibule into which the urethra 
 opens (Fig. 33, p. 90). Some cases present an appearance as if the 
 urethra did not open into the \Tilva, but into the vagina itself. A closer 
 examination will, however, reveal that this condition is due to an un- 
 common depth and narrowness of the sinus urogenitalis, so that what 
 appears to be the vagina is really the vestibule (per- 
 sistent sinus urogenitalis ; Fig. 98). 
 
 In Palfyn's case there was one sac, into which 
 opened a uterus didelphys and the intestine. 
 
 In cases of extroversion of the bladder the vagrina, 
 as well as the ileum and the colon, have been found 
 to open on the exposed raucous membrane. In 
 Lel)edeff' s case there was a congenital vesico-vagi- 
 nal fistula combined with hypospadias. 
 
 W. H. Baker of Boston has described and suc- 
 cessfully operated on a case in which the left ureter 
 opened into the vagina, instead of being connected with the bladder, 
 
 Fig. OS. 
 
 Persistent Sinus Uro- 
 grenitalis: C hyper- 
 trophic clitoris; B, 
 bladder; I', ure- 
 thra: V, vagrina; .•<, 
 sinus urogenitalis; 
 R. rectum. (From 
 Schroeder.) 
 
262 MALFORMATIONS OF THE FEMALE GENITALS. 
 
 The Hymen. 
 The hymen is not, as stated in most anatomical textbooks, a semi- 
 lunar fold of the mucous membrane placed at the entrance of the 
 vagina. It is now, as stated above, looked upon as being the whole 
 lower end of the vagina, and its shape varies very much. As a full 
 knowledge of the normal shape of the hymen is of great practical 
 value in legal questions, we will give some details on this subject. 
 Tardieu, who has examined more than 600 cases with special reference 
 to the hymen, admits five normal conformations, which he places in the 
 
 following order of decreasing frequency : 
 
 •^ 1. The hymen consists of a strip of tissue 
 
 ^S| \^ bent at the lower end so as to form two 
 
 £ .^^m^^:- % lateral lips, touching one another in a 
 
 m ^^V^^\ 1 vertical line ; which shape is almost con- 
 
 M W£'|W| S stantly found in childhood, and sometimes 
 
 S ^ ^ I ' - ^ I M. yet after puberty (Fig. 99, from Tardieu), 
 
 \ -' ^ ' 2. The hymen forms an irregularly circu- 
 
 "^^^^^^B" ^^^ diaphragm with a more or less large 
 
 i ^^^ ^K opening in the anterior third (hymen an- 
 
 --.z 1^^^^^^^^^^^^^^ nularis)} 3. The diapliragm is exactly 
 
 '' — ^=^^ ^^^^^^^fe circular, with a central circular opening 
 
 (hymen circularis). 4. The diaphragm 
 is crescent-shaped, with a concave border turned forward, and two 
 horns ending on the inside of the labia minora (hymen semilunaris).^ 
 5. The hymen is only represented by a low circular or semilunar ridge. 
 Besides these normal shapes the hymen presents several abnormalities. 
 According to Dohrn, an intact hymen may present indentations. In 
 the hymen denticulatus the edge does not form one smooth line, but is 
 divided into many prominences by short nicks. It is distinguished 
 from a ruptured hymen by the softness of the edge, the round contour 
 of the prominences and recesses, and the absence of cicatricial tissue. 
 The hymen fimhriatus has the edge split into a fine fringe, due to 
 papillary hypertrophy, but similar growths are then found on the sur- 
 faces of the hymen, on the labia minora, and round the urethra. 
 
 It is doubtful if the hymen is ever absent. At least Tardieu has 
 never seen a case in which there were not distinct remnants of it, but 
 the last-mentioned shape, where the hymen is reduced to a scarcely 
 prominent ring, can easily be mistaken for total absence. 
 
 Atresia hymenalis. — The hymen may form a completely closed 
 septum. This condition, like that of the presence of a diaphragm 
 higher up in the vagina, will cause retention of the menstrual flow as 
 a tarry mass (hcematocolpos), or the accumulated fluid may suppurate 
 (pyocolpos). 
 
 ^ Annvlus, ring. ^ Semi, half; luna, moon. 
 
THE IIYMES. 263 
 
 Abnormal Openings. — In otlu-r cajH^ the hymen has two ruimd 
 or IfiiiTthv iijK'nin^s (hi/mcn hij<tris^ or bifnutttrntux)} If the <»jm'|i- 
 inifs arc lar>io and the iiitcrvcniii^ tissiu* narrow, the case is caMe*! 
 hipiufi septus. Sometimes the partition ji;rows out from tht- ant<'rior 
 ami j>ostorior circiiinfcnMU'o, hut without joiuin<r in the niiddlc (/n/iiwn 
 giihsijifn.s). 
 
 Till' hymen may likewise be perforated by many small openings 
 {Jitliiu'ii cribriform /.v ).^ 
 
 FLh>^HY Hymen. — The normal hymen eon.«ists of a dftuMc layer 
 of MUK'ous membrane with an intermediate layer of mu.s<"ular fibres 
 and many blood-vessels. In abnormal ca<es this intermediate layer 
 may become so much developeil as to present a serious obstacle to 
 connection. 
 
 Double Hymen. — The hymen may be said to be double in ditieivnt 
 senses. Sometimes it is composed of two diaphragms pla<;ed (^ne alcove 
 the other, but the upper one in such cases is probably a traasverse sep- 
 tum near the lower end of the vagina. Sometimes this c<jndition is 
 due to accumulati<jn of mucus above the hymen, producing a dilatation 
 of the lower end of the vagina, limited above by a constriction, at the 
 seat of which the second hymen is developed. 
 
 Where the vagina is (l(juble there is generally a hymen in each half, 
 but often the lower part of one-half of the vagina may be absent, so 
 that the canal ends blind without any hymen. Such a condition will 
 give rise to the formation of a lateral collection of blood or other 
 fluid. 
 
 Finallv, the hvmen alone, in an otherwise sinofle vagina, mav Ije 
 separated in two by a septum running in an antero-posterior direction. 
 (See Hi/men septus.) 
 
 CoN( GENITAL Cysts. — Barstellberger has described a cyst of the size 
 of a lentil in the hymen of a newborn girl. Microscopical examination 
 showed that it had been formed by invagination from the epithelium on 
 the vulvar side of the organ. 
 
 The Hymen in the Xegro Race. — Is there any difference 
 between the white and the black woman as to the place of the hymen ? 
 Dr. E. B. Turnipseed of Columbia, S. C, asserted some years ago that 
 the hymen in the negress was situated from one and a half to two 
 inches " above the entrance of the vagina." He gave the details of 
 nine cu'ses, seven of which were in children eight to twelve years old, 
 in whom the distance was from a half to three-f[uarters of an inch 
 above the entrance. This assertion was corroborated by Dr. C. H. 
 Fort of Adams Station, Tennessee. He gives six cases. It is claimed 
 that the hymen in these cases was situated one or two inches "within 
 the vulva." The latter author claims likewise that the hymen of the 
 
 * Bis, twice ; /oris, door. * Feneslra, window. ' Vribrum, sieve. 
 
264 MALFORMATIONS OF THE FEMALE GEXITALS. 
 
 negress is of greater density than that of the -white ^\■oman. He thinks 
 that these two features, the high position and the unusual density, 
 " woidd enable any practised physician to distinguish the negro from 
 the white race, even in the dark, by aid of touch alone." On the other 
 hand, Dr. H. O. Hyatt of Kinston, X. C, claimed to have examined 
 a thousand negro women without remarking any difference between the 
 fru^o races in regard to the vagina and hymen. He thinks the assertion 
 of Dr. Turnipseed is based on a confasion of the rectilinear rima puden- 
 di and the round orificium vaginje. I have no personal experience on 
 this question to oifer. Dr. Hyatt is right, that the lower and upper 
 openings of the vulva are very often confounded, as I have pointed out 
 myself in the anatomical remarks forming the introduction to my paper 
 on the " Obstetric Treatment of the Perineum ;" but even if the two 
 above-named observers should have made this mistake, that could not 
 account for much more than one inch, and by no means for the distance 
 of two inches which they claim in some cases. Besides, it is not likely 
 that they would claim as a peculiarity for the negro race what they could 
 scarcely be otherwise than familiar with in the white race. If their 
 observation is correct, the explanation can only be that the sinus uro- 
 genitalis is deeper in the black race. It would be very desirable that 
 Southern practitioners, who have a larger field of observation in this 
 regard than we who live in the Xorth, warned as to the possible mis- 
 take pointed out, would pay attention to this interesting anthropologi- 
 cal cj^uestion, and give us a large number of exact obser%*ations of the 
 seat of the hymen in the negro woman. 
 
 As to the theory of the malformations of the hymen, it must be 
 remembered from the section on Development (p. 92) that this organ 
 is formed late in foetal life, beginning in the nineteenth week, at a time 
 when the Miillerian ducts long ago have opened into the sinus urogeni- 
 talis and been fused together into one canal. The atresia of the hymen 
 can therefore not be explained as an arrest of development, like that 
 which obtains when the same condition is found higher up in the 
 vagina or in the uterus, but it must be looked upon as an excess of 
 growth. iSTor can the double hymen simply be taken as an arrest of 
 development of the hymen itself, but must be regarded as an arrest of 
 development of the lower end of the IMullerian ducts, by which there 
 stays two openings, and the subsecpient development of a hymen in 
 each of them. ^Multiplicity of openings must be looked upon as the 
 result of an irregular 2:ro's\i:h. 
 
 The Vulva. 
 
 Absence of Vitlva. — The whole of the external genitals, together 
 with the anus, may be absent, a continuation of the skin without any 
 
THE VULVA. 
 
 265 
 
 oponiii!2;s ocfnpvinjj:; their place. This coiKlitioii is (hio to an arrest of 
 (level* >|niient at the \vv\ earliest period of" tJetal (levelopiiieiit, before 
 the appearance ol" the cloacal opciiiiii^- in the ("oiirth wi-eU. It is almost 
 always coml)iiU'(l with an arivst ol" (h'\-clopiiiciit in other orj^aiis, and is 
 onlv f'onnd in non-viahle fJetnses. 
 
 Ill other cases there is an aims, hut the vnl\a has not hecn formcnl, 
 the li'enital f"iirr()W having not become deep enou«ih to <»pen into the 
 sinus urogenital is. 
 
 Hypospadias.' — AVhen the posterior wall of the urethra is defective 
 the condition is called hypospadias (Fig. 100). If the defect extends 
 lar up, the control over the bladder is lost. 
 
 Fir;. 100. 
 
 Hypospadias: a, open canal, fijrmed by the anterior wall of the urethra, the posterior being 
 absent in this part; b, posterior, closed part of the urethra; d, hymen; e, opening in the 
 same. (From Wlnckel, after Mosengeil.) 
 
 Epispadias ^ is the name for a condition in -uliich there is a cleft in 
 the anterior wall of the urethra, which mostly is combined with a cleft 
 in the anterior wall of the bladder (extroversio vesicce). In the upper 
 part of the vulva, just below the symphysis pubis, appears the mucous 
 membrane of the open bladder (Fig. 101). There is no urethra. The 
 clitoris may be cleft. 
 
 The urethra forms originallv one organ with the bladder. Both are 
 a development of that part of the allantois which is situated inside of 
 the foetus. Thus this cleavage is not a simple arrest of development, 
 but is attributable to a deficiency of the anterior wall of the bladder, 
 as well as to an arre.st of development in the abdominal wall. 
 
 1 'Yrro, under ; c~a6ucj, I tear. ^ 'E-i, on ; ryKadi^i^, I tear. 
 
266 
 
 MALFORMATIONS OF THE FEMALE GENITALS. 
 Fig. 101. 
 
 Epispadias: a, fissure In the bladder; b, labium majus; c, clitoris; d, labium minus; e, hymen; 
 /, vaginal entrance. (From Winckel, after Kleinwachter.) 
 
 The clitoris has been found cleft, without any cleavage of the urethra 
 or bladder, but combined with a cleft symphysis and a deficiency in the 
 abdominal wall above the bladder. 
 
 Other Congenital Abnormities. 
 
 The clitoris may be absent, rudimentary, or, on the other hand, very 
 much enlarged. Hyrtl states that in some African tribes the clitoris 
 hangs down, covering the rima pudendi as a valve, and that the people 
 fasten it with a ring to the perineum as a protection for virginity. In 
 hermaphrodites it often becomes as large as a penis of moderate dimen- 
 sions. Bainbridge found in a woman whom he assisted in labor a cli- 
 toris about five inches long and of the diameter of a quiescent j)enis of 
 an adult, to which organ it became still more like by the presence of a 
 groove behind the glans. At a later examination it was found measur- 
 ing three inches in length and two in circumference. 
 
 The labia minora may likewise be absent on one or both sides. 
 
iiEnMAriiiinDisM. 207 
 
 There tnay 1k' found iuiir, or t-veii six, tliif to a loldiii;^ <»f' the (-(lifcs 
 (tf the <i;('iiital iiirrow. Soinctiiiies the hibia minora arc iiinrh loiiir«'r 
 than nsual, which peculiarity is ionnd eonstantly in Hottentot women 
 and has hci-n caUed the Jlolfnilol (ipion. These fhij)S are said to oWtain 
 a lenjith ot" eight or twelve inches. \\\ some tribes they are regularly 
 eut away by ti kind ot" eircumcisitjn. 
 
 The labia majora are more rarely the seat ol" a similar c<jngenital 
 hypertrophy. 
 
 Atresia vulixe supa^fidaliK. — The labia majora as well as the labia 
 minora may in the second half of ffctal life l)ecome agglutinated, and 
 coalesce more or less extensively from behind forward, so as to give 
 the appearance of an uncommonly long perineum. It is rare that the 
 nymplue are grown together to such an extent as to prevent urination 
 in the newborn child. Menstruation is unimpeded, but the dimensions 
 of the entrance may be so small as to oppose a serious obstacle to sexual 
 connection unless it be removed early in life. 
 
 Vuh-a infantilis. — By an arrest of development after the birth of the 
 child the vulva may retain in the adult the small dimensions of child- 
 hood. If, nevertheless, impregnation takes place, the condition may 
 give rise to difficulties in childbirth. 
 
 Hermaphrodism. ^ 
 
 Considerable practical no less than scientific interest attaches to that 
 group of malformations which are designated by the term " hermaph- 
 rodism " or " hermaphroditism ;" that is, the condition in which the 
 characteristics of the two sexes become more or less blended in one 
 individual. 
 
 The physician may have to decide at the birth of a child to what 
 sex it belongs — a decision which, if hastily made, may lead to the 
 gravest consequences and cause much unnecessary suffering, and Avhich 
 often cannot be made at all without an examination of the inner parts, 
 as in Sippel and Chalmers's cases, where the child to all appearances 
 was simply a male hypospadiaeus, while the autopsy revealed a perfect 
 uterus, ovaries, tubes, broad and round ligamenis. If there is any 
 doubt alx)ut the sex of a child, I think I^awson Tait's advice is a good 
 one — to bring the child up as a male. AVhen it grows up it will find 
 out that it is not formed like other boys, and when grown to manhood, 
 if unfit to perform the functions of the male, it will abstain from mar- 
 riage. Girls are often in an astounding degree ignorant of everything 
 
 ^ Hermaphroditus, a son of Hermes (^or Mercury) and Aphrodite (or Venus), accord- 
 ing to Grecian mytholoffv, became the object of the amorous desires of the nymi)h 
 Salmacis, who induced the gods to make them one body, retaining the characteristics 
 of both sexes. 
 
268 MALFORMATIONS OF THE FEMALE GENITALS. 
 
 belonging to sexual relations. An hermaphrodite brought up as a girl 
 may, therefore, marry without having any idea of being unfit for sexual 
 connection, or the male instincts may awake, and the male hermaphro- 
 dite, being brought up among girls, and placed in positions where the 
 instincts can be satisfied, much mischief may be done, as in the case of 
 Madelaine Mugnoz, the nun of Ubeda, who suffered death for rape. It 
 is so much wiser to follow this advice as the possibilit}'- of erring by so 
 doing is much smaller, male hermaphrodites being much more common 
 than female. 
 
 Important medico-legal questions attach to the question of hermaph- 
 rodism. Often males only inherit certain estates, and it may becouie 
 necessary to decide if the heir-apparent ftilfils the necessary require- 
 ment as to sex. In the United States the right of voting as a citizen 
 and of filling certain offices is restricted to the male sex, and conse- 
 quently a man's right to do so may be challenged on account of doubt- 
 ftil sex. Hermaphrodism may be claimed as entitling to divorce, or 
 the question may come up whether a child can be the offspring of an 
 hermaphrodite or not. 
 
 Klebs's division of the different kinds of hermaphrodism recom- 
 mends itself by its clearness, completeness, and practical value, and is 
 therefore a valuable guide which we will follow.^ This author dis- 
 guishes first true from spurious hermaphrodism. As true hermaph- 
 rodism only such cases are recognized in which a testicle and an ovary 
 are found in the same individual. Under the term spurious hermaph- 
 rodism he unites all those cases in which the genital glands belong to 
 one sex and the external organs and internal ducts approach more or 
 less the type of the other sex. 
 
 From the history of development we know that the genitals are com- 
 posed of three different parts : first, the sexual glands ; second, the two 
 sets of ducts (the Wolffian ducts, which are transformed to the tail of 
 the epididvmis and the vas deferens ; and the Mullerian ducts, which 
 form the Fallopian tubes, the uterus, and the vagina) ; and third, the 
 external genitals. These three portions having each its own inde- 
 pendent foundation, we can understand how one of them may become 
 developed according to a different t}'pe from the others. 
 
 True Hermaphrodism, or Androgynia {Her7}iaphrodismus 
 vents). — This group comprises only the cases in which a testicle and 
 an ovary are found in the same individual. This condition is normal 
 
 1 The commonly- followed system distinguishes between spurious and true hermaph- 
 rodism. In the first class are only placed slight cases, such as hypospadias, enlarged 
 clitoris, atresia of the vulva, etc., which we exclude all together. The second com- 
 prises three groups : 1, Lateral hermaphrodism, where there is a testicle on one side, an 
 ovary on the other ; 2, vertical or double hermaphrodism, where on the same side are 
 found male and female organs ; 3, transverse hennaphrodism, where the internal organs 
 are male, the external female. 
 
ni:i:M. i rnnonisM. !>(;!> 
 
 in iiiaiiv Inwcr aiiliiials, ami is (tccasi(Hially rniiiid in the liit;lic>(. Its 
 existi'iicc ill mail is yet denied by iiiaiiy, and most of the (dder eases 
 ar(> not reliaMe. Only those can eoniit in which a mieroseoj)ieal exam- 
 ination \ields a |»ositi\-e I'esnll. It has hecii claiiiiccl that hoth testidos 
 and holli ovaries ha\'e heeii I'oiind in one individual {fmr hllitl<r(tl licr- 
 iixi/ihrodistii) ; ami I tliinU IIe|)|iiier's ease is one in j)oiiit. Inthehodv 
 ol' a rhild that die<l at the age of two months he found (a) an orj^an 
 which with the same ri*>;ht can be called a liypos])adie penis and a 
 liypertrophied clitoi'is; (6) a cleft serotnm ; (r-) a sinns nrogenitalis and 
 Rosen mil Iter's oiuan representing parovarium and epididymis; further- 
 more, a ])rostate and both testicles; and, finally, a vagina, uterus, tubes, 
 both ovaries, round and broad ligaments. The microscopical examina- 
 tion showed the ovary to l)e full of Graafian follicles, some of which 
 contained an ovum, while the testicle was composed of seminal canals. 
 It seems that this most imjiortant case has been overlooked by Klebs, 
 since he does not even allude to it. 
 
 It has likewise been asserted that on one side there may be one 
 sexual gland, either a testicle or an ovary, and on the other both 
 a testicle and an ovary (true unilateral hermaphrodism) ; but no 
 authentic case is known of this kind. Klebs thinks that perhaps 
 Bannon's case belongs to this group, but it appears from his abstract 
 that he has not seen the original, since he is entirely misinformed 
 in regard to many important points. The individual died at the 
 age of twenty-six years, and was supposed to be a man. The exter- 
 nal genitals w^ere of an undecided character. There was a hymen, a 
 vagina, and a uterus, from the left upper angle of which started a 
 Fallopian tube, but it went between the uterus and rectum over to 
 the right side to a body which is called an ovarv'. On the same side 
 was found a testicle with epididymis, from which a long tube, which 
 Bannon takes to be a vas deferens, went to the right upper angle of the 
 uterus and communicated Avith its cavity. I therefore take it rather to 
 be an elongated Fallopian tube. Behind and partly in the internal 
 inguinal ring was found " a glandular organ." Xo description is given 
 of the latter, nor does it seem to have been examined microscopically. 
 The supposed ovary was submitted to such an examination, and a 
 drawing is given of its appearance ; but no description except the words 
 " the granules visible are not Graafian follicles, but appeared to be fat- 
 globules ;" and the drawing has not the slightest resemblance to the 
 structure of an ovary. The testicle had an albuginea and the tubular 
 arrangement proper to that organ. The fluid contained in the com- 
 mencement of the vas deferens and epididymis had the peculiar odor 
 and consistence of the human semen. Under the microscope it showed 
 numerous cells containing granules, but no trace of spermatozoids. It 
 is clear that it was only, so to say, accidental that the left genital gland 
 
270 MALFORMATIONS OF THE FEMALE GENITALS. 
 
 was found on the right side, and no genital character is claimed for the 
 " glandular organ " at the entrance of the inguinal canal ; and while it 
 must be admitted that the individual had a testis, it is not proved, and 
 not even made likely, that he had an ovary. But if Heppuer's case is 
 admitted as one of true bilateral hermaphrodism, we may of course as 
 well expect once to find a similar case with a double sexual gland on 
 one side and a single on the other. 
 
 It is difficult yet not impossible to understand how the same indi- 
 vidual can have more than one set of reproductive glands, for we have 
 seen (p. 76) that it is one and the same body, which, identical in the 
 beginning, later turns out to be either a testicle or an ovary. The 
 connective tissue that goes to form the ovary or the testicle is indeed 
 identically the same substance ; but perhaps the epithelial part of the 
 two glands has a different origin. Wakleyer thinks, namely, that the 
 seminal canals are formed as invaginations from the Wolffian duct, 
 while the follicles in the ovaries are derived from the germ-epithe- 
 lium. 
 
 We have furthermore seen (p. 92) that supernumerary ovaries may 
 be found, and that not only by a division of one larger body, but as a 
 separate body of the size of a normal testicle. As to testicles, there 
 is only one case on record of three testicles being found in the same 
 individual at an autopsy, and even this case is not beyond dispute. 
 The other cases regard living men, and are consequently still less con- 
 vincing (Foerster). If thus we can have more than two glands of the 
 same sex, the possibility of one or more of them having the type cha- 
 racteristic of the other sex is given. 
 
 It must be admitted that at the very earliest point of develop- 
 ment every human individual is, in a certain sense, hermaphroditic, 
 inasmuch as there is a common foundation for the urogenital system, 
 which very soon separates into two parts, the germ-epithelium and the 
 epithelium of the AVolffian duct, the first of which is developed to the 
 female sexual glands and ducts, while the second forms the male ducts, 
 the uropoetic system, and probably the male glands. Even in female 
 individuals the beginning of seminal canals are found in the parova- 
 rium, and, on the other hand, sometimes some large cells are found in 
 the surface epithelium of the testicle which are supposed to be primor- 
 dial ova. 
 
 The third possibility of true hermaphrodism is the presence of a tes- 
 ticle on one side and an ovary on the other {true lateral hermaphrodism). 
 From what we have just said about the identity of the two glands, it is 
 not unlikely that one might be developed according to the male and the 
 other to the female type. 
 
 The most important case of supposed true lateral hermaphrodism is 
 a specimen found in the pathological museum at Ziirich. It comes 
 
HKRMM'lUtnDISM. 
 
 271 
 
 Fig. 1(i-J. 
 
 iVoiii 11 newhorn child, aii<l was first dt'scrilMMl hy II. Meyer, and later 
 examined mierosenpicaily and do.s<'ril)e<l In' ]vl«'i)s. (For details wc 
 nui.-t refer tlie reader to the work of tlu; latter, luc. rit., \t. 728 ; here we 
 must limit oui'selves to the most important 
 features of the ea.so.) The child had a slntit 
 j)enis with a lar«;e glans anil a bulky pre- 
 puce (Fii;. 102). On the end of the ^lans 
 is a l)liud ui-ethra. lielow, the prepuce is 
 continued in a fissui'e, the posterior jjart of 
 which leads into the sinus uro»i;enitali.s. Be- 
 hind this openinjji; is a raphe uniting the two 
 hal\es of a well-tie veloped scrotum, in the 
 left half of whieh is found a testicle. From 
 the sides of the fjenital fissure, near the en- 
 trance to the sinus urogenitalis, start two low 
 
 ridw;es of skin which run backward and out- External Genitals in a case of her- 
 
 1 ^ ^i i f> ^1 • /-v ,1 maphrodismus lateralis: a, scro- 
 
 ward to the root Ot the penis. On the pos- tmn; 6, labia majora;c, prepuce; 
 
 terior wall of the sinus Urogenitalis is found '^' ^^^'^^ minora: e, entrance to 
 • T .1 1 /> sinus urogenitalis. (From Klebs.) 
 
 a colliculus semnialis with several fine aper- 
 tures, none of which lead to a vas deferens, but one, on the left side, 
 leads into a vagina and uterus arcuatus (Fig. 103). A slight swelling 
 round the genital canal at the seat of the colliculus seminalis shows the 
 micEoscopicaL structure of the prostate. From the right horn of the 
 
 Fig. 103. 
 
 Intemal Genitals of the same case of lateral hermaphrodism, seen from behind : a, bladder ; 
 6,6, ureters ; c, vaginal entrance : c, d, vagina ; d, external os ; e, e, Fallopian tubes ; /, ovar>-: 
 p, parovarium ; A, right Morgagni's hydatid ; t, testicle ; it, ovarian (or testicular) ligament ; 
 /, epididymis; in, bundle of vessels and nerves of the cord; n, vasa deferentia; o, o, hyda- 
 tids of left tube; p, peritoneal pouch in left half of scrotum, containing <■/, left round iiga- 
 ment, and >-, guberuaculum Humeri ; r, right round ligament; P. prostate. (From Klebs.) 
 
 uterus .start the round ligament, the ovarian ligament leading to a club- 
 shapetl body supposed to be an ovaiy, and finally the Fallopian tube. 
 Between the ovary and the tube is found a parovarium. The micro- 
 scopical examination of the supposed ovaiy shows total abtsencc of J'ol- 
 
272 
 
 MALFORMATIONS OF THE FEMALE GENITALS. 
 
 licles, with which the normal ovaries of newborn children are crowded. 
 The stroma is composed of a dense fibrous tissue with many nuclei, as 
 in the rete vasculosum testis, and tunnelled by numerous branching and 
 anastomosing canals from 8 to 20 micromillimeters ^ in width. They 
 have no proper wall, but the surrounding tissue forms a fine double 
 contour. Their interior is filled with small polygonal cells measuring 
 from 3 to 5 micromillimeters in diameter, and showing a nucleus and 
 a granular protoplasm. Besides these small cells are in the larger 
 canals found straggling larger cells measuring 11.4 by 7 micromilli- 
 meters, and distinguished from the others by their brightness. Klebs 
 takes them to be primordial ova. Furthermore, he found in the few 
 sections he made from the rare specimen a large round cavity measur- 
 ing 80 by 64 micromillimeters, and surrounded by concentric fibres of 
 connective tissue. It contained a fine granular mass and several nuclei 
 measuring 5 by 7 micromillimeters. Although no ovum was found in 
 this cavity, Klebs looks upon it as a follicle. 
 
 On the left side (Fig. 104 will give a clearer idea of the organs on this 
 side) the round ligament descends into the open peritoneal pouch con- 
 taining the testicle, and spreads out 
 ^^^- ^^^- on the walls of the sac. At the end 
 
 of the ovarian ligament (j), which 
 here must be called a testicular lig- 
 ament, is found an oval body which 
 both macroscopically and micro- 
 scopically answers to a testis. At 
 the upper end of the testis (^4) is 
 found a coniform protuberans {B), 
 which microscopically shows the 
 texture of the rete testis. Inside 
 of this body is found a bundle of 
 blood-vessels and nerves (P) corresponding to the spermatic cord, but 
 without any vas deferens. Between this bundle and the above-men- 
 tioned ligament is seen another ligament going from the testicle to the 
 bottom of tlie pouch in which the testicle is enclosed. This ligament 
 represents the gubernaculum testis {h). Above the rete testis is found 
 the epididymis, the head (C) forming a right angle with the tail (Z)). 
 From the tail start the vas aberrans Halleri {e) and some blood-vessels 
 going to the above-mentioned bundle representing the spermatic cord. 
 Finally, above the epididymis is seen the tube {K) with fimbriae (X) and 
 two small pedunculated cysts, the one {m) starting from the fimbria 
 ovarica, and the other (N) connected by means of a peritoneal fold with 
 the head of the epididymis, the hydatid of which it probably is. 
 
 I have given all these details because this is the best examined of all 
 ^ A micromillimeter, the sign for which is //, is one-thousandth of a millimeter. 
 
ITERMAI'linoi)Is.}f. 273 
 
 <US(><, l)Mt 1 (111 not ;ii:rcc with KIrhs ill liis cDiicliisidii tli:it the K-xiial 
 t:;l;iiitl on tlic i"i<;lit side is ;iii ovarv — :i coiicliisioii wliiih is \v;irr:iiitc<l 
 iicitlicr 1)V tlu' cxtcninl nppcaraiK-c nor l»y tlic striK-tiirc of" tlic IxmIv. 
 ()ii lilt' »'()iiti-arv, it scciiis to iiw that the (U'scriptioii nf tlic liistolof^ical 
 (Miiii|)nsiti(»n rciiiiiids iiuicli nioir of a testicle than of" an ovarv. 
 
 There is another ease of threat interest which j)crha[)s is one of true 
 hit<'ral hcrniaj)hrodism. It has the advantage over the former of Ix-ing 
 that of an a<hdt, bnt the disadvantajre that the person in (|nestion is 
 still livin*;, and that conse(|iicntly the nature of the internal parts is 
 subjected to doubt. Wi' refer to the famous Catharine or Carl Hoh- 
 nianu.' This individual has been most carefully examined by such 
 competent observers as O, von Francpie, Rokitansky, X. Friedreich, 
 S. B. Schultze, and P. F. Munde. We will use the masculine i)ro- 
 noun in speakino; of this person, since his male nature is proved beyond 
 a doubt, while the female is still sab judice. He was born in Bavaria 
 in 1.S24, and spent the first forty-six years of his existence as a female. 
 In his twelfth year the genitals and breasts increased in size, and soon 
 afterward he Ijegan to feel sexual propensities, which at that time were 
 entirely directed toward the male sex. At the age of seventeen he took 
 unto himself a male lover, with whom he cohabited for twenty years. 
 The attempts at coition were accompanied by the discharge of a thin 
 viscid fluid from the urethra, the emission of which coincided with the 
 org.ism and wiis not attended by any erection of the clitoris. Las- 
 civious thoughts would be followed by this same emission, and sexual 
 excitement always brought on a peculiar thrill or glow on the left; side 
 of the pelvis. In his nineteenth year a discharge of blood took place 
 from the urethra, which for some time returned at irregular inter- 
 vals and finally reappeared every tliree or four weeks, lasting from 
 three to six days. This regular Ijloody discharge was preceded by 
 tumefaction of the breasts, easy erectibility of the nipples, and the 
 secretion of a colostrum-like fluid, which could be pressed out from 
 the latter. This secretion disappeared again when he was about forty 
 years old, and in his forty-third year the bloody discharge stopped. 
 This periodical bloody discharge has been repeatedly watched and the 
 fluid examined microscopically, so as to exclude every fraud. It M'as 
 composed of mucus with fresh human blood-corpuscles exactly like 
 menstrual blood. In his twenty-fifth or twenty-sixth year beard-hairs 
 a})peared, which he tore out. 
 
 In 1870 he made his first attempt at sexual intercourse as a man, 
 and from that time he had nocturnal emissions of a fluid, the seminal 
 nature of which has been proved with absolute certainty. It lookeil and 
 smelt like semen, and on microscopical examination it Avas found to 
 abound in Avell-shaped spermatozoids in lively movement. 
 
 ' The name is sometimes spelt Homann (Rokitansky) or Humann (Von Franqu^). 
 Vol. I. — IS 
 
274 MALFORMATIONS OF THE FEMALE GENITALS. 
 
 Fig. 105.— Penis aud Scrotum, side view. 
 
 Fig. 106. 
 
 Fig. lOe.-Same, more from the front, a stylet introduced into the opening of the urethra. 
 
IIERMA PIIRODISM. 
 
 275 
 
 Frri. 107 
 
 Fi<; 108. 
 
 Fig. 107.— Upper Half of Anterior Surface, show- 
 ing the breasts. 
 
 Fig. 108.— Posterior Surface, showing the 
 long hair, the slender back, the bKoad 
 hips, and the finer build of the left side. 
 
 Fig. 110. 
 
 Fig. 109. 
 
 Fic. 110.— A supposed transverse section 
 through the pelvis: P. promontory; h, 
 urethra ; m, uterus ; k, sexual gland. Be- 
 tween u and k is seen the Fallopian tube. 
 
 Rectum 
 
 Fig. 109.— a supposed sagittal section : a, meatus ; v, entrance to vagina ; w, uterus. 
 
276 MALFORMATIONS OF THE FEMALE GENITALS. 
 
 Here, then, we have a human being uniting the production of semen 
 with a periodical discharge of blood mixed with mucus from the geni- 
 tals. Still, it would be risky to conclude from these premises that the 
 individual has double sex in the strict sense of the word. While the 
 presence of a testicle is proved, that of an ovary is yet doubtful. The 
 presence of a periodical bloody discharge from the genitals is not con- 
 clusive, since a similar condition has been found combined with normal 
 male genitals (Rayer), and especially in males suifering from h^^^ospa- 
 dias (Th. Allen, Morand). 
 
 Carl Hohmann has later donned manly attire, has had his hair cut 
 short, and is married to a woman. Formerly he used to have wavy, 
 black hair, descending to the waist, as seen in Fig. 108. The left side 
 of the face has a feminine type, and the whole left side of the body is 
 less strongly developed than the right. The beard is slight, but dis- 
 tinct. He has large, well-formed breasts, with large areolae and large, 
 prominent . nipples. The larynx is large, with prominent pomum 
 Adami, and the voice is deep and full, but Hohmann says he sings 
 soprano. The back has a female curve. The pelvis approaches the 
 male type, but seems to be more capacious than in the normal male. 
 The hips are broad and the knees converge as in a woman. 
 
 The external genitals present a masculine appearance. He has a 
 penis, bound as far as the glans to the subjacent integument. It is two 
 and a half inches long,' but during turgescence it measures five and a 
 half inches. At the end is a blind longitudinal furrow. The urethra 
 'opens on the posterior aspect of the glans near the corona, and admits 
 easily a sound measuring twenty-four millimeters in circumference, 
 which passes without resistance into the bladder. Below the urethral 
 aperture is a shallow recess covered with integument, but no trace of a 
 vagina. On the right side there is a well-developed scrotum and testicle, 
 with epididymis and vas deferens. The left half of the scrotum is 
 shorter, thinner, and more like a labium majus. At the bottom was 
 formerly found a hard mass without distinct limits, which even then 
 was looked upon as connective and adipose tissue, and which now has 
 disappeared. In the left groin is found a body of the size of a bean, 
 the nature of which cannot l^e ascertained, but which some observers 
 take to be an atrophic testicle, while others think it is the empty sac 
 of a crural hernia. 
 
 From the apex of the penis two tortuous folds of skin run upward 
 to the mons Veneris. It has been surmised that they might represent 
 labia minora. In the preceding case somewhat similar folds Avere found, 
 but there they started from a lower point — namely, from the posterior 
 end of the long cleft frsenulum, from Avhich point they ran over the 
 
 1 This is taken from Yon Franque's dravring. Friedreich says three inches, and 
 Munde one and a half. 
 
ni'.nMM'unoinsM. -iii 
 
 scrotum to the root of the penis {V"\\!^. 1(>2). Klclis statts {loc. cH., ji. 
 7.">.">) tli;it Bi'cisky li;is found similar folds in otherwise; entirely n<ti- 
 mnl women rnmiin<;- from the postei'ior commissure to the imier siu'facc! 
 of the lahia majora. 
 
 As to the conditi<»n of the internal jicnitals, a medium-sized male 
 catheter can ho introduced thron<2;h the urethra into a female <;<'nital 
 canal, which deviates somewhat to the left and terminates in a button- 
 shaped expansion (Fi}2;. 109, u), the fundus uteri, from wiiich a cord, 
 taUen to he a Fallopian tube, goes off to the left side of the pelvis, 
 where it terminates in a somewhat movable cylindrical body several 
 cubic centimeters larcro, which is sensitive to the touch, and probably is 
 the left sexual oland ; but wlicther it is a testicle or an ovary can only 
 be settled by a future post-mortem examination. Thus this case as 
 little as any other can be said to be positively jiroved to be one of 
 true herma[)hrodism. (Figs. 106-110, illustrating the description, 
 are taken from the American Journal of Obstetrics, 1875, vol. viii, 
 p. 615.) 
 
 Spurious Hermaphrodism (Hermaphrodisnius spurius, s. Pseudo- 
 hermaphrodismus). — By spurious hermaphrodism is meant the condition 
 in which the sexual glands belong to one sex, either masculine or femi- 
 nine, and the passages leading from them, as well as the external parts, 
 more or less approach those of the other. Spurious hermaphrodism 
 is subdivided according to the nature of the sexual glands into mals 
 psendo-liermaphrodmii and/(?»i«7e pseudo-hcrmapjhrodmn, each of which 
 comprises three groups, the first being formed by those cases in which 
 the ducts alone belong to the opposite sex {internal male or female pseit- 
 do-hcrmaphrodisrn) ; the second, by those in which the external parts 
 alone represent the opposite sex (external male or female pseudo-her- 
 maphrodiftm) ; the third, those in which both the ducts and the exter- 
 nal parts a})proach those normally found in the other sex (internal and 
 external complete male or female pseudo-hermaphrodism). 
 
 Slight aberrations, such as atresia of the vulva in the female or hypo- 
 spadias and slight enlargement of the prostatic vesicle in the male, due 
 to local disturbances during foetal development, are not counted as con- 
 stituting hermaphrodism, but it may of course become difficult to draw 
 the line. 
 
 Pseudo-hermaphrodism, as well as true hermaphrodism, dates from 
 the earliest periods of foetal development. It is much more common 
 in the male than in the female sex, and it reaches likewise its greatest 
 development in the former sex ; so that the vagina, uterus, and tubes 
 may be found more or less complet-ely developed in an individual with 
 testicles, vasa deferentia, seminal vesicles, and male external genitals. 
 
 The external genitals being formed of the same substance in the two 
 sexes, it is not possible to have a double set of them, one male, the other 
 
278 MALFORMATIONS OF THE FEMALE GENITALS. 
 
 female ; but some parts assume more of the one type, and others more 
 of the other. 
 
 The general appearance of the body, especially in regard to the 
 growth of hair, the development of the breasts, the prominence of the 
 pomum Adami, the breadth of the hips, and the angularity or round- 
 ness of the contour of the body, presents commonly a mixture of both 
 sexes, the preponderance being in conformity not with the real sex as 
 determined by the sexual glands, but with the external genitals. Thus, 
 a female with ovaries and male external genitals will, as a rule, be more 
 like a man as to build, and a male with testicles and female external 
 genitals commonly looks more like a female. 
 
 Literature Referred to} 
 
 Ahlfeld, F. : Di'e Missbildungen des Menschen, Leipzig, 1880. 
 
 : " Ueber einen Monopus mit vollstandigem Mangel der aeusseren Genitalien 
 
 und des Afters" {Arch.f. GyndL, 1879, vol. xiv. p. 276). 
 AiKMAN, John: "Case of Double Uterus and Vagina" {Am. Journ. Obst., 1872, vol. 
 
 V. p. 380, frona Glasgow Med. Journ., May, 1872). 
 Baek, B. F. : "A Case of Uterus Subseptus complicating the Third Stage of Labor" 
 
 {Am. Journ. Obst., 1883, vol. xvi. p. 180). 
 Bainbridge, J. N. and W. : " Case of Enlarged Clitoris " {Med. Times and Gaz., Jan. 
 
 14, 1860, vol. i. p. 45). 
 Baker, W. H. : " Malpositions of the Uterus " {New York Medical Journal, Dec. 
 
 1878). 
 Bannon, a. p.: '"'On Hermaphrodism " {Dublin Quarterly Journal, August, 1852, No. 
 
 xxvii. p. 66). 
 Barnes, F. : "A Case of Labor with Atresia Vaginae" {London Obst. Trans., 1883, 
 
 vol. XXV. p. 99). 
 
 : "Spurious Hermaphroditism" {Land. Obst. Trans., 1882, vol. xxiv. p. 188). 
 
 Barnes, R. : "On Hernia of the Ovary" {Am. Journ. Obst., 1883, vol. xvi. p. 1). 
 Bastelberger : "Cyste im Hymen" {Arch.f. Gyndk., 1884, vol. xxiii. p. 427). 
 Beigel, H. : Pathol. Anal, der Weiblichen Unfruchtbarkeit, Braunschweig, 1878, pp. 
 
 42, 43. 
 
 : "Uterus imicornis dexter mit eigenthiimlichen Verlauf der Tuba und des 
 
 ■ Ovariums links" {Arch.f. Gyndk., 1877, vol. xi. p. 380). 
 BoRiNSKY, S. : " Daseine Horn eines Uterus duplex als irreponibles Hinderniss fiir 
 
 die Extraction bei der Entbindung des andern Homes" {Arch, fur Gyndk., 1877, vol. 
 
 X. p. 145). 
 Breisky, a.: "Hydrometra lateralis" {Arch. fiir Gyndk., 1874, vol. vi. p. 89). 
 
 : "Pyometra und Pyocolpos lateralis" {Arch. fiir. Gyndk., 1871, vol. ii. p. 84). 
 
 : " Ein neuer Fall von Pyometra und Pyokolpos lateralis " {Arch, fur Gyndk., 
 
 1871, vol. ii. p. 451). 
 Brown, W. S. : "Atresia Vaginse" {Am. Journ. Obst., 1880, vol. xiii. p. 192). 
 Carter, C. H. : "Absence of the Vagina" {Lond. Obst. Trans., 1880, vol. xxii. p. 
 
 251). 
 Chalmers: "Hermaphrodite" {Lond. Obst. Trans., 1882, vol. xxiv. p. 239). 
 : "Spurious Hermaphroditism" {Land. Obst. Trans., 1883, vol. xxv. pp. 129, 
 
 162). 
 Chambers, T. : "A Case of Congenital Inguino-ovarian Hernia" {Lond. Obst. Trans., 
 
 1879, vol. xxi. p. 256). 
 
 1 Works mentioned in the preceding article (" Tlie Development of the Female Genitals ") 
 are not repeated. 
 
i.iTi:iL\Trni':. 279 
 
 ClkvELAND, W. 1".: •• liH.ini nf I Niul.tliil Si-x " {I,<,„<l. (JIjhI. Tinm., 18G8, vol. ix. 
 
 p. 29). 
 CoKN : "A Ca.SL' of Alxsenco of Uterus and V'liKiiui, and other Malformations" ffrorn 
 
 Annali Univvrmli <lf Mnl., Jan., 1HS4, in fnitnilU./. (lijiuil:., IH.Sl, vol. viii. p. 714). 
 Coi'KMAN, E. : "On tlio Tri-alrncnt of Impfrfoniti; llyim-ii " ( Litml. ObxI. 'J'rnnx., IWJ, 
 
 vol. X. p. 24G). 
 ('roS!«, E. : "A Case of Oeeliision of the N'agiiia complieated by Prejjnaney " (.4m. 
 
 Journ. ObsL, 1883, vol. xvi. (.. HO'.)). 
 Da V I li*, G. : "Abdominal ( 'ysl in a Newiy-liorn Chiiil" t Loml. OImI. Tramt., ]H~~ , 
 
 vol. xix. p. 5). 
 Davis, E. H. : "Case of Atresia of tiie Vagina" {Am. Jnurn. Ohd., 1872, vol. v. p. 
 
 396). 
 Dk Forest, W. : "Case of Spurious Ik'rmaphrodisra " {Aui. Journ. Obnt., 187G, vol. 
 
 ix. p. 500). 
 DiKNKR, G. A.: "Ein Fall von doppelter Gebiirmutter raitdoppelter Scheide (Uterus 
 
 didelphys c. vagina dnplice)" {Arch.f. Gyndk , 1883, vol. xxii. p. 463). 
 Don UN, K.: "Die Bildunjrsfehler des Hymens" {Zeitschr. f. Geburlshulje u. Gynd- 
 
 koloyie, 1884, vol. xi. p. 1 ). 
 
 : "Ein Fall von Atresia vaginalis" (ArrJi./iir Gyndk., 1877, vol. x. p. 544). 
 
 : "Ein verheiratheter Zwitter" {Arch. far Gynak., 1877, vol. xi. p. 208). 
 
 : "Ein verheiratheter Zwitter" {Archivfur Gyndk., 1884, vol. xxii. p. 225). 
 
 DouAN, A.: "Deficient Development of the Uterus (Ulermfcetalii), Atresia of the Os 
 
 Externum, Atropliy of the Ovaries, Insanity" {Loud. Obst. Trans., 1879, vol. xxi. 
 
 p. 253). 
 : " Dissection of the Genito-urinary Organs in a Case of Fissure of the 
 
 Abdominal Walls" (Joarn. Anal, and Physiol., 1881, vol. xv. p. 226). 
 : "Congenital Communication between the Rectum and the Genito-urinarv 
 
 Tract" {Lond. Obst. Trans., 1880, vol. xxii. p. 79). 
 Duncan, M. : "Case of So-called Imperforate Hymen" (Lond. Obst. Trans., 1882, 
 
 vol. xxiv. p. 212). 
 : " Delivery in a Case of Double Uterus" {Lond. Obst. Trans., 1881, vol. xxiii. 
 
 p. 21). 
 
 ' Pyometra " {Land. Obst. Trans., 1879, vol. xxi. p. 54). 
 
 Em.met, T. a.: "A Case of Hermaphrodism " {Am. .Town. Obst., 1881, vol. xiv. p. 
 
 882). 
 : " Congenital Absence and Accidental Atresia of the Vagina " {Am. Gyn. 
 
 Tran-i., 1877, vol. ii. p. 437). 
 FoERSTER, A.: Handbuch der Pathologischai Anatomie, 2te Aufl., Leipzig, 1863. • 
 
 Fort, C. H. : "Some Corroborative Facts in Regard to the Anatomical Difference 
 
 between the Negro and White Races" (Am. Journ. Obst., 1877, vol. x. p. 258). 
 Franque, O. von: " Beitrag zur Lehre (iber den Herraaphroditismus lateralis" 
 
 {Scanzoni^s Beiirdge zur Geburtshulfe nnd Gyndkologie, vol. v. p. 57, Wiirzburg, 1869). 
 Freund, Wm. a. : "Horseshoe Kidney, with Absence of Internal Organs of Genera- 
 tion" (.4m. Journ. Obst., 1876, vol. ix. p. 349, from Berl. Beitr. z. Geb. u. Gyn., iv. i.). 
 Friedreich, N. : "Der Hermaphrodit Catharina Honiann" {Virchoiu's A rchiv, vol. 
 
 xlv. pp. 1-8). 
 Galabix, a. L. : "Retention of Menstrual Fluid in one half of a Double Uterus" 
 
 (Land. Obst. Trans., 1882, vol. xxiv. p. 21). 
 Garrigues, H. J. : " The Obstetrical Treatment of the Perineum " (Am. Journ. Obst., 
 
 April, 1880, vol. xiii. p. 231). 
 Gervis, H. : "Case of Transverse Septum in the Vagina" {Lond. Obst. Trans., 1882, 
 
 vol. xxiv. p. 210). 
 : Case of Double Vagina and Uterus" {Lond. Obst. Trans., 1877, vol. xix. p. 
 
 271). 
 
280 MALFORMATIONS OF THE FEMALE GENITALS. 
 
 Gkace, H. : "Case of Double Uterus, with Simultaneous Gestation" {Lond. Obst. 
 
 Trans., 1863, vol. iv. p. 138). 
 Hegar, a. : Die Castration der Frauen, Leipzig, 1878. 
 Heppner, C. L. : "Ueber den wahren Hermaphroditismus heim Menschen" {Reich- 
 
 ert's Archiv, 1870, p. 679). 
 Hicks, J. B. : "An Unilateral Uterus and Kidney, with Two Ureters" {Lond. Obst. 
 
 Trans., 1879, vol. xxi. p. 57). 
 : " Case of Congenital Abnormality of the Uterus simulating Ketention of 
 
 Menses" {Lond. Obst. Trans., 1880, vol. xxii. p. 260). 
 
 : "Five Cases of Vaginal Closure" {Lond. Obst. Trans., 1863, vol. iv. p. 228). 
 
 : "Case of Pregnancy with Double Uterus and Vagina" {Lond. Obst. Trans., 
 
 1881, vol. xxiii, p. 23). 
 : "Vertical Septum in Lower Part of Vagina, impeding Labor" {Lond. Obst. 
 
 Trans., 1881, vol. xxiii. p. 24). 
 : " Absence of Uterus and Ovaries : on the top of the vagina a large cyst half 
 
 filled with a cheesy white matter, and the rest with dark grumous material like old 
 
 clots" {Lond. Obst. Trans., 1880, vol. xxii. p. 262). 
 HiLDEBRANDT, H. : "Die Krankheiten der Aeusseren Weiblichen Genitalien" {Bill- 
 roth's Frauenkrankheiien, vol. iii., part vii., Stuttgart, 1877). 
 HowiTZ, F.: "Laparotomi for Pyometra i hojre Uterushorn" {Howitz's Gyncek. og 
 
 Obst. Meddelelser, 1881, vol. iii. p. 70). 
 Hyatt, H. O. : " Note on the Normal Anatomy of the Vulvo-vaginal Orifice " {Amer. 
 
 Journ. Obsiet., 1877, vol. x. p. 253). 
 Jackson, A. K. : "A Contribution to the Relations of Ovulation and Menstruation" 
 
 {Journ. Am. Med. Assoc., Chicago, 1884). 
 JoHANNOVSKY, V. : " Einige Bildungsfehler der Weiblichen Genitalien aus der Gyna- 
 
 kologischen Klinik des Prof. Breisky in Prag" {Arch. f. Gyndk., 1877, vol. xi. p. 
 
 371). 
 Kaltenbach : " Demonstration eines Uterus unicornis mit geplatztem gravidem 
 
 Nebenhorn" {Arch. f. Gyndk., 1883, vol. xxii. p. 172). 
 Klebs, E. : Handbuch der Pathologischen Anatomic, Berlin, 1876. 
 Klob, J. M. : Pathologische Anatomic der Weiblichen Sexualorgane, Wien, 1864. 
 KussMAXJL, A. : Von dcm Mangel, der Verkiimmerung und Verdopplwng der Gebdrmidter, 
 
 Wiirzburg, 1859. 
 Lebedeff, a.: "Ueber Hypospadie beim Weibe" {Arch. f. Gyndk., 1880, vol. xvi. 
 
 p. 290). 
 Le Fort, L. : Des Vices de Conformation de I' Uterus et du Vagin, et des Mayens d'y 
 
 licmedier, Paris, 1863. 
 Lente, F. D. : "Operation for Atresia Vaginse" {Ain. Journ. Obstet., 1877, vol. x. 
 
 p. 85). 
 Leopold, G. : " Ein mannlicher Scheinzwitter, Pseudo-hermaphrodismus externus " ^ 
 
 {Arch. f. Gyndk., 1876, vol. viii. p. 487). 
 : "Ueber eine vollstandige mannliche Zwitterbildung" {Arch. f. Gyndk., 1877, 
 
 vol. xi. p. 357). 
 Madge, H. M. : " Four Cases of Congenital Imperforate Vagina, and one Case of Con- 
 genital Phymosis, occurring in the Same Family" {Lond. Obst. Trans., 1870, vol. xi. 
 
 p. 213). 
 Mann, M. D. : "A Specimen of an Infant Uterus Bicornis Duplex and Vagina 
 
 Septa" {Am. Journ. Obst., 1874, vol. vii. p. 274). 
 — : " Case of Uterus Bicornis, with a Partial Vaginal Septum " {Am. Journ. 
 
 Obst, 1877, vol. X. p. 666). 
 
 » Since there was a vagina eight centimeters long, I think this ought rather to be regarded as 
 a case of pseudo-hermaphrodismns masculinus internus and externus ; so much more so as the 
 examination was made on a living person, and perhaps rudiments of the uterus and the tubes 
 may have been present. 
 
i.rrEiiATi'Ri':. 281 
 
 Maykkikifkk, ('.: " Entwii-kfliiii^'slVliUr di-r ( iil);iriiiiitt«.'r" {IHIIidIIi's Fnuiinhnink- 
 
 fu'ilfii, vol. i. part 2). 
 Mkadows: "A Case oi" Inf;\iiiial Ilfniiaof tliu Ki;,'lit ( )v;irv siicccssriilly Removed" 
 
 (Loud. Ohnl. TntiiK., ISd'J, vol. iii. p. 4;Wl. 
 MeyKR. L. : lHt'rin{ti/(/<li)iniiuiicsoinSlcrtlil<tti(utrs(t>/, (ji[)C'iiliaf^on, 1S80. 
 
 : Ih't yonnulc SntiK/crxk-db, Fiidurl off Jiarst'lKiiuj, ( 'opfiihagen, 1882. 
 
 Moldkxiiaukr: " Ein hesoiuleiur Fall von 8c'li\vaiif?frsiliatl in eiiier c'inli(">inij,'fn 
 
 (iol):iriuutter" (Arch. J'iir Gyniik:, 1S7'), vol. vii. \). ITo). 
 Mo.s-<MANN, B. E. : "A Case of Congenital Atresia of the Vagina" (.!;«. Jonrn. Olntt., 
 
 18S1, vol. xiv. p. 564). 
 Mow AT, G. : "A Case of Apitarcnt Absence of Uterus" (Loud. ObM. Trtinx., 1878, vol. 
 
 XX. p. 289). 
 MUNDE, P. F. : "A Ciuse of Single Uterus with Hoiilile Cervix and X'agina" (Am. 
 
 Journ. Obst., 1878, vol. xi. p. 575). 
 : "A Case of Presumptive True Lateral Ilerniaplirodism" (Am. Jonrn. Obnt., 
 
 Feb., 1876, vol. viii. pp. 615-6ol). 
 Nackr: "Uterus bioornis septus, Vagina partim septa, Hsematometra dextra, IIa>nia- 
 
 tosalpinx dextra, IlaMnatocolpos, etc." (Arch. J'ilr Gyndlc, 1876, vol. ix. p. 471). 
 Neugebauer, L. : "F^inseitige Iliiuiatometra bei zweitheiligem Uterovaginalkanale" 
 
 (Arch. J'iir Grjndk:, 1871, vol. ii. p. 247). 
 Nieberding: " Casuistischer Beitrag zu den Gynatresien " (Arch, fiir Gynii/c, 1882, 
 
 vol. XX. p. 336). 
 Nielsen, P.: " Om Atrofi af Uterus" (Howitz's Gyncekologische og Obsfetricishe Meddd- 
 
 elser, Copenhagen, 18S4, vol. v. p. 74). 
 Olshausen, K. : " Die Krankheiten der Ovarien," Stuttgart, 1877 (Billroth's Hamlbuch 
 
 der Frauenkrankheiten, vol. ii.). 
 Osterloh: "Atresia ani vaginalis" (Arch. f. Gyncik., 1875, vol. vii. p. 565). 
 Palmer: "Two Ilerniaphrodite Sisters" (Am. Journ. Obnt., 1880, vol. xiii. p. 174). 
 Peaslee, E. R. : "Case of Uterus Didelphys Septus et Vagina Septa" (Am. Journ. 
 
 Obst., 1876, vol. ix. p. 651). 
 
 : "Solid Uterus Bipartitus" (.4m. Gyn. Trans., 1876, vol. i. p. 340). 
 
 PooLEY, J. H. : "On Imperforate Anus, the Rectum communicating with the Vagina" 
 
 (Am. Journ. Obst., Feb., 1872, vol. iv. p. 676). 
 : "Case of Absence of the Uterus and Vagina" (Am. Journ. Obst., May, 1871, 
 
 vol. iv. p. 70). 
 Prochownick: "Fall von Menstruatio pra?cox mit Sectionsbericht" (Arch. J. Gynak., 
 
 1881, vol. vii. p. 330). 
 Rheinstaedter : "Rndimentiire Entwickelung weiblicher Generationsorgane " 
 
 (Arch. f. Gyncik., 1879, vol. xiv. p. 497 1. * 
 
 Richmond, J. M. : "A Successful Operation for Atresia Vaginae" (Am. Journ. Obd., 
 
 1884, vol. xvii. p. 600). 
 Roberts, D. L. : " Bicorned Uterus" (Land. Obst. Trcms., 1872, vol. xiii. p. 312). 
 Roger.-;, L. : "A Case of Male ITermaphrodism " (.4??!. Journ. Obst., 1876, vol. ix. p. 
 
 171), from Cincinnati Lancet and Observer. 
 Rogers, W. R. : " Ca.se of Vagina and Uterus divided by a Septum " (Lond. Obst. 
 
 Trans., 1871, vol. xii. p. 29). 
 RoKiT.VNSKY : " Verhandlungen der "Wiener Gesellschaft der Aerzte " ( Wiener Medi- 
 
 cinische Wochenschrij't, 1869, p. 724). 
 Rose, Cooper : " Case of Extravasation of the Bladder, Absence of the Rectum, the 
 
 Colon opening through the wall of the Ectopic Bladder, Absence of the Symphysis 
 
 Pubis, and the Development of the Uterus in Two Lateral Portions" (Lond. Obst. 
 
 IVan.s., 1874, vol. xv. p. 128). 
 
 ■- : "Case of Extreme Hypospadias" (Lond. Obst. Trans., 1877, vol. xix. p. 256). 
 
 RorTH, C. H. F. : " Case of Absence of Vagina, with Retained Menses in Utero and 
 
 Fallopian Tubes" (Lond. Obst. Trans., 1871, vol. xii. p. 34). 
 
282 MALFORMATIONS OF THE FEMALE GENITALS. 
 
 Eouth: "Case of Bilocular Uterus " ^ {Lond. Obsl. Trans., 1871, vol. xii. p. 295). 
 
 Sappey, p. : Traite dJ Anatomic descriptive, Paris, 1857-64. 
 
 ScHATZ, F. : " Sieben Falle von unvollkommener Vereinignug des weiblichen Geni- 
 
 talkanales bei Erwachsenen" [Archiv far Oyndk,, 1871, vol. ii. p. 289). 
 : "Ein besonderer Fall von Misbildung des weiblichen Urogenital systems" 
 
 {Arch.filr GyniiL, 1872, vol. iii. p. 304). 
 
 "Geburt eines Monstrums. Drei Falle von einhornigem Uterus " (Arch, far 
 
 GynaL, 1870, vol. i. p. 153). 
 ScHoriELD, E. H. A.: "The Delivery of a Monster" {Lond. Obst. Trans., 1879, vol. 
 
 xxi. p. 71). 
 SCHROEDER, C. : Handbuch der Krankheiten der weiblichen Geschlechtsorgane, Leipzig, 
 
 1874. 
 Simpson, J. Y. : "Hermaphroditism" {Obstetric Works, vol. ii. pp. 203-328, Philadel- 
 phia, 1856). 
 SiPPEL, A.: "Ein Fall von schwieriger Geschlechtsbestimmung" {Arch. f. Gyndk., 
 
 1879, vol. xiv. p. 168). 
 Smith, A. G. : " The Position of the Hvmen in the Negro Race " {Am. Journ. Obst., 
 
 1877, vol. X. p. 638). 
 Smith, H. : "A Case of Delivery through an Imperforate Vagina" {Lond. Obst. 
 
 Trans., 1881, vol. xxiii. p. 117). 
 Squarey, O. E. : "Three Sisters in whom the Uterus and Ovaries were Absent" 
 
 (Lond. Obst. Trans., 1873, vol. xiv. p. 212), with other cases mentioned in the dis- 
 cussion. 
 Stadfeldt, a. : " Nogle Tilfselde af Misdannelser i Genitalkanalen hos Kvinden " 
 
 {Howitz's Meddelelser, vol. ii. p. 24, Copenhagen, 1879). 
 Svp^ASEY, E. : "An Interesting Case of Malformation of the Female Sexual Organs" 
 
 {Am. Journ. Obst, 1881, vol. xiv. p. 94). 
 Tait, L. : "Hermaphroditism" {Am. Oyn. Trans., 1876, vol. i. 318). 
 Tardieu, a.: Etude Medico-legale .sur les Attentats aux Mceurs, Paris, 1878. 
 Taylor, I. E. : " Atresia of the Vagina, Congenital or Accidental, in the Pregnant 
 
 or Non-Pregnant Female" {Am. Gyn. Trans., 1879, vol. iv. p. 404). 
 Teller, S. : "Repeated Pregnancy in a Uterus Bicornis" {Am. Journ. Obst., 1884, 
 
 vol. xvii. p. 142). 
 TuRNiPSEED, E. B. : " Some Facts in Regard to the Anatomical Difference between 
 
 the Negro and White Races" {Am. Journ. Obst., 1877, vol. x. p. 32). 
 Walker, H. F. : "A Case of Uterus Septus and Vagina Septa" {Am. Journ. Obst., 
 
 1875, vol. viii. p. 515). 
 Watts, R.: "Case of Double Vagina with Single Uterus" {Am. Joarn. Obst., 1877, 
 
 vol. X. p. 279). 
 Werner, M. B. : "Battey's Operation Performed in a Case of Malformation of the 
 
 Generative Organs" {Am. Journ. Obst., 1884, vol. xvii. p. 144.). 
 Werth : "Rudimentare Entwickelung der Miillerschen Giinge Doppelseitige Hernia 
 
 ovarialis inguinalis" {Arch. f. Gyndk., 1877, vol. xii. p. 132). 
 Whittaker, J. T. : "Agenesis Urethras, etc." {Am. Journ. Obst., 1870, vol. iii. p. 389). 
 Wilson, H. S.: "Notes on a Foetus" {Lond. Obst. Trans., 1879, vol. xxi. p. 58). 
 WiNCKEL, F. : Die Pathologic der Weiblichen Sezualorgane, Leipzig, 1881. 
 Wittner: "Einige Falle von Misbildung des Uterus," Leipzig, 1869 {Arch. fUr 
 
 Gyndk., 1870, vol. i. p. 190). 
 
 1 Seems to be a uterus bicornis uniforis. 
 
GYNECOLOGICAL DIAGNOSLS. 
 
 By EGBERT H. GKANDIN, A. H., M. \)., 
 Nkw York. 
 
 The (Ha<>;n()sis of disease of the feiiiule <>('ii('rative or<^ans is b&set by 
 peculiar difficulties to which no other branch of medicine can, in the 
 same degree, lay claim. The organs of generation in the female are 
 protected from scrutiny, at the outset, by that inherent modesty which 
 causes woman to rebel against the mere thought of examination, and 
 furthermore, these organs are so situated that it is largely by the sense 
 of toucli, direct or indirect, that deviation from the normal is to be 
 detected. The intimate connection also which exists between the 
 sexual and other systems of the human body can but increase the 
 obstacles in the way of localization of disease, necessitating, therefore, 
 the use of the judicial faculty in a peculiarly high degree. The gyne- 
 cologist hence must possess, aboye all, tact, delicacy of touch, and that 
 broadness of mind which will allow of his looking beyond the organs 
 he habitually treats, in the recognition of the fact that symptoms point- 
 ing to the uterus do not necessarily mean disease of that organ, and, 
 what is ('(iually true, that serious uterine disease may be masked under 
 symptoms directing attention to some other organ of the body. The 
 broad truth must not be lost sight of that gynecology is but a part of 
 a grand whole. Its basis is medicine, and it is irrational to enter on 
 its practice without ever bearing in mind that it is but a link in a com- 
 plex chain, which, lengthened in time, and still lengthening, necessarily 
 requires subdivision that each link may be better forged, each part more 
 fitly adapted to the whole. Therefore the natural origin and the need 
 of the '^ specialties," and therefore the too-little recognized truth that he 
 will make the most successful gynecologist who has first been a general 
 practitioner, and also that the latter cannot hope to vie with the former 
 without thorough and systematic training in the special manipulation 
 which belongs properly to modern gynecology. 
 
 Toward the diagnosis of disease of the female generative organs we 
 are assisted, even as in other branches of medicine, by the history of 
 the patient, whereby we obtain the rational signs, and by the local 
 examination, whereby we negative or confirm the diagnosis suggested 
 
 283 
 
284 GYNECOLOGICAL DIAGNOSIS. 
 
 by these rational signs. These two divisions I shall consider separately^ 
 first premising, in a general way, that the symptomatology should never 
 carry too much weight, for woman, especially Avhen the victim of fan- 
 cied disease, will deceive not only herself, but also her physician if per- 
 chance his credulity be stronger than his judgment. 
 
 Rational History. 
 
 In obtaining the rational signs it is of great advantage to proceed 
 systematically, and to follow the same routine method of questioning 
 in each case. For this purpose it is Avell to have a record-book, where- 
 in, under appropriate headings, the obtained answers — as well as, later 
 on, the results of the physical examination — may be recorded. Each 
 one may construct such a scheme for himself in accordance with the 
 manner which experience teaches him is the most appropriate for con- 
 ducting his examination. I therefore do not deem it necessary to intro- 
 duce one here. Sufficient the statement that, in general, our questions 
 should, at the outset, aim at obtaining from our patient information in 
 regard to what may be termed the etiological factors on which may 
 possibly depend the symptoms, which, later on, she herself is to be 
 allowed to give. Our verbal examination, hence, is first direct, and 
 then indirect. 
 
 By direct questioning we obtain answers to the following : 1, the 
 social position and occupation of the patient ; 2, the age and state 
 (whether married or single) ; 3, the number of children and miscar- 
 riages ; 4, the health of parents and previous personal health ; 5, the 
 performance of the menstrual function ; 6, the date of appearance of 
 symptoms. 
 
 The answers given to these questions obviously have an important 
 bearing on the further history of the case, and will govern us, in a 
 measure, in our decision as to the necessity of a local examination. 
 With the maiden, for instance, Ave may usually at once eliminate dis- 
 eases the followers of childbearing and of impure or inordinate coitus, 
 and direct our questions toward ascertaining the state of the general 
 health and the performance of the menstrual function. Knowledge 
 of the social position and occupation of our patient is of value, since, 
 obviously, that which is laborious or of a confined nature is apt to 
 impress alterations on the system either general or local, and since, too, 
 habits of indolence or of luxmy carry ills in their train, largely, in these 
 days, owing to the pernicious method of dress which is in vogue. The 
 age of our patient is particularly of value, as allowing the exclusion of 
 those new growths the tendency toward which increases with age, as 
 also as indicating to us, in certain cases, the prognosis as regards, it 
 may be, sterility, it may be the disappearance of some symptom the 
 
Jt.llloy.lL IIISTOIIY. 285 
 
 rclirl' trom which iii;i\ oiiK he lonkcd liir;!! the iiicii<i|»;iil-c. The state 
 jiikI the a^c lom'thci' arc to he taken into consideration in oim" decision 
 as to the necessity ola local examination ; and I wonid sav here thai in 
 the nnniarricd it is exceptional that an examination is reijnisite nntil 
 e-enerai eonslitntional measiu'es have heen tried withont avail. < )!" 
 eoin-se I exchide from this dietiim fnier<^eueies, sueii a.s .sudden heni- 
 orrhan'e or symptoms pointin<i; so dearly to the sexual organs that our 
 ])ast e.\j)erienee teaches ns it is hut tolly to temporize. 
 
 With the married, on the other hand, whilst we must guartl ourselve.s 
 auaiust the assumption that there necessarily exists disease of the gene- 
 rative oro-ans, our line of questioning nuist be widely diifereiit. The 
 fulfilment of the ]nirposes for which marriage Ava.s instituted too fre- 
 (piently entails functional or organic derangement, and, as it is our 
 business to use every proper means for the detection of al)normalities, 
 we need not be too chary in our speech — indeed, must sometimes, to 
 fulfil our ^\•hole duty, even ask questions which touch upon the mo.st 
 delicate possible ground. Such arc — the frequency of intercourse, the 
 sensations evoked, the completeness or incompleteness of the act, the 
 retention or non-retention of the semen : these are questions the answers 
 to which Avill frequently give ns a clue to the cause of mcnstnial 
 derangement or the possible cause of sterility. 
 
 If the patient be married, information must next be sought in regard 
 to the numl)cr of children or miscarriages she has had, of the interval 
 which has elapsed since the last delivery, as to the duration of the sev- 
 eral labors, instrumental interference, length of the puerperium, and 
 incidents jjeculiar to it. We are thus often led to suspect that our 
 local examination will reveal some injury to the genital tract, or pelvic 
 exudation recent or chronic — a suspicion which obviously influences 
 strongly in the decision as to the necessity of a local examination. It 
 is important also to question our patient in regard to the function of 
 lactation, on account of the very decided influence which its due and 
 jM'opcr performance has on uterine involution. In case of one or more 
 miscarriages, we must determine as accurately as possible the month at 
 which they occurred, ascertain the probable cause and the manner of 
 eare the patient received, and, where habit is the probable factor, seek 
 behind this convenient term for the real factor in order to scientifically 
 bring to bear on its cure every possible means at our disposal, including, 
 of course, examination and treatment of the husband in those cases, by 
 no means infrequent, where he must bear the partial or entire onus of 
 premature ])Hghting of the ovum. In this connection, too, it should 
 ever be borne in mind that the abuse — or, strictly, the use — of certain 
 means for the prevention of conception at such times when offspring are 
 not desired frequently acts like a double-edged sword, and through its 
 injurious etTcets on the sexual organism prevents the bringing to term 
 
286 GYNECOLOGICAL DIAGNOSIS. 
 
 of the ovum which has been fructified designedly. These means may, 
 therefore, be indirectly responsible for miscarriage, so that the question 
 is pertinent whether they are resorted to. 
 
 Inquiry in regard to'the health of our patient's parents is too often 
 neglected, and yet is of great importance. Whilst the influence of 
 heredity has never as yet been distinctly formulated, there are suflicient 
 data at our disposal to warrant the assertion that ancestral disease may 
 so modify the nutrition and configuration of the offspring as to render 
 it more accessible to disease, even if this be not directly implanted. 
 The so-called scrofulous taint may unquestionably, in a latent form, be 
 responsible for deviation from health in the genital system, even as it 
 is in other departments of the body ; and the like holds true of other 
 constitutional diseases which we are prone to look upon as hereditary. 
 I rank this question as an important one advisedly, because I know 
 that through a proper appreciation of its import very frequently the 
 prognosis and the treatment of apparent disease of the genital system 
 will depend upon and lie through constitutional measures rather than 
 local. 
 
 And this remark holds true as well of an associated question — the 
 previous state of health of the patient herself. Much valuable informa- 
 tion, and in an obscure case very necessary, may be gleaned from close 
 questioning on this point. A sore throat and loss of hair following 
 closely on marriage may, in the absence of certain positive signs, but 
 taken in connection with slight negative, offer a probable explanation 
 for frequent miscarriage. The parenchymatous degeneration of the 
 muscles which accompanies high febrile states not improbably may 
 modify the organs of generation sufficiently to prevent their normal 
 function. These remarks are simply made to indicate the line of 
 thought which answers to this question might suggest : to discuss the 
 subject at length w^ould lead me entirely too far. 
 
 We are next to obtain the menstrual history of our patient. In the 
 young and unmarried it is usually derangement of the menstrual func- 
 tion which brings the patient to the gynecologist — it may be amenor- 
 rhoea, it may be irregularity in, or pain during, the performance of the 
 function. These are the very cases in which there is difficulty, espe- 
 cially, in deciding as to the necessity of a local examination. I would 
 again strongly deprecate recourse to a local examination in the unmar- 
 ried before the special features of the case have been carefully sifted, 
 and varied and prolonged attempts have been made by means of 
 general constitutional measures to relieve what, in the young and grow- 
 ing maiden, is often due to method of life or to chlorosis. Nothing but 
 very urgent symptoms should justify local examination of the young 
 girl who has scarcely passed the pubescent period. In her, derange- 
 ment of menstruation, such as skipping a period, dysmenorrhoea, con- 
 
liATiosAL iiisronv. 287 
 
 «i|;('stive si^ns due to scanty How, arc not necessarily pathological factors. 
 It takes time for the nicnstrnal liahit to become rejruhirly and normally 
 ac(|uired ; and where an examination is needlessly resorted to an ludookt'd- 
 for effect may be profound injury to the maiden's morale. There is, 
 however, a i:;rou|) of symptoms which shoidd ever speak in favor of a 
 local examination, and this is constituted by the conjoined factors amcnor- 
 rhoea, eoni>;estive signs, and molimina. The regidar recurrence of these 
 symptoms shoidd suj::gest possible occ-lusion of the vagina with reten- 
 tion of menses — a c<»ndition calling for early resort to operative inter- 
 ference. 
 
 Our questions concerning menstruation should be in regard to the 
 age at which the function was established, the regularity with which 
 the flow recurs, the duration, amount, and character of the flow, the 
 presence of pain before, during, or after the flow, and the date of the 
 last menstruation. If amenorrhcea be complained of, we should always 
 bear in mind the physiological cause, and suspect pregnancy until we 
 have for ourselves disproved it. In exceptional cases, however, amenor- 
 rhcea will only apparently exist, for on close questioning the fact will 
 be revealed that for a number of days each month there is an increased 
 white discharge which the patient takes for an aggravation of her leu- 
 corrhcea, but which the physician, in case there be accompanying 
 molimina, will recognize as the so-called white menses, and thereby 
 essentially modifs' his prognosis. The presence of molimina also assists 
 us in our diagnosis and prognosis of those cases of amenorrhcea where 
 the local examination reveals an undeveloped state of the uterus or ovaries. 
 The number of days during which the flow" lasts, its amount (deter- 
 mined in our better classes by the average niunber of napkins worn), 
 the presence of clot or of membrane in the flow, — are all questions bear- 
 ings on our diagnosis and ultimate method of treatment. If menstrual 
 pain be complained of, it is important to time its rhythm — that is to 
 say, to determine whether the pain precedes, accompanies, or follows 
 the flow — for thus we are in a position to decide whether the probable 
 cause be uterine or ovarian. It is almost supei-fluous to state that it is 
 always essential to know the date of the patient's last period, although 
 undue* weight is never to be given to lier statement on this point should 
 the local examination give us cause to think that the patient is either 
 endeavoring to deceive us, or else that the discharge at the last stated 
 period occurred notwithstanding the presence of an impregnated ovum 
 within the uterus. 
 
 The last question, the length of time since the appearance of the 
 symptoms, has in part an etiological bearing and in part a diagnostic. 
 In the young unmarried female a common starting-point of symptoms 
 is imprudence during menstruation. By imprudence I refer not alone to 
 the neglect of avoidance of causes which result in checking this phys- 
 
288 GYNECOLOGICAL DIAGNOSIS. 
 
 iological function, and yet such a disagreeable function in so far as it 
 often interferes with the plans and wishes of, especially, our young 
 maidens of higher social life : my meaning is still broader, including 
 as it does the general neglect of proper rest, both mental and physical, 
 at the time of the periods the most critical of all — the year or so fol- 
 lowing the establishment of puberty. Derangements of menstruation, 
 chronic congestion and displacements of the pelvic organs, ovaralgia 
 and ovaritis, — such, in their ensemble, are the pathological factors which 
 may be traced to neglect of rational precautions during menstruation. 
 In the married, symptoms very frequently may be traced to abuse of 
 the sexual act. This is particularly noticeable in the newly-married, 
 in whom symptoms will be found to dejDend on the constant state of 
 congestion in which the pelvic organs are kept. Thus are explainable, 
 often, menorrhagia dating from the time of marriage, ovaralgia, back- 
 ache, dragging pains in the abdomen, vague hystero-neurotic symptoms. 
 A further cause of symptoms in the married is the resort to means for 
 the prevention of conception — in particular, I believe, vaginal injections 
 taken immediately after the sexual act, and in such haste that the tem- 
 perature of the water is not attended to, and in consequence the conges- 
 tion naturally following the sexual act receives sudden and harmful 
 check. Again, the measures resorted to by far too many married 
 women to destroy the undesired fruit of the womb obviously can but 
 react unfavorably on the pelvic organs. Abuse of function invariably 
 leads to pathological alteration : in order to determine, therefore, the 
 degree to which pathology has affected the sexual organism of our 
 patients it is necessary to know not only the cause of symptoms, but, 
 as far as possible, the length of time during which such cause has been 
 at Avork. Thus it is that even through questioning which bears more 
 particularly on etiology we are assisted toward correct diagnosis. 
 
 I have now sketched briefly the nature of what may be termed the 
 preliminary questions, and I pass to the consideration of symptoms 
 of which the patient complains or which are drawn out by the exam- 
 iner. And here I would remark that there are but few symptoms 
 which singly can properly be regarded as peculiar to disease of the 
 female pelvic organs. It is only, usually, when taken in their ensem- 
 ble that they justify the inference that there exists organic or functional 
 derangement. And even as symptoms of themselves are so deceptive, 
 so too should Ave carefully gauge our patient, lest she endeavor to de- 
 ceive us for a purpose or is in reality deceiving herself. Desire for 
 sympathy, the impulses of hysteria, the wish which is often the father 
 to the thought, — are each incentives in the making of a plausible his- 
 tory, the Avorth of Avhich it rests AAath the physician to decide. I do 
 not mean that he is not to give credence to the symptoms unless he can 
 find a cause ; I Avould simply Avarn against alloAving a skein of symp- 
 
RATIOS M. iiisronv. 28J> 
 
 toras skilfully woven t<i lead tlir |)('i(<|)ti(tii ami jiirluriiciit awav IVoiii 
 that wliicli really exists. It is well t<t(i to allow tlie patient to tell 
 her own story — a tedions inetluMl, eei-tainly, hut one tlirougli wliieli we 
 are more a|)t to reaeli the exact trntli than if lea<lin^r (jiiestioiis were 
 ])nt. Of course, alter the j)atient has told us all she can or will, it rests 
 with the exaniinei- to till in thi' »i:aj)s, and thereby jxissibly obtain infor- 
 mation which has been concealed. 
 
 In <i-cneral, the symptom w hicji ordinarily drives the patient to eoii- 
 sidt the uynecolo<;ist is pain. This pain may be in various [)ai1:s (;f tiie 
 body, and it is its association w ith (ttln-r syniptom> emanating from, or 
 so situated as to suiTLTCst their oriiiinati<jn in, some portion of the jreiiital 
 system which attracts attention to the pelvic organs. Pain in the Imck, 
 lumbar or sacral, is a symptom common to the majority of women, and 
 evidently its cause may be entirely independent of the uterus or its 
 adnexa. The lifting of heavy weights, occupations which reipiire j)ro- 
 longcd flexion of the triuik on the pelvis, the injudicious use of the 
 sewing-machine, — these are amongst the possible causes which, if per- 
 sisted in, imdoubtedly will lead to local pelvic disorder. When the 
 pain is chronic, however, sacral in site, and particularly Avhen it is 
 associated with dragging or bearing-down sensations in the abdomen, 
 then it rises to a higher level as a diagnostic factor, and our local 
 examination will in all probability reveal some displacement of the 
 nterus, injury to the pelvic floor, or interference with the circulatifjn 
 through the pelvic organs. Pain in the nates, running down the 
 dorsum of the thigh, will usually find its explanation in sciatica, but 
 if other factors in the history point to recent or chronic inflammatorv 
 pelvic exudate, this pain may find its explanation in the same cause. 
 Pain in the abdomen is next in frequency to pain in the back ; and here 
 we must determine its site, its constancy and duration, and its nature. 
 Suprapubic pain will direct attention to the bladder, and it will remain 
 for future examination to determine whether this organ is directlv at 
 fault, or indirectly through the mechanical pressure of the uterus or a 
 foreign growth. Diffuse abdominal pain, accom])anied In* distension, 
 suggests intra-alxlominal growths oi- fluid or affections of the perito- 
 neum. Pain in the iliac or ovarian regions is a frequent svmptom ; 
 and this pain is more frequently situated to the left than to the right. 
 While the local examination may reveal ovarian or obscure tubal dis- 
 ease, this ])ain is often present without adequate explanation, so that its 
 exact value as a diagnostic factor is not settled. In character it is usu- 
 ally either burning or lancinating ; and in tlie latter instance we will 
 often be led to surmise tubal disease. In a large ]iro]->ortion of cases 
 I have found pain in the left ovarian region dependent purelv on 
 chronic constipation, as evidenced by the fact that the pain entirelv dis- 
 appears on the patient acquiring the habit of daily defecation. The 
 Vol. I.— 19 
 
290 GYNECOLOGICAL DIAGNOSIS. 
 
 explanation, of course, of this association of pain and loaded rectum -is 
 simple when we remember how closely adjacent to the rectum lies the 
 left ovary, and how this latter organ will naturally suffer from the 
 pressure of the feces and from irritation by the scybala as they pass 
 downward. A curious point in connection with pain emanating from 
 the ovaries is that the site of the pain not infrequently does not corre- 
 spond to the affected organ. In other words, a left ovaritis is often 
 accompanied by pain in the right ovarian region, and vice versa. 
 
 Pain from both the back and abdomen frequently extends into the 
 legs, and is to be considered as purely reflex in nature. Abdominal 
 pain above the umbilicus will suggest, of course, organic or functional 
 derangement of one or another of the abdominal viscera according to 
 its site, although here as well the pain may be reflex from the pelvic 
 organs. If, instead of pain in the abdomen, enlargement is complained 
 of, our object should be to ascertain the length of time the enlargement 
 has existed, in what portion of the abdomen it first began, whether it 
 be permanent or not. The importance of these questions is apparent, 
 particularly in connection with the differential diagnosis of abdominal 
 tumors. 
 
 Pain in the head can scarcely lay claim to a place in the symptoma- 
 tology of disease of the pelvic organs, unless it be on account of the 
 frequency with which women complain of it. Its cause in the major- 
 ity of instances is constipation or chronic congestion of the pelvic 
 organs ; and in these instances the site of the pain is usually the 
 occiput. Rarely a hemicrania will apparently depend on inflamma- 
 tion of one or the other ovary, as is attested by its disappearance as 
 the inflammation abates. 
 
 Pain in the chest, if neuralgic, may emanate from disorder of the 
 pelvic organs, but usually this symptom will call for careful auscul- 
 tation and percussion at the hands of the gynecologist, even as it would 
 were the patient instead consulting a general practitioner. Shooting 
 pains through the mammse and enlargement of these organs will suggest 
 at once pregnancy, but both these symptoms may accompany uterine or 
 ovarian disease. 
 
 Pain in sitting should direct attention to the coccyx, or it may result 
 from anal or rectal trouble ; and the aggravation of sacral or abdominal 
 pain in standing or walking bears testimony to the probable existence 
 of some uterine displacement or sagging of the pelvic floor. 
 
 Pain on coitus, or dyspareunia, is a symptom which ordinarily the 
 patient will not mention of her own accord. This symptom is a fre- 
 quent cause of marital infelicity, and is therefore a sufficient justification 
 in itself for requesting a local examination. The cause we are not 
 always able to discover, but often, aside from disproportion in size 
 between the male and female organs, the local examination will reveal 
 
IlATloSM. IIISTniiw 2!»1 
 
 cai'iiiiflcs ot" tlir untliiM, a (li>|tl.it((| iitmis or ovarv, a >iiii|)lc li\ (x-r- 
 cestlu'sia atoi* witliin the ostiimi vauiiia.', an anal fissure, or rectal diseaH', 
 
 From the intimate syni|)atlietie relations between the stcunaeh and 
 the peKie orj^ans pain in the i'j)i<;astrie region is a fre(jnent svniptoin. 
 Obviously, tiiis ])aiii may depend on organic disease of the stomaeh, and 
 cidls for careful differentiation on the part of the <ryneeoIo<rist. A dys- 
 jH'psia purely i'nnctional in character, however, and evidence<l by either 
 simple j)ain or l)y nausea or vomiting, will fretjuently l)e of reflex nature 
 from the pelvis, and will suggest in the first j)laee pregnancy, particu- 
 larly if these symptoms are matutinal and before eating; and in the 
 seeond place, ovarian disease. Of course these symptoms may result 
 from mechanical jnvssnre of some abdominal tumor on the stomach, 
 but then there will be the further history of abdominal enlargement, 
 and our local exaiuiiiatinii will readily detect the cause of the digestive 
 disturi)ance. 
 
 Symptoms poiming to the bladder and the rectinn are too frequently 
 denied the imi)ortance they deserve. It is a fact on which sufficient 
 stress cannot be laid that disease situated in the latter organ may, espe- 
 cially in symj)to!uatology, very closely sinuilate disease of the reproduc- 
 tive organs, and the neglect of a proper appreciation of the bladder 
 symptoms may load the gynecologist far astray from the existing jiatho- 
 logical factor, ^^'ilil^t I cannot go so far as to say that a chemical and 
 microscopical examination of the urine should be made in ever}'^ case, 
 the same rule will hold in gynecology as in other dejiartments of medi- 
 cine — that the history of no case is complete until such an exami^lation 
 has been made. Certainly, in a case at all obscure we may thus become 
 p.)ssessed of very valuable information, and therefore every gynecMogist 
 should be informed in regard to the manner of properly examining the 
 urine. Women, as a rule, are able to retain their urine longer than 
 men — not that the capacity of the bladder is so much greater, but 
 largely through the educational force of habit. Frequent micturition, 
 therefore, is a symptom very likely to attract their attention, and it is 
 surprising how frequently one hears the complaint without being able 
 to formulate a cause. ]Mere frequency, aside from lesion of the kid- 
 neys, will usually result from mechanical pressure, perha])s of the 
 uterus, porhajis of a foreign growth. Frequency of mictin-ition asso- 
 ciated with scalding suggests a variety of causes, such as some derange- 
 ment of the urine, or cystitis, cannicles of the urethra or at the mea- 
 tus, or fissure of the neck of the bladder. Vesical tenesmus suggests 
 the same causes, as also, not uncommonly, a purely hypera^sthetic state 
 of the few muscular fibres which constitute the so-called sphincter of 
 the bladder. Sacculation of the posterior bladder wall into the vagina 
 or the same condition of the urethra, cvstocele and urethrocele, are fre- 
 quent causes of trouble in micturition, owing to the irritation of the 
 
292 GYNECOLOGICAL DLAGNOSIS. 
 
 residual urine in these artificial pouches. Calculus in the female is a 
 flirther cause, giving rise to the same symptoms as in the male. It 
 is not alone sufficient, however, to determine the frequency with which 
 micturition is performed and the presence or absence of pain, but we 
 miust also question our patient as to the color of the urine and as to 
 the presence of any noticeable sediment. It goes without saving that 
 constant dribbling may mean, in the female even as in the male, 
 hyperdistension of the bladder. If retention be complained of, espe- 
 cially if of recent occurrence, the thought of acute displacement of the 
 uterus at once presents itself, and the local examination will verify 
 our suspicion. 
 
 In regard to defecation, we should never rest satisfied with the state- 
 ment that the bowels move regularly. Women have verv peculiar 
 ideas in regard to the normal performance of this function, it being no 
 uncommon thing for this necessary demand of nature to be satisfied 
 only at intervals of days. Our questions, therefore, must be direct as 
 to whether the act is a complete one, as to the presence of blood or 
 mucus in the stools, as to the presence and site of pain before or after 
 the act, as to the regularity with which defecation is performed. The 
 answers to these questions will frequently suggest the cause of ovarian 
 pain previously complained of, foretell the existence of an anal fissure or 
 rectal ulcer, and point to the presence of rectal disease which otherwise 
 might be overlooked in our eagerness to explain the symptoms through 
 derangement in the sexual system. 
 
 The presence of vaginal discharge next claims consideration. It is 
 not sufficient to know that our patient has a discharge : the amount, 
 the color, the consistency, the odor, the persistence of this discharge, 
 are each factors of assistance in diagnosis, and direct questioning is 
 usually necessary to obtain the desired information. The mere pres- 
 ence of discharge is not. sufficient justification for a local examination. 
 A certain amount is physiological, and it should ever be borne in mind 
 that disordered conditions of the blood may give rise to a leucorrhoea, 
 even as disease of the vagina or uterus Avill. In general, a discharge 
 trifling in amount, whitish in color, of watery consistency, and odorless, 
 will yield to constitutional measures, and in the maiden the above con- 
 ditions should ever receive general treatment before subjecting her to 
 local examination. When, on the other hand, the discharge is tinged 
 with blood or discolored yellow, the inference is that local disease 
 exists, such as erosion of the cervix or inflammation of the endomet- 
 rium ; when, again, the discharge is sticky, we may at once assume that 
 the muciparous follicles which line the cavity of the cervix are secret- 
 ing abnormally as the result of disease of the cervix ; when, further, 
 the discharge is thick and creamy and associated with painful micturi- 
 tion, we think of disease of the vagina, possibly of an infectious nature; 
 
rnvsiLAL siass. 2f).T 
 
 wlit'ii, Hiuilly, the patient tells iis that the (li.s<'har{^e is very otfensive, 
 mali^^iiaiit disease or necrosis of" a l)eni<rn growtli snggests it.self. In 
 women who liave passed tlie inenopanse the sonree of a discharj^e 
 sliould alwavs he sini<j;ht for Ux-ally, and, it" watery and acrid, will he 
 found to (h'|)end <tn atony ot" the vagina, resnhing in the so-calle<l sen- 
 ile vaginitis; it" ot" the nature of a hemorrhage <»r i"oul, on malignant 
 disease. It l)y no means t'ollows, however, that a jjatient has no dis- 
 charge hecause she says so. ('ertain women do not notice a di-scharge, 
 and yet complain of pruritus — a symptom which of itself suggests a 
 discharge — and the local examination will freciuently in such ca.ses 
 reveal a leucorrlujea and its cause. If not, the urine should at once be 
 examined for sugar, since pruritus of obscure origin not uncommonly 
 is symptomatic of diabetes, in which event there probably exist the 
 further sym}>toms of loss of weight and polydipsia. 
 
 There remain now to be enumerated those variable and varying 
 symptoms which properly belong to women advanced in life, and 
 which are grouped within a few years preceding and following the 
 menopause. The pains and the aches are manifold, the hot Hashes and 
 the cold spells of frequent recurrence, and it is from the multiplicity 
 and variability of the symptoms, taken in connection with the patient's 
 age and menstrual history, that we are enabled to reach our diagnosi-s, 
 and feel justified in applying to the symptoms that vague but conve- 
 nient term, hystero-neurosis. ObvioiLsly, in these cases, a local exami- 
 nation will usually reveal nothing abnormal, and we should guard our- 
 selves against making one without stronger reason than these symptoms 
 jastify ; for our object should be not to attract but to distract the atten- 
 tion of these patients as far as possible from the sexual organs. Cha- 
 racteristic also of this time of life are the hemianesthesise and hyper- 
 sesthesije, the periodical swelling of the abdomen, the lump in the 
 throat, etc., which, while symptomatic of serious organic disorder to 
 the patient, are readily recognized by the physician as neither of central 
 origin nor of grave import, but as accompaniments of that ftinctional 
 disorder to which the old term *' hysteria" must needs still be applied. 
 
 I have now outlined the method after which we should obtain the 
 rational history, the nature of this history, and the bearing which indi- 
 vidual factors should have in determining us toward making a hx-al 
 examination. If, then, the symptoms justify, we thereby proceed to 
 obtain our physical signs, which, taken in conjunction with the rational, 
 go to form our diagnosis and to construct our prognosis. 
 
 Physical Signs. 
 
 The physical signs are obtainable through the local examination. 
 Before proceeding to this, however, it is essential to obtain what infor- 
 
294 
 
 G YNECOL GICA L DIA GNOSIS. 
 
 mation is possible from a study of the appearance of the patient. By 
 this I mean to search for the signs whicli point to ansemia, chlorosis, 
 acquired or inherited constitutional disease. Should the rational history 
 have directed attention to the thoracic organs, careful auscultation and 
 percussion should be resorted to. Such a preliminary physical exami- 
 nation requires but a moment's time, and yet may reveal signs which 
 will amply explain the rational history and negative for the time, per- 
 haps render entirely unnecessary, recourse to a local examination. The 
 face should be questioned for the almost characteristic markings of ova- 
 rian or malignant disease. In the unmarried particularly, where the 
 rational history or a glance at the configuration of the abdomen sug- 
 gests the possibility of jDregnancy, a step preparatory to requesting a 
 local examination is inspection of the breasts — not that the absence of 
 mammary signs should cause us to negative the possibility of gestation, 
 but because the presence of such signs, taken in connection with the 
 local findings, will frequently assist us in forming an opinion. In a 
 word, the routine rule should be to obtain every possible sign before 
 the local examination is resorted to, because we never know beforehand 
 how simple or obscure the case may turn out to be, and in the latter 
 instance any detail, however trivial, may be of marked assistance. 
 
 In order to make a thorough and careful local examination the gyne- 
 cologist needs, above all, a properly-constructed table on which his 
 
 patient may recline with com- 
 fort, and which may be readily 
 adapted to the necessities of both 
 the dorsal and left-lateral posi- 
 tion. I dismiss from considera- 
 tion the many complicated chairs 
 and couches offered to the pro- 
 fession. These are usually need- 
 lessly elaborate, and therefore 
 expensive. An ordinary table 
 with gentle slope backward, 
 provided with foot-rests and 
 with hair mattress or other 
 covering, of sufficient height 
 not to strain the examiner, is 
 the simplest and cheapest, and 
 answers every purpose, except 
 in the left-lateral position, 
 where, in the absence of an 
 attendant to hold the speculum, a lateral inclination of the top of the 
 table is practically a necessity. Any carpenter may construct such 
 a table, and therefore the physician, whose taste or means does not 
 
 Fig. 111. 
 
 Chadwick's Table (fur dorsal position). 
 
Via. 112. 
 
 2U0 
 
 Chadwick's Table (ciiiis's position). 
 
 necessitate or allow a iiaiKlsomely appointed or upholstered article, need 
 not bt' deterred I'roni p(»s.>;essino: one of the jirinie prere'^juisites to a 
 thorough local examination. Those who desire something handsomer, 
 
 Fig. 113. 
 
 Thomass Table as luiKiineii I'V Dr. B. H. DaguLi i-.i .i..i>al position). 
 
 however, will find the table devised by Thomas, or one of its modifi- 
 cations, well adapted for gynecological work. Among the Ix^st modifi- 
 
296 
 
 G YNECOL GICAL DIA GNOSIS. 
 
 cations^ are those of Chadwick, of Goodell of Philadelphia, and of Dag- 
 get of Buffalo. The great objection to Chadwick's table is the lack of 
 mechanism for obtaining the lateral inclination. It should be remem- 
 bered that the office lounge or sofa is simply a makeshift, and the phy- 
 sician will find that it rarely requires any persuasion to induce his patient 
 to recline on his table, provided she be assured that no unnecessary expo- 
 sure is entailed. 
 
 JSText in importance is the securing of the proper position, as will be 
 noted farther on, and preliminary to the position is the loosening of the 
 corsets and clothing, so that the abdomen may be readily accessible to 
 
 Fig. 114. 
 
 Thomas's Table as modified by Dr. B. H. Dagget (for Sims's position). 
 
 the examining hand and free play of the abdominal muscles secured. 
 The advantage of a good light is of course obvious. 
 
 The local examination should be made in stages, so to speak, and 
 these I shall describe separately and in succession according to the fol- 
 lowing scheme : 
 
 A. The Dorsal Position : 1. Inspection ; 2. Digital examination ; 
 3. Bimanual examination ; 4. Instrumental examination ; 5. Rectal 
 examination and conjoined rectal ; 6. Abdominal percussion, ausculta- 
 tion, mensuration, and palpation. 
 
 B. The Left Lateral or Sims's Position : 1 . Digital examina- 
 tion ; 2. Instrumental examination. 
 
 ^ A. G. Armstrong of Ashtabula, O., makes a table on the same general principles, 
 but rather too complicated. 
 
riFYsK .11. .sjt.ys. 297 
 
 C. Tin: Gkni'-Pkctouai- Position. 
 
 I>. Tin: Ki:i:<T Position. 
 
 Tin: l)i>i;-Ai, l'o>ii'ioN. — It i> tium tlii- |M»iti"»ii tli:it tlic <'\;iiiiiin'r 
 fVtM|iu'iitlv secures his most iiiiportaiit inf'oiMiiatioii, and the exainiii:itii)ii, 
 tlieivtore, should he ina«U' with tlie ureatest po.ssihle eare, since tlie tacts 
 not<Hl will vary pari j)(i.s.sh with the <leliheratoness ased and the e<lii- 
 catioii ot" the exainini!i<; lin;j:er. The patient shonld lie on her i>aek, 
 her hea<l resting on a low hard pillow, her nates at the very edjre ot* 
 the taltic, her thiuhs gently (lexed on tlie pelvis, her feet resting in the 
 I'oot-snpports. She should he covere<l by a sheet, and this may Ix? 
 raised or suitably arrantjed ibr tlie purposes of the fii'st ste|) — inspec- 
 tion. This inchules the abdomen, vulva, perineum, and anus. As a 
 routine measure it is not necessary, at the outset, to inspect the alxlomen. 
 Only where there exists obvious abdominal enlargement is it advisable 
 to Ix'gin with inspection of this portion of the body. Usually we await 
 the result of the digital examination, including the bimanual, before 
 resorting to this measure, for in the large proportion of cases it is 
 unnecessary'. Should its necessity be apparent, then, in connection 
 with inspection of the abdomen, we must frequently resort to ausculta- 
 tion and percussion, so that it will be more convenient to speak of this 
 measure later in connection with the other two. 
 
 Inspection of the external genitals should, at the first examination, 
 never be neglected. Much valuable information may thereby be 
 obtained, aside from the necessity of the physician protecting himself 
 against the transmission of pediculi or, above all, specific disease. The 
 hair surmounting the mons Veneris, therefore, should be looked at, 
 and suspicious sores sought for in every case, no matter what the s<x-ial 
 condition of our patient, before resorting to any further examination. 
 Erythema, eruptions, the evidence of scratching, the state of the labia as 
 regards swelling or abnormal development, are points which are quickly 
 taken in at a glance, and suggest irritating discharge, disease of the 
 vulva or its glands, the habit of self-abuse. The labia are now to he 
 gently separated and the vestibule investigated. The points to be 
 noted are, successively, the clitoris and its development ; the meatus 
 uriuarius — in regard to eversion of the mucous membrane of the 
 urethra, the presence of discharge or of caruncles; the hymen — whether 
 intact, distended, or torn ; the amount of discharge present in the vesti- 
 bule — its color and consistency ; the traces which parturition almost 
 invariably leaves at the posterior commissure. It is advisable at this 
 point to request the patient to strain or bear down, and to note the 
 effect which this act has on the perineum and anterior or posterior 
 vaginal wall, for thereby we are informed in regard to the tone of the 
 ]x'lvic floor, as well as in regard to the existence of sagging of the 
 vaginal walls. The finger — preferably the left index, although it is 
 
298 GYNECOLOGICAL DLiGNOSLS. 
 
 of great advantage to train ourselves to use the right index as well — 
 should now be introduced into the vagina ; and this brings me to the 
 consideration of what may be learned from the digital vaginal exami- 
 nation. 
 
 Whilst inspection may be performed sitting, or, preferably, standing 
 a little to the right of the patient, the digital examination can only 
 properly be made when standing between the patient's everted thighs. 
 The finger, previously anointed with oil — or, what serves the same pur- 
 pose and is more cleanly, with soap — should ever be introduced from 
 below upward, due care being taken not to carry along with it any 
 of the hair which frequently .profusely covers the organs of generation. 
 It should be introduced carefully, so as to give rise to no unnecessary 
 pain, and should note in succession the elasticity of the hymen if it still 
 exist, the presence of spasm, the temperature of the vagina, the state 
 of its walls whether rough or smooth, the direction of the canal, the 
 elasticity or tone of its walls. It may be well to state that my remarks 
 at this point concern more particularly the married, for in the unmar- 
 ried a vaginal examination should, in general, be preceded by the 
 rectal, as will be noted under that heading. The finger has now 
 reached the upper vagina, and more space for investigation may be 
 gained by gently but firmly depressing the perineum. The cervix is 
 next to be examined in regard to shape, density, size, direction, length, 
 and sensitiveness. 
 
 The majority of these factors materially assist us in diagnosis. The 
 shape, for instance, will often at once suggest a cause of sterility, as 
 where this is conical. By the density we differentiate the softening en 
 masse — gravidity, the softening around the external os — erosion, the 
 hard fibrous feel suggestive of advanced hyperplasia or of scirrhous 
 cancer, the large heavy cervix accompanying subinvolution. By the 
 direction we gain an idea of the probable position of the corpus uteri, 
 which our next method of examination is needed to confirm. The 
 position and condition of the external os are to be carefully noted, 
 especially as to whether it be lacerated or not, and, in the first instance, 
 as to whether the rent be unilateral or bilateral, the depth to which the 
 rent extends, and the sensitiveness at the angles of the rent ; and, in 
 the latter instance, as to the shape of the os, parous or not, and as to 
 the patency in degree and extent. This is all the information which 
 the unaided internal finger can to advantage glean. It may, of course, 
 pass to the vaginal vault, but any exact determination of the conditions 
 there present and of the organs adjacent to it must await our next step 
 — the bimanual or conjoined examination. 
 
 It is only in comparatively recent times that the necessity of the biman- 
 ual examination has been recognized and insisted upon. Now-a-days no 
 examination is complete, or even approximately correct, unless this 
 
rilYsicAL sKiys. 2119 
 
 iiU'tlmd liiis Im'cii svsl('iii:ili<;illy iixd. Ivxccption.illv only, as wIktc 
 there is jireat jidipo.-e <le\ (Inimiciil of (lie .-ilMlniiiiiial walls, iiitlariiiiia- 
 torv disease, or >iie|i li\ |)ei:i'>|li<>ia on the pail of oiir |»atient as to 
 interliTe with snllieient de|)ression of the ahiloineii, is it inijiossihle 
 to resort to this inaiio-uvre ; and in siu-h <'ases, in order to complete onr 
 (lia<;iiosis, it iiia\ i>e necessary to resoil to ana'sthesia. Otherwise, how- 
 ever, if the patient ocenpies the proper position, as already descrihed, 
 and the exaniinei" makes uciitle hut steady |»i-essnre in the ri^lit direc- 
 tion, the contents of tJM' pelvis and the tnpDm-njihy ol" it> coniaiiied 
 oi-uans mav he acciii'ately studied. To perform the hiinanual, the 
 examiner stands hetween the |)atient's everted thi<ihs, the Madder 
 havino-, if neeessarv, heen previously emptied ; |>laces his hand, pre- 
 lerahlv the riuht, on the alxhimeii ahout midway hetween the nmhilieus 
 and the puhes, and with the tint-ers maUes pi-essure in the direction of 
 the axis of the pelvic inlet, eounsolliiiij; his patient to hreathe quietly 
 and to relax hei- ahdominal nniseles as nuieh as is in her })ower. His 
 external hand will thus rea<lily eome upon the fundus of the uterus, if 
 this organ be in fair position or anteriorly disj)lace<I, or else will meet 
 the internal fiULi'er, which should he restinu" in the anterior cul-de-sae. 
 This cul-de-sae should now be exj)lorcd for evidence of thickening- 
 in the vagi no- vesical space, for the presence of a body which further 
 examination nuist distinguish as the fundus uteri, or tumor, or, excep- 
 tionally, an anteriorly displaced ovary. If this body be continuous 
 with the cervix, if motion imparted to it be communicated t(» the 
 cervix, if further ex])loration posteriorly to it reveal no other b<»dv, 
 we are assured that it is the fundus. If, on the other hand, we find 
 another body posterior to it, in connection or separate, we immediately 
 think of a tumor in the anterior fundal wall, loosely connected with or 
 independent of it. Then it may be necessary, as noted farther on, to 
 resort to the sound for differential diagnosis. If this body, however, 
 be small and sensitive, the ovary, out of position, suggests itself. The 
 finger in the anterior cul-de-sae should further seek for an angle 
 of flexion formed at the junction of the cer\'ix and body of the 
 uterus, and should note the elasticity of the cul-de-sac and its dejith. 
 The internal finger should now pass successively to the left and right 
 lateral culs-de-sac, the external hand bringing the organs w Inch lie in 
 these regions within reach. These regions are to be explored esjiecially 
 in regard to density, thickening, or fluetuation, suggesting rcH-ent or 
 chronic inflammatory processes, or alterations, inflammatory or not, in 
 the ovaries, tubes, or layers of the broad ligaments; and now, too, if 
 the patient be spare or there be sufHcient relaxation of the abdominal 
 muscles, the ovaries may be felt if in their normal position, and they 
 are distinguished by their size, sha]>e, and by the peculiar sickening 
 pain which pressure almost always will evoke. If the uterus be later- 
 
300 GYNECOLOGICAL DIAGNOSIS. 
 
 ally displaced, the fact may be detected whilst these lateral regions are 
 being explored. The finger should now pass to the posterior cul-de- 
 sac, and, under favorable conditions, the abdominal walls may be 
 sufficiently depressed to allow the external hand to meet it there. 
 The elasticity of this cul-de-sac should also be tested, evidence of 
 acute or chronic exudation sought for, the posterior ligaments of the 
 uterus tested for thickening, the depth of the cul-de-sac noted, and, 
 even as in the examination of the anterior cul-de-sac, the nature of 
 any body differentiated as the fundus, or tumor connected with or 
 independent of the fundus, and an angle of flexion is also to be sought 
 for. Here, too, the sound may be necessary to make the diflPerential 
 diagnosis, although ordinarily the conjoined fingers will suffice. Doug- 
 las's cul-de-sac is also a favorite resting-place for prolapsed ovaries, and, 
 as before, these may ordinarily be distinguished by their size, shape, 
 and sensitiveness. Scybala in the rectum can only be mistaken for 
 ovaries by the careless examiner. The next step is to test the mobility 
 of the uterus, to estimate its size and its shape, and the relation as to 
 direction this body holds to the cervix. The mobility is ascertained 
 by placing the internal finger on the cervix and pushing this in various 
 directions, or, if the uterus be not so displaced backward as to render 
 the step impossible, the external hand may grasp the fundus and tilt it 
 backward or forward or laterally. At the same time the shape and 
 density of the organ are estimated, and any unevenness of its walls 
 noted. When movement is imparted to the uterus, the examiner is to 
 note if pain is thereby given to the patient, and as to how much the 
 sphere of mobility is impeded in one or another direction according to 
 the conditions present which interfere with what his experience teaches 
 him is the usual range of motion. 
 
 It should never be forgotten, in estimating the probable relation 
 existing between symptoms complained of and uterine position, that 
 there is absolutely no fixed standard whereby the uterus may be judged 
 to be in or out of position. In regard to " the normal position of the 
 uterus " every woman is a law unto herself. The uterus has a range 
 of normal positions, and this range will vary in each woman according, 
 on the one hand, to the symmetry of her pelvis, and, on the other hand, 
 to the length of the ligaments which nature has supplied to the organ 
 to act as checks against its assuming a position which will — indeed, 
 must — evoke symptoms. And in this word " symptoms " we strike 
 the key-note of diagnosis of abnormal uterine position. Obviously, 
 the uterus may in one woman lie, for instance, farther fonvard than 
 in another without giving rise to symptoms from the side of the blad- 
 der ; and this for the reason that her pelvis is more capacious, or her 
 bladder less intolerant of interference, or the retro-uterine ligaments 
 longer ; and a like train of reasoning will apply to backward or down- 
 
nnsicAL siass. :>,()\ 
 
 wanl (li>|)l:ifcinciit. It is not -iiniciciil, tlicirrorc, iltr tlic cxariiiiK r to 
 coiicliidr tliat tlu- iitiTiis is ante- or rctrovcrtcd in a particnlar ("ase 
 l»ccaii>(' one or aiiotlici' aiitliority states dogmatical I v tliat the like |)<»si- 
 tion is altnoiiiial ; Ixit lie nin~t seek iiirtlicr as to whether tlie j»ositi(»n 
 which he determines will account for the synijitonis. ll' not, the j)o.si- 
 tion is not al)norniaI i'uv thi> |i:nticiihir woman. I wonid Tnrther hiv 
 stress on the fact that, ordinarily, the himamial examination alone will 
 tell n< snllicient in re<iard to the jxtsition of" tiie nterns and its mohilitv 
 to render rei-onrse to instrnmental means unneccssarv. 
 
 Closely eoiineeted with the himanual are other methods of" conjoined 
 inanipid;ition, sueh as vesieu-reetal, reeto-abdominal, vajri no- rectal. The 
 ]»in-|)(»sc's of these manipidations, their indications, and the information 
 to be thus derived will find an aj)propriate plaee under the next head- 
 in<>- and in eonneetion with it. 
 
 Rcdal Examination. — This method (tf examination is repugnant 
 alike to the physieian and the patient. I eannot, as some do, consider 
 it necessary as a routine measure. The information to l)e thus obtained 
 in retiard to the uterus and its adnexa is of limited nature, and never 
 so thorouo-h as that yielded by careful bimanual examination where the 
 conditions are favorable. Except, therefore, where the rational history 
 suggests rectal disease, or \vhere the bimanual is for one or another 
 reason incom})lete or unsatisfactory, I would limit this examination in 
 general to cases where congenital or acquired imperfections or obstruc- 
 tions of the genital canal forbid the methods of examination alreadv 
 detailed, and to virgins in order to acquire information which might 
 justify us in rupturing the hymen for purposes of more exact diagnosis. 
 Although, however, I restrict the necessity of a rectal examination 
 within these general limitations, I would note here that not infre- 
 quently obscure symptoms, not explainable from the side of the uterus 
 and its adjuncts, will be found to depend on such, in aj^pearance, insig- 
 nificant lesions as small rectal ulcer or anal fissure, even though these 
 symptoms do not, in the lea.st, suggest the likelihood of rectal disorder. 
 In order to properly make a rectal examination it is essential that the 
 rectum should have been evacuatc^l beforehand. It will hence be often 
 necessary to postpone such an examination until the ])atient's second 
 visit, that she may prepare herself for it by an enema. The index 
 finger, gently insinuated through the sphincter ani, will readily detect 
 any foreign growth or stricture of the canal, and if the uterus be in fair 
 position the cervix may be felt pressing against the posterior vaginal wall. 
 The posterior limits of Douglas's cul-de-sac may be investigated, as 
 well as its contents. Xow, by resorting to abdomi no-rectal examina- 
 tion the pelvic organs are depressed nearer to the rectal finger, and the 
 posterior surface of the uterus may be paljiated, as well as frequently 
 the ovaries in normal position, and exceptionally the broad ligaments. 
 
302 GYNECOLOGICAL DIAGNOSIS. 
 
 This last condition may be better satisfied by resorting to vagino-rectal 
 examination, whereby a double tenaculnm fixed in the cervix causes an 
 artificial prolapse of the uterus, and thus approximates its lateral sur- 
 faces with the ligaments to the rectal finger. AYith the finger in the 
 rectum an excellent opportunity^ is also offered for investigating the 
 integrit}^ of the perineal body, to be accomplished either through 
 inserting the thumb of the same hand into the vagina, or else, as is 
 less awkward, the index of the other hand. 
 
 A further conjoined method of rectal examination, the vesico-rectal, 
 is of special utility in those cases where there is possible absence of the 
 uterus, and Avhere inversion of this organ needs to be carefully differ- 
 entiated. Here it is better practice to introduce a sound within the 
 bladder rather than the finger, for thus we obtain as exact information 
 without risking injury to the urethra or vesical neck. AVe may also 
 paljjate the anterior surface of the uterus by means of the finger in the 
 bladder, although the vagino-abdominal method, assisted, if need be, 
 by an anaesthetic, is much to be preferred. Finally, I would allude 
 here to Simon's method of rectal examination by means of the entire hand. 
 This method has never become popular, and I question if to-day it is 
 considered a justifiable procedure from a gynecological standpoint. The 
 method requires aneesthesia, and, unless the examiner's hand be smaller 
 than the average, the injuiy done to the patient is likely to be greater 
 than any possible good which might result from the information thus 
 obtained. I believe that through the methods of examination which I 
 have already described a diagnosis may be reached, if one is at all pos- 
 sible, without resorting to Simon's procedure, and I therefore simply 
 mention rectal exploration by the entire hand in order to condemn it. 
 
 I have now noted in succession the various methods of digital exami- 
 nation appropriate to the dorsal position, and have stated the general 
 information to be thence derived. In the natural order of examination 
 there are instrumental means of diagnosis which will be resorted to in 
 this position before the patient assumes the left-lateral. I therefore 
 deem it better to describe them here, rather than in connection with 
 the description of more special instrumental measures. 
 
 The instruments of particular utility in the dorsal position are — 1, 
 the sound ; 2, cylindrical and plurivalve specula. 
 
 T}\e Sound. — The best form of this instrument is that devised by 
 Simpson. It is sufficiently flexible to allow of its being bent by the 
 hand to any desired curve, and yet not so much so as to bend on itself 
 when it comes in contact with a foreign body or is insinuated into a 
 fold of the cervical mucous membrane. The guiding hand is therefore 
 ever conscious of the location of the point of the sound. A further 
 advantage is the knob marking the depth of the normal uterus, 
 whereby the finger, along which the instrument should he passed, is 
 
I'llYSK'AL SIGNS. 303 
 
 cmistMiitK' iiit'oniu'il nf ilic prou'i'c.-s tlic mhiikI is iiiakiiij:-. TIm' tliick- 
 ness of this iiistrunit'iit is only a disatlvaiitatic in tliosc cases where 
 tliere exists sharp Hexioii or (•t)ii<;eiiital »»r aei|iiii"e<l stenosis of the cer- 
 vical I'aiial, iiiHler which coiKlitioiis, as will he noted in its |)roj)er j)hi<"e, 
 the proix' is to he used. 
 
 TIu' judicious use of the sound may revi'al very iiuportant inlornia- 
 tion. Its injudicious use may result in serious damaj^c to the ])atient. 
 The contraindications should therefore ever be borne in mind, and 
 these are two in munl)er — ]»reu'nancv, peritoneal or cellular iuHainma- 
 tion. These conditions having- been strictly eliminated, the sound, 
 
 Fig. 115. 
 GcoT/£MANN&Co. 
 
 Simpson's Souud. grariuatcd. 
 
 used with care, can scarcely inflict damasje. Whilst I cannot ^o so 
 far as to say that no diaiiiiosis is complete nnless the sound has been 
 used, I advise its systematic employment in every case where no con- 
 traindication exists. The instrument may, of course, be introduced 
 with the patient in the semi-prone as well as in the dorsal position. 
 This is largely a matter of individual choice or of habit. Personally, 
 I favor the introduction in the dorsal position, because just previous to 
 its use we may ordinarily assure ourselves bimanually of the position 
 of the uterus, and are therefore better able to formulate the curve 
 which the instrument must have and the direction it will have to take. 
 The sound, then, held lig'htly Ijctween the forefinger and the thuml) of 
 the right hand, is to be introduced along the index of the left hand as 
 a guide until it reaches the external os ; passing through this along 
 the canal to the internal os, the handle is to be depressed, elevated, or 
 rotated according to the probable site of the fundus as deduced from 
 the bimanual. If during its progress the point catches in a fold of 
 the mucous membrane, the instrument is to be \vithdrawn and again 
 introduced. Absolutely no force is to be used, the instrument being 
 allowed, as it were, to find its 0'\vn way. The information to be 
 derived from the use of the sound is — the patency and size of the 
 external os and of the cervical canal, and the state as regards smooth- 
 ness or roughness of its lining membrane; the sensitiveness and the 
 patency of the internal os ; the degree of flexion ; the depth of the 
 uterus ; the sensitiveness of the endometrium ; the exact position of 
 the fundus ; and the general direction of the uterine axis. It is evi- 
 dent, therefore, that, aside from giving us infitrmation which is other- 
 wise not obtainal)le, the S(jund will vcrifv nuicii which the biuiaiuial 
 
304 GYNECOLOGICAL DIAGNOSIS. 
 
 has taught us, and also, where the bimanual has been impossible or 
 unsatisfactory, supplies the facts which we would otherwise lack. The 
 value of the instrument for purposes of differential diagnosis is also 
 apparent ; as, for instance, where the bimanual has revealed a tumor in 
 front of or behind the uterus the sound will tell us which is the corpus 
 uteri and Avhich the tumor. As for the use of this instrument as a 
 uterine redressor or to test the mobility of the uterus, I most unqual- 
 ifiedly condemn it. I know that in skilful hands it mav be made to 
 subserve these purposes without necessarily inflicting injurv ; but, 
 knowing also that damage may be done through the purchase which 
 the instrument necessarily takes at the fundus, I reject the sound and 
 uniformly use one of the special instruments constructed as redressors, 
 and which take their point cVappui at the external os. It will be 
 noticed that I have not referred to the introduction of the sound 
 through the cylindrical or the plurivalve specula. I do not favor 
 such a procedure, because I know that the careful introduction of the 
 instrument is best assured when the finger in the vagina acts as a 
 guide, and also because there are positions of the uterus where these 
 specula seriously interfere with the passage of the instrument, occa- 
 sionally prevent it entirely. 
 
 The Cylindrical and Plurivalve (■specula. — The uses of the speculum 
 in the dorsal position are xery limited. Indeed, I question if gynecology 
 would ever have obtained the rank it holds had not the genius of Sims 
 rendered evident the immense advantage offered by the specular exami- 
 nation made in the position ordinarily known by his name, and which 
 I shall describe farther on. And the truth of this assertion is borne 
 out by the fact that skill in the diagnosis and in the treatment of uterine 
 disease, properly so called, is most marked in those countries where the 
 dorsal position is made to subserve the purposes of the digital exami- 
 nation, and the left-lateral the specular. Through both the cylindrical 
 and the plurivalve specula the field of vision is limited, the play of 
 whatever instrument is necessary for diagnosis and treatment is nar- 
 rowed and often negatived, and certain lesions of the cervix may be 
 effaced or obscured which it is of paramount importance to detect. 
 I need only instance the fact tliat laceration of the cervix is mistaken 
 for ulceration by those examiners who habitually use these specula and 
 the dorsal position. Hence, personally, I recommend the use of the 
 speculum in the dorsal position solely for the purpose of making 
 applications to the vagina or external os. For purposes of diag- 
 nosis I do not favor it at all, because the limited information thus 
 obtainable may be secured to better advantage in the lateral position, 
 and, at the same time, facts may be ascertained and treatment be 
 employed which cannot be in the dorsal position. I would note here, 
 hf)wever, that occasionally, as where the rational history suggests abun- 
 
J'lIYSlCAL SfGNS. 
 
 305 
 
 <l;iiit IciicDrrlid'M, it is :i(lvi>al)lc to iiitroiliicc the spcciiliiiii hofore the 
 tiiiiicr, and then the cvliutlriral spcciiliiiii will sullicc to .sliow us the 
 source of the (iiscliaruv. 
 
 Cyliiulrieal spa-ula arc constructed preferahly ol" ;i:lass or hard rub- 
 ber. The Fcro;ussou uiay l>c takcu as a type, and is to he obtained in 
 
 Fig. 110. 
 
 Fergusson's Speculum, 
 
 nests of various sizes. This speculum is readily introduced, previously 
 anointed with oil or soap, by depressing the perineum ^vith its point 
 and gently insinuating it up to the cervix. If the vaginal walls be 
 not specially lax, and if the cervix be in fair position, there is but 
 little difficultv in eno-aging: the external os in the field of vision. 
 Oftener than not, however, the speculum must be withdrawn and 
 reintroduced a number of times before this can be accomplished, and 
 where the cervix lies far backward it requires considerable ingenuity 
 and patience to see it at all. 
 
 Valvular specula are constructed of either two, three, or four blades. 
 
 Fig. 117. 
 
 A'"- 
 
 Brewer's Speculum. 
 
 Many have been invented, and each doubtless remains in favor with its 
 inventor, although, for reasons already sufficiently state<l, they are one 
 and all inadequate for purposes of accurate diagnosis and treatment 
 according to the requirements of modern gynecology. It is out of tlie 
 question to attempt a description of the many forms here. I content 
 Vol. I.— 20 
 
306 
 
 GYNECOLOGICAL DIAGNOSIS. 
 
 Notts's Speculum. 
 
 myself with mentioning, as typical of the bivalve, Brewer's speculum ; 
 
 of the trivalve, Notts's ; of the 
 Fig. 118. quadrivalve, Meadows's. These 
 
 specula are introduced closed and 
 afterward expanded, and may be 
 used in the lateral as well as in 
 the dorsal position. It is safe 
 to say, however, that the gyne- 
 cologist wdio has once accustomed 
 himself to Sims's speculum will 
 never desert it for any form of 
 plurivalve ; and it is equally true 
 that the general practitioner, 
 desirous of doing something 
 more for his patients than apply- 
 ing the time-honored, but to-day 
 almost neglected, stick of lunar 
 caustic to the cervix, must learn how to use Sims's speculum and the 
 left-lateral position. And therefore it is why I do not deem it neces- 
 sary to sj)end time and waste space on a description of the many forms 
 of multivalve specula and their manner of introduction. A science 
 should be practised correctly or not at all, and surely no gynecologist 
 w^ill to-day claim that he is able, through any form of multivalve 
 whatever, to accomplish what he can through a Sims. And, whilst my 
 remarks here are limited to diagnosis, how much more forcible do they 
 become when applied to the treatment of intra-uterine disease ! Both 
 exact methods of diagnosis and correct methods of treatment are only 
 possible to a limited degree through tubular and plurivalve specula. 
 Aside from the exceptions already noted (applications to the vagina 
 and cervix), I see no further use for these instruments, and believe 
 that the time has come when they should be weeded out of the already 
 too cumbersome gynecological armamentarium ; and my belief is the 
 firmer because of the fact, to be noted farther on, that the oft-repeated 
 objections to Sims's speculum are really not tenable. 
 
 Since the points to be noted through the speculum appear to better 
 advantage through Sims's than any other, their description is deferred 
 for a time, and it remains now to consider the final diagnostic measures 
 which properly belong to the dorsal position. 
 
 Examination of the Abdomen : Inspection, Mensuration, Aus- 
 Gultation, Percussion, Palpation. — In inspection of the abdomen we 
 are to look for the whitish lines, lineje albicantes, the result of the rup- 
 ture of muscular fibrils and evidence of distension of the abdominal 
 walls ; we are to note the shape, whether flat on the surface and bulg- 
 ing in the flanks, whether round or spherical, suggesting in turn ascites, 
 
PHYSICAL SIGNS. 307 
 
 <>vai"i:in <'yst, or j^ravidity ; \vc arc to seek luovcnioiits of the surf'atx*, 
 su;;ji;e.stin<;; arterial pulsation, Inetal motion, pa-ssage of" flatus through 
 the intestines; projection at any one p(jrtif»n, suggesting hernia, Hl)roi(ls. 
 These are possibilities which eitiier our previous examination or that 
 whieh is to foMow will verily. 
 
 Mensuration is more [jarticularly of service to the obstetrician. Still, 
 in eonneetion with the growth of abdominal tumors the gynecologist 
 must fre<iuently have recourse to this measure. The measurements oi' 
 greatest service are those taken at the level of the umbilicus and from 
 the ensiform cartilage to the pubes. We are thus kept informed as to 
 the rate of growth of tumors, and may satisfactorily check their dim- 
 inution under treatment or at the approach of the menopause. 
 
 Auscultation and percussion are similarly — especially the former — 
 of greater utility from an obstetrical than from a gynecological stand- 
 point. Xot uncommonly, however, the gynef.-ologist is called upon to 
 make a differential diagnosis of pregnancy in its later stages, and then, 
 obviously, the obtaining of the foetal heart through auscultation is of 
 essential importance. Succussion, or the splashing of fluid in the abdo- 
 men on change of position of the patient, is thus also obtainable, as 
 well as the bruits suggestive of change in the blood-vessels or pressure 
 upon them. Percussion is one of our most valuable means of obtain- 
 inu; information in regard to the nature of abdominal enlaro;ements. 
 The uniform and general tympanitic note, characteristic of gaseoas dis- 
 tension of the intestines ; the dull note in the flanks and tympanitic in 
 the epigastrium, suggestive of ascites ; the local dulness accompanying 
 local tumor or distended bladder ; the shading off of the dull into the 
 tympanitic, or vice versd, suggestive of tumor growing from above, or 
 the reverse ; the sense of resistance to the percussed finger, suggestive 
 of either fluid, semi-fluid, or solid contents, — such, in outline, are the 
 points obtainable through percussion. 
 
 Palpation of the abdomen, as already stated, is not necessary- as a 
 routine measure in gynecological practice ; but when the histori', 
 appearance, or digital examination renders probable the presence of 
 abdominal enlargement, then this measure must be resorted to ; and it 
 is essential that the patient should be properly prepared for the neces- 
 sary' manipulation, and that the examiner should proceed systematically 
 and with gentleness. The bladder having been emptied, the clothing 
 loosened, and the abdomen exposed, the examiner stands on the 
 patient's right, and, encouraging her to relax the abdominal muscles, 
 depresses with the tips of his fingers, gently but firmly, the various 
 regions of the abdomen. Where, from excess of adipose development 
 or h%-persesthesia of the abdominal walls, manipulation is impossible or 
 unsatisfactory', then, should the necessity of palpation be obvious, 
 recourse must be had to anaesthesia, when a tumor, otherwise undis- 
 
308 GYNECOLOGICAL DIAGNOSIS. 
 
 coverable, may be revealed, or else one manifest, but of uncertain nature, 
 may disappear (so-called phantom tumor). The facts to be learned from 
 palpation may be summarized : The probable abdominal or pelvic ori- 
 gin of a tumor ; the density and general outline of such tumor ; its 
 single or multiple nature ; its fixation or mobility ; its size and depth 
 below the surface ; its probable connection with other organs ; the pres- 
 ence of fluid, general or localized, in the abdominal cavity. Thus, then, 
 we differentiate between abdominal and pelvic tumors proper, or simple 
 enlargement of abdominal organs ; thus we recognize a movable kidney, 
 a multi- or unilocular ovarian cyst, subperitoneal fibroids, the gravid 
 uterus, the uterus enlarged by cyst or new growth of solid or semi-solid 
 nature, abscesses within the abdominal walls, hernia, aneurism : indeed, 
 in a favorable case, the skilled examiner may often so thoroughly pal- 
 pate as to be assured in turn of the probable gross condition of every 
 one of the important abdominal organs. It is out of place to do more 
 than refer here to the value of abdominal palpation to the obstetrician 
 in determining the position of the foetus within the uterus, the existence 
 of multiple gestation, etc. 
 
 The Left-lateral Position. — Thoroughness and ease of exami- 
 nation in this position will depend on its being properly and exactly 
 assumed. The position aims at bringing the force of gravity to bear on 
 the abdominal and pelvic organs, whereby they are caused to sink down- 
 ward and upward, thus tending to produce a vacuum in the vagina, 
 which the external air, on separating the labia, rushes in to satisfy, and 
 thereby balloons out the vagina and the vaginal vault. To obtain these 
 conditions at their maximum the thorax must be the lowest point and 
 the sacrum the highest when the patient is lying in this position. Even 
 as in the dorsal position, and still more essential, the patient's clothr 
 ing must be loosened from around the waist and compression of the 
 chest-walls by the corset removed. The steps by which this position 
 may be assumed are as follows : The patient, resting on her left natis* 
 at the edge of the examining-table to the left of the mid line, places 
 her left arm behind her and lies down diagonally across the table, the 
 left cheek on the pillow and the left thoracic wall against the mattress. 
 She has thus rolled over on her chest, and the lowest point of our posi- 
 tion has been obtained. Next, the thighs are flexed on the trunk, the 
 right more than the left, so that the right knee projects considerably 
 over the left, and the legs are placed at a right angle to the thighs. The 
 pelvis has now been elevated, and the sacrum is the highest point of 
 the position. During this manoeuvre the nates are often pushed too far 
 up on the table, so that, as a further step, it is necessary to draw them 
 well down to the edge. The hands may now grasp the lateral edges 
 of the table, and the patient is in position. She should be covered by 
 a sheet, which is tucked around the superior (right) leg and thigh, the 
 
I'll y sir A/, Slays. 
 
 noo 
 
 Icl't It l;' and tlii<;li being covcrcil l)y a tttwcl, tho vulva, jK-riiuMim, and 
 anus aloiic remaining" cxixtscd. '^|"'li(' tal)l(' slioidd We so placed that the 
 lijilit niav strike slaiitiii<ily, IVnni lu-forc backward, on these parts. If 
 the tabic have the lateral inclination rcierre<l to in the remarks on this 
 sul)jcct, it is obvious that the force of jfravity may still further be called 
 into i)la\- lt\' utiii/.inii- it. This inclination, however, whilst a decided 
 ad\anta<i;e if the examiner have no assistant, is not indispensable. 
 
 Before proceedino- to a description of the methods of examination in 
 tho left-lateral position, it seems proper to consider very briefly the 
 objwtions to this position advanced, in |)articular, by ouv transatlantic 
 
 Ftg. 119. 
 
 The Left-lateral Position (after Munde, from Hegar and Kaltenbach.) 
 
 brethren. These objections are three in number : 1. There is greater 
 exposure of the patient than in the dorsal position. 2. The change to 
 this position from the dorsal requires extra time and trouble. 3. The 
 use of the left-lateral position necessitates the presence of an assistant. 
 The first objection is not founded on fact, and, even though it were 
 true, the patient would not object to greater exposure if assured that 
 at the same time she receives greater benefit. The truth is, that in the 
 left-lateral position, the patient being properly arranged, the vulva, 
 perineum, and anus are alone exposed, and these parts it is essential 
 to expose also in the dorsal position in order to introduce a tubular or 
 valvular speculum. The second objection — to grant for a moment that 
 it is worthy of serious consideration — falls to the ground in the face of 
 the assertion, not to be denied to-day, that the extra trouble simply 
 leads to correct diagnosis and effective treatment. The third objec- 
 tion is, in a measure, valid. It is simply a Avise precaution for the 
 physician, when able, to have a trained assistant present to assist him 
 
310 GYNECOLOGICAL DIAGNOSIS. 
 
 in arranging his patient and to hold the specukim. The presence of a 
 nurse is a safeguard against blackmail, and equally so whether the 
 patient be examined in the dorsal or the left-lateral position. It is a 
 great convenience, too, to have some one at hand to hold the Sims's 
 speculum, but where the amount of practice or the means of the 
 physician do not necessitate or allow the constant presence of the 
 trained nurse, I can affirm that he may intelligently and correctly use 
 this instrument alone, if he but possess one of the modified forms 
 which will be described farther on. I believe, indeed, tliat the above 
 objections to Sims's instrument and position are simply, in part, the 
 outcome of ignorance as to use and benefits obtainable — in part of 
 unwillingness to change from routine and time-honored methods. 
 
 Digital Examination in the Left-lateral Position. — For diagnosis by 
 means of the finger this position presents no advantages over the dorsal ; 
 indeed, it is decidedly inferior, seeing that the inner organs have gravi- 
 tated away from the outer. For the same reason the bimanual cannot be 
 performed satisfactorily in this position, aside from the awkwardness of 
 the attempt. The external genitals may, of course, be inspected nearly as 
 well as in the dorsal position, the integrity of the perineum be tested, and 
 as for the anal region, it may be more closely examined. It is in this 
 position that the rectum may be everted by means of a finger in the 
 vagina, and a fissure or ulcer readily brought to view. Frequently, 
 by means of one or two fingers, Douglas's cul-de-sac may be more 
 carefully explored than in the dorsal jjosition, and the nature of a 
 post-uterine tumor better appreciated. The extent, also, to which pos- 
 terior adhesions limit the mobility of the uterus may be more correctly 
 determined, and the backward displaced uterus 'more effectually elevated 
 by the finger in the lateral position. Barring these exceptions, the chief 
 utility of this position, as intended by Sims, its originator, is the 
 exposure of the vaginal vault by means of the speculum he devised, 
 and which has made much of modern gynecology a possibility. 
 
 Specular Examination in the Lefi-lateixd Position. — There is but one 
 speculum of use in the lateral position, and this is the duckbill or 
 Sims's. The cylindrical speculum, the various bivalves and multi- 
 valves, may, of course, be inserted into the vagina, but the disad- 
 vantages are the same as, and the advantages no greater than, have 
 already been noted under the dorsal j)osition. What we need in the 
 lateral position is a perineal retractor and an instrument for dejiressing 
 the anterior vaginal wall. These purposes Sims's duckbill speculum 
 and his depressor subserve perfectly. 
 
 The chief bar to the general use of the unmodified duckbill is 
 the fact that an assistant to hold it is practically a necessity when it 
 is desired to introduce instruments into, or to make applications to, 
 the uterine cavity. It is possible to perform these manipulations 
 
I'llYSlCAL SfGNS. 
 
 311 
 
 alone, cxccptioiiallv, if llif (xaiiiiniiiu-tal)!"' Iiavc tln' lateral iiieliiia- 
 tion, the uterus l)e in fair pusitiuii, and the vaginal walls not markedly 
 relaxed ; for under sueh favorable eireumstanees the anterior va;,nnal 
 wall will <;ravitale upward, the de|)iv»or may he dis|)ensed with, and 
 
 I-'k;. 120. 
 
 b'lo. 121. 
 
 <^ 
 
 Sims's Depressor. 
 
 the examiner's rio-lit hand is thus left free to 
 manii)ulate as he ))leases. As a rule, however, 
 if the examiner l)e alone, hoth his hands arc 
 occupied, the one with the si)eculum and the 
 other with the dej)ressor, .so that he can ac- 
 complish nothing beyond getting a view of 
 the cervix. And therefore it is that Sim.s's 
 original instrument has been .so variously 
 modified, nsually in order to make it .self- 
 retaining. AVheu we consider how indispen- 
 sable Sims's .speculum is for both diagnostic 
 and therapeutic purposes, and therefore how 
 essential it is that the general practitioner, the 
 exigencies of whose practice do not reqnire the constant attendance of a 
 nurse, shonld be able to scientifically nse this instrument when using it 
 
 Fig. 122. 
 
 Sims's Speculum. 
 
 Hunter-Erich Speculum. 
 
 at all, we are not slow to accord a word of praise to each gentleman 
 who has aimed at modification, even though of all the various forms 
 there is scarcely one which is not open to objection, largely on the score 
 
312 
 
 G YNECOLO GICAL DIA GNOSIS. 
 
 of complexity. Without any desire to be invidious I shall refer here 
 to only two modified Sims's which may be used to advantage without 
 the assistance of a nurse. The one is Hunter's modified Erich, with 
 which, although I am not personally familiar, I am assured by many 
 gentlemen any desired manipulation is possible. It is in appearance 
 rather complicated, but after a certain amount of practice much time is 
 not required for adjustment. It is not possible to give a clear descrip- 
 tion of this instrument in words, and I content myself with figuring it. 
 Another modified form of Sims's speculum, which from extensive per- 
 sonal experience I can recommend, is that devised by Thomas, essen- 
 tially modified by M. D. Mann, and recently altered in certain 
 respects by myself. The original instrument had a sacral-piece 
 attached to it, and was more complicated than the later models. 
 Mann dispensed with this piece, and at the same time had the blade 
 and depressor lengthened and broadened. The instrument then con- 
 sisted of a Sims's blade with attached depressor, this latter so articu- 
 lated to the blade as not to interfere in any way laith the field of vision 
 nor with instrumental manipulation, and — a most important point — so 
 as not to distend in the least the ostium vagince. Further, a hook (Fig. 
 
 Fig. 1 23. 
 
 1. Mann's Speculum. 
 
 2. Tenaculum for Mann's Speculum. 
 
 123, A) was placed on the depressor-shaft to which the tenaculum, used 
 to draw down or steady the uterus, might be attached. This instrument 
 is shorn of the objections common to other modified Sims's. I have 
 recently had the instrument altered by adapting the depressor to the 
 lower surface of the blade, fitting a flange, to hold up the superior 
 buttock, to the upper surface of the blade, and by shortening the 
 depressor bar. This instrument may be held by the left hand, or 
 else, when the depressor handle has been screwed down and the handle 
 
I'll y SIC M, srnxs. 
 
 .'ii;i 
 
 of the instrumont removed, we lia\c d .svY/'-rr/r/////?}// speciiliim, nnd hoth 
 liauds are free. 1 liave tested this iiisti'iimeMt iiiitldidly, and am aide 
 with it to pcilonii, in Sinis's position, unassisted, any inanij)uhition 
 (applications to endometrium, < iircttinji', ete.) proper to olliee practiee. 
 
 ()ther I'orms of s|)eeula devise<l as seli-i'etaininji,- are those of Kminet 
 and (if StudK'v and Darrow. These are, however, eom|)lieate(l, and are 
 a|)t til alarm the patient \)v the time and manipuhitiou necessary fur 
 tlu'ir adjustment. I helieve that either through the IIunter-Ericli or 
 throuiili Mann's speculum, or its modification, the general })ractitioner 
 ^\■ill he ahle, without an assistant, to make a correct diagnosis and aj)j)ly 
 the re([uisite treatment ; and that there is, therefore, no longer any excuse 
 tor the halfway measures commonly, particularly in Europe, resorted to 
 through the cylindrical or nudtivalve instruments. 
 
 Introdiidion of Sim.s's SpcvK/itin. — This instrument may be intro- 
 dueed either along the index finger of the right hand as a guide, or 
 
 Fio. 124. 
 
 Munde's Flange Speculum. 
 
 else independently of a guiding finger. I much prefer the latter meth- 
 od, mainly because thereby soiling of the finger is avoided. The 
 speculum is readily inserted as follows: The examiner, sitting on a 
 stool or chair a little to the left of his patient, separates the labia with 
 the thiiml) and index of the left hand, and, holding the speculum, pre- 
 viously lubricated, between the fingers of his right hand, inserts the 
 point of the blade into the vulvar cleft and pu.shes the blade along the 
 ])osterior vaginal wall. If care be taken to keep the blade ])ointing 
 backward toward the coccyx, it \vill necessarily seek the posterior cul- 
 de-sac and lie behind the cervix. The speculum is now to be trans- 
 ferred to the left hand and the perineum retracted with an upward 
 inclination. The right hand. In- means of the depressor, pushes down 
 the anterior vaginal wall, tlie cervix ordinarily comes into view, and 
 the speculum is handed to the nurse, if one be present, who holds it in 
 
314 GYNECOLOGICAL DIAGNOSIS. 
 
 position with her right hand, whilst her left j)nlls up the superior but- 
 tock. This last stej? is rendered unnecessary if the speculum have 
 adaj)ted to it the flange devised by Munde for keeping the right but- 
 tock out of the field of vision — a modification which will be found par- 
 ticularly of use when the nurse is desired to hold some other instru- 
 ment for the examiner, and can do so in her left hand. Exceptionally, 
 in pluriparse with loose and flabby vaginal walls, or when from ante- 
 rior displacement or distortion of the uterus the cervix lies far back in 
 Douglas's cul-de-sac, it is impossible to obtain a satisfactory view of 
 this organ without resorting to a further instrument, the tenaculum. 
 
 Fig. 125. 
 
 Emmet's Tenaculum. 
 
 By hooking this into the anterior lip of the cervix and making gentle 
 traction the cervix may be brought into view. The traction must be 
 
 Fig. 126. 
 
 Sims's Tenaculum. 
 
 gentle, especially if, as a result of our bimanual examination, we have 
 obtained evidence of, or have reason to suspect, recent or chronic cellu- 
 litis or pelvic peritonitis. 
 
 The speculum in position, we are now able to note the appearances 
 of the cervix. 
 
 The Appearances of the Cervix through Sims^s Speculum. — The chief 
 cervical appearances to be noted are the color, shape, condition of the 
 external os, and the discharge issuing from it. The color of the cervix 
 varies from light-pink, the normal, to blue or violet, a sign of conges- 
 tion and suggestive of pregnancy, subinvolution, ovaritis, mechanical 
 interference with the pelvic circulatory system. The shape, unaffected 
 by disease, may be roundish, conical, or flattened. The site of the 
 external os, in the centre or to one side, its size, pinhole (a frequent 
 explanation of sterility), patent to the finger (suggestive of recent mis- 
 carriage, disease of the endometrium or endocervix), fissured or lace- 
 rated (evidence of childbearing), are further j^oints to be noted. The 
 distinction between an erosion, ulceration, and laceration may now be 
 readily made without the source of error referred to under the subject 
 of multivalve specula. The eroded, everted mucous membrane of a 
 lacerated cervix may be rolled in by tenacula, and the superficial 
 denudation of epithelium accompanying a catarrhal erosion is clearly, 
 
I'llYsiCAL SIONS. 315 
 
 at ;i <il:iii('(', tlillrrt'iil IVoiii (lie cxcaxatinii the rcsnlt oC ulceration. TIm- 
 color and the natiircol" tlic discliarui' issuing- I'roiii tlic external os jiivc 
 us an inklinL!; of the ])i-ol»al)I<' main source, jxtints already referred to 
 under tlie head ol" tlic diiiital examination. The reaction of thi.s di.s- 
 eharu'i' niav he tested, and if acid will oiler a valid explanation ol" the 
 eausi" of sterility. 
 
 Introduction of the Probe. — Where, owing to narrow external os or 
 cervical canal, or to sharj) flexion, it was found inipossihie to pass the 
 sound in the dorsal pi>sition, the prohe — a miniature flexible soun<l — 
 mav now l)e used. It goes without saying that previous to tiie attempt 
 to pass this in.-trunient the position of the uterus has, where possible, 
 
 Fig. 127. 
 
 Emmet's Flexible Probe. 
 
 been a.scertained binianually, and that the absence of the contraindi- 
 eating factors already referred to has been determined. The probe is 
 to be bent according to the direction it will probably have to take in 
 order to reach the fundus, and the depth of the canal may be measured 
 and its sensitiveness ascertained, even as noted when speaking of the 
 sound. 
 
 It is not in place to describe here the further nses of Sims's position 
 and speculum, such as for the efficient tamponade of the vagina and the 
 making of applications to the uterine cavity. The value of this posi- 
 tion and speculum for the use of special instrumental diagnostic means 
 will be noted farther on. 
 
 The Genu-Pectoral Position. — For purposes of diagnosis this 
 position is of little value ; and fortunately so, because it is a difficult 
 position for the patient to retain for any length of time, and one par- 
 ticularly oifensive to her modesty. Its chief uses, and \qv\ important 
 ones, are for the thorough tamponade of the vaginal vault, and for the 
 reposition of a dis])laeed uterus M'hich defies our efforts in tlie left- 
 lateral position. To assume it, the patient kneels at the e<lge of tlie 
 table and leans forward, so that her chest-wall, not her eli)ows, shall 
 rest on the mattress. Obviously, gravity may now act to the greatest 
 possible advantage, so that, when on lifting the perineum with Sims's 
 speculum the vagina is opened and the pneumatic pressure of the air 
 is superadded, the pelvic organs, unless jxithological alterations inter- 
 fere, sink upward and dowuAvard beyond the efficient reach of the 
 examining finger. It is in this position that the length of th(^ infra- 
 
316 GYNECOLOGICAL DL4.GN0SIS. 
 
 vaginal portion of the cervix may be accurately determined ; but with 
 this exception and the therapeutic measures noted above, the genu- 
 j)ectoral position fulfils no purpose which the left-lateral may not to 
 better advantage. 
 
 The Erect Position. — Examination in this position is attained by 
 the patient, with legs separated, standing in front of the examiner, 
 whilst he rests on one knee or sits, and, introducing the hand under 
 the clothing, carries the index finger along the perineum into the 
 vagina. For diagnosis this position is rarely available, for under us- 
 ual conditions the uterus lies more horizontally, and the cervix, hence, 
 is far back out of easy reach of the finger. In this position, however, 
 we may determine the elFect of intra-abdominal pressure on the pelvic 
 organs, and detect downward sagging of the uterus which was not 
 appreciable in the dorsal position, thereby finding an explanation 
 for backache or bearing-down sensations otherwise of obscure origin. 
 
 Special Instrumental or Exploratory Means op Diagnosis. 
 
 Having now considered the general and routine measures of use in 
 the diagnosis of disease of the female generative organs, I proceed to a 
 description of those special means, recourse to any one of which may be 
 necessary in order to complete our diagnosis. I shall consider these 
 measures under the following subdivisions : 
 
 A. Instrumental examination of the urethra, bladder, and rectum ; 
 
 B. Dilatation of the cervix for diagnostic purposes ; 
 
 C. Curetting of the cervix and uterus for diagnosis ; 
 
 D. Artificial prolajDse of the uterus for diagnosis ; 
 
 E. Aspiration through the vagina or abdomen for diagnosis. 
 
 A. Instrumental Examination of the Urethra, Bladder, 
 AND Rectum. — The instruments at our disposal for examination of 
 the urethra and bladder are few in number, and, owing to the limited 
 expansibility of the meatus and urethra, the ocular evidence of disease 
 obtainable is at best unsatisfactory. The use of the finger for purposes 
 of exploration I must consider unjustifiable unless there is strong pros- 
 pect of sufficiently relieving our patient to atone for the not impossible 
 laceration. Ordinarily, by means of the sound — the uterine will gen- 
 erally suffice — we may detect the same pathological conditions as the 
 finger could, and yet we thereby subject our patient to no risk of injury. . 
 In addition to the sound, the speculum and the endoscope are the instru- 
 ments available for diagnosis, and they are best introduced with the 
 patient in the dorsal position. The sound wall determine the sensitive- 
 ness of the urethra and bladder, the smoothness or roughness of the 
 mucous membrane, the presence of stone or of large foreign growths. 
 Sensitiveness, varying in degree, will suggest caruncles, fissure, or 
 
SPECIAL LWSTJtUMJ.xr.ii. .1/ /•;. I .v.v or j)i.\(;.\()sis. 
 
 in 
 
 cystitis. lv\;iiiiiii;itioii ol" the iii-iiic will (litliTciitiatc tlic lattci-, and 
 recourso t<> iiis|)('cti(»ii, the rnnncr. The iirctliral s|m(iiIiiiii is coii- 
 stnictctl citlici- nl" <;lass, liihiilar in lltnii, or of" metal, uilii divcrtrciit 
 hraiiclics. Tliroiijili siicli sju'ciila tin- cdloi- and iiitc^irity of the iirctliral 
 mucous uiembrane may he noted, earuneles (leteete< I, au<l, except ionalK, 
 a fissure at the vesical neck. Refleeted li^ht will jrreatly assist in such 
 an examination. In the ahsence of a speciilnm the oidinarv (lressin<;- 
 forccps or a steel-hranched uterine dilatoi- will allow us t(j in.«-pect 
 tlie urethral mucous mcmi)i"ane. As typical of the endoscope, I 
 instance that of l>r. Skene of Brooklyn, althoujih, excej)t in his 
 hands, it has not l)cc(»iiic widely us(m1. It consists of two jx^rtions — a 
 
 Fi(i. 128. 
 
 Skene's Endoscope. 
 
 glass tube and a blackened secti(jn of a cylinder containing a mirror 
 placed at an acute angle at its distal extremity. The glass tube fits 
 into the cylindrical section ; the mirror, attached to a handle, lies in 
 the glass tube ; and ^vhen the cylinder has been introduced into the 
 urethra light reflected from a head-mirror upon the mirror in the tube 
 illuminates the urethral mucous membrane, and the trained eye may 
 detect alterations within the urethra. Beyond this, whether speculum 
 or endoscope ])e used, inspection extends to an unsatisfactory degree, 
 owing to the difficulty of illuminating the cavity of an organ the walls 
 of Avhich constantly tend to ai)i>roximatc except when dist(>nde(l by 
 fluid or disease. Fortunately, diseased conditions of the bladder may 
 ordinarily be diagnosticated by means of the sound and associated 
 ■examination of the urine, and therefore, from a diagnostic standpoint, 
 it rarely becomes necessary to resort to either the speculum or the endo- 
 scope. It is in place here to refer to the possibility of sounding the 
 ureters, and of occluding one or the other by the finger, in order to 
 detect disease of the urinary tract above the l)ladder, and limited pos- 
 sibly to one ureter or kidney. Such mann?uvres are yet in their infiincy, 
 and, whatever the possibilities for the future, up to the present have 
 yielded no results of a practical nature. 
 
318 
 
 GYNECOLOGICAL DIAGNOSIS. 
 
 I will simply refer here to a surgical method of diagnosis which has. 
 yielded excellent results in the hands of the originator, Dr. Emmet, 
 and which is possibly destined to take the lead of all other methods of 
 diao-nosticatino; disease of the bladder and its neck. This method con- 
 sists in buttonholing the urethra, and the procedure will be described 
 in connection with the special diseases of the urinary tract. 
 
 The necessity of careful rectal exploration, in every case where the 
 symptoms are otherwise unsatisfactorily explained, has already been 
 insisted upon. Specular examination of the rectum as a routine meas- 
 ure is not necessary, but it should never be neglected in any case where 
 there exists a suspicion of disease of the upper rectum. This examina- 
 tion is painful, ordinarily requires previous distension of the sphincter; 
 and it is necessary, therefore, to resort to anaesthesia. The advisability 
 of a thorough cleansing of the lower bowel by purgative or enema, 
 before resorting to rectal examination, is sufficiently apparent. The 
 general indications for a specular rectal examination are complaint of 
 pain before, during, or after defecation and the presence of blood, pus, 
 or membrane in the dejections, provided the signs find no explanation 
 in the digital eversion of the rectal mucous membrane alreadv referred 
 to, and in the absence of such an obvious, although not always suf- 
 ficient, cause as hemorrhoids. The specula of utility are either tubular 
 or valvular. For general purposes the blade of a small Sims's will 
 suffice for diagnosis, although a much more convenient instrument, 
 when the examiner is without an assistant, is that devised by Kelsey 
 
 of New York. The special 
 ^^*^' advantage of this instru- 
 
 ment is the fact that a 
 large surface of the rectal 
 mucous membrane may be 
 inspected through it with- 
 out the anus being stretch- 
 ed to any great degree. 
 Whatever the form of in- 
 strument used, either re- 
 flected light, or that from 
 one or another of the port- 
 able electric light appara- 
 tuses recently devised, is 
 almost a necessity for exact 
 diagnosis. The patient 
 may occupy either the dorsal or the left-lateral position, although a better 
 view may be obtained from the latter. The points to be noted through 
 the speculum, some of which must escape the examining finger alone, 
 are — the color and integrity of the rectal mucous membrane, erosion,, 
 
 Kelsey's Rectal Speculum. 
 
SPECIAL rNSTBUMhWTAL .1/ /■;. 1 .V.V OF DIAt.WOSlS. :',]'.} 
 
 ulccriitiiin ami lissurc, |i()l\|)i, carciiKniia, ami li>liil<ni.- ()|>ciiiiiL''s iVinii 
 ischio-i'cclal nv pelvic ahsccsscs. 
 
 y>. Dll-ATATIOX .OF 'rilK ( 'KI;\I.\ Koi; DiACNosilc I'llM'oSKS. — In 
 order lo e\|>lt>re the iiiteridi- df the uterus with the liiiiicr, the cervical 
 canal iiui>t lirsl, apart tVoiii the puerperal state, he widely dilated. To 
 
 Fiti. i:JO. 
 
 Goodell-EUinLaT's Dilators. 
 
 accomplish this we have at our disposal three classes of instruments : 
 1, steel-branched dilators and conical graduated steel or hard-rubber 
 sounds ; 2, rubber dilatable tubes ; 3, tents. 
 
 The steel-branched dilators are the best agents for rajnd dilatation, 
 and will rarely fail in accomplishing their purpose, except where there 
 exists excessive rigidity of the cervix (from hyperplasia or cicatriza- 
 tion). As types of these dilators I would mention that of EUinger 
 and that of Palmer. EUinger's instrument is scarcely powerful enough, 
 unless the cervix is readily dilatable, and it is also objectionable on 
 account of the number of lodging-])laces for dirt it offers. Goodcll of 
 Philadelphia, however, speaks of it highly as modified by himself, and 
 justly so, since his modification has essentially improved the instru- 
 ment. He has had it constructed of two sizes — a small with slender 
 blades, and a larger one Avith powerful blades which do not feather, 
 and with a screw attachment to separate the blades. This .screw-attach- 
 ment is a real advantage, for thereby we are enabled to dilate slowly, 
 allowing the muscular fibres of the cervix to yield to the applied force. 
 
320 
 
 GYNECOLOGICAL DIAGNOSIS. 
 
 instead of rupturing them. Another excellent dilator is Palmer's. It 
 also is furnished with a screw attachment, and it will dilate to quite 
 one inch, sufficient to allow the average index finger to pass. The 
 larger Goodell-Ellin^er dilates to an outside width of one and a half 
 inches. 
 
 The conical graduated sounds will accomplish dilatation as effectively 
 as the steel-branched dilators, although they take more time, and their 
 use has the decided disadvantage of requiring counter-pressure on the 
 
 Fig. 131. 
 
 Light. 
 
 Heavy 
 
 Palmer's Dilators. 
 
 fundus through the abdominal walls ; and in many cases this manoeuvre 
 fails, for the simple reason that the body of the uterus is too markedly 
 displaced backward to be reached by the external hand. However valu- 
 able these sounds, therefore, for purposes of treatment where dilatation 
 is desired for digital exploration, I can conceive them only of use where, 
 
 Fig. 132. 
 
 Hanks's Cervical Dilator. 
 
 through the smaller sizes, sufficient preliminary dilatation is requisite to 
 allow of the introduction of a branched dilator. These sounds have 
 been variously constructed and modified. The most serviceable prob- 
 ably, certainly as good as any others, is the set devised by Hanks of 
 
 New York. 
 
SPECIAL iysTi:rMi:\T.\L Mi.wys of in.iayosis. 
 
 321 
 
 'I1ir nil.lxi- iiiIm-, (.1- \v:itcr-(lil:it(.r>, arc al.-n rtl'cclivc <lilatiu^ ajziciitji, 
 Imt thcv aiv sittucr in action tliaii tlic l»raiicli<Ml (lilatr.i>, and have tlie 
 disailvantauc common lo all rnbln'r, of lVc(incnlly proving (Icfcctivf at 
 the v«TV time when sci-vicc 
 IS r('(|nirc(l. I Iksc instni- 
 mcnts arc rc|>i-csciito(l by 
 Molcsworlirs and Eiiimct's. 
 
 Tents are tlie slowest of 
 all dilating agents, and for 
 |)iirelv exploratory pnrposes 
 tlicv will doubtless, in gen- 
 oral, yield to the branehed 
 dilators, except w here there 
 is a verv rigid cervix to 
 be overcome. They p(wse.ss, 
 however, certain therapeutic 
 uses for which they must 
 be retained. They are con- 
 structed either of compress- 
 e<l sponge, of laminaria, of 
 tnpelo, — these, at least, are 
 the sole agents of value for 
 sufficient dilatation to allow 
 of exploration. 
 
 Sponge tents have long 
 been in fav<jr on account 
 of their great and equable 
 expansile power. The great 
 objection to these tents is 
 the fact that their use is li- 
 able to be followed by sep- 
 sis, notwithstanding careful 
 antisepsis both in prejiara- 
 tioii and in introduction. For this reason, therefore, they are gradu- 
 ally being superseded by the tnpelo for exploratory ]iurposes. 
 
 The laminaria has but little dilating power comparatively, and this 
 power is lea.st effectual at the very p(Mnt where dilatation is most 
 desired — the internal os. This form of tent, therefore, may lie ruled 
 out as an agent of value for dilatation to be followed by digital ex})l or- 
 ation. 
 
 The tnpelo (root of the Xyssa aqnatk-ci) is the agent j^rrr exfcUence in 
 
 tent form for dilating pnrposes. Its expansibility is nearly equal to 
 
 that of the sponge, it dilates equably throughout its length, it does not 
 
 abrade the cervical tissues to the same extent as the sponge, it is excep- 
 
 VoL. I.— 21 
 
 Emmet's Water-Dilator. 
 
322 
 
 GYNECOLOGICAL DIAGNOSIS. 
 
 tional for its proper use to be followed by sepsis. The sphere of dila- 
 tability of this tent is well represented in the accompanying cut (Fig. 
 
 Fig. 134. 
 
 Molesworth's Hydrostatic Dilator. 
 
 135). The tupelo was introduced to the notice of the profession by Dr. 
 Sussdorff of ISTew York City, and may now be obtained in varying sizes 
 and lengths, although a large one may be readily whittled to the desired 
 size. 
 
 The indications in general, aside from therapeutic purposes, for the 
 
 Fig. 135. 
 
 r'r^ 
 
 Dilatability of Tupelo Tents (after Mund^). 
 
 use of dilating agents are hemorrhage from the uterus not explainable 
 by recourse to other diagnostic means, and the necessity of ascertaining 
 
SPECIAL lNSTRUMEi\TAL .UAVl.V.S' OF DIAGNOSIS. 323 
 
 tlic IdCMtiiHi and atlai'liiiiciil ol" an intra-iitci-iiic u'i''»\vtli. I )ilatati<tii 
 siiMicicnl tor i-xploratory [nuposcs should ever he considered a minor 
 ()j)eration, i'e((uii'ini:- anu'stliesia, and is to he perl'ornied at the patient's 
 house; and altei- the use of any (hlatini;- a^cnt the patient .-hould 
 remain in hed Irom twenty-lour to thii'ty-six hours, and, as a prophy-j 
 laetie measure, opium shouM he achninistered and heat applieil to tlie 
 al)domen. In ea.-e the s|)onii'e tent is useil, it is a eai-(linal ride not to 
 follow the lirst tent immediately hy another, and disregard of this rido 
 is respousihie foi- many a ease of fatal septietemia. 'J'he .same eiiiiti(Mi 
 is not applieahle to the tujH'lo tent. 
 
 Ordinarily, where dilatation is desired for diaj!;n()stie pnr|)oses, the; 
 cervical canal will he sullieiently patulous to allow of the intrcxiuction 
 of the dilatino- a>i-eut without previous incision (»f the external os. 
 Should this he necessary, however, there is little added risk, except 
 where a sponoe tent is the dilating- agent, provided due antise^jtic 
 precautions are taken before and after the operation. 
 
 From what precedes, it is apparent that I favor as dilating agents, 
 for purposes of exploration, the steel-branched dilators where rapid 
 dilatation is desired, and the tupelo tent in case of excessive cer\'ical 
 rigidity and where the slower action of the tent may be awaited. Both 
 the dilator and the tent are best introduced through Sims's specnlum, 
 the position of the uterus having been first determined bimanually. 
 The vtigiua should always first be irrigated with clean boiled Avater, to 
 which carbolic acid or corrosive snblimate may be added. The size of 
 tent snitable to the case is readily introduced by grasping it bv an ordi- 
 nary dressing- forceps, the cervix being steadied by a tenaculum fixed 
 in its anterior lip. In case the Goodell-Ellinger dilator be used, the 
 smaller size may be passed first, and dilatation by it will pave the 
 way for the introduction of the larger size. Occasionally, independ- 
 ently of the puerperal state, the cervical canal may be dilated by means 
 of the finger, and wherever possible the finger of course ranks above 
 all other agents. 
 
 Whatever the means employed, dilatation once accomplished, the 
 patient should lie in the dorsal position and the index finger, pre- 
 viously disinfected with care, is to be jiassed to the fundus, this in turn 
 being depressed through the abdominal walls. We are now in a posi- 
 tion to examine carefully the entire endometrium. Thus the finger 
 notes the smoothness or roughness of the mucous membrane, and is 
 able to detect the presence of any foreign body, such as a tumor and 
 its attachment or a remnant of secundine or placenta, and we may 
 resort at once to the necessary treatment. Our exploration ended, if 
 no surgical procedure or ajiplication be resorted to, the uterine cavity 
 should be thoroughly douched with hot water, plain or with the addi- 
 tion of some antiseptic, and in case of hemorrhage it may be swabbed 
 
324 GYNECOLOGICAL DIAGNOSIS. 
 
 with tincture of iodine, and both the cervical cavity and the vao-ina 
 tamponed. 
 
 C. The Curette as a Diagnostic Agent. — In this instrument 
 we possess a very vahiable means of acquiring information in reo-ard 
 to the contents of the uterine cavity and the condition of its lining 
 membrane. There are two varieties, the sharp and the dull. For 
 diagnostic purposes the latter alone is of use. The former has thera- 
 peutic uses which the latter can, at times, only partially fulfil. Eeca- 
 mier, the inventor of the curette, had it constructed Avith cutting edge, 
 and therein he was imitated by Sims in his instrument. It was 
 reserved for Thomas to devise the dull instrument and to point out 
 the information to be derived from its use. The dull curette is made 
 in three sizes, has a flexible shaft alloAving of bending to any desired 
 curve, and the scraping edge is smoothly flattened so as to prevent its 
 injuring the endometrium. 
 
 Fig. 136. 
 Thomas's Dull Curette. 
 
 The indication, in general, for the dull curette may be said to be 
 uterine hemorrhage or profuse leucorrhoea which yields neither to gen- 
 eral nor to local measm^es, and suggests, therefore, the j)resence of an 
 intra-uterine gro"\vth or degeneration of the endometrium requiring 
 recourse to active therapeutic measures. This instrument may be used 
 with safety in office practice, provided the object be diagnosis. Where, 
 as the result of its diagnostic use, disease is revealed requiring resort to 
 the more active use of the dull or to the sharp curette, then it is advis- 
 able to defer further manipulation till the patient can be seen at her 
 house. The contraindications to the use of this instrument are exactly 
 the same as those which apply to any instrumental interference with the 
 uterine cavity — suspicion of jDregnancy and evidence of recent exudation 
 around the uterus. No anaesthetic is required, since the use of the curette 
 for diagnosis is practically painless. Preliminary dilatation of the cervix 
 is rarely requisite, because in the very cases where the curette is indicated 
 for diagnosis the hemorrhage or leucorrhoea has softened the cervical tis- 
 sues and accomplished dilatation to a sufficient degree. Where this is 
 insufficient, however, gentle dilatation with a steel-branched dilator will 
 allow of the passage of the smallest sized curette, which practically suf- 
 fices for diagnosis alone. 
 
 The curette can only effectually be introduced through Sims's specu- 
 lum, and it goes without saying that the position of the uterus should 
 first have been determined bimanually, and the direction of its canal 
 
Sl'KClAL L\STnrMi:.\TAL Mh'.WS OF lH.idXOSfS. .TJ') 
 
 l>V IllCMIIS of tlic M)llinl u|- |>I<i1m'. Tllc illt Indllctinii of tlic clirctt*' is 
 
 tiicilitatcd l»N' liookiii;^' ;i (cnMculiini in tlh- nntcrior li|i «tt' tlif cervix, 
 \vlu'rt'l)v tin- iitcnis is stciidicd, mikI l)y iiiiikiiij;- ;^ciiti(' down ward trac- 
 tiiiM the axis, in case ol" lliximi, is in a iiKa.-nrc >trai;:litcn('d ont. TIm- 
 instrument is to l)e ;x'ven the curve wliieli the |>revi<ius intr(tdueli<>ii ot' 
 the sound or j)rol)e has proved necessary, and passed to the I'undns. It 
 i-; held liiihtlN' hetween the thiiinl> and inch'X. and the entire endo- 
 nu'triuni is earetullv l)ut <i<'ntly scra|ied. The sensation coninnnii- 
 eatetl to the tiuLl'ers of rousxhness or smoothness of the eiid(tnietrinm, 
 ot" ine(|ualities in its surlaee, and the g;ratin«;' sound often andihle as 
 tlie iustnnnent passes, in particuhir, over tlie cervical mucous mem- 
 hrane, suti;t;est in turn ])ossil)ilities even before the dehris from the 
 curetting is examined. The uross appearance of the deljris, if any, 
 will frequently make our diaj>nosis ; its, for instance, where munerous 
 ^granulations or vei>,etations are removed, or where, not uncommonly, a 
 portion of the sei'undines from a neglected or not suspected miscarriage 
 is hrouo-ht to light. AVhere there is any doubt, however, resort to the 
 mii-roscope may reveal the structure typical of malignant disease. In 
 case of polypus, also, the curette, presenting a broader surface than the 
 sound, will give us more definite information in regard to its attach- 
 ment. The aj)[)lication of the curette with care Avill rarely be followed 
 by much hemorrhage; still, the better practice is to make an afler- 
 ap[)lieation of iodine to the endometrium, and in cases where the 
 uterus is enlarged and heavy to tampon both the cervix and the 
 vagina. Prophylaxis can never harm, and may do good. 
 
 D. AiiTTFirTAL Prolapse of the Uterus for Diagnosis. — This 
 diaijrnostic means need rarelv be resorted to. The manoeuvre is oidv in- 
 dicatetl where the bimanual examination fails to give us exact informa- 
 tion in regard to the nature or insertion of a tumor closely related to 
 the uterus, and also where, owing to great adipose development in the 
 abdominal walls, the external hand cannot depress the body of the 
 uterus sufficiently to enable the finger, exploring its cavity, to reach 
 the fundus. I question if it be not wiser to attempt to finish our 
 exploration under anse-sthesia, for it strikes one as crude to thoroughly 
 dislocate any organ of the body from out of its natural })osition. The 
 method is rather more in favor in Europe than with us, and appar- 
 ently only exceptionally is damage inflicted. The contraindication to 
 artifieitd prolapse is the presence of exudation, recent or chronic, around 
 the uterus — a factor which of itself would prevent the success of the 
 manoeuvre, even if the attempt, under the circumstances, were not to 
 be condemned on account of the likelihood of relighting the inflam- 
 matoiy process. 
 
 Artificial prolapse is accomplished in- hooking a strong double 
 tenaculum or vulsellum into the cervix, and slowly making traction 
 
326 
 
 GYNECOLOGICAL DIAGNOSIS. 
 
 until the cervix appears at the ostium vaginae. This accomplished, 
 the finger in the rectum, or, exceptionally, in the bladder, may to 
 better advantage j)alpate the posterior and anterior walls of the uterus, 
 or the finger within the uterine cavity may more readily explore the 
 fundus of the uterus. On releasing our hold on the cervix the uterus 
 will return to its position. 
 
 E. Aspiration through the Yagina or Abdomen for Diag- 
 nosis. — We possess herein a very valuable means of obtaining informa- 
 tion in regard to the contents, and, in a measure, in regard to the nature, 
 of abdominal and pelvic tmuors. Aspiration for diagnosis, when care- 
 fully performed, may be said to be practically free from danger, although 
 in general it is wiser to explore at the patient's house. It is necessary 
 to remove only a small amount of fluid ; such, for instance, as may be 
 drawn into the ordinary hypodermic syringe. The large Dieulafoy 
 
 aspirator is therefore, for 
 diagnostic purposes, not 
 requisite. A long needle, 
 attached to the pocket hypo- 
 dermic syringe, will reach 
 deep-seated tumors, whilst, 
 of course, the usual needle 
 will suffice to explore super- 
 ficial tumors. A very con- 
 venient portable aspirator 
 is shown in the annexed cut. 
 Dieuiafoy's Aspirator. Whatever the locality to 
 
 be aspirated, careful preliminary disinfection should be the rule. In 
 aspirating through the vaginal vault the needle may be passed along 
 
 Fig. 138. 
 
 Emmet's Aspirator Syringe. 
 
 the finger and thrust into that portion of the tumor where fluctuation 
 is most distinct, avoiding, of course, a part where pulsation marks the 
 
sriX'iAL L\sTnrMi:.\TAL mi:a.\s or dtacxosis. ?>21 
 
 prcsriice ol' an artcrv ; or else tlic va<iinal vault may he lir.-t cxijoscd 
 tlirou^li Siins's spcciiliiin. The ^rfoss apiH'arance ol' tlic fluid with- 
 drawn will l"i((|iitiiily iiiaUf mir diai^iiosis ; as, for iii!staii<-t', where 
 blood is ohtaiiied from a |)ost-iiteriiie tiiiiioi-(h!i'mato('ele) or j)ii.s (pelvic 
 ahscoss). The diU'erontial dia^iutsis of al)(lominal tuiiiors, hy exainina- 
 tioii of the fluid removed, will usually recjuire resort to the mieroseo|)e, 
 and even then it is still an o|)en (|Uestion as to whether the eharaeter- 
 i.sties are nni"ailini;ly diat>;nostic of" the special form of jrrowth. 
 
 It is not in place here to describe the chemical tests to which the 
 fluid may be subjected or to broach the subject of the " ovarian cell." 
 Such (piestions will be discussed elsewhere. The jjoint at issue will 
 ordinarily lie between ovarian cysts, intrali*!:amentous cysts, and fibro- 
 cystic j^rowths of the uterus. Cystic growths of the liver and kidney 
 may usually be recognized under the microscope by the presence, in the 
 first instance, of degenerated liver-cells and cholesterin ; in the second 
 instance, of urea or uric acid. PIvdatid cysts are recognized through 
 the characteristic booklets of the parasite. Finally, as pointed out by 
 Munde, the aspirator needle will often reveal to us the reason why an 
 old pelvic cellulitis will not yield to routine treatment, by withdrawing 
 a small (|uantity of ])us situated so deeply as not to yield fluctuation 
 to the examiniuo; finuer. 
 
GENERAL CONSIDERATION OF GYNECOLOG- 
 ICAL SURGERY. 
 
 By E. C. DUDLEY, A. B., M. D., 
 
 Chicago. 
 
 Antisepsis. 
 
 I:n'ASMUCH as the minor gynecological operations which are per- 
 formed for the relief of maladies that are not often fatal, nor even 
 always disabling, have occasionally been followed by sepsis, metro- 
 peritoneal inflammations, cellulitis, and sometimes even by death, 
 therefore the practitioner in the hope of spontaneous recovery has 
 often preferred palliative and temporizing measures, however unprom- 
 ising, to the exclusion of surgical measures, however rational. But the 
 application of the antiseptic principle now renders the minor gyneco- 
 logical operations and office manipulations comparatively free from 
 danger. 
 
 Prophylaxis. — The essential object of antiseptic surgery is cleanli- 
 ness — not sesthetic but surgical cleanliness. To secure and to maintain 
 surgical cleanliness many antiseptic materials have been employed, of 
 which the most generally approved is carbolic acid, but the solutions 
 should be made with great care, lest a part of the acid settle to the 
 bottom of the vessel, and, being pure acid instead of solution, produce 
 a serious burn when applied. The addition of 10 per cent, of glycerin 
 to the pure acid renders it more easily soluble. A saturated solution 
 of boric acid or a 3 per cent, solution of salicylic acid is free from 
 caustic properties and is an excellent antiseptic. Permanganate of 
 potash in solution decomposes so readily than it is unreliable for anti- 
 septic purposes. Solutions of corrosive sublimate may be conveniently 
 made by mixing a 10 per cent, alcoholic solution with sufficient water to 
 make the required strength, which should be from 1 : 1000 to 1 : 10,000. 
 The stronger solutions are adapted to the cleansing of the hands and 
 other cutaneous surfaces, and the weaker for washing the sponges dur- 
 ing operations. Corrosive sublimate tarnishes metallic instruments and 
 destroys their plating, but has the advantage of being odorless and in 
 ordinary solutions of not roughening the skin. It is a most reliable 
 germicide. 
 
 328 
 
.\.\risi:rsis. ,",2f) 
 
 Tlic soap, ^I\ I'ci'iii, \;i>t'Iiiic, or nil wliidi i-; ii-iiiilly kept l»\' the 
 (»pci';it(ii"'s (;il)lc In)' liiWriralimi n|" the linger- and in-trimiciils iiia\' Itc 
 coiitainiiiati'd with ii'oimrilKral uv dllitr viiMis, ami iiiav iliiis Itccoinc a 
 nuMliiiiii ot" iulc'ction. Ni-itlicr tlic tiii>i,i'rs nor tlic spi'ciihini, tiicrcforc, 
 slioiild ))(' hi-oiiuiit in <'<>ntact with the luln-icMtinji- sui)stanc(' iiiilcss they 
 hi' f'ri'c I'roni vat;inal ami ntlur sccrrtions. 'I'lic caincrs- hair pencil 
 brush and the spi>iit!;c' faunut he properly cleansed, and they are there- 
 lore unfit lor rcp(>ated use. Absorbent cotton wound u|ion an a|)plieator 
 oi- stick or lii-aspcd by dressiuji- forceps may I)e used for [)urp(»ses of 
 niedicatioii or for wipini>; out the va<2;iua, and should then be destroyed. 
 No special cleausiuii- of the vulva aiul vagina is re(|uii'ed i'ny ordinary 
 oflice manipulation of these ori;aus except the vaginal douche, which 
 the patient usually takes before a})plying: for treatment. If the intra- 
 uterine cavity is to be instrumentally or di<!:itally explored or treated, it 
 is best to wipe out the vagina with dry absorbent cotton, and then with 
 absorbent cotton saturated with a 5 per cent, solution of carbolic acid 
 in olvcerin or with a solution of corrosive sublimate, 1 : 2000. By this 
 means the endometrium is protected against the entrance of septic mat- 
 ter, which otherwise might be carried in from the vulva or vagina on 
 the instruments. But previous to any surgical operation on the genital 
 tract or in the abdomen the field of operation and Mhatever may possil)ly 
 be brought in contact therewith should be rendered surgically clean, and 
 so maintained throughout the operation and during convalescence. This 
 treatment relates alike to the most trifling and to the most severe opera- 
 tions, because the former are by no means free from danger of fatal 
 sepsis, and because a performance of seemingly minor importance in 
 the beginning may end accidentally or purposely in opening the 
 abdomen or in some other capital operation. Therefore, the vulva 
 should be thoroughly and repeatedly "U'ashed with tar soap and water, 
 and the hot vaginal douche should be applied twice a day during the 
 week previous to operation, each douche to contain a small quantity 
 of castile or tar soap, except the last to be given just before operation, 
 which should be a solution of corrosive sublimate, 1 : 4000. 
 
 The ordinary ]iractice of simply cleansing the instruments after each 
 examination or treatment in water or soap and water is inadequate and 
 unsafe. ^T]sthetic cleanliness does not absolutely destroy virus and pre- 
 vent its instrumental conveyance from one patient to another. Perfect 
 surgical cleanliness, however, may be secured in the following manner: 
 First, let the instruments be carefully washed in the ordinary way, with 
 hot water and soap ; then let each instrument be thoi'oughly ^viped over 
 Avith absorbent cotton saturated with carbolic acid and glycerin, equal 
 parts. To do this easily two strong forceps are needed — tme in the 
 left hand to hold the instrument, and the other in the right to hold the 
 cotton. The instruments thus moistened with acid are now thrown into 
 
330 GENERAL CONSIDERATION OF GYNECOLOGICAL SURGERY. 
 
 a pan containing water which has been boiled and filtered. This water 
 and the adherent acid make an excellent solution in which to keep 
 the instruments during an operation. If the instruments have been 
 unusually exposed or if they are to be used in the abdomen, it is well 
 to render the disinfection absolute by passing them slowly through 
 the flame of a Bunsen burner or of a spirit-lamp before applying the 
 carbolic acid. 
 
 The cleansing and disinfection of the operator's hands and nails even 
 after ordinary digital examination are imperative, not only to guard 
 against the carrying of poison to the patient, but to prevent self-inocu- 
 lation of specific or non-specific virus through some abrasion upon the 
 hand. 
 
 The annoying presence of fecal matter during a surgical operation 
 and its possible septic results may be avoided by giving the preparatory 
 cathartic so early that its action will be complete on the day before. In 
 order to render the sponges free from foreign and septic matter, first 
 thoroughly beat and wash out all the sand (this may require hours of 
 patient labor) ; then soak them over night in dilute hydrochloric acid, 
 to dissolve out calcareous matter ; and after washing out the acid, the 
 sponges, which will then be much softer and more elastic, may be put 
 away in self-sealing fruit-jars containing a 5 per cent, solution of car- 
 bolic acid or a 1 : 2000 solution of corrosive sublimate, the solution to 
 be changed every week. The boiling of sponges is an excellent anti- 
 septic measure, but it causes great shrinkage and hardening, and very 
 much lessens their absorbent qualities. 
 
 The ligature and suture silk may be made thoroughly aseptic by 
 boiling it for five minutes in pure carbolic acid, and then for twenty 
 minutes in a 5 per cent, solution. The best braided silk thus treated 
 may be kept for months without injury in small wide-mouthed bottles 
 well corked, or in special ligature bottles, containing a 5 per cent, 
 solution of carbolic acid. The braided silk is preferable to the twisted, 
 because the latter is usually injured, sometimes destroyed, by boiling in 
 pure carbolic acid. 
 
 The field of operation, rendered aseptic in the manner already 
 described, may be kept so during the operation if attention be given 
 to the cleanliness of hands, sponges, instruments, and other appliances. 
 The occasional irrigation of the wound during the operation, and 
 especially Avhile it is being closed with sutures, is of great value to 
 ensure perfect contact of the wound surfaces without the intervention 
 of blood or other foreign bodies. 
 
 The object of after-treatment is to maintain cleanliness. At the end 
 of the operation all particles of tissue and clots of blood should be 
 removed and the parts thoroughly cleansed by the hot-water vaginal 
 douche, which should be repeated every twelve hours until several 
 
ANTfSEPSrS. 331 
 
 (lavs aflcr the rciii(i\':il of the -iiliircs. Aft<'r njici-atlon-- on the exter- 
 nal p'liitalia the tlitiicln' should al-o he t;-iv('n alter each cvaciiation of 
 the howfls or hhiddcr. 
 
 Schrocdcr and (tthci' (Jci-nian f»|)ci-ators ('ni])loy con.-tant ini;ration 
 (luring- operation. This re(|nires the j)atient to he in the dorsal posi- 
 tion, and when the o|)eration is intrava;:;inal neeossitatos the n.se of 
 Simon's s|)eeninni. (See Fi*;-. 139.) Dr. Engelmann of St. Louis, in 
 a eonununieation to the American Medical Association, 1885, .stron<rly 
 advocates this method, which he has improved hy the em])loyment 
 of hot antiseptic solutions foi- the irrigatinir fluid. He uses a hot 
 solution of corrosive suhlimate, 1 : 2000, or a 2 per cent, .solution 
 of carbolic acid made with boiled and filtered water. A special 
 assistant, standing somewhat to the rear and to the left of the ope- 
 rator, manages the douche. A fountain syringe or bucket contains 
 the fluid, which is c<jnducted to the wound through a rubber tube five 
 feet long, supplied m ith nozzle, and a stopcock to be controlled by the 
 thumb of the hand which holds the nozzle. The opening in the end 
 of the nozzle is one-eighth of an inch in diameter. The bucket, placed 
 about three feet above the field of operation, gives enough force to the 
 stream to keep all blood constantly washed away, which is to be done 
 with an even, steady current directed just above the field, and regulated, 
 without splashing, according to the amount of hemorrhage. The tem- 
 ])erature of the irrigating fluid should be about 120° F. The hand 
 which holds the speculum as the water flows over it would recognize 
 excessive heat Avhile the patient is under ether. The external geni- 
 talia may be guarded Avith lard as an additional safeguard against 
 scorching. The urethra is especially sensitive to hot water, and should 
 therefore be avoided in directing the stream. The hot douche by rea- 
 son of its hemostatic and cleansing properties lessens the flow of blood 
 and keeps the parts clean, and, inasmuch as it removes all necessity 
 for sponging, it shortens the time of the operation. The antiseptic 
 value of the hot douche is proved by the fact that its advocates suc- 
 cessfully employ silk sutures, which with the ordinary methods of 
 operation often cause suppuration and failure of union. 
 
 After the sutures have been tied the wound is to be dried Avith 
 absorbent cotton dusted with iodoform and covered with iodoformed 
 cotton or gauze, to be removed in four days ; then the parts should be 
 again dried, dusted, and repacked. Two or three dressings may be 
 required before the removal of the sutures, after that but one. Opera- 
 tions on the external genitals, however, necessitate the frequent renewal 
 of at least a part of the dressing to provide for the action of the bowels 
 and for micturition ; but in such cases the hot-water vaginal douche 
 repeated two or three times a day would be preferable to the dry anti- 
 septic dressing. 
 
332 GENERAL CONSIDERATION OF GYNECOLOGICAL SURGERY. 
 
 The leading features of the German method, as modified by Engel- 
 mann, are Simon's speculum, the dorsal decubitus, the hot antiseptic 
 douche, the absence of sponges, and the simplicity of after-treatment. 
 The advantages claimed are greater cleanliness, simplicity, and speed. 
 
 Treatment of Septic Gynecological Wounds. — Certain nat- 
 ural conditions are favorable to the healing of wounds on the cervix 
 and vagina. The opposite vaginal wall in contact with the wound 
 excludes the air and acts as a compress, and the vagina itself is an 
 excellent substitute for the drainage-tube. But the conditions after 
 intra-uterine operations are less favorable, because the uterine canal is 
 at an acute angle to the long axis of the vagina, and the cervical por- 
 tion of this canal, naturally narrow, may have become narrower from 
 disease. Therefore, secretions accumulating in the uterine cavity may 
 not be easily expelled by force of gravity or by uterine contractions^ 
 but, on the contrary, may be confined and become infectious with, 
 inflammatory and sej^tic results. The condition simulates that of a 
 deep abscess at the end of a long and tortuous sinus. On general prin- 
 ciples the therapeutic indication is clearly to cleanse the cavity and to 
 keep it as nearly aseptic as possible by irrigation. Although this treat- 
 ment is often followed by excellent results, it, unfortunately, is not free 
 from grave objections, and often proves even more dangerous than the 
 disease. Sometimes the stimulating presence of the irrigating fluid or 
 of the cannula through which it is injected causes the uterine walls to 
 contract upon the instrument so forcibly that the return flow is impeded^ 
 and the fluid may pass into the Fallopian tubes, especially if they have 
 been dilated by disease, with grave inflammatory or septic results; 
 moreover, intra-uterine injections without invasion of the Fallopian, 
 tubes have many times been followed by painful uterine contrac- 
 tions, pelvic inflammation, and death. These injections are there- 
 fore only to be employed when the canal throughout is open or can be 
 made sufiiciently open to permit free outflow, and even then with great 
 caution. To guard against obstruction of the outflow by contraction 
 of the uterus upon the instrument it is necessary to use some one of 
 the double uterine catheters — Molesworth's, Nott's, or Bozemann's, for 
 example — which have been specially devised for the purpose, and 
 which are similar in construction to Skene's double catheter for irri- 
 gation of the bladder. Preparatory dilatation may be required before 
 intra-uterine irrigation can be safely undertaken. 
 
 The treatment of septic wounds in the uterine cavity involves some 
 of the vexed questions in gynecology. It is often difficult to determine 
 whether the disease is confined to the uterus or whether the wounded 
 surface has not rather served as an avenue through wliich bacteria 
 may have passed to the pelvic cellular tissue or to the peritoneum, and 
 there produced results which not only could not be reached by intra-- 
 
wjii:y TO <>i'i:i:.\ri:. 3.33 
 
 iilci'iiic trcMtiiiciit, lull wliirli -iirli trc;iliiiciit iiiiL''lil <'\<'ii I'Mij^^-cnitc. 
 'I'lic |):ittiloiis cdiKlitioM (if tlic utcriiu' canal iti inicrpcral can's makes 
 the oi'iiaii easily aixl safely accessilile, and the ti'eatnieiit tliereiorc more 
 effect i\-e. The most eifieicnt aiiti>e|tsis in |Mirely surgical gynecology 
 is o'cneralK' prnpliyiactie. 
 
 Opium, Quinine, and Ice. 
 
 In addition to antise])sis certain other precautions against cellnlitis, 
 |)t'ritonitis, and metritis slionld he enforced, especially in cases jiredis- 
 posed hy a pi'cvions attack. Prepai'atorv to operation the ])atient mav 
 he fortiHed hy fnll doses of (piinine, and f(»r two or three days after the 
 operation this sh< mid he continued and sn])plemented with o|)iimi to con- 
 trol pain, and with the icc-hladdcr over the hyj)ogastrium. Tiic thin gum 
 rul)l)cr ice-l)ladder is most convenient, but the ordinary sheet irum rubber 
 two feet square, such as dentists use for the rubber dam, may be substituted 
 by gathering up its sides and corners above tiie ice and tying them with 
 strong twine. To prevent the annoying condensation of water on the 
 outside of the rubber bag another piece of rubber or oiled silk should 
 be Avrap})ed about it. Great reliance may be placed upon opium, 
 quinine, and ice, not only for prophylaxis against inflammation, but 
 also as a remedy in the acute stage. Ice is much more certain in its 
 results than the time-honored and conventional hot flaxseed poultice. 
 
 When to Operate. 
 
 It may be urged as a general, though by no means a universal, 
 proposition that the female genitalia should be exempt from all inter- 
 ference during menstruation. For example, it Avould be unwise to 
 o])erate for laceration of the cervix or perineum or for vesico-vao-inal 
 fistula during menstruation. But when menstruation is so long con- 
 tinued or so profuse as to endanger health or life, immediate inter- 
 ference may be demanded. Indeed, it has not been proved that opera- 
 tions are decidedly more dangerous in the menstrual than in the inter- 
 menstrual period. The presence of the menstnial fluid, hoAvever, is 
 unfavorable, though not usually disastrous to union by first intention. 
 An operation if performed immediately upon the cessation of the flow 
 might cause it to reappear, and if too near to the anticipated period it 
 might excite premature menstruation. The best time, therefore, is 
 between the third day after the cessation of one period and the tenth 
 <lay before the anticijiated appearance of the next. 
 
 The question of primary or sec(jndary operations after the })uerperal 
 lacerations has been much discussed. Emmet's operation for laceration 
 of the cervix should l)e delayed until after the puerperium, though a 
 
334 GENERAL CONSIDERATION OF GYNECOLOGICAL SURGERY. 
 
 few cases of the immediate operation successfully performed have been 
 reported. For laceration of the perineum, however extensive, the im- 
 mediate operation is desirable for two reasons : The torn parts can be 
 accurately adjusted to their former relations, which is almost impos- 
 sible in the secondary operation ; and the operation if well performed 
 generally results in union, and thereby protects the patient against septic 
 infection through the torn surfaces. The writer therefore would advise 
 the primary operation of perineorrhaphy even as late as two days after 
 delivery. He has repeatedly operated on the second and third days, and 
 once on the ninth, and with scarcely an exception the delayed operation 
 has resulted in satisfactory union. If, however, the primary operation 
 has been delayed for a number of days, it is best before introducing the 
 sutures to denude with the curved scissors a narrow strip all around the 
 torn surfaces, in order that fresh surfaces may be brought together. A 
 delay of a few hours after delivery ensures greater freedom from capil- 
 lary oozing from the torn surfaces, which sometimes occurs after closure 
 of the wound and which may prevent union ; and moreover, if anaes- 
 thesia be required, it is better to wait for permanent retraction of the 
 uterus, otherwise the anaesthetic may cause relaxation and consequent 
 uterine hemorrhage. 
 
 It is the duty of the accoucheur at the close of the puerperium to 
 examine the uterus, vagina, and perineum, and to repair any puerperal 
 laceration or injury before its evil results have developed. Operations 
 may be necessary, therefore, during lactation. The child should be 
 kept from the breast only until the mother has fully recovered from 
 the anaesthetic. 
 
 Operations during pregnancy should not be undertaken save in rare 
 cases in which the life or health of mother or child is seriously in- 
 volved. Matthew D. Mann^ of Buffalo has collected 90 cases in which 
 gynecological operations have been performed on pregnant women ; of 
 these, abortion followed from the operation in 20 cases ; and of these 
 20, only 4 died. His conclusions, which, as he says, may or may not 
 be verified by further observations, are as follows : 
 
 "1. Pregnancy is not so decidedly a bar to operation on the pelvic 
 organs as is generally supposed. The results, however, vary with the 
 operation and the organ operated upon. 
 
 " 2. Union of denuded surfaces is the rule, and the cicatricial tissue 
 formed during the earlier months of pregnancy is strong enough to 
 resist the shock of labor at term. 
 
 " 3. Operations on the vulva involve very little danger either to 
 mother or child. 
 
 " 4. Operations on the vagina are likely to cause severe hemorrhages, 
 but are not otherwise dangerous. 
 
 ' Gynecological Transactions, 1883, vol. vii. 
 
wifi:\ TO ()j'Kn.\TK. 335 
 
 "5. X'cncrciil \\;irts ;iii(l vcp'talinii-; oi" Iari:<' >!/•<■ mikI noti-.-Nphilitic 
 arc Ix'st ti'catcd l)v i'ciii(i\al, w lictlici' tlicy Dcciir in (he vaj^ina or arc 
 (•(»ii(iiu'(l t(» (lie vulva. 
 
 " (). Applications of nitrate ot" silvci- and astrinj^ents of" lliis class 
 niav lu' made with safety to the vagina and cervix. Din'nsihlc jutisons, 
 like earholic acid or iodine, should not he used pure or in stronjr sohi- 
 tions for such applications. 
 
 "7. Operations iijxin the hhidder and urethra are not dangerous or 
 likelv to l)e followed l>y abortion. 
 
 ** 8. Operations on the rectum involving the sphincter ani, even if 
 slight in their character, arc dangerous. 
 
 "9. The operation for vcsico- vaginal fistula sh(»uld not he under- 
 takiMi during pregnancy, as the dangers of hemorrhage and al)orti<»n 
 are considcrahle. 
 
 '*10. Plastic operations on the cervix and perineum may, if neces- 
 sary, I)e undertaken in the earlier months of pregnancy with a fair 
 ])rospect of success, and with a good chance that the results may not 
 be impaired by labor. 
 
 "11. Small polypi of the cervix may best be treated by torsion or 
 strong astringents. If cut, there is some danger of abortion following. 
 
 " 12. Large polypi may, if causing hemorrhage, be removed at once, 
 with a fair chance of good results. If not doing any harm, then re- 
 moval is best left until near the close of pregnancy. 
 
 "13. Cancer of the cervix discovered during pregnancy should, if 
 possible, be removed at once." 
 
 The possible necessity implied in the tenth proposition, which would 
 demand a plastic operation on the cervix or perineum of a pregnant 
 woman, must be extremely rare. 
 
 Two or more gynecological operations may safely be undertaken at 
 one time if the patient be in good condition, if the operations do not 
 conflict one with the other, and if the operator be rapid and dexterous. 
 Trachelorrhajiliy and perineorrhaphy, and sometimes trachelorrhaphv, 
 anterior elytrorrhaphv, and perineorrhaphy, are permissible at one sit- 
 ting. Trachelorrhaphy and the operation for hemorrhoids are often 
 combined. The author has frequently operated for laceration of the 
 perineum and for hemorrhoids at the same time, and always with satis- 
 factory results. When operations on the cervix and anterior vaginal 
 wall are combined with perineorrhaphy, the cervical and vaginal 
 sutures must not be removed until the fourth week, when the peri- 
 neal union will be firm enough to withstand moderate distension of 
 the vulva by the speculum. Trachelorrhaphy should not be combined 
 with curetting, dilatation, incision, or with any other intra-uterine one- 
 ration, because operations on the uterus, especially on the interior of the 
 uterus, are peculiarly liable to be followed by mctro-peritoncal inflam- 
 
336 GENERAL CONSIDERATION OF GYNECOLOGICAL SURGERY. 
 
 mation and sepsis, and because trachelorrhaphy would interfere with 
 free drainage of the secretions from an intra-uterine wound, and would 
 thereby increase the danger. Moreover, an accumulation of coagulated 
 blood might be forced by uterine contraction through the closed cervix 
 and thereby destroy the union. 
 
 During epidemics of infectious or contagious diseases operations on 
 the female genitalia are prohibited by the increased liability to sepsis 
 and pelvic inflammations, and if possible should be avoided ; nor 
 should they be undertaken while the patient is suffering from any 
 acute disease. The immediate operation of perineorrhaphy, for exam- 
 ple, usually fails if closely followed by inflammation of the mammary 
 gland. 
 
 The occasional necessity for surgical interference during the acute 
 stage of pelvic inflammation justly excites the greatest fear, yet the 
 dread of such interference is sometimes exaggerated. The septic and 
 inflammatory results of a gangrenous intra-uterine fibroid or of the 
 secundines of an abortion might be vastly more dangerous than the 
 operation for their removal. 
 
 Preparatory Treatment. 
 
 Syphilis, gout, rheumatism, Bright's disease, purpura, or faulty 
 nutrition from any cause may prevent union, and may therefore require 
 ■constitutional tonic and hygienic treatment preparatory to operation. 
 
 In the presence of a periuterine exudate and thickening, with fixa- 
 tion of the uterus, which always persist for a variable time after pelvic 
 cellulitis and peritonitis, it is safer to defer all surgical operations until 
 time and treatment have reduced the products of inflammation and the 
 periuterine tenderness to a minimum, and until the mobility of the 
 uterus has returned. While the slightest trace of a former cellulitis or 
 peritonitis exists, an operation, however trivial, may result in a fatal 
 recurrence of the inflammation. In such conditions, therefore, it is a 
 safe rule to delay operation. Dr. H. C. Coe,^ on the other hand, has 
 shown that old chronic thickenings are not always the material products 
 of inflammation, but may be the simple result of cicatricial contractions 
 following local peritonitis, and that they are not a positive contraindi- 
 cation to operation. 
 
 The objects of local preparatory treatment are not only to remove 
 the products of inflammation, but to render the field of operation 
 as free from disease as possible. A lacerated cervix in a state of 
 granular erosion and cystic degeneration, or a vesico-vaginal fistula 
 encrusted with phosphatic deposits, would not give the greatest promise 
 
 ^ " Transactions of the Woman's Hospital Alumni Association," American Journal 
 ef Obstetrics, February, 1886. 
 
orL'iiA rios- T. I /;/. /•;. 337 
 
 of imioii l)y first intention. 'IMicrcforf, tlic liot-watcr vaginal (IomcIk-, 
 iotlinc applications, tlic daiK' lainpnn of ali<oi'lniit cotton >alnra(c<l with 
 pure ijlvccrin or olvccrin coiiiltimd wiih aliini, laniiin, or iodolorni, ami 
 tlio pnnctiirini;- <if" rctcnt ion-cysts, may Wc i('<|nircil lor many weeks 
 hcforc the cervix is in a condition i;iv(»ral)Ie foi' union. The fistnla 
 mav rc(|iiire lon<i' and patient vaiiinal dilatation hcforc its edges can 
 even he approximated. But sometimes the induration, lixation, and 
 ])eriiiterino tenderness do not yield to the usual treatment of hot water, 
 jrlyeerin tampons, iodine, and rest ; numerous eases of granular erosion 
 of the cervix are not influenced by topical applications, liowevcr long 
 continued. I n some cases neither the general nor the local condition can 
 l)c materially improved except by a successful plastic operation ; then 
 the gentle and i-aj)id manijndations of an exj)ert o|)erator may result in 
 less injury to the nervous system of a debilitated patient, in greater 
 freedom from inflammatory reaction, and in more satisfactory union, 
 than an inexperienced operator could secure under more favorable 
 conditions. 
 
 Emmet recommends a hot vaginal douche of 120° F. to be given 
 for thirty minutes just before an operation. This is for the double 
 purpose of cleansing the vagina and of so constricting the capillaries 
 that hemorrhage from denuded surfaces may be partially prevented. 
 Just before giving the auresthetic the operator should make a careful 
 examination by conjoined manipulation to satisfy himself that the 
 patient is free from cellulitis or peritonitis which may have become 
 active since the examination. 
 
 The dress of the patient should he such as would ordinarily be used 
 in bed, and should be supplemented by open drawers, stockings, and a 
 flannel blanket. The night-dress may be drawn up about the waist to 
 protect it from blood, and a large folded towel or sheet may be placed 
 under the patient's hips to keep the blanket which covers the table from 
 being soiled. 
 
 Operation-Table, 
 
 The operation-table should be approximately 48 inches long, 24 
 inches wide, and 27 inches high. The ordinary- kitchen table or 
 narrow dining-table, with the leaves down, covered with a blanket or 
 quilt, fulfils all the requirements. Greater length is objectionable, 
 l)ecause when the thighs are flexed and the hips drawn toward the 
 operator, the head should be near to the ana?sthetizcr, who stands at 
 the end of the table opposite the operator. A chair or stand may 
 be placed temporarily for the feet while the patient is being etherized. 
 The bed is too low, too yielding, and too large for operative purjioses. 
 An operation-table specially devised for hospital practice should have 
 attached at the end a coj)pcr or porcelain basin, into which the Avater 
 Vol. I.— 22 
 
338 GEXEEAL COXSIDEEATION OF GYNECOLOGICAL SURGERY. 
 
 may flow should it he necessary to wash out the bladder or vagina 
 during operation or to operate under the hot antiseptic douche. 
 
 Anesthesia. 
 
 The principles which apply to aneesthesia for surgical purposes in 
 general apply also without change for the operations of gynecology. 
 Sulphuric ether is safer than chloroform, and should therefore be pre- 
 ferred, however short the operation may be. In exceptional cases 
 complete anaesthesia by ether proves \ery difficult or impossible. 
 The Vienna mixture, composed of one part alcohol, two parts chloro- 
 form, and three parts ether, may then be substituted until anaesthesia is 
 complete, when the ether should be resumed. Emmet has pointed out 
 that when the kidneys are not sotmd, chloroform is much safer than 
 ether, and should therefore always be used under such conditions. 
 
 The hydrochlorate of cocaine used hypodermically at or as near as 
 possible to the field of operation, in doses of one half grain or more, 
 produces perfect local anaesthesia of short duration, which may be pro- 
 longed by repeating the dose. Many of the minor gynecological opera- 
 tions, such as curetting, dilatation of the uterine canal, division of the 
 cervix, and unilateral trachelorrhaphy, may in this way be performed 
 with little or no pain. The maximum dose of cocaine has not been 
 fixed, but it has been given in doses of several grains. As a local 
 anaesthetic it is more reliable when used h^-podermically than when 
 brushed over a mucous or cutaneous surface. Intolerance by idiosyn- 
 crasy has occasionally been obser\^ed, but the possible dangers of the 
 drug are unknown. A 4 per cent, solution sprayed over the Schnei- 
 derian membrane has caused alarming symptoms. 
 
 Materials for Sutures. 
 
 Silk, catgut, and silver ^ are the materials most commonly employed 
 for sutures in gynecological operations ; each has its peculiar advantages 
 and disadvantages ; neither is universally to be preferred. 
 
 Silh. — The braided absorbs less moisture and is superior to the t^- isted 
 silk both for sutures and ligatures. The best braided silk is that of 
 Archibald Turner & Co. Xo. 7 is suitable for sutures in plastic 
 operations on the perineum, vagina, and cervix, but it is too heavy for 
 the ligation of small vessels. Silk sutures and ligatures, if rendered 
 thoroughly aseptic according to the directions given in the section on 
 Gynecological Antisepsis, will remain aseptic for four or five days, and 
 
 ^ Silver-plated copper-wire, -which is qinte as good as pure silver for plastic opera- 
 tions, can, be obtained of Codman & Shurtleff. Boston, at about one-eighth the cost of 
 silver. 
 
M.\ii:/!/\f.s FOR si'miES. .'5;59 
 
 if" |M<»tr(tcil 1)\- :i>(|>ti<- (lr('»iiiu: wliitli in jxyiHH-olfjfrical wr)rk is not 
 
 alwiiNs |)(t.-«sil)lf — tlicy may I'cmain rican I'or a \v<'<'In, hnt afb-r that, in 
 (•((nst'iincnco ni' tlicir al)soi-l>in^' t|iiMliti(s, tlicy arc lialdc to Ix-i-onjc 
 soptif tuul to cause suppuration. Sutures and li<ratures »jf silk in the 
 aluloininal cavitv, however, do not heconic se|)tic or pnKhice suj>pu- 
 ration it" thi' oj)cration has been aseptii-, and they may therefore he 
 left permanently, heinir more rcliahle than eatjrnt. 
 
 Caff/ut, if aseptic when ustnl, is less liable to produce suppuration 
 than silk ; it usually disappears by absorption in four or five days — 
 makes an excellent lij^ature for small vessels in plastic operations, in 
 which it mav be cut short and the wound closed over it. Catgut sutures 
 are useful also for operations on the vaginal wall or cervix when per- 
 formed in connection with perineorrhaphy, because they disapix-ar in a 
 week l)v absorption, and thereby obviate the necessity of distending the 
 recently-unite<l perineum for tiieir removal. But the al)sorbability of 
 catgut may cause it to disappear too soon, and the wound then, deprivetl 
 of needed support, may reopen. To guard against this, Lister advises 
 that it be soaked tor thirty-six hours in a mixture of chromic acid 1 
 part, carbolic acid 200 parts, and water 4000 parts, and then dried. 
 Just before using it should be moistened with carbolic-acid Mater. M. 
 D. Mann of Buti'alo, after considerable experience, says that catgut pre- 
 pared in this way gives little or no trouble from too rapid absorption. 
 
 The silver suture, with which Marion Sims demonstrated the curabil- 
 ity of vesieo-vaginal fistula, is most frequently employed for gyneco- 
 logical plastic operations in the United States. It is specially adapted 
 for plastic surgery, because it cannot by the absoq:)tion of moisture 
 become septic and produce inflammation and suppuration, with conse- 
 quent s.welling and strangulation of the included tissues. It is indeed 
 not likely to cut through or to cause strangulation, even though left in 
 place for a month. Xo. 26 silver wire is generally recommended for 
 perineorrhaphy, Xo. 27 for trachelorrhaphy, and Xo. 28 for vesico- 
 vaginal fistida ; but the heavy Xo. 26 Avire is less liable to cut, gives 
 better support to the wcjund, and is generally suitable for all plastic 
 gynecological operations. 
 
 Comparatively speaking, aseptic silk or catgut sutures may l)e use<l 
 for any jilastic operation, and in the hands of a skilful operator they 
 usually prove satisfactory ; but the former become septic in a few days, 
 and the latter may be absorbed too soon ; either material, therefore, is 
 less reliable than silver. Silver sutures are generally to be preferrcnl 
 in plastic operations, and especially in operations which require them to 
 be left for more than six or seven days, or after which there may be 
 traction on the sutures or a tendency to gajiing of the wound. Such 
 operations include trachelorrhaphy, vaginal fistula, and the extravagi- 
 nal portion of colpo-perineorrhaphy. But in the intravaginal portion 
 
340 GE^'EEAL CONSIDERATION OF GYNECOLOGICAL SURGERY. 
 
 of colpo-perineorrhaphy silk or catgut is preferable to silver, and catgut 
 is specially applicable to the vaginal portion of Emmet's ne^v operation 
 of perineorrhaphy. Eor trachelorrhaphy silver sutures are preferable 
 even when the j)erineum is closed at the same time, because in uterine 
 tissue they do not cause suppuration even if left for three or four weeks, 
 when the new perineum will be firm enough to permit the careful pas- 
 sage of the speculum for their removal. 
 
 Assistants. 
 
 Four assistants are usually required for a gynecological operation — 
 one to give ether, one to wash sponges, one at the operator's left to hold 
 the speculum, and one at the operator's right to sponge and render 
 other assistance. If the operation be on the perineum or vulva, and 
 the patient be in the dorsal decubitus, the thighs must be flexed and 
 held in the lithotomy position by the two assistants on the right and 
 left. The assistants in charge of the ether and sponging should be 
 physicians. The washing of sponges and holding of the speculum may 
 be done by nurses. The occasional occurrence of acute synovitis in the 
 knee-joint following operations on the perineum was unexplained until 
 Dr. E. H. Webster of Evanston, Illinois, suggested that while holding 
 the thigh in the lithotomy position an assistant by carelessly throwing 
 his own weight upon the patient's leg or by leaning heavily upon it 
 might flex the joint to a dangerous degree. Various contrivances have 
 been devised for holding the legs when in this position, but they are 
 unnecessary. 
 
 Miscellaneous Instruments. 
 
 When the field of gynecological diagnosis and therapeutics was 
 chiefly confined within the circumference of the cervix uteri, the 
 various cylindrical bivalve and polyvalve specula were seemingly ade- 
 quate to the needs of the practitioner ; but the development of surgical 
 gynecology, especially that relating to the puerperal lacerations and 
 other injuries, dates from the invention of the perineal retractor of 
 Marion Sims. 
 
 In the United States, Drs. Sims and Emmet with Sims's speculum, 
 the latero-prone or Sims's position, and the silver suture gave to j)las- 
 tic surgical gynecology its greatest impulse. Then Gustav Simon and 
 his followers in Germany with a modification of Sims's speculum, the 
 dorsal position, and the silk suture popularized the operative method 
 now almost universally adopted throughout Germany, 
 
 Shns^s Speculum. — In order to appreciate the action of Sims's specu- 
 lum it becomes necessary to study the effect of the latero-prone or 
 
M/s( •i:l la sf.o [ w lysrn i 'mi:sts. :\\\ 
 
 Sirns's position upon tin- |Klvi<- oii^nn^. IJkf tlic kiicr-i-lu'st position, 
 of which it is a niodilication, it causes the vaji;iiia to fill with ail', ami 
 the anterior and postei-ior vaj::inal walls — or, to speak more coiiij)re- 
 hcMLsively, the piil)ic an<l sacral setrineiits of the pelvic {{(tor — to .-ep- 
 arate. The speciiluni then exau-^erates tin- etfect of this position hv 
 hookini;- (tr drawinj^ back the j»ei-inenni, which <'Xj)oses ahno-t tin? 
 entire surface of the widoly-o|)eiie(l vairina, and causes the cervix to 
 he drawn somewhat forward toward the vulva. Two recpiirements are 
 essential to th(> successful use of Situs's sj>eculum — correct |)osition of 
 the patient ami |»i-oper lioidiiiii" of the in>trument. The patient is to lie 
 j)laced on the left side, the hi[»s l)ein«r over the left-hand corner of that 
 end of the table which is t(»ward the operator; the knees are to Im? 
 drawn up toward tlie abdomen, anil the right thigh flexed slightly more 
 than the lefV. The left arm then rests behind the patient on the table. 
 This permits the right shoulder to be thnjwn forward and depressed 
 toward the right side of the table, so that the position becomes latero- 
 jn'one — /. e. lateral and slightly prone at the hips, and almost whollv 
 })rone at the shoulders. The left side of the head rests upon the table, 
 the face looking to the right. The right arm hangs over the right side 
 of the table, and the long axis of the trunk extends obliquely across the 
 table from left to right. 
 
 Modifications of Sims's speculum to make it self-retaining and to dis- 
 pense with the assistant have been devised by Emmet, Studley, Hunter, 
 Erich, and others, but, for surgical purposes at least, with but imper- 
 fect success. Proper holding of the instrument and correct position 
 of the patient will secure more light and space than can be gained bv 
 any other means. A detailed description of the manner of using 
 Sims's speculum will be found in the article on " Gynecological Diag- 
 nosis." For surgical operations or explorations in the rec-tum Sims's 
 speculum and Sims's position are incomparably superior to all others. 
 
 Simon's speculum (Fig. 139) is a perineal retractor similar to Sims's, 
 but with shorter and flatter blades, which are made of different shapes 
 and sizes, and are adjustable on a handle, so that they may be changed 
 to meet the requirements of the case. It is the favorite instrument of 
 the Germans, and differs from Sims's chiefly in the manner of its use, 
 which requires the patient to be in the dorsal decubitus and the thighs 
 to be flexed as in the lithotomy position. An objection to the instru- 
 ment is the greater liability of the vesico-vaginal wall to fall down 
 tcjward the speculum and of the lateral walls to fall together, and 
 thereby to obscure the field of operation. To obviate this, Simon uses 
 a smaller though similar retractor which acts in the opposite direction, 
 like the anterior blade of the bivalve speculum. Lateral depressors 
 also are often required on either side, all of which are more or less in 
 the operator's way. Moreover, tlie introduction of the sound, curette, 
 
342 GENERAL CONSIDERATION OF GYNECOLOGICAL SURGERY. 
 
 or of other instruments to the interior of the uterus is more difficuk in 
 the dorsal than in Sims's position, and if the organ be ant everted or 
 anteflexed the instrument is especially liable to be arrested at some 
 point on the posterior wall of the. cervix or at the internal os, and 
 refuse to pass farther. Sims's speculum is more easily held, requires 
 fewer assistants, fewer attachments and depressors, than Simon's. It 
 gives the maximum amount of light and space, and therefore probably 
 never will l^e superseded bv any other instrument. 
 
 Fig. 139. 
 
 Simou's Specula : blades of various sizes and shapes. 
 
 Vulsellum forceps, similar in constniction to those shown in Fig. 
 154, but with heavier blades and longer teeth, are designed for various 
 operations on and about the cer%dx. They are used for holding the 
 cervix during amputation and for making traction in the removal of a 
 uterine fibroid. Emmet's double teuaculimi forceps (Fig. 140) answers 
 the same purpose. It is well adapted for the removal of any intra- 
 uterine mass requiring traction ; its teeth lap one over the other when 
 closed, which adds materially to the strength of their grasp ; its blades 
 and handles are bent in opposite directions with a .sigmoid cur^'e, so 
 
Mis< j:ij.a si:<) i :s i.wsri: i miixts. 
 
 343 
 
 that it may l>c out i>|' the (ipi-rator's \\:iy when IhM hv :iii a~-i>t- 
 aiit. 
 
 Kimiict's (l<iiil)l(' tciuiciiliiiii is used lor >tca<l\iMti- tlic iitci'iis (liiriii<^ 
 amputatitiii oi'tlu' cervix or (Im-in^i- intia-iitcriiic ujiciatioii.-. It is licld 
 
 I'lu. 14U. 
 
 Emmet's Double Tenaculum Forceps. 
 
 in the Icl't liaiid, and may he introduced into the cervical canal with its 
 teeth adjusted, as in Fig'. 141 ; then by depressing the thumi>-piece at 
 A the hUules are widely separated, the canal put upon the stretch, and 
 its opposite walls penetrated and held by the teeth. Its hold upon the 
 
 Fig. Ul. 
 
 Emmet's Double Tenaculum. 
 
 tissues may be loosened by drawing back the ratchet at B with the 
 index finger, 
 
 Sponge-Holders. — For intravaginal operations three or four or more 
 
 Fig. 142. 
 
 -iiiis's Siiongc'-hulder. 
 
 .sponge-holders (Fig. 142), twelve inches long, are usually required, in 
 which sponges trimmed to the desired size and shape may be fa-stened. 
 Scissors. — The minor gynecological operations may be performed 
 either with the sci.ssors or with the knife, and the choice depends much 
 
344 GENERAL CONSIDERATION OF GYNECOLOGICAL SURGERY. 
 
 upon the education and habits of the operator. The scissors certainly 
 cause less hemorrhage, and when one becomes accustomed to their use 
 he can work more accurately and more rapidly. Any strong, well- 
 made, slightly curved scissors wall suffice, but those of Emmet are 
 specially adapted to intravaginal, perineal, and vulvar operations. 
 
 Fig. 143. 
 
 Emmet's Scissors for dividing the Cervix. 
 
 Fig. 143 show^s a pair of blunt-pointed scissors, with straight blades 
 bent laterally upon the shank at an angle of forty-five degrees. They 
 are useful for dividing the cervix, for making an artificial vesico-vaginal 
 or urethro-vaginal fistula, and for dividing cicatricial bands in the vagina. 
 The slightly- and strongly-curved scissors are almost indispensable 
 
 Fig. 144. 
 
 Emmet's Slightly-curved Scissors. 
 
 for denuding in plastic operations ; the slightly-curved (Fig. 144) are 
 used for perineal and for ordinary intravaginal denudation ; the strongly- 
 
 FiG. 145. 
 
 Emmet's Strongly-curved Scissors. 
 
 curved (Fig. 145) are convenient for denuding a strip high up across 
 the vagina or cervix uteri in fistula and cervix operations. The scis- 
 
MISCELLANEO US INSTR UMENTS. 
 
 345 
 
 sors rcprc'sontcd in V\\j:^. 1 II ami 1 15 arc curved toward tlic rinlit, and 
 arc intended to he used in tlic iMi^lit liand. lOinniet mentions al>o two 
 others with curves to the left, hut it is scarcely j>ossihlc to iinajiine an 
 operation in which the lattei' would he neccssarv. 
 
 Kniniet's wire scissors, with hlades |)ointed and sli<xlitlv curve<l on 
 the Hat, are iisctul lor cuttinii' wire, and s<»nietinies lor cutting out cica- 
 tricial tissue, 'i^he sli<ihtly-curved scissors ol" Fig. 144 answer all the 
 purposes for which straight scissors are usually cniplove(l. 
 
 Eniniot's hall-and-socket knife (Fig. 14(1) has a hhule which niav ho 
 firmly attached at any angle to the shank hy closing the handles, which 
 
 Fig. 146. 
 
 Emmet's Ball-and-Socket Knife. 
 
 are provided with a lock at the end. The knife may be used in places 
 whicli are inaccessible to the scissors. 
 
 The Tenaculum. — Xuinerous tissue-forceps have been devised for 
 grasping the tissues to be denuded or excised, but a properlv-constructefl 
 tenaculum in the educated hand is the most convenient and effective 
 instrument for this purpose. Witli the tenaculum the operator can 
 
 Fig. 147. 
 
 Uterine Tenaculum. 
 
 pick up and hold a smaller amount of ti.-^sue, and can therefore denude 
 more su]K-rficially, than is possible with the tis.sue-forceps. The instru- 
 ment (Fig. 147) has a perfectly straight hook a little more than a quar- 
 ter of an inch long and at right angles to the shaft. It .should be .so 
 strong and .stiff that considerable force may be applied in the line of 
 the in.strument without breaking or bending the hook, or in a lateral 
 direction without liending the shaft. The uterine tenaculum is u.<eful 
 not only in denudation, but also in almo.st ever^- .step of a gvnecoloirical 
 examination or operation. In some operations as many as four of them 
 may be required. 
 
346 GENERAL CONSIDERATION OF GYNECOLOGICAL SURGERY. 
 
 Plastic Operations. 
 
 The subject comprehends all oj)erations for the repair of the puerperal 
 lacerations and injuries, such as laceration of the cervix uteri and peri- 
 neum and vesico-vaginal fistula. Union by first intention, which is an 
 essential requirement of plastic surgery, Avill almost invariably result 
 from a correct operation. In certain cases of vaginal fistula in which 
 there has been great loss of tissue from sloughing, failures may arise 
 from the cicatricial character of the parts or from difficulty in holding 
 the edges together. Perineorrhaphy in very fat subjects, especially when 
 the rupture extends through the sphincter ani muscle, may fail after 
 the most skilful operation, but generally the conditions of success are 
 within the control of the operator. These conditions are simple but 
 absolute, and the operator ^vho has neglected them cannot fairly attribute 
 his failure to the debilitated state of the patient or to chance or to acci- 
 dent. Indeed, union must almost invariably follow if the surfaces to 
 be united are properly prepared and kept in contact for a week. The 
 first condition, antisepsis, has been discussed. The others Mall be pre- 
 sented in the following paragraphs. 
 
 Denudation. — The patient having been etherized, placed in posi- 
 tion, and the field of operation exposed, the surfaces to be united 
 should be denuded. Correct denudation is a prerequisite to healing 
 
 Fig. 148. 
 
 Denudation with the Tenaculum and Scissors. 
 
 by first intention. Surfaces to be united should be so denuded that 
 when brought together they will fit accurately, otherwise a part of the 
 denuded surface, being in contact with an unclenuded surface, must heal 
 by granulation and suppuration, which ma}^ excessively irritate the rest 
 of the wound, and would always produce cicatricial tissue, which is very 
 
PLASTK ' OPERA TIOSS. 
 
 .347 
 
 Yia. 149. 
 A 
 
 (•Kjcctioiiahlc. riif tltiiiidcHl siirfiicc .-lioiild Im- .«.iii(i(»tli and l"nc rnini 
 sIihmIs, which iiiiuht die and 1k'<'oiiic sniirc<'s (»l" s('|»(i<- iidi-ctiuii. Kvcrv 
 particle of in(>iid)raiic oi- -kin within the area <>t' dcniidatioii .shonld l>c 
 .scrnjnil(iii.>ly removal. If the surface l»c |Mrfceily healthy, the more 
 siiperlicial tlie (K-niidatioii the better, hut diseased and ci<'atricial ti.-sues 
 do not readily unite, and sliould therefore, wlien practicahh-, he reinove<I. 
 r Fiw;. 148 sliows the action of the tenaeuhun and scissor.- in denudiu}^. 
 The superiority of the tenaculum as a substitute for the tissne-force]>s 
 nmst l)e<'ome a|)parent to any one who will familiarize himself with its 
 use. 
 
 Xccil/rs. — A round nefnlle is j)referal)le to one with a cuttin}^ e<l<re. 
 The latter makes an incisiMl wound which is <i;enerally Uh) large for the 
 sutin-e, hlecnls more freely, is ])rone to suj)purate, and requires more 
 time for healinu". The former makes a j>unctured woiuid which read- 
 ily shrinks down upon the suture, is less liable to blee<l or to suj»pu- 
 rate, and heals more (luickly after the removal of the suture. Many 
 of the most dexterous operators are ])artial to the straight nee<lle in 
 preference to the curved, espcvially when the long needle is used as in 
 perineorrhaphy. The straight needle has two advantages : first, how- 
 ever deej>ly it may be buried in 
 the tissues, the position of its 
 jxjint can always be determined 
 from its direction and length ; 
 second, the force em})loyed in its 
 introduction being in the direc- 
 tion of the needle, it may with- 
 out danger of breaking be of 
 mucli smaller calibre than the 
 curved needle, Avhieh must be 
 introduced by a force exerted in 
 the line of a tangent to the curve. 
 
 The straight needle therefore 
 requires less force for its intro- 
 duction, is less liable to break, 
 and makes a smaller wound. Moreover, the simple rotation of the 
 needle forceps on its long axis by a turn of the Avrist enables the (jj)e- 
 rator to swxx>p the straight needle around a curve in the vertical plane, 
 or it may be carried around a curve in the horizontal plane l)y loosen- 
 ing and tightening the forceps grasp upon the needle at very short 
 intervals, so that the angle between the forceps and the needle may 
 change almost constantly during its passage. In this way the straight 
 needle may be made to carry a suture around a curv'e quite as accu- 
 rately as the curved needle, and ofteji more easily. Obviously, the 
 lock forceps, which do not |>ermit this freedom ui' motion, are imsuitetl 
 
 ===^ 
 
 A, .straight needle for external .«utures in peri- 
 neorrhaphy. B, straight and curved needles 
 for operations on the vaginal walls and the 
 cervix, and for vesico-vaginal fistula : the 
 upper needle under B is trocar-pointed for 
 very dense tissue. C. Simpn'.s strongly -curved 
 needles for vesico-vaginal fistula. 
 
348 GE2sERAL CONSIDERATION OF GYNECOLOGICAL SURGERY. 
 
 to such manipulations. Fig. 150 represents Emmet's needle-forceps 
 without lock. The eye of the needle if included in the grasp of the 
 forceps may be crushed ; to avoid this, grasp it on the proximal side 
 
 Fig. 150. 
 
 Emmet's Needle-Forceps. 
 
 The spring between the handles causes them to open when the 
 grasp is relaxed. 
 
 of the eye. The plain round point, however sharp, sometimes encoun- 
 ters great resistance in being passed through dense tissue. The trocar 
 point represented in Fig. 149, B, or the saddler's point, is less objec- 
 tionable than the cutting edge, and may be introduced almost a.s- 
 easily. 
 
 Various needles with handles attached or detached and of different 
 curves and shapes have been devised, some Avith eyes at their points, 
 some without eyes, and others of cylindrical form, through which the 
 wire is passed lengthwise from one end to the other. They complicate 
 rather than simplify an operation ; they make punctured or incised 
 wounds many times larger than the sutures which they are to contain ; 
 they are in no respect suj^erior to the simple needle and thread. 
 
 The Application of Silver Sutures. — Xo. 26 silver wire, the proper 
 size for gynecological oj)erations, is too heavy to be threaded directly 
 into the needle, but it may be easily drawn through upon a loop of 
 silk, cotton, or linen thread secured to the eye of the needle by a half 
 
 Fig. 151. 
 
 The Thread Loop, ten inches long, secured to the needle by a half knot for drawing through 
 
 silver wire. 
 
 knot, as represented in Fig. 151. The knot should be drawn tight to 
 prevent slipping, and the wire bent sharply over the loop, as shown in 
 Fig. 152. 
 
PLASTIC ni'KiiATinss. 
 
 r>.4n 
 
 Vu.. 152. 
 
 BefoH' the iiitn»(lnctir»ii oftlic sntiiics, approximate the (Ifmuhnl siir- 
 facos with teiiaciila t<» (Ictcnniiic wlu'tlicr tluv arc of such size and shajH- 
 that their union will pHnhice the (UtiirHl 
 result, and whetiier accurate coaj)tation of 
 their inar»:ins can he secured without un- 
 due traction, which mijrht cause the sutures 
 to cut out. Then hook up the niar<::iu of 
 the wound with a tcnacuhun, introduce the 
 needle, and when its point aj)})ears j)lacc 
 the tenaculum under the point of the nee- 
 dle and apply counter-pressure, as in Fig. 
 152, until the needle can ha seized and 
 drawn through with the forceps. Some 
 operators use the blunt hook (Fig. 153) 
 for counter-pressure, but a strong tenacu- 
 lum which will neither break nor bend is 
 often preferable, because it may also be 
 fixed in the tissues at the very point where 
 
 the operator desires to force the needle showing counter-pressure and the 
 ,,,.,, ^ attached wire, nine to twelve 
 
 through, and it thereby ensures greater inches long, which is about to 
 precision in directing the neetUe to its ^ '^^^"'^ through by the thread 
 
 ^ . . ® loop. 
 
 point of exit. The ase of the tenaculum 
 also avoids multiplicity of instruments. 
 
 Uterine tissue is often so dense that great force is required to drive 
 
 Fig. 153. 
 
 SI-'EP-SBiijaDUDLEY 
 
 Emmet's Counter-pressure Hook, for making pressure beyond the point of the needle as it is 
 passing through the tissues. 
 
 the needle through it. For this reason the passing of the needle is 
 often the most trying part of trachelorrhaphy. 
 
 Fig. 154. 
 
 Vulsellum Forceps, with fine short teeth to gra.^p the cervix in passing the needle for trache 
 lorrhaphy. Between the two teeth of each blade is a deep opening to accommodate the 
 |.a.ssage of the needle. The instrument is provided with scissor-handles, and is about ten 
 inches long (modified from Hanks). 
 
 In making counter-pressure the tenaculum may slip and the uterus 
 receive a violent and sudden jerk, which is not without danger, espe- 
 
350 GENERAL CONSIDERATION OF GYNECOLOGICAL SURGERY. 
 
 cially when often repeated. This may be avoided and the operation 
 facilitated by holding the flap in the vulsellum forceps (Fig. 154) while 
 the needle is being forced through between its teeth. These forceps 
 may be made by filing the teeth of Hanks's forceps shorter and finer, 
 and by filing a deeper opening between the two teeth of each blade. 
 The sutures should be about one-fourth of an inch apart — should 
 include considerable tissue, and if possible to avoid it should not pass 
 through the denuded surface or be in contact with any portion of the 
 wound, because when at a distance from the denuded surface they are 
 less liable to irritate and produce swelling or inflammation, and are 
 therefore less liable to cut. 
 
 As each wire is drawn through on the thread and temporarily secured 
 by a slipknot, as shown in Fig. 155, it is held out of the way by an 
 assistant until all have been passed. Theii, one after another, they are 
 
 Fig. 155. 
 
 Fig. 156. 
 
 Before twisting, showing a su- 
 ture in position, with the slip- 
 knot. 
 
 Before twisting, all the sutures in position. One 
 is being separated from the others by a tenac- 
 ulum preparatory to twisting. 
 
 picked up, as in Fig. 156, and the traction is made upon the free end 
 until the slipknot has been drawn down upon the tenaculum Avithin an 
 inch of the wound. (See Fig. 157.) 
 
 To prevent the ends of the suture from slipping out of the grasp of 
 the twisting forceps, the wire is twisted for a short distance below the 
 slipknot by rotating the handle of the tenaculum two or three times 
 between the thumb and finger (Fig. 158). The twisting forceps are 
 now applied over the slipknot, the loose wire cut off, and the suture 
 shouldered by the tenaculum (Fig. 159). 
 
 When the twisting forceps have been applied and the suture has been 
 shouldered (Fig. 159), the No. 26 wire will be found stiff enough to 
 hold the margins of the wound in contact. The shield (Fig. 161) is 
 
PLASTIC orr.i:. i wo a'.v. 
 
 {51 
 
 now :i|)|)lic<l, ami the siitiirt' is t\vi>tc<l duwii to the sliouldci- {V'xv:.- 1 'i*-^)) 
 hut no rarllicr, Ix'caiisc. tlic iiiar«;'ins ol' tlic wdiiiid licin^- ali'cady in 
 
 Fig. 1A7. 
 
 Y\u. l.'.s. 
 
 The slipknot being drawn down 
 on a tenaculum. 
 
 Twisting a suture with the tenaculum to pre- 
 vent the wire from slipping out of the grasp 
 of the twisting forceps. 
 
 contact, the wire if twisted beyond the .shoulder woidd ."^trano-ulate the 
 tissues, and either cut through them or cause sloughing. If the wound 
 
 Fig. 159. 
 
 Shouldering a Suture. 
 
 cannot he brought together or nearly t(_)gether by shouldering, it is 
 evident that the traction upon the sutures, even though they be twisted 
 
352 GENERAL CONSIDERATION OF GYNECOLOGICAL SURGERY. 
 
 only to the shoulder, may cavise them to cut or the flaps to slough, and 
 the operation to fail. The object of shouldering, therefore, is twofold : 
 first, to show that the flaps can be held together without undue traction ; 
 second, to limit the twisting and thereby prevent strangulation. The 
 twisted portion of the suture should now be bent down upon the sur- 
 
 FiG. 160. 
 
 Emmet's Modittcation of iSiius's Twisting Forceps. 
 
 Fig. 161. 
 
 Sims's Shield. 
 
 face in the direction where it will cause the least irritation, and cut off 
 about half an inch from the line of union. (See Fig. 163.) 
 
 Before twisting the sutures all bleeding points should be controlled 
 by torsion or by fine catgut or fine silk ligatures, cut short. Catgut 
 makes the best ligature for small vessels in the deeper portions of the 
 wound, because of its ready absorbability. 
 
 Thorough sponging or irrigation for the purpose of cleansing the 
 
 Fig. 162. 
 
 Fig. 163. 
 
 Twisting a Suture. 
 
 Bending the twisted portion of the suture 
 down upon the vaginal surface. 
 
 wound during the twisting of the sutures is imperative. Any particle 
 of coagulum or shred of tissue left in the wound will act as a foreign 
 body, will decompose, and may prevent union. Just before twisting, 
 two of the sponges on the sponge-holders may be trimmed to a small 
 
PLASTIC (>ri:i: ATioss. 
 
 353 
 
 sI/<' ami III a foiiiral slia|t(' with tln' scissors, Utr use wliilc the woiiikI 
 is Ix'iiiLi" closcil. 'Pin- ))rac(ic(' of opcraliiiji; under" tlic coiistaiit hot 
 antiseptic (loiiclie enables {\\v operator to discard the spctiij^e entirely 
 and to secure perlect cicaidiiicss. (See Antisepsis.) 
 
 The application ot" the silver sntiire to the vajiina and cervix differs 
 in some details from its ap|»Iication in perineorrhaphy, but ll^r the 
 technique of special ojx'rations the student is referred to the special 
 suhjects. 
 
 The aj'lcr-/rc(ifiii(iif has been j)artially discussed under Antisepsis and 
 otliei- means to jireN'cnt pelvic inflammation. Further information may 
 be found in those articles which relate to special oj)erations. 
 
 licmond of iSati(rc{i. — Sutures alxjut the vulva and perineum slnndd 
 be removed in about seven days. If left much longer they become 
 
 Removing a gilver Suture. 
 
 loose or cause suppuration. In the vaginal walls they may be left, if 
 necessary, several days lonjrer. In the cervix, where suppuration seldom 
 occurs, they should be removed in ten to fourteen days, unless perineor- 
 rhaphy has been done at the same time, in which case their removal 
 cannot safely be undertaken in less than three or four weeks. To 
 remove a suture seize the twisted portion of the wire Avith a dressing- 
 forceps, and with the wire scissors cut the nearest side of the loop. 
 (See Fig. 1G4.) This tends to hold the freshly-united Avound together 
 
 Voi,. I.— 23 
 
354 GENERAL CONSIDERATION OF GYNECOLOGICAL SURGERY. 
 
 during the withdrawal of the wire. If the loop be cut on the farther 
 side, its removal would tend to reopen the wound. 
 
 Dilatation of the Uterus. 
 
 It is impossible by means of any speculum yet devised to inspect the 
 interior of the uterus, but its cavity may be made surgically accessible 
 to the palpating fingers and to various instruments by dilatation. The 
 principal objects of dilatation are to overcome stenosis or stricture of 
 the uterine canal, to diagnose and remove causes of pathological uterine 
 hemorrhage, such as granulations, polypi, and the remains of abortion, 
 and to cure pathological flexions. The uterus may be dilated by incis- 
 ion, by tents, by graduated sounds, and by dilators with diverging blades 
 constructed on the principle of the glove-stretcher. 
 
 Incision of any portion of the uterine canal may be required to 
 render the endometrium accessible for instrumental or manual inter- 
 ference. But incision is specially applicable to the lower part of the 
 cervical canal and to the external os, and is performed for congenital 
 or acquired stenosis to ensure the free outflow not only of menstrual 
 fluid, but also of the uterine mucus, which if retained becomes offen- 
 sive, irritates the intra-uterine mucosa, and causes hypersecretion. 
 Oftentimes the uterine secretions are so impeded in their passage 
 through the strictured os externum that they accumulate, distend the 
 uterine cavity, and ai'e thrown off" at irregular intervals with expulsive 
 pains simulating labor-pains. This explains certain cases in which 
 there is a recurrence in the intermenstrual period of all the painful 
 phenomena of obstructive dysmenorrhoea. In such cases permanent 
 cure succeeds the operation recommended by Fritsch ' of Breslau, which 
 is as follows : The patient being in Sims's lateral position, the vaginal 
 portion is seized from the inner side of the os with a sharp tenaculum. 
 An incision is then made one centimeter long in the direction opposite- 
 to the traction of the tenaculum ; this is repeated on the opposite side 
 and in front and behind. The four flaps thus formed are seized one 
 after another with a tenaculum, and about half of each cut away. 
 After this, retraction of the remaining portion of the flaps occurs and 
 the external os remains funnel-shaped. The ordinary bilateral incisions 
 show a decided tendency to reunite, and are therefore objectionable. The 
 incisions may be made with the scissors (see Fig. 143) or with the knife 
 (see Fig. 146). 
 
 Schroeder of Berlin^ in certain cases, especially of intra-uterine 
 
 polypi, incises the cervix bilaterally, seizes the posterior lip with a 
 
 vulsellum forceps, and with his finger as a dilator works his way; 
 
 to the uterine cavity. The uterus dilated in this way and Avell drawn. 
 
 ^ Diseases of Women, Am. ed. ^ American Journal of Obstetrics. 
 
DiLATATiDX OF Till: rTi'.in's. :*,rtr) 
 
 (lowM is very accc.-.-ililc. In Sclii'ncilcr's iiiciIkkI the lalcral incisions 
 
 I'xtcntl into tlir (laiiu't'i'i'iis nci^lilturli I of (he |>araiMcti-ia. Tlic >al(.'ty 
 
 of tlic operation nnist tlicrcrorc (Icpcnd npon tlioronjili antisepsis. It 
 is inipraetieable in u ri«>id uterus to incise and dilate accordin^r to 
 Sdiroeder's method. 
 
 Tents. — Spon;^-e, sea-tan<ile, and tu[)elo are the materials eomnmidy 
 used. If intrcnhieed into tht- uterus in the dry compressed state, the 
 nnicoiis seeretion, stiinuhited by their proscnoo, causes them to swell 
 laterally to a diameter two or tlirce times greater, and correspondingly 
 to dilate the canal. 
 
 Sponge tents, which have a dilating power of about three times their 
 diameter, are made t>f disinfected compressed sponge, straight or curved 
 to tit the uterine canal, and perforated from end to end to admit a strong 
 
 Fig. 165. 
 
 A Sponge Tent with thread passing through it. Before introduction the ends of the thread 
 should be tied together.i 
 
 thread (see Fig. 165), by means of wliieh the tent may be held together 
 during removal. Otherwise a fragment may be left behind and be an 
 unsuspected source of dangerous infection. 
 
 The sponge tent not only expands, but at the same time softens the 
 walls of the uterus, and thereby prepares them for further dilatation 
 and renders the cavity more accessible for surgical manipulation ; in 
 this respect it is more effective than tupelo or laminaria, and much more 
 effective than steel dilators, M-hich usually leave the uterus so elastic that 
 immediately after their removal the introduction of the finger or of an 
 instrument for diagnostic or surgical purposes may be impossible 
 without further dilatation. But the softening effect is the result of 
 excessive irritation, congestion, and secretion due to the presence of 
 the sponge. Under such conditions it may, in an incredibly short 
 time, become offensive and dangerously septic from decomposition of 
 the absorbed secretions. It often also becomes so adherent and incor- 
 porated with the intra-uterine membrane that portions of the epithelial 
 layer may be stripped off with its removal. The surfaces thus exposed 
 would furnish a ready avenue for the absorption of the secretions. Dis- 
 
 ' Tkoma.^ on the Diseases of Women, p. lOo, Oth etl. 
 
356 GENERAL CONSIDERATION OF GYNECOLOGICAL SURGERY. 
 
 astroiis results seldom follow the application of a single sponge tent 
 unless the patient has suliered from a previous cellulitis or peritonitis, 
 but the danger increases rapidly with the introduction of the second 
 and third. Many operators now discard them altogether. 
 
 Tupelo tents, made from the tupelo tree [Ni/ssa aquatica), expand 
 less powerfully but more rapidly than sponge to about double their 
 compressed size, and, inasmuch as they do not so readily become offen- 
 sive from decomposition of the absorbed secretions, they are less dan- 
 gerous. They are straigLt and inflexible, and therefore not easily intro- 
 duced in cases of acute flexion, especially when there is immobility at 
 the angle of flexure. They are, however, very smooth, and slip into 
 place when the canal is straight or nearly straight more easily than 
 sponge. If the tent selected is found on trial to be too large, it need 
 not be thrown away, but may be easily cut down to the required size 
 with the penknife. A standard author has included among the many 
 advantages of the tupelo tent the possibility of recompressing it for 
 rej)eated use, but for obvious reasons such a practice can be neither safe 
 nor permissible. 
 
 Laininaria tents, also called sea-tangle tents, have more expanding 
 power than tupelo and less than sponge, but their action is so slow that 
 
 they are liable to be expelled 
 ^'''" ^' from the uterus before they have 
 
 become sufficiently extended to 
 be self-retaining. They have 
 but one advantage over tupelo, 
 which is their flexibility. After 
 soaking in warm water for a few 
 minutes they may be bent to 
 any desired curve, and may therefore be introduced in cases of uterine 
 flexure. Fig. 166 represents a laminaria tent perforated from end to 
 end to make it dilate more rapidly, according to the recommendation 
 of Dr. Greenhalgh of London. Expansion of laminaria is very slow, 
 requiring thirty-six hours for the maximum dilatation. 
 
 Introduction and Removal of Tents. — Unless the uterus be 
 so low that the os externum is near to the \mlva, a speculum will be 
 required for the introduction of a tent. Sims's speculum is most suit- 
 able, and indeed indispensable in difficult cases, especially when the 
 uterus is much anteflexed or anteverted. Before introducing the tent 
 the vagina and \'Tilva should be thoroughly cleansed, the cervix exposed 
 by the speculum, and the direction and curve of the uterine canal ascer- 
 tained by the probe ; then a tent of corresponding curve should be 
 seized in the forceps and introduced while the cervix is fixed with a 
 tenaculum, as shovm in Fig. 167. A small tampon of antiseptic cot- 
 ton should then be placed against the cervix to hold the tent in place. 
 
 A Sea-tangle Tent. 
 
DILATATIOS or Till-: CTl^RUS. 
 
 357 
 
 Tlif time ivtiuiroil for a s|)()nn;c or iiijicId t<» ivacli its luaxiimitii dilata- 
 tiuii is tVoiu six to twelve lioiirs. Several small tents may l)e iiitro- 
 diieetl at one time instead <it" a single largo one. 
 
 The tent may sometimes he removed by traetion <tn the attached 
 thread, but when considerable force is re([uired it is better to use tlie 
 
 Fio. 107. 
 
 Introduction of a Tent (Sims's). 
 
 speculum and forceps, and in making traction to use counter-pressure 
 against the cervix, which may be steadied by placing tsvo fingers 
 against it, or by fixing it with the vulsellum forceps, or by encircling 
 it with the fenestrated end of a Sims's depressor. After the removal 
 of the tent some blood usually flows from the intra-uterine surface, 
 which is usually more or less abraded, especially if a sponge tent has 
 been used, and the endometrium should therefore be thoroughly washed 
 out with an antiseptic solution, to be followed with an application of 
 Churchill's tincture of iodine over the entire uterine cavity. In cases 
 ref[uiring further dilatation the iodine should be omitted until the last 
 tent has been removed. The danger of continuous dilatation by intro 
 ducing one tent after another is very great. As already stated, the 
 alarming results have generally followed the use of the second or the 
 third tent, seldom the first. A tent should not be allowed to remain 
 in the uterus more than twenty-four hours under any circumstances, 
 and generally not more than twelve. 
 
 Graduated Sounds. — The uterus, like the urethra, may be dilated 
 by means of graduated sounds. Fig. 168 shows Fritsch's uterine dila- 
 tors. Peaslee, Hegar, and Hanks have devised similar instruments 
 which are equally serviceable. They are particularly adaptetl to cases 
 in which the abdominal walls are thin and lax, so that the uterus may 
 be easily fixed by the hand oxqy the abdomen, while one sound after 
 
358 GENERAL C.ONSIDEBATION OF GYNECOLOGICAL SURGERY. 
 
 another is forced into the canal until the required dilatation is accom- 
 plished. If the abdominal walls are thick and tense, it is necessary to 
 place the patient in the latero-prone position, to use Sims's speculum, 
 
 Fig. 168. 
 
 Fritsch's Uterine Dilators. 
 
 and during dilatation to fix the cervix with the vulsellum forceps. In 
 such cases the diverging instruments are preferable. 
 
 Diverging Instruments. — Innumerable instruments have been 
 
 Fig. 169. 
 
 Schultze's Dilator. 
 
 devised with blades which diverge and dilate the uterus when the 
 handles are pressed or screwed together. (See Fig. 169.) 
 
 Schultze's dilator and Goodell's modification of Ellinger's dilator^ 
 have serrated blades to prevent them from slipping out during the pro- 
 
 FiG. 170. 
 
 Nott's Uterine Dilator. 
 
 cess of dilatation : this accident is much more liable to occur with the 
 latter instrument, on account of the parallel action of its blades, and 
 notwithstanding strong counter-traction with the vulsellum forceps it 
 does occur in many cases long before dilatation can be completed. The 
 blades of the Schultze's dilator diverge in a fan-like manner, and are 
 
 ^ See p. 319 in "Gynecological Diagnosis." 
 
DiLAiAi'ios nr mi: rri.iirs. riolj 
 
 tlieivfurc a little more liable to injure the uterus, but tlie\' dn iidt >Iij) 
 out, and are tlieref"i)re tu be I'e-erved for ea.-cn in uliieli tlie I'liliuiier 
 iiLstruiueut eaniiot be retaiue<l. Tlie.-e dihitors are <:ciierall\ too lie;i\ \- 
 to be inserted until (lie way lias been opened by ;i liu|||«r instruinent, 
 like Xott's (>ee V\\l,. ITOj, or by the siiialler Liradii.itcd x.iind, ( I''i^. 
 IGS), or by a tent. 
 
 Dr. (i lell ' of l*liiladelj)hia lias been l"orenio>t aiiioii^ the advocates 
 
 of" this inethoij ol' dilatation. In a lar^c experience with extn-ine dila- 
 tation under ether he has had in» fatal roiilt and no serious inflain- 
 niatory disturbance, lie carries the <lilatation to three-fourths of an 
 inch in the thin-walled, unyielding infantile ut<'rus, and to (jue and a 
 fourth inches in other instaneos. In case of a ri*;id, unyielding;, or thin- 
 walled uttM'us, which niiuht tear from rai)id expansion of the dilatin<r 
 blades, it is better to eoniiuence dilatation with a s|)on<i;e or tupelo tent, 
 the .softeniiiu; influenee of which renders the eanal more easily and 
 thorou;ihly dilatable by the forcible method. 
 
 The dangers are traumatic and .septic, the Ibrmer even t<j the extent 
 of rupture of the uteru.s and consequent peritoniti.s, and death mav 
 result from over-distension by rapid dilatation of a rigid uterus. The 
 latter danger i.s preventiblc by antiseptics. The speeial dangers of 
 dilatation by tents, and the impossibility of enforcing thorough anti- 
 sepsis in their use, have been considered in a previous paragraph. It 
 would, however, be a fatal mi.stake to suppose that antisepsis deprives 
 dilatation bv any method of all its perils. All manipulations of this 
 class, says Fritsch, are dangerous, and not to be employed unless the 
 indication is quite clear. Existing pelvic inflammation, acute or chronic, 
 is a serious contraindication. Indeed, the history of a majority of fatal 
 cases includes previous cellulitis, peritonitis, or metritis. Dilatation, 
 however slight, by any method, .should be regarded as a surgical opera- 
 tion, should always be done at the patient's house, never at the office, 
 and should lie followed by rest in bed for a time varying from one to 
 seven davs. Forcible dilatation either bv sounds or bv divertfing; instni- 
 ments requires an ansesthetie, except when the dilatation is to be slight. 
 If there be tenderness about the uterus or other signs of inflammation, 
 or if the patient has suffered from a previous attack, ice should be kept 
 over the hypogastrium, quinine should be given in full doses, and opium 
 according to the jiain until the danger has passcfl. 
 
 The special advantages of each method of dilatation mav be sum- 
 marized as follows : 
 
 Incision. — Contraction of the os externum and lower ])ortion of the 
 uterine canal is be.st treated, according to the nature of the case, either 
 by Fritsch's operation for enlarging the os externum In- incision or by 
 Schroeder's operation of bilateral incision of the cervix. 
 
 ' American Journal nf Obstetric^, 18S4. p. 1170. 
 
360 GENERAL CONSIDERATION OF GYNECOLOGICAL SURGERY. 
 
 Tents. — Sponge tents are the most dangerous, tiipelo least. Lami- 
 naria lias but one advantage over tuj^elo, its flexibility and adaptability 
 to a tortuous canal. In a case of rigid liyjDcrplastic or thin- walled 
 cervix not safely dilatable by rapid means the tent is specially indi- 
 cated as a means of preparation for rapid dilatation by graduated 
 sounds or diverging instruments. 
 
 Graduated Sounds and Divei^ging Dilators are generally the safest 
 and most eifective means of dilatation, and should have the preference 
 unless the softening effect of the tent is specially desired. 
 
 The Curette. 
 
 The curette is a spoon-shaped instrument, fenestrated or non-fe- 
 nestrated, with a dull or sharp cutting edge, which may be introduced 
 into the uterus, with or without previous dilatation, for the purpose of 
 scraping away diseased tissue for diagnostic or remedial purposes. The 
 instrument, first introduced in 1843 by R^camier, has passed through 
 many modifications and received the severest censure, not wholly unde- 
 served, on account of its disastrous results, among which are perfora- 
 tion of the uterus, cellulitis, peritonitis, metritis, and septicaemia. 
 
 The indications for the curette are hemorrhage and septicaemia, due 
 to the presence of some intra-uterine cause. 
 
 The dull wire curette of Thomas (see Fig. 171) fulfils nearly all the 
 
 Fig. 171. 
 
 Thomas's Dull Wire Curette. 
 
 indications of the instrument, and in suitable cases its use is almost 
 entirely free from danger. It is made of flexible copper wire. The 
 loop at its extremity has slightly flattened but not cutting edges. Its 
 shank may be bent like a probe to conform to the direction of the 
 uterine canal, and whatever the force applied it is not likely to injure 
 the sound tissue, while it easily removes the soft, friable products of 
 hyperplastic endometritis called granulations, or the secundines of an 
 abortion, or soft tumors malignant and benign. 
 
 Simon's steel curette (Fig. 172), not fenestrated, or Sims's fenestrated, 
 each of which is provided with a sharp cutting edge, should be reserved 
 for the removal of diseased mucous membrane or of malignant tumors 
 
77//; \-.\<;l.\.lI. TAMI'OS. .".01 
 
 wliii'Ii resist the dull iiotniiiicnt. ( 'iii-cttcs n\' various sizes are r(M|iiirci[ 
 aeeordiiu'" tn the aiiudiiit to 1k' ri'iii(tvc<l ami llw size of the uterine m\- 
 itv. The smaller sizes may he introduced and used without previous 
 dilatation. Hurini^- tlie operation, wliicli is best pei'l'ormed tliroUL;li 
 
 Kk;. 172. 
 
 ^ 
 
 '^^^^^ 
 
 Simon's Sharp Steel Curette. 
 
 Sims's speeuhini, the eervix is held bv a uterine tenaeuhun. After all 
 the di.seased tissue has been removed the endometrium should be wiped 
 out with absorbent eotton, and then with cotton .saturated with Church- 
 ill's tincture of iodine. The danger.s, contraindications, and precautions 
 are the same as in dilatation of the uterus. 
 
 The Vaginal Tampon. 
 The tampon should fulfil the double object of preventing hemorrhage 
 and of pnjdueing such pressure against the upper portion of the vagina 
 as to impede the flow of blood to the uterus. In ca.ses of extreme hem- 
 orrhage it often becomes necessary, before placing the tampon, to plug 
 the cervical canal with cotton saturated with tincture of iodine or some 
 other astringent. This cervical tampon should be composed of a single 
 piece of cotton, so that it may be easily removed. The material of the 
 tampon should be cotton made into pledgets about two inches square 
 and half an inch thick, and saturated with a solution of aliun and 
 squeezed dry. Its application through Sims's speculum, which for this 
 purpose is almost indispensable, has been well described by Emmet. 
 The following is the substance of his directions : Empty the bladder, 
 place the patient in Sims's position, and introduce the speculum. 
 Remove all clots, smear the vagina thoroughly Mith va.>^eline or lard, 
 which renders the canal more distensible and the packing le.ss painful, 
 and tends to retard the flow of blood between the tampon and the 
 vaginal walls ; then place a pledget of cotton, freshly dampened with 
 a solution of alum, over the cervix ; then roll up a mass and place it 
 in the posterior cul-de-sac, also on each side and in front ; cover all 
 this with a flat jiiece of cotton ; then place pledgets around the cervix 
 in a circle, and fill in the centre ; press back the cotton from the cir- 
 cumference to the centre with a stout whalebone or wooden stick in the 
 left hand and a pair of dressing-forceps in the right, and as room is 
 
362 GE^EEAL CONSIDERATION OF GYNECOLOGICAL SURGERY. 
 
 thus gained fill in with more cotton. When the vagina has been well 
 filled press it firmly back with the stick from the anterior wall toward 
 the hollow of the sacrum, and slip the speculum in front of the mass. 
 As the speculum is drawn back bv the assistant the space left will 
 extend nearly to the uterus. This is to be filled in the same manner, 
 and the speculum repeatedly withdrawn and replaced in front of the 
 mass, and the remaining space again filled, until the whole canal is 
 firmly packed. Xo violence should be used, but by going around and 
 around the mass and firmly packing in with the stick and the forceps 
 one small portion after another, the pelvic basin may be almost entirely 
 filled. If the tampon be large, confine the patient in bed and give an 
 anodyne. Should the anodyne fail to give relief, the lower portion of 
 the cotton may be removed. If there be retention of urine, it should 
 be drawn Avith an elastic male catheter. The tampon should not be 
 left longer than twenty-four hours. Before applying another it is best 
 to wash out the vagina with an antiseptic douche and to relieve the 
 bowels by an enema. 
 
 Dr. Frank P. Foster ^ of New York recommends lampwick as an 
 excellent material for the tampon, on account of ,the ease of its intro- 
 duction and removal even without a speculum, and on account of its 
 ready absorbability. He says : " When the tampon is to be removed 
 the patient simply makes traction upon the portion of wicking that 
 was left hanging from the vulva, and the mass within the vagina is 
 unwound as the traction proceeds ; consecjuently, no large wad has to 
 pass the vaginal orifice and the extraction of the tampon is painless. 
 Besides the advantage of its greater absorbent property, I find that 
 wicking is better adapted to the easy and rapid performance of such a 
 proceeding as I have described than any of the other substances men- 
 tioned, including the roller bandage. Moreover, it is sometimes desir- 
 able to tampon the cervical canal, or to introduce a medicinal agent into 
 the uterine canal in such manner as to ensure its prolonged contact with 
 the endometrium. For such purpose an inch or more of the end of 
 the wicking may be stiffened with gelatin, and then, after having been 
 dipped into the liquid to be applied, be introduced into the canal by 
 means of a pair of dressing-forceps. If care is taken not to coat the 
 whole circumference of the wicking with the gelatin, the liquid medic- 
 ament readily permeates the stiffened wacking, and a considerable quan- 
 tity of it may thus be introduced within the uterine canal. Enough 
 more wicking is then inserted into the vagina to act as a tampon, and 
 when this is removed the portion originally introduced into the uterus 
 comes out with it." 
 
 '^ Nexv York Medical Journal, June, 1880. 
 
GENERAL THEllATKl TICS 
 
 13v ALEXANDER J. C. SKENE. >I. D.. 
 Brooklyn, N. Y. 
 
 A RATIONAL system of tlierapeuties is based upon a knowledge of 
 the various morbid states, a clear comprcliension of the uature and 
 action of the ai^ents employed in the treatment of disease, and a judi- 
 cious adaptation of the latter to the relief of the former. 
 
 It is presumed that the readers of this work are familiar with dis- 
 eases in general and the means to be used in their treatment. ^ly task, 
 therefore, is limited to a general consideration of the selection and 
 administration of the most reliable means to be employed in the man- 
 ay;ement of the diseases which come under the care of the o:vne- 
 cologist. 
 
 The order in M'hich I intend to discuss the several branches of this 
 subject is to consider very briefly some of the chief points in the man- 
 agement of functional derangements, and then the general and local 
 treatment of the organic diseases of the uterus chiefly. 
 
 The derangements of menstruation, classified according to their causes, 
 are malnutrition, morbid innervation, and organic diseases of the nutri- 
 tive system Avhich give rise to conservative amenorrha?a. Reference 
 may he made also to derangements or absence of the menses due to mal- 
 formations and diseases of the sexual organs. 
 
 In the treatment of all the derangements of the menstruation the one 
 cardinal })oint must ever 1)0 kejit in mind — viz. to remove the c;.iise, be 
 it local or general, upon which the derangement of the uterine function 
 dejKMuls. 
 
 Anienctrrhrea and scanty menstruation, so frequently due to ansemia, 
 promptly yield to restorative tonics and proper food. This is one of 
 the best-establishal facts in thcrajieutics. Iron is of course the restor- 
 ative tonic most to be depended upon in the management of antemia. 
 However, there are some ideas regarding the use of the diflerent jinj)- 
 arations and the combinations of iron with other remedies which must 
 be mentioned in this connection. 
 
 The muriated tincture of iron is one of the oldest and most reliable 
 of all preparations, and answers in the great majority' of (uses. It may 
 
364 GENERAL THERAPEUTICS. 
 
 be confidently used at all times, except when there is some objection 
 made on the part of the patient or when ausemia is associated with 
 some other disorder which demands attention. Sometimes the remedy 
 disagrees with the patient or she fancies she cannot take it ; then some 
 other preparation may be used. 
 
 The fastidious will take the tartrate of potassa and iron in wine, and 
 sometimes profit by it, while others will take iron in jiill form with 
 great advantage. When the anaemia is accompanied with other morbid 
 states, remedies may be combined with iron to remove these complica- 
 tions. In subjects whose breathing capacity is limited the action of 
 iron will be aided by combining with it chlorate of potassa, which is 
 said to aid in the aeration of the blood. Again, in torpor of the liver 
 muriate of ammonia acts well ; hence a good combination for such 
 subjects is the tincture of iron, chlorate of potassa, and the muriate 
 of ammonia. 
 
 When there is exhaustion as well as impaired nutrition of the ner- 
 vous system nerve-tonics should be added to the iron. Strychnia is a 
 favorite remedy, and many of the ready-made tonics of the present 
 time have for their chief ingredients iron and strychnia. This remedy, 
 however, is not a restorative tonic in the true sense of the term. At 
 best it can only arouse the nerve-energies for a time, and hence its use 
 should never be long continued, neither should the doses given in 
 amenorrhoea be large. 
 
 There are other nerve-tonics better adapted to the depressed state of 
 the nervous system accompanying the menstrual disorders. The phos- 
 phates have long had a reputation in the list of the nerve-tonics, and 
 they should be combined with iron whenever called for. The pyro- 
 phosphate of iron was at one time popular, and deservedly so. Among 
 the various preparations of the phosphates, Parrish's compound syrup of 
 phosphates is quite equal, if not greatly superior, to many of the fashion- 
 able compounds of the present day. Phosphorus is of course the thing 
 required, but it is difficult to administer. A solution of phosphorus, 
 in cod-liver oil, put up in pills, is one of the best ways of giving it, but 
 the odor and taste are so disagreeable that many patients cannot or will 
 not take it. 
 
 Some of the cerebro-spinal stimulants act well in the menstrual dis- 
 orders due to depressed and exhausted states of the nervous system. 
 Belladonna, cannabis indica, and all of this class, when given in doses 
 snfficient to stimulate the nervous system, sometimes appear to act 
 favorably in amenorrhoea and scanty menstruation. In their action 
 they appear to sustain the nervous system when given in small and con- 
 tinued doses. In regard to belladonna, hyoscyamus, and all of that 
 class, they should be given in small doses — very much smaller than 
 recommended in the textbooks. These stimulants act best in those. 
 
OENKR. I /. Tin:i:. i rr.VTK s. ;j<j."> 
 
 oases of" tlcprcssi" III rrom cxliniislinii iVoin ovci'-raliiiiic when :i~s(ici;ilc<| 
 with imjM'i'lcct nu'iisti-iiatioii. 
 
 'riit'i'c is a larii'c class of luciistnial (Icraiiticmciits diir in <lcraiit:<'(l 
 iinifi'valioii in (he Inrni nl" niidiic cxcitciiicni, and not nccc.-.-ardv 
 accompanied witli aiitcinia. A .-Ironi;- impression mad(! upon tlic ner- 
 vous system from any cause snllicieut to jn'oduce shock will arrest the 
 menstrual liinctions in many cases. So also over-mental excitation 
 from auv cause will, it" louu; contiuued, hav(! the same eilect. In all 
 this class of oases uorve-scdatives are iudicated — reuiedies that will 
 liive the required sedation without the objectionable effects of such agents 
 as opium and chloral hydrate. These should be in such cases avoided, 
 because this class of jiatients ac({uire the habit of .takin*^ such nerve- 
 sedatives with extraordinary facility. 
 
 The bromides take the highest rank in the manajrement of these 
 Ciises. In acute cases the bromide of sodium should be oiven in fidl 
 doses until all the nervous perturbation is overcome, and ^\■hen this is 
 aceom})lished it frequently happens that the menstrual function will be 
 established without further treatment. The use of this remedy should 
 be limited to acute derangement of innervation in women otherwise in 
 good health. AVhcnevcr tliere is general weakness from impaired 
 nutrition the bromides should not be given in large doses nor long 
 continued : enough to procure quiet sleep (if it is poasible to do so 
 with bromide) and relieve the nervous excitement is all that is required 
 ot" this remedy. In such conditions the bromides will often fail and 
 other remedies must be resorted to. A favorite combination of mine 
 is the extracts of valerian, conium, and lupuline with camjihor, given 
 in a capsule. This often answers the purpose of a nerve-sedative, giv- 
 ing sleep and a disposition to rest, which affords the patient time and 
 inclination to menstruate. Valerianate of zinc, valerianate of ammonia, 
 monobromide of camphor, bromide of zinc, and like remedies are all 
 of some service in such cases, and should be resorted to when the other 
 means have failed. 
 
 The ])ermanganate of potash has recently been introduced by Sydney 
 Ringer of London as an excitant of the menstrual function. I have 
 used this remedy in a number of cases of amenorrhoea, and have derived 
 lienefit from it ; but I have not had the extraordinary results from it 
 that would enable me to speak in such strong praise of it as many have 
 done. At first I gave it in ])ill form, and that may have been against 
 its success. But when I gave it in solution it did not always satisfy 
 me. One troul)le is to get it into the circulation, it is such an easily 
 decomposed stuff. I have seen recently that oleate of manganese is 
 commended by Dr. Franklin H. ]\[artin in the JfrrJiral Record for 
 June 27, 1885. The binoxide of manganese has also been used in its 
 place witli alleged good residts. 
 
366 GENERAL THERAPEUTICS. 
 
 The rule is that when all the conditioDs necessary to menstruation 
 are restored the flow will return. Still, there are cases of amenorrhoea 
 which occur with or without apparent cause, and persist long after the 
 appreciable defects in general health have been overcome. In such 
 cases we seek for remedies that will act directly upon the sexual organs 
 to re-establish their function if entirely absent, or to increase the fl(jw 
 if it is deficient in quantity. The agents generally used for this pur- 
 pose are sabina, aloes, caulophyllura, myrrha, cimicifuga, tanacetum, 
 cantharides, and guaiac. The action of tliese remedies is to produce 
 stimulation and irritation of the mucous membrane of the alimentary 
 canal, and it may be presumed that a similar effect, though in a less 
 degree, is produced upon the uterus. 
 
 The congestion of the pelvic organs caused by these drugs may act 
 as an exciting cause of menstruation if they are given at a time when 
 there is a predisposition to menstruate and the local and general con- 
 ditions necessary to menstruation have been established. They are cer- 
 tainly worse than useless when given in cases of amenorrhoea due to any 
 constitutional or local affection, such as anaemia, deranged innervation, 
 and disease of the uterus or ovaries. 
 
 There is also great difficultv in estimatino; the value of the so-called 
 emmenagogues, because of the fact that the menstrual function will 
 recur in the great majority of cases when the causes of the amenorrhoea 
 have been removed. Therefore, when emmenagogues are given and 
 the menstrual flow is established, it is not sufficient proof that the medi- 
 cines used have produced the results observed. Again, I have observed 
 that in cases of amenorrhoea in which no cause could be discovered the 
 so-called emmenagogues have failed to restore the menses. They are 
 agents v.hich are capable of doing harm by deranging the digestive 
 organs, and hence I very seldom use them ; and from all that I can 
 learn of the practice of others, they are not so frequently resorted to 
 as formerly, and there is reason to believe that they will soon fall out 
 of use entirely. 
 
 There are other agents which have been used to promote the men- 
 strual flow in cases where the amenorrhoea has remained after the gen- 
 eral condition of the patient has been restored to health and the flow 
 has not returned. Of these agents it may be said that they are not 
 likely to do harm, and their recognized general therapeutical action 
 suggests at least the possibility of their being useful. These are the 
 diffusible stimulants, like alcohol, ammonia, camphor, chloric ether, 
 and acetate of ammonia.. 
 
 There are two conditions in which these remedies are indicated. The 
 first is where the subject has been exposed to cold at the time w'hen the 
 menstrual flow should ap]iear, but does not. AVe counteract the effects 
 of the cold and equalize the circulation by means of a warm bath, and 
 
ai:si:i:. i /. tiii:i:a i'EUTK x 307 
 
 then ainiinuiia with caiiiplinr, a small (l(is<' of warm \i\\\ or wliisUcy 
 juiiicli, <»r tin- acetate of aiiimuiiia will olteii ^ive ^<»o<l results. To tlu^ 
 otlw'r clas^ heloiiir those who ha\e >\ liiptoliis of a leildeliev to liieiistril- 
 
 ati' — /. f. have a menstrual molimen, hut the flow does not appear. Iti 
 sueh eases the remedies referred to may he ••m|»loyed with advantajre. 
 In those of full hal)it aleohol -hoidd he avoided. in -ueli eiLses the 
 ammonia and camphor will act hest. 
 , In all countries where malarial poison prevails deranticil menstruation 
 is frecpiently e.vperienced : the effect ol' thi- miasm ujion the lunetion of 
 the uterus is manifest in many ways. The ana-mia which so fi-e<juently 
 ocelli's in malarial })oisonin<5 produces ameiiorrho'a. The elVect <tf the 
 poison on the nervous system gives a like result. Chronic malarial 
 poisoniiiiT, with morhid chanj^es in the abdominal viscera, inHuenees 
 menstruation in a marked degree, Anienorrhfea is observe<l in these 
 sui)jects occasionally, hut menorrhagia is perhaps more common. 
 
 In all cases arising from this common cause quinine and arsenic are 
 the agents to dej)en(l ui)on. In cases of long standing with engorge- 
 ment of the abdominal viscera and enlargement of the spleen and 
 liver an occasional dose of mercury aids greatly in the treiitment. 
 Finally, when all the causes have been removed and the menstrual 
 function is not established, and the means usually employed to restore 
 it have failed, electricity is well worthy of a trial. The interrupted 
 current is said to be the most valual^le form of the electric treatment. 
 
 General or central faradization may be tried, and if this fails the 
 current should be passed through the pelvis, one electrode Ijeing placed 
 over the sacrum and the other over the pubes. The l)est way of all is 
 to pa.ss one electrode into the uterus and the other over the .sacrum 
 and pul)cs alternately. But this method is seldom practicable in the 
 unmarried, 
 
 Xew impressions fnjni change of surroundings are often of great 
 value in obstinate cases. Change of air gives increased vigor to the 
 nutritive functions, and new subjects of interest and new associations 
 are marked stimulants to the brain and nervous system; all of which 
 favor the highest functional activity of the uterus. 
 
 The CoiiHiitutional and Local Treatment of Orr/anic Diseases of the 
 Serual Orr/ans, especiaUy the Zleriis. — On this subject there is possibly 
 less harmony of opinion and practice among g^mecologists than there is 
 in reg-ard to the foregoing subject. Yet all know xery well that local 
 diseases, ormnic as well as functional, are lar^elv under the control of 
 constitutional medication. 
 
 The sexual organs being dependent upon the general nutritive system 
 for su])port and the general nervous svstom for innervation, it follows 
 that through this relationship they are dependent in health and disease, 
 and that anv marked defect in the general health must act to the injurA' 
 
368 GENERAL THERAPEUTICS. 
 
 of the sexual organs. It is also clearly apparent that to affect the sex- 
 ual organs with therapeutic agents we must often take the nutritive and 
 nervous systems as the channels through which to reach them. 
 
 There are a vast number of ways by which the general organization 
 works to the detriment of the sexual organs, and in the jDractice of 
 gynecology the general health must at all times be looked after, both 
 in connection with the causation and treatment of uterine and ovarian 
 diseases. It is also well to keep in mind that constitutional remedies 
 reach and act upon the sexual organs through both the nutritive 
 and nervous systems. Owing to this correlationship of the general 
 organization and the sexual system the remedies employed l)y the gyne- 
 cologist may be classified as follows : First, remedies which act indi- 
 rectly upon the sexual organs by modifying the general nutrition ; sec- 
 ond, remedies which act through the nervous system ; third, remedies 
 which act especially upon the sexual organs, either through the circu- 
 lation or nervous system ; fourth, agents used locally which influence 
 morbid states of the sexual orrans. 
 
 Under the first head may be classed all agents which are capable of 
 improving general nutrition. This embraces a field altogether beyond 
 the scope of this work, and hence I must limit my labors to the consid- 
 eration of the derangements of nutrition most commonly seen in con- 
 nection with diseases of the sexual organs, and more especially to those 
 functional disturbances of the nervous svstem and digestive org^ans 
 caused by, or at least aggravated by, uterine and ovarian diseases. 
 Prominent among these will be found impaired appetite and constipa- 
 tion. The loss of desire for food or a capricious appetite may be wholly 
 due to derangement of the nervous system, the stomach itself being 
 free from organic disease. 
 
 If this functional disturbance exists long, gastric catarrh is likely to 
 come in due time. The former may usually be distinguished by the 
 fact that the appetite is capricious, at times good and at other times 
 poor. The tongue is not always coated, but more often light red and 
 the papillse prominent. In the latter (catarrh) there is usually a con- 
 stant loathing or dislike for food, and the tongue has the swollen and 
 coated appearance characteristic of that disease. 
 
 In the management of either form of the gastric disorder the qtian- 
 tity and character of food are of primary importance. Full details of 
 the dietetics of this class of cases must be obtained from works on the 
 2)ractice of medicine. A word or two may, however, be admissible. 
 
 As a rule, the likes and dislikes of the patient regarding food should 
 be respected, unless in cases where the nervous system is markedly per- 
 verted and the fact is manifested by unreasonable capriciousness. In 
 order to get a beginning to improve great advantage may be obtained 
 by using the digested foods. Peptonized milk, gruel, and beef should 
 
genkhal Tiii:iiAi'j-:uTrcs. 30f) 
 
 be tried. Lately I have hecii able to iioiirisli some of <lie most ohsti- 
 nati' etuies with the jircparation known as " Fairchihl's liumani/.ed 
 milk." This is intended lor iiilants, hnt it has proved of great service 
 in l)('<;innin<;- the ti'eatmcnt of many eases of feeble indif^cstion. 
 
 l'\)reed feedin«;- has been j^reatly in vo<^ne of late,and it luus its advan- 
 tage's. The method is to bei^-in by givin<>; small doses of food at short 
 intervals, and increase the (jnantity regnlarly until the capacity of tak- 
 ini;; an abundance is developed. The system is an admirable one, and 
 is es[)eeially suited to the cases of gastric neurosis and reflex gastric dis- 
 t)rders. It has its limits, however, as there are cases where it seems to 
 be unsatisfactory. As soon as the patient has improved sufficiently in 
 the power of digestion a liberal and varied quantity of food should be 
 
 The medicinal agents to be employed to aid digestion and create an 
 appetite are of two classes — sedative and tonic. Gastric sedatives will 
 quiet irritation and ira])rovo the appetite in certain cases. Of these, 
 bismuth, oxalate of cerium, and hydrocyanic acid are the most reliable. 
 The oxalate of cerium should be given in larger doses than the books 
 direct. Five or six grains before meals are a sufficient dose. These 
 remedies should be given half an hour before meals. 
 
 The tonics are the vegetable bitters, the preferable ones being colura- 
 bo, quassia, and cedron. The drachm doses of these bitter tinctin-es 
 generally given do not act well in the cases under consideration. Such 
 doses contain too much alcohol for irritable stomachs unless largely 
 diluted, and then the quantity is too great. Half a drachm, or even 
 less, in a little warm water is more efficient and acceptable. Two or 
 three drops of nux vomica in a small wineglass of warm water acts 
 well with many. Two drops of wine of ipecac, added to the nux vom- 
 ica makes a most valuable combination. Four drops of fluid extract 
 of cedron given in water is also of great value in giving an ajijietite. 
 The bitter is clear, well defined, and passes away very soon, leaving an 
 agreeable taste in the mouth. 
 
 ]\Iuch may be done by a competent nurse who understands liow to 
 offer tempting articles of diet. 
 
 When food is being taken in fair quantities only half the battle is 
 won in many cases. The digestion may be labored and attended with 
 much distress — in some cases immediately after eating, in othei*s an hour 
 or two after. INIuch of this may be avoided by giving food that is easily 
 digested. If this fails, the digested foods ali-eady referred to should 
 be given. Pepsin helps this labored digestion in certain ca.ses, while in 
 othei*s it is useless. When pepsin alone fails, I have combined with it 
 lactic acid and some aromatic, like tincture of cardamom. This is given 
 after the meal in hot water. 
 
 The disagreeable behavior of the stomach is often greatly aggravated 
 
 Vol. I.— 24 
 
370 GENERAL THERAPEUTICS. 
 
 by the state of the bowels. Indeed, many times I observe that when 
 the bowels are made to act properly the stomach, which has been out 
 of order, takes up its duties at once. 
 
 Constipation of the bowels is an almost ever-present state in those 
 who have disease of the sexual organs. This is caused either by 
 deranged secretion of the alimentary canal, impaired nmscular action, 
 deranged innervation, or all three together. The condition of the 
 tongue and the character of the discharges will show imperfect secretion, 
 and this can best be relieved by beginning with a dose or two of mer- 
 cury. A dose of blue mass with a grain of ipecac, at night, followed 
 if need be by some gentle laxative, will often give good results. For 
 those who alternate between constipation and diarrhoea a favorite pre- 
 scription is blue mass, calcined magnesia, aromatic syrup of rhubarb, 
 glycerin, and peppermint-water. 
 
 To keep the bowels in order after one or more doses of these altera- 
 tive cathartics the mineral waters, natural or artificial, will answer well 
 for those whose secretions are retarded. In the use of these there are 
 two rules which ought to be observed : First, to give the water at least 
 one hour before meal-time, the morning being preferable if the patient 
 can take it then ; and second, to select by trial the water which suits the 
 case in hand. Practitioners are apt to use some favorite water for all 
 cases, while the rational method is to select from the many the one 
 which gives the desired results in severe cases. 
 
 When the constipation is due to muscular and nervous debility, 
 mineral waters and saline laxatives rarely agree well. They cause 
 flatulence, pain, and occasionally nausea. In such conditions tonic 
 laxatives are required. In the use of these there are some rules which 
 should be carefully observed. They should be given in small doses, 
 repeated often enough to give the desired effect and no more, and they 
 should be continued until the habit of constipation is completely broken 
 up, and resumed upon the first indication that the trouble is returning. 
 If the adaptation of the remedies is right, the doses can be gradually 
 diminished in quantity and frequency, in place of having to increase 
 the medicine to get the desired effect. 
 
 Belladonna stands at the head of the list of agents in the treatment 
 of constipation occurring in gynecological cases. If given alone in 
 small doses, often repeated, it will answer in some cases. It is of course 
 seldom given alone, but in combination with other laxatives. 
 
 Nux vomica is often employed, but it is objectionable. It acts only 
 for the time, and if continued long it loses its effect, requiring a larger 
 dose to be given in order to obtain any effect at all. The most that can 
 be said of it in the management of constipation is that it may be useful 
 at the beginning of the treatment to give the patient a start in the 
 right direction in cases of marked debility. 
 
GENERAL THERAPEUTICS. .371 
 
 One of the most reliable coinbiiiations that I have found is one f^raiu 
 of sulphate of (jiiiiiiiie, one-tenth of a <rrain of the extract of Ix'lla- 
 (lonna, and half a <j;rain of tiic compound extract of colcK-ynth, made 
 into a pill. One of these given with each meal has helped more cases 
 than any other prescrij)tion. As the patient jrains strcn<^th tlu; munlx'r 
 ol" doses can he ri'dnceil to two (jr one a diiy, and linallv half of a pill 
 every day or every seeoud day. 
 
 In cases of amenorrhea or scanty menstruation the a(picous extract of 
 aloes may he used in place of the colocynth, a (piarter of a grain usually 
 being sullicient. When pills are objectionable to the patient, the fluid 
 extract of podophyllum, one or two dro[)s, tincture of colocynth, six 
 drops, and fluid extrac-t of belladonna, one-third of a minim, should be 
 given after meals in a little glycerin and some aromatic which is agree- 
 able, like pe|)j)ermint-water or cardamom. The compound licorice 
 powder should not be forgotten. A teaspoonful of this prej)aration, 
 if carefully prepared by being thoroughly pulverized and mixed and 
 given at bed-time, will do well in many cases. 
 
 We now come to the consideration of the therapeutic agents which 
 act upon the sexual organs through the ultimate general nutrition. 
 Some of these agents act through the circulation and innervation, nifKl- 
 ifying the state or quantity of the blood which supplies the sexual 
 organs, thereby affecting their condition and action. The type of this 
 cliiss is ergot. This agent is well known to possess very extraordinary 
 power to excite muscular action in the uterus, but its greatest value is 
 limited to obstetric practice. There it is the most certain and reliable 
 of all medicinal agents in its uniform action under given circumstances. 
 It is far from being so useful in the practice of gynecologv. Muscular 
 contraction of the uterus can only be possible when the organ is devel- 
 oped either by gestation or intra-uterine neoplasms ; hence ergot is not 
 often efficient in disorders of the uterus. 
 
 It has been claimed that ergot, by causing contraction of the mus- 
 cular walls of the blood-vessels, is valuable in all congested states of 
 the uterus, but, practically, this is not of much account. It is true 
 that the ergot causes contraction of the blood-vessels generally, but in 
 order to make it of much value in local congestions it requires to be 
 given in large doses and long continued, so that long before much 
 benefit could be gained in disease of the uterus its constitutional effects 
 become so marked that it has to be suspended. 
 
 Practically, then, its use in gynecology is limital mostly to cases of 
 intra-uterine growths where it is desirable to cause contraction of the 
 uterus in the hope of arresting their growth or expelling them, and in 
 subinvolution of the uterus, where the object is to cause active contrac- 
 tion of the uterus in the hope of stimulating the process of involution. 
 
 When the uterus after confinement remains large, soft, and vascular, 
 
372 GENERAL THERAPEUTICS. 
 
 ergot does appear to have some effect in condensing the tissues and 
 lessening the congestion. Still, granting all this, ergot is not sufficient 
 alone to complete involution in all cases, but it may be a valuable aid. 
 
 Alteratives which favorably influence general nutrition often act 
 indirectly upon diseases of the sexual organs. The principal remedies 
 of this class are mercury, iodine, and arsenic. They are of the most 
 service in overcoming the evil results of the products of bygone inflam- 
 mations, such as cellulitis and peritonitis, the latter especially. They 
 are perhaps most efficacious in ovarian inflammations of a sul^acute 
 character. They have been used also in endometritis, but they do not 
 seem to accomplish much in that affection. 
 
 To favor the absorption of the products of pelvic cellulitis and peri- 
 tonitis the bichloride of mercury, combined with iron when necessary, 
 has been commended, and no doubt it is of great service. After using 
 it for a time it may be followed by the iodide of sodium if the general 
 nutrition permits it. The iodide of iron will answer better when iron 
 is indicated. 
 
 The selection of these agents should be made according to the condi- 
 tion of the patient of course. When general disintegration is sluggish 
 and there is much flesh, the mercury, followed by iodine, generally is 
 best, and when there is ansemia the iodide of iron should have the 
 preference. To be effectual these remedies should be continued for a 
 Ions: time. A similar course of medication is indicated in old inflam- 
 matory diseases of the ovaries and Fallopian tubes. 
 
 Chloride of gold has recently been commended in diseases of the 
 ovaries. I presume it should be classed among the alteratives, but I 
 have not seen any effects from it that would warrant my indorsing it, 
 neither have I heard any very reliable records in its favor. 
 
 In regard to arsenic, its well-known effects upon the nutrition of the 
 skin and mucous membranes entitle it to consideration in the treatment 
 of obstinate inflammatory diseases of the uterus and Fallopian tubes. 
 It should be given in small doses (two or three drops of Fowler's solu- 
 tion) and continued for a long time. When given in this way it will 
 apparently improve the nutrition of the mucous membrane of the 
 uterus, judging from my observations in the management of cases 
 of obstinate cervical catarrh and membranous dysmenorrhcea. 
 
 There is another class of remedies — quite a large one — which act 
 mostly through the nervous system, and upon which the gynecologist 
 greatly relies. This class may be subdivided into nerve-tonics and 
 sedatives. Of those classed as tonics, some may be considered as stim- 
 ulants by therapeutists, but it will suffice for the present purpose to say 
 that under the head of tonics I shall class all those that temporarily or 
 permanently increase nerve-force. Nux vomica is an agent which acts 
 well in cases of marked debility, and is often quite effectual in cases in 
 
CKSKUM TIIF.llM'FJ'TICS. ?u\ 
 
 whicli there is m'licnil weakness ol' tlic nervous system due to ut«riii(! 
 or ovarian disejtses. It is elaiineil by some to exert :i marked ionic 
 ellect ii|»nn the sexual oriT'i"'^, i»nd Ma ett'eet us a general t«jnie is I'ully 
 un(K'i-stoo(L It is only temporary in its elleets, howrvcr, and it" lon^ 
 eontinued proves injurious. If »riv<'u tor a len<ith ol' time, it is 
 ohserve<l that laijicr doses are neeessary to jj;ive the desired ellect, and 
 when the medicine is withdrawn a lowering; ot" the nerve-force takes 
 place. In this it resembles in its ac-tiou the alcoholic stimulants. As 
 a remedv, then, it is oidy to be used at the bejjjinnini; of the treiitment 
 to sustain the patient until more permanent restoratives have had time 
 to build up the strenirth. To start the ease in the way of improve- 
 ment is the chief otfiee of this remedy. 
 
 Belladonna and a«;ents belonjijing to that class, when given in small 
 doses at regular intervals, exert a decided tonie influence, especially 
 upon the organic nervous system, while at the same time the eifect 
 upon the sexual organs is slightly tonie and sedative. General nutri- 
 tion is aided by them, and patients will often acquire better spirits and 
 sleep better while taking them. 
 
 Hydrobromide of hyoseiue is a new remedy, which acts in a way 
 similar to belladonna, and is even more effieient. When given in doses 
 of the one-hundredth of a grain, more or less according to tlie case, it 
 gives an improved tone to the nervous system, improves the capillary 
 circulation, and relieves some of the wandering, ill-defined pains so 
 commonly associated with diseases of the uterus and ovaries. 
 
 Zinc and phosphorus represent the class of nerve-tonics Avhich aid in 
 restoring the nervous system to a better state, and it may be said of all 
 these that so ftir as they improve the general system, just so far do they 
 aid in relievino- diseases of the sexual organs. 
 
 Quinine is an agent -worthy of the special attention of the gynecol- 
 ogist. It is well known that quinine will stimulate uterine contrac- 
 tions during labor in case the nervous system becomes exhausted, and 
 presumably it may improve local innervation in disease. It is also a 
 valuable remedy in cases of neuralgic pains in the pelvis. In view of 
 thes2 facts it is reasonable to suppose that its action upon the pelvic 
 organs may be more than that of the ordinary tonics. At any rate, 
 as a {general tonic it ranks among; the hiijhest in the manatrement of 
 uterine and ovarian diseases. 
 
 Electricity has been more urgently commended perhaps than any 
 other agent in the practice of gynecology. After carefully examining 
 the testimony given in our literature, and making such clinical obser- 
 vations as I could regarding electricity, I have come to the conclusion 
 that when used generally it is capable of improving nutrition, and in 
 some cases it quiets nervous irritation, and the sexual organs come in 
 for their share of the general improvement ; but general faradization 
 
374 GENERAL THERAPEUTICS, 
 
 or galvanization has no direct or specific effect when used in this way. 
 Regarding the local effects of electricity something will be said far- 
 ther on. 
 
 Sedatives are so frequently called for in the practice of gynecology 
 that the subject requires its full share of attention. In view of the 
 suffering of those who have diseases of tlie sexual organs, the practi- 
 tioner naturally turns to opium as the most potent remedy, but in this 
 branch of practice it is often the most disastrous in the ultimate results 
 of its use. 
 
 In acute disease, like pelvic peritonitis and ovaritis, opium is the 
 remedy of most value, but in the less acute affections it is seldom cura- 
 tive and nearly always dangerous — dangerous because of the great 
 facility with which this class of patients acquire the opium habit. No 
 remedy can be more gratifying to both patient and physician in its 
 immediate results ; but it relieves only, does not cure in many cases, 
 and therefore should not be used when it can be avoided. 
 
 A similar though less severe verdict may be rendered in regard to 
 alcoholic stimulants. These are seldom well borne by patients with 
 diseases of the pelvic organs, and hence there is less danger in pre- 
 scribing them, because there is less likelihood of patients acquiring 
 an abnormal desire for them. 
 
 Chloral hydrate may be mentioned in this connection, only to suggest 
 caution regarding its use by the gynecologist. The most that it can do 
 is to produce sleep. It does not in small doses relieve pain as opium 
 does, and, more than that, chloral is more liable to produce irritation 
 of the sexual organs than opium. Several patients who have tried 
 opium and chloral to ease their sufferings have told me that chloral 
 caused sexual excitation, while opium subdued it. 
 
 Bromide of sodium is the great sedative in the practice of the gyne- 
 cologist. It not only relieves much of the suffering, but it has, through 
 its sedative effect, a curative influence in many of the diseases of the 
 sexual organs. By relieving the nervous excitation and irritability it 
 lessens the congestion of the pelvic organs, and hence tends to relieve 
 many of the inflammatory diseases and functional derangements. There 
 are two ways of using bromides, according to the effect desired — the 
 one to break up nervous symptoms, the other to induce sleep. Full 
 doses, repeated until the specific effects are produced, should be given 
 when the object is to break up a train of nervous symptoms due to dis- 
 ease of the pelvic organs. When this is accomplished the patient will 
 generally emerge from the effects of the bromide in a quieter and better 
 condition to respond to the general restorative treatment. 
 
 In some of the weak, nervous cases one may be at times afraid to 
 push the bromides very far, for fear that the prostrating effects might 
 prove dangerous. Caution in this is wise and necessary, and yet the 
 
GFXFRAL TUKUArET'TTCS. 370 
 
 puticnt must bo l)r(niii,lit imkIct llic rcuu'dy to <;:c't the full honcfit, 'I'o 
 acroiiiplish the «j:;(kk1 and avoid the danger small doses of mix V(»miea 
 should i>e eomhiued with the bromide. Dif^italis also may be added if 
 the heart-aetiou is weak. 
 
 \\'hile advoeatiug' tlu; lilxTal use of" bromide; I would sav that it 
 should not be lon<r continued. 1 rarely give this (b*u<r ionj^er than a 
 week or two, except it may be one dose in the aiternoon and evening 
 to j)rolong the night's sleep. 
 
 AVhen bromide is not well borne or docs not give the desired effect, 
 cannabis indica may be tried. Conium also does well, and may be 
 combined with camphor, croton chloral, lupulin, belladonna, ttsafretida, 
 and castor, but they all may be cousitlered a.s substitutes to be used in 
 rare cases when the bromides fail. 
 
 Next to the bromides among nerve-sedatives, and perhaps first among 
 them, is massage. The introduction of this treatment into rational 
 therapeutics was a most valuable contribution. It is employed usually 
 to aid Nutrition, and for this purpose it is of great benefit, but it is an 
 excellent nerve-sedative. A skilful nurse can by systematic manipula- 
 tion soothe the tegumentary nerves and produce that normal tiredness 
 which invites rest and sleep. That which used to be the property of 
 ignorant and designing magnetic rubbers is now modified and adapted 
 to rational use. It is a " stone which the builders rejected " for a time, 
 but now fills an important place in therapeutics. 
 
 This massage is true jDassive exercise, the only way that exercise can 
 be given without exhausting or taxing the nerve-centres. By this 
 means the muscular system can be toned down to the condition adapted 
 to normal rest, and a like effect appears to be produced upon the si)inal 
 nerves. This therapeutic agent is of so much importance that reference 
 will be again made to it as we proceed. This part of the subject would 
 be incomplete without mentioning electricity. That this agent is useful 
 most practitioners will acknowledge. In my own practice I have not 
 been satisfied that it accomplishes much, excepting in a certain class of 
 cases. 
 
 Those who suffer from functional derangements of the sexual organs 
 and nervous system because of imperfect development or misdirected 
 and unoccupied nerve-energies — in short, spoiled girls and women — 
 require a very diflferent course of treatment from those who suffer from 
 more definite diseases. The great object is to find mental and physical 
 employment for them which will turn their attention away from them- 
 selves. Here also isolation is an important factor, but it is not for the 
 sake of rest, but change of occupation. 
 
 To remove such cases from the influence of kind but unwise friends, 
 and place them in the more wholesome society' of a nuree and physician, 
 is a great gain. And then their whole time should be profitably occu- 
 
376 GENERAL THERAPEUTICS. 
 
 piecl. A portion of the clay should be devoted to the Turkish or 
 Roman bath, and if there is a well-defined hysterical element present, 
 the cold pack, shower-bath, and needle-bath may all be tried in turn. 
 In the external use of water the rule is warm water for the weak and 
 nervous, and cold water for the strong and hysterical. 
 
 Gymnastic exercise, adapted to the condition of each patient, is one 
 of the most valuable means in the management of such cases, and 
 should come in after strength has been gained by massage. If there 
 is any pelvic disease which forbids the use of the ordinary calisthenics, 
 the extremities should be thoroughly exercised while the patient is 
 reclining. There is no one agent so potent in relieving chronic conges- 
 tion of the internal organs as muscular exercise. It is equally efficient 
 in quieting that nervous irritability which is expressed in the hosts of 
 wandering aches and pains which torment this class of patients. 
 
 The condition of a brain which has for a long time been wholly 
 occupied in looking after the frailties of the body can be greatly 
 improved by directing the will-power to the exercise of the ihuscles. 
 I frequently see women who because of some uterine displacement or 
 circumscribed pelvic cellulitis are directed to rest in bed without any 
 mental or physical employment. Such imprisonment is sufficient to 
 make an invalid of the best kind of human material. To keep an 
 army in good condition requires constant occupation of both officers 
 and men, and this rule applies to many of our sick folks. Our 
 medical literature could well affbrd to have a chapter on Employ- 
 ment for Invalids. 
 
 After muscular exercise, electricity comes in to fill up time, and is 
 useful to that extent at least. Patients who liave some hysterical ele- 
 ments associated with these diseases of their pelvic organs are usually 
 most benefited by electricity. So says Rosenthal in his book on Dis- 
 eases of the Nervous System, and my OAvn limited experience agrees with 
 this. Some of them, perhaps many of them, are feeble and require 
 medication. Soothing medicines and nerve-tonics may all be required, 
 and should be employed while the massage, gymnastics, and baths are 
 being used. 
 
 The local treatment of the diseases of the uterus, the one organ of 
 the sexual system which is most amenable to local treatment, will be 
 fully discussed elsewhere. Some general remarks, however, on the 
 principal facts in uterine therapeutics may be permitted in this 
 connection. 
 
 Local treatment of diseases of the uteiTis should be employed with 
 the view of accomplishing two objects : First, to remove the disease ; 
 and second, to restore the organ to its normal condition. It will at 
 once be inferred that if the first object is attained the second will follow 
 as a natural consequence, but it may or may not, according to the cha- 
 
GENEUAL rin:uAPEUTics. 377 
 
 ractcr ol' the (rcatniciit (.'iii|>Iii\ci|. 1 aiii .-:ili.-(l<'(| ili;it in timrs |Ki~t, 
 ami cNcii at prt'sciit, miifli (»!' the trcatiiu'iit oi" iitcriiio disease, wliile 
 it anvsts the iiitiaininatorv trouhk', jji'oves so destructive to the iionual 
 structure of the or<;au as to reuder the last condition of the patient 
 ■worse tlian the first. 
 
 Disregarding nuieh ot" the; coul'iising and contradictory literature on 
 the subject, I shall endeavor to fix attention upon a few points which I 
 regard as well established and likely to be of service in the treatment 
 of uterine disease. 
 
 The important questions which come up for consideration on this 
 subject are — first, to what part of the affected organs can applications 
 be made ? second, what curative agents shall be employed ? and third, 
 how shall they be applied ? 
 
 Turning to textbooks or the current literature of the profession in 
 search of an answer to the first question, I find the greatest diversity 
 of opinions. The pioneer gynecologists of Europe, such as M. Gendrin, 
 M. Jobert de Lamballe, Bennet, and Simpson, rarely if ever made ap- 
 plications beyond the os internum, believing that uterine inflammation 
 could be cured by treating the cervix and cervical canal. On the other 
 hand, we find that Aran, Scanzoni, and Gantillon, and in our own 
 country Dr. Henry Miller (who, by the way, was the first to employ 
 intra-uterine medication in this country), Kammerer, Xott, Peaslee, 
 and many others, relied to a very great extent on intra-uterine appli- 
 cations for the relief of endometritis and uterine catarrh. ]\Iany more 
 names might be mentioned to show the want of harmony among physi- 
 cians on this point, but no useful knowledge could be gained thereby. 
 
 The only point of interest which we can learn from this review is 
 that, so far as M-e can judge, intra-uterine medication is more exten- 
 sively employed now than formerly. Believing, then, that time tends 
 to drift us to the side of correct therapeutics, it may be inferred that 
 local applications to a part or to the entire lining membrane of the ute- 
 rine cavity arc sometimes necessary, if not indispensable, in treating 
 endometritis. 
 
 In seeking an answer to the second question we encounter a variety 
 of medicinal agents, ranging from the actual cautery to the blandest 
 anodyne lotion. Reviewing the nature and effects of the vari(Uis reme- 
 dies used in the treatment of uterine disease, we could in no way be 
 guided thereby in making a selection. 
 
 Bearing in mind, however, the second object to be gained — namely, 
 to restore the organ to health and leave it uninjured in structure — the 
 therapeutist is bound at once to reject all the more ])owcrful and 
 destructive agents, such as nitric acid and chromic acid, caustic potash, 
 and the actual cautery. All these have been n-ed, and are now, though 
 less extensively, I trust, than formerly, in the treatment of simple 
 
378 GENERAL THERAPEUTICS. 
 
 chronic endometritis or hypersemia of the mucous membrane of the 
 cavity of the uterus. 
 
 Leaving out of account the value of these potent agents in the treat- 
 ment of malignant diseases of the uterus, I desire to be distinctly 
 understood as opposed to their use in the treatment of the benign ute- 
 rine disease. I readily admit that inflammation of a mucous mem- 
 brane can and may have been " cured," as the expression is, by such 
 means. The surgeon can " cure " a gleet by burning out the whole 
 mucous membrane of the urethra with caustics. There would be noth- 
 ing left there but a cicatrix, which could not secrete the glairy mucous 
 discharge of gleet ; but most men, I am inclined to think, would prefer 
 the disease to such treatment with such results. The oculist could 
 "cure "a chronic conjunctivitis in the same way, but I fear the eye 
 would be hardly presentable afterward, and it would surely fail to per- 
 form its function. Still, there are those who treat the same affection of 
 the mucous membrane of the uterus with these destructive agents, and 
 the results which follow can be easily imagined. It may be argued, I 
 am aware, that strong caustics are being used less and less by the pro- 
 fession in the treatment of uterine disease, and I am glad to believe that 
 such is the case. The nitric and chromic acids and other caustics are 
 being laid aside, but only, I fear, to give place in some cases to new 
 but none the less destructive agents: I allude to galvano-cautery and 
 thermo-cautery. These have become the " fashionable " caustics or 
 cauteries of the day, and I most thoroughly appreciate their value in 
 the treatment of malignant disease when the destruction of tissue is 
 called for. But in the treatment of benign inflammation they cannot 
 fail to work a great and uncalled-for destruction, like the other agents 
 used in the past. 
 
 In the management of uterine diseases one may be guided by some 
 of the generally accepted rules laid down by surgeons for the treatment 
 of inflammation generally — viz. : place the diseased organ at rest, quiet 
 irritation by sedatives, and relieve the congestion by depletion, astrin- 
 gents, alteratives, and sedatives. To accomplish these objects we must 
 employ all the improved means brought forward by modern investiga- 
 tion, changing and adapting them so as to meet the peculiarities of each 
 case. First, then, secure rest by having the patient abstain from long- 
 continued standing or walking and from over-excitement of the sexual 
 function. If the uterus is displaced, replace it, and sustain it in its 
 normal position by the supjwrt of a M-ell-fitting pessary if need be. 
 
 To relieve pain and quiet the irritation a vaginal or rectal suppository 
 made of extract of belladonna, one-eighth to one-half grain, with cocoa- 
 butter, used at bedtime, will often give great relief. Suppositories 
 of iodoform and of conium are also of service when used in the same 
 way. 
 
GENERAL TIIEUAPEUTICS. 379 
 
 I desire to call attriitioii spcrially to the next ai:;<'iit — iiaiiK-ly, dcplc- 
 tioii — JH'causi' 1 i-('i;anl it as a remedy of some value. lii maUiii^^ tliis 
 stiitoinent I iiin aware tliat I eiieoiiiiter miieli j(roi'cssi(tiial |ireju<liee. 
 BkHxUettini:; 1i:ls ceased t<» l»e the I'asliioii of the day. The lancet is 
 comleiniK'd as a " little instrument of mij^lity misehief." Few of the 
 VountJ-er menibei-s of the i»r(»fe.ssion have ever si-en ii })atient bled. 
 Local depletion held its own some time after general veneseetiou was to 
 a great extent abandoned, but even this hits gradually given way to the 
 popular prejudii-e of the day. Nevertheless, the fact in surgical thera- 
 peutics remains true as ever, that the removal of bl(»od directly from 
 the vessels of an inflamed or congested organ gives some temporary 
 relief. 
 
 Frequent repetition of bloodletting should be avoided, but when a 
 case is first seen in which there is marked congestion the abstraction of 
 a little blood by a few punctures around the os externum, or the super- 
 ficial scarification of the mucous membrane about the external os, will 
 pave the way to other applications. To practise depletion exclasively 
 and persistently, as some of the older gynecologists did, is certainly 
 injurious, but as a means to be employed in suitable cases it is worthy 
 of consideration. 
 
 Hot water used as a vaginal douche is an antiphlogistic of much 
 value. It depletes the parts by stimulating the circulation, and is 
 M-ithal something of a local sedative. It is an exceedingly popular 
 remedy at the present time, and is used rather indiscriminately in all 
 diseases of the pelvic organs and with heroic persistency. If properly 
 used, it gives relief in congestion of the vagina and uterus, and in 
 cellulitis when the inflammation is limited to the cellular tissue about 
 the cervix uteri. It is also of service in the passive congestion which 
 often accompanies imperfect involution, but in pelvic peritonitis, salpin- 
 gitis, and ovaritis it is often harmful. 
 
 The most effectual way of using the hot-water douche is to place the 
 patient on her back over a bed-pan and use a fountain syringe. The 
 reservoir should be elevated enough to give the required force to the 
 stream. The vaginal tube should be perforated on the sides near the 
 end, but the extreme end should be closed. This will guard against 
 forcing water into the uterus. The temperature of the water may 
 range from 95° to 110° F., the higher temperature being used only 
 when agreeable to the ]iatient. The quantity to be used may be from 
 one to two gallons. "When too large a quantity at a high tem]>erature 
 is used at the beginning of treatment, it sometimes causes fiiintness. 
 It is well, then, to begin at a lower temperature, and gradually increase 
 the quantity as the patient gets used to it. It is also very liable to do 
 harm when used, as it often is, after plastic operations about the cer- 
 vix uteri and perineum. 
 
380 GENERAL THERAPEUTICS. 
 
 Another means of depletion was introduced l^y J. Marion Sims. He 
 used a small vaginal tampon of cotton saturated with glycerin, which 
 caused free exosmosis from the mucous membrane, thereby relieving 
 capillary engorgement and oedema. 
 
 Position has much influence in modifying the circulation in the pel- 
 vis, and hence patients should avoid the too common habit of sitting 
 all day in a chair because tliey suffer when they w^alk. Short periods 
 of walking or riding, followed by rest in the recumbent position, should 
 be directed. 
 
 When from long-continued congestion the mucous membrane of the 
 cavity of the uterus has become hypertrophied, giving rise to that con- 
 dition known now as endometritis polyposa, the use of the curette 
 gives the most promjrt relief. The blunt instrument- should always be 
 used, because it is perfectly effective and free from danger. Dilatation 
 of the cervix with tents as a preliminary to the use of the curette should 
 be avoided. No such dilatation is needed, as a rule. When the mucous 
 membrane is hypertrophied, the canal of the cervix is usually suffi- 
 ciently dilated to admit a curette large enough to do the work. By 
 carefully adhering to this rule of practice the pain and danger from the 
 use of the tents are avoided, which are great advantages to the patient. 
 In the great majority of cases of corporeal endometritis with thicken- 
 ing of the mucous membrane the use of the curette gives prompt and 
 permanent relief. Still, there are some who may require other local 
 treatment. 
 
 There is so much risk in treating the mucous membrane of the cavity 
 of -the body of the uterus that there are certain precautions which should 
 be kept in mind. The principal rules for guidance may be formulated 
 as follows : That intra-uterine applications should not be used until 
 other means have been thoroughly tried and have failed ; the uterus 
 should be in or near its normal position ; the cervix uteri should be 
 sufficiently dilated to allow the fluid to esca])e from the cavity of the 
 body ; such an instrument should be used as will aid in effecting a free 
 reflux or regurgitation. 
 
 After having carefully freed the cervical canal from the secretion, 
 the easiest and most effectual way of making applications is to use a 
 glass pipette Avith a small rubber bulb at one end, the other end being 
 curved like a uterine sound. The solution to be used is drawn up into 
 the glass tube by the rubber bulb ; the instrument is then passed up to 
 the OS internum or to the fundus uteri if desired, and as it is withdrawn 
 pressure upon the bulb forces out tlie solution and brings it in contact 
 wnth the entire lining of the canal. The method generally in use, of 
 dip])ing a probe wrapped in cotton into the solution, and passing that 
 up into the canal, is very unsatisfactory. The cotton on the probe 
 injures the mucous membrane, and tlie solution is deposited about the 
 
G EX Ell A L TilKllM'KrTirS. 381 
 
 OS extcniuiu, very little if any j^ettiii;; iij) into the canal. '\\iv injection 
 or instillation >lioulil l>e made very slowly, IjeeaiLse the uterus will not 
 tolerate distension. 
 
 The hiandest Hiiid on;:;ht to be tried first, in order to te-t the toler- 
 ance of the uterus; a little warm water with tahle-salt 1 have found 
 agreeahle; perhaps cocaine would be the l>est ; and no a;^ent whatever 
 should be used which mitrht jx-rmanently injure the nnicous membrane. 
 
 In most cases the canal of the cervix is sulHcienily ojmmi to permit 
 intra-uterine applications, but it may be neces.sary to pnxiuce dilatation 
 as a pn-liminarv stej). \\ hen such is the ease the u<ii of the uterine 
 dilator will answer. 
 
 The treatment of the cervical canal is fortunately simpler, being 
 more easv to reach and nuicli more tolerant of irritation. The only 
 ditHculty in the way of making ai)plications is the tenacious secretion 
 which tills the canal. This should be removetl with a small curette 
 before makinir the a])plication. 
 
 Regarding the agents to be used in cervix or body a long list might 
 be given. It will suffice to say that the safest and most efficient are 
 mild solutions of sulphate of zinc, chloride of zinc, nitrate of silver, 
 tiimiie acid, tincture of iodine, and carbolic acid, my own preference 
 for general use being tincture of iodine two parts and carbolic acid 
 one part. The fref{ue'.icy with which these local aj)plications should 
 be ma<le depends upon the nature of the lesions. In oi'dinarv cervical 
 and corporeal endometritis ouce every five or six days will suffice. This 
 gives time for the tissues to fully profit by the application made before 
 it is repeated. 
 
 I am aware that the practice with some is to make local applications 
 every day or every other day, but I know that this constant manipulat- 
 ing is irritatiny; and does more harm than Q-ood. 
 
 Cocaine, the therapeutical action of which has recentlv been discov- 
 eretl, is a most valuable addition to the materia niedica. The irvnecol- 
 ogist hfis long felt the need of some agent that would, when applied 
 locally, act as an anaesthetic, and cocaine has largely supplied the much- 
 needed agent. Its chief value is in rendering the parts to which it is 
 applietl less sensitive during the application of curative agents which 
 are necessarily painful. Cocaine lessens the blood-supply in the jiarts 
 to which it is applied, at the same time that it benuml)s them, and on 
 that account it was hoped that cocaine would be a valuable remedy in 
 inflammatory aifections. It appears, however, that its effects are very 
 temporary, and it remains to be seen how efficacious it may be in this 
 respect. 
 
 It has also been used as a local anaesthetic while ])erforming plastic 
 operations ujion the pelvic organs. In this it has ])rovc(l to be too su- 
 perficial in its action to control the pain caused by wounding the deeper 
 
382 GENERAL THERAPEUTICS. 
 
 nerves. Perhaps by using it hypodermically or applying it to the 
 exposed parts as the operation progresses it may prove of yet greater 
 capabilities. So far, I have found it very useful in relieving tenderness 
 of the vulva, which makes examinations of the pelvic organs by toucli 
 and speculum otherwise impossible. 
 
 It also relieves the painful urination of urethritis, and also the pain 
 caused by injections in this affection if used frequently. It also 
 benumbs the mucous membrane of the cervical canal, so that the ute- 
 rine sound or dilator can be used in sensitive cases without the usual 
 pain. Possibly, it may relieve the sensitiveness of the corporeal mucous 
 membrane, thereby rendering intra-uterine medication less painful and 
 dangerous. But this has yet to be demonstrated. 
 
 To carry out a systematic course of treatment, such as has been 
 briefly referred to here, is difficult in general practice. Granting that 
 one has the requisite medical and surgical knowledge, it is difficult to 
 obtain the means necessary. In private life proper nursing is hard to 
 obtain. There are few who can afford a well-trained nurse for any 
 length of time, and if that obstacle be overcome the constant interfe- 
 rence of relatives and friends thwarts the effbrts of both physician and 
 nurse to obtain and keep complete control of the patient. This throws 
 extra care upon the physician or surgeon, and limits the number of 
 cases that one can take charge of. In view of these facts it may be 
 concluded that one can treat a larger number of cases in an institution 
 especially arranged for that purpose with more ease and satisfaction than 
 in private practice. 
 
ELECTRICITY IN GYNECOLOGY. 
 
 Br A. D. ROCKWELL, A.M., M. D., 
 Nkw York. 
 
 While electricity as a therapeutic agent uiuloubtedly finds its widest 
 field in neurologicid eases, yet it is by no nieane to be restricted to the.se 
 contlitions. In every special department of medicine it nmst at times 
 enter as an important factor, and those who would keep abreast the 
 current must reci)gnize this fact. ()[)hthaliuolo<iy, laryngology, derm- 
 atoh)gy, even obstetrics, own its value, but it is in the treatment of 
 certain gynecological cases that its greatest efficacy lies. I have for 
 yeare held that it should occupy a far higher place in the armamenta- 
 rium of the gynecologist than it has yet occupied, but until experts in 
 this department give the subject their personal attention by making 
 themselves familiar w'ith the physics and physiology of electricity and 
 the dilfereutial indications for its use, and finally supplement theoretical 
 knowledge by clinical experience, the popularization of this invaluable 
 remedy for the relief of the disea.ses of women will be slow. 
 
 Almost every disease peculiar to women has been treated by electri- 
 city, and if the many remarkable results recorded could be accepted as 
 typical of the ordinary effects of electrization, it might be considered 
 almost a panacea for this class of cases. 
 
 While disorders of menstruation, engorgements, flexions, prolapsus, 
 atrophy, etc. have all been treated with more or less success, it should 
 always be borne in mind that in the majority of the diseases peculiar 
 to women this success has followed when the electrical has supple- 
 mented, and not superseded, other and more thoroughly approved 
 methods of treatment. In estimating the value of electricity not 
 only in gynecology but in every other class of disease, it is essential 
 that its general therapeutical action be properly appreciated. The 
 old idea that it was merely a stimulant, useful to prick up paralyzed 
 muscles, limited its application for many years to the various forms 
 of paralysis. 
 
 The acceptance of the view that electricity is a tonic, and a'' .such has 
 a powei'ful influence over nutrition, has wrought a revolution in electro- 
 therapeutics, and readily accounts for its value in such a wide variety 
 of disea.ses. 
 
 But not only is electricity a stimulant and a tonic, but under certain 
 
 383 
 
384 ELECTRICITY IN GYNECOLOGY. 
 
 conditions it acts as one of our most efficacious sedatives, and, paradox- 
 ical as the term "stimulating sedative tonic" may at first appear, all 
 experience is in favor of this term as expressive of its place in 
 medicine. 
 
 The stimulating effects of electricity are in reality far less important 
 than those of sedation and improvement in nutrition, and only because 
 its power of stimulation was formerly regarded as almost the exclusive 
 test for the use of electricity in medicine can we account for its slight 
 progress in professional popularity through so many years. AVe now 
 know that it relieves many forms of pain, gives tone to the system, 
 and frequently improves nutrition after ordinary tonics and sedatives 
 have failed. 
 
 As in many of the diseases peculiar to women it is of prime import- 
 ance to improve both the local and the general nutrition, and to pro- 
 duce not only stimulating but sedative effects, it is quite iu order here 
 to say a few words iu regard to the methods by which these results 
 can be obtained. 
 
 General Faradization. 
 
 Electricity is no exception to the general law that in order to obtain 
 the constitutional tonic effects of a remedy the whole system must be 
 brought under its influence. It is not a whit more irrational to expect 
 one to appreciate the full tonic effects of cold water by washing one arm 
 only than it is to expect the full effects of electricity by using it locally. 
 Experience here confirms analogy, and teaches that the constitutional 
 tonic effects of electricity can only be obtained by making the applica- 
 tions all over the person and to the central nervous system. The 
 results of these methods are variously modified according to the con- 
 ditions of disease or special idiosyncrasies of the patient. 
 
 It may be here remarked, also, that there is no remedy to the effects 
 of which there is a more varying degree of susceptibility. Some 
 patients, for example — and perhaps the majority— experience a feeling 
 of enlivenment and exhilaration after a judiciously-directed general 
 application. In others the tendency may be to sleep, and in such 
 cases the patient should be permitted, and even enjoined, to quietly 
 repose for some time after. Because of this disposition to sleep which 
 is so often observed, it becomes in many cases desirable, especially when 
 insomnia is present, to administer the applications at night before retir- 
 ing. The relief from indefinable nervous pains and from general and 
 local weariness is a very agreeable and not infrequent temporary effect 
 of general faradization. Sometimes this feeling of relief lasts for sev- 
 eral hours, and at other times for a much shorter period, but in either 
 case persistent efforts will, as a rule, result iu more or less permanent 
 benefit. 
 
LOr.l L TZF.D FL FXTH IZ. I TION. 385 
 
 The most thoroii;;!! form of «z;tMR'ral furadi/.atioii dcmaiids tliat tljc 
 Avliolo surface of the body, from the erowii of tin; head to the soles of 
 tlie feet, shall he suecossivolv hronjrht under th<; iulluence of the faradic 
 current. Vov this |)ur|)()S(' the feet of the jwtient may he placed upon 
 a broad ])iece of copper, to which the; nei^ativo })i>le is attached, while 
 the positive (either the moistened hand of the ojjerator or a line and 
 soft sj)oni;"e enclosing a metal ball) is applied to the various porticjns 
 of the body. To successfully utilize j»;eneral faradization requires some 
 mechanical dexterity, entire familiarity with the instruments required, 
 a complete knowleduje of electro-therapeutical anatomy, and a personal 
 acquaintance with the sensations and behavior of all portions of the 
 body under tlie different electric currents. The true method of learn- 
 ing the art of general faradization is by repeated observations of its ap- 
 plication to the living subject, by personal experience of its sensati<jns 
 and results at the hands of practised adepts, and by careful experinieiit- 
 ing ou diverse temperaments and in opposite states of disease.^ 
 
 Localized Electrization. 
 
 As the term sufficiently indicates, localized electrization is supposed 
 to affect but a comparatively limited portion of the body, and its effects, 
 primary, secondary, and permanent, are not at all such as those that 
 have just been considered. 
 
 The object of localized electrization is to confine the direct action of 
 the ciu'rent, so far as possible, to some particular part of the body. 
 This is accomplished by placing electrodes so that the current in pass- 
 ing from one to the other shall chiefly traverse the special part to be 
 affected. When the current is localized by means of moistened elec- 
 trodes, it diffuses itself through the body between the electrodes in 
 various directions. The extent of this diffusion will be variously 
 modified by the relative position of the electrodes and the structure 
 and relation of the parts that lie between them. It is manifest also 
 that the effects of the current will be greatest near the electrodes and 
 least at the farthest point l)etween them. The strength of the current 
 being the same, small electrodes are more painful than those with a 
 broad surface, and metallic more than wet sponge or flannel. The least 
 painful form of artificial electrode is a soft sponge with a broad surface 
 and well moistened, or, better still, one of absorbent cotton covered with 
 chamois-skin. 
 
 Localized electrization has to a limited extent the same direct effect 
 on the part to which the ap]ilication is made that general electrization 
 has on the Avhole bodv. The leadino; and (general effect of localized 
 
 ^ For fuller details of tliis method the reader is referred to Beard and Euckwell's 
 Practical Treatise oh Medical and Surc/icat Electricity. 
 Vol. I.— 25 
 
386 ELECTRICITY IN GYNECOLOGY. 
 
 electrization, and one Avhich is a complex result of the various special 
 effects, is inaprovement in nutrition. Localized electrization of an atro- 
 phied or poorly-nourished muscle causes that muscle to improve in size 
 and strength ; localized electrization of an atrophied or poorly-nour- 
 ished organ, as the uterus, causes it to increase in size and improve in 
 functional activity. When the nutrition of an atrophied part is im- 
 proved, it grows larger; when the nutrition of an hypertrophied part 
 is improved, it grows smaller. In both atrophy and subinvolution of 
 the uterus I have iu various instances verified this statement. 
 
 The local treatment of the uterus and its appendages may be either 
 external or internal. The external treatment consists simply in placing 
 one pole in front over some portion of the abdomen, according to the 
 indications of the case, and the other over the lower lumbar region. 
 This method is frequently of essential service in the disorders of men- 
 struation and in ovarian pain, and iu the case of virgins should cer- 
 tainly be attempted before resorting to the internal method. The local- 
 ization of the current in the uterine organs is in this way of course only 
 partial, and far less effective tlian internal applications, and the benefit 
 derived is undoubtedly in part due to the effects of the current on the 
 lower part of the spinal cord and the abdominal ganglia of the sym- 
 pathetic. 
 
 The internal treatment of the uterus and ovaries may be effected in 
 several ways. Usually, the introduction of one pole is sufficient, the 
 other being applied externally either at the nape of the neck near the 
 sixth cervical vertebra, over the lumbar region, or, as is most generally 
 the case, on the abdomen, according to the special indications of the 
 case in hand. 
 
 The internal electrode may be applied either to the cervix uteri, to 
 the interior of the uterus, or in the rectum. In the treatment of dis- 
 placements it has been customary to apply both poles internally, one to 
 the uterus and the cither in the rectum or bladder, according to the 
 character of the flexion. Applications to the cervix are made by lueans 
 of an insulated electrode with a metallic bulb, or, instead of the bulb, 
 small plates may be used to clasp the os. Excepting where cauterizing 
 effects are desired, the internal electrode should be covered with cham- 
 ois, soft sponge, or absorbent cotton. An ordinary Sims sound, if 
 insulated to within about an inch of the extremity, answers very well 
 for an intra-uterine electrode. 
 
 The vagina may be treated by a straight or slightly curved metal 
 electrode — a method which may sometimes prove useful in the treat- 
 ment of leucorrhoea and prolapsu.s.' When we desire in these local 
 applications the mechanical rather than the chemical effects of elec- 
 
 ^ These various electrodes ■will be found illustrated in the catalogues of most instru- 
 ment manufacturers. 
 
LOf'AT.TZF.J) KLKfTUIZATlnS. 3g7 
 
 tricity, as is tlie case in the troatiiiciit of (lisplacouiciits, tin- Caradif mr- 
 rt'nt is to l)(' prct'crrcd to the ^ilvaiiic 
 
 It is an interesting and important I'act to he lioriic in niin<l that 
 internal are relatively far less j)ainful than external application^. \'ery 
 many, therefore, in Hi-st attemptinji; this method of treatment are sur- 
 prised that the sensiitions under the broad surface of the external elec- 
 trode are comj)lained of more than those at the point of contact of the 
 small internal electrode. It may he here stated, in general, that the 
 negative pole is far more frequently indicated for internal apj)lications 
 than the positive. More specific statements will he made when cnii>id- 
 ering individual diseases. 
 
 SniKNGTH OF Current. — In the use of electricity in gynecology, 
 as well as in other forms of disease, it is essential that the strength of 
 the current be always known to the operator. The variation of the 
 strength of the faradic current cannot be so readily appreciated bv anv 
 instrument of precision as can that of the galvanic current, and fortu- 
 nately the same necessity does not exist. The strength of the former 
 can always be approximately estimated by the appliances attached to 
 the apparatus. 
 
 For the intelligent use of galvanism, however, a galvanometer, 
 registered in milliamperes, is of the first importance, and no one can 
 hope to perform satisfactory work without it. There can be no question 
 but that too weak currents have hitherto been used in the treatment of 
 many diseases of the female sexual apparatus. Various conditions 
 which I formerly failed to relieve have of late years responded far 
 more readily to treatment, simply because of the greater intensitv of 
 current that I have, with increased boldness, attempted. Opinions 
 may differ in regard to the number of milliamperes necessary to 
 accomplish a given object. Some observers, and notably Apostoli in 
 France, make use of most powerful currents; in the treatment of uterine 
 fibroids and hyperplasia uteri especially his milliamperes often register- 
 ing considerably above a hundred, and Engelmann claims to have gone 
 as high as two hundred and fifty. Excepting for electrolytic jiurposes, 
 however, it is rarely necessary to use a strength of more than fifty milli- 
 amperes. 
 
 The covering of the metal electrode is not of prime importance, so 
 long as the proper strength of current is attained. This much may, 
 however, be said in regard to electrodes : they var\' decidedly as to 
 their conductibility. The ordinary sponge electrode is necessarily 
 bulky, offering a greater resistance to the passage of the current than 
 some others. A large amount of electrical force is therefore lost. This 
 loss cannot be afforded, especially when the phvsician, as is generally 
 the case, has but a limited number of cells at command. Far better 
 than sponge, in that it conducts more readily and can be changed for 
 
388 ELECTRICITY IN GYNECOLOGY. 
 
 every patient with little expense, is the ordinary absorbent cotton. A 
 thin layer is spread over a flexible metal plate with a covering of 
 chamois. 
 
 The size of the external electrode is determined by the strength of 
 the current. It should vary in diameter from two to six inches or more, 
 according as the current varies from five to fifty milliamperes in strength. 
 Such details, however, each worker will readily discover for himself. 
 Individuals are so differently susceptible in this respect that no state- 
 ment in regard to size of electrode is applicable to all. A statement 
 that has been already made I here repeat : It should never be forgotten 
 that the female generative organs are not at all sensitive to electrical 
 applications, whether galvanic or faradic. The most excessive pain 
 may be occasioned and decided escharotic effects follow where the 
 electrode is applied to the skin, while absolutely no sensation has been 
 experienced at the point of contact of the internal electrode. The inter- 
 nal electrode will cause little or no pain even when a strength of fifty 
 and even more milliamperes is used, and the only way to obviate the 
 acute burning at the external electrode is to have it very large, covering 
 even the whole abdomen if necessary. For this purpose Apostoli uses 
 a layer of clay over the abdomen. This, however, is not necessary, as 
 a well-covered plate, say of heavy tin-foil, kept in place and closely 
 applied to the skin by a sand-bag, will do equally well. 
 
 Disorders of Menstruation. 
 
 Amenorrhsea, dysmenorrhoea, and menorrhagia are the symptoms for 
 the relief of which electricity in some form is very frequently indi- 
 cated, but the measure of success to be obtained by this as by all other 
 methods must depend upon the causes or special character of the symp- 
 toms. It is often asserted that electrization acts most capriciously in 
 these affections, but to all who are conversant with uterine pathology 
 these inconsistent results are entirely explicable. Cases that are in- 
 discriminately treated must frequently result in a manner very disap- 
 pointing. 
 
 In offering a favorable prognosis in a given case of suppressed men- 
 struation it is assumed that no serious local pathological condition exists. 
 In cases associated with, and more or less dependent upon, chlorosis or 
 nervous exhaustion the important thing is not to specially stimulate the 
 uterus, but to change the constitutional condition which is the cause of 
 the suppression of the function. Accordingly, the treatment by general 
 faradization, combined with such internal medication as may be spe- 
 cially called for, is generally sufficient without applications directly to 
 the uterus. Indeed, the majority of cases of functional disease of the 
 uterine organs require general as well as localized electrization. There 
 
j)is()i:i)i:i:s of Mhwsr/n'ATiox. 389 
 
 is IK) (Icpai'tmciit in wliidi iiu»ic inistaUcs have hccn made hv too cxclii- 
 sivc'ly local I'lictrical trratiiu-iit than in j;ynfcolo;ry. 2S'o case of I'iuk;- 
 tional tli.stnil)an((' of tlic nicins >lionl(l he ahaiidoned until {xciicral uh 
 well as oxti'rnal and internal loc;di/('d electrization has heen tried. Oik; 
 of the stron<;-est evidences of the heuelicial residls to he ohtained hy 
 general fara«lizatioii in cases of anienorrhu3a lies in the fre(|iiently 
 ohserved fart that, when treated for other conditions, patients not 
 infrecjucntly speak of some chanjie in the character of the menses. Jn 
 some cases they are brought on before their time — in others, much 
 increased in (juantity. 
 
 In addition to methods of application there are several other })oints 
 to be considered. The time of making the applications is not unim- 
 portant. It is an advanta;j;e, in amenorrlKoa at least, to concentrate a.s 
 many aj)j)lications as possible during the few days that i)recede the time 
 for the api)earance of the menses. And yet, as the great thing in all 
 but recent and temporary cases is to remove the chlorosis or nervous 
 exhaustion with which the menstrual disorder is associated, and of 
 which it is a prominent factor, the advantage of this is hardly as great 
 as has been supposed by some. AVhatever method is used, time is also 
 necessary to ensui'e results. While it is true that a single application, 
 especially internal, may bring on the menses — may even cause the blood 
 to appear during the sitting — ^yet in the majority of instances treatment 
 must be more or less protracted in order to ensure permanent relief. 
 
 The kind of electricity to be used is also a question of prime import- 
 ance in the treatment of amenorrhea. All three forms, galvanic, 
 faradic, and franklinic, have been used successfully, and not infrequently 
 M'hen one kind fails after repeated efforts another succeeds. Experience 
 has not, however, altogether failed to afford some data for the best 
 methods of procedure. In any case of amenorrhcea where the patient 
 is weak and ansemic, with other and well understood evidences of mal- 
 nutrition, the faradic current is strongly indicated over the galvanic. 
 As already stated, the applications should be general, althoutrh the 
 local treatment, when permissible, is always in order and undoubtedlv 
 hastens the effects desired. Localized galvanization is, as a rule, not 
 only not indicated, but in many cases, as I have had abundant occasion 
 to observe, tends to induce a condition of nervous irritation that is 
 exceedingly unpleasant. It is only as regards the local application that 
 this objection to the use of galvanism holds in these cases. Central 
 galvanization may very effectually supplement the action of general 
 faradization in the hysterically inclined and the sleepless, calming fre- 
 quently in a wonderful degree and producing refi-eshing slumber. If, 
 on the contraiy, the patient is robust and of a fidl habit, galvanism is 
 likely to be of far greater service than either faradism or franklinism. 
 
 The applications should by preference be local and internal, although 
 
390 ELECTRICITY IN GYNECOLOGY. 
 
 external treatment alone may in many cases be sufficient. As it is 
 often desirable that mechanical effects be produced, it is frequently of 
 service to rapidly interrupt the current, taking care to avoid too pow- 
 erful contractions of the external muscles, I have frequently known 
 menstruation to follow the use of franklinic electricity, but a consid- 
 erable experience has convinced me that it is for this purpose not only 
 inferior to dynamic electricity, but in the long run is equal to neither 
 of its two forms, galvanism and faradism. For some unexplainable 
 reason, however, it does in this disease as in several others sometimes 
 act when dynamic electricity has failed, illustrating the limitations of 
 our knowledge of the differential indications for the use of the differ- 
 ent forms of electricity. In regard to the choice of poles, it makes 
 little if any difference when the faradic current is used which is 
 selected. In the use of galvanism, however, I most decidedly prefer 
 the positive pole as the internal. Its superiority over the negative pole 
 for the relief of this symptom depends most probably upon its greater 
 influence over unstriped muscular fibre. 
 
 Dysmenorrhcea. — The very satisfactory results that frequently 
 follow the applications of electricity in dysmenorrhcea will not' be 
 denied by those who have had any adequate experience in its use. 
 Either of the three forms of electricity may be of service, but, as a rule, 
 the galvanic current is far more effective in affording relief than either 
 faradism or franklinism. It is in the so-called neuralgic dysmenor- 
 rhcea and that due to spasm of the os uteri that galvanism is more 
 especially called for. External applications alone are sometimes suf- 
 ficient, but if these fail the case should not be abandoned until the 
 internal method is faithfully tried. 
 
 In many cases great relief will follow applications to the cervix uteri 
 after persistent external treatment has failed. To those who understand 
 the physical and chemical effects of galvanism it would seem hardly 
 necessary to say a word against the use of anything but a steady con- 
 tinuous current, yet instances not a few have come under my observa- 
 tion where practitioners have failed to C!onsider this simple point, and 
 have thus occasionally aggravated the symptoms for which relief has 
 been sought. In most cases of ordinary dysmenorrhcea, whether treated 
 externally or internally, my method is to gradually increase the strength 
 of the current without interruptions. 
 
 The strength Avill depend altogether upon the character of the case 
 in hand. Some will bear, and be benefited by, a current of thirty 
 milliamperes and more, while others wouJd receive injury rather 
 than benefit from such strong currents. Let the first application 
 be tentative, and the strength best suited to the case will soon be 
 found. When prolonged and strong applications are necessary, the 
 ordinary uterine electrode applied directly against the tissues is some- 
 
DISORDERS OF MESSTRVATIOy. .•>91 
 
 times followed hy iukIik' local ii'ritatioii. 'J\» avoid this the f'ollowiiif^ 
 ineth(Kl eati Ije lollowed to advautaj^c : Soft and line sprtji^ros may he 
 ciiref'ully packed around the cervix, pressing up against the ImxIv ol'the 
 uterus. Against these is gently hut firmly pressed a flat nu-tallie elec- 
 trode covered with wet ehamois-skin. Jiy interralating a rheostat, and 
 heginning with the least possible current-strength, the nundjer of cells 
 that mav gradu:dly and without discomfort be brought int(» the circuit 
 far exceeds the mnnber that could be used without this preraution. It 
 will be readily understoinl that in gradually increasing the current in 
 this way it is as important to as gradually decrease it before removing 
 the electrodes. 
 
 In amenorrhcea, either pole, when applied to the uterus, may be fol- 
 lowed by the best of results. The negative in the subjective sensations 
 that it causes is the stronger, but the positive Ls decidedly preferable 
 in some cases, because its tendency is to more readily contract the 
 involuntary muscidar fibres. In the treatment of neuralgic dysmen- 
 orrhcea, also, the positive pole locally applied is undoubtedly prefer- 
 able. On physiological grounds alone this conclusion might readily 
 enough be reached, but, unfortunately, electro-physiology is as yet but 
 a very uncertain guide in many casas. I have therefore for years care- 
 fully observed, and as carefully recorded, the differential effects of the 
 poles in this condition, and have become convinced that the average 
 results are superior when the positive pole is used. When, however, 
 dysmenorrhcea is due to mechanical causes that are well defined, when 
 the nerve-filaments are pressed upon by exudations, when the canal 
 is occluded by chronic inflammatory swellings, — the negative pole is 
 alwavs to be used. 
 
 Menorrhagia. — In the electrical treatment of menorrha^ia the 
 results are not so frequently efScacious, by any means, as in the forms 
 of disordered menstruation just considered. In very many cases its 
 origin is such that electricity can prove of but little if any value, while 
 there arc other cases where the benefit to be derived cannot be over- 
 estimated. On the same principle that we use general fm-adization in 
 cases of amenorrhcea associated with, and perhaps dependent upon, a 
 weak chlorotic condition of system, we make applications of it where 
 similar symptoms are associated in the menorrhagic subject. In not a 
 few such cases I have known simple external treatment by this method 
 to be followed by comj^lete and permanent cessation of the excessive 
 flow and a corresponding improvement in appearance and strength. 
 In menorrhagia due to such local causes as misplacements, intra-uterine 
 morbid growths, certain affections of the ovaries, etc. ordinary electrical 
 applications are of doubtful efficacy. Electrolytic interference, however, 
 where uterine fibroids or polypi are the cause of the excessive flow not 
 infrequently effects most marvellous changes. Ou the other hand, when 
 
392 ELECTRICITY IN GYNECOLOGY. 
 
 an excessive flow occurs (especially toward the decline of sexual activity), 
 partially dependent perhaps on inactivity of the liver or constipation and 
 associated with a degree of nervous exhaustion, the indications are self-evi- 
 dent, and are excellently met by the powerful constitutional tonic effects 
 of general faradization. A notable illustration of the remarkable results 
 that may follow treatment in such condition was illustrated in a com- 
 plicated case that I once saw with Dr. W. G. Ailing. The patient was 
 a married woman, aged forty-six, who for at least four years had suf- 
 fered at each menstrual period a frightful loss of blood. The imme- 
 diate effects were to render her completely colorless and almost pulseless, 
 from which she slowly rallied, to be again similarly reduced by a return 
 of her courses. It is quite evident that if menstruation had occurred 
 every four weeks, the patient could hardly have survived for so long 
 a time her repeated depletions; as it was, she was just enabled, by the 
 aid of a good appetite and vigorous digestion, to regain a measure of 
 strength and color before the recurrence of her trouble. The intervals 
 between the recurrences of menstruation were ordinarily from six weeks 
 to two months. I began treatment by general faradization in the decline 
 of one of these hemorrhages for the relief of the persistent insomnia 
 resulting from her aneemic condition. It aided very greatly in inducing 
 sleep and relieving pain, and markedly hastened returning strength. 
 Shortly after these tentative applications were begun I met, at the house 
 of the patient, Dr. Ailing, under whose care she had been a short time 
 before, and from whom she had received continued and judicious 
 treatment, both constitutional and local, but without decided relief. 
 The uterus was found to be three and a half inches in length and 
 slightly retroverted, and when the probe was carried into the cavity at 
 the first examination slight hemorrhage followed its withdrawal and a 
 small fungoid mass came away. Further examination revealed consid- 
 erable fungoid degeneration of the mucous membrane. 
 
 I proposed alternating the general treatment with intravaginal and 
 mild iutra-uterine applications (five to eight milliamperes). This 
 method of procedure was repeated up to the day of menstruation, the 
 patient in the mean while having regained, with far more than ordinary 
 rapidity, her color and strength. The flow Mas considerably more 
 profuse than normal, but could not be compared in severity with those 
 that had previously occurred. In ten days the flow ceased, and treat- 
 ment was continued until the return of the catamenia, when a still 
 greater improvement was evident. For three months this treatment 
 was kept up, when the patient left the city for the summer with the 
 feeling that her recovery was an assured, if not an accomplished, fact. 
 Several years have since elapsed, but there has never been a recurrence 
 of these hemorrhages, and the patient has at all times since been in 
 the enjoyment of excellent if not robust health. 
 
OVARITIS AM) OVAIIIAN NEURALdlA. 393 
 
 Ovaritis and Ovarian Neuralgia. 
 
 Rensoiiiiii;- iVom Miialouv and I'loiii the wdl-kiiuw n ])liysicai and 
 pliysiolon-ical c'lU'cIs ol' t'lccti-icity, i( is (|ui(r certain tlial this a^(•nt, in 
 sonic lorni and 1)V some of (lie various inetliods oi" a|)|)lication, ou;;lit 
 to liavc a certain \'aliic in o\arian ncnraii^ia, and cncu in I lie .subacute 
 and chronic varieties of ovaritis. Kxpcriciice very positively confirms 
 these tlieorctical suj!;<;-estioiis, hut \)\ no means so uiiilormly as in con- 
 gestions and neuralt2;ic pains of a more siiperlicial < haiacter. , 
 
 In anv ,<>;ivcu ca.se of chronic ovarian pain it is impossihle to speak 
 positively in rcu'ard to the measure of heiicHt to l)e obtained by tiie use 
 of electrieitv. 'I'iie only tliinu: to do is to make an cllbrt, and in a cer- 
 tain proportion of cases the results obtained will abundantly reward us 
 for the labor expended. 
 
 Nor is it always possible to decide beforehand what form of electricity 
 or Avhat methixl of aj^plication is specially indicated. In the treatment 
 of neuralgic pains in general I have found that certain symptoms, read- 
 ily enough elicited, are of much value in enabling one to decide as to the 
 hind of electricity needed. Reference is made to the effects of pressure, 
 ■wliii'h generally either increases the pain or to a greater or less extent 
 affords a sense of relief. In the first instance galvanism almost inva- 
 riably is to be preferred to faradism in the local application, although 
 the faradic current in many of these cases may be ap})lied Avith ad- 
 vantage by the method of general faradization. The surface stim- 
 ulation has an undeniably beneficial action as a derivative, probably 
 through the reflex influence exerted, Avhile the generally sedative and 
 at the same time tonic action of thorough applications is often .seen 
 in an equalization of the circulation and consequent relief of local 
 congestions. 
 
 On the contrary, in those forms of pain M"here firm and prolonged 
 pi-essure is followed by a sense of relief the faradic current locally ap- 
 plied is, as a rule, far more efficacious. In many cases of this kind I 
 liave even known galvanism to aggravate the distress. This principle 
 as to the effects of pressure, although by no means an ab.solute law, is 
 an exceedingly useful guide in differentiating between the two forms 
 of dynamic electricity for the relief of external neuralgia ; and in the 
 same way, although perhaps to a less extent, I have found it valuable 
 in the consideration of the treatment of ovarian ]xiin. As illustrating 
 this point, I briefly refer to the case of a young lady .sent me by Dr. T. 
 G. Thomas. This jmtient was and had been suffering for months from 
 a pain of a dull, aching character in the region of the left ovary. No 
 internal apjilication was made by me : I therefore cannot say as to the 
 sensation that might have been produced by pressure more directly 
 against the ovary, but from without the deepest and firmest pressure 
 
394 ELECTRICITY IN GYNECOLOGY. 
 
 was followed by no sense of discomfort ; on the contraiy, such pressure 
 was felt to be a grateful relief. Local applications of the faradic cur- 
 rent through a period of several weeks appreciably relieved the pain, 
 but failed to entirely dissipate it. Franklinism was now resorted to. 
 The patient, seated on the insulating stool, was subjected to a surface 
 stimulation over the affected part, and with the result, after a few appli- 
 cations, of entirely and permanently relieving the distress for which 
 relief had been sought. 
 
 It is in deep-seated, dull, and aching pains that franklinism by 
 means of the roller electrode is especially efficacious, and in some cases 
 of ovarian pain where pressure does not increase the distress it is more 
 efficacious than faradism. In an undoubted case of chronic ovarian 
 inflammation, however, galvanism is without doubt far more efficacious 
 than the other forms of electricity, and in doses of from ten to twenty- 
 five milliamperes is often followed by most grateful relief. 
 
 Subinvolution, Superinvolution, and Atrophy. 
 
 That nutrition may be variously modified by electricity is now an 
 accepted fact, and yet its action upon normal and abnormal tissue may 
 be diametrically opposite. This apparently paradoxical action of elec- 
 tricity is no new thing. We constantly find that it relieves both anaes- 
 thesia and hyperesthesia. It is used successfully to excite torpid excre- 
 tory processes, and also to restrain this function when too active. In 
 the same way it may cause increase or it may cause diminution in the 
 size of a part or organ. Goitres, for example, are readily reduced in 
 size, and sometimes entirely disappear, under simple external galvan- 
 ization ; and so with other forms of morbid growths. On the other 
 hand, it is well known to all whose experience has been at all extended 
 that normal tissue may be surprisingly developed by jDersistent local 
 application. 
 
 It is perhaps not out of place to say here, as an illustration of this 
 point, that the arms of the author have been much increased in size, 
 and even strength, by the frequent action of a current of faradism on 
 them through a series of years in the line of professional work. Guided, 
 then, by this experience, we may reasonably expect that more or less 
 benefit will follow the application of electricity in the opposite condi- 
 tions of sub- and suj^erinvolution, and also in atrophy of the uterus. 
 In superinvolution I have had satisfactory experience in but one case, 
 where the condition was due to a dangerous and difficult labor in which 
 it became necessary to dismember the child. For two years menstru- 
 ation had appeared but two or three times, and upon measurement the 
 uterus was found to be but about one and three-fourths of an inch in 
 length. The patient was treated almost daily for about three months 
 
SVBLWOLUTIOy, SUI'ERISVOIJ'TIOy, AXJ) ATI'JU'IIY. 300 
 
 l>y iiittTiial :ij)j»lic:i(i(»iis ot" hulli farailisni and jralvaiiisin, wlicii a sli<;lit 
 show apjK-aivil. The neirative pole wits used directly {o the uterus per 
 vajjjinani, and od'a-sionaliy intru-uterine applieiitions were made. At 
 the next nienstiniation, a lew weeks sui)S((juently, the How was nuieh 
 more abundant. 1 rej^ret to siiy that alter the first month I nej^leeted 
 to repeat the measurement, and since the rather sudden diseontinuanc« 
 of treatment no opportunity has presented itself, The rcap|)earance of" 
 menstruatiou would, however, seeui to be sufHeieut evidence of" the entire 
 success of the efforts made. 
 
 Dr. Fordyce Barker, in some remarks made In'forc a late meetin*:: of 
 tlic Amerieau Gynecological Society on superinvolution, declared that 
 but a small proportion of cases could be benefited by any method of 
 treatment. In his o|)inion very little could be accomplished when the 
 difiiculty was associated with evidence of arrested or defective ovulation, 
 while in those cases where benefit was derived there w'as always evi- 
 dence of active ovulation. He enumerated as symj)toms of the exist- 
 ence of ovulation associated with superinvolution disturbance of the 
 vascular or nervous system at or near the menstrual period, such as 
 intense headache, flushing of the face and congestion of the eye, pelvic 
 pain and sense of dragging, with nausea, vomiting, etc. In the fore- 
 going case some of these symptoms were distinctly marked, and so far 
 forth are confirmatory of Dr. Barker's experience. At stated periods 
 there were severe headache, pelvic pains, aud nausea ; associated with 
 these symptoms, and far more persistent than any of them, was intense 
 melancholia. With the return of menstruation all these disturbing: 
 symptoms disappeared. 
 
 In subinvolution of the uterus my experience has been somewhat 
 greater. Among several cases where undoubted amelioration occurred 
 I have in mind one in particular which Dr. T. G. Thomas saw with 
 me aud pronounced to be one of subinvolution. The menstruation 
 was excessive, with abundant leucorrhoea, together with other symj)toms 
 attributed to the size and weight of the organ. Occasional local appli- 
 cations of the galvanic current wrought within a few months a verv 
 great change in the condition of things. The menstruation, instead of 
 being excessive and continuing for nearly a week, became almost scantv, 
 with a duration of only twenty-four horn's, the leucorrhoea ceased to 
 annoy her to any extent, and the various other symptoms supposed to 
 be dependent upon the enlarged uterus entirely disapi)eared. In most, 
 if not all, cases of subinvolution we must depend mainly ujion the gal- 
 vanic current, although the faradio current is by no means useless. The 
 negative pole is applied internally, and a strength of from twenty to 
 forty railliamperes is amply sufficient. 
 
396 ELECTRICITY IN GYNECOLOGY. 
 
 Uterine Displacements. 
 
 That electricity is capable of being utilized far more than it ever has 
 been in the various forms of uterine displacement, in this country at 
 least, there can be but little doubt. The rationale for its use is indeed 
 so clear that from the standpoint of theoretical considerations alone one 
 might be pardoned for regarding it as almost a specific in this class of 
 cases. 
 
 The two most important factors that make up the value of electrical 
 applications in displacements are probably the hypersemia, and especially 
 the contraction of muscular fibre, that follow its use ; and as the con- 
 traction of a muscle determines the amount of its nutrition, it follows 
 that if a current of electricdty is localized in a given point of the uterus, 
 that part will contract, its nutrition be improved, and at the same time 
 counteract any flexion in the opposite direction. It must be confessed, 
 however, that even in experienced and competent hands the results of 
 electrical treatment in this special field have not equalled the brilliant 
 promises of some, and especially of Tripier, who has written much 
 upon this topic. As the effects we desire in these cases are purely 
 mechanical, the faraclic current is the form indicated. The simplest 
 and probably least efficacious method is to introduce one electrode 
 behind the os uteri, while the other is applied externally over either 
 the pubes or the sacrum. As the internal electrode is larger than that 
 employed in intra-uterine applications, and the mucous surface not so 
 sensitive, a much stronger current can be employed ; and so far forth 
 this method has an advantage over applications to the interior of the 
 uterus. In prolapsus uteri much benefit has often followed this method 
 of treatment by the tone imparted to the relaxed vaginal walls. A 
 more effective localization of the current is accomplished by introdu- 
 cing one electrode into the uterus, while the other is placed externally ; 
 but more effective still is the internal use of both poles. In cases of 
 anteflexion, one pole, the curve of its stem corresponding to that of the 
 sacrum, is introduced into the rectum up to the point nearest the poste- 
 rior wall of the uterus. In this way the current is quite accurately 
 localized in the posterior uterine wall, causing contraction and improv- 
 ing nutrition. In retroflexion the first electrode, instead of being 
 passed into the rectum, is introduced into the bladder and applied to 
 the anterior wall of the uterus. When the faradic current is used — 
 and this form is chiefly indicated — the relative positions of the poles 
 would seem to be of no special importance, although for the intra- 
 uterine electrode the anode is preferred by some, on the theory that it 
 has a greater power over uustriped muscular fibre. Tripier, however, 
 recommends that the negative pole be placed in the uterus, because it 
 is the stronger (in the sense of being more powerfully felt). 
 
J'F.llirTKIlIM': Il.h'MATOCKfJ-:. 397 
 
 'riu' pain is soinetinies coiisidiTal)!!', and is due (o I \\i» causes : 1st, 
 the coiicciitrali'd action of the electricity on the nincoiis incniliranc; 2(1, 
 the contraction of tlic ntci'inc librcs. In other cases vi^vy little dis<'oin- 
 I'ort is prodnccd. \W l)e<:;innin<;' with a ycyy weak current and ;;i-adu- 
 allv increasintr it a much >'Tt!ater stren<«lh can he endured than if this 
 preeaution is not ohserved. In this eoinieetion it may he pertinent to 
 the suhjeet to say that when voluntary nuiscles are subjected to the 
 action of the poles of oitluir a <;alvanic or eleetro-nia<;netic battery con- 
 tractions instantly occur. Those contractions continue, as is well known, 
 durinji; the passage of the faradi<' cm-rent, but quickly relax after the 
 fii"st shock of the o-alvanic. When, on the contrary, invohnitary mus- 
 cular librc <»f which the uterus is composed is subjected to the influence 
 of the electric current movements are not induced until a certain time 
 after the tissues have been acted upon. The movements thus excited 
 continue for a time after the cessation of the current, and do not, as 
 in the case of voluntary nmscles, cease as soon as the electrodes are 
 removed. 
 
 It lias been observed time and time again in the electrical treatment 
 of uterine affections, when the local method only has been used, that 
 marked effects upon the general system have been produced and severe 
 symptoms of hysteria, neuralgia, and nervousness have been greatly 
 ameliorated. If with the local we combine the general or central treat- 
 jnent to Mhicli allusion has already been made, these constitutional 
 effects become much more marked. An interesting point to which I 
 have given much observation relates to various nervous symptoms 
 and certain pathological conditions of the female generative organs 
 as they are connected as cause or effect. 
 
 This subject need not l)e discussed here further than to refer to the 
 difficulty that is frequently experienced in forming a correct opinion 
 as to whether various neuralgias and other kinds of pain, together Avith 
 certain characteristic nervous derangements associated with uterine dis- 
 orders, exist independently or are dependent upon such disordei-s. Too 
 frequently, without doubt, such dependence does exist, and all efforts to 
 alleviate the nervous symptoms prove more or less futile until the orig- 
 inal uterine difficulty has been overcome. In other cases, as I have 
 demonstrated to my satisfaction many times, severe hysterical symp- 
 toms, neuralgias, etc., supposed to be entirely dependent upon disease 
 of the uterus or its appendages, recover in great degi-ce under electrical 
 treatment, while yet no progress has been made in the purely local 
 treatment. 
 
 Periuterine Hematocele. 
 Apostoli treats these tumors by the chemical caustic action of the 
 negative pole. A non-retractile fistula is thus made, the tendency of 
 
398 ELECTRICITY IN GYNECOLOGY. 
 
 which is to remain open and with adhesions between the pathological 
 cavity and the external mucous niembrane. The strong caustic action 
 obtained by this method modifies the nutrition of these pathological 
 cavities and leads to rapid retrograde metamorphosis. The method is 
 quick in action, and he claims for it perfect safety. It is a2")plicable 
 as well to abscesses, fibromata, interstitial myomata, and extra-uterine 
 cysts. 
 
 Ovarian and Fibroid Tumors, Polypi, etc. 
 
 In ovarian and fibroid tumors the electrolytic method is undoubtedly 
 worthy of consideration, although the results have not as yet been suf- 
 ficiently satisfactory, in ovarian tumors at least, to commend themselves 
 strongly to authorities in the department of uterine surgery. The fol- 
 lowing is an extract from a resume of what has been attempted and 
 accomplished in the electrolytic treatment of ovarian tumors : ^ " 1st. A 
 number of ovarian tumors reported on reliable authority have been 
 completely cured or permanently improved by electrolysis; twenty- 
 eight out of fifty-one cases, or about 55 per cent. 2d. In a number 
 of these cases electrolysis was followed by dangerous (thirteen, or 25.4 
 per cent.) and even fatal results (nine out of these thirteen, or 17.6 
 per cent, of the whole fifty-one). 3d. Further, six cases out of fifty- 
 one received neither benefit nor injuiy from the treatment, and four 
 were only temporarily improved; total, ten, or 19.6 per cent. We thus 
 have a total of twenty-three cases, or 45 per cent., in which the elec- 
 trolytic treatment failed to accomplish the object for which it was 
 
 administered 6th. Notwithstanding these undoubted cures the 
 
 percentage of successes of oophoro-electrolysis (55 per cent.) compares 
 unfavorably with that of ovariotomy (70 to 80 per cent. ; Spencer 
 Wells, 78 per cent. — in 1876 as high as 91 percent.) And so also 
 do the deaths by electrolysis (17.6 per cent.) nearly equal those fol- 
 lowing ovariotomy in recent years (20 to 30 per cent., to 22 per cent.), 
 and far exceeding those occurring in the last series of fifty-five cases of 
 Spencer Wells (5 or 9 per cent.)" 
 
 The method of operation in these cases is simple, and, with a proper 
 knowledge of electro-physics and a greater experience in the details of 
 treatment, it goes without saying that better results ought finally to 
 reward efforts in this direction. While the percentage of cures by 
 electrolysis could, in all probability, never rise as high as in ovariot- 
 omy, fatal results ought to be reduced to a minimum. In other words, 
 in those cases where no benefit accrues I believe it to be quite possible 
 to avoid injury in nearly all cases. 
 
 In the treatment of uterine fibroids by electrolysis we can rarely 
 
 i"TheValne of Electrolysis in the Treatment of Ovarian Tumors," Gynecological 
 Transactions, 1878, by Paul F. Munde, M. D. 
 
or.iAv.i.v .Lv/> Fin no 1 1) tumors, polypt, etc. 399 
 
 li(>|K' to see tliein (lis:ii)]M:ii' entirely ; iii(lee<l, where onliiiarv surf!:ieal 
 proeedure is possiMe there is no reason lor atteniptint;- this nietho(L Jii 
 some eases ot"an intraninral character, liowever, where radical operative 
 stej)s are inadmissihle, luiicli can lie aeeoinplished lor the relief of the 
 patient. 1 have referred elsewhere' to the very enconra^in^ resnlts 
 obtained in several such eases, hut in no instance was tin- relief more 
 marked than in a recent ease, whieli is worthy of record as illustrative 
 of the <ireat Ix-nelit that mav result from the metliod : 
 
 The patient, a maiilen lady aged forty-seven, had begun to suffer in 
 this way many years before. She had consulted various authorities 
 both liere and abroad — in this country Dr. T. Addis Emmet, who pro- 
 nounced it a case of intramural fibroid. Without attempting to give 
 dimensions, it is sufficient to say that the tumor was quite large, and 
 while it interfered greatly with easy and rapid locomotion, this was of 
 little consequence compared to the inconvenience and actual distress due 
 to pressure both on the rectum and bladder. The cervix uteri was greatly 
 enlarged, and almost like cartilage in the sensation it gave to the touch : 
 as a result, she sutfered much from incontinence of urine, while the 
 constipation was excessive and had to be relieved by frequent injections. 
 The benefit following the absorptive action of the galvanic current in 
 this case was most marked. The neck of the uterus became appreciably 
 softer and very decidedly reduced in bulk, and the patient returned to 
 her home almost entirely relieved of the distressing symptoms from 
 which she had suffered so long. 
 
 In those cases where it can be readily accomplished the electrolytic 
 method may be attenijited, and in a certain proportion of cases radical 
 results have been said to follow. The very strongest currents must be 
 used, but, notwithstanding, in the majority of cases fibroid tumors, 
 whether internal or external, will not entirely disappear, even under 
 the most thorough electrolytic treatment. 
 
 External fibroid tumors indeed are hard and drv — rlo not in anv case 
 readily respond to electrolytic action. In uterine fibroids, however, the 
 process of absorption seems to be more readily excited bv electrolvsis, 
 and the treatment is worthy of more extended trial in cases not suitable 
 for the knife. There can be no question that by means of negative 
 electro-puncture, and Avith currents of the strength of forty or fifty 
 milliamperes, uterine ]iolypi can be successfully treated. Both Apostoii 
 of France and Engelmann of this countr\- use, however, much stronger 
 currents than this in the electrolytic treatment of fibroid tumors. Engel- 
 mann claims to have used as high a strength as two hundred and fiftv 
 milliamperes with no ill effect. It can seldom, if ever, however, be 
 necessary to attempt such heroic treatment as this, but if ever attempted 
 it should be only through a gradual increase of the current-intensity. 
 ^ Lectures on Medical and Surgical Eleclricity, p. 106. 
 
400 ELECTRICITY IN GYNECOLOGY. 
 
 In order that such extraordinary intensity of cuiTent may not cause 
 great pain, Apostoli uses an electrode for external application sufficiently 
 large to almost entirely cover the abdomen. This electrode is sculptors' 
 clay, held in place by gauze. A material easily obtained, and answer- 
 ing perhaps equally well, is absorbent cotton. A thin layer, sufficient 
 to retain a moderate amount of moisture, may be placed upon a large 
 flexible metal electrode, the cotton being covered by chamois-skin. In 
 the electrolysis of fibroid and other tumors the needle to be introduced 
 into the tumor should, as a rule, be connected with the negative pole. 
 There can indeed be very few exceptions to this rule. 
 
 Apostoli teaches that if hemorrhagic tendencies exist the positive 
 needle should be used, since the effect of the positive pole is to arrest 
 hemorrhage through coagulation. If the tumor is easily accessible, 
 needles connected with both poles may be introduced into the tumor. 
 Engelmann teaches that if profuse menorrhagia or metrorrhagia be 
 associated with fibroids, these tendencies must be overcome by positive 
 electro-cauterization before resoi'ting to electrolysis. A platinum sound 
 is used, and a current of one hundred milliamperes is applied to the 
 uterine cavity. 
 
 In applying the positive pole to mucous membranes, platinum or 
 gold should always be used, since other metal electrodes, such as silver, 
 copper, or steel, readily become oxidized and imbedded in the tissues. 
 In the positive electro-cauterization of hemorrhagic fibroids, which 
 should precede negative electro-puncture, the rule is to use a current- 
 strength of one hundred milliamperes or thereabouts. If a copper or 
 silver probe is used, the strength must be much less, not over ten or 
 fifteen milliamperes. 
 
 For the electrolytic treatment of fibroid tumors, says Engelmann, 
 the ^'electrodes needed are a gold or platinum sound of ordinary 
 dimensions, and a needle or stylet of the same material (though the 
 steel instrument may be used), well fixed in a firm handle ; for punc- 
 ture through the vagina this instrument should be of a length equal 
 to that of other gynecological instruments, sound or applicator; for 
 both sound and stylet we must have a separate insulator of heavy 
 rubber — better still of glass, which may be kept more thoroughly 
 aseptic. The abdominal or dispersing electrode is a thin plate of lead 
 or tin alloy, as large as it can be used upon the abdomen, averaging 
 six by nine inches, covered with a thin layer of sculptors' clay held 
 in place by gauze, or with punk or absorbent cotton and a soft, thin 
 buckskin cover, which is equally good." 
 
 " The shape which admits of the use of the largest possible plate is 
 the oval, or, better still, the modified form of my plate, oval with con- 
 vexities to avoid the thighs. This electrode is thoroughly soaked in 
 water as warm as is comfortably borne, and snugly adapted to the 
 
OVARfAX AXD FinnOID Tl'}fOnS, rOLYPT, ETC. 401 
 
 abdomen, that it may rest in j)la('o a icw miiiutcs hcCoro treatment is 
 bcj^un, the eurrent tlicn juussinj:^ more readily, witli le.s.s j)ain ; the fric- 
 tion, as I may say, caused by the efforts of the electric current to pjuss 
 the resistance oHered by the dry epidermis bein*; possibly a source of 
 pain, certainly lessening the effect of the current by loss of intensity in 
 overcoming th(; greater resistance. If this precaution is not observed, 
 the operator will find an intense burning din-ing the first few minutes, 
 which lessens, however, as the tissues beccjme soaked; the desired 
 intensity having been attained, notwithstanding that no more cells are 
 inserted into the circuit, the galvanometer will indicate an increase in 
 high intensities of as much as ten milliamperes, and yet the pain lessens 
 decidedly if the positive be the dispersing pole. I have even seen it rise 
 from fifty to a hundred milliamperes, without augmenting the number 
 of cells, when the abdominal plate had not been placed until the last 
 moment, so that the dry epidermis offered a resistance at first difficult to 
 overcome. In other words, when the epidermis becomes soaked, less 
 resistance is offered, more electricity passes, and if the positive be the 
 dispersing pole the pain is lessened by the anaesthetic effect of the pole, 
 diminished at times to a minimum, though the intensity of the current 
 be increased. Before placing this plate we must examine the abdomen 
 to see if it shows any abrasions or excrescences ; if so, they may be 
 covered with a small piece of oiled silk or plaster, as such a spot would 
 be the centre of intense pain if not guarded. An abrasion, a small 
 blister where the epidermis is removed, centres upon itself much of the 
 electric force, which always seeks the best conductor ; or if an excrescence 
 the increased pressure would cause a concentration of the current at this 
 point. The plate having been placed, it is covered by a warm, dry towel 
 or a piece of oiled silk, to guard all garments in contact with it from 
 moisture, which may lead to serious colds, to injury, as well as mere 
 discomfort." 
 
 " The stylet or sound, whichever is to be used, is steeped in a strong 
 antiseptic solution, as is also the glass or rubber insulator ; the vagina 
 also should be cleansed. For electro-cauterization the sound, covered 
 up to two inches of the point by the insulator, is introduced into the 
 uterine cavity Avith the utmost care ; if possible it is preferable to intro- 
 duce the sound by the sense of touch. If the stylet is used for electro- 
 puncture, the point of entry having been carefully decided upon, the 
 instrument is introduced, the point guarded by the index finger of the 
 left hand, the handle grasped firmly by the right, counter-pressure being 
 made upon the abdominal protuberance. The puncture is then made for 
 a depth of from one to three inches, according to the size of the tumor; 
 the insulatino; cover is moved close against the vaginal and cervical mem- 
 brane, and care must be taken that the entire surface of the instrument 
 not in action is guarded. The activity of the battery is now tested ; the 
 
 Vol. I.— 26 
 
402 ELECTRICITY IN GYNECOLOGY. 
 
 rheophores are attached to the electrodes and the screws firmly bound ; 
 the galvanometer needle must point directly to zero. The abdominal 
 plate, evenly adapted everywhere, is held down with gentle pressure by 
 the hands of the patient, while the operator either fixes the sound or 
 stylet with an absolutely steady hand or rests it upon some suitable 
 support, as the slightest motion, any jarring of cords or battery in 
 portable batteries, must be avoided. The patient must breathe evenly 
 and steadily, and allow her hands to follow the respiratory heavings of 
 the abdomen ; we must see that the thighs nowhere touch the edge of 
 the electrode, and if perchance the probe is to be passed through a 
 speculum, the slightest contact of its metal surface with the pole must 
 be avoided. When any pain or discomfort that may have been caused 
 by the introduction of the instrument has ceased, the current is estab- 
 lished and gently increased, in the first sitting, in the course of a minute 
 up to fifty or a hundred railliamperes; later, when the sensibilities of 
 the patient have been tested, one hundred and fifty to two hundred, and 
 even two hundred and fifty milliamperes, may be attained in the same 
 time. For very sensitive patients I use the water-rheostat, by means of 
 which we can attain the desired intensity, increase and diminish the cur- 
 rent, without even the slight shock caused by the addition of element 
 after element ; a resistance of five hundred or one thousand ohms is 
 inserted, the number of cells probably needed thus brought into action, 
 and the intensity gradually attained by decreasing the resistance in the 
 rheostat ; for the breaking of the current the resistance is increased until 
 it surpasses the intensity of the elements in the circuit." 
 
 " The first sitting should not be continued beyond five minutes, the 
 current remaining at its height three minutes, then being slowly reduced. 
 Currents of two hundred milliamperes I have continued for eight min- 
 utes in later stages of the treatment. During the passage of the current 
 the operator must constantly observe both his galvanometer and the 
 patient. The needle should remain perfectly steady : during the first 
 minute it will show an increase of a few milliamperes, but there must 
 be no oscillation, which indicates jarring or shock. The face of the 
 patient and the galvanometer must be constantly observed, and tlie 
 operator must be on the lookout for any evidence of irregularity : a 
 momentary contact of sound and speculum would produce a terrific 
 shock. If the bare sound should touch the vaginal membrane it would 
 burrow its way and leave a grayish bed ; if the thighs touch the edge 
 of the abdominal plate, which must always be covered by the overlap- 
 ping conductor, an intense burning is experienced — if not so covered, a 
 shock ; and these shocks are trying, if not dangerous, with such intensi- 
 ties. The most intense shock is caused by a carelessness of which no 
 one who ventures upon this treatment should be guilty, the sudden 
 breaking of any one of the connections in the circuit, the dropping of 
 
or.iA'/.i.v .L\7> riniioin 'iTMons, rou'vi, irra 403 
 
 tlir i-lio()i)lioro iVniii ilic liiinliiiL:;-j)().st at the battery or iVmn tlw clec- 
 ti-odc, or tlio iiKtvin^- of oiic of the switches nl" tlic hattcry. In a port- 
 able battery especial care iiiiist be taken lest disturbaiiee be caused, tl>e 
 slii»litest jar dI" llie batterv caiisini;- iiiididatioiis of the current and shock. 
 At the point at which the stylet is inserted a <:;rayish-yellow loam will 
 aecunudate, its mass depending; upon the intensity and duration of tlie 
 current." 
 
 "After the inll intensity has l)Con attained and continued as loiifj; as 
 it seems necessary, the current is slowly reduced i'rom cell to cell with 
 the utmost evenness and gentleness, and the eircuit opened when at 0. 
 If the |)atient be N'ery sensitive we may diminish the current by slowly 
 increasing the resistance by the water-rheostat. When the current has 
 been broken the rheophores are detached and the aetive interpelvic pole 
 is first removed with the utmost caution ; the abdominal plate is then 
 taken otf, the siu'culum inserted, and the vagina cleansed. 
 
 " 1 am in the lial)it of dusting the cervix with iodoform and insert- 
 ing a tampon of salicylated or boratcd cotton ; in case of puncture I 
 use the styptic iron cotton directly upon the point of attack, and pack 
 it firndv to counteract the possibility of hemorrhage as far as possible. 
 The patient should then lie down or go to bed if at her home, and, if 
 not, as soon as she reaches it; but in all events she must rest in the 
 office long enough to thoroughly dry her garments, which are more or 
 less moistened by contact with the electrodes notwithstanding all care; 
 in cold weather this precaution must be invariably observed, as serious 
 injury may follow neglect. Twenty-four hours' rest is generally all that 
 is needed, but in individuals more susceptible it is well that they use the 
 ice-bag upon the abdomen and remain in bed several days. The inflam- 
 matory swelling which sometimes follows is thus best counteracted and 
 most rapidly reduced ; l)ut even when it does occur I have never seen it 
 accompanied by constitutional disturbance or elevation of temperature. 
 
 " The puncture should, if possible, be made through the cervix into 
 the mass of the tumor ; if the first is above the os, the next should be 
 below, Ibllowed by one to the right and then to the left ; if this is not 
 well feasible, we seek the point of greatest projection, toward the vagina, 
 avoiding the peritoneum. In some cases a gush of blood, very ]>rofnse 
 while it lasts, but not of long duration, may take place within the ten 
 hours following the application, and the patient must be forewarned, 
 that she may not be alarmed. The firmly-packed iron cotton tampon 
 is the best preventive, but the hot-water injection should also be recom- 
 mended, as the patient will be much better satisfied to have some means 
 at hand to counteract this apparently threatening symptom."^ 
 
 By this method Apostoli and Engelmann have treated a large num- 
 
 ^ "Electricity in Gynecology," bj' George J. Engelmann, Transactions of the American 
 Gynecological Society, 1S86. 
 
404 ELECTRICITY IN GYNECOLOGY. 
 
 ber of cases, and claim most excellent results. Although the tumor is 
 not made to disappear, in nearly every case groAvth has been arrested, 
 and in mauv instances the size of the tumor markedly diminished. 
 
 Chronic Cellulitis and Peritonitis. 
 
 In the treatment of the sequelfe of pelvic inflammation electricity is 
 not infrequently followed by the most satisfactoiy results. The benefit, 
 indeed, to be derived from this method of treatment in such conditions 
 is only indilferently appreciated by gynecologists. For the absorption 
 of old exudations in other parts of the body, the galvanic current has 
 long been known to be most efficacious, but only within a comparatively 
 recent period has it been tested in the thickening and infiltration result- 
 ing from inflammation of the pelvic cellular tissue. The negative pole, 
 consisting of a metal ball or concave clasp, is to be used internally. 
 
 If the metal electrode is applied directly without the intervention of 
 a sponge or chamois covering, care must be taken not to use currents 
 sufficiently strong to prodtice eschars. This mishap may occur even 
 without the knowledge of the patient, and it is therefore always 
 safer to use a covered electrode. I have seen this treatment, judi- 
 ciouslv and persistently carried out, melt away not only large pelvic 
 deposits, but dissipate a most severe and persistent sciatica that had 
 resisted every well-recognized method of treatment, and restore power 
 to limbs wellnigh paralyzed. In these cases both sciatica and paralysis 
 were occasioned by the pressure of the exuded material upon the pelvic 
 floor, and could not have been relieved excepting through the disappear- 
 ance of the morbid products. A current strength of twenty or thirty 
 milliamperes is usually sufficient. Apostoli uses negative electro- 
 puncture in these cases, and very strong currents, from which he has 
 seen only the yery best results. 
 
 Hyperplasia Uteri. 
 
 The very disagreeable symptoms that are so often associated with this 
 intractable condition are occasionally vers' much ameliorated by the per- 
 sistent use of the galvanic current. The intra-uterine electrode may be 
 used, but the current must be weak and the applications short, so as to 
 avoid unpleasant electrolytic effects. As a rule, however, extra-uterine 
 will accomplish quite as much as intra-uterine applications. The dis- 
 advantage of the applications by the former method, that it is not 
 so direct, is more than balanced by the far greater tension of current 
 that can be used when with a large sponge-covered bulb electrode firm 
 pressure is made around and above the os uteri. In one case of hyper- 
 plasia uteri treated some months since the benefit accruing from persist- 
 
EXTRA-rTKiiisi: rnjy.x.iycy. 40o 
 
 ent extra-utoriiie applications was seen in a greatly incre{i.se<l menKtrual 
 flow and in the relief of severe <j:astral<:;ia. But the most speedy ami 
 etleetive nu'th(Kl of treat injr areolar liyperpl:L>;ia is hy electrolysis. One 
 or two needles may be thrust into the hardenetl tissues parallel to the 
 canal, and a current of from forty to sixty milliamperes usetl. There 
 can Ik- hut little (jucstion that the needles should hy [)relerence be con- 
 nected with the net^ative pole, although Menic^re ' claims to have treats! 
 one hundred cases, always using the positive as the active pole; but as 
 he regards six months as the average time required for the treatment, it 
 is evident that his results would be more speedy and satisfactory if he 
 used the negative pole for its electrolytic action and the positive exter- 
 nally. It is seldom that the positive pole is indicated in electrolytic 
 operations, unless the object is to decrease an active hemorrhage or to 
 cause a blood-clot, as in the case of erectile tumors. The positive pole 
 is more liable to cause a slough, and is far less efficient as an absorbent, 
 than the negative. 
 
 Other conditions for which the galvanic current may be used with 
 liopes of beneficial results are pachysalpingitis and lymphadenitis.- 
 Apostoli has reported some cases of hsematocele cured by this method. 
 
 Stenosis of the Uterine Canal. 
 
 In stenosis of the uterine canal the action of the galvanic current is 
 most valuable, and iu many cases is sufficient to afford complete relief. 
 I have treated several of these cases by electro-cauterization, and in 
 each instan(?e Avith most satisfactoiy results. A sound of the proper 
 size having been introduced, it is connected Avith the negative pole, the 
 positive being applied to the abdomen. A strength of fifty milliamperes, 
 continued for five minutes, will, as a rule, be found sufficient. In my 
 own cases the number of applications that were found necessary to effect 
 a permanent cure ranged from six to twenty-five. 
 
 Extra-uterine Pregnancy. 
 
 My experience in the treatment of extra-uterine pregnancy has been 
 given elsewhere,^ hence it will be unnecessary to repeat in full detail 
 here the various cases that serve to prove the feasibility of the operation 
 as well as its great value. That the destruction of fcetal life could be 
 easily affected by electricity admitted of no doubt, but whether it was 
 possible to do this without in any way injuring the mother was a ques- 
 
 ^ Gazette de Gynecolngie, Feb., 1886. 
 
 ^ Dr. Paul F. Mnnde lias reported in the Amfricnn Jovmnl of Obstetrics for Dec., 
 1885, some very interesting cases of this character treated by electricity. 
 ^ A Practical Treatise on Medical and Surgical Electricity, etc., 4th ed. 
 
406 ELECTRICITY IN GYNECOLOGY. 
 
 tion that could be determined only by an experimental effort. This 
 opportunity was afforded some years ago by a case in the practice of 
 Dr. Charles McBurney, when the method was suggested by Dr. T. G. 
 Thomas, and I was asked to superintend the operation. The case was 
 one of tubo-interstitial pregnancy at the third month, and terminated 
 favorably by the expulsion of the foetus and placenta through the ute- 
 rus. Subsequently, eleven other cases fell under my observation, all 
 of which I submitted to similar treatment, and with results entirely sat- 
 isfactory. The history of most of these cases will be found recorded in 
 my fifth edition of Beard and Rockwell's Medical and Surgical Elec- 
 tricity. In one of these cases at least there was a subsequent conception, 
 followed by a safe delivery of a healthy child. In these operations the 
 galvanic current alone was used, the position of the poles varying ac- 
 cording to the position of the foetal mass, and the strength of the cur- 
 rent according to the susceptibility of the patient and the probable dis- 
 tension of the Fallopian tube. As there is probably no remedy to the 
 effects of which there are such different degrees of susceptibility, it is 
 impossible to do more than approximately state the current-strength 
 called for. In my own cases the current varied in strength from ten 
 to twenty milliamperes. 
 
 An interrupted rather than a continuous current is to be employed, 
 although there may be an advantage in its rapid increase by means of 
 a rheostat. In this way the chemical and physiological effects are 
 greatly increased, without the disagreeable effects, and even the danger, 
 that might accompany an interruption of the same strength of current. 
 The danger to be apprehended from an injudicious application of the 
 farad ic or the interrupted galvanic current is the possibility of ruptur- 
 ing the over-distended- tube. How great this danger is it is impossible 
 to say, but that the possibility exists cannot be questioned. In one 
 case, where the pregnancy had advanced nearly to the fourth month, 
 the necessity for caution forcibly presented itself to me. By gradually 
 increasing and as gradually decreasing the strength of the current I was 
 enabled to use without fear a power of twenty milliamperes where, with 
 interruptions, I had feared to use more than five. In regard to the 
 position of the poles, my custom has been to place the positive exter- 
 nally. This should consist of a broad, flat sponge pressed firmly on 
 the skin and directly over that portion of the tube where the foetus is 
 developing. The negative pole is used internally, and may be carried 
 up to the foetal mass, either through the vagina or rectum according to 
 the position and size of the tumor. 
 
 In the twelve cases that I have recorded the operation was performed 
 through the vagina in nine and the rectum in three. As there seems to 
 be no way of determining positively Avhether the foetal life is immedi- 
 ately destroyed by the first application, it has been customary to repeat 
 
EXTRA-UTERINE PREGNANCY. 407 
 
 it three or four times; and as Imt little jtaiii is caused, there can he 
 no special ohjcftioii to its repetition on this scon*. 
 
 All nu'dical and snry;ieal pnx-edures, however, that are not al)Sohitely 
 necessary are ohjcetionahle, and a remote possihility even of an accident 
 of tlie kind to which reference has been made — viz. ruj)ture of tlie tube 
 — sn<i;<;ests that these applications he made no more frecpientlv than will 
 suffice to accomplish <»ur ohject. I think it ]»roper, therefore, to sav 
 that a strent^th of current just sufficient to destroy the fo'tal life is it 
 all prohahility capai)le of doing it at once, and that all suhsecjuent 
 efforts serve only the purpose of hastening the process of absorption. 
 
 Ajiplications that are made solely for this j)nrpose eaiuiot be at all 
 objecti«Mial)le, as the galvanic cnrrent without interruption is the kind 
 to be used. A most important point in tlie consideration of this opera- 
 tion is its simplicity as well as its certainty. I find the idea ver\- widely 
 prevailing that the operation is purely electrolytic, necessitating the 
 introduction of needles into the foetal nest. Happily, such is not the 
 case, for any such procedure might itself be attended with danger, and 
 certainly with considerable pain. The negative electrode consists of a 
 metal ball, and is applied to, and not into, the tumor. 
 
 From its greater power of overcoming resistance, as well as other 
 physical and physiological reasons, it will seem that galvanism ought 
 to be preferable to other forms of electricity in this condition. Fara- 
 dism has, however, been used with success, although in every one of 
 my own cases galvanism has been the sole reliance. The galvanic cur- 
 rent LS more certain in its action and its effects are felt deeper, Avhile 
 its influence on the process of absorption is of course far greater than 
 that of farad ism. 
 
 In any case of tubal pregnancy — and especially in those advanced 
 conditions ^diere the tube is greatly distended and there is danger of 
 spontaneous rupture — the possibility of hastening the catastrophe in 
 the attempt to destroy the life of the foetus should never be lost sight 
 of. The tubes themselves are but slightly supplied with muscular 
 fibre, and the danger would more especially arise from the powerful 
 compression that is liable to be exerted by the abdominal muscles, and 
 the effort should be so to diffuse the current proceeding from the exter- 
 nal pole as to produce the least mechanical effect possible. 
 
MENSTRUATION, AND ITS DISORDERS. 
 
 By W. gill WYLIE, M. D., 
 
 New Yoke. 
 
 Menstruation, when normal, could be better described by a physi- 
 ologist, but some knowledge of it is as essential to the gynecologist as 
 the knowledge of the anatomy of the generative organs. We will 
 not attempt to go fully into the physiology of the subject. 
 
 In healthy, well-developed women between the ages of fourteen and 
 forty-four menstruation occurs once a month, except during pregnancy 
 and lactation. It usually begins in temperate climates at the age of 
 thirteen to fifteen, but in many instances much earlier, and often not 
 till sixteen years or later. In warm climates it begins much earlier, 
 and in cold climates later. It may be delayed by serious illness, such 
 as ansemia, etc., or it may be hastened by an indoor and indolent life, 
 and on this account it comes earlier in those brought up in large cities. 
 
 Just previous to the first menstruation a girl shows marked indica- 
 tion of rapid development. Her breasts enlarge, hair grows on the 
 mons Veneris, her figure fills out, and her manner becomes shy and 
 retiring. As a rule, menstruation is preceded by a feeling of weight in 
 the pelvis and slight fulness of the breasts. Not infrequently there is 
 some backache, but in many instances the first conscious indication is a 
 flow of blood. 
 
 The time of the flow is from two to eight days. If less than t^vo or 
 more than eight, it usually indicates either local or general disease. 
 The amount of flow is estimated to be from two to nine ounces. If 
 less than five or six ordinary napkins or more than eighteen are pretty 
 well saturated, then the amount may be considered abnormal. The 
 periodicity is very variable : now and then we will meet a woman who 
 menstruates on or about the same day of each month. More frequently 
 it returns every twenty-eight days, but not infrequently it occurs every 
 three weeks. In most cases it varies slightly. Usually for several 
 hours it is slight in quaiitity, and may be light in color ; on the second 
 or third day it is usually at its height and the flow is dark, and unless 
 very free it will not coagulate on account of admixture with the vaginal 
 secretions. After the third or fourth day it ceases gradually. 
 
 408 
 
MEySTIiUATfOX, A.\I> ITS DfSnRDFnS. 409 
 
 Until Bischoir advanced and l*lli■l^(•l• clahoi'atcd and dcvclojx'd the 
 tlieory of ovnlation and ovarian ii-i-ilatinii as the cause of menstruation, 
 it wiLs tlic belief tiiat (lie nicnstnial hlmul was accuniulaUid to snj)j)lv 
 the fetus, and was thrown oil' as noxious niatei'ial unless the woman 
 heeame pret^iiant. For many yeai's and until very recently ovulation 
 has been considered the startint:;-|)oint oi" menstruation, and Prtii<:;er's 
 tlieory has been the acce|)ted doctrine. But lately, since UKUistruation 
 luus been f nuid to continue with re<i;ularity in many ciuses after com- 
 plete removal of both ovaries, other views are assumiiifr more promi- 
 nence. One of the most striking is that of Williams's des(|namation 
 theory, wherein he claims that the lining membrane down to the mus- 
 cles is thrown oif with each menstruation. 
 
 The writings and investigations by Kundrat and Engelmann attracted 
 much attention. They claim that only the superficial layer undergoes 
 degeneration and is thrown oif. Instead of examining the uterus after 
 death, Moricke curetted the uterus of living women during menstrua- 
 tion, and on examination of his scrapings claims that no part of the 
 lining membrane is thrown off. 
 
 Leopold thinks that the bleeding is explained by the anatomical 
 arrangement of the blood-vessels of the endometrium. He does show 
 that the arterioles supplying the capillaries are relatively larger and 
 more numerous than the veins that carry off the blood ; and from this 
 he claims that when there is a sudden afflux of blood to the uterus 
 the capillaries will bleed, because they are subject to great pressure, 
 as the veins cannot carry off the blood as fast as it is supplied. 
 He denies that there is fatty degeneration of the superficial or any 
 other layer, and says that the bleeding is due to rupture of the 
 capillaries. 
 
 Lawson Tait now claims that it is not the ovaries, but the Fallopian 
 tubes, that influence menstruation — that menstruation is induced by the 
 active movements of the tubes to grasp the ovaries. But women some- 
 times menstruate regularly when both tubes and both ovaries have been 
 removed. I know one who has missed not more than two menstrua- 
 tions in tw^o years and a half, although I have both of her tubes and 
 ovaries in a jar. 
 
 Lowcnthal ^ has come out with a new theory — viz. " A Graafian 
 follicle ruptures and liberates a mature ovum, Avhich, having passed 
 through the tube into the uterus, imbeds itself in the mucous mem- 
 brane ; its presence sets up hyj^erplasia and forms the menstrual 
 decidua. If this ovum is impregnated, the menstrual decidua develops 
 into the decidua of pregnancy ; but if it is not fertilized, after a time 
 it perishes, and by its death causes the disintegration of the menstrual 
 decidua, and thus menstruation is induced." This may occur, but it 
 
 ^ Archiv fur Gynafc, Bd. xxiv. Hft. 2, and Bd. xxvi. Hft. 1. 
 
410 MENSTRUATION, AND ITS DISORDERS. 
 
 does not explain menstruation when there are no ovaries to supply the 
 ovum, as in those numerous cases where both tubes are occluded by 
 imflammatory adhesions. 
 
 In the American Journal of Obstetrics (1885, vol. xviii. Nos. 2, 3, 
 4, 5, and 6) Dr. Mary Putnam-Jacobi elaborates the theory — " First, 
 that the essential and efficient cause of the menstrual hemorrhage lies 
 in the accumiilation of blood in the periuterine and utero-ovarian 
 sinuses. Second, that this accumulation does not constitute a conges- 
 tion But that the immediate cause of the determination of 
 
 blood to the reproductive organs is the gradual enlargement by growth 
 of the venous reservoirs destined to contain it." She explains the 
 " mechanism by which the material for reproductive nutrition is evacu- 
 ated." " When fecundation has not occurred, the growing endomet- 
 rium, arrived at a certain point of development, is then arrested by 
 the non-expansion of the uterine cavity. The opposing surfaces of the 
 endometrium touch, press against each other ; the vitality of the sur- 
 face epithelium is impaired ; it exfoliates, laying bare the surface capil- 
 lary loops, which break at some point, so that capillary oozing begins," 
 etc., etc. She also gives an explanation of the " mechanism by which 
 hemorrhage is averted after fecundation," and explains " the individual 
 variations in the subjective and objective phenomena of the menstrual 
 cycle and of early pregnancy." 
 
 These views, as given by Dr. Jacobi, are exceedingly interesting and 
 in many respects new, and many of the statements are so rational that 
 they must be accepted ; but the very completeness of it impresses one 
 with the fact that as yet it is theoretical. 
 
 Although the generative organs are essential to reproduction, they 
 are not essential to the individual and are not necessarily used. Disuse 
 in organic life means in time atrophy and death. Therefore, menstrua- 
 tion may be intended to take the place of the free exercise of the func- 
 tions of these organs, and thus compensate for the restraint and disuse 
 so much and so necessarily practised by civilized races. It seems to 
 regenerate a part at least of the uterus, and keep it in proper condition 
 to receive and nourish the ovum when impregnated. 
 
 In treating uterine diseases it is important to recognize the fact that 
 for several davs before and durins; menstruation the uterus is somewhat 
 enlarged, and the lining membrane of the uterus may be injured or 
 menstruation disturbed by the use of sounds or any direct applications 
 — that, as a nile, interuterine treatment or operative procedures should 
 not be made for at least one week previous to menstruation, nor sooner 
 than three or four clays after it has ceased. 
 
 Disorders of menstruation cannot properly be classed as diseases, for 
 any one of the disorders of menstruation may be one of the symptoms 
 of several different diseases. On this account we cannot be expected to 
 
AMi:s()i:nu(i:.[. 411 
 
 fjo too iiuu'h into details of (rcatiiiciit, etc., as iiiiK-li of it \voiil<l he a 
 r('|)('tiliou of that i^'ivcii l)y tliosc wfitiii;^- on the dillrrciit (liscascs. 
 
 Amenorrhcea. 
 
 Tlic word " aiiuMiorrlid'a " is \\^vi\ to indicate suppression or cessa- 
 tion ot" tlie menses between the aj^e of pnberty and the nienopanse. 
 Altht)ni2,h nienstrnation may oecur during pregnancy or hictation with- 
 out necessarily indicating serious disease, amenorrJKea nuist he consid- 
 ered normal during pregnancy and lactation, and before puberty and 
 after forty years of age. 
 
 Amenorrhcea may be caused in two ways : 
 
 1st, it may be due to the debilitating influence of some constitutional 
 disease or acute general disease. 
 
 2d, it may be due to local disease or to imperfect development of the 
 generative organs, or to atrophy of one or more of these. 
 
 During the active stage of, and convalescence from, serious debilitating 
 diseases, such as the essential fevers, phthisis, etc., amcnorrhoea is to be 
 expected and is desirable, and, instead of being an indication of local 
 disease, shows that there is nothing about the generative organs which 
 would induce hemorrhage, that might lessen the chance of the patient's 
 recovery. 
 
 In chlorosis and anremia amenorrhcea is especially desirable, and 
 when menstruation exists with well-marked ansemia it indicates that 
 there may be an abnormal state of the lining membrane of the uterus ; 
 and it may be as important to treat this condition, and thus induce 
 amenorrhcea, as it would be to stop a very much more violent hemor- 
 rhage occurring in one whose general condition is good. 
 
 Five years ago a large, handsome Avoman, about forty-two vears old, 
 came to me for treatment. She had the characteristic skin of chronic 
 anaemia, with puffed lower eyelids, swelling above clavicles, swollen 
 feet, etc. ; was always tired and much dej^ressed. She had a dragging 
 pain in her back, etc. On physical examination I found a large retro- 
 verted and retroflexed uterus. She said that she had been treated for 
 two years by two of our most prominent specialists, who had used ]ies- 
 saries, iodine, hot water, etc. Her menstruation was pretty regular, 
 and the amount lost was not more than a vigorous, healthy woman 
 should lose ; but I concluded that, taking into consideration her gen- 
 eral condition, if the uterus was normal she should have amenorrlm^a. 
 I did not think the displacement alone accounted for the menstruation. 
 I dilated the cervix, and with a Sims curette succeeded in removing about 
 a tablcs]ioonful of fungus granulations, and at once established amcnor- 
 rhrea, and after a few months improved and finally cured her ansemia, 
 and all indications of local disease disap})eared. Since then I have 
 
412 MENSTRUATION, AND ITS DISORDERS. 
 
 treated other cases of chlorosis by giving treatment to bring about 
 amenorrhoea when the general health indicated it. When amenorrhcea 
 is due to ansemia or any other disease, menstruation usually returns 
 when the disease causing the debility is cured ; but when the disease 
 occurs during the period of development, say from ten to sixteen years 
 of age, if the disease is prolonged and greatly reduces the vital force, 
 develoj)ment of the generative organs will be checked, and the final 
 result may be a state of imperfect development of the generative organs, 
 which not only unfits them for performing their functions normally, 
 but renders them an easy prey to disease. Thus, amenorrhoea caused 
 by general debility may exist after the patient's general health has been 
 fully restored. When it does exist after the general health is restored, 
 local treatment should be resorted to, to prevent further degeneration 
 and atrophy, and if possible to stimulate the uterus and adnexa to com- 
 plete development. When we find amenorrhoea in connection with a 
 small, imperfectly developed hypersesthetic uterus, or a small uterus asso- 
 ciated with cystic degeneration of the ovaries or catarrhal disease of the 
 Fallopian tubes, we must trace back the history with great care to be 
 able to determine whether the imperfect development is due to congeni- 
 tal influences or to the direct influence of some debilitating disease, im- 
 perfect nutrition, or bad hygienic conditions acting during the period 
 of development of the generative organs, Amenorrhoea may be caused 
 by superinvolution of the uterus, or atrophy of the tubes and ovaries 
 the result of extensive or destructive inflammatory local disease. Dur- 
 ing the acute stages of uterine and periuterine inflammation menstrua- 
 tion may be excessive, but when contraction of adhesions over the tubes 
 and ovaries takes place, or when fatty degeneration and cystic degenera- 
 tion take place in the uterine tissue, scanty menstruation is the rule, 
 except when fungous granulations line the ^iterine canal. 
 
 It is a well-established fact that extreme mental emotion in many 
 women, such as fright, anxiety, grief, etc., may for a time suppress men- 
 struation. Women who for good reasons have great anxiety about the 
 appearance of "their menstruation may cause temporary suppression by 
 the nervously anxious state they get into when it is due. 
 
 It would seem that some women are liable to acute catarrhal disease 
 of the uterus in the same way as they are to catarrh of nose and throat, 
 and exposure to cold near the time of the menses may cause suppres- 
 sion. But, as a rule, these are only temporary in their eflect, and are 
 not so serious as the amenorrhoea now so very common in young 
 women who are urged on in intellectual studies, in addition to an 
 indoor life and other bad hygienic influence, during the period of the 
 active development of the generative organs. They thus acquire the 
 habit of using up their vital force, so as to delay or render very imper- 
 fect the development of the generative organs. These organs are the 
 
AMEXORRHCEA. 413 
 
 last to (l('V('I(t|), ami imt liriiij;' cssciilial t<t life nor to mental or manual 
 work, tlu'V aro the (irst to fail. ( )nc ol" tlic first indications of" tliis 
 serious troiil)l(' is <l('!av in the coininLT of tlic menses or suppression 
 after liavin;^; l)e!j,un. In tnatint:: ol" I )y-nienorrli<i'a 1 will refer aj^ain 
 to this important suhjeet, for I think that the im|)erf"eet development 
 brou^iht about in this way is the essential cause, not only of many eases 
 of ainenorrluea and dysmcnorrhoea, i>ut also explaias why so many 
 aj)parently healthy women have uterine disease and why the cervix 
 is so freipiently torn, ete. 
 
 Great care must be taken to diagnose pregnancy as a cause of amenor- 
 rhani, and where there is doubt time alone Mill enable one to be sure 
 of a diagnosis. 
 
 With extra-uterine pregnancy amenorrhoca or scanty menstruation 
 exists, and yet the uterus fails to enlarge as it would do in normal 
 pregnancy. Great changes of the mode of living, such as a sea-vo}'age, 
 may for a time cause amenorrhcea. 
 
 Scanty Jlen.sfruafion. — Almost all that has been said about amen- 
 orrhcea may be said about scanty menstruation. Very much the 
 same causes would induce it, and its treatment should be very sim- 
 ilar. 
 
 Amenorrhcea may also be due to absence of the uterus or the ovaries 
 and tubes when removed by operation or congenitally absent. In con- 
 genital absence of the vagina, or in complete occlusion or atresia of the 
 cervix or vagina, the menses may be retained and cause the accumula- 
 tion of a large amount of tarry mucus and blood in a pouch formed 
 by the upper part of the vagina or the uterine cavits*. These mav be 
 mistaken for amenorrhcea, but can hardly be classed as amenorrhcea. 
 They would come under the head of imperfect development or disease 
 of the cervix and vagina. 
 
 Treatment. — Since the old idea of the noxious influence of retained 
 menstrual blood has been given up and the ovulation theort" accepted, 
 emmenagogues have not been very much used. 
 
 Practically, little good is done by the use of medicines in amenor- 
 rhcea, except as they may be made to improve the general health of the 
 patient. Amenorrhcea brought about by debility due to general and 
 not local disease does not require special treatment, unless the amenor- 
 rhcea continues for some time after the patient has fully recovered her 
 general health. 
 
 In anaemic and chlorotic subjects iron in suitable forms will often 
 cause menstruation to appear, but this may be by improving the con- 
 dition of the blood rather than by specific action. 
 
 Aloes in cases of suppression of the menses, if used at or near the 
 time that menstruation is due, may bring it on, but it probablv acts by 
 irritating the intestines and thus causing pelvic congestion, and not by 
 
414 MENSTRUATION, AND ITS DISORD EBS. 
 
 any specific action. Other medicines, such as potassium permanganate, 
 binoxide of manganese, oil of savine, mustard, etc., are used as emmen- 
 agogues, but their usefulness is very doubtful. 
 
 The application of heat by means of hot baths to the feet or hips 
 may be safely used, but except where menstruation is about due they 
 are not to be relied upon. 
 
 Local treatment is chiefly useful in cases of imperfect development, 
 especially where amenorrhoea occurs during the period of development. 
 
 At the same time that an eifort is being made to improve the general 
 health of the patient stimulating applications may be made to the 
 uterus and the vagina. Hot-water vaginal douches of half a gallon, 
 given at 105° to 115° F., with the patient lying on her back, are some- 
 times efficient, and can always safely be made supplemental to more 
 active local treatment. 
 
 As a stimulating and safe application to improve the local circulation 
 of the pelvis I prefer a solution of one part of boro-glyceride, one of 
 alum, and fourteen of pure glycerin, to be applied to the vagina by 
 means of firm rolls of absorbent cotton from one and a half to two 
 inches long and from one-half to one inch thick, tied with a string at 
 one end to facilitate removal, thoroughly saturated with the solution, 
 and applied twice a week, each application remaining twenty-four or 
 forty-eight hours. This application causes a profuse watery flow, and 
 keeps up a very active pelvic circulation, and after a few weeks' use 
 improves the local condition and stimulates development. If there 
 are catarrhal disease and more or less contraction and atrophy of the 
 endometrium associated with amenorrhoea, after the above applica- 
 tions have softened the parts and rendered the uterus freely movable 
 the cervix should be dilated and stimulating interuterine applica- 
 tions made. 
 
 Electricity regularly applied to the cavity of the uterus and over the 
 ovaries seems to stimulate development in some cases. 
 
 In those cases of suppression where ten or twenty years ago leeches 
 to the cervix, bleeding from the arm, and emmenagogues were given, I 
 usually give a free laxative and apply the boro-glyceride and alum- 
 and-glycerin pledgets, and order hot-water douches and baths, and an 
 anodyne if needed. In a few days both the general and the local 
 congestion are relieved. 
 
 In cases of amenorrhoea where there are symptoms of pregnancy 
 or reasons to suspect it, no interuterine examinations or active treat- 
 ment should be given, as a matter of course, but simple laxatives and 
 the cotton pledgets saturated with boro-glyceride and alum-and-gly- 
 cerin mixture to relieve congestion will do no harm. They soften 
 the parts and enable one to make a more certain diagnosis. 
 
ji//;.voA'/;//.ir,7.i .i.\7> mi:ti:')i:/:iia<;ia. 410 
 
 Vicarious Menstruation. 
 
 A"icari(»iis incnstniation may occur in (•(Uiiicctioii with amciiDrrliu'a 
 or scanty menstniation. \\'cll-iiiari<ctl cases arc rare. Its >i;^iiilicaiiec 
 is not of" ^rcat liuporlaMcc. It intlicatcs a watery and poor condition 
 of the blood, usually associated with a constitutional tendency to l)lced, 
 due in some cases to a lauity sttitc of the blood-vessels. The blood may 
 come from the throat, nose, ji'ums, breasts, or an open sore or wound, 
 and it mav show itsi'lf with reji;nlarity at the time of the menses or 
 when the circulation is disturbed on account of the menses beinu- .sup- 
 pressed. 1 have seen it to a slisi'ht extent occur in a woman in whom 
 at the autopsy not even a sign of the uterus or vagina could be Ibimd, 
 althouo;h two ovaries were found — one in the canal of the round lig- 
 anient of the right side, the other near the hilus of the left and only 
 kidney. 
 
 I now have under treatment a patient with occlusion of the vagina 
 who regularly eacli month has nose-bleed. An an?cmic woman nnder 
 my care, the mother of six children, when pregnant with her seventh 
 child menstruated with perfect regularity from the bladder for eight 
 months. Except a slight catarrh of the bladder that had existed pre- 
 viously, and now exists eighteen months after the birth of the child, no 
 other disease has been made out. After the birth of the child she had 
 aracnorrho?a for sixteen months. The flow from the bladder was dark 
 in color and quite free, and lasted five or six days. 
 
 Unless the hemorrhage is such as to cause trouble from the amount 
 of blood lost, special treatment is not usually indicated. Cure the cause 
 of the amenorrhoea, and in most cases the vicarious menstruation will 
 cease. 
 
 Menorrhagia and Metrorrhagia. 
 
 The term '' menorrhagia " is used to indicate excessive or prolonged 
 menstrual flow, while " metrorrhagia " is uterine hemorrhage occurring 
 independently of the menses. It must not be forgotten that the amount 
 of blood lost by different women at menstruation varies very greatly, and 
 the length of normal flow and intervals between the menses also varies 
 greatlv. The best indication of its being abnormal is either a sudden 
 change in the usual length of time or quantity of flow, and its influence 
 on the general health of the patient. 
 
 Menorrhagia, and especially metrorrhagia, as a rule, indicate local 
 disease or a change in the tissues of the lining membrane of the uterus 
 the result of disease. In diseases such as scorbutis, chlorosis, and in 
 some women variola, rubeola, typhus fever, malaria, etc., where the 
 blood is changed in character, there will be an increase in the amount, 
 and especial Iv in lengthening of the time, of the menstrual flow. As 
 
416 MENSTRUATION, AND ITS DISORDERS. 
 
 has already been pointed out, amenorrhoea is the rule under such con- 
 ditions of the blood, and a careful investigation will often disclose a 
 local state of the lining membrane, such as fungous granulations, which 
 will account not only for the menorrhagia, but for the existence of men- 
 struation at all under such conditions ; and when the local disease is 
 removed it will be easier to cure the disease affecting the general health. 
 Sometimes menorrhagia seems to be due to disturbances of the general 
 circulation, such as is caused by stenosis or insufficiency of the mitral 
 valves, emphysema, the pressure of a large tumor, or the use of active 
 vascular stimulants, such as quinine, etc. This influence, of course, 
 would be more likely to affect a uterus that is not in a perfectly normal 
 state, and we can often prevent injurious effects by correcting what- 
 ever local disease or abnormal condition may be found. 
 
 Therefore, we must come to the conclusion that bad conditions of the 
 blood and disturbances to the general circulation seldom cause menor- 
 rhagia as long as the generative organs are normal, and very rarely 
 could induce metrorrhagia, except when acting on an abnormal or dis- 
 eased local condition. Local conditions that cause menorrhagia and 
 metrorrhagia may be divided into two classes — those due to abnormal 
 conditions of the adnexa and periuterine tissues, and those due directly 
 to abnormal conditions or disease of the tissues of the uterus. The 
 latter is by far the more important of the two, and when uterine hem- 
 orrhage becomes greatly prolonged or recurs persistently it will usually 
 be found that fungous granulation or some such change in the lining 
 membrane has taken place. In acute inflammation of the periuterine 
 tissues caused by salpingitis, ovaritis, etc. there may be either menor- 
 rhagia or metrorrhagia ; but this local flow often gives relief to the 
 pain, and unless excessive — as it seems to us favorable to the progress 
 of the periuterine disease — it is best not to check it. This flow, which 
 so frequently occurs during an acute attack of local peritonitis, will not 
 recur with the next menstruation, and by waiting long enough a differ- 
 ential diagnosis can easily be made. Unless the hemorrhage be very 
 profuse, it is usually better to wait until it has recurred once or twice 
 before resorting to curetting. 
 
 Myomatous fibroma and other tumors of the uterus rarely cause 
 hemorrhage unless they are so situated as to increase or change the 
 vascular condition of the lining membrane of the body of the uterus. 
 It is not uncommon to find enormous subperitoneal fibromata attached 
 to a small uterus which does not bleed excessively at any time. Even 
 very vascular myomata may be attached at or below the vaginal junc- 
 tion and lift the uterus to the ensiform cartilage, and yet not cause 
 menorrhagia. I operated on such a case not long since, and a few 
 months ago I removed a fibroma the size of the head of a five-year- 
 old child, distending the cavity of the cervix, which had elevated the 
 
MhWojiJniM.iA A.\i> Mi:ri:<ini:iiA(;i.\. 417 
 
 siiimII :iii<l linn hndyortlir iitciii> l<i llir iiiiiLiliciis, nml \(| ihcrc iicvci" 
 liad l)ini citlici' iii('Miirrli:i<;ia oi- iiictrori'linviin, imr (iNsniciiorrlKr'a. V\tv 
 sonic vcars past, iiisl('a<l <»!" resort iii<i' to Hater's operation for removal 
 <»t" tlie ovaries or jterloi-niiiiti li\>tereetoni\ for iiterin*- lieniorrliatic, I 
 have lirst tried tlie elleet of enrettint;' tlie eavity of the litems. Tlie 
 resiihs have heeii so satisfactory and histiii*;- that I have lost tlie chanec 
 <if |ierforiniiiu- laparotomy in a lar^'c miiid)ei" of ease.-. And I can sav 
 the same in regard to those eases where the hemori'ha;^-e appears to he 
 due to ovaritis. I wonid always use the curette in such eases, oven 
 thonii'h the evidence of Lirannlatioiis were iiex'cr so slight, hefore I'csort- 
 iiiii' to laparotomy lor nterine hcinori'liauc Acute inllammation of the 
 litems may cause snppression of the incnsti'iiation, and usually results 
 in irrcunlar mcnstrnatioii ; hnt when, as it (tften is, associated with sni)- 
 involntion after lahor, and especially aiter abortions, fiing:ons granula- 
 tions form, and in inanv cause menorrhauia. Some such chaiiiros in 
 the vascular con<lition of the lininti' membrane of the body of the 
 uterus will be found in the vast majority of instances to be the 
 immediate cause of both raenorrhagia and metrorrhagia, of course 
 excluding cancer, sarcoma, large polypi, etc. Subinvolution, follicu- 
 lar and glandular disease of the cervix associated with laceration, 
 displacements, etc., may be called the primary cause ; but the cases 
 of menorrhagia and metrorrhagia associated ^vith or follo\ving these 
 conditions are \ery rare that do not cease after proper preparatory 
 treatment and cui-etting. 
 
 Cancer in women over thirty-five years of age is the most frequent 
 cause of metrorrhagia, and on account of the importance of recogniz- 
 ing this disease in its earlier stages it is the duty of a doctor to insist 
 upon a local examination, as being the only certain means of making 
 a diagnosis. 
 
 The menopause has been commonly credited with causing both men- 
 orrhagia and metrorrhagia, both by doctors and patients, but I have 
 rarely seen a well-marked case occurring at that time without its being 
 due to some well-defined uterine disease, most frequently directly caused 
 by either fungous granulations or cancerous disease. If physicians could 
 be generally impressed with these facts, we would not so frequently see 
 cancer of the cervix advanced to a hopeless stage before an examination 
 is deemed necessary, on account of the erroneous belief that irregular 
 uterine hemorrhage is normal at the menopause. Retained meml)ranes 
 after labor and abortions not only may induce puerperal hemorrhage, 
 but may in time cause morbid growths, such as fimgous granulations, 
 and thus induce menorrhagia. We will not attempt to speak more 
 explicitly of hemorrhage due to this cause. 
 
 Treatment. — In describing the causes of menorrhagia and metror- 
 rhagia the treatment has been indicate<l, and we will now speak chieflv 
 Vol. I.— 27 
 
418 
 
 MENSTRUATION, AND ITS BIS ORDERS. 
 
 of the special treatment, and more particularly of the two principal 
 local means of correcting uterine hemorrhage. 
 
 Haemostatics acting through the general system on the uterus are 
 sometimes useful in decreasing the flow, but are rarely curative in their 
 action. Ergot, when the uterus is enlarged, will cause uterine contrac- 
 tions, but it cannot be relied upon to control menorrhagia or metror- 
 rhagia. A fresh preparation of cannabis indica, given in pretty full 
 doses twice a day, wdll in many cases control or lessen the flow in 
 menorrhagia. Complete rest in bed also diminishes the flow. But to 
 cure menorrhagia or metrorrhagia local treatment must be given in the 
 great majority of cases. The tampon as generally used does more harm 
 than good. In the first place, unless it is properly applied by an expert 
 it rarely stops hemorrhage of consequence, and usually merely conceals 
 it for a time ; secondly, in using a tampon, and leaving it in place 
 longer than is necessary to cause a clot to form, we violate one of the 
 most important laws of good surgery — namely, obstructing free drain- 
 age. We also run the risk of forcing irritating and perhaps septic 
 
 Fig. 173. 
 
 Sims's Curette. There are three sizes. It is made of steel, with edges sharp enough to scrape^ 
 hut not sharp enough to cut with. 
 
 material from the uterine cavity into and through the Fallopian tubes 
 into the peritoneum. The same objections hold good against the use 
 of tents, especially sponge tents. When a tampon is to be used the 
 cotton pads should be squeezed out in a solution of bichloride, 1 to 
 5000, and well sprinkled with iodoform before being inserted. A 
 good pair of Sims's uterine dilators, when properly handled, soon 
 enable one to dilate the cervix uteri, and when a piece of retained 
 placenta or fungous granulations are effectually removed by means 
 of a Sims curette, any bleeding that may follow can, as a rule, be 
 controlled by the use of hot water at a temperature of 120° F., fol- 
 lowed by ice- water, either injected or quickly applied by small sponges 
 on sponge-holders. 
 
 It is better to keep the patient on the table for half an hour or 
 longer after curetting, so as to prevent hemorrhage, than to insert a 
 
D YSMENORRHCEA . 419 
 
 tainjxtii I'or the purpose. The j;ynoe()lotj;i.st who cannot use Sims's 
 steel curette witliout seriously iujuriiij; the uterus is not skilful enou;ih 
 to use any curette. By cleanliness and the use of antisepti<-s (he onlv 
 real (lanii:er in its ux — namely, scpti<- poisoning — is re<Uice<l to a 
 
 ininunn. 
 
 Even in severe uterine lienionhage after abortion it is best to at 
 once dilate the cervix with a dilator, and remove with the curette 
 any retained nicnihrane, and avoid the use of either sponjre or other 
 tents or tanipi>ns. 
 
 Dysmenorrhoea. 
 
 The term "dysmenorrhoea" is generally used as meaning painful 
 menstruation, but othei's define it so as to include pain just before, 
 during, and just after menstruation. 
 
 There is but little doubt that for at least one week before the men- 
 strual flow shows itself there is an increase^ the amount of blood in 
 the pelvis, and there is good reason to think that this increase of vascular 
 tension in and about the uterus gradually grows greater up to the time 
 that menstruation begins. Xow, if we are to include all the disturbance 
 and pain caused by this gradual distension of the pelvic vessels, and the 
 pain that occurs with the flow and that which sometimes occurs when 
 the flow is more or less suppressed, in our description of dysmenorrhoea, 
 there would be little to distinguish it from the pain of pelvic peritonitis, 
 ovaritis, etc. It seems to me that it is best to limit the use of the word 
 "dysmenorrhoea" to describe the difficulty caused by the flow from the 
 time it begins in the uterus — which may be hours before it shows itself 
 at the vulva — until it ceases. To get a clear conception of dvsmenor- 
 rhoea it is important to recognize the fact that we frequentlv see cases 
 where severe pelvic pains, especially pain over one or both ovaries, that 
 has gradually grown worse for several days previous to menstruation, 
 subside as the flow begins, and disappear when it is Avell established. 
 It is plain that the flow relieves the vascular tension, and thus lessens 
 the pressure on the sensitive ovaries, tubes, or periuterine tissue ; yet 
 many authors describe fully what they call " ovarian dysmenorrhoea." 
 
 Ovarian disease often complicates menstruation, and when menstrua- 
 tion is difficult and creates such an irritation as to increase for the time 
 the actual amount of blood in the pelvis, instead of lessening it, the 
 ovarian pain may be intensifie<l ; but T am inclined to doubt if ovarian 
 disease ever directly causes painful menstruation. Certain diseases of 
 the ovaries may bring about structural changes in the uterus, and dys- 
 menorrhoea be the residt, but the immediate cause of the dysmenorrhrea 
 is in the uterus. Ovulation occurring in a diseased ovar^' or in one 
 encased in inflammatory- adhesions may take place at the same time 
 with the menstrual flow, and thus cause pain ; but unless it can be 
 
420 MENSTRUATION, AND ITS DISORDERS. 
 
 shown that the menstrual flow causes ovulation this pain cannot be 
 fairly termed dysmenorrhoea. There is some reason to think that the 
 Fallopian tubes may be active at or about the time of menstruation. 
 In removing the appendages for disease I have several times found the 
 fimbriee spread out over the surface of the ovary, just as the fingers 
 would be when one picks up a large ball, and firmly fixed by adhesions. 
 Now, under what conditions this takes place I do not know, and we do 
 not yet know what the normal action of the tubes is during menstrua- 
 tion, but I am certain that we often find marked disease of the tubes 
 and ovaries fixed by adhesions in women who do not have dysmenor- 
 rhoea; on the contrary, they feel better at that time than at others. In 
 quite a number of cases I have succeeded in curing the dysmenorrhoea 
 that complicated salpingitis by dilating and treating the uterine canal 
 before operating for removal of the tubes and ovaries. In three well- 
 marked cases I failed to cure the dysmenorrhea because the treatment 
 caused fresh pelvic peritonitis and cut short the interuterine treatment ; 
 but this was not an unlooked-for result, although long preparatory 
 treatment was given in each case to render the uterus movable and 
 lessen the chance of disturbing the periuterine tissues. After three 
 years' close observation of many cases, during which time I have 
 removed the tubes and ovaries for disease thirty-seven times, I have 
 come to the conclusion that the change that takes place in the pelvic 
 tissues for some days previous to menstruation often causes increased 
 pain in diseased tubes and ovaries, but that, except in those cases where 
 other causes for dysmenorrhoea exist, the menstrual flow actually gives 
 relief, especially if the patient is in bed. It is true that in well-marked 
 cases of disease of the uterine appendages the patient may suffer from 
 dysmenorrhoea, but a careful investigation of these cases will in most 
 instances disclose abnormal conditions about the uterus that will account 
 for the dysmenorrhoea. 
 
 Just before and during menstruation women with periuterine disease 
 may have increased pelvic pains when up and about, and especially 
 when standing, but these are due to the influence of gravity causing 
 pelvic congestion, and not to the flow. 
 
 Disease of the, uterine appendages undoubtedly often complicates, and 
 is frequently associated with, dysmenorrhoea, and certain destructive 
 diseases of the ovaries and tubes may in time cause structural changes 
 in the uterus that may result in dysmenorrhoea ; but I doubt if dys- 
 menorrhoea, properly speaking, can be called ovarian dysmenorrhoea. 
 
 Most of the attacks of pelvic peritonitis so common in, and so cha- 
 racteristic of, salpingitis occur at or about the time of menstruation, 
 and very frequently complicate dysmenorrhoea. Hemorrhages may 
 form haematoceles, serous effiision due to local peritonitis take place, 
 and other causes of pain may complicate menstruation, but these are 
 
l)YsMi:s(n:i:iiii:A. .121 
 
 not tliu' It) the Miciistnial flow : tlicy mav he caused hv llic <'liaii;j:('s out- 
 side of tlie uterus wliieli tenuiuale in menstruation. 
 
 Ivrn)i,()(;v. — 'Piie lluw of nieustniatidn is cau.-ed Uyelianges that take 
 place in the liuiu;;- inenihrane of the utci'us, and when |)ain results from 
 this How its cause is to he found in the tissues irritatetl j)y or |)ressed 
 upon l)v the Mow. 
 
 Kxciudiuij; those rare eases whei'e there is disease or occlusion or com- 
 plete atresia of the vagina or an imj)erforate hymen that may cause |)ain 
 by obstruetini; the flow, there are only the endumetrium and the under- 
 lying' uterine walls in which to examine for obstruction to the How. 
 When th(> flow is ol)strncted it may accumulate in the uterus, distend 
 the cavitv, and j)ress upon the linint;- meml)i'ane or muscular wall, and 
 thus cause pain, es[)ecially if these are diseased ; or when ohstructed it 
 may accumulate in the periuterine tissues, al)normally distend the 
 blood-vessels, an<l thus cause pain, especially in diseased periuterine 
 tissues or oriians ; or it may be driven into and through the tubes, 
 e.speeially if diseased, and irritate the tissues of the tubes or perito- 
 neum, and thus cause })ain ; l)ut in all of these the obstruetion is the 
 essential, and therefore the real, cause of the dysmenorrhrea. 
 
 We know that many tissues when normal are not painful A\hen 
 pressed u[)on, but that when diseased or wli(»n they have been changed 
 by disease, especially by what we term inflammatory disease, these same 
 tissues become exquisitely sensitive to very slight pressure, and often 
 become incapable of performing their normal functions without creat- 
 ing pain located in themselves or by what we call reflex action in some 
 other tissue or organ. 
 
 If we knew definitely the physiological processes of normal menstru- 
 ation, we could soon determine the true pathology of dysmenorrhoea ; 
 but since our knowledge is so slight and the views of the best inves- 
 tigators are so conflicting, we are obliged to rely u])on clinical experi- 
 ence to guide us. My experience has led me to some very definite con- 
 clusions about the cause of dysmenorrhoea. In the majority of instances 
 I think it is caused by a hyperaesthetic condition of the endometrium, 
 especially at or near the os internum, often combined with more or less 
 stenosis or induration at this point — stenosis due to degeneration, con- 
 traction and atrophy, the result of imperfect development followed by 
 disease, or disease followed by induration, atrophy, and contraction. 
 These same conditions, in all probability, render abnormal the processes 
 that take place in the endometrium previous to and during the flow — 
 may cause it to disintegrate and exfoliate in pieces, and add to the pres- 
 sure of the blood or cause spasmodic muscular contractions, etc. The 
 hypergesthesia may induce spasmodic uterine contraction, which luay 
 cause the pain without the presence of any special induration or stenosis 
 at or about the os internum. 
 
422 MENSTRUATION, AND ITS DISORDERS. 
 
 Take a well-marked case of dysmenorrlioea, and pass a large sound, 
 yet one that may be passed into a normal uterus without causing pain 
 as it passes the os internum : it causes a severe aching pain, and fre- 
 quently the patient will voluntarily exclaim that it causes the same pain 
 as menstruation. Even in those who have only slight dysmenorrhoea 
 very little pressure with the blades of a uterine dilator will cause the 
 characteristic pain. 
 
 It only causes confusion to classify dysmenorrhoea as neuralgic, 
 ovarian, obstructive, etc. Clinically, it cannot be done. It is true 
 that ovarian and other diseased tissues about the pelvis become more 
 painful on account of the vascular tension in the pelvis before and until 
 menstruation is well established ; but unless there are abnormal changes 
 in the lining membrane or decided obstruction to the flow menstruation 
 will relieve the pain caused by congestion in the i^eriuterine tissues. In 
 acute inflammation or disease of the uterus itself, unless the flow is 
 retarded by pressure of the swelling, menstruation lessens the pain, 
 and the pain varies inversely wath the amount of the flow. 
 
 The hypersesthetic and indurated state of the tissues so characteristic 
 of typical cases of dysmenorrhoea appears to be an abnormal condition, 
 the result of imperfect development and atrophy, or disease followed by 
 atrophy, rather than the existence of an acute disease. I have never 
 been able to determine whether fissures about the os internum may 
 not sometimes cause \he hypersesthesia and dysmenorrhoea. 
 
 Many of the worst cases of dysmenorrhoea occur in young women 
 during the period of development, without their ever having had any 
 symptoms of local disease, unless the slight leucorrhoea which may be 
 present at times be so considered. This leucorrhoea would not be a 
 symptom of anything more than a subacute catarrhal condition of the 
 endometrium, which Avould be likely to occur in imperfectly developed 
 and atrophying tissues ; nor would we expect imperfectly developed and 
 atrophying tissues to either resist disease or go through an elaborate 
 change every month normally. Therefore, anything which arrests or 
 renders imperfect the development of the generative organs may indi- 
 rectly cause dysmenorrhoea ; or any disease of these organs that results 
 in degeneration and local atrophy may cause dysmenorrhoea. 
 
 Dysmenorrhoea is very frequently associated with a bad condition of 
 the nervous system — a " neuralgic diathesis," if you wish to call it so ; 
 but this is no certain indication that the neuralgic diathesis causes the 
 dysmenorrhoea. It is more than likely that both are the result of some 
 constitutional disease or of imperfect nutrition. 
 
 Cystic degeneration of the ovaries is often associated with dysmenor- 
 rhoea, and it is more than likely that a disease of the ovaries resulting 
 in degeneration and atrophy may thus cause the conditions in the ute- 
 rus which induce dysmenorrhoea ; but the natural result of atrophied 
 
X» YSMESOliniHEA. 423 
 
 ovaries, iis a rulo, is ainenorrlKiia. In most cases it is piohalile that 
 the saiiu' iuHueiu-es wliirh cause cystic (lej^ciu ration and atrophy of 
 the ovaries render imperfect the development of the uterus; and 
 this residts in atrophy, contraction, and hypcra'sthcsia which causes 
 the dysnicuorrh(ea. 
 
 In nulliparous women characteristic cases of dysmenorriujea are 
 nearly always associated \\'\\.\\ decided anteflexion, but it has never 
 been satisfactorily j)roven that the flexion is ever the cause of the 
 dysmenorrhoea. That a man feeble from sickness bends over when 
 he walks does not j)r()ve that the pain he may endure or his loss of 
 strength is due to the flexion of his spine. 
 
 Yeiu's ago I abandoned the prevailing belief that anteflexion fre- 
 quently causes dysmenorrhoea directly by mechanically closing the 
 canal, ^^'iu•n the flexion is extreme it may to some extent obstruct 
 a free flow from the uterus, but unless there is associated with the 
 flexion a hypersesthetic state of the lining membrane, and this, as it 
 nearly always is, complicated by contraction or inability to expand, 
 there w'ill be no dysmenorrhoea. Dilate the cervix and cure the hyper- 
 aesthesia, and the dysmenorrhoea disappears, although the flexion 
 remains. It may be said that when you dilate the cervix you 
 straighten the uterus, and it is this that cures the dysmenorrhoea ; l)ut 
 the answer to this is that until the uterus begins to develop strength 
 under the stimulating influence of treatment the uterus bends on itself 
 as soon as the dilators are removed, although one or two effectual dila- 
 tations may completely relieve all pain at menstruation. Besides, when 
 a stem pessary is used and dysmenorrhoea is relieved by it, the uterus 
 is not only straightened, but the cervix is dilated and a decided change 
 brought about iu the lining membrane by the presence of the pessary 
 in the uterus. 
 
 The use of vaginal anteflexion pessaries may palliate some of the 
 symptoms associated with dysmenorrhoea, but unless the hot-water 
 douches used to keep the pessaries clean, or the laxative and tonics 
 given to improve the general health usually prescribed m ith the use 
 of the pessary, stimulate development, the pessary will have but little 
 influence on the dysmenorrhoea associated with the flexion. 
 
 Extreme retroflexion when the uterus is forced down against the 
 sacrum between the utero-sacral ligaments may, by interfering with the 
 uterine circulation, obstruct the flow and cause pain with menstruation. 
 Extreme stenosis of the os externum may obstruct the flow and cause 
 dysmenorrhoea. This may be due to congenital influences or be the 
 result of disease, or be due to cicatrization from the use of caustics, 
 galvano-cauteries, etc. 
 
 If we are right when we say that dysmenorrhoea is chiefly due to a 
 hyperjBsthetic condition of the membrane lining the body of the uterus, 
 
424 MENSTRUATION, AND ITS DISORDERS. 
 
 associated with a contracted or inelastic and irritable state of the tissues 
 at or about the os internum, and that in most cases this condition is 
 brought about by incomplete or arrested development of the generative 
 organs, followed by atrophy or by degeneration the effect of local 
 disease that results in degeneration and atrophy, not only are the 
 indications for treatment of dysmenorrhoea made plain, but also the 
 very great importance of preventing the further advance of the serious 
 condition connected with it, of which the dysmenorrhoea is one of the 
 first undoubted symptoms. 
 
 It is a well-recognized fact that dysmenorrhoea is much more common 
 among highly-educated and well-to-do classes than among the laboring 
 classes. This is probably due to two causes : 1st. Among the rich the 
 law of survival of the fittest is interfered with ; that is, among the poor 
 the feeble and sickly children die in infancy or early youth, while many 
 children of the rich with inherited tendencies to disease are by the 
 better care that they receive enabled to reach puberty. 2d. As the 
 children of the rich approach puberty the girls are kept indoors, 
 deprived of fresh air and sunlight, and by custom compelled to lead 
 physically passive and indolent lives as compared with the poor or 
 working class. Besides being enfeebled by bad hygienic environments, 
 they are compelled to expend all available force in intellectual work at 
 a time when the generative organs should be developed. Even where 
 a good constitution is inherited, and sufficient food, exercise, and sun- 
 light are allowed to fairly well develop the muscular system, if emotional 
 and intellectual work is forced upon them during the period that the 
 generative organs should be developed or allowed force to develop, they 
 will be likely to suffer from dysmenorrhoea due to imperfect develop- 
 ment of the generative organs. Numerous examples of this class can 
 be found among the scholars of our normal schools, for it is here that 
 the brightest graduates of our high schools go, their successes, prizes, 
 etc. being additional incentives to keep up the intellectual strain, and 
 thereby longer delay the full development of the generative organs. 
 In this country intellectual education is more general among women 
 than in any other, and the influence of imperfectly developed uteri in 
 causing laceration of the cervix, etc. may partly explain why so many 
 women, comparatively speaking, seem to suffer with uterine disease. 
 
 The generative organs are not essential to the life of the individual, 
 and, being last to develop, naturally may be the first to suffer if the 
 vital forces are insufficient or if they are forcibly absorbed by brain- 
 work. It would seem that a certain amount of surplus of strength 
 and force is requisite for the perfect development of the generative 
 organs. If women are to avoid diseases of the generative organs and 
 are to bear children, their vital forces should not be exhausted nor 
 forcibly diverted by emotional or intellectual work during the period 
 
that tlu'v aiv cliaiiijiii^' I'roiii <;irlli<i()(l t<> wtmiaiihoud. Dm'iiit,^ tlic 
 jH'ritxl (if (lc'V('l(>|)iiu'iit, tVtiiii ten to seventeen yeai's oi" atic, ;:(i(m1 HmmI, 
 free open-air exei'cise, and sinilii;lit are e>|ieeiall\' needed, and lr<'edoni 
 from emotional excitement, eare, and anxiety is desiralile; and all 
 intelleetnal elTort that is lahorions or al)sorl)in<;' shonld and can he 
 deterred nntil Ihll development of the u'enerative or<2;ans has heen 
 secured. 
 
 To ]>rcvent the etVeets of either ii'eneral or local disease resnltinj;- in 
 dysmenorrluea it is important not oidy to enre the disease, hnt also to 
 not too Ion*;- delay liivin^- stinudatinu; local treatment when indicated 
 bv the eontimumee of amenorrluea, in order to prevent degeneratioa 
 and atrophy. 
 
 Tin:A'r>[K\T. — To relieve the pain caused by disease of the tubes, 
 ovaries, or periuterine tissues, so far as menstruation intluenees it, the 
 best thing to do is to increase the flow rather than stop it. 0[)ium not 
 only dulls the pain, but at the same time seems to relax the local con- 
 gestion, and thus increases or equalizes the flow. Its influence in this 
 respect on the congestion due to acute local inflammation of the uterus 
 itself is still more marked. Local treatment to the uterine cavity 
 should not be undertaken in these complicated cases until they have 
 been rendered subacute and the uterus made movable by the prolonged 
 use of simple vaginal application, which will improve the circulation 
 of the pelvis, and thus cause the absorption of most of the products of 
 inflammation and render pliable the peritoneal adhesion that may be 
 present. When the uterine sound is used, it will show in Avell-marked 
 cases of dysmenorrhoea associated with ovarian disease that a h^'per- 
 sesthetic and more or less inelastic, if not contracted, condition of the 
 endometrium has been the real cause of the dysmenorrhoea. 
 
 I have had very little satisfaction in the use of medicine in curing 
 dysmenorrhoea by any specific action, and I only use anodynes as pal- 
 liatives in case of severe pain until the dysmenorrhoea is stopped by 
 improving the general health or by local treatment. 
 
 To illustrate what I consider to be the best plan of treating typical 
 cases of dysmenorrhoea, I will describe the different steps that I am 
 in the habit of pursuing in my private practice. 
 
 A young woman, say of seventeen years, is brought to me by her 
 mother. After taking a careful history of the case, inquiring especially 
 as to any disease or sickness that she may have had since nine years of 
 age, and as to her mode of life and studies during that time, I do not 
 at first advise a local examination, but make sufficient examination to 
 detect any signs of a complicating or constitutional disea.se. If she is 
 inclined to constipation, I order either pulv. glycerrhiz. co. to be taken 
 at bedtime, or fl. ext. cascara before meals. I prefer these i^reparations, 
 for I know^ that thev mav be used Avithout necessarily fostering the fixed 
 
426 MENSTRUATION, AND ITS DISORDERS. 
 
 habit of using laxatives. If she is aneemic I order Blaud's pills, one 
 after each meal, as being one of the best forms in which to give iron. If 
 she. complains of being tired and wakeful or nervous, I order a tablespoon- 
 ful of the syrup of the hypophosphites, to be taken after meals. If her 
 appetite is poor or there are more marked evidences of faulty assimila- 
 tion, I order a glass of pancreatized milk with each meal, or a bottle 
 of Brush's koumyss twice a day. If she is at school she is ordered to 
 give it up and to spend much of her time in the open air, and to come 
 iu contact with healthful, agreeable ]3eople whose presence does not 
 excite or exhaust her. This plan of general treatment will often give 
 relief in a few months, and if persevered in will in simple cases eifect 
 a cure without any local treatment, which on account of its disturbing 
 and trying effect on sensitive girls is to be avoided if possible. If the 
 above fails after a fair trial, then I order in addition that hot vaginal 
 douches be properly given for ten days previous to each menstruation. 
 If this does not steadily improve the condition of the patient and 
 lessen the dysmenorrhoea, I then advise a local examination. In cases 
 of long standing the ostium vaginae may be found extremely sensitive 
 and abnormally contracted — in fact, in a state probably not unlike that 
 of the endometrium. In these, on account of the hypersesthesia, etheriza- 
 tion may be required to obtain even a simple examination with the index 
 finger. While the patient is under ether it is well to thoroughly dilate 
 the vagina, so as to lessen the pain of subsequent treatment. 
 
 After ascertaining the condition of the uterus and other organs as far 
 as practicable, I at once begin treatment by the application of pledgets 
 of cotton saturated with a mixture of pure glycerin and boro-glyceride : 
 the latter is an antiseptic and prevents fermentation, etc. that may follow 
 the use of simple glycerin. The applications are made to the vagina 
 twice a week, kept in for twenty-four hours, and vaginal douches given 
 when removed. They will cause a free watery vaginal discharge, and 
 after two or three weeks will soften and render less sensitive the vagina 
 and enable you to freely move the uterus. In well-marked cases of 
 dysmenorrhoea the uterus will be found abnormally small, the cervix 
 pointed and hard, with its axis parallel with that of the vagina, the 
 intravaginal anterior lip being very short and the posterior long; and 
 the fundus will usually be flexed forward. If the patient gives a his- 
 tory of habitual constipation, the left broad ligament will give evidence 
 of having been stretched, and the left ovary will be found prolapsed to 
 the level of the vaginal junction, and the broad ligament feel full and 
 elastic on account of the varicosed state of the pampiniform plexus — a 
 condition similar to varicocele in the male. There may be a leucor- 
 rhoeal discharge, with a slight granular eroded condition of the endo- 
 metrium in and around the os externum. After rendering the uterus 
 movable by this preparatory treatment, and having ascertained the 
 
D YSMENOn II IKEA . 
 
 427 
 
 Fio. 171. 
 
 absence of any (•()iiij)lic;itiiiti,- pc riiitciiiir inllanunation, the va<rina is 
 swabluHl out M-itli a sol. hidildi-. hut., 1 to ."}()()(), and tlien a clean 
 sound is passed for the first time. ^Vs a rule, it should be curved to 
 suit the degree of flexion. As it reaches and passes the os internum 
 the i)atient will complain of the same j)ain as that caused by mciistnia- 
 tion, and as the sound is withdrawn a little blood 
 mav show itself at tiie os extenuuii. Having had 
 the case under prei)aratory treatment k)ng enough 
 to be sure of a correct diagnosis, and having rcn- 
 tlcrcd tlic uterus movable, and feeling satisfied that 
 there is no ju'riuterine disease, such as a distended 
 tube to be ruptured during the act of dilating the 
 cervix, the case may be considered ready for the 
 next step in the treatment — namely, dilatation. But 
 if the case is complicated by periuterine congestion 
 or "subacute inllammation," the simple glycerin 
 ])le(lgets are replaced by similar pledgets saturated 
 with a mixture of alum one part to pure glycerin 
 fifteen parts and one part of boro-glyceride. The 
 size of the pledgets is gradually increased. As a 
 rule, an ordinary case M'ill be much changed in two 
 or three weeks by this preparatory treatment ; the 
 vagina is less sensitive and larger; the cervix is less 
 pointed and its axis directed farther backward ; the 
 periuterine tissues are softened and less painful upon 
 examination. Occasionally a case of long standing, 
 in which the nervous system has been seriously af- 
 fected, will require six or eight weeks of such treat- 
 ment before the next step can be safely undertaken. 
 Dilatation. — The patient being in Sims's position, 
 the vagina is sponged out with a solution of 1 to 3000 
 bichloride or 1 to 20 of carbolic acid. All instru- 
 ments are kept in a solution of carbolic acid. Then 
 a Sims uterine dilator is inserted in the uterine canal. 
 By allowing the instrument to ascend with the ut(M'us 
 to the vault of the vagina and carefully watching the 
 amount of separation of the blades, there will be no 
 danger of the dilators slipjiing and the degree of 
 dilatation can be readily regulated. The dilator, 
 Avhen j)roperly curved, can be passed almost as easily as a curved 
 sound ; the blades should be forced apart about four lines. The 
 amount of force required for this dilatation will, of course, vary 
 greatly, but usually in old cases it is considerable, especially those of 
 the imperfectly developed t^qie. This procedure causes more or less 
 
 irodified Sims Dila- 
 tor, made of steel so 
 tempered that the 
 blades will remain 
 parallel under 200 
 pounds of pressure. 
 
428 MENSTRUATION, AND ITS DISORDERS. 
 
 (and in some cases intense) pain, similar to that due to menstruation. 
 The dilator is withdrawn and the cervical protector introduced into 
 the OS internum. An applicator previously wrapped with cotton is 
 dipped into pure carbolic acid ; the free acid having been rubbed 
 off, it is passed through the tube of the cervical protector directly 
 through the os internum, and thoroughly applied by turning it about 
 and slightly withdrawing the tube and applicator. About twenty 
 grains of iodoform are blown against the cervix as the speculum is 
 withdrawn. In some cases the pain is immediately relieved ; rarely 
 the patient complains of cramping pain for several hours. AVhen prop- 
 erly performed as directed above, and if antiseptic precautions were 
 used, I have never seen any harm from this treatment in uncomplicated 
 cases. The first dilatation can be made at the patient's home, and she is 
 kept in bed for the rest of the day or until all disturbance has ceased. 
 As a rule, it is best to allow at least a week to pass before the dilatation 
 
 Fig. 175. 
 
 i.'RaV^DLRS-tO. 
 
 Wylie's Cervical Protector, made and used fourteen years ago : three sizes. 
 
 is repeated. The glycerin pledgets can be inserted as usual. Some- 
 times I repeat the dilatation three times between the menses, but usually 
 twice is sufficient ; and if the dilatation can be carried to the point where 
 the blades are four lines apart at the os externum, the dysmenorrhoea is 
 relieved in the majority of cases where there is no active endometritis or 
 endocervicitis, and in favorable cases it is the beginning of a permanent 
 cure. Much will depend upon the condition of the general health and 
 on the readiness with which the lining membranes of the uterine canal 
 respond to the treatment. AYhere the tissues are not sensitive and the 
 uterus is small and atrophied, I use iodine in place of carbolic acid, or 
 I applv electricity directly to the uterine tissues and persist in the treat- 
 ment until the uterus develops. 
 
 Besides the vaginal and periuterine hypersesthesia, any complica- 
 tion, such as vaginitis, acute endocervicitis, metritis, or local peritonitis, 
 should be treated before resorting to dilatation for the removal of dys- 
 menorrhoea. In those cases Avhere catarrhal disease and anaemia are 
 active agents in causing the disease or hypersesthesia at the os 
 internum, the dysmenorrhoea will of course be likely to return, unless 
 these conditions are permanently corrected. The changes produced by 
 this treatment are — a shortening of the cervix, a nearer approach to 
 the normal direction of the axis and shape of the vaginal cervix, and 
 a complete alteration in the mucous lining. Any subacute congestion 
 
T)YSMi:x()in:u<K.[. 420 
 
 witli faulty socrotions is usually cund, the secretions of the cervix 
 beconiiuj^ transparent like the white of au egjr. After this treatment 
 a sound can be })a.ssed to the I'undus without causinj^; pain. This simple 
 method of dihitinji; and the use ol" the cervical pnjtector enable one to 
 make ell'ectual application to (he linin>i membrane of the uterus, ^^'ith- 
 out dilatation ai)plicati(ins to the endometrium are out of the (juestion, 
 and without the cervical protector most of the solution w(tuld be 
 absorbed or rubl)ed or squeezed oif by the walls of the cervix. 
 
 Vivn/.sion. — In married M'omen, if nothing is done to prevent impreg- 
 nation, sterility will often be cured by this simple dilatation. But in a 
 certain number of cases this method gives only temi)orary relief The 
 vaginal part of the cervix is abnormally long and pointed and hard, 
 and does not shorten np after dilatation, and the stenosis is accompanied 
 by so great a change in the muscular walls, or there is so strong a tend- 
 ency to spasmodic contraction of the os internum, that simi)le dilata- 
 tion will not cure the dysmenorrhcea or sterility, and it becomes neces- 
 sary to resort to divulsion or a modification of Sims's operation, A\hich 
 is a combination of divulsion and incision, with the use of a hard- 
 rubber intra-nterine drainage-tube instead of a glass plug or stem 
 pessary. I employ the above preparatory treatment with pledgets of 
 cotton saturated with glycerin, etc., always carefully treating any com- 
 plication, such as periuterine inflammation, beforehand ; for as long as 
 the uterus is fixed by old adhesions any dilatation or operative pro- 
 cedure is attended with risk. AVhen the uterus is movable, so that the 
 cervix with little resistance or pain can be pulled well down to the 
 vulva while the patient is in Sims's position, it is usually safe to 
 operate. ]\Iy patient is instructed to take a laxative and bath, to have 
 fresh clothing, bedding, etc., and to take a vaginal douche of solution 
 of bichloride, 1 to 3000, preparatory to the operation. Instruments 
 needed : one dozen sponge-holders, with new aseptic sponges ; Sims's 
 speculum, depressor, forceps, sound, tenaculum, uterine dilator, appli- 
 cator, hard-rubber drainage-tube, a needle-holder, and a threaded 
 slightly curved needle with silver wire, 
 to be used in case the circular artery is ^ ig. - . 
 
 severed. A straight bistoury can be 
 used in place of a Sims uterotorae, and, 
 unless the tissues above the os internum 
 are to be divided, it will do nearlv as 
 
 ,, rr<i • n '• Wylie's Hard-niliber Intra-uterine Drain- 
 
 well, lliese instruments are all im- age-tu1)e. nine in set. three sizes ill 
 
 mersed in o-per-cent. solution of car- I'-^nfth- an*^ three. calibres ; Nos. is, 20, 
 
 1 and 22 (American measure). 
 
 bolic acid. The patient, being ether- 
 ized, is put in Sims's position ; the vagina is carefully s]X)nged out with 
 1 to 3000 bichloride solution ; a strong tenaculum is fixed in the anterior 
 lip of the cervix, ^vhich is ]iulled to the vulva. "With the sound the 
 
430 MENSTRUATION, AND ITS DISORDERS. 
 
 uterus is explored ; the dilator is then introduced, and the uterine canal 
 slightly dilated, so as to allow the blade of the bistoury to pass readily. 
 If the shape and condition of the cervix requires it, the cervix is divided 
 posteriorly. The blade of the latter is then introduced, cutting edge 
 backward, up to the os internum or the point of flexion ; the posterior 
 wall of the cervix is divided in the median line for half an inch or 
 more, according to the length of the infravaginal jDart of the cervix ; 
 the lining mucous membrane is divided the full length of the cervix ; 
 and the muscular walls are also divided for some distance under the 
 external mucous membrane covering the infravaginal cervix. As a 
 rule, there is very little bleeding, and where the circular artery is 
 normally placed it will not be divided. It is a mistake to divide all the 
 muscles, and especially the vaginal mucous membrane of the cervix, as 
 far as the vaginal junction. After this incision the dilator is introduced 
 and the os internum freely divulsed. Dr. Sims always divided the 
 anterior wall at the os internum with his uterotome, but I have for 
 several years past trusted to the dilators to overcome all constriction at 
 this point, for I have never seen a full-sized plug introduced after the 
 incision through the os internum without the free use of the dilators. 
 The dilatation should be done slowly, so as to give time for the tissues to 
 stretch and not tear. In many cases the amount of force needed to- 
 overcome the constriction is very great — not less than the full force 
 of the grip of one hand ; if this force be kept up for a minute or two, 
 it will usually suffice, and it is well to repeatedly try to introduce the 
 intra-uterine drainage-tube, and to be satisfied with the amount of dila- 
 tation when a full-sized moderately curved tube can be introduced to 
 its full length (two and a quarter inches), and remains in place without 
 being held in position. It is at this point of the operation that failure 
 is often made, for many times the point of the tube, especially if straight,, 
 strikes at the os internum at the point of flexion, and forms a j)ouch 
 beliind it, which, with the elongation caused by the stretching of the 
 cervix, allows the tube to enter the cervix almost to its full length. 
 This leads the operator to think that it has entered the cavity of the 
 fundus, and he inserts his tampon, etc. Now, the test whether the tube 
 has passed the os internum and entered the cavity of the fundus is, that 
 it will remain in place and not tend to spring back ancl out as soon as 
 pressure is removed. Once it is well through the os internum, it i& 
 grasped by the circular fibres and remains in place. In some cases, of 
 course, it is more difficult to pass the tube than in others. Where the 
 flexion is decided and the lining membrane of the cervix lax, the point 
 of the tube invariably glides behind the os internum and puts the 
 lining membrane and the posterior wall of the cervix on the stretch. 
 More than once I have seen this operation done, and the tampon put 
 in to hold the tube forcibly in place, and afterward had the opportunity 
 
j)YsMi:s(n:i:ii(i:.{. WW 
 
 to j)rov(' that the cavity nf the I'liiidiis Imd ii(»t hccu ciitcrcfl hy citlicr 
 tlic kiiill" or tiil)i'. KvcM ill the liaiids of Dr. Sims liiiiix-Il" I liavc seen 
 lailiirc to <jet a good-sized liiass |)liij;' in at one sittiii<:. I am *)iiilc <cr- 
 taiii tliat this diilictdty accounts lor some ot" the t'aihires to do "rood hy 
 this opi'i'atioii. In certain eases it wonhl seem next to imjtossihh- to 
 intro(hiee Simpson's or IVaslee's ntei'(iti>me, or any straiglit in.-trnmcnt, 
 withont first dihitint;- the external os by tents or other means to I'chix 
 the OS internum and sti-aiiihten the canal. Straij^ht dilators may ho 
 made to pass up int<i the cervix two inches or even more, but they will 
 ])ush the OS forward or to one side, and will not enter the cavity «»f' the 
 liuulus of the uterus, characteristic cases heediutj; dilatation. 1 have 
 had Sims's dilator made with blades curved so that it can be passed as 
 readilv as a sound. Tt should be of the very best steel, so as not to 
 yiekl under pressure, and the joints should be sufficiently far back to 
 allow the blades to open and yet remain nearly parallel. The joint is 
 held by an adjustable screw that enables it to be taken a[)art to be 
 cleanetl. 
 
 When the tul)e can be readily pa.ssed into and through the os inter- 
 num, it is Mcll to a[)ply a little pure carbolic acid on an api)licator to 
 the lining membrane of the cervix, then to replace the plug, cleanse the 
 vagina, and blow into it a half drachm of iodoform ; this is absorbed 
 more slowly and remains longer than any other antiseptic. Dr. Sims 
 made it a rule to insert styptic cotton against the plug and cervix, and 
 then over this a firm tampon, the object being to prevent hemorrhage 
 and at the same time keep the plug in place. I do not place the pledg- 
 ets until the hemorrhage is completely checked, and usually the pres- 
 sure of the tube stops the oozing if there is any. If the circular artery 
 is cut, I ligate it by passing a silver suture around and twisting it. 
 When all oozing has ceased and the tube is in place, pledgets of cotton 
 squeezed out in 1-to-oOOO bichloride solution and sprinkled with iodo- 
 form are put under and in front of the tube, the object being to keep 
 the tube in position. After each urination the vulva should be washed 
 with antiseptic .solution (bichloride 1 to 5000), and iodoform sprinkled 
 over it for .several days. On the third day I remove the cotton and 
 in.sert fresh pledgets after thoroughly cleansing the vagina, the tube 
 being left undisturbed. On the sixth or seventh day I remove the tube, 
 and after cleaning it and the vagina I replace it and keep it in position 
 either with iodoform cotton pledgets or a vaginal pessary. It is allowed 
 to remain for a week or two longer as the case may seem to require it. 
 Dr. Sims usually removetl the tube on the fifth day and left it out, but 
 I prefer to retain it in place until the surface is entirely healed. Unless 
 the tube is a verv large one it can .safely be left in place during men- 
 struation. I use intra-uterine drainage-tubes which have one or more 
 deep grooves in them, so as to permit free drainage, and my objection 
 
432 MENSTRUATION, AND ITS DISORDERS. 
 
 to the iron or styj^tic cotton and large firm tampons is that drainage is 
 obstructed, and thus the risk of septicaemia increased, and the fluid 
 dammed back in the uterus may be forced into and through the tubes 
 into the peritoneal cavity. When the case has been properly prepared 
 and the above precautions have been taken, the risk is very slight and 
 the result most satisfactory. To get good results one must do all that 
 can be done to improve the general health of the patient and give the 
 proper preparatory treatment, which not only lessens the chances of 
 doing harm, but also enables one to carefully study the case and patient 
 and eliminate complications, such as diseased tubes or ovaries, etc. If 
 one takes a delicate and weak woman with an imperfectly developed 
 uterus, with a degenerate and granular eroded mucous lining, and 
 divides the cervix too freely, or when discission is not needed, he may 
 relieve the dysmenorrhoea, but he will do his patient harm, and sooner 
 or later she may have an everted and diseased cervix resembling a 
 lacerated cervix and requiring the same treatment. 
 
 If one divulses the cervix or divides it with a knife while the patient 
 has a diseased tube tense with an irritating or poisonous fluid or a dis- 
 eased ovary filled with tense cysts, any of these may burst or break and 
 cause local peritonitis. Or if one operates, without using antiseptics or 
 preparatory treatment, upon a patient with a diseased mucous mem- 
 brane, he may cause the extension of the local poisoning to the deeper 
 literine or periuterine tissues, and get what we call inflammation ; but 
 this is the fault of the operator and not of the operation. Eliminate 
 failures to diagnose serious complication, and blood-poisoning from 
 lack of care in cleanliness or from prejudice against the use of anti- 
 septics, and this operation becomes one of the simplest in uterine 
 surgery. 
 
 I have never believed in the necessity of the bilateral operation. In 
 those cases where Dr. Sims recommended it I would dilate and drain 
 or divulse and keep open with a drainage-tube. 
 
 If the dilatation is imperfectly done, the relief, of course, is only 
 temporary, but when thoroughly done and repeated, say twice in two 
 or three months, it will often effect a permanent cure in cases of even 
 ten years' standing. I know several whom I treated as long ago as six 
 or eight years, and they are well to-day. Undoubtedly, there are cases 
 that can be relieved of dysmenorrhoea, but not cured of sterility ; for 
 there are some cases in which the organs have reached only a very im- 
 perfect degree of development, or have atrophied and changed so much 
 that they cannot be fully developed by any treatment. In some of 
 these the local application of electricity will do good by stimulating 
 development. It is a simple matter to apply electricity, but its use 
 must be kept up for several weeks before it will have a perceptible 
 effect. The galvano-electric pessary of Simpson may be used in cer- 
 
i)YsMi:y(jnnii(K. i . 433 
 
 tain indolent cases, htit it innst be closely \vat<'lie<l. A jxood drainajxo- 
 tnhe ol" hard rnl»l)er is nnicji safer and |»erliaj)s e»|iially ellicacions. If 
 a woman witii dysinenorrluea is (o many, she shoidd marry early in 
 lile, ft>r the chances of ])re<^nancy and fnll (h-veloj»ment then are 
 undonhtcdly better than later. I am certain it hel|)s these eases, for 
 normal erotic excitement stimidates de\('l(i|)iii( iit and ascits alniormal 
 fnnctional deranirement and bad habits. 
 
 C'hildbearing is the best means of completing devel()|»iiient and mak- 
 ing a permanent cnre in such cases. One would expect that small, im- 
 perfectly-developed uteri would be torn more frequently than in the 
 average case of labor; and this is a fact, especially if the labor is qui(;k, 
 for the cervix requires time to get into the best condition for full expan- 
 sion. I have foiuid tiiat more depends upon the condition of tiie mucous 
 membrane at the time of laceration and shortly after labor than uj)on 
 the size of the os or the extent of the tear. Diseased tissues heal badly 
 and tend to swell, evert, etc. 
 
 Sponge Tents. — For more than ten years I have not usetl tents in 
 these cases. Without doubt, some cases can be cured with them, but 
 their use is more dangerous than that of the dilator, and much more 
 inicertain in results. If tents must be used, I have them made with 
 iodoform mixed in the gum, and I use iodoform and bichloride tam- 
 pons to keep them in place. I never allow them to remain more than 
 twelve hours, for they fjrm a most excellent nidus for germs, and for 
 a time they prevent drainage from a very much irritated, rapidly secret- 
 ing mucous membrane, and may force some of it into the Fallopian 
 tubes, etc. 
 
 Dilatation by Sound. — \yhenever I see a specialist using a set of 
 graded uterine bougies or sounds, especially such as are nearly straight, 
 I know that he is travelling over an old road that was pointed out by 
 Mackintosh many years ago. The uterus is too movable and elastic 
 to permit of the use of sounds to the best advantage, and many a case 
 has been sounded up to the os internum and not beyond. 
 
 To Simpson belongs the credit of the first uterotome, but Sims was 
 the first to perfect that instrument and to understand fully how to use 
 it. He pointed out the mistake of using automatic and straight utero- 
 tomes in the uterus. 
 
 In June, 1873, Dr. John Ball of Brooklyn, X. Y., read a ]>aper 
 before the Medical Society of Kings county on rapid dilatation of the 
 cervix uteri for the relief of stricture, etc., and in 1877 he presented a 
 paper on the same subject before the New York State ^Icdical S(X'iety. 
 About this same time Ellinger of Stuttgart advocated forcil)le dilata- 
 tion. Dr. Ball reported a number of cases successfully treated by rapid 
 dilatation, and in this country introduced the method of ** rapid dilata- 
 tion " now so earnestly advocated by Dr. Goodeli, whose methods are 
 
 Vol. I.— 23 
 
43-t MENSTRUATION, AND ITS DISORDEBS. 
 
 essentially those of Dr. Ball. There can be no question about the suc- 
 cess of divulsion, but there are many cases which can be perfectly cured 
 by moderate dilatation, which is not only less dangerous, but I think 
 gives better results in those cases where imperfect development is more 
 marked than spasmodic stricture. For it is not a powerful and spas- 
 modically constricting muscle that is to be overcome, but a feeble, 
 degenerate organ that needs to be stimulated to healthy development. 
 In cases of atresia of the cervix where the vaginal cervix is large and 
 only slightly flexed and pointed, where Dr. Sims advised the bilateral 
 incision, I use divulsion and insert a drainage-tube; and I do the 
 same in cases of chronic catarrh where there is indication of strict- 
 ure of the cervix. But when I am treating sterility, and have a flexed, 
 hard, and pointed cervix to deal with, I am sure that the knife, applied 
 as above advocated, is an improvement upon simple divulsion, for the 
 OS externum tends to contract and close the opening after the latter 
 operation unless the tissues are torn by the instrument. Still, I con- 
 fess that we could more easily dispense with the uterotome than with 
 uterine dilators. There is less risk in opening the uterine canal with 
 dilators than with the uterotome, but dilators can do serious harm when 
 the dilatation is carried too far ; and if one uses a screw to force open 
 the dilators the risk is greater than when he uses his hand or hands to 
 regulate the amount of dilatation. 
 
 Use of Pessaries in Dysmenorrhoea. — If the use of pessaries in such 
 cases had never been taught, much harm would have been averted and 
 more progress made in the right direction. Only very rarely can we 
 afford some relief by the use of an anteflexion pessary, but at best it 
 is only palliative and can be dispensed with. It is not so much by 
 straightening the flexion that the pessary does good as by preventing 
 prolapse, and perhaps by steadying the fundus. As to the use of stem 
 pessaries for straightening the canal, they may do good by stimulating 
 development, but many of them are dangerous instruments. 
 
 Membranous Dysmenorrhcea. 
 
 If we could accept the desquamative theory of Dr. John "Williams, 
 it would be easy to explain membranous dysmenorrhoea ; and if the 
 view advocated by Kundrat and Engelmann of the growth of the 
 utricular glands and proliferation of round cells before menstruation, 
 and the exfoliation of this proliferated mucous membrane during the 
 flow, is correct, then we could say that membranous dysmenorrhcea is 
 merely an exaggeration of a normal process, and the membrane comes 
 away en masse instead of in minute particles. 
 
 I am inclined to believe that the process which takes place in the 
 
MI:MIII!.1\(K\S DYSMENOIHIIKEA. 4.'i.j 
 
 ii(cnis luid Icatls ii|) tn nicMstniatioii is una of" growth — a pn'j)aratinii 
 lor Mrcuiiancv (similar tu the luiti'ilivr node tliat pr('('(!(k'.s the formation 
 of a l>ii(l oil a tree, as Mary l'iiiiiaiii-.]ai(»l)i wdultl express it) — ami, 
 iiiilfss impreiiiiatioii takes place ami stimulates and directs further 
 "■rowtli, that disiuti\u,ratioM will take |)laee and the aecunudated blood 
 escape and the tissues ai;ain start another eyelo of lii-owth. If this dis- 
 inteii-ration takes place by fatty degeneration, and the lower or under- 
 Ivini; part deijenerates before the superfieial part disintej^rates, the 
 latter mav be thrown olf in shreds or ca.st off in one piece. This 
 abnormal process may be the result of the preparatory growth g<»ing 
 too far in developing a decidual mcml)rane, or it may be the result of 
 some irritating disease abnormally increasing tiie supply of blood, thus 
 indueiijg excessive growth of the lining membrane, or the irritation 
 may so greatly increase the normal vascular tension that the superficial 
 layer is dissected off by hemorrhage in the deeper layer. 
 
 PATiiOLOfTV. — The membrane may be thrown of}" in separate pieces 
 or it may be expelled in one piece, a triangular-shaped sac with three 
 openings — one, the largest, the os internum ; the other two, much 
 smaller, representing the openings into the Fallopian tubes. The 
 inner surface is smooth, while the outer surface is ragged and shreddy. 
 Small perforations where the uterine glands have penetrated can usually 
 be detected. It is undoubtedly composed of the superfcial layer of the 
 endometrium, with perhaps an abnormal amount of connective tissue. 
 
 SY.Mr»T()Ms. — In some cases it would seem to be inicomplicated by 
 any definite disease, and the membrane is cast oif in tangible pieces 
 every month on the second or third day of the flow, which is accom- 
 panied by severe colicky pains, sometimes of the most violent nature. 
 The flow may be somewhat intermittent, due probably to the membrane 
 ]>lugging the os internum. During the flow the patient may be in an 
 ex(piisitely sensitive or hypcrfesthetic state. Other cases are irregular, 
 menstruation being at times nearly normal. 
 
 Meml)ranous dysmenorrhoea is oflen associated with uterine catarrh 
 and other diseases, but these alone do not account for it. A well- 
 marked case usually continues as long as the patient menstruates. 
 
 The decidual membrane of an abortion may be mistaken for mem- 
 branous dysmenorrhiea, but the repeated occurrence of the meml)rane 
 in membranous dysmenorrhoea and the absence of the villi of the cho- 
 rion under the microscope as a rule make a diagnosis comparatively 
 certain. 
 
 Treatment. — To make sure of a diagnosis it may be necessary to 
 treat, and if possible cure, any existing complication. After this I 
 would treat the tlysmenorrho?a in very much the same Avay as has 
 already been recommended — by free dilatation or divulsion and inter- 
 uterine ap]ilications, and tiie jn-olonged use of an intra-nterine drainage- 
 
436 MENSTRiyATION, AND ITS DISORDERS. 
 
 tube. If all these measures failed and the symptoms justified so 
 extreme a measure, with the patient's consent I would not hesitate to 
 remove the uterine appendages to induce premature menopause. As a 
 rule, after thorough dilatation and the proper treatment of complications, 
 the pain will be very much less, and by the use of an anodyne once a 
 month the patient can be made comparatively well. 
 
 I have seen severe cases of dysmenorrhoea in which the membrane is 
 not cast off in large, tangible pieces give almost precisely the same kind 
 of persistent colicky jjains and cause the same nervously hypersesthetic 
 state, so that I have concluded that the symptoms were due to the same 
 abnormal conditions as existed in well-marked cases of membranous 
 dysmenorrhoea ; but the uterus did not have the power to expel the 
 membrane. 
 
 The Menopause. 
 
 Take ten or twelve of the best known works on gynecology, and in 
 most of them the word " menopause " is not to be found in the index, 
 and in none is it more than mentioned incidentally. 
 
 As a rule, menstruation ceases between the ages of forty and fifty, 
 the average being at about forty-six years of age. It may continue 
 after fifty or stop before forty, but this is exceptional unless caused by 
 disease. Cases of premature menopause have been reported as occur- 
 ring under thirty, and at a recent meeting of the New York Obstetrical 
 Society Dr. T. A. Emmet reported a case where menstruation had con- 
 tinued apparently normally in a woman seventy years old, but he had 
 not made any local examination. 
 
 A woman in jDerfect general health, and not having any local disease 
 nor any abnormal conditions of the tissues the result of previous local 
 disease, should cease menstruating without any special general or local 
 disturbance ; and many Avomen do pass the menopause without suffer- 
 ing. But so common is it for women to have unusual hemorrhage and 
 suffer greatly from reflex nervous affections at this time that it is a pop- 
 ular belief, shared by most of the medical profession, that it is what any 
 woman must expect ; and unless life is endangered by hemorrhage or 
 insanity is imminent, it is not to be regarded as an abnormal thing to be 
 carefully investigated and treated. Every specialist knows how com- 
 mon it is for women between forty and fifty years of age to come to 
 him and say that for months, or even a year or more, they have had 
 irregular or more or less continuous flow, etc., and on examination he 
 has found cancerous disease so far advanced that it is too late to give 
 material relief "When he asks why they did not come to be exam- 
 ined long ago, they reply, " I thought it was only change of life, 
 and my doctor did not ask to make an examination." Hemorrhages 
 from fungous granulations, polypi, and fibroids are often neglected 
 
THE Mi:.\()r.\rsh'. 4:n 
 
 li)r the sMiiic rcasim until cNtnnic aiiinnia cuiujm'Is thoiii to seek re- 
 lict" ("nun .-(line niic nut ,-:iti>li('il in tliinkiiiLi "it is only tlw rliMiij^c; 
 of lil".'.'" 
 
 I'lcinatnic nicnopansc in;iy l»c tlic result ol" j)rolon<re(l anienoi"rli(r>:i 
 after eonstituti(»nal diseiise, w here from iinperfeet <levelo|)inent or atro- 
 pliv from local disease, eomhiiied witli a l»ad eon<lition of tlie hlood, 
 tlie organs have peniumeiitly lost the power to perform their fuiietions. 
 It is im|)oi-tant on this aeeouiit to examine earcfnily into th(! cause 
 of prolouii-ed anionorrlKoa, especially in those eases where it continues 
 after the <j;eneral health has been restored. Sometimes stimulatin<r 
 local treatment arrests the atrophy and restores the or<rans to a nor- 
 mal state. 
 
 Removal of the uterine appendages before puberty w(»nl<l in all 
 probability prevent menstruation in any case, but, although it is the 
 rule for the menopause to be induced by the removal of the tubes and 
 ovaries after puberty, yet in some cases menstruation will continue 
 where the ovaries and the greater part of the tubes have been carefully 
 removed. As Tait's operation is done to-day, usually, from a fourth 
 to three-fourths of an inch or more of the tubes are not cut away, 
 and in many cases the greater part of the pampiniform plexus is left 
 intact. Dr. Mary Putnam-Jacobi in her description of her theory 
 of menstruation gives the most rational explanation that I have 
 yet seen why removal of the a]ipendages does not always stop men- 
 struation. 
 
 If menstruation at the menopause is excessive or too frequent, its 
 cause should be investigated as carefully as at any other time. Fun- 
 gous granulations are very common at this age, and mucous and fibrous 
 polypi are especially apt to develop at this period. If neglected, they 
 may stop bleeding, but not until the patient's general health is injured, 
 either from actual loss of blood or from reflex disturl)ances caused by 
 the granulations or polypi irritating and preventing the uterus from 
 undergoing normally the atro]ihy and other changes that sliould take 
 place at this age. 
 
 Strong, vigorous women may menstruate after fifty, but when a 
 woman past forty-eight years of age has excessive or even full men- 
 struation and is anjemic, or is very nen'ous and at times has *Miot 
 flashes" running up and down her back, if the os is dilated and the 
 uterus curetted, either fungous granulations or a nuicous ])olypus or 
 fibroids will, as a rule, be found, and when thoroughly removed the 
 menopause will at once come on, and if the cervix is occasionally 
 dilated the nervous symptoms will disappear. 
 
 In four instances where women long past the menopause have come 
 to me for vague nervous symptoms similar to those common at the 
 menopause, on examination, finding the uterus abnormallv large for 
 
438 MENSTRUATION, AND ITS DISORDERS. 
 
 that time of life — one was sixty-three years old — I dilated and re- 
 moved shrivelled-up polypi. In one case the largest resembled a 
 small dried pear. The final results were good in every case. 
 
 In the spring of 1880 a rather thin, wiry woman was sent to me by 
 Dr. Greenough of this city. She said that she had dysmenorrhoea 
 when young, but had not had any special uterine disease that she was 
 aware of. She had married when thirty, and about five years later her 
 menstruation had ceased, and had not shown itself except two or three 
 times, when she had a scanty flow, for the past two years, and that dur- 
 ing this time she had had hot flashes and all kinds of nervous symp- 
 toms, had taken all kinds of remedies, but that she was growing thin, 
 sleepless, etc., and that Dr. G. advised her to have a local examination. 
 I found the vagina and uterine appendages normal so far as I could 
 discover; the uterus was a little below the normal size, but not as 
 small as is usual two years after the menopause. It was anteflexed 
 and in about the normal position. In and near the os the mucous 
 membrane had a peculiar coppery or yellowish stained appearance, 
 which I had now and then seen about the cervix uteri of women past 
 the menopause. In passing a sound I found the os internum con- 
 tracted, and as the sound passed into the cavity of the fundus it gave 
 exquisite pain, and reminded me so forcibly of the condition of the 
 uterus so very common in young women suffering with dysmenorrhoea 
 due to imperfect development that I made up my mind to give it the 
 same treatment as I ^vas then using for the relief of dysmenorrhoea. I 
 gave the usual preparatory treatment, and dilated the cervix with a 
 steel dilator, and applied, by means of an applicator and cervical pro- 
 tector, pure carbolic acid to the endometrium. I warned her, as I do 
 in cases of dysmenorrhoea, that the first dilatation might be quite f>ain- 
 ful and increase her nervousness for a day or so, but that the second 
 would not be so painful, and the third still less so, and that if this 
 treatment helped her I could probably cure her. The dilatations were 
 made about a week apart. The result was magical : her nervous sys- 
 tem quieted down, she could sleep, eat well, and she steadily improved 
 in general health. Twice within six months she had a slight return 
 of the reflex symptoms, and the dilatation and applications were 
 repeated with equally good results. In a year's time she had gained 
 twenty-six pounds in weight and claimed to be perfectly well. Since 
 then I have treated a large number of cases suffering from reflex ner- 
 vousness at and soon after the menopause by dilatation and applica- 
 tions, and with most excellent success. In two or three of these cases 
 the nervousness was extreme, and the patients had been through all 
 kinds of treatment in the way of medication, water-cures, and even 
 "rest-cures," without permanent relief; yet they were cured in a very 
 short time by dilatation and intra-uterine applications. 
 
77//; MESoiwrsE. a:V.) 
 
 In some cases tlic peculiar :i|)|)(';ir;mci' -it" tlic niiiciiiis iiiciiiliraiic at 
 the OS is M(t( |)rcs(iit, lait tlic cervix to the os iiileniiim may In; per- 
 fcH'tlv noi'iiial, and the suhjcetive syiiiptoiiis may not directly point to 
 aii\- local disease; yet when the sound is passed you <i(.( the character- 
 istic j)aiii, and ol'tcu a slight How ol" Mood may escape IVom the os as 
 the sound is withdrawn. The following case is a udod illustration : A 
 handsome fleshy woman, fifty years old, marrie<l thirty years and never 
 ])reunant, canu' to me complaininsi; of" pal|)itation, irretiular action of" 
 the heart, extreme nervousness and sleeplessness, with loss of" aj)petite, 
 and occasionally an acid diarrhoea the result of indio(.stion. She had 
 recently lost her mother and two other members of" her family, which 
 at first seemed to aeeonnt for her condition. No organic lesion of the 
 heart, kidneys, etc. could be found, and she said that several months 
 previous her menses liad ceased without giving lier mucli trouble, but 
 now and then she had hot flashes. At this time no local examination 
 was made, and for three or four months she was treated for her indi- 
 gestion and what seemed to be nervous prostration ; finally, anodynes 
 had to be freel}' used, and there was no improvement. In going over 
 her case I learned that she had been treated for uterine displacement in 
 early life, and had worn a pessary for ten or fifteen years, but six or 
 eight years ago had removed it and got along as well without it as A^ith 
 it — that she had at times some dragging sensation about the back and 
 sides, and still had at intervals the " hot flashes." She consented to a 
 local examination, I found great relaxation of the vaginal walls and 
 marked prolapse with the fundus backward. The cervix seemed per- 
 fectly healthy. The prolapse was treated by means of cotton pledgets 
 saturated with glycerin and boro-glyceride-and-alum mixture, and all 
 local symptoms were relieved, 15ut her reflex nervous symptoms con- 
 tinued. Three weeks later, when the sound was introduced the endo- 
 metrium at and above the os internum was found exquisitely sensi- 
 tive, and the uterine canal measured three inches in depth. The 
 cervix was dilated and pure carbolic acid applied. After the third 
 dilatation every symptom disai)peared, her menses returned, and for 
 six months were perfectly regular and she was in excellent health. 
 She passed the seventh month without menstruating, and Avhen the 
 next menses were due her heart trouble, indigestion, and nervousness 
 came back. One dilatation relieved her, and now her health is as 
 good as ever. 
 
 Whether this hypenesthetic condition of the endometrium is due to 
 a subacute form of endometritis or the result of previous disease affect- 
 ing the tissues in such a way as to prevent them from undergoing nor- 
 mally the changes that should take place at the menopause, is yet to be 
 determined ; but the success of dilatation of the cervix uteri and appli- 
 cations of pure carbolic acid to the endometrium, combined with the use 
 
440 MENSTRUATION, AND ITS DISORDERS. 
 
 of cotton pledgets saturated with a mixture of one of alum, two of 
 boro-glyceride, and fourteen of pure glycerin, placed in the vagina 
 twice a week to stimulate and improve the circulation of the pelvis, 
 has been such as to convince me that much suifering, and perhaps 
 sonie cases of insanity, can be prevented if the treatment is properly 
 applied in well-marked cases of reflex disturbances occurring with the 
 menopause. 
 
STERILITY. 
 
 Hy a. REKVRS JACKSON. A.M., M. D. 
 
 CnH'ACin, ll,I,. 
 
 AccoRDixcj to statistics based upon many thousands <»f ohsfrvatioii.s, 
 al)out one niarrian'c in ten is untVnitf'nl. This tiu-t alone is siiHieient to 
 estal)lisii the <;reat importance of the snbject of sterility, whether it bo 
 viewed from a scientitic, .social, or politico-economical j)oint of vie\v. 
 
 \\'hile, in this article, my observations will have reference especially 
 to the sterile condition as it alFccts the woman, it is obviously necessary 
 to notice the fac-t that in any ca.se of infertile marriage the lack may be 
 attribntable to the male, and that in settling the diagnosis this po.ssibility 
 should always be considered. Indeed, the observations of recent writere 
 seem to show that the fault lies much more iVc(iuently with the male 
 than has usually been suppo.sed. Thus, Kehrer ' examined 40 ca.ses in 
 which he iiucstigated both the male and female, and, omitting the con- 
 sideration of some doubtful ca.ses, the male was found to be in fiiult in 
 31,5 j)erceut, of the entire uiuuber, Noeggerath found 8 in 14; Gros.s,^ 
 basing his couclusions on the examination of 192 cases, including the 
 above, states that the male was deficient in one case out of every six. 
 The j)roportion may be even greater than thi.s, for, while the data 
 quoted by Gross are of much value, they are quite insufficient to deter- 
 mine the question. 
 
 The c.s.scntial conditions of human fecundation are these : 
 
 1. Semen containing living spermatozoa must be deposited within 
 the genital pa.ssages of the woman, 
 
 2. A spermatozoon must come in contact with a mature healthy 
 ovule at some point beyond the internal os uteri — that is, in the cavity 
 of the uterus, in the Fallopian tube, or on the surface of the ovarv, 
 
 3. To enable the impregnated germ to become developed into a 
 viable new^ being it mast find a suitable location for lodgment and 
 nourishment. 
 
 The elaboration and deposition of the semen constitute the special 
 functions of the male. Those of the female are threefold, and com- 
 prise the reception of the niiile organ, ovulation (including the matura- 
 
 » Centralbhtt filr Gyncikolofjie, No. 23, 1879. ^ ^]/„^ Sterility. 
 
 441 
 
442 STERILITY. 
 
 tion and dehiscence of the ovule), and the furnishing of a proper nidus 
 for its attachment and nutrition. 
 
 The necessary functions, then, for the reproduction of the human 
 species are as follows : 
 
 1. Insemination; 
 
 2. Impregnation ; 
 
 3. Ovulation ; 
 
 4. Gestation ; 
 
 5. Parturition. 
 
 Any one or more of these processes may be defective, although the 
 latter will not concern the present inquiry. 
 
 1. Incapacity for Insemination. 
 
 A number of circumstances may interfere with the process of insem- 
 ination. They may arise from default on the part of either the male 
 or female. 
 
 A man may possess ample virile power, the genital organs may not 
 present any abnormality, and yet semen may not be secreted ; or, semen 
 may be secreted in proper quantity, but contain no spermatozoa; or, the 
 spermatozoa may be few in number, motionless, or their movements 
 may speedily cease after emission. In short, the man may be sterile. 
 
 Or he may be impotent. By this term is understood the inability to 
 accomplish the sexual act. This condition may depend upon a variety 
 of causes, and may be absolute or relative, permanent or temporary. 
 Aside from vice of conformation or other imperfection of the genital 
 organs, the defect may result from long and exhausting diseases, from 
 the premature or excessive use or from the abuse of the sexual function; 
 or it may arise from purely moral causes. Cases of the latter class are 
 of great interest and frequency. Mere timidity sometimes results in 
 sudden loss of power under circumstances in which it should be great- 
 est, the fear of being unsuccessful sometimes becoming the cause of 
 failure. A wife may by lack of complaisance cause impotence in a hus- 
 band who with proper encouragement would have full virile power. 
 
 Frigidity, which is not uncommon in the woman, is rare in the man. 
 This condition is characterized not only by absence of erection, but by 
 absence also of venereal desire. 
 
 Seminal fluid is deposited in the vagina by the function of coition, 
 the joint act of the male and female. In this process the male is essen- 
 tially active, while the female is relatively passive. With the former, 
 erection of the penis is necessary to penetration, and orgasm to ejacula- 
 tion : with the latter, there is frequently neither erection nor orgasm. 
 However, if the act be normally and perfectly performed, both parties 
 should participate in both erection and orgasm. 
 
INCAPACITY FOR lySEMIXAT/nx. 443 
 
 Tilt' t'cinale is jn-oviilrcl with an a|i|)ai-al ii- which, iiiidi r strirtly n«»r- 
 inal conditions, is caj)al»ic of clli'ctini;- an erection as coni|)lclcly ;is occnis 
 in the male, and tlie mechanism is similar in hoth. Cnder the infln- 
 cnce of sexual excitement in the female MoimI Hows in inerca-sed anionnt 
 to the cavernous bodies of the clitoiis and the hulhs of the va;^ina. 
 These erectile structures are encircled at their hiLse hy constricting^ uuis- 
 cles which ohstnut the ictiu-n How of blood, and cause them to attiiin 
 their maxinuim (h'^ree of tiiri;-escence and hardness. At the same time, 
 the jilans of the clitoris becomes endowed with an exalted degree of 
 sensibility, resulting in the venereal orgasm. Under the same excite- 
 ment the levator ani muscle, embracing the lateral and posterior por- 
 tions of the vagina in the form of a dee}) crescent, contracts and presses 
 the erected penis from behind and from both sides forward against the 
 anterior pelvic wall (Hildebrandt). The clitoris, in its hardened c(jn- 
 dition, does not change its direction, as does the male organ, but, being 
 fixed by its frsenuni, projects downward and fVjrward toward the vaginal 
 orifice, and during coitus is brought into nearer contact with the dorsal 
 face of the penis, and the repeated frictions become the chief cause of 
 voluptuous sensations. 
 
 The observations of Litzman,^ Wernick, Fallen/ Beck,^ Munde, and 
 others have shown that the orgasm affects the uterus also in a remark- 
 able manner. At the height of excitement the organ assumes a more 
 perpendicular position and sinks lower in the pelvis. The os becomes 
 softer and rounder, dilating and contracting with rapid alternations, 
 while at the same time the labia project and retract in such a manner 
 as to constitute a "suction" effect, each gaping being accompanied by 
 the emission, almost in jets, of clear, viscid mucus (Munde). This 
 process is of short duration — shorter than the orgasm in the male — 
 and at its close the parts return to their ordinary state. 
 
 Although it has never fallen to my lot to witness the local phenomena 
 of orgasm in the female, I have, while making digital examinations, 
 frequently been conscious of a change occurring in the position of the 
 cervix, with a simultaneous softening of the part. 
 
 Knowing as we do how perfectly means are adapted to ends ever^'- 
 where in the construction of our bodies, it is reasonable to suppose that 
 these provisions would not exist M-ithout reference to the perj)etuation 
 of the species. 
 
 Many women deny absolutely that they experience any orgasm or 
 any degree of ])leasurable sensation during the sexual act. Such 
 women are impotent. The impotency does not, however, imply ster- 
 ility, for it is admitted that women who are thus functionally defi- 
 cient may conceive and bear children, although they are less likely 
 
 ' Flint's Textbook of Phy.nolorfy, 1879, p. 891. 
 
 ^ St. Louis Med. and Surg. Journ., 1872. ^ Am. Journ. Obd., vol. viii. p. 507. 
 
444 STERILITY. 
 
 to do so than those in whom the functions are normally per- 
 formed. 
 
 The causes of impotency in women, when purely functional, are not 
 understood. The condition may be the result of some nervous defect, 
 or in some cases may be purely j)sychical. It is doubtless a not infre- 
 quent cause of domestic unhappiness, and possibly of disease. 
 
 The sexual sense in women varies greatly. In some it seems to be 
 quite as keen as in the male ; in others — and this class comprises the 
 greater number — it exists in moderate degree, its intensity being in pro- 
 portion to the more or less favorable character of the exciting circum- 
 stances. In still others — a considerable number— it is wholly absent, 
 or at least not evoked by the sexual act. Even among this latter class 
 it is possible that the capacity for sexual enjoyment is not so entirely 
 deficient as is commonly thought, but held in abeyance for want of suf- 
 ficient stimulus. Certain abnormities of the pelvic organs are known 
 to influence sexual desire. Versions of the uterus have been known to 
 abolish it, the wearing of a pessary to restore it, and the removal of the 
 instrument to be followed again by its loss. 
 
 Dr. E, J. Ill has reported ^ that in 44 cases in which trachelorrhaphy 
 was performed for laceration of the cervix uteri there were 34 in which 
 there was loss of sexual appetite and orgasm before the operation ; in 1 
 case there was increase (nymphomania) ; 3 of the subjects were widows ; 
 and from 5 he could get no answers to his inquiries. Of the 34 cases, 
 27 were entirely cured, and regained sexual desire and potency after the 
 operation. In the remaining 7 sexual appetite did not return. Dr. 
 Munde^ also mentions a case in which the closure of a laceration of the 
 cervix uteri restored sexual power, which had been lost apparently by 
 the injury. These observations have an evident bearing upon the 
 theory of uterine orgasm, for a laceration of the uterine cervix extend- 
 ing beyond the crown would obviously interfere with the alleged suc- 
 tion-power of the OS uteri ; and if this constitutes a feature of the 
 orgasm, the latter would be interfered with also. 
 
 On the contrary, certain other pathological conditions are known to 
 greatly intensify the sexual desire, this being especially true of conges- 
 tion and inflammation of the ovaries. Some women are absolutely 
 frigid except at or near the menstrual period. 
 
 By some it is thought that uterine erection is necessary to conception, 
 and that the absence of orgasm is no proof that some degree of erection 
 does not take place. Those who hold this view believe that conception 
 is more likely to happen when the orgasms in the male and female occur 
 simultaneously, or when that of the male is precedent ; that the semen 
 is projected into the uterus at the moment of ejaculation, or is drawn in 
 by the subsequent aspiratory action of the uterus already mentioned ; 
 ^ Trans. New Jersey Med. Soc, 1882. ^ Am. Journ. Obst., vol. xv. p. 90S. 
 
lyCMWCITY Foil ISSHMISATION. \ \o 
 
 and thai tlic spcniiato/oa have no pnwi r oT ,-(|(-|)i<ij)iil>i<iii wliat- 
 
 I'lial (he jt't of sciiifii <lncs soiiK'diiM's ciitrr (lii-cctiv the utciiiK' cav- 
 ity at the tiiiu; <tf cniission is very |»r<)l)al)Ic, altlioiii^li tlic i'act is not at 
 all |>roven hv such a case as lliat iiiciiti<»iic<I l>y Addon,' who states that 
 Raisch cxaniiiicil a woman killed l)\- licr husband in the very act oi' 
 adultci'v, and found semen in the hody of the uterus;- for the presence 
 of the fluid may have l)een the result of a |)i-evious act of intercourse. 
 Nor does this view of the process by any means j)reelude the existence 
 of, or the necessity for, a seIf-|)ropellin<^ power on the part of the sj)er- 
 niatozoa, hy which they are enahh.'d to pass upward when deposited in 
 the lower part of the vagina within or even upon the external genitals, 
 or to make their way throuiih minute openings in any part of the gen- 
 erative passages. 
 
 The obstacles which are sometimes overcome by spermatozoa in their 
 onward journey are almost incredible. Bozeraan^ relates a case occur- 
 ring in his own practice in which there was a continuous flow of urine 
 from the os uteri arising from a vesico-utero-cervical fistula. Notwith- 
 standing this advei'se current they reached their destination in the cavity 
 of the uterus, and conception, gestation, and a safe delivery followed. 
 The same writer mentions another case which ha[)])ened in the practice 
 of Simon, in Heidelberg, in which a vesico- vaginal fistula, complicated 
 with stenosis of the vagina, had been operated upon for incontinence 
 of urine by closing the mouth of the vagina about half an inch behind 
 the meatus urinarius. The operation was so nearly successful that an 
 opening only the size of a cambric needle was left. Strangely enough, 
 the spermatozoa passed through this minute orifice, traversed the 
 steuosed vagina, Avhich was then the receptacle of the urine from the 
 bladder, and made their entrance through the os uteri into the cavit}' 
 of the organ. Conception and gestation followed, but resulted in the 
 death of the patient. Court}',* Winckel,^ and others have reported 
 similar cases. The former also relates a case in which the entire 
 uterus was removed bv Koeberle, the ovaries being; left. A small 
 fistula remained, forming a communication between the vagina and 
 the abdominal cavity. The woman subsequently had an abdominal 
 pregnancy. 
 
 The following case may serve to illustrate not only the difficulties 
 under which eonccjition may take place, but also the fact that gestation 
 may sometimes contiiuie under most adverse circumstances: 
 
 ' " Generation," Repertoire general des Sciences medicale.$, tome xiv. p. 68. 
 
 2 Fallen, Amer. Journ. Obsf., 1880, p. 519. 
 
 =» Xew York Med. Journ., Dec. 24, 1884. 
 
 * Uteru-% Ovaries^, and Fallopinn Tubes, |>. 789. 
 
 ^ Med.-Chir. Rund.-ichau, Dec, 1877- 
 
446 STERILITY. 
 
 Conception while Wearing an Intra-uterine Stem. — Emily T , 
 
 aged twenty-five years, came under my care August 21, 1884, for 
 dysmenorrhoea. She had been married three years, and had not been 
 pregnant. I found, on examination, a marked anteflexion of the cer- 
 vix, which was conoidal and pierced by a typical pinhole os. It was 
 only with great difficulty that I could introduce a probe into the cavity 
 of the uterus. On September 2d, under etherization, I forcibly dilated 
 the cervix to a moderate extent and introduced a Chambers divaricating 
 stem. Menstruation occurred September 19th, and again October 18th, 
 each time with pain, although less than heretofore. On November 1 9th 
 a menstrual period commenced which lasted four days and was painless. 
 ISTo discharge appeared dm'ing December or January. On January 23, 
 1885, I examined her and found that she was undoubtedly pregnant. 
 I carefully removed the stem, the operation being attended by a slight 
 flow of blood and mucus. I was fearful that an abortion would follow, 
 but there was no untoward result, and a male child was born September 
 4th, at term. 
 
 Coitus may be Impossible.— Besides the various physical and 
 functional causes of male impotence, there are many conditions on 
 the part of the female which may prevent the accomplishment of the 
 sexual act. Among these may be enumerated the following : 
 
 Faulty development of the external genital organs ; 
 
 Hypertrophy of the labia ; 
 
 Hypertrophy of the clitoris ; 
 
 Tough or hypertrophied hymen ; 
 
 Atresia or stenosis of the vagina ; 
 
 Vaginal or vulval tumors. 
 
 Faulty Development of the Genital Organs. — The abnormities of 
 the external sexual organs which may prevent intercourse are congen- 
 ital or acquired, and may result either from insufficient or excessive 
 development. 
 
 Among the minus conditions of development are those in which 
 there is absence of some one or more of the vulval organs. The 
 absence of the clitoris, hymen, or labia, or their rudimentary growth, 
 would obviously not interfere with coitus, provided the vagina were 
 sufficiently pervious. The latter organ is, however, sometimes com- 
 pletely absent or defective in its lower portion, a mere depression pre- 
 senting between the labia niajora, at some portion of which is found 
 the meatus urinarius. In some of these cases repeated attempts at 
 intercourse have resulted in the conversion of this opening into the 
 copulative organ. 
 
 Sometimes the vagina is divided by a longitudinal septum which may 
 interfere with congress unless one or both sides be sufficiently capacious 
 for intromission. 
 
[S< '. I /'. U 'ITY FOR ISSI:MIS. I 770 .V. | 1 7 
 
 Dr. v.. I>. -MapDthor ivpoits' the atse of a lady, twenty-oi^ht ywirs 
 of a<i:«', wlin icniaincd storilc aftor oi<;ht ycai-s <jf niarriwl life. An 
 examination discctverud the existence of a nieinhrane which en^sed the 
 v:itj:;ina at right angles three inches above the oarunculie niyitifonnes. 
 in this was a circular hole one-sixth of an inch in diameter, through 
 which the sound parsed into a cavity above. The membrane was 
 excised, its removal disclosing a normal os and cervix. A glass dila- 
 tor was worn for Hve weeks. Pregnancy ensued. 
 
 Either as a congenital condition or as a result of subsequent inflam- 
 mation the labia majora are sometimes adherent partially or throughout 
 their whole extent, an opening for the escape of urine only l>eing left 
 and the line of union i)eing marked by a mere chink or furrow. 
 
 Hypertrophij of the Labia. — An opposite and more numerous class 
 of ca«e.s than the foregoing is that in "which congress is prevented by 
 undue enlargement of the parts from excess of development or as the 
 result of disease. Any of the organs may be thus affected. Scanzoni 
 states that he knew a family residing near Wiirzburg in which the 
 mother and three daughters had the labia excessively developed in a 
 manner similar to that of the Hottentots. He also mentions the case 
 of a girl of seventeen at Prague in whom the hypertrophied labia 
 formed a tumor larger than the head of an adult man, hanging down 
 to the middle of the thighs. About the year 1865 I saw an unmar- 
 ried woman, about twenty years of age, who had an hypeitrophy of 
 the left side of the vulva involving; the o-reater and lesser lalna through- 
 out their entire extent. It formed a protuberance larger than a hen's 
 egg, which would evidently have been an impediment to intercourse. 
 The enlargement was congenital, and had not perceptibly increased for 
 many years. Surgical interference was declined. 
 
 The labia may also be greatly enlarged from elephantiasis or from 
 the presence of fibrous, cystic, or other tumors, so as to prevent marital 
 congress. 
 
 Hypertrophy of the Clitoris. — The clitoris has been seen so exces- 
 sively developed as to resemble the male organ, and even to weigh 
 several pounds, closing completely the entrance to the vagina. 
 
 Touf/h or Hypei-trophied Hymen. — The hymen may be so thick and 
 so dense in structure as to prevent intercourse. It has been developed 
 in such a manner as to project in the form of a fleshy tumor between 
 the labia.^ Yet it is well known that while such condition of the hymen 
 may prevent intromission, it is no absolute bar to conception, providing 
 the organ be perforate, for a single drop of semen finding its way into 
 the vagina of an otherwise healthy woman may result in pregnancy. 
 The hymen has not infrequently been found intact at the onset of labor, 
 
 1 British Med. Joum., Sept. 4, 1880. 
 
 * Boivin and Duges, Traile des Maladies de P Uterus. 
 
448 STERILITY. 
 
 showing that its rupture is not necessary to conception. Usually, this 
 condition has been found in unmarried women who have permitted lib- 
 erties within what they believed to be safe limits ; but it has also been 
 observed in married women from unusual rigidity, great distensibility, 
 or defective '^''rility on the part of the husband. 
 
 Atresia or Stenosis of the Vagina. — As already stated, the vagina 
 is sometimes, though rarely, imperforate in some part of its course. 
 This results, after puberty, in menstrual retention. A more frequent 
 condition, which may be either congenital or acquired, is a narrowness 
 of some portion of the canal. Stenosis of the passage throughout its 
 entire extent, whether as a congenital condition or as the result of sub- 
 sequent cicatrization, is exceedingly uncommon. 
 
 Vaginal Tumors. — The vagina may be so occupied by cystic tumors, 
 polypi, or inversion of the uterus as to prevent the admission of the 
 male organ. 
 
 2. Incapacity for Impregnation. 
 
 Impregnation implies the contact of a living spermatozoon with a 
 mature healthy ovule at some point beyond the uterine cervical canal — 
 a requirement which may be prevented or interfered with, more or less 
 completely, by many circumstances. 
 
 Coitus may be Possible, but Difficult or Painful. — This 
 condition, to which the term dyspareunia has been given by Robert 
 Barnes, is of very great frequency. It may exist in various degrees, 
 from mere discomfort to such intensity of suiFering as to lead to entu'e 
 abandonment of sexual attempts. In many of these cases the woman 
 may be potentially fertile, lacking only the normal conditions of im- 
 pregnation. Independently of its influence upon fertility, dyspareunia 
 is a frequent source of domestic unhappiness on the part of both hus- 
 band and wife. It is of obvious importance, therefore, in every such 
 case to seek for the cause or causes which may be operative. These are 
 numerous, and not always easily discovered ; and, inasmuch as women 
 are usually reticent upon the subject unless interrogated, the investiga- 
 tion should be close both in questioning and examination. 
 
 The following conditions are arranged for convenience under the 
 head of dyspareunia, but it should be remembered that many of them 
 act in other and more certain ways in the production of sterility than 
 by reason of the difficulty or pain of intercourse occasioned by them. 
 Indeed, merely painful intercourse does not necessarily involve sterility, 
 and in some instances only induces it by limiting sexual relations. The 
 causes of dyspareunia are chiefly the following : 
 
 Disproportionate size of the male Awkward sexual attempts ; 
 
 and female organs ; Vulvitis; 
 
INCAPACITY FOR 7.1//7;/.v;.V.I 770X 449 
 
 Stenosis of va^iiKi ; Oophoritis; 
 
 Vairiiiisiims ; IVlvic iiiflammaton' exudations; 
 
 \'ai;inal or vulvar liypcriL's- Urethral caruiu'Ies ; 
 
 thesia ; Fissure of tiie ostium vaginie ; 
 
 Uiidiu' shortness of the va<rina; Xeuroiiiata ; 
 
 Lacerations of the eervix uteri; Coeeyodynia; 
 
 InHaniiuation of the uterus; Fissure of the anus; 
 
 Disease of the eervix uteri ; Rectal uh-er; 
 
 I)isj)laeeinent.s of the uterus ; Hemorrhoids. 
 Prolapsed ovary ; 
 
 JjUproportlon of Male and Female Sexual Organs. — This is some- 
 times very great. The ostium vaginae may be small or even of normal 
 size, while the male organ may be unusually develoj)ed. This sort of 
 ill-mating is occasionally productive of intense distress. The first sex- 
 ual attempts in such cases are unsuccessful, and if pei-sisted in result in 
 producing irritation and congestion of the structui"es of the female, and 
 thas induce additional elements of pain. 
 
 Awkward Intercourse. — Even in the absence of any disproportion 
 a similar state of irritation of the genitals may be provoked by rough 
 and awkward attempts at intercourse. Usually, the normal vulvar 
 mucus is present in sufficient quantity to so luljricate the parts that 
 penetration is effected "without injury to the female organs. But where 
 it is deficient, and not increased by sexual desire or by preliminary dal- 
 liance, much suffering may result. 
 
 Vulvitis. — Inflammation of the external genital organs mav arise 
 from varioas irritating causes, and declare its presence by tumefaction, 
 heat, tenderness, and a ])uruing sensation. These symptoms are aggra- 
 vated by the chafing produced by walking or other exercise. Fat 
 women are especially liable to an erythema from the excessive friction 
 to which the parts are subjected. This may proceed to involvement of 
 the deeper tissues, and finally result in glandular or cellular inflamma- 
 tion and abscess. It may likewise extend to the vagina, urethra, and 
 inner surfaces of the thighs. Intercourse in such cases is attended by 
 great suffering, and is, at the same time, most prejudicial. 
 
 Stenosis of the Vagina. — Either as a congenital defect, as the result of 
 injury, the action of chemical irritants, or as a sequel of exanthematous 
 diseases, the vagina may be so greatly contracted as to cause painful 
 intercourse or prevent it wholly. 
 
 Vaginismus. — By this term is understood a condition of the parts 
 about the hymen and vaginal entrance which, in its more marked forms, 
 results in extreme suffering whenever any attempt is made to effect pene- 
 tration, or even to touch the parts. The constricting muscles around 
 the mouth of the vagina are thrown into a state of spasmodic action so 
 Vol. I.— 29 
 
450 STERILITY. 
 
 great as to occlude the entrance, and the finger when introduced seems 
 held as though it were in a vise. In some instances an apparent cause 
 for this condition may be observed in patches of redness, erosion, or 
 neuromata about the vestibule or the carunculse myrtiformes, but in 
 others nothing whatever can be detected to which the phenomenon 
 can be referred. Usually, the seat of vaginismus is at or near the 
 vaginal entrance. Dr. H. R. Storer has called attention, however, 
 to the fact that there also exists a second variety which is seated 
 higher up, and which, depending upon violent vaginal spasm, expels 
 at once and forcibly everything deposited there; for example, the 
 spermatic fluid. This he was enabled to remedy, and so cure ster- 
 ility, by resort to a simple ring pessary, which gave the canal some- 
 thing to grasp. 
 
 Vulvar or Vaginal Hypercesthesia. — A similar condition to the fore- 
 going, characterized by extreme sensitiveness of the vulva and vagina, 
 exists sometimes without the presence of the spasmodic constriction 
 which constitutes the essential feature of vaginismus. Usually, the 
 symptom is wholly subjective, and can only be attributed to some 
 occult condition of the nerves supplying the parts. 
 
 Undue Shortness of the Vagina. — In some cases the vagina is unduly 
 short, being not more than two or three inches in length, and neces- 
 sarily maintaining the cervix uteri in a position abnormally near the 
 vulva. Unless great care on the part of the husband be exercised the 
 parts soon become tender and dyspareunia results. According to 
 Courty,^ this condition of the vagina may be productive of barren- 
 ness in another way — namely, by favoring the formation of a copula- 
 tive sac outside of the axis of the uterine canal, and consequent mal- 
 direction of the semen. 
 
 About twelve years ago I examined a sterile woman, thirty-two years 
 of age, who had been married five years and who had never menstru- 
 ated. Her health had always been excellent. The mammae were large 
 and the external genital organs perfectly developed. She confessed to 
 having both sexual desire and enjoyment. The vagina w^as not more 
 than two inches in depth, and was very narrow, especially at the upper 
 portion, which terminated in a flat, button-like, non-projecting hard- 
 ness about a quarter of an inch in diameter, situated at the proper site 
 of the vaginal portion. I was unable to detect any opening in it. 
 With a male sound in the bladder and a finger in the rectum there 
 was felt a firm body an inch long and half an inch wide occupying 
 the place of the uterus. No ovaries could be felt. 
 
 Lacerations of the Cervix Uteri. — These do not usually occasion pain- 
 ful intercourse, although I have seen several cases in which there was 
 no other apparent cause for the symptom, and in which the latter 
 
 ^ Uterus, Ovaries, and Fallopian Tvhes, p. 790. 
 
iNCArAciTV FOR iMi'iii:<;sATiny. .j.-ji 
 
 promptly (lisapju'aivd alter the iiijuiy was repaired. This eomlilioii 
 may also pivvi'iit rruitfiiliiess hy iii(liieiii«r cirly al)nrtii)ii. 
 
 UUrinc Injhunnutfion. — The iiillaiiiiiiatory alleetioiis of the iil<riis 
 are almost always pi-oduetixc ol" pain and tondcrness, especially in the 
 lower seuineiit ol" the or^aii, which is likewise increased in bulk and 
 lower in tlii' pelvis, and hence more suhjeet to ineehanieal injniy 
 dnrini;- coitus. 
 
 J)is(<(sc of the Ccrrix Utn-i. — Diseased conditions of the cervix uteri 
 Avhich involve loss of substance or other chany;e of structure sometimes 
 produee |)ain and undue sensitiveness of the parts. Not always, cer- 
 tiiinly, for in many cases extensive erosions and hvi)erj)lastic conditions 
 of the cervix ji;ive rise to no complaint whatever. This is ntttablv true 
 in cervical e})ithelioma j)rior to the involvement of the surnjundiug 
 connective tissue. 
 
 DispUu'i'iiivntH of the Uterus. — Certain malpositions of the uterus occa- 
 sion dyspareunia by occupying the vagina, as occurs in inversion and 
 prolapsus. Ordinarily, however, the forward and backward displace- 
 ments, including flexions, act only indirectly througli the congesticju and 
 consequent tenderness of the organ induced by its abnormal position and 
 shape. 
 
 Prolapse of the Omrij. — Whenever an ovary is prolai)sed in any 
 considerable degree it commonly becomes excessively tender. It is 
 likewise usually enlarged. It occupies a position more or less low in 
 Douglas's space, where it is exposed to pressure during defecation and 
 to impingement of the male organ during intercourse. Dyspareunia 
 from this cause is in some instances very great — not, however, nnless 
 the prolai)sed organ be the seat also of inflammation or neuralgia. I 
 have in a few instances found one or both ovaries occupying the lower 
 portion of the vagino-rectal cul-de-sac M'ithout giving anv evidence of 
 undue sensitiveness, or, indeed, producing any uncomfortable symptom. 
 
 Oophoritis. — When the ovary is inflamed, whether it be in place or 
 prolapsed and whether the inflammation be acute or chronic, the oriran 
 becomes extremely sensitive, and dyspareunia from this cause is usuallv 
 of a most intense character. 
 
 Pelvic IiiffaiiDiiafori/ ExurJafions. — Inflammatory exudations the result 
 of pelvic cellulitis and peritonitis constitute frequent sources of painful 
 congress, and without careful examination they may be easily overlooked. 
 Sometimes the tenderness will be confined to a single spot of hardness 
 not larger than a ])ca on one or other side of the uterus. Usually, 
 however, in cases of this character the pain results either from the 
 stretching of adhesions which interfere Avith the normal mobilitv of the 
 uterus, or from deposits in the tissues about the ovaries, Falh^pian tubes, 
 and in Douglas's space. 
 
 Urethral Caruncles. — These consist of proliferations of the nmcous 
 
452 STERILITY. 
 
 membrane within or near the urinary meatus, and form an occasional 
 cause of both painful intercourse and dysuria. These bodies vary in 
 size from that of a pin's head to a large raspberry, and are some- 
 times the seat of excessive sensibility. A similar condition, but with- 
 out elevation of the surface, is one in which patches of mucous mem- 
 brane in various parts of the vestibule become denuded of epithe- 
 lium, and are exquisitely painful under the slightest touch. These, as 
 well as the smaller carunculse, can only be detected by carefid inspection. 
 
 Fissure of the Ostium Vaginae. — A slight laceration may be produced 
 at the first sexual attempts, and unless the parts are permitted to rest 
 sufficiently long for healing to take place a fissure similar to those 
 sometimes seen at the anus may remain and become the seat of intense 
 pain. 
 
 Neuromata of the Genital Tract. — These are commonly situated on 
 some part of the vulva and in the vagina. The following is the only 
 case of this character with which I have met : 
 
 Dyspareimia Cured by the Removal of a Small Neuroma of the Vagi- 
 nal Wall. — A few years ago I was consulted by a gentleman in refer- 
 ence to dyspareunia on the part of his wife. They had been married 
 four years and were childless, although there was a history of two 
 doubtful abortions at five or six weeks. During the past year inter- 
 course had become gradually more and more painful, and had not been 
 attempted for several months. The seat of pain was just within the 
 entrance of the vagina. An inspection of the vulva revealed nothing 
 abnormal. The introduction of the finger was attended by pain which 
 the patient located on one side about an inch from the vaginal orifice. 
 Pressure or slight friction upon this spot caused intense pain. There 
 was no spasm. When I avoided the spot no pain was produced. Sep- 
 arating the parts antero-posteriorly with a bivalve speculum, I brought 
 the tender space into view. There was neither swelling nor redness 
 apparent : it looked precisely like the opposite side. With the tip of 
 a uterine sound I made pressure in the neighborhood of the seat of 
 pain, and suddenly the patient started and exclaimed, " That's the 
 place !" Thus directed, I could detect a slight elevation of the surface 
 caused by a minute tumor not larger than a grape-seed. Passing a 
 small hook beneath and raising it, I excised it with scissors. Immedi- 
 ately, while the cut surface was yet bleeding, I could press the sound 
 into the spot without evoking the former pain. The sides of the cut 
 were brought together with a stitch, and soon united. The cure was 
 complete. 
 
 CoGcyodynia, etc. — In addition to the causes of painful intercourse 
 already mentioned, there are othei'S which do not have their seat in the 
 genital organs, but in neighboring structures, and hence the latter 
 should not be omitted from the investio-ation. Among these the more 
 
INCA VArlTY !•') 11 IM 1 'li !■:( / A'. 1 1 7 ON. 4 ->;} 
 
 frequent are coeeyndynin, lissiire of tlie ami>, reefal nicer, mikI licnMH- 
 rliuids. 
 
 thtrifodi/iiia is the tenn used to desijrnatc a paiiiiiil st:ite ol" the |);irts 
 in tli(> iUM't!:lil)()rlii)()(i of the coeeyx. It is usually j)urely neural;;ie in 
 character, althou«;h souietinies depeudeut uj)ou structiu-al disease of the 
 hoiie, the pci-iosteuiM, or the siu'roiiiidiiin- parts. When j)resent, the 
 pain is excited or a«;<iravated i)y any inov<'nieut of the ])art, as occiu's 
 iu risiiiji; from the sittiui:; posture, duriu<>; defecation, or in coj)ulation. 
 
 Fissure of the Anus. — Cracks or fissures at the anus are occasionally 
 a source of very considerable pain durinii; and after intercourse. TIm-v 
 are soinetiines so sliii;ht as to escape detection except by a most careful 
 examination. Their presence may be suspected when defecation is fol- 
 lowed by habitual pain or aehino-, especially if at times there is observed 
 also the discharge of a droj) or two of blood. 
 
 In'itnble Ulcer of the Rectum. — This condition, like the preceding, 
 can only be determined by a rectal examination. 
 
 Pahiful Heiiu)rr]ioi(h. — Hemorrhoids Avhich have become inflamed 
 are sometimes extremely painful, and may then constitute a cause of 
 dysparcunia. 
 
 The Semixal Fluid may xot coxtain axy Spermatozoa ; on, 
 
 THE LATTER MAY BE DeAD OR POSSESS DeFICIEXT VITALITY WIIEX 
 
 Deposited ix the Yagixa. — The pathological changes Avhich may 
 take place in the seminal fluid, and the conditions of the testicles which 
 result in the absence of spermatozoa or iu their scantiness or feeble 
 vitality, are not known. Whatever they may be, they are certainly not 
 usually capable of detection. 
 
 Male Sterility depending upon Ai^pevmatism. — In Xoveml^er, 1883, a 
 lady, thirty years of age, Avho had been married seven years and Avho 
 had never conceived, consulted me in reference to her barrenness. Her 
 history gave no clue as to its cause. Her health Avas perfect ; every 
 function was properly performed. Her husband was four years older 
 than she, healthy, affectionate, and sexually vigorous. Between them 
 there Avas no incompatibility of temperament. A careful examination 
 of the generative organs revealed no abnormity of conformation, con- 
 dition, or position. 
 
 In a subsequent interview with the husband I learned that prior to 
 his marriage his habits had been rather irregular, and that at the age 
 of twenty he had contracted a gonorrhoea which resulted in tenderness 
 and swelling of both testicles. At the time of my examination I could 
 detect nothing wrong with any of the genital organs. I suggested an 
 examination of the semen, and a few days afterwai'd placed under tlie 
 microscope a portion of the fluid taken from the vagina of the wife 
 within an hour after coitus. Xot a spermatozoon could be found. 
 This examination was repeated after a fortnight's abstinence from 
 
454 STERILITY. 
 
 intercourse with the same negative result. The man was absolutely- 
 sterile. 
 
 It would seem that spermatozoa belonging to the same emission vary 
 greatly in their power to resist destructive influences. The observations 
 of Sims, Haussmann, and others show that the great majority of them 
 perish in the vagina within a very few hours after their deposition, and 
 that those which retain their vitality cease to move after twelve hours. 
 Some are motionless from the first. Those which reach and enter the 
 cervical canal live much longer. When the external os uteri, the cer- 
 vical canal, and the secretions were normal, living spermatozoa were 
 found in the passage seven and a half, and by Percy eight and a half, 
 days after coitus. 
 
 Healthy Speematazoa aftee being Deposited in the 
 Vagina may be Destroyed befopvE reaching the Cervical. 
 Canal. — The most frequent cause of the untimely death of sperma- 
 tozoa is the acid nmcus of the vagina. The degree of acidity varies 
 greatly in different women, and in the same woman at different times. 
 Not infrequently, a decidedly sour odor may be detected during the 
 introduction of the speculum, and the mucus at such times will intensely 
 redden litmus-paper. Spermatozoa perish immediately in such a fluid. 
 This condition is thought by some to be more frequent in blonde women 
 with red complexions than in brunettes. 
 
 On the contrary, the slightly alkaline mucus of the interior of the 
 uterus is favorable to the vitality of the spermatozoa, as already shown. 
 But when the uterine secretions are altered by disease they likewise 
 cause their speedy death. Levy ^ of Munich made microscopical exami- 
 nations to determine the condition of the spermatozoa at different inter- 
 vals after coitus in 60 women who were sterile. Catarrh of the uterus 
 was present in 57 of them. In every case the number of spermatozoa 
 found within the cavity of the uterus was small, and they had all 
 become motionless at the end of five hours. In healthy women the 
 movements continued at least twenty-six hours. 
 
 In 408 cases of sterility collected by Kammerer ^ uterine catarrh was 
 present in 342. That the condition is a very common one among 
 sterile women there can, therefore, be no doubt; and Sims and others 
 have stated their belief in its great frequency as a causative agent. 
 But it seems to me that more importance has been attributed to it in 
 this respect than facts warrant. We know that women may conceive 
 when the vagina is constantly bathed with the offensive discharge from 
 carcinoma of the uterus, even when it is so acrid as to cause removal of 
 epithelium and epidermis. It is likewise well known that a continually- 
 leaking vesico-vaginal fistula is no bar to conception. Hence I can- 
 
 ^ Obstetrical Journal of Great Britain and Ireland, vol. vii. p. 471. 
 * Transactions New York Academy of Medicine, part vii. of vol. iii. 
 
INCAPACITY FOR IMPRKf! NATION. 455 
 
 not thiiilx llial the oi'diiiary catai-rlial (liscliar^c froiii llic "(.nitals is so 
 ^rcatlv inimical to the lite of tlic sptTinato/cta as lias been supposed. It 
 is ti'iu! lliat the siip|)i'essi()H, or even tlie (liniiniition, ot" a leneorrii«eal 
 (liscliari;'e may In- (piiekly Inllowcd Wy impreguation, hnt this fact does 
 not prove that the presence (tfthe leucoiTJKea was the eansc; of the j)re- 
 eedinti' infertility, l^^)r, heiiii;- only a symptom of strnctnral disease 
 which nnlittcd the nterns for fni'iiishini;- a siiitaMc nidtis for the u'crm, 
 the ahateiuent of the dischar<;'e may be a consecpience of removal of the 
 lesion which prodneed it. Impregnation pi-obably occurs much more 
 frequently in these eases than is supposed, but owing to the defect in 
 the nesting and developmental processes very early abortion habitually 
 takes place. 
 
 Biegel has found that all of the following agents are destructive of 
 spermatozoa: water, saliva, sour milk, alcohol, ether, chlorofjrm, crea- 
 sote, tannin, acetic acid, mineral acids, metallic salts, ethereal oils. 
 
 Semen may be Deposited in the Vagina and prevented 
 
 FROM OCCUPYING A POSITION FaYORABLE TO FECUNDATION. — The 
 
 emitted semen normally forms a pool in the upper posterior portion of 
 the vagina, into which the cervix uteri settles after intercourse. Every 
 facility is thus afforded for the entrance of spermatozoa into the uterine 
 canal. Various conditions may, however, to a greater or lesser degree, 
 interfere with this disposition of the seminal fluid. Among these may 
 be enumerated the following : absence of the vaginal portion ; conical 
 elongation of the vaginal portion ; unequal size of the uterine lips ; 
 cervical hypertrophy ; laceration of the cervix uteri ; uterine flexions 
 and versions ; prolapse and inversion of the uterus ; abnormal attach- 
 ment of cervix to vagina. 
 
 Semen may be favorably Deposited in the Vagina, but 
 unable to advance to the Cavity of the Uterus. — The 
 abnormal conditions which may act as impediments to the progress of 
 the spermatozoa are chiefly as follows : 
 
 Atresia or stenosis of the os uteri and cervical canal j 
 
 Uterine flexions and displacements ; 
 
 Tumors of the uterus ; 
 
 Uterine polypi ; 
 
 Mucous plug in os and cervix uteri ; 
 
 Hypertrophied cervical rugfe; 
 
 Deformity of uterine cervix and labia. 
 
 Atresia or Stenosis of the Os mid Cervix Uteri. — Atresia — that is, 
 complete closure of the os uteri or cervical canal — is absolute in its 
 power to prevent conception. Occasionally the os uteri is found 
 wholly imperforate, either as a congenital defect or as the result of 
 adhesive inflammation. Complete congenital closure of the os uteri 
 is very rare : the acquired form may, however, occur from cicatriza- 
 
456 STERILITY. 
 
 tion after inflammation produced by injuries during parturition, sur- 
 gical operations upon the parts, or the application of powerful caustics 
 to the interior of the canal. In these cases only a limited portion of 
 the canal is usually involved. 
 
 Not only is the condition a barrier to the entrance of spermatozoa, 
 but also to the exit of mucus and blood. Hence, except in the case 
 of an infantile or non-secreting uterus, it would be attended by recur- 
 ring pains, and, if of sufficiently long standing, by enlargement of the 
 uterus from retention. 
 
 Stenosis, or a narrowing of the cervical canal, may occur at either the 
 external or internal os or at any portion of the passage. The canal of 
 the cervix should be considered physiologically normal when it is able 
 to perform its functions with comparative ease and painlessness. This 
 it may do although of greater length, lessened calibre, and more tortuous 
 di^^ection than usual. It is obstructive only when it does not readily 
 transmit blood or mucus from the uterine cavity or permit the ingress 
 of spermatozoa. A normal cervical canal is hence a relative and not an 
 absolute thing, and cannot be determined simply by measurements. 
 
 Whatever may be the method or mechanism by which spei'matozoa 
 pass through the cervical canal — whether by a suction process on the 
 part of the female or an inherent power of progression in the sper- 
 matozoa — it is certain that the latter are capable of advancing from the 
 vagina inward through a much smaller space than is necessary for the 
 transmission of blood and mucus. Hence a woman may have obstruct- 
 ive dysmenorrhoea and yet not be sterile. Indeed, except in complete 
 closure it is doubtful whether mechanical impediments to the union of 
 the spermatazoa and ovule play so important a part as has commonly 
 been supposed, A constriction of the cervical canal to the size of the 
 minute openings of the uterine extremities of the Fallopian tubes would 
 be regarded as very extreme, and yet the spermatozoa pass through the 
 latter without difficulty. 
 
 It should be remembered, too, that there are usually other factors 
 present than the mere narrowing of the canal. When the constriction 
 is at the os externum, the secretions of the uterus are jDrevented from 
 escaping and the canal above is expanded and filled with a glairy, 
 tenacious mucus, which may be seen to escape sometimes in large 
 quantity by the introduction and separation of a pair of forceps. There 
 is in these cases — whether as cause or effect — a follicular cervical endo- 
 metritis, the cystic enlargements assisting to impede the exit of the 
 mucous secretion and constituting an obstacle to the ingress of the 
 sperm. 
 
 I do not by any means deny that even a moderate degree of constric- 
 tion may hinder, to some extent, the passage of spermatozoa, or that, 
 when the narrowing is great, there is commonly both dysmenorrhoea 
 
iNCAPAriTY FOR iMrm:ay.\TioN. A'u 
 
 and sterility ])rosent ; hut it is well kiKtwii that in such oases, while 
 dihitation may he elVectiNc in wholly relieving the (lysineiiorrhu'a, it 
 is more likely to fail iliaii to succeed in removing the sterility. 
 
 Flexions and Disp/acnnmLs of the Uterus. — These do not necessarily 
 determine sterility, although conception may he difllicult where they 
 exist. 1 have known many instances in which there existed a flexion 
 so acute as to })revent the introduction of the sound and to occasion 
 severe dysmenorrhoea, and yet conception took place shortly after mar- 
 riage w^ithout the subject having undergone any treatment whatever. 
 Nevertheless, when flexion is so extreme as to bring the ©imposing ute- 
 rine walls into firm contact, there would manifestly be interference with 
 the progression of spermatozoa. In 114 cases of sterility reported by 
 Biegel in which the causes seemed evident there was some form of dis- 
 placement in 40 — that is, 35 per cent. In 26 there was version, in 12 
 flexion, and in 2 prolapse. Mayer's 272 cases show 60 of anteflexion, 
 37 of retroflexion, 35 of anteversion, 3 of retroversion — nearly 50 per 
 cent. In Kammerer's table of 408 cases ^ there were of anteflexion, 83 ; 
 retroflexion, 71 ; descensus, 8 ; prolapse, 1 — nearly 40 per cent. In 72 
 cases observed by myself (p. 463) there were 16 of anteflexion, 9 of 
 retroflexion, 3 of anteversion, 7 of retroversion — 40.3 per cent. 
 
 It would appear from these tables that displacements of the uterus 
 constitute a very frequent and important feature in the causation of 
 sterility ; and doubtless such is the fact. But what has been stated in 
 regard to uterine catarrh is equally applicable here — namely, that in all 
 or nearly all cases of chronic displacement there are present other com- 
 plicating morbid conditions to which the infertility may be ascribed 
 with as much plausibility as to the malposition. 
 
 Tumors of the Uterus. — Fibro-myomata, especially when located in 
 the cervix, are sometimes so situated as to prevent, or at least greatly 
 obstruct, the passage of semen through the cervical canal. When they 
 are small and occupy the lower portion of the cervix, they do not 
 usually produce either pain or menorrhagia, and may hence be readily 
 overlooked unless their possible presence be taken into consideration. 
 Such tumors may distort the uterine cavity and cause catarrh and 
 thickening of the lining membrane, and thus act both mechanically 
 and chemically. 
 
 Submucous tumors of the uterus may prevent conception by the men- 
 orrhagia -which they usually cause, the profuse flow of blood carrying 
 the ovule away from the uterine cavity. Winckel reports' that the 
 most common complication of uterine fibroids found by him was the 
 existence of adhesions between the uterus and neighboring organs, these 
 being present in 21 out of 34 cases examined. 
 
 Uterine Polypus. — Polypi of the uterus which wholly or partially 
 
 ' Loc. cit. ^ Med.-Chirurgical Rundschau, Dec, 1877, 
 
458 STERILITY. 
 
 obstruct any part of the cervical canal may act as an impediment to 
 the onward movement of spermatozoa. If a polypus becomes strangu- 
 lated and gangrenous, as sometimes happens, the resulting acrid dis- 
 charge may be destructive to the vitality of the spermatozoa. 
 
 Mucous Plug in Os and Cervix Uteri. — The firm, dense mass of 
 mucus which is found so frequently filling the cervical canal and hang- 
 ing from the os uteri is a mechanical obstacle to the ingress of sperma- 
 tozoa. It is a result of chronic cervical endometritis, and is removable 
 only with the greatest difficulty. Haussmann found an abundance of 
 spermatozoa entangled in one of these mucus masses. Usually, it is 
 washed away by the menstrual discharge, and conception may occasion- 
 ally take place when insemination occurs shortly after a menstrual 
 period and before the plug reappears. 
 
 Hypertrophied Cervical Rugm. — Chronic inflammation of the cervix 
 may act injuriously also by producing hypertrophy of the cervical rugse, 
 and causing an abnormal degree of coaptation of the opposing surfaces. 
 
 Deformity of the Uterine Cervix and Labia. — Various malformations 
 of the vaginal portion, involving its length, thickness, shape, and direc- 
 tion, may make impregnation impossible, or at least highly improbable. 
 It may be so greatly hypertrophied in its longitudinal direction as to 
 bring the os uteri almost to or quite beyond the vulva, the fundus of 
 the organ remaining in its proper place. Sterility always accompanies 
 this condition. Or the labia may be wholly absent, the os uteri pre- 
 senting, instead of a horizontal fissure, a circular orifice situated at the 
 apex of the cervix. This opening is sometimes so small as to be invisi- 
 ble to the naked eye and capable of admitting only the smallest probe. 
 This condition of the os, termed " pinhole," situated at the extremity 
 of a conoidal cervix, is a not infrequent anomaly. Here both the nar- 
 rowness of the OS and the shape of the cervix are causes both of dys- 
 menorrhcea and sterility. A semilunar form of the os is likewise 
 unfavorable to conception. 
 
 Another variety of labial deformity is that in which one lip, usually 
 the anterior, projects beyond and overlaps the other. In this condition 
 the OS is closed to ingress from the vagina, although no eifective obstacle 
 may be offered to the passage of menstrual blood from within outward. 
 
 3. Incapacity for Ovulation. 
 
 Heretofore, I have considered the conditions which may interfere 
 with the elaboration of capable spermatozoa and their access to the 
 interior of the uterine cavity. Their existence is, with scarcely an 
 exception, ascertainable by touch or sight. There are other circum- 
 stances, however, which are equally unfavorable to fecundation, and 
 which are almost entirely beyond our means of investigation, and also 
 
ixrAp.irrrv for ovriArroy. 450 
 
 uii:mu'nal)le to curative trcatiiR'nt. I ivfci* (o tlictsc which j)r(!Vont the 
 ilevL'lo|)iueiit and separation of a mature ovule and its transmission to 
 the uterine cavity. They inchide the al)normities of development and 
 the oriijanic and functional tliseases of the (jvaries and Fallopian tuijes. 
 Tiiey ai'c not accessible to our sense of si};ht, and onlv imju'i-feetlv, if 
 at all, to toiicli. Hence their diaj^nosis must always be doubtful duriiij^ 
 lif,'. 
 
 TiiH OvuLK MAV NOT Matimik. — It is probable that many ovules 
 escape from the Graafian follicles in an immature state, and are inca- 
 j)ablo of impreijnation. Doubtless, the function of ovulation is more 
 perfectly and more fretpiently performed in some women than in others. 
 This fact may explain Avhy it is that some women conceive with more 
 or less rei2;ularity every fifteen or eighteen months, and others only at 
 intervals of several years; why thousands of sexual connections should 
 be barren, and a single one under apparently similar circumstances be 
 fruitful ; and why in some cases pregnancy should occur only after 
 many years of unfruitful married life, the observable conditions being 
 apparently unchanged. We know absolutely nothing of the possible 
 pathological changes in the ovule which may hinder its ripening or 
 render it incapable of fructification. 
 
 Disease of the Ovaries. — It is not difficult to understand that any 
 diseased state affecting the nutrition of the ovaries might result in the 
 production of diseased or defective ova, and yet it is not unusual for 
 women whose ovaries are studded with cysts or otherwise diseased to 
 conceive and give birth to healthy children. 
 
 Abnonnal States of the Blood. — In extreme angemia conception does 
 not take place, the defective condition of the blood being probablv the 
 cause of immaturity of the ova. On the other hand, conception is rare 
 also in women who present undue fatty accumulation, although their 
 blood may be perfectly normal in quality. 
 
 Tubercle, Syphilis, Gonorrhoea. — The cachexise of tubercle, the poi- 
 sons of syphilis and gonorrhoea, or great general debility resulting 
 from any other cause likewise have a deleterious eifect upon the fe- 
 cundity of women. 
 
 The relations of gonorrhoea to sterility have during late years excited 
 a great deal of interest and provoked much discussion. The extension 
 of the gonorrhoea! virus from the vagina to the uterus, and thence to 
 the Fallopian tubes, pelvic peritoneum, and ovaries, inducing inflam- 
 mation of a most rapid and destructive character in one or more of 
 these organs, is not infrequent. Such a result may take place long 
 after the acute symptoms have subsided and a slight gleet alone 
 remains. These facts have long been known and understood. It 
 remained, however, for Dr. Noeggerath of Xew York to proclaim a 
 far greater and more widely-reaching significance to an attack of gou- 
 
460 STERILITY. 
 
 orrlioea than had been accorded it hitherto. His views concerning the 
 relations sustained by the disease, especially in that which he denom- 
 inates its latent form, were first published in 1872.^ The theory 
 advanced by him was so startling, so novel, and the issues involved 
 in its acceptance so important, morally and physically, that it at once 
 challenged the attention of the entire medical world. Briefly, his 
 views were embodied in the following propositions : 
 
 " 1st. As a rule, gonorrhoea, both in the male and female, persists 
 during the life of the individual, in spite of apparent cure. 
 ' " 2d. There exists, therefore, a latent gonorrhoea in the male as well 
 as the female sex. 
 
 " 3d. This latent disease, both in the male and female, may cause 
 either a latent or an acute gonorrhoea in a previously healthy person. 
 
 "4th. A latent gonorrhoea manifests itself in women in time as 
 acute, chronic, or recurrent perimetritis, an ovaritis, or as a catarrhal 
 affection of the individual parts of the mucous membrane of the 
 genital tract. 
 
 " 5th. The wives of those men who at any period of their lives have 
 had a gonorrhoea remain, as a rule, sterile. 
 
 " 6th. Those who may become pregnant either abort or bear only 
 one child. In excejDtional cases three or four children may be pro- 
 duced. 
 
 " I believe," he says, " I do not go too far when I assert that of 
 every one hundred wives who marry husbands who have previously 
 had gonorrhoea scarcely ten remain healthy : the rest suffer from it or 
 some other of the diseases which it is the task of this paper to describe. 
 And of the ten that are spared we can positively affirm that in some 
 of them, through some accidental cause, the hidden mischief will sooner 
 or later develop itself." 
 
 In a subsequent paper " Dr. Noeggerath reiterated his opinions con- 
 cerning the influence of latent gonorrhoea on the fertility of women, 
 adducing additional cases and arguments in their support. 
 
 The extreme views of Dr. Noeggerath, especially those which imply 
 the latent character of the disease, have not been generally accepted by 
 the medical profession. While many cases both of acute and chronic 
 inflammatory pelvic disease have an obscure origin, and while it is 
 freely admitted that gonorrhoea in both the acute and chronic stage is 
 capable of giving rise to the various conditions (perimetritis, salpingitis, 
 oophoritis, etc.) attributed to the latent disease, yet the theory of life- 
 long latency seemed so visionary, so illy sustained by many of the cases 
 cited, and was, above all, so discordant with many well-known facts, 
 that it has failed to enlist very many adherents. That a man who has 
 
 ^ Latent Oonorrhcea in the Female, bv Einil Noeggerath, Bonn, 1872. 
 " Trans. Amer. Gynecological Society, vol. i., 1876. 
 
jyCirACITV FOR LIKSTATION, 401 
 
 a gliH't, liowcver slight, may infect a woman with gonorHura is not 
 tloiihlliil. J>ut when all evidences of the disease have disapjieaicd, and 
 have boon absent for mauy years, lea\iiig no (race liciilnd, the case is 
 different, and i'aith must largely take (he [)laee of fact. 
 
 Tin; Ovule may not Escapk from tmh Ovaijy, ou may not 
 Reach the Uterine Cavity. — In order (ha( conccpdon may taUe 
 place it is just as necessary that (he ovide shoidd (ravel outward as 
 that spermatozoa should pass inward. It may be })revented from doing 
 this by thickening of the follicular walls; imbedding of the ovaries in 
 a mass of inllanuuatoiy exudation (|)eri-o(")[)horitis) ; closiu'c! of the 
 Fallopian tubes; dilatation of the l''alloj)ian tubes (hydrosalpinx, pyo- 
 salpinx, hajmatosalpinx) ; salpingitis; ]»erisalpingitis; peri- and para- 
 metritis; pelvic jxn-itonitis; pelvic cellulitis; (cohesion of fimbrifc to 
 ovary; closure of uterine opening of tubes by metritis, polypus, or 
 tumor; inability of fimbria to reach ovary. 
 
 The o])portunities for studying pod-morion these more hidden of the 
 various abnormal causes of sterility are infre([uent — a fact which gives 
 additional value to the report of Wiuckel ^ based upon an examination 
 of 150 autopsies of women who died between the ages of fifteen and 
 fifty years. Diseases of the ovaries, tubes, and surrounding structures 
 of a character to make conception impossible were so numerous, and so 
 incapable of detection during life, as to throw much doubt as to whether 
 or to what extent an existing sterility may be caused by lesions ascer- 
 tainable before death. Atresia of both tubes was found in 9 cases; 
 enlarged cervical and corporeal nuicous follicles were found in 22 caseS; 
 in 7 of which there were also adhesions about the uterus, tubes, ovaries, 
 and rectum; in 2 cases cystic tumors were found in both ovaries; and 
 in 30 cases a single ovary was cystic. In 15 cases conception was 
 impossible from abnormality of the tubes. 
 
 4. Incapacity for Gestation. 
 
 The Ovule may enter the Uteeine Cavity, but fail to 
 FIND A Suitable Soil for its Attachment and DEVEL(^p:\rENT. — 
 The raucous membrane which lines the corpus uteri is a highly-organ- 
 ized structure, having for its principal function the furnishing of a suit- 
 able nidus for the reception and sul)sequent growth of the ovum. To 
 do this it must be in a healthy condition. But iutra-uterine disease is so 
 frequent that I have come to consider it the commonest of all the causes 
 of sterility. Chronic endometritis, the most frequent abnormal condi- 
 tion, probably acts in a threefold manner: 1, by giving rise to the 
 characteristic profuse gelatinous discharge, and thus hindering the 
 ingress of spermatozoa; 2, by destroying the vitality of the spernia- 
 
 ^ Med.-Chir. Rundschau, Dec, 1877. 
 
462 STERILITY. 
 
 tozoa ; 3, by rendering the mucous membrane unfit for the fixation and 
 development of the ovum. Especially by this latter method is it 
 effective. 
 
 Inflammatory disease, therefore, while not necessarily or usually a bar 
 to conception, prevents fruitfulness by interfering with gestation. Im- 
 pregnation probably occurs much more frequently in these cases than is 
 supposed, but owing to the defect in the nesting and developmental 
 processes it is followed by very early, and generally unrecognized, 
 abortion. And the proper ajipreciation of this fact will furnish the 
 key to the cure of many otherwise incurable cases of barrenness. 
 
 Subjective Symptoms of Stebility. 
 
 So far, the causes of sterility Avhich I have enumerated are chiefly 
 anatomical in character and capable of verification either before or after 
 death. But inasmuch as disordered function is always dependent upon 
 structural change — although the latter may be frequently undiscover- 
 able — subjective symptoms, having their apparent or probable origin in 
 the pelvis, should not be ignored in any case under investigation. In 
 the table compiled by Kammerer,^ out of 408 cases of sterilit}^ dys- 
 menorrhoea was noted in 69 ; menorrhagia and metrorrhagia in 57 ; 
 scanty menstruation in 41 ; premature menstruation in 4 ; menstruation 
 never appeared in 2 ; menstruation tardy in 8 ; vaginismus was present 
 in 2; hysteria in 16; nervous headache in 3; intercostal neuralgia 
 in 1. 
 
 It is not difficult to understand how some of the foregoing conditions 
 would be likely to entail infertility, independently of their accompany- 
 ing structural change. Thus, a profuse uterine discharge of any nature 
 may act mechanically by Avashing away an ovule before or after impreg- 
 nation. Painful menstruation is frequently — the membranous variety 
 always — accompanied by sterility ; not, certainly, because of the pain, 
 . but because this is the result in a very great proportion of cases of some 
 obstruction, organic or functional, to the free escape of blood — an 
 obstruction which we can readily believe might, although in a lessened 
 degree, interfere with the ingress of spermatozoa. 
 
 The relationship between dysmenorrhoea and sterility has been fre- 
 quently observed, but whether it is a causal one — and if so, to what 
 degree or in what class of cases — has not been settled. Certainly, the 
 conditions which occasion dysmenorrhoea are not always such as would 
 produce sterility. Kehrer found that a history of painful menstruation 
 before marriage was only slightly more frequent in sterile than in fer- 
 tile women. 
 
 The following table is based upon the study of 72 cases of sterility' 
 
 ^ Loc. cit. 
 
SUBJECTIVE SYMPTOMS OF STKllILITY. 
 
 403 
 
 Abnormities of 
 the Uterus. 
 
 Positional. 
 
 Structural. 
 
 occiirrin«; in luv own iir:i<'ti(T, and shows the acconipanvinji', and po-si- 
 bly c'tioloj^ical, condiiions prt-.-i-nt : 
 
 Table shou'iii;/ (he AhiiDniuil ( uiKl'dloiia preacnl in 7 J t'oHOi of >Skr'd'dy 
 
 ill the Female. 
 
 Anteversion 3 
 
 lietroversion 7 
 
 I Lateroversion 6 
 
 I- Desieiisus 10 
 
 Antetle.xion 1^ 
 
 Retri>fle.\iou 9 
 
 Hypertrophy 1" 
 
 Deformed cervix 13 
 
 Fibro-myonia 3 
 
 Polypus 5 
 
 Cancer 3 
 
 Stenosis os externum 8 
 
 Atresia os externum 1 
 
 Stenosis os internum 9 
 
 Stenosis cervical canal 3 
 
 Undeveloped uterus -i 
 
 Small cervix 7 
 
 Chronic corporeal endometritis 17 
 
 Chronic cervical endometritis 23 
 
 f Ovarian tumor 3 
 
 Chronic pelvic abscess 4 
 
 ] Adherent displacement of uterus 4 
 
 j Tubal distension (?) 2 
 
 Pelvic swellings of doubtful nature 5 
 
 Vaginitis 7 
 
 . Chronic cystitis o 
 
 f Dysmenorrhcea 16 
 
 Menorrhagia and metrorrhagia 11 
 
 Amenorrhcea 1 
 
 Spamenorrhoea 11 
 
 Tardy menstruation (after 18 years) 3 
 
 Premature climacteric 2 
 
 Dyspareunia 9 
 
 Hysteria 7 
 
 Irritable bladder 12 
 
 Impotence (38 inquiries) 11 
 
 Leucorrhrea 47 
 
 r Persistent hymen 2 
 
 I Cystic labial tumor 1 
 
 1 Urethral tumor 1 
 
 L Vulvitis 3 
 
 (Excessive obesity 5 
 Anaemia 3 
 Secondary syphilis 2 
 Tuberculosis 3 
 
 Extra-uterine. 
 
 Functional Pelvic Abnormi- 
 ties. 
 
 Abnormities of 
 Organs. 
 
 External 
 
 Abnormities of Nutrition. 
 
 Among the foregoins: ca.ses there were many Avhicli presented compli- 
 cations. Thus, a retroverted uterus would also be enlarged, be the sulj- 
 
464 STERILITY. 
 
 ject of enclometritis and its consequent leucorrhoea, be surrounded by 
 the remains of pelvic inflammation, and possibly be accompanied by 
 still other conditions any one of which might be sufficient to produce 
 sterility. Indeed, it is rather unusual to find a case of barrenness in 
 which only a single detectable cause is present ; and even in such a case 
 there is always the possible coexistence of some one of the hidden causes 
 which have been enumerated. (See p. 457.) In 2 of the cases there was 
 a marked growth of hair on the face. In 21 cases the husbands were 
 questioned : 6 confessed to having had gonorrhoea ; in 1 of these a 
 single testicle had been inflamed, and in 1 both had been afifected. In 
 4 cases the external organs were examined and found normal in all : 1 
 of these was aspermatic. In 2 cases there was an admitted history of 
 syphilis : 1 was cured prior to marriage ; the other still had occasional 
 mucous patches in the mouth. In the 72 cases examined there was 
 found the following degrees of sterility : 
 
 Never had child 59 
 
 Had 1 child 9 
 
 Had 2 children 3 
 
 Had 3 " 1 
 
 Diagnosis. — Sterility in a woman is not a definite condition. It is 
 one which exists in different degrees; it may be absolute or relative, 
 temporary or permanent, congenital or acquired, complete or partial. 
 
 Sterility is absolute when dependent upon some incurable or uncured 
 condition in the woman which would be efficient under all circum- 
 stances; relative, when she is fruitfid with one mate and not with 
 another, several examples of this kind having been recorded. It is 
 permanent when the cause is not capable of removal ; temporary, w^hen 
 dependent upon some curable local or general condition. It is congeni- 
 tal when produced by some inherent organic defect ; acquired, when the 
 deficiency is the result of subsequent accident or disease. A woman is 
 completely sterile Avhen she does not conceive at all ; partially or com- 
 paratively, when the degree of fruitfulness is less than that of the aver- 
 age of women, either as regards the total number of children produced 
 or the length of time which elapses between their births. 
 
 Matthews Duncan quotes from Ansell's tables, which he considers 
 the most complete and reliable, to show that in 6000 cases 3159 children 
 — more than one-half — were born within one year after marriage; 2163 
 in the second year ; 421 in the third ; 137 in the fourth ; and only 292 
 were born in all the subsequent fourteen years. Hence sterility may be 
 suspected in a woman Avho has passed the first year of married life 
 without conceiving, and the presumption grows stronger with each suc- 
 ceeding year, and after the fourth the probabilities of conception are 
 exceedingly small. 
 
SUlUlXTlVh- SVMI'TfJMS OF STIULIUTY. K;.", 
 
 A<'c»)r(liiii:; to tlu' dcdiK'tions of Duiu-aii, hascd iijxm tlio tahlcs of 
 Anscll aiul liis own, the average interval between successive eliiMren is 
 twenty nionilis; so that when a married woman do(!S not hear a child 
 every twenty months (hn"in<;- the cliildl)eai'iii;;- period she oxliihits u 
 (leti"r(>e of ivlative sterihty. These tahles show also that the averaj^e aj^e 
 ot" commencing;- cliildhearinii' is twenty-six, and the mean a<re at tlu; ter- 
 mination thirty-eight years ; hence the averajic jx'riod of childhearinj^ 
 is twelve years. 
 
 'i'he cliildl)earin<i' pt'riod for most women is considerably short ei' than 
 that which elapses l)etween the bci^innini^ and ocssation of the; menstrnal 
 fnnetion, tlie latter eontinnin*^, as a rule, seven or eight years after the 
 former has ceased. 
 
 Women who exhibit only a comparative degree of sterility are very 
 numerous, but their unfruitfulnoss rarely becomes the subject of inves- 
 tigation or treatment. U'lieir condition, therefore, as a class is of more 
 interest to the })olitical economist than to the physician. The women 
 for whom medical aid is likely to be invoked are principally those who 
 have either had no children or who have ceased to produce without 
 apparent reason after bearing one or more. Hence, the diagnosis will 
 consist not so much in determining the existence of barrenness as in 
 ascertaining its cause in any given ease. It has already been shown 
 that these are very numerous, and not always apparent. Some, it is 
 true, are obvious enough on the most superficial examination, while 
 others are undiscoverable by the most careful employment of all the 
 means at our disposal. And we should hold always in vicAV the import- 
 ant fact that in a very large number of instances the causes are multi- 
 ple, and that it is hence necessary, after discovering a probable one, to 
 search for the existence of all possible complications. The methods bv 
 which this is to be accomplished cover the entire range of gynecological 
 diagnosis, the details of wdiich do not come properly Avithin the scope 
 of this article. 
 
 Order of Invesfir/ation. — A case of sterility' should be studied svstem- 
 atically. While, as already shown, a majority of women conceive dur- 
 ing the first year after marriage, and a very large number during the 
 second, yet in a considerable percentage of cases conception does not 
 occur until the third ; so that it may be premature to conclude that a 
 woman is sterile until after the end of three years of married life, and 
 not even then unless it appear that husband and wife are in good gen- 
 eral health and the conditions of intercourse favorable. 
 
 Statements of the patient may furnish valuable information concern- 
 ing the degree of regularity, character, and amount of menstrual or 
 other discharges ; pain, itching, or other disordei's of sensation ; the 
 presence or degree of sexual desire or gratification. But these and all 
 other subjective features are suggestive only, and not at all conclusive. 
 
 Vol. I.— 30 
 
466 STERILITY. 
 
 Physieal Examination of the Female. — A physical examination of 
 the woman is indispensable. So many of the causes of sterility are of 
 an organic or mechanical character, and detectable only by objective 
 research, that their presence or absence should be determined, if possi- 
 ble, at the outset. The various malformations and diseases of the vulva 
 may be readily detected by inspection and touch. If dyspareunia in 
 any degree be present, its cause or causes should be carefully sought for. 
 The ostium vaginae and vaginal canal, as regards their size, dilatability, 
 and degree of sensitiveness, should be tested by the careful introduc- 
 tion of first one and then two fingers. The paravaginal structures 
 should be interrogated with reference especially to the existence of 
 swellings and points of tenderness. The vaginal touch should always 
 be supplemented by simultaneous hypogastric pressure. In this man- 
 ner may be ascertained the condition of the uterus as to size, position, 
 sensibility, and shape ; also the condition of the other pelvic structures, 
 including the Fallopian tubes and ovaries. In any doubtful case the 
 recto-abdoniinal examination should also be employed, since by this 
 method the upper and posterior pelvic contents are brought into closer 
 contact with tlie finger. To ascertain the source and nature of abnor- 
 mal discharges an examination by the speculum is necessary. By this 
 means we are also enabled to learn the size of the os uteri, the presence 
 and appearance of erosions, ulcerations, fistulous openings, or other con- 
 ditions involving alterations of color or character of surface. By the 
 use of the uterine probe or sound we may ascertain the permeability, 
 size, and sensitiveness of the orifices and canal of the cervix. 
 
 Such an examination as is here briefly indicated, if carefully con- 
 ducted, should not fail to detect any condition capable of preventing 
 the access of the semen to the interior of the uterine cavity, and, if it 
 should prove to be negative in results, must eliminate a very large 
 number of the admitted causes of sterility. (See p. 455 et seq.) 
 
 Examination of the Hale. — If, after having proceeded thus far, no 
 apparent cause for the infertility be found, we can no longer assume 
 that the fault is with the woman, although it may still be so, and the 
 next step should be the investigation of the husband. Our inquiries 
 will have reference to the past history and present condition concerning 
 sexual abuse, gonorrhoea, gleet, urethral stricture, orchitis, syphilis, 
 degree of virility, and character of the semen. To obtain knowledge 
 upon these points may require the exercise of a good deal of tact on 
 the part of the physician. Many men prefer not to know — or at least 
 not to have others know — of any sexual deficiency on their part. They 
 are not averse to furnishing information concerning their virile power 
 when this is satisfactory, but not when it is otherwise ; and in my own 
 experience there has been on the part of most husbands a very great 
 unwillingness to have their procreative power tested, especially when 
 
suii.ii'J'rivi'. sYMi'foMs or sTi:i:ii.iiY. 407 
 
 llic rcsiill (if the iii\csli<4;ilii)ii scciiicd ili >iil)i fill. In one iiistaiicc, in 
 wliicli I III re \\:is iiiiccrtiiiiily :is to wIkhii (Ik; iiiriTtiiily slioiiM he 
 ascrihid, iIk' IuisIkuuI toKl iiu- thai '///'/• / had trailed his irij'r nii.stic- 
 ec.ssfu/li/ for si.r montha he would suhmit /limsr/f to utvoitif/atian. 
 
 It' (he male ori^aiis ho apparently normal in structure aixi fuiiff i(»ii 
 an examination of the seminal llnid nnder the micro>copc should ho 
 mide. A single di'op is siiHieient. Ilie semen should Ite ohiained :is 
 soon alter emission as possihle, and })laee(l under the slide helore it has 
 h'cn exposed to a low temperature or other influence known to he 
 inimical to the vitality of the sperniatozoa. In this way it may he 
 determined Mhether any spermatozoa are present, and if so whether 
 they he dead and motionless or alive and active. If spermatozoa he 
 ahsent or without motion, the man is sterile. 
 
 In order to ascertain the influence of the vaginal secretions ui)on the 
 sjiermatozoa the interior of the vagina should he exposed hy a speeuhun 
 within an hour or two after coitus, the woman in the mean time retain- 
 ing the recumhcnt posture. A portion of the semen may be readily 
 ohtained hy means of the hypodermic syringe or a small glass tube, 
 pipette, or dropping-tube. The cervical mucus may be obtained in the 
 same manner by previously introducing into the canal a pair of uterine 
 forceps about half an inch and then separating the blades. 
 
 If seminal fluid can be traced into the cervical canal, we may usuallv 
 assume that it will enter the uterine cavity. Nevertheless, it may yet 
 be prevented from doing so by stenosis of the canal higher up, by flex- 
 ions, polypi, myo-fibromata, etc. ; but the existence of these and anv 
 other detectable abnormities will, presumably, have already been ascer- 
 tained. 
 
 Hidden Causes of Steriliti/. — Thus for, the examination will have 
 had reference to the conditions of the spermatozoa, and to those Avhich 
 may interfere with their progress to the interior of the uterus, and at 
 all stages of the investigation there has been a possibility of attaining 
 some degree of definite result. AVe now come to the consideration of 
 the various obstacles which may exist to the further progress of the 
 spermatozoa toward the ovary, the maturing of the ovule, its dehis- 
 cence and transmission to the uterus, and the conditions necessar}'- for 
 its normal implantation and development. Here all is doubtful ; specu- 
 lation must take the place of observation. The organs concerned are 
 beyond our sight and accurate reach. AVe know, or believe, that cer- 
 tain diseases, deformities, and displacements of the ovaries, Fallojjian 
 tubes, and uterus are caj)able of successfully interfering with ovulation, 
 conception, and gestation ; but we cannot with certainty detect tlieir 
 presence or degree during life unless there ho enlargement, and not 
 always even then. This seems the more to be regretted in view of the 
 fact that an undeveloped ovary, a contracted, closed, or distended tube. 
 
468 STERILITY. 
 
 an inflaramatoiy exudation or adhesion, an endometritis — all undiscov- 
 erable by diagnostic procedure — far more certainly determine sterility 
 than does an ovarian cystoma or a tumor of the uterus. 
 
 Prognosis. — The prognosis of sterility in any given case must 
 depend upon the nature of the cause and its susceptibility of removal. 
 The most favorable cases are those in which the barrenness is produced 
 by some evident and removable mechanical impediment to the access 
 of the sperm to the cavity of the uterus ; as, for example, an unbroken 
 hymen, displacements and flexions of the uterus, stenosis of the os 
 uteri externum, etc. The cases in which essential organs of reproduc- 
 tion are absent or in which there exists irremediable impediment to 
 coitus are manifestly hopeless. Many of the causes of dyspareunia 
 are curable, and in such cases, provided there be no coexisting cause 
 for the sterility, the prognosis is favorable. A history of gonorrhcea 
 in the husband or wife, even though the ordinary symptoms be no 
 longer present, is unfavorable. The prognosis is also bad when no 
 cause is apparent, for this may consist of some of the more hidden 
 conditions, mechanical or physiological, incapable of recognition and 
 unamenable to treatment. 
 
 Treatment. — The treatment of sterility is notoriously unsatisfac- 
 tory. In order to be rational it is clearly necessary that the cause or 
 causes of the condition be ascertained ; and it has been already shown 
 how difficult it is in many cases to succeed in doing this, while in 
 others it is impossible. In some cases treatment of any kind will be 
 clearly useless; for example, those in which important organs are 
 absent, imperfectly developed, or incurably deformed, and those in 
 which insurmountable obstacles exist to intercourse or to the transit 
 of semen to the cavity of the uterus. Other conditions which produce 
 inaptitude for germination (non-ovulation), and which prevent the 
 transmission of the ovule to the uterus, are inaccessible and equally 
 incurable. 
 
 It is not my province in this article to enter into a detailed account 
 of the treatment of all the various conditions which have been enume- 
 rated as causes of sterility. Such details may be found in the system- 
 atic books on gynecology, to which and to other portions of this work 
 the reader is referred. Hence what I may say concerning the treat- 
 ment of the sterile condition will be merely of a suggestive or general 
 character. 
 
 No treatment should be attempted for sterility alone which involves 
 danger to the life of the woman. The desire for offspring may be 
 strong, and the importance of an heir appear under some circumstances 
 very great, but these considerations should not influence a surgeon to 
 imperil a life by an operation of complaisance which must, even when 
 successfully done, be of doubtful efficacy. Likewise, no dangerous 
 
SUBJECTIVi: SYMPTOMS OF S'I'IHH LITY. 4G9 
 
 operative Ireatineiit should 1k' iiiKlcrlakcii ii|i(iii ihc woiiiini iiiilf-- it 
 shall previously ajipear beyoud reasonable doiiltt dial (lie iludl lies 
 with her aud not with lu'r mate. The (piestiou presents a diiVcrent 
 aspect when opci'ative or othci' (rcatnicnt is coiitcniphiicd lor ihe <'iiic 
 of some paiidul or dant;'erous complication, as dysparcunia or dysmt n- 
 ori'lKca. Here tlu' cond'ort and health of the patient are involvf.'d, and 
 the i-emoval of the disturhinij^ clement may ineidentally remove tlie 
 intertility as well, the latter being, however, a secondary consideration. 
 
 PiH'suino- the order which has been observed in this article, I shall 
 bricHv sun'ti'est the treatment suitable ibr die various causal eniKJiiioiis 
 ot" barrenness in the woman, accoi'dinu:; as they interfere with insem- 
 ination, imj)res;nation, ovulation, and gestation. 
 
 Tirdfiiicnt of Incapacity for Insemination. — This class of causes 
 includes all those which make coitus impossible, diflicult, or j)ainrul. 
 (See }). 458 d scq.) 
 
 Intercourse with a woman is always possible when the vulva and 
 vagina are sutheiently pervious to permit the entrance of the male 
 organ, although the act may be difficult or unbearably painful. 
 
 W'luMi the sides of the vulva are adherent, partially or M'holly, they 
 juay be separated by a knife, scissors, or by a combination of cutting and 
 tearing, the opening thus made being maiutaiued by the insertion an<l 
 retention of some smooth, hard substance in the form of a cylinder or 
 plug to be w^oru in the vagina until the raw surfaces have become 
 com[)letely healed. 
 
 More extensive operations of the same nature are indicated when there 
 is })artial or complete closure of the vagina. If any portion of the 
 vaginal tract be completely closed and the uterus and ovaries be 
 present aud functionally active, an operation to permit exit of the 
 retained menstrual fluid may be demanded. In cases in Avhich the 
 occlusiou and retention have existed for a long time, such changes 
 may have taken place in the internal organs as to constitute incurable 
 causes of infertility. 
 
 A double vagina may be remedied by removing the dividing septum 
 by scissors. 
 
 A persistent hymen, if perforate, is readily removed or divided Avith 
 blunt-pointed scissors, one blade being pushed through the opening, the 
 incisions, which should be numerous, being toward the circumference. 
 If imperforate it M'ill call for attention probably before marriage for the 
 symptoms of retention. 
 
 Hypertrophy of the clitoris or labia when so great as to be obstructive 
 to intercourse demands amputation. Vulvar or vaginal tumors should 
 be removed. 
 
 Treatment of Incapacity for Impregnation. — The conditions comprised 
 under this head are those which prevent the meeting of the spermatozoa 
 
470 STERILITY. 
 
 with the ovule. (See p. 455.) They are divisible into two classes, as 
 already stated — namely, those which prevent the semen from passing 
 inward, and those which prevent the ovule from passing outward. 
 Some of these obstructive conditions are successfully treated with more 
 or less difficulty, while others are wholly incurable — or, rather, the 
 sterility dependent upon them is incurable. For example, a distended 
 Fallopian tube or a chronically inflamed ovary may be removed, but 
 the procedure could not, of course, benefit barrenness dependent upon 
 disease of the ablated organ. 
 
 When great disproportion exists between the male and female organs 
 it may be proper to make a number of incisions at the circumference of 
 the ostium vaginse, and follow the operation with the use of a large 
 vaginal plug to be worn for two or three weeks. Otherwise, the con- 
 dition is irremediable. 
 
 Nothing can be done for a congenitally short vagina; the condition 
 persists through life. Painful urethral caruncles and sensitive mucous 
 patches on the vestibule should be excised and their bases cauterized by 
 nitric acid. Fissures of the ostium vaginse and of the anus are com- 
 monly curable by extensive forcible dilatation. Ulcers of the rectum 
 should be treated by appropriate methods, according to the extent and 
 nature of the lesion. Hemorrhoids may be removed by ligature or 
 injection with dilute carbolic acid. Lacerations of the cervix uteri 
 should be closed by operation whenever they produce dyspareunia, 
 impotency, or are sufficiently extensive to permit eversiou. Coccyo- 
 dynia, when merely a neurosis, as it frequently is, may be treated as 
 such, but when dependent upon necrosis of the bone, the latter should 
 be removed. Vaginismus and vulvar hypersesthesia should be treated 
 by removal of any sensitive remains of the hymen or other painful spots, 
 and subsequent long-continued dilatation. A displaced uterus, if not 
 retained in malposition by adhesions, should be put in proper place and 
 maintained there by means of a suitable pessary, and any accompanying 
 metritis, endometritis, or subinvolution should be treated by appropriate 
 means. Flexions of the uterus may be treated by slow or rapid straight- 
 ening with bougies having different degrees of curvature — a method 
 sometimes temporarily beneficial — or by the use of intra-uterine stems. 
 If these means fail and the flexion involve only the cervix, the latter 
 may be incised in such a way as to straighten the canal, and thus tem- 
 porarily remove the impediment to egress of the menstrual discharge 
 and ingress of spermatozoa. A flexion may be remedied sometimes 
 sufficiently to permit conception, but it is very likely to return, some- 
 times even after parturition. 
 
 Many of the deformities, congenital or acquired, of the cervix and os 
 uteri which are productive of sterility are curable by surgical methods, 
 while others are quite unamenable to all the resources of art. 
 
sii;.ii:crivE sYMi"r()M>< or stihiii.ity. 171 
 
 All iniporlnratc os iitrri slioiild l)c iicatcil hy iiiaUiiij^ an incision at 
 the projuT site and |)a.ssin;; into it a sound in <»r(|cr to asccrlain tlje 
 oxistoncc and condition of the ccrvi<"il <-anal and os intcrninn. IltliL'so 
 bt' found sullicicntly |)atul«»us, it will only Ix? necessary t<» enlaru^c the 
 incision ci-ucially, and maintain its patency by the daily introduction 
 of a l»oii<^ic. A Ix'tter method, however, consists in the rciuoxal of a 
 conical |)ortion one-third of an in< h at the base and cxiendinjr a half 
 inch or more into the cervical canal. If the os internum and e.xterniun 
 be perforate, but with narrow openin<>;s, these may !)<• ( idarucd l)y dila- 
 tation or incision. If the method by dilatation be ch(»sen, it may be 
 (lone slowly or ra[)idly. Much controversy has arisen u[)on this subject, 
 aiul wide ditferenccs of opinion exist as to which is the better metiuMl. 
 If we accept all the testimony which has been given in regard to it, we 
 must conclude that all of the ditt'erent procedures are temporarily suc- 
 cessful ; that all are followed, sooner or later, by a return of the stenosis ; 
 that dysmenorrhoea has been relieved in a large and sterility in a smtdl 
 number of instances; that all are likely in a small percentage of cases 
 to be followed by endometritis, pelvic cellulitis, or peritonitis. My own 
 preference is for rapid dilatation under anaesthesia, and the maintenance 
 of the patency thus obtained by the introduction of a hard-rubber bou- 
 gie at intervals of three or four days in the beginning, and then of 
 from one to four weeks. The instrument should be carried into, and 
 not beyond, the internal os one or two days before an expected men- 
 strual period. 
 
 Hypertrophic elongation of the cervix should be treated by amputa- 
 tion of the redundant tissue with a knife or galvanic cautery. "When 
 one of the uterine lips projects beyond the other, overlapping and 
 partly closing the os uteri, the projecting portion should be removed 
 sufficiently to restore the symmetry of the parts. 
 
 Fibro-myomata of the uterus should be dealt with quite independ- 
 ently of their influence upon fecundity. If the symptoms produced 
 by their presence should be so grave as to impair health, they should 
 become the object of either palliative or radical treatment, the details 
 of which will depend upon the size and position of the tumor and the 
 age and general condition of the patient. The methods of treatment 
 most relied upon are the administration of ergot, enucleation, removal 
 of the ovaries, and hysterectomy. Manifestly, these methods wotdd 
 some of them only ensure sterility. 
 
 Uterine polypi, when productive of hemorrhage, pain, or catarrh, 
 should be removed by torsion, the ecraseur, scissors, or gal vain »- 
 cautery. 
 
 The dense, viscid, mucous plug which is so constantly present as a 
 result of chronic cervical endometritis may be removed temporarily by 
 means of small pieces of sponge the size of a pea held in the blades of 
 
472 STERILITY. 
 
 a forceps. It is frequently a tedious process, however. The menstrual 
 discharge usually washes it away, so that for two or three days after a 
 period very little of it can be seen. In all cases an effort should be 
 made to cure the intracervical disease which causes it — commonly a 
 difficult matter. An essential requisite iii the treatment of this obsti- 
 nate disease is thorough dilatation of the canal in order that the mucus 
 should be permitted to escape so soon as formed, and to enable any 
 therapeutic application to come fairly in contact with the secreting sur- 
 faces. The opening should be sufficiently large to permit the introduc- 
 tion of a No. 16 bougie prior to each application. Much of the fail- 
 ure to treat this disease successfully is to be attributed to the omission 
 of this preliminary measure : with it, I have usually succeeded in 
 removing cervical inflammation of very long standing, and am obliged 
 only rarely to resort to the ablation of the glandular structure, although 
 this must sometimes be done. 
 
 For excessive acidity of the vaginal mucus an alkaline treatment 
 should be adopted, including alkaline drinks, baths, and vaginal injec- 
 tions. Solutions of bicarbonate of soda, borax, Vichy water (Pajot) 
 are suitable for this purpose. Byasson recommends as an injection 
 the following: Water, 1000 grammes, the white of one egg, and 90 
 graonnes of phosphate of soda. In this solution he was able to keep 
 spermatozoa alive for twelve days. It is probable that the occasional 
 successful results which have attended courses of treatment at alkaline 
 springs and baths have been in this class of cases. 
 
 Treatment of Incapacity for Ovulation. — Strictly speaking, the term 
 " ovulation " includes only the processes concerned in the germination, 
 maturation, and dehiscence of the ovule. But for my present purpose 
 I desire to include also its transmission from the ovary to the cavity of 
 the uterus. In this enlarged sense the conditions which may interfere 
 with the series of processes necessary for conception are very numerous. 
 (See p. 461.) So far as these pathological states may affect injuriously 
 the health of the subject, they may interest the surgeon, for many of 
 them are curable by surgical methods, but inasmuch as the cure involves 
 in many cases the removal of the ovaries and Fallopian tubes, the ster- 
 ility is made absolute. It is true that recovery may take place after 
 repeated attacks of pelvic inflammation, and that lapse of time may, 
 with suitable persistent treatment, bring resolution and absorption of 
 inflammatory exudations ; but after the pelvic organs have become sol- 
 idly matted together with adhesions such recovery must be rare, if, 
 indeed, it ever occurs. Any treatment of the inflammatory affections of 
 the pelvic structures, so far as these relate to the sterile condition, must 
 be made in the earlier stages of the disease in order to be effective. 
 
 Treatment of Incapacity for Gestation. — This depends chiefly upon 
 the presence of a diseased condition of the endometrium which pre- 
 
SUIUITTIVK SYMPTOMS OF STKIUIJTY. 473 
 
 vents j)r()(liicti\'('iicss l)\- intri-fci-in^ w ilh (ixalion and (li'vclnpinciit of 
 tlic nviliii. 
 
 \\ lu'ii we foiisidcr Imw iiiaii\ ol ilic piMx^csseH (;<)iici'nii(l in L''<'ii('ra- 
 tioii ;iro wliollv nKH'liaiiical, it docs not soeiii sui'prisinj;- that in <a-(- of 
 sterility j)rt'S('ntiii<2; some apparent ol)stacle of" a |)liysi(al diaiactt r lliis 
 should l»f promptly accepted as th(! elli(!ieiit cause, an<l that ni(!chaniciil 
 metliods should he resorted to lor relief". And it is uiKpiestionahle that 
 verv many oi' the conditions which have heen mentioned as causes of 
 infertility can he o\ iieonie only by sui*j2;ical mean.--, li is c(|ually true 
 that the mere I'cmoval of such ohsf laiction may he, and frecjuentlv is, 
 suilicieiU. IWil there are many cases in which soniethinj^ more is 
 needed — cases in which operative and medianical methods do not 
 meet all the requirements. For exann)le, a pronounced flexion of 
 the uterus is a frequent cause of sterility; and clinical exj)ericnce has 
 seemed to demonstrate that the efficient removal of the distortion and 
 tlie enlargement of the abnormally small cervical ciinal have been 
 sometimes followed by conception. Far oftener, however, these means, 
 while promptly relieving the accompanying dysmenorrhoca, have failed 
 to remove the sterility — failed, doubtless, for the reason that they did 
 not remove some other condition than the mere narroAving of the cer- 
 vical canal, and which was the potent factor in production of the bar- 
 renness. And even in those cases in which conception has followed 
 the use of the surgical means for enlarging a narrow cervical canal the 
 fact does not at all prove that the result was a consequence of the mere 
 enlargement of the passage-way; for, wdiether the operation be done by 
 dilating or cutting instruments, something more is effected than the 
 mere stretching and cutting. Indeed, these procedures make, in addi- 
 tion, a very profound impression not only upon other portions of the 
 uterus than those directly attacked, but one which extends also to 
 neighboring parts. And I do not doubt that long-standing conges- 
 tions and inflammations wdiich have prevented the uterus from j)rop- 
 erly receiving and nourishing the ovum have sometimes been thus 
 removed. Further, I believe that it is because the diseased conditions 
 mentioned or similar ones are not always removed by the operations re- 
 ferred to that sterility is not more frequently cured by their employment. 
 The same may be said of displacements of the uterus, which are 
 thought by many to be the most frequent of all the mechanical causes 
 of sterility. In a paper read before the American Gynecological Soci- 
 ety* I made the following statement in regard to the relations existing 
 between sterility and uterine displacements: "Of these, retrovei*sion 
 and anteversion form the great bulk, prolajisus being com]xirativelv 
 infrequent, and even when present, not likely, per se, to prevent con- 
 ception. Even the versions of the uterus are not necessarily produc- 
 
 * Ih-ansaclions, 1879. 
 
474 STERILITY. 
 
 tive of infertility. They may constitute a difficulty in the way of 
 impregnation, but nothing more ; and they only do this when the os 
 uteri is pressed against the vaginal wall or carried far from its normal 
 position. That these malpositions are, however, sometimes the only 
 causal elements of the sterility is shown clinically by the success which 
 occasionally follows the replacement of the organ and its retention in 
 proper position by means of pessaries. But here too, just as in the case 
 of flexions, these mechanical devices are only exceptionally successful. 
 In the great majority of cases they fail. AVhy ? Because nine-tenths 
 perhaps of all chronic uterine displacements are complicated ^vith 
 chronic uterine disease, which the mere replacement of the organ is 
 inadequate to remove. Practically, it does not matter, so far as the 
 therapeutics of these coexistent conditions are concerned, whether the 
 inflammation or hypertrophy (or %vhatever the disease may be) or the 
 malposition has appeared first — which is the cause and which the effect. 
 We find them together, and both must be cured. Usually, they must 
 be cured simultaneously if at all; for curing one does not, unless excep- 
 tionally, cure the other. And just here we have, as I believe, the fun- 
 damental fact which explains why mechanical treatment alone so often 
 fails to remedy the sterile condition. A displacement or a flexion is 
 rectified, perhaps, but an endometritis which coexists, and which is the 
 potent factor of causation, is not removed, and the sterility remains. 
 Not only this : from the persistence of the inflammation the displace- 
 ment or deformity itself is likely to return. Hence, w4iile we cannot 
 discard the pessary, and while by its use great amelioration of the 
 patient's symptoms may be effected, and while, still further, the mere 
 replacement of the uterus may sometimes be sufficient to restore the 
 organ to a healthy state, we cannot rely upon this latter result. So, 
 when sterility complicates displacement we must expect to find disease 
 also, and this latter, as well as the malposition, must be removed if we 
 would cure the barren condition." 
 
 In cases of sterility attended by inflammatory disease of the pelvic 
 organs too much stress cannot be put upon the importance of sexual 
 repose. This can frequently only be obtained by separation of hus- 
 band and wife. 
 
 It has been generally thought that conception is much more likely to 
 occur within a few days subsequent to a menstrual period. This belief 
 was based upon the theory which regarded menstruation only as depend- 
 ent upon, and an epii)henomenon of, ovulation — a theory so inconsist- 
 ent with many now admitted facts as to be no longer held by some, and 
 very loosely by others. Fecundation may result from a coitus had at 
 any time between two menstrual epochs, the essential requisite being the 
 junction of the ovule and spermatozoa. Nevertheless, it is still true 
 that the most favorable period for the occurrence of conception is 
 
AJrnilrJAL IMl'lLlKiSATlOS. 17.'* 
 
 within the \\\>>{ ci^lit or ten days after tlio cessation of a iiiciistnial 
 How, ht'caiist' the iiicroascd coii^cstioii (»t' all tin- |M'lvic orj;aiis (liiriii;^; 
 the talaiiH'iiial (luxinii occasionally dclcniiiiio the more hasly nij)tiire 
 ul" a iiiaiure lollicle. 
 
 Artificial Impregnation. 
 
 1m certain cases of sterility it may he i»ro[)er t<j attempt artificial 
 impregnation. This consists in the mechanical intnxluction ui' sper- 
 matic Hnid into the uterine ("avity. The eases which are es|x*cially 
 aila[)ted t<» tliis metluxl of treatment are those in which there is some 
 obstacle to the passage of the si)ermatoza from the vagina to the inte- 
 rior of the ntmuis, as occurs in Hexions of the neeU on the b<xly of the 
 oruan and stenosis of the cervical canal. 
 
 Prior to resorting to this method it should he certainly known that the 
 hushand is fecinid, as indicated by a u<^»rmal condition of the semen; 
 that the menstrual function is properly performed ; tiiat the pelvic and 
 genital organs of the female are normal ; that all other rational meth<M:ls 
 of treatment have failed. In every case the consent of both husband 
 and wife should be obtained. 
 
 The attempt having been decided upon, coitus is practised in the 
 ordinary manner. Subsequently, within one or two hours, the woman 
 having in the mean time maintained the recumbent posture, a small 
 quantitv' of the semen in the vagina is drawn into a properly-con- 
 structed syringe which has been previously warmed to the temperature 
 of the body. The tip of the instrument is then carried through the 
 cervical canal to a point just beyond the os internum, when a single 
 drop is forced forward by a partial turn of the piston. The tul)e is 
 held quietly in the cervix for a few seconds, and then carefully with- 
 dj'awn. The woman should lie in bed several hours immediately fol- 
 lowing the operation. Girault ^ prefers to the syringe a hollow sound 
 for the introduction of the semen. The instrument, properly charged, 
 is placed within the neck of the uterus, and the fluid is discharged by 
 blowing through the tube with the mouth of the operator. 
 
 Tiie degree of success which has attended the meth(xl of artificial 
 impregnation is not known. During the year 1866 the late Dr. Mar- 
 ion Sims made 55 experiments on 6 different women. Many of the 
 operations were imperfectly done or performed under unfavorable cir- 
 cumstances. In a single instance conception occurre<l, but even this 
 was inconclusive, since the exj>eriment was ])recede<l and followed bv 
 ordinary cohabitation. Girault^ has had eight successes, 0!ie a twin 
 pregnancy; the number of experiments not given. De Sinety^ says: 
 
 ' Etude mr la Generation nrtificielle dansPE-ip^ce humaine, Paris, 1869. 
 * Loc. ci(. ' Manuel de Gi/necologie, 1879. 
 
476 STERILITY. 
 
 " The successes obtained after eight or ten futile attempts are an 
 encouragement for the repetition of this manoeuvre a certain number 
 of times." Richard ^ states that Gigon, Lessueur, Delaporte, and other 
 French physicians have also been successful in artificial fecundation, but 
 does not give details. 
 
 Artificial impregnation has never become popular with the medical 
 profession, notwithstanding the great scientific interest which attaches 
 to the subject. Many have condemned the practice without, it seems 
 to me, any very good reason. It aims to accomplish by comparatively 
 harmless means an end which all gynecologists are willing to attain by 
 more dangerous methods, for surely no one can claim for the various 
 remedies in vogue for overcoming flexions and stenosis of the cervix 
 uteri a degree of safety at all comparable with that used in artificial 
 impregnation. Objections which have been sometimes urged on merely 
 ethical grounds may very properly be left for the disposal of the parties 
 chiefly interested — namely, the husband and wife. 
 
 Eustache ^ says : " This last intervention — ultima ratio — is not con- 
 demned by either morality or religion; it is justified by the essentially 
 legitimate and essentially moral desire to have children, and also by a 
 certain number of incontestable successes." 
 
 ' Histoire de la Generation, p. 255. 
 
 ^ Manuel pratique des Maladies des Femmes, 1881, p. 732. 
 
DISEASES OF THE VULVA 
 
 By MATTIIKW D. MANN, A.M., M. D., 
 
 liUFFALO, N. Y. 
 
 Malformations of the Vulva. 
 
 As the congenital nialf'orniations of the vulva have been already 
 fully described/ it is only necessary to say here a few words concern- 
 ing their treatment, so far as that may be required. 
 
 Hypospadias and Epispadias are virtually incurable defects, but the 
 discomfort and annoyance can sometimes be materially diminished by 
 carefully devised plastic operations. AVhere the anterior wall of the 
 urethra is wanting, even when the defect extends entirely through the 
 mons Veneris, flaps can be obtained from the sides and the parts brought 
 together, so as materially to better the patient's condition, and even 
 give retention of urine. Schroeder^ reports two successes where these 
 conditions existed. In hypospadias the chances of success are much 
 less, and the patient is reduced to the necessity of wearing a urinal. 
 Several have been devised for these cases expressly. 
 
 In hcnnapJvodism no special treatment or operation is indicated. 
 
 The clitoris, if greatly enlarged, and the source of discomfort, may 
 with safety be amputated. INIason^ successfully amputated with the 
 ^craseur a clitoris four inches long. 
 
 The labia minora are sometimes very large, but they seldom cause 
 anv inconvenience. In those cases in which there is a supersensitive ct)n- 
 dition of these organs, Carrard^ has '' verv recentlv been able to show 
 that the cause is an increase of their nerve-fibres in the form of INIeiss- 
 ner's tactile bodies, also in the form of club-shaped terminations and 
 peculiar tactile bodies having an aggregation of adenoid tissue." If 
 such conditions exist, they are of course incurable, and can only be 
 relieved by the total excision of the affected organs. In other cases 
 there is simply chafing from clothing, or, in very stout women, from 
 
 ^ See article on Malformations of the Female Genitals. ]i. 2G4. 
 
 2 Lehrbuch d. Gyn., v. Aufl. •'' New York Mcdiml Review, May 1, 1868. 
 
 * Quoted by Winckel from ZeiUchriJ't /. Oeburish., x. 62. 
 
 477 
 
478 DISEASES OF THE VULVA. 
 
 contact with surrounding parts. The result is more or less burning 
 and itching, which produce a great deal of discomfort, and may inter- 
 fere with locomotion or the sexual act. 
 
 These symptoms may be relieved by hot baths, astringent lotions, 
 ointments, or dry powders, as talc, bismuth, and boric acid. If, how- 
 ever, the symptoms j)ersistently recur, removal of the parts may be 
 indicated. The operation is a simple one, and can be done with knife 
 or scissors, and the edges brought together with fine continuous suture. 
 If hemorrhage is feared, the cautery-knife may be used. 
 
 Masturbation, it has been asserted, sometimes results in hyper- 
 trophy of the nymphffi, and even of the clitoris. To this many 
 objections, based on accurate observations, have been made. The worst 
 case of masturbation I ever saw, presented abnormally small clitoris 
 and nymphse, and I have several times seen Avell-marked hypertrophy 
 where the most positive assurances made the existence of this habit out 
 of the question. On the other hand, there is good ground for thinking 
 that unilateral hypertrophy of the nymphse may result from long con- 
 tinuance of the habit. A number of cases bearing on this point have 
 been reported ; ^ and while it can by no means be considered as patho- 
 gnomonic, still its presence must give rise to a very strong suspicion. 
 It is noted that in the case of right-handed women the right labium 
 is enlarged, and in the left-handed the reverse occurs. 
 
 As additional jDoints in the diagnosis of masturbation. Dr. Routh and 
 Dr. Hey wood mention^ that they have observed that in Avomen guilty 
 of this practice the pudendal hair is straight. Dr. Heywood has also 
 noticed that in many cases the nymj^hse were not only lengthened, but 
 granular on their external aspect, and had flattened follicles filled Avith 
 sebaceous matter. This condition of the labia may perhaps be a cause 
 rather than a result of masturbation, the continual local irritation 
 directing the Avoman's attention to the parts. I have seen it exist 
 without any signs of the practice. 
 
 The operation of removing the clitoris and nymphse for the cure of 
 masturbation and nymphomania Avas at one time much practised ; but 
 after a very bitter controversy, Avhich makes one of the most unhappy 
 episodes in gynecological history, it Avas condemned, and has been 
 almost entirely giA^en up. 
 
 Atresia may be either congenital, or acquired during infancy or child- 
 hood. It is very rarely met Avith, In the acquired form agglutination 
 of the labia takes place as the result of inflammation or ulceration. In 
 either case, Avhen discovered, the adherent surfaces should be torn or 
 dissected apart, and the raw surfaces kept from again uniting by 
 pledgets of lints placed between them. 
 
 ■^ British Gynecologiaal Journal, Feb., 1887, p. 503. 
 ^ Brit. Gyn. Journ., he. cit., p. 505. 
 
is.n'i:fi:s axd n'oiwDs of the vulva. 
 
 479 
 
 Injuries and Wounds of the Vulva. 
 
 Iiijiirics (•(' the \iil\;i may l)c (Ii\iili'il iiiti> three classes, aoconlinjr to 
 tlu'ir cause: tlicv may be in-otliircd hy accidental external violence, 
 (liUMiiir coitus, and dnrint:' lal)or. 
 
 W'oiNDs I )r K ro Accidental External Violenxe. — Tlie gen- 
 ital or<i;ans are so well protected by their loeati(jn that accidental 
 woinuls are necessarily rare. The most common accident is a I'all 
 on some sharp body, which may thus bruise, cut, or penetrate the 
 ]>art, AVounds ot" this descrijition are also met with amontr tlie lower 
 classes from kicks with heavy boots. In this case the vulva maybe 
 onlv bruised ; or, should the tissues be caught between the boot and the 
 
 Fig. 176. 
 
 Veins of the Vulva (Kobelt) : a, bulb of the vagina ; /(, dorsal vein of the clitoris ; e, inter- 
 mediary plexus ; g, vein of commuuication with the obturator vein ; I, obturator vein. 
 
 pribes, a wound, almost as clean-cut as though made by a knife, may be 
 made. The labia majora are the parts mo-st generally injured ; but the 
 deeper parts may also be affected, and, although not cut through at 
 once, may slough subsequently. In this way the nympha? and clitoris 
 mav be injured, and even a portion of the urethra lost. The nature of 
 the wound due to a fall must depend entirely on the object inflicting 
 the injury. If the person fall, for example, on the sharp back of a 
 chair or the edge of a box, a deep cut may be made. Should the 
 object be smaller, it may enter the vagina and cut or penetrate its 
 walls. 
 
480 DISEASES OF THE VULVA. 
 
 The symptoms are pain and hemorrhage if the skin has been broken, 
 soon followed by swelling, and later in some instances by sloughing. In 
 case the skin is not broken, but the deeper and softer tissues ruptured, 
 a rapid eifusion of blood may take place into the tissues, forming a 
 large tumor known as a pudendal hsematoma. 
 
 If the deeper structures, as well as the skin, are opened, a very pro- 
 fuse hemorrhage will follow. This will be particularly severe in case of 
 the rupture of the large veins (Fig. 176) in the neighborhood of the clito- 
 ris and nymphse. These veins, being valveless and very large, allow of a 
 rapid loss of blood. If the vagina be penetrated, any of the surround- 
 ing organs may be wounded and inflammation follow. 
 
 Injuries from Coitus. — It is certainly a very strange circumstance 
 that sexual intercourse is sometimes attended with severe, and even dan- 
 gerous, laceration not only of the hymen, but of the vulva and vagina as 
 well. The possibility of this has been doubted by some high authorities, 
 but the evidence seems too strong to be denied. Sir Spencer AVells, 
 Munde, Chadwick, Schroeder, and others^ have reported cases where 
 this accident has undoubtedly happened. In some instances the extent 
 of the injuries makes it seem almost impossible that the finger or some 
 other instrument was not used. Eents have been recorded of the hy- 
 men and vestibule ; of the fossa navicularis, extending into the rectum, 
 making a vulvo-rectal fistula ; of the anterior vaginal wall, making 
 a vesico-vaginal fistula; and of the posterior wall, making a recto- 
 vaginal fistula. 
 
 The causes noted have been extreme violence in the sexual act, 
 excessive disproportion between the male and female organs, narrow- 
 ness of the vagina, as in very young and very old women, and unnat- 
 ural positions in coitus. 
 
 The symptoms have been extreme pain during coitus, and hemor- 
 rhage, sometimes of an alarming kind. The flow is esjoecially free if 
 the bulb of the vagina is torn. Permanent fistulas have been observed 
 to follow these lacerations (Price, Wells, and others). 
 
 Injuries during Parturition. — The discussion of these injuries 
 belongs more properly to writers on obstetrics. Their prevention can 
 only be achieved by a proper management of the second stage of labor, 
 and even with the greatest exercise of skill is not always possible. 
 Their immediate treatment seldom falls to the gynecologist, but the 
 secondary operations make up a considerable share of his surgical 
 work. This subject will be treated of in a separate article. 
 
 Treatment — The treatment in all the above cases, except those due 
 
 to labor, must vary with the severity and nature of the injury. If it 
 
 be a simple bruise of the labia, cold applications and rest will be all 
 
 that is required. If there be deep cuts, they should be carefully 
 
 ^ Am. Journ. Obstetrics, vol. xix. p. 832. 
 
i.\.j{i:ii:s A.\n woiwds of riii-: vilva. 4.si 
 
 (•l('aii>f<l with ail aiili>i'|)tif sdliitioii, all torti liit- <tl ti.->ii(' tiiiiiiin-<l 
 otV, and the (hIj^os, as well it< the (Iccjxr pail.*, I)i(iii};lit to^ctlicr with 
 sutures if |Htssil)li'. I)raiiia<i:('-tulH's will .seldom he rc(|iiin'f|. If \iu- 
 leiit lu'inorrhatic he iircsciil, dccj) sMtiiivs arc f^ciicrally the hcst method 
 of control lint;- it, all lar<ic arteries havinj; been fii>t earefiilly twisted, 
 or tied with eatirnt. .\> the heiii(irrha<ic is, as a nde, mostly venous, 
 if the sutures do iKtt control it, linn pressure hy a comiM-e-^ and a 
 T l)anda<i:e will usually suffice, 
 
 \\'hen we have to deal with a decj) |)enetratinL^ wound olthe vatriiKi, 
 il' the licmorrhage be severe, a carel'ul examination of the wound throuj^h 
 a spociduin should first be made, sutures applied if necessary, or the 
 va*>:ina may be securely tamponetl. The tain])()n can be moistened with 
 alum-water and freely sprinkled with iodoform, in which case it may 
 be safely left in place for four or five days, without fear of decomposition 
 and conse(|uent sepsis. If the perineum be torn, it may be closed by 
 sutures at once, as in the ordinary secondary operation. If the injury 
 is confined to the hymen or to more superficial parts, a tampon may be 
 api)lied to fill the vauina, before making compression with a pad and a 
 T bandage. 
 
 Where operations for the closure of wounds of the vulva are under- 
 taken, even in very unpromising cases, careful antisepsis, such as wash- 
 ing Avith carbolic or sublimate solutions, Avith the free use of iodoform, 
 aided by the naturally high vascularity of the parts, Avill generally 
 secure primary union. 
 
 In the case of young children, ail defects due to injuries, old or 
 recent, should, if possible, be repaired before puberty, as it can scarcely 
 be doubted that the subsequent regular development of the parts will 
 go on more naturally. 
 
 As regards the injuries due to childbearing, professional opinion is 
 pretty well agreed, that the primary operation is, in any but the most 
 trivial cases, the proper treatment. In the lesser degrees of laceration 
 the writer has a number of times seen most excellent results from the 
 use of the serres-fincs.^ 
 
 AYliere the laceration extends through the sphincter ani and up the 
 recto-vaginal septum, the advisability of the immediate operation is not 
 so generally conceded. The writer would give it as his opinion, after 
 some very fortunate results, that an operation is not oidy possible, but 
 is strongly indicated. The use of antiseptics makes danger from im- 
 prisf>ned fetid lochia a purely preventable danger, and one which should 
 not contraindicate the operation. If union occurs, the patient is saved 
 from a great deal of suffering ; and if it fails, the success of a secondary 
 operation is in no way interfered with. Alloway's method" has in my 
 hands proved satisfactory, not only in the lesser degrees of laceration, 
 
 ' Am. Joum. Obstet., Nov., 1874. ^Am. Journ. Obstet., vol. xvii. p. 380. 
 
 Vol. I.— 31 
 
482 DISEASES OF THE VULVA. 
 
 but even where the sphincter has been torn. Permanent fistulse, due to 
 accidents or coitus, are to be treated in the same way as those due to labor. 
 
 Hernia. 
 
 Women are liable to the same forms of hernia that are found in men. 
 Many of them resemble exactly, in symptomatology and treatment, those 
 found in the male, while others are changed in some particulars by the 
 different anatomical conditions existing in the two sexes. But besides 
 those which they have in common with men, women are subject to 
 certain peculiar distinct varieties. 
 
 The varieties which are peculiar to women, or are materially modified 
 by the anatomy of the female pelvis, are — 
 
 1. Inguinal or suprapubic hernia. 
 
 2. Elytrocele, or vaginal hernia. 
 
 3. Pudendal hernia. 
 
 4. Cystocele, or hernia of the bladder. 
 
 5. Rectocele, or hernia of the rectum. 
 
 6. Perineocele, or perineal hernia. 
 
 1. Inguinal Hernia (Anterior Labial Hernia, Episiocele). 
 — Portions of the abdominal contents may come down through the 
 abdominal ring into the labium majus in the female, in a manner 
 exactly analogous to scrotal hernia in the male. The treatment is 
 practically the same, whether by truss or radical operation ; but the 
 diagnosis presents some peculiar features. Early in its descent the 
 hernia makes a small tumor in the region of the external abdom- 
 inal ring. It gradually pushes its way down into the labium majus, 
 where it makes a swelling of the part. Such a hernia may occur on 
 one side alone, or there may be one on each side at the same time. 
 
 Diagnosis. — Early in its career, a hernia is liable to be confounded 
 with diseases of the round ligament, or accumulations in the canal of 
 ISTuck. Later on it may be mistaken for cysts or abscesses in the 
 labium, cyst or abscess of the recto-vaginal gland, and tumors in the 
 labia. It must not be forgotten, that the ovary may make a part of 
 the contents of the hernial sac, giving it a density and a painful cha- 
 racter entirely unlike other forms of hernia. Hernia of the ovary is 
 often congenital. The uterus has been found to make up the con- 
 tents of a hernial sac; and, pregnancy occurring, laparo-hysterotomy 
 was necessary to accomplish delivery. Two such cases are quoted by 
 Winckel. A careful attention to the general rules for diagnosing her- 
 nia will serve to distinguish it from the diseases mentioned. 
 
 Inguinal, as well as umbilical hernise, are not uncommon complica- 
 tions of ovarian and other abdominal tumors. Advantage may be 
 taken of an ovariotomy or other abdominal section to cut out the ring, 
 
inn: MA. 4Hi] 
 
 in the case of an alxloniinal i-ii|)(iii'c, »ir to unite the edges of the rin^r 
 with (•atii:nt sutni-c at'tci" iVcshcniiiii- its cdiics, TJic dangers of the major 
 ojH'ration arc not thus materially increased, 'flic wi-iter has followed 
 this practice in several instances with satisfactory resnlts.' 
 
 •2. VA(iiNAL Hkijnia (Vacjinal P^ntkuocklk, Colkockm:, or 
 Elvtuocelk). — A vaginal hernia may he defined to he the extrusion 
 of a portion of the ahdominal contents through an oj)ening in tlie mus- 
 enlar coats of the vaginal walls, the })erit(jneal and mucous membranes 
 remaining intact and covering the hernia. The existence of a (hstinct 
 rupture in the muscular coat is doubted by some, and there is no post- 
 mortem reeord to prove it; but in several reported eases, the presence 
 of a distinct ring in the vaginal wall, with only a thin covering to the 
 protruding gut, would seem to point very decidedly to the existence of 
 such a rupture, in some cases at least. 
 
 Came. — The cause is sometime.s a sudden i'all or jar of the body, or 
 some great muscular effort, such as lifting, or straining at stool. Prob- 
 ably the most frequent causes are pregnancy and parturition. The 
 physiological softening of the tissue Avhieh takes place at this time 
 prc^lisposes to the rupture, and is aided by the increased pressure on 
 the pelvic floor, and the still greater increase of intra-abdominal pres- 
 sure during the pains, especially if the labor be long and severe. Sir 
 Astley Cooper believed that the reason of the comparative rarity of this 
 form of hernia is that the oblique portion of the pelvis is unfavorable 
 to its production. In the erect, as well as in the sitting posture, the 
 intestines fall rather upon the symphysis pubis than upon the uterus 
 and the parts behind it. The uterus is then pushed toward the rectum, 
 and Douglas's cul-de-sac closed. Were the intestine commonly found 
 filling the cul-de-sac, undoubtedly this form of hernia would be much 
 more common. 
 
 The situation of the ring or opening is usually behind the uterus ; but 
 cases have been described where it was lateral, or even anterior to the 
 uterus. These latter cases greatly resemble pudendal hernia. A case 
 which recently occurred in the practice of Dr. W. H. Heath of Buffalo 
 was of this nature (Fig. 177). The hernia came down in front of the 
 uterus, which was retroverted, pushing the vaginal walls before it until 
 it presented a considerable tumor at the vulva. The mass was easily 
 rethiced, and I succeeded in retaining it in place by a Hofmanu's 
 pessarv. 
 
 Si/mptoms. — The symptoms are, when the hernia occurs suddenh-, a 
 sense of something giving way, followed by pain and a feeling of ful- 
 ness in the vagina. The pain may be intense and alarming, or very 
 slight at first. AVhen the trouble develops slowly, there will be more 
 
 ^ For a fuller consideration of those classes which resemble those found in the male, 
 the reader is referred to the works on general suriierv. 
 
484 
 
 DISEASES OF THE VULVA. 
 
 or less interference with locomotion, pain on coitus, bearing-down and 
 often colicky pains, with constipation. In one case (Barker) there were 
 numerous attacks of sudden and severe j)ain with all the symptoms of 
 peritonitis, evidently due to some spasmodic contraction at the neck of 
 the sac. The pain yielded to morphine and other treatment, and the 
 
 Fig. 177. 
 
 Anterior Vaginal Hernia. 
 
 patient made a good recovery. The function of the bowel is often 
 interfered with, though no case of actual strangulation has come to 
 my knowledge. Thomas has pointed out that it may occur, as a result 
 of pressure in labor, from inflammation, fecal impaction, torsion of the 
 contents of the sac, or the presence of a tumor. 
 
 During labor the pain caused by the presence of the gut in advance 
 of the foetal head may be sufficient to stop the labor, and be accom- 
 panied with all the symptoms of shock. There will then be found a 
 characteristic tumor in the vagina, or such a tumor may appear at the 
 vulva. 
 
 Diagnosis. — The diagnosis must depend on finding the hernial pro- 
 trusion within the vagina, or outside the vulva. It must be differen- 
 tiated from tumors of the uterus and vaginal wall, solid, cystic, or gas- 
 eous. From solid tumors it could be distinguished by its consistency, 
 the hernia being soft and yielding. The presence of an enlarged ovary 
 or small pedunculated fibroid in the sac, might greatly increase the dif- 
 ficulties of the diagnosis. The peculiar characteristic would be the 
 ability to reduce it, especially with the patient in the knee-chest posi- 
 
iu:i:MA. 485 
 
 tioii. 'riicrc would also be iin|nil>(' on <'oii<;liiiitr and incrca'^c of tin- 
 liinior on strainini:. Intestine in the .-ae niiulil liive a sense oi' jrni- 
 ulihLi' to the tiMich ami le-dHMhci' on |)cren.~--ion, thoii;^h it is (o In- 
 remembered tlial ^as and Ihiid are \>y no means eonstantlv loinid in 
 the small intestine. 
 
 The tnnioi- is nsnally |icar— haix'd, ni-uwiiiM .-mailer n|i\\ar<l, thus 
 resembjiiii;- a ]toly|)iis. It may I'c-aeh the si/e of a lletal head at the 
 very outset, thoiiuh ii'enerally quite small. It must be remembered that 
 thesae may contain, besides intestine, omentum and fluid. ( )nocase* i.s re- 
 ported where the tumor was mistaken for a juilypus and icmoved, witli, 
 of eourse, fatal results. To make sure that it is not a prolajise of tiie 
 rectum throuuh the vaiiinal wall, the rectum mav be fdled with water, 
 or a combined vauinal and rectal examination made. The e<1t:e of the 
 hernial sac or the rin<i- is sometimes to be distinctly felt, but, when 
 recent, or before induration has taken j)lace, is not alwavs discoverable. 
 
 The aspirator needle mi<iht atlbrd valuable confirmation in cases of 
 doubt. Should the ui'inary bladder make part of the hernia, imperfect 
 emi)tyino: might lead to cystitis. In tliis case, examination by the sound 
 or Hn-icr throntrh tlie urethra would l)e indicated, if doubt shoidd exist, 
 
 Trcatinnd. — In the way of treatment the first thino; is, of course, to 
 reduce the rupture. This may be done by taxi.s, and will be greatly 
 aided l)y jiuttingthe patient in the knee-chest position. Should this fail 
 and the symptoms be urgent, the whole hand might be introduced into the 
 ret^tuni and the mass pulled back through the opening. There is, how- 
 ever, a.s has been already explained, little danger of strangulatiou. The 
 pain in the acute cases may l)e relieved by morjihine, or, if severe enough 
 to warrant it, by inhalations of chloroform. If it occur or is found to 
 exist during labor, the intestines must be reduced, and held back bv the 
 hand, until the presenting part has passed the ])oint of escape. If this 
 be impossible, the labor should be expedited by forceps or rapid extrac- 
 tion. After the reduction of the rupture in the non-pregnant condition, 
 an effort must be made to hold it up by a pessary or supporter of some 
 kind. A sponge has been used with success, the patient introducing it 
 before rising in the mornimr- ^<> Y\\\e can be given as to the sort of 
 pessars' to be used, as this must depend entirely on the situation of the 
 rin<r. If the opening be high behind the uterus in the posterior fornix, 
 a permanent cure might be effected by obliterating the fornix by a ]>lastic 
 operation, uniting the ])osterior wall of the cervix with the jiosterior \\all 
 of the vagina to a point below the opening, great care being taken not 
 to open into the peritoneal cavity while denuding the tissue. Should 
 relief be unattainable in any other Avay, tiie sac might be oj)ened and 
 the edges of the ring, if there be any, united bv suture. If done with 
 proper precautions, the danger would l)e but slight. 
 1 Cenlralblatt f. Gyn., vol. iii. p. 103. 
 
486 DISEASES OF THE VULVA. 
 
 Dr. Thomas proposed^ and successfully carried out a novel plan in 
 the case of a large hernia which was causing the patient very great dis- 
 tress. He made an abdominal section, and after emptying the sac and 
 inverting it, j)ulled it up and fastened it to the abdominal wound, sus- 
 taining it by two needles, in the same way that the stump is held up in 
 hysterectomy. He found a large, soft, subperitoneal fibroid tumor of 
 the pelvic connective tissue which had made part of the contents of the 
 sac. This was removed at the same time. 
 
 In cases occurring during labor, a prolonged and unremitting observ- 
 ance of the recumbent posture during convalescence, has several times 
 been found to be all-sufficient to eifect a permanent cure. 
 
 3. Pudendal Hernia (Heenia Labialis Posterior, Hernia 
 Vagino-labialis). — These names are given to that form of hernia, 
 in which the rupture appears in the posterior part of the labium majus. 
 The escaping portion of the abdominal contents makes its way in front 
 of the uterus, alongside the vagina and bladder, and between them and 
 the levator ani muscle, through the pelvic fascia, and finally, passing 
 through the pelvic outlet, enters the lower portion of the labium majus, 
 where it presents as an elastic swelling. The course of the hernia is 
 just along the ascending ramus of the ischium. 
 
 This form of hernia is rare, but seems to be more common than 
 true vaginal hernia. The sac usually contains small intestine; but 
 the large intestine and omentum may be present in it, and in a case 
 described by Hodgen there was a large accumulation of fluid. The 
 size of the tumor is not usually great — as large as a pigeon's egg — but 
 in Hodgen's case the mass weighed ninety-four pounds. In shape the 
 hernia is pyriform. It usually increases gradually in size, and does not 
 bear so constant a relation to pregnancy as the vaginal form, though the 
 relationship is retained to a degree. There is little or no pain accom- 
 panying it unless it reaches a great size. The escaping gut is usually 
 easily reducible, and often goes back when the patient reclines. It 
 enlarges on coughing and bearing down. 
 
 Diagnosis. — This form of hernia is differentiated from . an inguinal 
 hernia which has descended into the labium by its position, being much 
 farther back. On following up the hernia as it returns into the peri- 
 toneal cavity, the finger will pass into the vagina. The upper part of 
 the labium and the external abdominal ring are free, and pressure made 
 on this point will not hinder recurrence of the tumor. As regards its 
 diagnosis from other tumors and enlargements, the same rules apply, 
 which decide us in any form of hernia. It may be mistaken for a 
 hydrocele of the round ligament, new growths in the labium, and for 
 hsematoma and abscess of the vulvo-vaginal glands. In both cases 
 the history, together with the position of the enlargement, its persistence 
 
 ' iV. Y. Med. Journ., Dec. 26, 1885. 
 
ni:i:.\/.i. 487 
 
 under niaiiipiilation, and tlic absence of llie nsnal siiriis <•(' iicniia, niav 
 he relied upon. I 'n(|iiesti()nal)ly, the Lli'eatest <lan<;ei-, as Tliomas jHtints 
 (lilt, is ill llirLictlini; llie possihihty of hernia in this position, and (h'aw- 
 in«;- dethietions withont eonsiderinj:,- it. The re.-iilt.- of siieli a ini-lal^f 
 niiiiht perhaps hi- (hsasti'ons. 
 
 Tiu ((hill III. — The treatiiieiit of tiiis hernia is e->eiitiall\' (hllieiih. 
 As in vaginal hernia, a |)essai'\ wuin in the va<iina may he siillieient 
 to retain the intestine in phiee, hut many ol»staeles stand in the wav 
 ot' siieeess. A truss ])ri)periy adjii.-ted, or a T l)an<la<re, niav he snfti- 
 eient. In every ease an eH'ort sliouhl he made to suj)])oi-t the hernia, 
 as it may become <ji:reatly enlarged, and j)ro(hiee serious trouble or 
 even death (Hotluen). There are, apparently, no eases of irreduei- 
 ble hernia ol" this class, thoutyh symptoms of straufrulation may (x-eur. 
 Taxis, aided by the knee-chest position, Avill probably cause the mass 
 to return in every case. There is little chance of a cure by radi- 
 cal operative measures ; as the exact situation of the neck of the sac 
 would be hard to determine, and would probably be too hi<rh to be 
 easily reached, except by laparotomy. Thomas's operation miiiht be 
 apjilicable to a case of this kind, should the symptoms warrant it. In 
 a case observed and described by Winckel,^ lie succeeded in holdinu; uj) 
 the hernia by first freshening the periphery of the surface over the rup- 
 ture for about 1.5 cm., and rein verting this portion by sutures. After 
 iniion had taken place the thinned and dilated skin was much thicker, 
 contracted, and more resistant ; and a carefully applied truss, Avhich 
 before was useless, now gave a good result. A truss made on the plan 
 of a T bandage, with an upright, holding a pad or cup-shaped sujiport, 
 would seem most likely to succeed. 
 
 4. Cystocele (Hernia of the Bladder). — This consists of a 
 prolapse of the anterior wall of the vagina, carrying with it the closely- 
 attached bladder. It is usually clue to some lesion of the pelvic floor 
 in childbirth.^ 
 
 5. Rectocele (Hernia of the Rectum). — This is a condition 
 affecting the posterior wall of the vagina and rectum, analogous to 
 cystocele.^ 
 
 n. Perineal Hernia (Perineocele). — Many writers describe a 
 form of hernia in which the intestines make their way first into Douglas's 
 cul-de-sac, and then force a passage through the ])erineum between the 
 vagina and rectum, a]>pearing as a tumor near the anus. In the male 
 such a hernia is doubtless possible ; but, after a careful examination of 
 all the accessilile literature on the subject, I am convinced, that in the 
 female, such a hernia is impossible and never existed. The testimony 
 
 » Pathol, d. Weibi Sex. Org., 1881, p. 282. 
 
 ^ For full description see article on the Vagina, Vol. II. 
 
 ' See articles on the Perineum, Vol. II. 
 
488 DISEASES OF THE VULVA. 
 
 of the older writers must be thrown out, as they did not sufficiently 
 distinguish a rectocele with ruptured perineum, cystocele, etc. Many 
 of the cases are too im23erfectly described, and some of them were not 
 true perineal hernia, but simply a prolapse of the intestine into Doug- 
 las's pouch. Pirogoff has described a case (see article on Anatomy) in 
 which this pouch descended to the floor of the pelvis, between the whole 
 length of the vagina and the rectum. Supposing such a condition, and 
 a displacement of the uterus toward the symphysis pubis so that the 
 entrance to the pouch is brought well forward, a prolapse of the intes- 
 tines might readily follow. But that the perineum could be penetrated 
 by the descending gut is hardly possible, considering its dense structure 
 and the soft and easily displaced vaginal and rectal walls, by which it 
 is confined before and behind. The point of least resistance would be 
 through the vulvar opening, displacing the vaginal wall and the peri- 
 neum before it. No modern authority, with whom I am familiar, has 
 seen and reported a case, and the later medical journals have been 
 searched in vain. The term "perineal hernia" has been applied to 
 the condition which is here described as pudendal hernia, and this is 
 one source of confusion and error. Since writing the above I have 
 had access to Winckel's splendid work on the pathology of the female 
 organs, and he takes much the same ground as is here taken against 
 the existence of such a rupture, and considers that it is certainly not 
 proved. 
 
 Prolapse of the intestine into an unusually deep Douglas's pouch is 
 very rare. It may give rise when it occurs to many disagreeable symp- 
 toms, such as fulness, constipation, and colicky pain. It may be easily 
 recognized by conjoint examination in the vagina and rectum. The 
 intestine is easily replaced, and may be kept in place by a retroversion 
 pessary — one with a large bulbous extremity best filling the space and 
 keeping the intestine in place. A patient wearing a pessary for such 
 a condition, should be cautioned against a possible strangulation by the 
 intestine slipping by the pessary and being unduly pressed upon. 
 
 Hydrocele (H. muliebris, Cyst of the Round Ligament). 
 
 These terms are applied to a collection of fluid in the canal of ISTuck. 
 The condition is a very rare one ; and until quite recently the literature 
 of the subject has been very scanty, Hart, Thomas, Wile, and Hennig 
 being among the first to draw attention to it. Many of the textbooks 
 are silent on the subject. About fifty cases in all have been so far 
 described. 
 
 The canal of Nuck is usually obliterated before birth, but occasion- 
 ally the whole or a part may remain open. If the whole is open, 
 affording a connection with the abdominal cavity, the result may be the 
 
csca]M' into it of some ol" tlu' :il)(l<iiiiiiial contents, citlicr intestinal or 
 Hniil. If only a |iail rmiains open, the opcniiiL; ;il tlir lan^; Ix'inu 
 closed, the niemWranc nia\' take on a secretorv action, resultinf; in the 
 i'orniation of a cy.-^l. The <'an>e ol" this condition i> little nndcr^tood. 
 Tniumatisni, {)re<;-nancy, and lahoV ha\-e hecn thonLiht in a few ea>c> to 
 luivo had some share in its prodnction, hnt in the niajoritv ol" ca,-(s no 
 cause lias l)een assiiiiied, "^riie llnid is usnally of a |)ale straw color, con- 
 taining albumen, salts, and e])ithelial cell>, and occasionally hlood, 
 Karoly, pus and o-as are found as the residt ol' inllannnation, or septic 
 inoculation of the cyst. 
 
 This disease lias been found in all periods of life, from two to seven- 
 ty-oni' years. It is rather more common on the ritrht side than on the 
 left, and in a few instances both sides have been affected. 
 
 S//iit])(oins. — The clinical history of the disease is very short. It 
 usnally lH>>;'ins as a painless swellinjj; in the neighborhood of the 
 external abdoniinal ring. This swelling grows slowly, and gives little 
 inconvenienee until it reaches considerable sizc.^ It may finally enlarge 
 to the size of a child's head, or may never exceed that of a marble. 
 Dyspareunia, sterility, and interference with locomotion, as well as 
 reflex nervous symptoms, may be the only results. In a few instances 
 inflammation has resulted either from surgical interference or from too 
 great expansion of the sac. Erysipelas has several times followed 
 operative procedures. 
 
 Diagnosis. — The diagnosis should not be difficult except in certain 
 complicated cases, and yet the mistake has frequently been made of 
 confounding it with a rupture, particularly with strangulated hernia. 
 The situation of the tumor, just below the abdominal ring, or in the 
 labium majus, if large, might lead to such a mistake ; but the history 
 of the case, its long duration (years in many cases), the fact that it can- 
 not be and never has been reducible, absence of impulse in coughing, 
 and, finally the light test, as in hydrocele in men, — may serve to dis- 
 tinguish it in unct)mplieated cases. The peculiar feel of water in a 
 tense sac, should serve as an aid to the experienced touch, and would 
 be quite different from that presented by intestine or omentum in a 
 hernial sac. In cases complicated by inflammation, where the cyst 
 contains pus or blood and gas, the diagnosis will be more difficult. It 
 is not to be forgotten also that a hydrocele and a hernia may coexist. 
 In doubtful cases puncture with an aspirator-needle is not only safe, l)ut 
 necessary for the establishment of a certain diagnosis. To distinguish 
 a bad case, with fever and vomiting, from strangulated hernia, the 
 absence of obstipation should be conclusive. To diagnose this disease 
 from cysts in other parts of the labia is difficult, but, fortunately, of 
 little practical moment, as the treatment would be the same in any ease. 
 
 ' See case of Dr. Baker, p. 535. 
 
490 DISEASES OF THE VULVA. 
 
 Treatment. — The treatment must be varied according to the case. If 
 the fluid can be returned to the abdominal cavity by taxis, this should be 
 done, and the pressure of a truss may then suffice to cause adhesive inflam- 
 mation, and obliteration of the sac. In case the fluid is encysted, simple 
 puncture may be enough to effect a cure, but usually something more is 
 required. If, after evacuation, an irritant is injected into the sac, inflam- 
 mation will be set up and a cure effected. For this purpose a few drops 
 of tincture of iodine or carbolic acid have been successfully used. In 
 other cases it has been found better to lay the whole sac open, pack it 
 with lint, and allow it to e-ranulate and heal from the bottom. In case 
 of suppuration of the sac, a free incision and packing with lint and iodo- 
 form, or some similar antiseptic, is certainly indicated. Hening cured 
 one case with an iron wire, carried through the cyst and left for some 
 time. After simple evacuation care should be taken not to manipulate 
 the parts too much, so as to set up inflammation and suppuration. Per- 
 fect rest for a day or two, with moderate pressure from a compress and 
 bandage, should be the after-treatment. In this disease, as in several 
 other affections of the vulva, the greatest danger, unquestionably, lies 
 in a wrong diagnosis and consequent improper treatment. 
 
 Vulvitis (Inflammation of the Vulva). 
 
 There are five forms of vulvitis described — viz. the simple, gonor- 
 rhoeal, follicular, diphtheritic, and phlegmonous. 
 
 Simple Vulvitis. — Acute catarrhal vulvitis, except in a very mild 
 form, is a rare disease in the adult ; among children it is quite com- 
 mon. Nearly all cases met with among women can be safely classed 
 under the head of specific disease. In a subacute or chronic form it is 
 more common. When acute and non-specific, it is generally confined 
 to the vulva alone, and does not involve the vagina. 
 
 The causes of the acute form are injuries and operations, awkward 
 and immoderate coitus, irritating discharges, and want of cleanliness. 
 
 The first symptoms are heat, burning, and moderate swelling of the 
 parts, with redness and pain, especially on motion. This is followed 
 by a free secretion of muco-pus, which continues for a time, with an 
 abatement of the symptoms. 
 
 The course of the disease is usually self-limited, but may run into 
 the chronic form. It has been asserted (Bedford) that this disease is 
 contagious ; but of this we have no proof, and, until we learn more cer- 
 tain ways of distinguishing this disease from gonorrhoea, we can neither 
 deny nor confirm the assertion. 
 
 The causes of the subacute form are different. Here we have the 
 irritating discharges from the vagina playing the most important part. 
 The discharge is often only slight, merely sufficient to spot or stain the 
 
VVLVITIS. 491 
 
 liiKMi, and is oltcn oi' a ycllowisli or nivonisli color, and of" a sti'ictlv 
 imicoid I'onsistciicv. 'I'lic iiuicoiis mcinliranc may he soiiicwliat swollen 
 and piiIlN , and, in lonL^-conlinncd <-a.--i's, nia\' l)ci-oiiic ulccratcfl. 1 )i;i- 
 iK'tos is also vi-ry conunonly a('coinj)anit'(l by vulvitis — so nuicli so that 
 its continuod presence should always lead to the examination ol' the 
 urine i'or snuar. It slmidd he remembered that dialx'tes may exist 
 without |)olyuiMa, and is olten met with about the time ot" the meno- 
 j)ause. The vulvitis oi" diabetes often presents a ))eculiar copj)erv-red 
 color (^W'inckel). .Vmmoniaeal ni'ine, when eoiul)ine<l \\\\\\ inconti- 
 nence or a vesico-va_<i'inal iistula, will also t!;reatly irritate the mucous 
 nuMubrane which is constantly l)atlied with it. ^^'ant of cleanliness, 
 es])ecially in very hot weather and in very lleshy persons, may ])roduce 
 the tlisease. Masturbation and excessive vcnery more oiten cause this 
 form than the other. AVhen not due to the state of the urine, this dis- 
 ease is comnionlv found in unmarried, and especially voung;, women 
 
 The symptoms are more or less burning and itching of the parts, 
 generally intermittent, worse one part of the day than another, and the 
 jiresenee of a discharge. The constant scratching may lead to the 
 establishment of the habit of masturbation. 
 
 Treatment. — The treatment of the acute form must consist, first, of 
 rest in bed until the acute symptoms have passed. General treatment 
 should be such as w-ould tend to reduce arterial tension and allay 
 excitement. For this purpose aconite and saline laxatives are indi- 
 cated, especially if there be any fever. Locally, soothing and emollient 
 applications, together with strict attention to cleanliness. The lead- 
 and-opium wash is very generally recommended and used. Frequent 
 ablutions from a fountain syringe of hot boric-acid solution, followed 
 by dusting the parts with oxide of zinc or iodoform, will be of great 
 service. All ointments made of lard or animal fats, unless containing 
 an antiseptic, should be withheld ; as, by decomjiosition of the fat, they 
 tend to increase the irritation. Vaseline thickened with wax, or lano- 
 lin, is a suitable base for ointments. After the acute stage is over, 
 astringent lotions, such as mild solutions of alum, or subacetate of lead, 
 or nitrate of silver, may be used. 
 
 In the subacute form great care should be taken to remove all irri- 
 tating discharges. If the urine is ammoniacal, it shoidd be rcndei'cd 
 acid by the use of benzoic acid (benzoate of amnion., gr. x, every four 
 hours). Hot douches to the vagina, and cotton balls introduced within 
 the vagina, to collect and keej) l>ack discharges, are also of great bene- 
 fit. For local applications nothing acts so quickly and beneficially, as 
 a solution of silver nitrate, ten grains to the ounce, brushed over the 
 l^uis every day or every other day. If this fails, a stronger solution 
 can be employed, or some other simple astringent used. It must be 
 
492 DISEASES OF THE VULVA. 
 
 borne in mind, however, that no permanent cure can be effected until 
 the irritating discharge is stopped at its point of origin. 
 
 Diphtheritic Vulvitis. — A careful search has brought to light 
 no recorded cases of simple primary diphtheria of the vulva in a non- 
 pregnant adult. If it ever occurs, it must be very rare. On the vulva 
 and vagina of children it is sometimes met with during epidemics. 
 Occurring in the course of an attack having its primary seat elsewhere, 
 or in the course of one of the exanthemata, it cannot be classed as a 
 distinct disease, but is rather an epiphenomenon. In puerperal women 
 during certain epidemics of puerperal fever, especially in large lying-in 
 hospitals, it makes up a considerable part of the local lesions, and is a 
 very dangerous complication. (The reader is referred to Dr. Lusk's 
 excellent paper on puerperal fever in Pepper's System of Medicine.) 
 
 GoNORRHCEAL VULVITIS. — As this is but a single factor in the his- 
 tory of a disease involving other parts as well, it will be considered 
 under the general title of Gonorrhoea. (See Diseases of the Vagina, 
 Vol. II.) 
 
 Follicular Vulvitis. — This form of inflammation affects the 
 sebaceous, sweat- and hair-follicles, which are so freely scattered over 
 the labia majora and minora. The mucous follicles of the vestibule, 
 as well as the glands of Bartholin, are not usually affected. The disease 
 is fortunately rare. In general diffuse inflammation of the parts the 
 structures named are affected, but in the disease now under considera- 
 tion they are the sole or principal part diseased. 
 
 Causes. — The causes are usually some irritating secretion from the 
 vagina, want of cleanliness, leaving the secretions between the folds 
 of the parts until they undergo decomposition and become irritating. 
 Pregnancy is often a predisposing cause. 
 
 Symjjtoms. — The symptoms are heat and burning, and above all itch- 
 ing, of the parts. The irritating character of the discharge from the 
 inflamed glands, as well as any previously existing discharge, makes an 
 irritated and sensitive condition of the surrounding surfaces. This is 
 increased by the constant scratching to relieve the itching. Secondary 
 results are painful micturition and dyspareunia. 
 
 Pathological Anatomy. — The affected glands become much enlarged 
 and noticeable, and the surface around them red and swollen. The 
 mouths of the glands are often stopped, the secretions are retained, 
 and suppuration takes place. The glands which are not stopped pour 
 forth a quantity of thick paste-like secretion, which in bad cases collects 
 and forms a thick layer in the folds and creases of the membranes, com- 
 pletely covering up the glands. 
 
 Prognosis. — When occurring during gestation, the disease may be a 
 serious complication, sometimes resulting in abortion. Fortunately, 
 in these cases it usually ends with the pregnancy. In other cases it 
 
vri.viTis. 403 
 
 iMMv run ;i Imiii- cniirsc, jxnHliially yielding; to trcatinciit ; or mav, if 
 lU'-^lcctt (I, oi' cNcii ill ~|>;tc of all that can be done, run on in tlic clii'onic 
 form. It may then Ixcoinc a really I'orniidahlc alTection, rendcrinj; tlio 
 patient nearly or (|iiite in-aiie iVoin the con-tant irritation, itehiiiu-, and 
 hurninii- *d' the parts. 
 
 Tnatijuiif. — In the acute iorm, cl(aiilincss is tlu' first rc(|ui>ite. If 
 there is nuieh vaginal discharge, this must be first relieved, or at least 
 kept from the parts, l)y pledo-ets of dry absorbent cotton pushed into 
 the mouth of the vaiiina and fmpiently ehan«2;ed, tog:ether with fre- 
 (pient vauinal injections, to wash away the discharge, as well as to cure 
 the vauinal disease on which the discharge depends. As local apjilica- 
 tions, hot sitz-baths (75° to 80° F.) and the frequent washing of the 
 parts with very hot solutions of borax, alum, or carbolic acid (1 : 40 or 
 stronger) may accomplish a good deal. In the more chronic forms, solu- 
 tions of nitrate of silver, 10-15 grains to the ounce, will be of great use. 
 Persulphate of iron in weak solution has been recommended. Oint- 
 ments, Avith vaseline, or vaseline and wax (oj to .5j) as a Ijase, may be used, 
 nuHlicated with subacetatc of lead, bismuth, oxide of zinc, salicylic acid, 
 or iodoform, and should be kept constantly smeared over the parts. In 
 very bad chronic cases, strong solutions of silver nitrate (.5j to ,5j) may be 
 used, after a thorough cleansing of the parts ^vith soap and Mater. In 
 extreme cases the removal of the entire mucous membrane affected, has 
 been resorted to. Great attention should be paid to the general health 
 and nutrition. Tonics, cod-liver oil, and similar preparations should 
 be used. The use of narcotics to quiet pain and produce sleep is 
 attcMided with great danger, from the tendency to rely u])on them, and 
 thus form a habit. Opium, in particular, and chloral should be Avitli- 
 held until the case is found to be hopeless. This applies as well to 
 ])ruritus, eczema, and other diseases attended with itching and con- 
 seijuent sleeplessness. 
 
 Phlegmonous Inflammation of the Vulva. — This consists in 
 an inflammation affecting the connective tissue of one or both labia. 
 It may follow a simple catarrhal inflammation, or be caused by mechan- 
 ical violence. Prostitutes are peculiarly liable to this disease, and all 
 the cases with which I have met have been among this class. After 
 lasting a Aveek or ten days the inflammation may subside, or it may 
 result earlier in suppuration. In this way deep abscesses may form, 
 and considerable sloughs come away. In other cases the disease seems 
 more closely allied to the furuncular process. Hildebrandt states, that 
 many deep abscesses opening on the vulva, have their origin in the 
 deeper parts of the pelvis, from parametritis, bone disease, and ulcer- 
 ative processes in the urethra and vagina. With this statement we are 
 unable to agree, never having seen any cases to bear out this view. 
 
 The treatment of simjile inflammation consists in hot fomentations, 
 
494 DISEASES OF THE VULVA. 
 
 lead-and-opium wash, and hot sitz-baths. Sulphide of calcium, in 
 small doses frequently repeated, has the reputation of warding olf sup- 
 puration in kindred affections, and will be worthy of trial here. If 
 matter forms, it should be let out by free incision as soon as possible. 
 The hypodermic injection of cocaine has served an excellent purpose in 
 my hands in deadening the pain of this little operation. 
 
 FuRUNCULOSis (Boils). 
 
 Boils on and around the vulva are not very uncommon. They often 
 depend on some constitutional condition, the exact nature of which is 
 not well understood. They sometimes originate in an inflammation of 
 the sebaceous or hair-follicles, and then closely resemble acne in the start. 
 They are distinguished from that affection by their size and number. 
 The irritation caused by the pulling out of a single hair may be the 
 starting-point. Poisonous secretions or discharges may also be the 
 exciting cause. When resulting from a general cause, they are apt to 
 be persistent ; occurring in successive crops, and lasting a long time. 
 Some will suppurate and discharge ; while others simply swell up, and 
 afterward gradually fade away, leaving a red indurated spot. 
 
 Their favorite seat is the outside of the labia ; but occasionally they 
 extend up on to the thigh, or over the mons Veneris, completely dot- 
 ting this with boils in various stages of gro^^'th and decadence. When 
 occurring singly, they sometimes infiltrate the surrounding tissues, mak- 
 ing a large abscess, which lasts for considerable time unless opened arti- 
 ficially. 
 
 Treatment. — This should be both general and local. The general 
 treatment should be of a restorative nature — tonics, cod-liver oil, and 
 especially the hypophosphites, which seem to have a controlling action 
 on the dyscrasia. The sulphides also are of benefit. As to local treat- 
 ment, the removal of all possible sources of irritation should be the 
 first thing. When the boil has really declared itself, early incision, 
 even before the formation of pus, will abort it. This can.be done 
 almost painlessly by the use of cocaine hypodermically. A rather free 
 incision should be made, and then followed by an antiseptic lotion on 
 a compress. In some cases it has been recommended to touch the cut 
 surfaces with carbolic acid and glycerin, equal parts, or nitrate of silver. 
 The object of this doubtless is to prevent absorption by the raw surfaces. 
 After pus has formed incision and poultices are indicated. 
 
 Ulceration and Fissure op the Vulva. 
 
 Specific Ulceratiox. — Hard and soft chancres are very common 
 among prostitutes. A consideration of these diseases is outside of the 
 scope of this work. 
 
fEDEMA OF Till-. VllA'A. A\)o 
 
 NoN-siM'.cMic rLCKii.VTloN iiltlic viilvji, cxccpt ill cliildlu'd, is ;i 
 ran' aflrcti" 111. It is (K'CJisi(»ii;illy in<l \\ itli, cspcciallv aiimiij^- j)rostitiit('s, 
 I'oriiiiiiL; -mall sensitive scjrt's artniixl the cut raiicc ol' the vajiiiia or on 
 tlic liviiicii. Ill poorly-noiirislicd wuiiicii a sli«ilit rupture (tf tlic pcri- 
 11(11111 will soiiictiiiu's result in a >iiiall ji'rauulatiiijz; surface ()!• nicer, very 
 tender and w itli sli<ilit tendeney tn lical. Tlic-c |)ccnliar ulcers are kept 
 up l)y till' tension of eieatrieial hands drauin^j;' on the parts with the 
 movements of the patieut, and uu»y be so sensitive as to cause <;reat 
 sufferinj;- and entirely prohibit intereourse, I have also seen ulceration 
 around the clitoris seemiugly dependent on a depressed state of the 
 "•eneral svstem. 
 
 Trvdiiiuiit. — As it is easy to give the parts perfect physiological rest, 
 the treatment of lissure of the introitus vaginae is comparatively easy. 
 By securing |)erfect rest, and by the application of iodoform, or mcjder- 
 ately strong solutions (10 to 30 grs. to 5j) of nitrate of silver, bismuth, 
 or oxide of zinc, the disease is generally quickly cured. In the case 
 of ulcers dei)ending on cicatrices fi-om a ruptured perineum, it may be 
 necessary to cut the bands which pull on the edges of the sore, and thus 
 give the parts rest. Usually com]ilete healing then rapidly ensues. 
 Severe ulceration sometimes occurs in the course of the continued fevers 
 anil in wasting disease. 
 
 CEdema of the Vulva. 
 
 Owing to the amount of loose connective tissue in and around the 
 vulva, these parts are frequently the seat of oedema. This may be 
 inflammatory in its origin, as in phlegmonous inflammation, or it may 
 be only a symptom. In the latter case, its cause must be looked for 
 either in some general condition, a disease of some distant organ, or in 
 a disease in the pelvis impeding the return eircnlation. Among the 
 general conditions causing oedema the commonest by all means is ]>reg- 
 naney. The distant (organs, disease of which gives rise to oedema in 
 this region, are the same as those causing oedema in other parts of the 
 body which are usually coincidently affected — viz. the kidneys, heart, 
 and liver, particularly the former. In the last stages of wasting dis- 
 ease it is not uncommonly met with, and is seen also in cancer of the 
 uterus and in chronic pelvic inflammations. Fibroid and ovarian 
 tumors, as well as diseases of the vagina, are sometimes, though 
 rarely, accompanied by oedema of the vuKa, the lower extremities 
 usually being affected at the same time. The swelling may become 
 so great as to materially interfere with the comfort of the patient. In 
 extreme ca.ses the circulation is so far affected that gangrene and septic 
 processes may follow'. 
 
 Treatment must, in the main, be directed to the general condition 
 
496 DISEASES OF THE VULVA. 
 
 causing the oedema. If extreme and causing suffering with danger of 
 sloughing, multiple punctures may become necessary to relieve the ten- 
 sion. This procedure is not, however, without danger ; as the parts are 
 prone to take on inflammatory action, the punctures being the starting- 
 points. If punctures are made, antiseptic washes must be freely used. 
 Carefully-graduated compression with a pad or an elastic T bandage 
 may be of service, combined with the recumbent posture. 
 
 Gangrene of the Vulva. 
 
 In the adult, gangrene is usually found as a result of labor with pre- 
 vious oedema, or of some mechanical violence. It may also result in 
 non-pregnant women as a consequence of oedema, thrombosis, or hsema- 
 toma. Several cases have been reported where, from the use of a tam- 
 pon wet in perchloride-of-iron solution, extreme sloughing of the vulva 
 and vao-ina has followed. It also occurs in the course of the exanthe- 
 mata, preceded usually by an inflammatory process. 
 
 In young children there is a form of gangrene which is held by 
 some ^ to be identical with noma and hospital gangrene. The disease, 
 according to this author, is contagious and iuoculable. It begins as a 
 whitish blister, which soon changes into an ulcer and grows rapidly, 
 the surface being covered with a soft gray or brownish membrane. It 
 resembles diphtheria in some respects, but can be distinguished from it. 
 The disease is local in its origin. The affected portion becomes gan- 
 grenous, and loss of substance takes place. The prognosis is bad, gen- 
 eral putrid infection usually taking place. 
 
 Treatment. — In the ordinary forms the principal point is to guard 
 against septicaemia. To this end all sloughing masses must be cut 
 away, care being taken not to cut living tissue more than is neces- 
 sary. Where fresh tissues are cut, the mouths of the vessels must be 
 sealed by the actual cautery, and free use of antiseptics resorted to. 
 In noma, iodoform is claimed to act as a specific ; chlorate of potas- 
 sium is also highly recommended. Internally, tonics and stimulants 
 must be freely used, and the strength maintained by abundant nour- 
 ishment. 
 
 Varicose Veins of the Vulva (Phlebectasia). 
 The veins of the vulva may be permanently dilated, sometimes form- 
 ing immense tumors or swellings. This affection is found at all ages', 
 though rarely among the young. It is usually related more or less 
 closely to pregnancy, but cases have been observed in women who had 
 never been pregnant. I have met with one such case. If antedating 
 pregnancy, it is always aggravated at that time. 
 
 ^ Damien Surjus, lliese de Lyon, 1882. 
 
JLKMATOMA, Oil TllROMni'S OF Till: VILVA. 497 
 
 ('(luxe. — A contrt'iiital <>r ac<|iiirt'(l thiniiiii<:- of tlic walls (iCllic vciii.s 
 must be supposed ; in addition to this an increase in the venons pres- 
 snre, due to obstruction of" the rctnrn circnlation. These conditions arc 
 ni(»st perfectly fnllilied in pre<inancy, and we find the disease more 
 <'onmion at that time. In the non-pregnant tlie same e<»ndition mav 
 be prcuhu'cd bv tumors, also bv (obstinate constipation with strainint:- at 
 st<tol ( WincUcI), Jjit'ting heavv weiulits, the constant maintenance ot" 
 the erect posture," may also have an influence in causing the diflicultv. 
 
 Syinptotns. — The symptoms are the presence of more or less swelling 
 of the external genitals. It is sometimes confined to the labia, or mav 
 atftH't the nymplue, the mons, and inside of tiie thighs as well. One or 
 both sides may be affected. Holden' saw a ease as large as a child's 
 head. The swelling is usually quite irregular in outline, and the tumor 
 is sofit and easily compressible, being much more prominent when the 
 patient is standing. There is often a great deal of heat and burning 
 in the parts, and sometimes obstinate pruritus. Rupture may take 
 place and the resulting hemorrhage be quickly fatal. The dangers 
 of rupture are increased during labor. If the rupture is confined to 
 the walls of the veins, and the skin remains intact, a hsematoma 
 Mill result. 
 
 Treatment. — Remedies directed to the condition of the veins Mill 
 accomplish little. Ergot, hamamelis, and other drugs, used both 
 externally and internally, have entirely failed in my hands. The 
 M'earing of a properly-constructed pad or supporter may diminish the 
 tendencv to groMth, and in one case under mv care certainlv gave great 
 relief. All attempts to tie the veins or to inject astringents into them 
 M'ould be certainly useless. If pregnancy should occur in a bad case, 
 abortion in the early months Mould seem to be fully justified. The 
 patient must be Marned of the danger of rupture and hemorrhage, and 
 told of the proper way of treating herself until she can obtain aid — 
 viz. by assuming the recumbent posture and making direct digital pres- 
 sure upon the bleeding point, or by a pad and T bandage firmly applied. 
 This treatment may be supplemented by the use of astringents, by com- 
 pression M'ith a pad outside against a firm tampon inside the vagina 
 and vulva ; or the parts may be compressed against the pubic bone. 
 If a large tear or rupture take place, such as might occur in labor, 
 bringing the parts together by deep sutures may be necessary. At all 
 times constipation, and consequent straining, must be avoided. 
 
 HEMATOMA, OR ThROMBUS OF THE VuLVA. 
 
 This may be defined to be an efftision of blood into the tissues of the 
 vulva from the rupture of a vessel beneath the surface. The vessel 
 
 > X Y. Med. Record, Julv, 1S68. 
 Vol. T.— 32 
 
498 DISEASES OF THE VULVA. 
 
 ruptured is usually a vein, as it is not at all likely that an artery of 
 any size could be ruptured in the soft tissues in which they are 
 imbedded. 
 
 The causes are external violence, such as a kick, blow, fall, or instru- 
 mental delivery ; and violent muscular eifort, as in labor, or straining at 
 stool. The predisposing causes are pregnancy and varicose veins, but 
 neither of these is necessary for the occurrence of rupture. 
 
 Symptoms. — When rupture takes place the tumor develops rapidly. 
 It may be quite small, or so large as to block up the vagina and 
 urethra ; and, if it occur during labor, it may be a barrier to the pas- 
 sage of the child. The seat is usually in the labia majora or in the parts 
 near the clitoris. Winckel mentions having seen the blood escape into 
 the remains of the hymen, forming a tumor as large as a bean or larger. 
 If the tumor is small, very little inconvenience will be produced, but 
 absorption will generally quickly take place. In the case of a large 
 tumor absorption may take place ; but there is more likelihood of sup- 
 puration and gangrene of the parts. The tumor then swells, becomes 
 hot, tender, and painful ; the skin assumes a bluish and purplish hue ; 
 and more or less constitutional disturbance ensues. Should the accident 
 happen near the end of pregnancy, the ensuing labor is apt to cause 
 either a renewal of the hemorrhage, or gangrene and sloughing of the 
 parts. It might be well, should a large swelling exist when labor 
 begins, to open it and turn out the clots. 
 
 Treatment. — For the lesser cases, little need be done except to protect 
 the swollen part from irritation. Should inflammation threaten, the 
 persistent application of cold by^ the ice-bag or rubber coil should then 
 be tried; should the symptoms not soon show an improvement, free 
 incision is indicated. It must not be forgotten that quite threatening 
 symptoms may be abated by treatment ; and, on the other hand, after 
 suppuration has once begun, the earlier the incision the better. When 
 incision is made all the clots should be turned out, ragged edges trimmed 
 off, and any sloughing tissues removed. Thorough irrigation of the 
 wound with an antiseptic solution should then be made, the surfaces 
 sprinkled with iodoform, and the cavity packed with gauze or cotton. 
 This may be repeated until the wound is healed. Should hemorrhage 
 occur after opening, it can be stopped by pressure, or the application of 
 alum or other astringent. (For further details of this subject the reader 
 is referred to works on obstetrics, to which it more properly belongs.) 
 
 Diseases of the Vulvo -Vaginal Gland. 
 
 It is surprising how little has been written in American literature 
 concerning the affections of these glands ; and yet Hildebrandt declares 
 them to be among the most common affections of the external genitals 
 
jjj^L'Ash'.'^ (jf rill-: vri.Vd-VM.iXM, <;lam). 49U 
 
 — ail (tj)iiiinii ill wliicli, as a|i|>lii:il)|c to a ci riaiii das.- dl' sncict\-, I can 
 a-ric". 
 
 CaTAKKII uF the Gl.AXns. — II\ ixTscrrctiiiii fioiii flic (flaiid is 
 rarely observed. Winekel .states, that lie lias seen tlie disease last iiir 
 iiidiitlis. 'i'lie duet is then dilatccl so that a sound can i)e {)assed, and 
 a viscid niiieus may lie i'orced out l)y pressure. It" the secretion is too 
 thick to tlow out, the mouth ol* the tilaiid may heeoine elosed and a 
 retention-cyst tbrnied. Kricli ' has reported some eases of" " paroxvsms 
 in the female resemblin*!; nocturnal eiiiissioiis in the male." 'i'liat this 
 does (K'cur 1 can also testify, havinji; met with a ease. 
 
 The treatment of" catarrh of" the glands is very unsatisfactory. I have 
 succeeded in dilating- the duct in one instance and injecting strong 
 solutions of" carbolic acid with benefit. In case nocturnal ])ol]utions 
 become excessive, so as to weaken the individual, af"ter the failure of 
 treatment calculated to restore the general health, Winekel has pro- 
 posed the extirpation of the gland. 
 
 Inflammation of the Duct. — The excretory duct is about 2 cm. 
 long, and opens just in front of the hymen or its remains, A fine proljc 
 can generally be made to enter it. This duct may become obstructed 
 by inspissation of the secretion (catarrh), but this generally occurs as the 
 result of an acute inflammation of the nuicous membrane in and around 
 the mouth of the duet. It may be obstructed also by venereal warts, 
 either in the duct or outside near its mouth. This inflammation may 
 be traumatic, but by all means the most common cause is gonorrhoeal 
 infection. As the result of the retention of the secretion, or of the 
 products of the inflammation, a tumor or cyst is formed, which gradu- 
 ally grows until sometimes it is as large as a hen's egg. This crowds 
 toward the middle line and obstructs the entrance of the vagina. Ac- 
 cording to Hildebrandt,^ as the distension goes on a point is finally 
 reached A\here, through the distension of the external tissues, the duct 
 is easilv opened; so that the secretions, generally pus, make their Avay 
 out, and the tumor collapses. As the conditions Avhich originally 
 caused the excessive secretion and occlusion still exist, the sac soon 
 fills again, with a like result. Sometimes an acute inflammation of 
 the superimposed and adjacent tissues is set up, attended with much 
 pain and annoyance to the patient. 
 
 Usually, the course of the disease is run in about a week. 
 
 Diagnosis. — The size and position of the swelling, just outside of the 
 vaginal entrance, its superficial seat, and perhaps the history of previous 
 swelling and collapse, with a discharge of mucus or pus, will serve to 
 distinguish it from inflammation and abscess of the gland proper. 
 
 Treatment. — The treatment should be begun with an effort to re- 
 
 ' Mnnihnd Me-l Joxrn., 1882, vol. ix. p. 348. 
 ^ Billroth'^ Handbuck d. Fraiwidrankheiten. 
 
500 DISEASES OF THE VULVA. 
 
 establish the natural opening of the clnct. This may be done by care- 
 fully probing the canal, and, once an opening is found, by dilating it 
 with graduated sounds. In searching for the opening to the duct it 
 must not be forgotten that there are two or more mucous follicles 
 opening in its immediate neighborhood, which may be mistaken for it. 
 If warts exist, they must be removed, and the associated gonorrhoea! 
 vaginitis cured. If it be found impossible to discover the duct, the 
 swelling may be opened and the contents evacuated. If it again fills, 
 a piece may be cut from the walls of the cyst with scissors, first lifting 
 the wall with a tenaculum, so as to make a permanent opening. The 
 cyst should be thoroughly irrigated, and a solution of silver nitrate 
 (3j— 5j) be injected ; or the cavity painted out with strong tincture of 
 iodine. I have found carbolic-acid solutions (1 : 20) serviceable in 
 mild cases. 
 
 IxFLAMMATiox OF THE Glaxd Peoper depends in the vast major- 
 ity of cases on an extension of a gonorrhoeal inflammation from the 
 vulva through the duct. In proof of this the gonococcus has been 
 found in the secretions from diseased glands. Inflammation may also 
 follow the introduction of other irritating vaginal discharges, such as 
 those from cancer, and also from traumatism. As a result of the inflam- 
 matory swelling of the mucous membrane the duct always becomes 
 closed. The inflammation almost invariably ends in suppuration 
 and the formation of an abscess. It is a more serious affection than 
 the one already described, in that it involves more tissue, makes a 
 much larger tumor, and produces more constitutional disturbance, 
 with fever. 
 
 Undoubtedly, many of the cases of so-called abscess of the gland 
 of Bartholin involve only the duct. If the abscess goes on uninter- 
 fered with, it ends with rupture, sometimes through several openings. 
 These leave fistulse, communicating with a common cavity and opening 
 on the surface of the labium majus. Before rupture takes place the 
 tumor is situated deeply in the lower part of the labium majus. It 
 can be felt, if small, by placing the index finger within the introitus 
 vaginae and the thumb outside of the labium. The tumor may reach 
 a very great size, with extensive inflammation of surrounding parts, 
 before rupture takes place. The inguinal glands of the affected side 
 are sometimes enlarged and tender. 
 
 Diagnosis. — The position of the tumor will serve to distinguish it 
 from most other diseases. The aifections with which it might be con- 
 founded are pudendal hernia, hydrocele, and other kinds of abscess. 
 From the first two, the history, together with the character of the 
 tumor, and the presence of inflammation and its symptoms, should 
 distinguish it. The different abscesses which are met Avith are either 
 traumatic in their origin, or result from the sujjpuration of a pre-exist- 
 
I)/sj:asi:s of 'riir: skix afff.ctisc tiif vflva. 501 
 
 in«i|; cyst or liii'iii;it(»iii;i. In all (Iwsc iii^taiiccs the historv will aid in 
 tlic (liajiiiosis. Alts'-csscs arniiiid tlic rcrtiiin may also closclv simulate 
 abscess ot" this nland. 'riicsc aiisccsscs al\\a\s rcsidt iVoiii fecial dis- 
 ease, such as ideei-ation, lissure, stricture, or hemorrhoids. The historv 
 of" such |)re-existiu<;- trouble, together with the result of" a rectal exam- 
 ination, will <;'euerally throw li;:.ht on the ease. I have seen several 
 siieh abscesses resulting- from stricture ol" the rectum, and in each case 
 there was a labio-i-ectal fistida. 
 
 Treatment. — This will depend on the stai^c of the disease. If seen 
 early and of a traumatic nature, leeches may be a])])lied. II" of a .-jx- 
 cific character, nothino- can be done to abort the attack, and we have 
 only to await su|)|)ni-ation, which can be ha.stcned by poultices. As 
 soon as the j)rcscnce of pus can be made out, a free incision should be 
 made on the inner side of the labium majus. The cavity nuist then be 
 irrij>;ated and washed out with the silver-nitrate solution, and packed 
 with iodoform cotton. This may be repeated several times, until the 
 cavity fills by granulation. If a recurrence takes place, a large piece 
 of the wall of the abscess should be cut out, and the cavity painted out 
 with some strong caustic, such as nitric acid. It is sometimes recom- 
 mended to extirpate the gland, a matter of no great difificulty. An 
 incision should be made over the gland, the whole enucleated, and 
 the fresh surfliccs brought together with deep sutures. Free incision 
 and caustics will suffice in almost all cases. 
 
 Diseases of the Skin affecting the Vulva. 
 
 Under this head will be considered those diseases affecting the vulva 
 Avhich are commonly included among the diseases of the skin. 
 
 Alopecia. — The hair on the external genitals is generally lost after 
 each labor; but the loss and the reproduction are so gradual, being sim- 
 ultaneous, that the fact is not generally noticed. In certain diseases 
 in which there is a great lowering of the general system, the wa.sting 
 aifecting particularly the genitals, the growth of the hair is interfered 
 with, and it may be entirely lost. This occurs sometimes in cancer of 
 the uterus, especially in old women. Premature and senile baldness, 
 which so commonly affects the scalp, is rarely seen affecting the pubic 
 hair. 
 
 Alopecia areata, the nature of Avhich is not well understood, though 
 many consider it as parasitic, sometimes affects the whole body or 
 certain circumscribed areas, one of which may include more or less 
 of the external genitals. As the presence or absence of hair on the 
 pubes is of little consequence, no treatment directed to this region is 
 necessary. 
 
502 DISEASES OF THE VULVA. 
 
 Inversion of the Haie of the Labia (Trichiasis). — Meigs ^ has 
 described two cases where strong stiif hairs, found on the edges of the 
 labia, were turned in, as they sometimes are on the eyeHds. This condi- 
 tion provoked considerable irritation and led to intense pruritus. Such 
 conditions are rare, and would be apt to be overlooked. Removal of 
 the oifending hair and the destruction of the follicles by electrolysis 
 would be the only and a most effectual treatment. 
 
 Herpes vulvaris (iJ. pudendalis). — This affection is not very 
 common, and is chiefly met with in young women and among the 
 unchaste. Greenough considers that gonorrhoea and the venereal dis- 
 eases are predisposing causes. There is certainly an individual pre- 
 disposition without assignable cause, which shows itself by repeated 
 attacks. The parts usually affected are the labia majora, and occasion- 
 ally the nymphge and the skin around the vulva. It generally causes 
 very little pain or sensation of any kind, but it may begin with burn- 
 ing and itching, and even rarely with severe neuralgic pain. There 
 are in the beginning vesicles, singly or in groups, on a slightly red- 
 dened base. The contents of the vesicles soon become turbid, and 
 crusts form, so that at the end of two days only scales or scabs can 
 be found. There may be one or more groups of vesicles, usually not 
 more than two or three, rarely ten or fifteen. The scales or crusts may 
 come off and leave a slight ulcer. The course of the disease is usually 
 about a week ; but often one crop of vesicles is succeeded by another, 
 so that the whole course of the affection may be extended over a num- 
 ber of weeks. If there is much itching, the consequent scratching may 
 result in excoriations, or even large deep ulcers. 
 
 Diagnosis. — Great care must be taken not to confound this simple 
 disease with true venereal ulcers. The diagnosis can usually be made 
 by watching the case, and observing the formation of new lesions, and 
 the rapid and complete disappearance of the old under simple treat- 
 ment. For this reason all caustics, which might make indurations, are 
 to be withheld, and simple ointments used, which will not obscure the 
 course of the disease. If under this plan of treatment the ulceration 
 grows larger and suppuration takes the place of the watery discharge, 
 the specific nature of the ulcer will be manifest. 
 
 Treatment. — It is advised by some authorities to withhold water in 
 any form as an application to the affected parts. Ointments of borax, 
 or boric acid, or oxide of zinc, or lead may be used with benefit. Duhr- 
 ing recommends borated cotton as a dressing. A large pad can be 
 worn and kept in place by a bandage. Dusting with talc, calomel, 
 bismuth, or starch may prove efficacious. A gouty or lithsemic con- 
 dition of the system sometimes accompanies herpes, and perhaps stands 
 
 1 C. D. Meigs, Am. Jown. of Med. Scl, 1862, xliii. 328. 
 
DISEASES OF THE SKl.X AFFECTiyO TlIF VULVA. OCJ^ 
 
 ii) the rchitioM ot" caiix' and ctlfct. Miilicatioii (liiLftod tu its rclicl' is 
 certainly indit-atcd if it is found to exist. 
 
 I'uiUKJo. — This alVcftion, <ii'iu'rally callfd liciien by Jiritisli writers, 
 is a j)aj)idar disease, whicli sometimes attacks the jrenitals in connection 
 with its aj)|)earance on other parts of the hody. As it is cliaracterized 
 hy i:;reat itching-, its aj)]K'arance is apt to be much altered by the fre- 
 quent scratchinir; jind a diaijnosis can best be made by examinintr 
 other parts of the body where the eru})tion remains unchanged, as 
 advisetl by ]Mr. Tait. 
 
 The treatment rec<)inni('ndcd is diy ])owd('rintj with bismuth and 
 similar sul)stances, or bathing with strong solutions of carbolic acid. 
 Careful attention should be paid to the patient's general health. The 
 disease is very difficult to cure and runs a long course. 
 
 Erythema. — The outside of the labia and the contiguous parts of 
 the thigh, as well as the cleft between the nates, are often affected by 
 this disease, especially in hot weather. It is brought on by exercise, 
 want of cleanliness, and irritating discharges, and is sometimes so great 
 an annoyance as to compel almost complete abstention from walking. 
 A case under my care has resisted almost every treatment, and has 
 experienced really severe suffering. It is commonly met with in fat 
 people, but a peculiarly thin and sensitive skin seems to be a pre- 
 requisite. The affected parts become red, irritated, and even raw. 
 They are ver\' sensitive, and the movement of one surface on another 
 causes considerable pain. 
 
 Treatment. — As, in these cases, there is generally a tendency to sub- 
 oxidation, the condition of the urine should be carefully examined, and 
 the lithaemic condition, if present, removed by alkalies, careful diet, and 
 exercise. Locally, dr^'ing powders afford much relief. Bismuth and 
 boric acid, one part to ten, and powdered talc, are among the best. 
 
 Eczema may be either acute or chronic. 
 
 Acute Eczema. — The manifestations of this disease on the vulva do 
 not differ much from those on other parts of the body ; it is a compar- 
 atively rare affection. Its causes are obscure, but it is sometimes 
 de])endent on uterine or ovarian disease, leucorrhceal discharges, and 
 diabetes. The parts attacked may be the labia or mons, and the 
 process may even extend into the vagina. The labia become swollen 
 and red; vesicles appear, which soon break and leave a raw surface, 
 from which a thick, gluey fluid is freely secreted. This discharge 
 stiffens on the clothing when dry, and forms crusts over the affected 
 part. Op])osing surfaces are often glued together. The symptoms are 
 burning and itching, sometimes of the most agonizing character. The 
 
504 DISEASES OF THE VULVA. 
 
 disease may begin as an acute affection ; but, if not removed by treat- 
 ment, it tends to become chronic. 
 
 Chronic Eczema. — This form of the disease may be subacute from the 
 start, or may result from an acute attack. The parts usually affected 
 are the crease between the labia majora and minora and the mons. 
 We find a red, slightly raised surface ; the color varying from light to 
 dark red, and fading imperceptibly into the surrounding skin. The 
 portion attacked may be quite small, or extend over a considerable sur- 
 face. Sometimes the skin is covered with scales ; and there may be 
 deep excoriations and small crusts, due to scratches. The surface may 
 exude small quantities of clear watery fluid. The symptoms of this 
 form do not differ much from those of the acute disease. There is 
 usually a burning and itching, worse at different parts of the day, and 
 a feeling of stiffness in the parts. The disease is very rebellious to 
 treatment, and when cured in one place often moves to another. 
 Sometimes it responds quickly to treatment, and recurs again with 
 equal promptitude. 
 
 Treatment. — For the acute form the black wash is highly recom- 
 mended, together with oxide-of-zinc or calomel ointment. Carbolic- 
 acid ointment (1 : 60) is also of value. The crusts, if formed, must 
 be all removed by poultices and the parts kept perfectly clean. For 
 this purpose water should not be used, but oil or vaseline on absorb- 
 ent cotton or lint. 
 
 In the chronic form great relief to the itching may be derived from 
 the application of very hot water on a sponge, followed by carbolic- 
 acid ointment. I recently cured a most persistent case with borax and 
 glycerin. The tarry preparations, such as oil of cade made into an 
 ointment, will be found beneficial ; and painting the parts with very 
 strona: solutions of silvei* nitrate or tincture of iodine once in four or 
 five days does good. 
 
 Erysipelas. — When confined to the vulva this disease does not 
 differ from the same affection found elsewhere on the body. It is not 
 uncommon in children, especially infants, and is said to be common in 
 women subject to discharges from the vagina of an irritating character 
 (Hildebrandt), as in vesico-vaginal fistula. The treatment is to be car- 
 ried out on the same general principles as when other parts are affected. 
 
 Pityriasis versicolor. — This disease is due to the gro^vth of a 
 vegetable parasite {Microsporon furfur). It is characterized by irreg- 
 ular spots or blotches, of a yellowish color, slightly raised above the 
 surface. Sometimes the spots are of a brownish, dirty color. It may 
 be distributed over large areas or confined to the mons and vulva, 
 extendino- more or less on to the abdomen and thighs. It often causes 
 
disi:asi-:s of the sk/x affkctisc tiif vii.va. 505 
 
 ^rciit anxiety, as do most diseases on the skin of tlie vulva, on aeeonnt 
 of a suspicion ot" its speeilie nature, and is n(»t uiil"re(|uently mistaken 
 for sonietliing of tliis kind. If there is any douht, a niieroscoj)ic 
 examination of the serapings from affected spot.s will set it at rest. 
 Trcdf incut. — This consists simply in the ap])lication of a jiarasitieide. 
 For this purpose corrosive sublimate will he found efficient in solution 
 of 2 to o grains to the ounce. Solutions of hyposulphite of soda, car- 
 bolic acid, and tincture of iodine will also answci-. Fi-e(pient washinjrs 
 with stron»5 soap will render the action of the a])j)lications more certain. 
 Great attention to cleanliness is necessary in all cases. 
 
 Scabies, — This affection seldom occurs on the genitals, but the pos- 
 sibility of such an event must not be forgotten, as an accurate diagnosis 
 is essential to success in treatment. A careful examination of the hands 
 will serve to make the diagnosis complete. The usual sulphur treatment 
 is quite applicable. As it may complicate other forms of skin disease, 
 or even cause them, the possibility of its occurrence should always be 
 borne in mind. 
 
 Pediculus pubis. — The crab-louse is a not infrequent inhabitant 
 of the mons and adjacent parts. In the earlier stages of its occupancy 
 the only symptom is itching, so that the presence of this symptom, 
 without other good reason, should always lead to an examination, when 
 the presence of the intruder can be made out. The cause is almost 
 always direct transference from body to body, usually at the time of 
 sexual intercourse. Cases have been reported where the method of 
 transference was inexplicable. The amount of local disturbance varies 
 with the individual and the length of time the parasites have been 
 present. When an eruption exists it usually resembles an eczema. 
 The animal is to be found closely adherent to the roots of the hairs. 
 The excrement and ova can also occasionally be seen. 
 
 Treatment. — The object is to destroy the parasite. This can be done 
 with a mercurial ointment or wath some liquid preparation. Tincture 
 of del]ihinium has long and justly enjoyed a great rc])utation. A solu- 
 tion t)f carbolic acid (5 per cent.) and corrosive sublimate (1 : 1000) will 
 also act efficiently. It has been recommended (Tait) to begin the treat- 
 ment of most of the eruptions around the vulva with carbolic-acid 
 lotion, in order to remove the possibility of this complication — a sug- 
 gestion which can be well carried out, especially in the lower walks of 
 life and in dispensary practice. 
 
 Pruritus vuly^. — A large number of the eruptive and inflam- 
 matory diseases of the vulva are attended with more or less marked 
 itching and burning. In the disease under consideration this symp- 
 
506 DISEASES OF THE VULVA. 
 
 torn exists, but without apparent anatomical lesion, at the seat of the 
 itching, as its cause. 
 
 Cause. — There are several varieties of the aifection, dependent on 
 the cause. Unquestionably, one of the most common forms is that 
 due to an irritating discharge. The discharge may be either urine, or 
 abnormal vaginal, uterine, or urethral secretions. So commonly is this 
 symptom found in diabetes that an otherwise unexplained pruritus 
 should always lead to an examination of the urine for sugar. The 
 vaginal discharge may be profuse and noticeable, attracting the patient's 
 attention at once, or it may be so small in amount as to have entirely 
 escaped notice. The discharge may have its origin either in vaginitis, 
 endometritis, cancer, or other growth. Before the menopause attacks 
 of leucorrhoea of uterine origin, attended by pruritus, are not uncom- 
 mon, and are generally transient, being easily relieved by treatment 
 or soon passing ofP if left alone. After the menopause these transient 
 attacks are more seldom met with, and the condition, once established, 
 is apt to remain indefinitely as senile catarrh. These cases aiFord the 
 most rebellious examples of pruritus. It must not be supposed that 
 endometritis and vaginitis alone can be the source of the irritating dis- 
 charge. It may come from the urethra as the result of a urethritis, 
 from Skene's glands in the urethra, from the vulvo-vaginal glands, or 
 even from the mucous follicles. These facts must not be overlooked 
 in searching for the cause. 
 
 Another form of the trouble is that due to purely neurotic influences. 
 These cases are met with most commonly during pregnancy, and the 
 itching sometimes extends from the vulva over the abdominal walls, so 
 as to involve nearly the whole body. It has been thought to explain 
 these cases, by supposing that the irritation is spread by direct inocula- 
 tion with secretions from the finger-nails of the patient. This, how- 
 ever, will not explain all the cases, nor is this supposition necessary, as 
 dermatologists admit a pruritus of neurotic origin. 
 
 Still a third class is described, where the itching is attributed to the 
 presence of parasites. These may be the ordinary pin-worms which 
 so commonly affect the rectum. They have been asserted to act in 
 two ways — either by reflex action or by direct contact through migra- 
 tion into the vagina. The latter mode may occasionally occur in very 
 young children, but the writer has never seen anything of the kind in 
 adults, and doubts its possibility. If the worms do get into the vagina, 
 the only way they could act on the vulva would be by means of a dis- 
 charge, induced by their presence in the vagina. Vegetable parasites 
 have been asserted to grow in the secretions and to be the cause of the 
 pruritus. The Leptothrix vaginalis and Oldium albicans are the varie- 
 ties described, the latter being considered the most important in its 
 eifects. 
 
vjsi:asj:s of the skis AriKcnsa Tin: vriVA. 007 
 
 It must n(»t 1)0 f()r<i(»tt('ii t!i:it many of" the diseases <»!' the vulva 
 alreatlv (lesei'ihed have as a prdiiiiiieiil >\iii|)t(iiii weli-mai'ked |)niritiis. 
 
 Si/iiijitoiiiK. — The |)riiii:ir\' >\ iiipldiii i- an itrliin^ on the -iirliicc ut' 
 the vulva. It may lie ei>nliiied to a limited area oi' e.\teu<l oNcr all 
 the external <>i'«:aiis. A common seat is hetweeii the labia minoi'a 
 and majora, also nu the inner surliiees of the laliia majoi-n. The jirri- 
 neum may he a Heeled, and the itehinj;' extend to the j)arts ai'onnd the 
 amis. The .siMisation is ol"ten desei'ihed as an itehinu' or hurnin^'-, w ith 
 an almo-t nneontrollalilc desire to scratch and tear the pai'ts I'or the 
 |)nri)(»se ot" *iainint;- reliei". The trouble is not <i'enerally constant, 
 thouii'h in some ea.ses it is so. It is more commonly intermittent, the 
 remissions varying from hours to days or weeks. In some cases it 
 eomes on at niuht after iictting into bed. This is ])articidar]y true of 
 the neurotic form. In other eases it is worse in the early morning or 
 some particular part of the day. Again, it will only be i'elt when the 
 menstrual jieriod is approaching or just after its close. After the dis- 
 ease has lasted for some time the parts either become thickened and 
 leathery from constant rubbing, or they become covered with fun-ows 
 and ulcerati(His from the use of the finger-nails. These furrows, being 
 raw or covered with crusts, greatly resemble an eruption. In fact, an 
 eczema may be thus induced and complicate the original malady. 
 
 Treatment. — The first step, in the institution of a rational treatment, 
 is to find the cause and nature of the disease. If it be parasitic in its 
 origin, the parasites must be removed. For ])in-worms nothing is bet- 
 ter than quassia infusion. The treatment must be directed both to the 
 vagina and the rectum, the original source of the worms. For the veg- 
 etable parasites solutions of carbolic acid or sulphate of zinc will .-uffice. 
 If the symptom is due to any of the eruptions, or local inflammatory 
 affections found on the vulva, treatment for these particular conditions 
 must be employed. If none of these conditions exist, a careful search 
 nnist be made for an irritating discharge. This may be so evident as 
 to attract the patient's attention and be by her recognized as the cause ; 
 but, again, it may be so slight as to escape entirely her observation as 
 well as that of a careless investigator. In order to determine the 
 causative relation of a suspected vaginal or uterine discharge, we may 
 first carefully clean out the vagina by an injection of hot water and 
 borax, and then lightly pack the vagina with dry salicylated or boratcd 
 abs(,)rbent cotton. This will hold back the discharge, and in proportion 
 to the relief afforded by the packing will the causative influence of the 
 discharge be known. Having once determined the influence of the dis- 
 charge, proper means may be taken to relieve it by aj)propriate treat- 
 ment, directed to the vagina, cervix, endometrium, etc. In my hands 
 the plan of ]iacking with dry cotton or simply placing a large A\"ad of 
 drv absorbent cotton within the mouth of the vau'ina — somethini:: which 
 
508 DISEASES OF THE VULVA. 
 
 the patient soon learns to do for herself — has often served to afford 
 immediate relief, while treatment was being directed to the removal of 
 the cause. 
 
 For the alleviation of the symptoms many things have been recom- 
 mended. Very hot water, applied directly to the parts with a large 
 sponge, often aifords great relief. The water may be medicated with 
 borax, boric acid, soda, tobacco (|ss-Oj), lead, carbolic acid (.5j-§iv), 
 zinc sulpho-carbolate (3ij-5iv), tincture of opium, etc. The following 
 are a few formulae which have been found useful, and are taken mostly 
 from Goodell : 
 
 I^. Acidi acetici, f|j ; 
 
 Glycerini, f^iij- 
 
 M. et Sig. Apply locally. 
 
 ^. Acidi carbolici, gr. xij ; 
 
 Morphinae acetatis, gr. viij ; 
 
 Acidi hydrocyan. dil. f^ij ; 
 
 Glycerini, f §j ; 
 
 Aquam, ad f^iv. 
 
 M. et Sig. Apply locally. 
 
 ^. Chloralis, 
 
 Camphorse, da §ss. 
 
 Misce, et adde — 
 
 Unguenti, |j ; 
 
 Acidi borici, .5ss. 
 
 M. et Sig. Apply with a brush. 
 
 !^. Potassii cyanidi, gi'-j~iyj 
 
 Liq. calcis, ' fgiv ; 
 
 Adipis, Siv. 
 
 M. et Sig. Apply locally. 
 
 Many similar formulse Avill be found scattered through the textbooks, 
 but these have proved more or less useful in the writer's hands, and 
 can therefore be recommended. 
 
 In the purely neurotic form, remedies directed to the general nervous 
 system, as well as local sedatives, may be of benefit. Among those 
 most likely to do good are the bromides and zinc. 
 
 In diabetes cleanliness is of the utmost importance, and every drop 
 of urine should be washed away from the vulva as soon as it is passed. 
 Thomas advises, in order to keep it from touching the parts, the regular 
 use of the catheter. In pregnancy the condition of the cervix and vagina 
 must be carefully investigated, and local treatment used if necessary, 
 as has been found quite safe. In the gouty diathesis which will not 
 uncommonly be found complicating these cases, especially where there 
 
SERPfdiyors vasci-laj: DrjiKyKiiArioy. 509 
 
 is an tH'Zcnia, tlic iitiiiost care iniist l)c taken witli the diet. All sweets, 
 pastry, and i-icli and nndit;('stil)Ie t'ttdd nnist Ix- av<tide<l, and the patient 
 ur«;etl to taUe plenty ol" exercise ont of" dooi's. A re.-oit to the alkaline 
 mineral watiTs and hot snlphnr haths will oiten do <;(»od. It is not to 
 he (orootten that the p>nty diathesis is j)artienlarlv eoninion in this 
 eoinitry anion«i- women, and is es|)ecially apt to show itself ai)()iit the 
 time of the menopanse. As a local a|»plication eocaino, cither as an 
 uintnient with huiolin or vaseline, or sprayed on in watery solntion, 
 sometimes affords relief. The solution must be strong, and even then 
 the effeet soon passes off. Its use in my hands has been unsatisfaetory. 
 
 Serpiginous Vascular Degeneration. 
 
 This is an affection described by Mr. Lawson Tait,' which consists 
 of a progressive atroj)hy of the mucous membrane covering the inner 
 surfaces of the nymplue. It occurs only at or after the climacteric, 
 and is a very distressing and intractable complaint. The symptoms 
 are dyspareunia, or total suspension of marital intercourse, from the 
 intense ]>ain produced by the act ; also a slight yellowish discharge 
 and scalding on passing water. Inspection will show one or tAvo spots 
 of redness on the mucous surface of the nymphae, varying in cohjr 
 from a pale brick-red to a bright ]>ur]ile. The spots are exquisitely 
 sensitive to pressure. If watched for a long time, these spots will be 
 seen to disappear from one ])lace and to appear in another, or the dis- 
 ease extends serpiginously, disappearing from the old site as it pro- 
 gresses toward the new. The course is very slow, lasting for years, 
 for it seldom stops until it has passed over the Avhole mucous surface 
 of the nymphfe. During its progress the vestibule slowly contracts 
 until the introitus vaginae is so small as scarcely to admit a finger. 
 
 Microscopically, Mr. Tait has found that all the textures are re- 
 moved, except a few fibres of connective tissue ; the walls of the caj)il- 
 laries are left thin and dilated, while the nerve-filaments are almost 
 unprotected, thus explaining the chief clinical features of pain, vascu- 
 larity, and later contraction. Finally, the nerves and vessels disajijiear 
 and the pain and redness subside, leaving only a cicatricial contraction. 
 
 The prognosis is good as to ultimate relief from suffering, but the 
 chronic course of the disease, extending over years, and the residting 
 contraction, should be explained to the patient. 
 
 The treatment advised is to touch the parts with strong carbolic 
 acid. This gives temporary relief. Applications of a plug of cotton 
 soaked in a saturated solntion of neutral acetate of lead in glycerin, 
 placed betAveen the nymphae at bedtime, is also useful. A pledget of 
 dry cotton inserted between the affected parts is also advised to give 
 
 ^ Diseases of Women, p. 43, 1877. 
 
510 DISEASES OF THE VULVA. 
 
 relief in walking. Any existing uterine or vaginal disease producing 
 an irritating discharge should receive attention. 
 
 I have never met with any cases of this disease, and am unacquainted 
 with any references to it in American medical literature. Mr. Tait 
 thinks it is often overlooked, and that many cases of so-called vagi- 
 nismus are due to its presence. 
 
 Hyperesthesia of the Vulva. 
 
 This condition of the vulva was first described by Thomas,^ and cer- 
 tainly deserves general recognition. In describing it I shall follow 
 closely the excellent account given by Dr. Thomas. 
 
 It consists of an excessive sensibility of the nerves supplying the 
 mucous membrane of some portion of the vulva. The area of tender- 
 ness may be confined to the vestibule, to one labium majus, or to the 
 meatus urinarius. The whole surface of the vulva except the outside 
 of the labia majora may be affected, as the writer has once seen. The 
 disease is fortunately not very frequent, though in this country it is 
 certainly much more common than the disease described by Mr. Tait 
 (see previous page). It seems not to be a true neuralgia, but an abnor- 
 mal sensitiveness in the sensory nerves supplying the parts. There is 
 no inflammation, but perhaps a few spots of erythematous redness here 
 and there. 
 
 Cause. — It occurs most commonly at or about the menopause, and is 
 predisposed by hysterical and hypochondriacal states. As exciting 
 causes chronic vulvitis and irritable urethral tumors may exist, but 
 in other cases no cause whatever is to be found. 
 
 Symptoms. — The principal symptom is pain on sexual intercourse. 
 Any friction, even a cold or unexpected current of air, produces dis- 
 comfort, while pressure is absolutely intolerable. Walking becomes 
 difficult and the general health suifers. The mind is disproportion- 
 ately disturbed and depressed. " In some cases it seems to absorb all 
 the thoughts, and to produce a state bordering upon monomania." 
 
 Diagnosis. — It must be distinguished from the serpiginous degenera- 
 tion of Tait, Avhich it closely resembles, except in pathology and ulti- 
 mate result; also from vaginismus and irritable urethral tiunor. 
 Neuroma may also produce similar symptoms. 
 
 Treatment — The treatment is in the main unsatisfactor5^ Thomas 
 declares that he has not succeeded in relieving a single case. In one 
 case, which I had the opportunity of seeing with Dr. Thomas, he 
 dissected off nearly all the mucous membrane from the vulva, with 
 only temporary relief Sims has done the same operation without suc- 
 cess. Thomas recommends change of scene and surroundings, separa- 
 
 ^ Diseases of Women, p. 145, 1880. 
 
s^As^f or riii: mi'sclks of the pklvic ii.ooii. -^w 
 
 tion IVoiii the IiiisIkiikI, witli the use <if all agents to rotttcc the ^(•iici-al 
 health; all local pelvic disease is to he cured, and tiic ailected j)arts to he 
 iVe(|iieiitly hatlied with warm water and sedative siihstaiu'cs applied in 
 the I'orni of ointments. Amonii' such suhstanees niav he mentioned car- 
 holii' aeid, cocaine, chloi-oloini, iudoiunn, bismuth, and evanitle of 
 potassium. 
 
 Spasm op the Muscles of the Pelvic Floor. 
 
 Any or all of the muscles <i-oin<r to make up the pelvic floor may 
 become spasmodically contracted. These spasms are manifested most 
 eommonly diu'ing coitus, or during an attempt at it, but in some of the 
 nuiscles — the sphincter ani, for example — the spasm occurs at other 
 times. To a spasm affecting particularly the constrictor vaginae nuis- 
 cles we give the name of " vaginismus ;" when the deeper muscles, 
 especially the levator ani, are affected, the name of vaginismus superior 
 has been applied. As these affections seem to be different, though 
 closely related, they Mill be described under different heads- 
 
 YAGixiSirrs. — The name " vaginismus " was first given by Sims 
 (1861) to a spasm of the constrictor vaginae muscles, manifested par- 
 ticularly on an attempt at intercourse. Huguier (1834) was perhaps 
 the first to describe spasmodic contraction of these muscles. Kiwisch 
 called it spasmus vaginae, while Simpson described (1859) the same 
 thing under the name of vaginodvnia. The exact definition o-iven bv 
 Sims is, " an excessive hyperaesthesia of the hymen and vulvar outlet, 
 associated with such involuntar}- spasmodic contraction of the sphincter 
 vaginae muscle as to prevent coition." 
 
 Cause. — About fcM' diseases of women has there been more differences 
 of opinion than about this. It is now quite evident that there are sev- 
 eral classes of cases, differing in their nature and cause. In one class 
 the cause is to be found in some pathological lesion in or about the 
 vulvar outlet ; in another class the seat of the irritation causing the 
 reflex spasm of the muscle is found to be in distant organs, as in the 
 uterus, ovaries, or rectum ; while in a third class no lesion can be found, 
 but we must look for the cause solely in the nervous system. 
 
 In the first class undoubtedly the lesion, found usually in the hymen, 
 is most commonly induced by repeated and unsuccessful attempts at 
 coitus. The cause of the fiiilure may be the awkwardness of the hus- 
 band, through which he presses the penis in the wrong direction ; but it 
 may be, and most commonly is, found in some partial obstacle on the 
 part, of the woman. This may be a rigid and resisting hymen, an 
 unusually small vulvar orifice, or a relative disproportion between the 
 male and female organs. Again, the difficulty may be found, as Schroe- 
 
512 DISEASES OF THE VULVA. 
 
 der has pointed out, iu the fact that the vulva is placed too high on the 
 pubes, so that the space between the under edge of the symphysis pubis 
 and the fourchette is so narrow that there is hardly room for the male 
 member. In this case the penis either presses into the fossa navicularis, 
 or more commonly impinges on the parts around the meatus and presses 
 them against the bone, and may even dilate the urethra so as to admit 
 of entrance there. Whatever the hinderance, the frequent unsuccessful 
 attempts at intercourse, long continued and forcible, gradually induce a 
 sensitiveness and soreness of the parts, sometimes accompanied by 
 excoriations, as the writer has several times seen — sometimes by sim- 
 ple hyper£esthetic spots, so that the woman suffers extremely at each 
 attempt. Following a law which exists in other parts of the body, 
 the muscles surrounding the aifected tender parts take on a con- 
 dition of reflex spasm, and the condition of vaginismus is fully 
 established. 
 
 In the second class we put cases dependent on what might be called 
 accidental and concomitant lesions. These are uterine disease, such as 
 displacements, endometritis, and lacerated cervix ; a prolapsed and tender 
 ovary ; vaginitis ; disease of the rectum, as piles, fissure and pin-worms ; 
 other diseases of the vulva, as fissure, herpes, eczema, and \'nlvitis. 
 These cases are distinguished from those of the first class by the fact 
 that the disease does not come on at the beginning of married life, but 
 later, after the sexual act has been many times successfully accom- 
 plished, and even after children have been born. 
 
 In still another class we must look for the cause more in the nat- 
 ural disposition of the individual. A timid, nervous young woman 
 who bears pain badly — and in this respect women differ markedly — is 
 greatly agitated and very apprehensive at the approach of her husband. 
 An instinctive dread causes her to offer more or less resistance, which 
 hinders the proper accomplishment of the sexual act. The husband's 
 efforts, perhaps forcible and rough, are attended by more or less pain, 
 and this magnifies her dread and in turn increases her resistance. The 
 muscles of the thighs and abdomen — in fact, the whole muscular system 
 — are thrown into a state of tension almost amounting to spasm. In 
 the case of the muscles around the vulvar outlet this contraction is 
 heightened by the actual contact of the penis, and a condition of spasm 
 is finally induced, as bad as in any of the other cases. Thus we have a 
 vaginismus in which there is no pathological lesion, and yet the slight- 
 est touch of the vaginal outlet is sufficient to call into being all the cha- 
 racteristic symptoms. The cause is evidently largely mental, a fear of 
 an anticipated pain being all there is in the beginning. Unquestion- 
 ably, hysteria mav plav a large part in the causation, and is always to 
 be taken into account. 
 ■ In the experience of most authors, as well as in that of the writer, 
 
m'ASM or rill-: Mrs<ij:s nr riii: i-i:iaic i-i.non. 013 
 
 the most coiniiioii cases, as well as tlu- severest, are those oi' the first 
 chiss, the h'sioii heiiii:-, as Sims pointed out, a tender, hypenestlietie 
 coMintion of the liynieii oi' [Kirls iiinin'diatcK' ai'miiid it, aec(iiii|i:ini('d 
 by more oi' h'ss (•on^('stioll and <trten eroded and reddened spftts. 
 
 Si/iiij)lniiis. — The |n-inei|)al symptoms are excessive pain and spasm 
 oi" till- muscles ai'oimd the vid\a, in(hiccd 1)\- attempt-< a( >c\iial inter- 
 course. So severe docs thi' pain ix'eomc that the patient '^-cts to reallv 
 dread the approach of lier hnshand, and all attempts are linallv uiven 
 up. II" a vatiinal examination is made in i»ad cases, so great is the 
 j)ain and nervous apprehension that the patient is tlirowu into a state 
 of violent nervous conuuotiou. ( )ften tliere will he u;encral nuiscular 
 agitation, intermittent rigors, and a most dcplnral)le state aniountinir to 
 even terror and agony (Sims). If now the finger is pressed into the 
 vagina, the muscles will generally be found to Ix' in a state of violent 
 contraction. This spasm may be shared by all the nniscles of the 
 pelvic floor, especially the sphincters. In some cases the spasm and 
 pain are not so severe, amounting rather to a hinderance than an abso- 
 lute prevention to connection. Other causes have been noted for the 
 spasm. Thomas mentions a case where there was a tendencv to 
 spasm " upon sudden changes of position or washing the genitals." 
 In another case the spasm was brought on by contact of the clothing 
 or finger used to stop a pruritus vulvae. AValking has also pnjved 
 sufficient to bring on an attack. Barnes observed cases where attemj)ts 
 at connection were followed by convulsions and syncope. 
 
 Diar/nosis. — The history of the case will be generally sufficient to 
 determine the nature of the affection complained of. A careful dis- 
 tinction must be made between vaginismus and dyspareunia dependent 
 on other causes and unassociated with spasm. If there is any doubt, a 
 vaginal examination will generally bring on a spasm accompanied by 
 severe pain. In some cases even the touch of a camel's-hair pencil 
 will be enough to provoke the characteristic symptoms. On the other 
 hand, the writer has seen cases where a vaginal examination, even with 
 a speculum, Avas possible without bringing on a spasm, and yet the 
 slightest atteiupt at intercourse caused the introitus vaginne to shut up 
 as if held by a clamp. In another case the patient could introduce 
 herself the largest-sized Sims dilator, but coitus was impossible. Both 
 these were nervous eases, and one of them had borne a child, impreg- 
 nation having followed a single successful coitus. 
 
 P/-or/>(o.s/.s. — If a local cause can be found for the disease, the 
 chances of a perfect cure are good ; but when the disease seems tt) be 
 dependent on a purely nervous condition, it is extremely difficult to 
 cure. If left to itself without treatment, the disease Avill continue 
 indefinitely. Jenks rejiorts a ease of thirty years' standing. It is 
 often supposed that ehildl)earing will certainly cure the disease ; this, 
 Vol.. i.—:vA 
 
514 DISEASES OF THE VULVA. 
 
 however, is a mistake, especially in the nervous cases, as the writer has 
 several times witnessed. 
 
 Treatment — The treatment proposed by Sims, originated after much 
 research and many trials, was based on his idea of the pathology, and is 
 the best yet devised for the cases which I have described as belonging 
 to the first class. His plan consists in first dissecting away with curved 
 scissors the whole of the hymen. This leaves a raw surface which heals 
 by granulation. In order to prevent this, as well as to immediately 
 control hemorrhage, I have brought the cut edges of the mucous mem- 
 brane together with a continuous suture of fine catgut, thus avoiding 
 the production of a cicatrix. After the wound has healed, the next 
 step is to enlarge the opening of the vagina, thus cutting the tense 
 and tender cicatrix if there be one. Sims's plan is as follows : " Place 
 the patient on her back, as for lithotomy ; pass the index and middle 
 fingers of the left hand into the vagina ; separate them laterally, so as 
 to dilate the vagina as widely as possible, putting the fourchette on the 
 stretch ; then with a common scalpel make a deep cut through the vagi- 
 nal tissue on one side of the mesial line, bringing it from above down- 
 ward and terminating at the raphe of the perineum. This cut forms 
 one side of a Y. Then pass the knife again into the vagina, still dilat- 
 ing with the fingers as before, and cut in like manner on the opposite 
 side from above downward, uniting the two incisions at or near the 
 raph6, and prolonging them quite to the perineal integument. Each 
 cut will be about two inches long — i. e. half an inch or more above the 
 edge of the sphincter, half an inch over its fibres, and an inch from its 
 lower edge to the perineal raphe." 
 
 The further treatment consists in the wearing of a glass dilator de- 
 vised by Sims and known by his name. This must be introduced and 
 worn daily for several weeks, or till the parts are entirely healed and all 
 sensitiveness removed. 
 
 In the nervous cases, if there is no lesion discoverable, the forcible 
 dilatation of the parts under ether — and for this purpose I have found 
 Goodell's speculum a most excellent instrument — followed by the glass 
 dilators, gradually increasing the size until the vagina is thoroughly 
 dilated and all tendency to spasm relieved, I have found a satisfactory 
 method of treatment. If the spasm depends on diseases of other 
 organs, these diseases must be removed by appropriate treatment ; and 
 this may in itself be enough, or it may be necessary to order the dila- 
 tors for a time. Successful cases are reported of the cure of this symp- 
 tom following the removal of hemorrhoids, and also of thread-worms 
 from the rectum, corrections of uterine displacements, inflammations, 
 and other similar conditions. Still, the cardinal point is the overcom- 
 ing of muscular spasm, and this can best be done by Sims's dilators, 
 either with or without previous cutting. 
 
SPASM or Till'. MISCLES OF THE PELVIC ILOOll. ol5 
 
 Tlic |il:iii III" :ill(i\\ iiii;- cditiis while llic [Kiticiit i- iiiidcr •■liliu-iirnriii, 
 witli tlic li<)|H' that |>rt';;ii;ui<'V may lltlldw, is not to bo rccoiiiinciKlcd. 
 Cocaine lias also hci'ii advised, l)iit on oi'dtirintr it to be j)ainted on bv 
 (lie Im.-baiid, liiiiisell" a medical man, 1 was siir|)rise(l at his re|)ortin<»; 
 that the i-ocaine, while destroying' the sensitiveness of the vulva, also 
 destroyed his power of erection. Still, favorable eases have been re- 
 ported. Hot donehes, sit/-batlis, and anodyne a])plieations may be 
 beiieticial, while the dilators are also bein»;' used daily. If ninch irri- 
 tation of the nnieous membrane around the vulva exist, ajiplieations 
 of solution!? of nitrate of silver (1 <)-()() o-i-. to 3J) often do ^ood. 
 Tincture of iodine and ointments of iodoftrm or cocaine mav be of 
 use. Simpson's suggestion of cutting the jjudic nerve is of doidjtliil 
 expediency. 
 
 Vaginismus Supekiok. — A condition of spasm of the muscles 
 during coitus, by which the penis is imprisoned a\ itliiii the vagina, Avas 
 noticed as early as 1729 by Sehuregius.' Others have noticed it, but 
 to Hildebrandt^ we are indebted for a full exposition of the sulyect. 
 He maintains that the spasm, which is met with in the upper part of 
 the vagina, is due to the contraction of the levator ani muscle. He 
 gives as cause some irritable or sensitive point high up within the 
 vagina, as an irritable abrasion of the cervix or a tender j)r()lapsed 
 ovary. In the last edition of the work ZweifeP takes issue with Hil- 
 debrandt, and maintains that the levator ani alone cannot be the seat 
 of the spasm, as it does not encircle the vagina, and therefore could not 
 retain a speculum or swollen glans penis, as Hildebrandt asserts. He 
 locates the sjiasm in the external muscles. This view would seem to 
 be upheld by a very remarkalile case of coJue-sionis in coitu rej)orted 
 by Dr. E. Y. Davis,* in which the penis Avas so firmly imprisoned dur- 
 ing coitus that it was necessary to chloroform the woman before it could 
 be released. " In this case there must have been also spasm of the 
 muscles at the orifice as well as higher np, for the penis seemed nipped 
 low down ; and this contraction, I think, kept the blood retained and 
 the organ erect." Debraud,^ on the other hand, quotes a case in which 
 the contraction was about t^^•o inches from the vagmal entrance and a 
 little below the neck of the uterus and the vaginal cul-de-sacs : there 
 seemed to be two nuiscular bands at this point, one on each side, which, 
 contracting, narrowed the canal ; the contraction was voluntary. I have 
 seen spasm of the levator ani excited by moving the ti]^ of the finger, 
 which had been introduced into the vagina, after the sphincter muscles 
 
 » Med. Sews, Nov. 29, 1884, p. 603. 
 
 ^ Hnndbuch d. Fraucnhrankh., Billroth, 1st ed. 
 
 ^BiUroth's Deutsche Chirutyie, Lf. Ixi. •• Med. Xeuy, Pec. 13, 1884, p. 673. 
 
 ^ " Des Retrecissenients du Conduit A'ulvo-vaiiiiuil," Med. Xews, loc cit. 
 
516 DISEASES OF THE VULVA. 
 
 had relaxed. The effect of this contraction was to press the finger 
 closely against the lower edge of the pubes, and to hold it quite firmly. 
 There was no ring of contraction encircinig the vagina. 
 
 I have met with several cases in which spasm of some of the muscles 
 of the pelvic floor, accompanied by great pain, came on suddenly with- 
 out any apparent cause, most often during sleep. This spasm in one 
 case seemed to affect the internal sphincter ani muscle, and unless 
 relieved would last almost continuously for days. It was easily stopped 
 by a suppository or rectal injection containing opium. It seemed in this 
 case usually to follow diarrhoea and to be accompanied by constipation. 
 Hildebrandt has met with similar cases. 
 
 The treatment of these rare forms of spasm has already been alluded 
 to in the text. All irritable tender points must be relieved. Section 
 of the affected muscles has been suggested, as well as neurotomy, but it 
 is little likely to be of use. When the spasm is continuous, relief may 
 be obtained by anodynes applied as near the affected muscle as possible. 
 The bowels must be carefully regulated, and all sources of irritation 
 removed, wliile the general health is carefully looked to. 
 
 COCCYODYNIA OR OOCCYGODYNIA. 
 
 This is a rather frequent painful affection of the muscles, tendons, 
 and nerves of the os coccyx, with or without disease of the bone itself. 
 It was originally described by Nott, but was overlooked and nearly 
 forgotten until 1861, when a knowledge of it was revived by Simp- 
 son and Scanzoni. 
 
 Cause. — Unquestionably, childbearing is the most frequent cause, but 
 it may undoubtedly occur in women who have never borne children 
 and in men and young children. Other causes are mechanical vio- 
 lence, as a kick, blow, or fall upon the coccyx, or horseback riding ; 
 uterine, ovarian, and rectal disease ; cold and exposure, especially, as 
 pointed out by Simpson, when conjoined with the rheumatic diathesis. 
 
 Pathology. — Displacement, fracture, and caries of the coccyx have 
 frequentlv been noted. But something more than a dislocation of the 
 bone is necessary, as every gynecologist must have frequently observed 
 such dislocations without any accompanying pain. Hyrtl found thirty- 
 two cases of luxation of the bone with ankylosis in one hundred and 
 eighty pelves — a number far greater than the corresponding cases of 
 coccygodynia. There must be, then, conjoined with the disease or 
 displacement of the bone a hypera^sthetic or neuralgic state of the 
 tendons or ligaments attached to the bone. This may be due to a 
 chronic inflammation of the tendinous structure, or a direct involve- 
 ment of the nerves themselves. As this condition of the structures 
 involved may exist without any displacement or disease of the bone, 
 
COCcynDYMA nil (OCCYanhV M.\. .',17 
 
 So wi' i>tt<ii liiiil tlif Ijiiiii', so far a> we can <li.si'oVfr, iti every n-iM-*! 
 iionual. ( )ii tlir tttlicr hand, the Ijoiic may Ixj tlie real s«,'at ot" tlic 
 (liseaso, caries existing, and tlio syiujitoms refusing; to yield until the 
 diseiLsctl bone is removed. A number otsueh eases have Ix-fn reported. 
 Rheumatism ol" the muscles or tendons Iuls l)een observetl, the disease 
 iK'intr accomj>auied by other rheumatic; manifestations, such as liunbafo 
 or muscidar rheumatism in other parts. Uterine and ovarian di.s<'a.se 
 may al-o be the start ini(- point. 
 
 Sifiitj»fi)iiis. — Pain in the reirion of the coccyx, a<r<jravate<I bv anv 
 motion which brings into action the mu.seles attachcfl to the c<k-cvx, 
 is the principal symptom. Tiie patient suffers on .>»ittinjr down and on 
 risiui:; attain, espcrially if she maintains the sittin<r position for long. 
 Deflation is often a<r<>nizing, and coitus almost unendurable; sometimes 
 even walking will increase the pain. The patient is often obliged to sit 
 on the side edge of the chair, so as to avcjid pressure on the bone, and 
 to use the arms and hands as aids in getting up. 
 
 Diagnosis. — The conditions from Avhich this must be di.stingui.shed 
 are diseases of the rectum and anus, neuralgia of the sacral nerves, and 
 hysteria. A physical examination will generally serve to make the 
 diagnosis. With one finger in the vagina or rectum and the thumb 
 outside, the lione can be seized and moved, when the characteristic j)ain 
 will be produced. Pressure on the bone through the skin will also pro- 
 voke pain. Negative evidence will be the absence of di.sease in the rec- 
 tum and of pain on pressure over the inner surface of the sacrum. The 
 hysterical counterpart of the disease may be distinguished by absence of 
 fracture or caries, and by "noting the irregularity of the pain in the 
 hysterical affe<-tion, an indescribable affectation of suffering, and the lack 
 of consistency in the behavior of the symptoms " (Goodell). 
 
 Pror/nosis. — The disease shows little tendency to spontaneous recov- 
 ery, but, fortunately, nearly all cases can be cured by proper nueasures. 
 
 Treatment. — The hysterical form mast be treated by agents directed to 
 the general condition of the nervous svstem, as well as to the rennjval 
 of any uterine or ovarian disease. The rheumatic form must be treated 
 by remedies directed toward that condition, together with careful atten- 
 tion to diet and exercise. Counter-irritation by the actual cauter}* or blis- 
 ters will also do good in this form. In the milder forms of the disease 
 the endermic use of morphia, the use of ointments of veratria and 
 aconite, should be tried. Electricity' has been successfully emplove<l — 
 a mild galvanic current with one pole (— ) in the rectum and the other 
 (+) on the outside. In rheumatic cases faradization is generallv likelv 
 to do more good. Should all these measures fail, a more radical plan 
 may be adopter!. We have two operations — separation of the coccvx 
 from all its tendinous or muscular attachments, and total extirpation 
 of the bone. The first plan was proposed by Simpson, the last bv Xcjtt. 
 
518 DISEASES OF THE VULVA. 
 
 The separation of the ligaments is to be clone subcutaneoiisly, A 
 tenotome is introduced under the skin near the end of the bone; it is 
 then carried up over the bone with its flat side toward the outer surface, 
 until the point is above the sacro-coccygeal articulation ; it is then car- 
 ried to one side of the bone, and turned so that its cutting edge is 
 toward the rectum, and withdrawn, severing, as it passes, all the tissues 
 attached to the side of the bone. It is then carried up on the other 
 side and the operation repeated. The second side may be cut without 
 taking the knife entirely out of the wound. If a hypodermic injection 
 of coqaine into the affected part (lOlTL of a 4 per cent, solution) be given 
 just before operating, no pain at all will be experienced. The writer 
 has performed this little operation several times with fairly good results. 
 If it fail to give relief, the plan suggested by Dr. Thomas may be tried. 
 He cuts down upon the bone, raises it with the finger, and severs all its 
 attachments with scissors. 
 
 When the bone is carious, and in other cases where milder means 
 have failed, Nott's operation is the only one which offers any prospects 
 of relief. The bone is laid bare, its attachments severed, and the bone 
 disarticulated. It will be found convenient, after cutting down to the 
 bone, to disarticulate it first and enucleate it, as it were, beginning at 
 the base and finishing with the point. " A hea\y pair of forceps is 
 necessary to hold the bone and lift it up while the attachments are cut 
 with scissors. The resulting wound must be left to heal by granula- 
 tion, a drainage-tube being left in place for several days to ensure a 
 free discharge from the cavity, and antiseptic injections used as long as 
 there is any discharge. I have operated several times with complete 
 relief to the symptoms, though they had lasted for years. Many other 
 successful cases have been reported. 
 
 New Growths op the Vulva. 
 
 Lupus of the Vulva. — Dermatologists describe two forms of this 
 disease, L. erythematosus and L. vulgaris. The first-named does not 
 seem to occur on the vulva, the face and scalp being its favorite seat. 
 This form is non-ulcerative. 
 
 Lupus vulgaris, Esthiom^ne. — Duhring describes lupus vulgaris 
 to be "a cellular new growth characterized by variously sized and shaped 
 reddish or brownish patches, consisting of papules, tubercles, or flat in- 
 filtrations, usually terminating in ulceration and cicatrices." If the 
 tubercular nature of the affection be admitted, we must consider it 
 rather as a specific inflammation than a new 'growth. With this 
 exception it is well to keep the definition in mind, as it will help to 
 exclude certain affections wrongly described as lupus. 
 
NEW Cliowrils OF IIIK 177. IM. :,\\i 
 
 J'Wtjincitfi/. — I >( riii:il()l()i;i,^t> dcchirc |)i"iiii;iry Iii|iii- ol" llic\iilva U> 
 be fXft'cdiiiuly raic ; iiiaiiy aiitlj(»i"s do iidt even mention it; hut, as 
 mij::lit 1h' ('Xpcctcd, the jiyii('C()li)<;ists meet with it more coriiinonlv. 
 Dimcau and Tait both (Icdai'c that they have met with it (piitc often, 
 the hitter most often in |»ri\ate |)ractict', the lorniei- in hospital-. In 
 this country it must be rai-e, as it is scarcely menti<»ncd in ^;ynccoh(<r- 
 ical ti'xtbooks (»!' American orijiin. Tlie writer has met with it but 
 once. The frecjuencv asserted by Duncan an<l 'I'ait mnst l)c ascribed 
 to their coiisich'rinLT as hipus certain concbtions not so considered bv 
 other authorities/ Probably less than fifty cases have been re])orted 
 all tojjether. 
 
 A(j('. — The disease on other })arts of tiic body seems to affect the 
 vcrv young, though rarely observed before the second year of life. 
 Of cases occurring on the vulva in Taylor's table,^ the youngest was 
 thirteen and the oldest fifty-six. Tlie period of greatest liability, 
 according to West, is between twenty and thirty. 
 
 Etiology. — Attempts have been made to show that all the cases of 
 ulceration around the vulva described as lupus are in reality due to 
 syphilis. This attempt has failed, as Taylor^ has well shown. As 
 has already been mentioned, the tendency of late has been to class this 
 disease rather with the inflammatory affections than with new growths. 
 Recent experiments would seem to point to a specific germ, the bacillus 
 tuberculosis, as its cause, thus grouping it with tubercular inflamma- 
 tion — a class of diseases now well recognized as much more common 
 than was formerly supposed. 
 
 Koch, Cornil, Doutrelepont, and others have shown the presence in 
 lupous tissues of all sorts of a bacillus identical with that found in, 
 and supposed to be causative of, true tubercle. These bacilli are very 
 scanty, but still, it is asserted, are always present. Inoculation with 
 these same tissues has produced tuberculosis in the lower animals. 
 Artificial cultivations of the liacillus obtained from lupus, extending 
 over many months, have retained their identity and their power of 
 inoculation. These facts in the pathology of the disease, if accepted, 
 are of great importance in their bearing on therapeutics. 
 
 The existence of a peculiar diathesis, the scrofulous, has been 
 asserted * to exist in proportions varying from 30 to 60 per cent, in 
 cases of lupus. In certain cases, on the contrary, perfectly good 
 health has been specially noted. Accepting the infection theory, we 
 naturally look for the cause in the direct inoculation of the specific 
 bacillus, together with a certain jjredisposition or diathesis which en- 
 ables the bacillus to retain a foothold once obtained, and to grow and 
 multiply. But even admitting this to be true, it only partially ex- 
 
 ' See Obstetrical Trans., 1885, pp. 24:^--2.")0. ^ Gi/n. Trans., 18S1, p. 210. 
 
 ^ Loc. cit. * J. C. White, BcfUni M. and S. Journ., vol. cxiii. p. 409. 
 
520 DISEASES OF THE VULVA. 
 
 plains the phenomenon ; for this manifestation of the bacillary inva- 
 sion is so different, anatomically and clinically, from that ordinarily 
 seen in other forms of tuberculosis, that some modifying condition, not 
 yet understood, must be supposed in order to account for it. While the 
 bacillus of lupus will produce tuberculosis, lupus has not yet been pro- 
 duced by any form of artificial inoculation. The source of the bacilli 
 is not far to seek. The spores are found to be present in all places 
 where phthisis exists, so that only a superficial excoriation or abrasion 
 is necessary to give a point of entrance. Once engrafted into the tis- 
 sues, it grows and disseminates itself, but only very slowly and appar- 
 ently with great difficulty. Should it gain access to the circulation, a 
 general tuberculosis may follow. If we reject the theory of a specific 
 bacillus, we know nothing of the causation of this disease. 
 
 Pathological Anatomy. — Virchow grouped lupus with the granulo- 
 mata, and the lesion does seem to resemble granulation tissue. It affects 
 mostly the cutis or mucosa, sometimes penetrating the deeper structures, 
 but never, apparently, affecting bone. Lupus in other parts of the 
 body occurs mostly in nodules or tubercles. Dr. Thin, however, asserts 
 that in the vulva it is rather difftised through the tissues, like any 
 chronic inflammation, the greater number of cells being in the neigh- 
 borhood of the vessels. Here we find a thick infiltration of leucocytes, 
 the infiltration tending to spread and coalesce with neighboring foci. 
 The infiltrated tissue tends to form new tissue, which in turn may ulcer- 
 ate. There may be also an excessive formation of epithelial or epider- 
 mic cells over the affected part, with exfoliation. Mixed with the small 
 cell-infiltration there are also certain epithelioid and giant-cells. The 
 tubercle bacilli may be found in the tissues after proper preparation, 
 but sometimes an immense number of sections, forty-seven in one case 
 (Gushing), may be necessary before they can be recognized. There is 
 but little tendency to cheesy degeneration, in which respect this tissue 
 differs greatly from tubercular tissue found elsewhere. There is always 
 more or less hypertrophy of surrounding tissue, and in some cases the 
 tubercles are heaped together like strawberries (Taylor), which masses 
 may in turn coalesce with larger masses. 
 
 Clinical History. — Duncan makes two principal forms, L. minimus 
 and L. maximus. The former, he says, occurs mostly within the vulva, 
 and may on superficial examination be mistaken for urethral caruncle 
 or eczema of the vestibule or pruritus pudendi. In another place, how- 
 ever, he expresses his doubt as to the identity of these slight cases with 
 true lupus. Without a microscopic examination of the tissues or a more 
 detailed description we must admit his doubts as the truth. 
 
 Clinically, we may make three principal divisions : 1, Lupus ser- 
 piginosus, ulcerans, or exulcerans ; 2, lupus perforans ; 3, lupus 
 prominens. 
 
Mjw anownis (jf tui: vii.va. o-ii 
 
 LiifiUf st'r/ilt/liiosii.s. — In this fonii the -iipcrtici.-il tissius stt'in to Ijr 
 tilt' ones ntl'fctcd. Tlic l:il)ia niajnra, i>r tlic <t<:im' iM-twci'ii tlic lal)ia and 
 tlu' tliiiili, arc nttcn tin- |Kirt- lii'.-t attached (Taylor). Soinctinjcs tlic 
 discasi' Ix'irins on tlic cervix or within the va;,'^ina, and works its wav 
 oiitwaivl. Px'uiiinin;^- as a small tiiherclc, or tid)crcles, «»f" a i"cddi.-h or 
 hrow iii-li color, the disease {iradnally c\tcnd>, the atf'eetcd ti.-.-ncs hreak- 
 intr down into idccrs, which s|)rcad nntil the labia, nions, and, in Tact, 
 the whole vulvar and anal rc<iions, are involve(l in one extensive jiatch 
 of tid)ei'cular ulceration. In the centi"al ]»ortion ol' the di-(a~ed |»ai1> 
 cicatrices may iorm, in turn to i)e atiaiu attacked and destroye<l, or the 
 healin<i: process may extend and he ])ermanent. In some of" the eases 
 granulations sprin<>: up around the ulcers, ^iivinu- the form known as 
 lupus hypertroj)hicus. 
 
 LujjKs j/crjorans. — The disease sometimes shows a tendency to attack 
 the deeper tissues rather than the supcrfieial, undermininjr, and finally 
 destroyinij:, the overlyiuu' ])atches. In this way the rectum, vajrina, 
 and Madder may be attacked, and g-reat destruction caused in the deep 
 tissues, forming large caverns with perhaps only small external open- 
 ings. These forms may coexist, as Huguier, t<j whom we owe the first 
 (1848) descripti(jn of the disease, points out. He describwl and pic- 
 tured a case with deep perforating ulcer of the vulva, and sujx-rficial 
 ulcerations around the anus, with great hyj)ertrophy. 
 
 In lupus promiiuns the tubercles seem to be the distinctive feature. 
 They grow and coalesce, forming large bright scarlet or reddish, and 
 sometimes brownish-purple, masses as large as half of an e^rvr cut in its 
 long axis (Taylor). These masses may be several inches long, and six 
 or eight of them may coexist (Fig. 178). This form seems to affect 
 mostly the outside of the vulva. 
 
 In all the forms there is more or less hypertrophy of the labia minora 
 and majora, and the clitoris, or even the whole vulva may lie simi- 
 larlv affected. This is entirely inde])endent of the gro^vth of true luj>ous 
 tissue in the ])arts, though of course the lupus must antedate the hyj)er- 
 trophy. The enlarged parts are then hard, pale, or dull white. The 
 hypertrophy remaining after the disease is of a similar nature. 
 
 The discharge from the ulcers varies. In some cases there is " laud- 
 able " pus, in others a sero-pus, and in some only a watery discharge. 
 Some of the cases seem to have a great tendency to hemorrhage. ^lat- 
 thews Duncan describes a form of the disease which he calls lieme»r- 
 rhagic lupus, and reports four cases.' The microscopic examination 
 of these cases shows a different histological structure from ordinaiy 
 lupus. This form is generally insensitive, but occasionally is tender 
 and painful. He reports one casew^here the hemorrhages extende<l over 
 fourteen years. The hemorrhages may l)e long and slight, or short and 
 
 * Edin. Mid. Journ., .July. 1SS4. 
 
522 
 
 DISEASES OF THE VULVA. 
 
 very severe. Dr. Duncan considers this disease to be allied with senile 
 vaginitis. From his descriptions it can hardly be a true lupus. 
 
 Symptoms. — The symptoms of ordinary lupus are almost none. In 
 many cases the patient seems to be in perfect health; in the majority 
 
 Fig. 178. 
 
 B 
 
 Lupus Prominens : A, hypertrophied labia minora; B, after application of escharotics. 
 
 of cases there is little pain. If the rectum or other passages are 
 aifected, there may be stricture or fistulee with attendant symptoms. 
 
 Prognosis. — Lupus is seldom a fatal disease. It runs a very long 
 and chronic course, and in a small percentage of cases ends in spon- 
 taneous recovery. A still larger number are cured by appropriate 
 treatment. Taylor collected the statistics of 21 cases : 6 were cured ; 
 7 relieved, 4 not relieved, and 4 died. From this we see that nearly 
 two-thirds were cured or relieved. 
 
 Diagnosis. — The diseases most likely to be confounded with lupus 
 are cancer, syphilitic ulceration, ulcerative chancroid, and elephantiasis. 
 From cancer it can be diagnosed by its extreme slowness of growth, 
 often great hypertrophy of surrounding tissues, and prominent tuber- 
 cles. The general health of the patient is good, and there is absence 
 of general symptoms. The presence or absence of pain is not to be 
 depended on as a distinguishing mark. From syphilitic disease the 
 affection is distinguished \vith more difficulty, but the histor}^ of the 
 case and the behavior under treatment will give aid. Extensive 
 
.v/.ir enow 'JUS or riii: vilva. .02;J 
 
 sy|iliilitic iilcrrntinii nl' ilic \iil\:i i^ even iiiorc rai-c iliaii true liipii--. 
 I'lia^t'tlniic cliaiii'if i> iniicli iimrc i;i|>i<l in its <;i(i\\tli, :iii<l tlic coldr 
 <»(' tlic Ikisc is iiittri' n-niy and ycllnw i.-li-\vliitc tluui in lupus. When 
 clcai-cd ()t"»lis(liar<i't' the l)asc is red. ( "lianci-<tid lias none of (lie iliick- 
 cniui;,- of >iirr(inn(linM- (is>ii(', ami tnlicrdi' lui'niatinn is waiilin;.^; tlio 
 liistory will also scrvt' to cxclndc it. in ln|)us the in<:ninal inlands 
 arc seldom if over enlarircd. Tlu' examination of the diseliarnes for 
 l)acillii> (iil»ercnlosis with an ailirmatixc I'e.-ult will he deeisixc, hut a 
 nciiative result will prove nothing-. It is not to he forp»tten that ean- 
 eerons disease may develoj) on lupous tissue and ohseure the diatrnosis. 
 
 Treatincid. — Internal medication will accomplish hut little. There is 
 no specific for this disease. The drui^s which have hecn mo.st used are 
 arsenic, itidinc, and mercury, the so-called alteratives, toirether with 
 agents supposed to have an eflect on the strumous diathesis — cod- 
 liver oil and iron. Their use has {)rovcd unsatisfactory, and thev can- 
 not he depended on to the exclusion of local and surgical treatment, 
 which offers almost the only hope of success. 
 
 Acting on the parasitic theory of the disease, recent authorities have 
 recommended the antiseptic method of treatment ; and if the methods 
 of the older writers be examined, it will he found that the most success- 
 ful have heen those which are in harmony with this idea. If we con- 
 cede that lupus is a form of tuberculosis, and that tuberculosis is due to 
 the presence of a bacillus in the tissues, the only rational plan is to use 
 such agents as will destroy the cause. Koch by his investigations has 
 shown which are the agents most potent against the parasites ; among 
 them he names mercuric chloride first, and chlorine, iodine, and bro- 
 mine Maters in the order named. 
 
 Doutrelepont in 1884 tried the bichloride, and was quickly followed 
 bv others in trials of this agent, as well as of others of a similar nature, 
 such as sulphurous, carbolic, and salicylic acids, Veiy successful 
 results have been recorded by the dermatologists with lupus on other 
 parts of the body, but so far the writer has seen no reports from the 
 gynecologists. This is due, doubtless, to the rarity of the cases. Dr. 
 J. C. AVhite^ reports twelve cases, mostly affecting the upper extremi- 
 ties. His plan of treatment was to use a sublimate solution (i— 1 gr. 
 to .sj\ applied for half an hour night and morning, followed by an oint- 
 ment of the same (gr. j to sj). Xear the mucous surfaces he found 
 salivation easily induced, but on the skin no such trouble was encoun- 
 tered. His conclusions are very positive as to its curative effect : " If 
 its use be contiiuied long and thoroughly enough, a point not yet sutti- 
 eiently determined, I see no reason to doubt its absolute power over the 
 parasitic nature of lupus." 
 
 Mr. Hutchinson has strongly recommended sulphurous acid, and 
 
 ' Boston Med. and Surg. Joum., Oct. 29, 1885. 
 
524 DISEASES OF THE VULVA. 
 
 Marshall has advised salicylic acid. Lately, iodol has been used with 
 success. A 10 per cent, ointment of pyrogallic acid is highly recom- 
 mended. It attacks only the diseased tissues, which it turns black. It 
 must be repeated several times. 
 
 Surgical interference has been generally recommended. This has 
 included the excision of the diseased parts as far as possible, scraping 
 with a sharp spoon, scarification, the application of the red-brown cau- 
 tery, the more extensive destruction of tissue by the white-hot point, 
 and boring the tissues with points of silver nitrate : all these methods 
 have their uses. The soft tissues can be scraped away with the spoon, 
 and the sublimate solution applied to the diseased surface, thus bring- 
 ing it in contact with deeper portions of tissue and hastening the cure. 
 Large hypertrophic masses, which would shut in diseased surfaces and 
 prevent their proper treatment, may be excised. There is but slight dan- 
 ger of hemorrhage, as bleeding points can be picked up by haemostatic 
 forceps as the incision is extended. There is little hope of getting pri- 
 mary union after such incisions, and probably brushing over the cut 
 surfaces of tissue with the cautery may be a wise precaution, as it is not 
 to be forgotten that after any cutting operation on lupous tissue a gen- 
 eral tubercular infiltration is possible. Lately, Pick of Prague has rec- 
 ommended^ cauterization by electrolysis. The tissues being first painted 
 with cocaine, the positive current is applied to the surface with a bare 
 metallic electrode. In this way the tissues are destroyed almost 
 painlessly. 
 
 Elephantiasis Aeabum (Pachydermia). — The pathology and 
 etiology of the affection usually described under this head seem to differ 
 so much in the diiferent descriptions of individual cases that it would 
 appear as if two distinct diseases, closely resembling each other in 
 many points, but still with marked differences both in cause and 
 mode of growth, have been confounded. The first of them is the 
 true elephantiasis arabum, and the other we may best define as 
 fibroma diffusum. 
 
 The generally accepted definition of elephantiasis as given by Duhr- 
 ing is as follows : " It is a chronic hypertrophic disease of the skin and 
 subcutaneous connective tissue, characterized by enlargement and deform- 
 ity of the part affected, accompanied by lymphangitis, swelling, ccdema, 
 thickening, induration, and papillary growth." Following the statement 
 of Schwimmer, most modern authorities, especially the German, hold 
 that the erysipelatoid attacks, by which true elephantiasis arabum of the 
 extremities is characterized, are absent in elephantiasis of the vulva. 
 This statement, however, I cannot find to be confirmed by those who 
 have observed the disease in tropical climates, and therefore must hold 
 1 Med. Press of Western New York, March, 1887. 
 
.v/;ii' (Uiowriis OF TiiF. vriA'A. 020 
 
 tliiil the (lIscMSc ticscrilxil \>\ I lie ( Icniiaiis ditlci'.- in llii- if.<|M'<t, ;i.- well 
 as ill (itlicrs, IVkiii the tnic ( )iMciit;il Ixpc 
 
 AiKttlicr |»i)iiit dl" (litVcri'iicc is foiiiid in the cmiix'. I^l(j)li:iiiti:i.-is 
 arahiiiu is now <|iiilc generally a<linitt<'(l to l)c (Ik- ronit ni" a |»arasitt', 
 which is ((» l)c t'oinid at rci-taiii times in the alVcctcd part, while no 
 such cause can he discdxci'cd in the (Usease as (h'sci'ilx'd and seen in 
 Nofthern Kurojtc and this country. (citain anatomical diHerencos 
 also exist which will he descrihed later on. 
 
 llnhUdt. — The disease is very rare in the Northern portion.- of the 
 United States, hut is a little more common in the Southern States, 
 esjK'cially anion^- the e(»lored race. In certain countries ir is endemic, 
 especially in low-lyino- districts, sea-coasts, and islands. It is verv 
 trc([nent in tiie West Indies, some ])ortions ot" South America, Africa, 
 India, ami other tropical climates. 
 
 FAioUxjy. — The cause of the disease is an inllammation and oUstrnc- 
 tion of the lymphatics (Dnhring-) ; and this has been attrihuted ' to the 
 presence in the blood and lymphatics of the Filaiue s(ni(/iiinis /loiitlnia 
 and its ova. The disease is not contagious or hereditary. 
 
 Pdthohf/ical Anatomi/. — The principal lesion seems to consist in an 
 immense proliferation of the connective tissue, with a orcat amount of 
 serous iniiltration. The skin or mucous mend)rane coveriuir the 
 affected part is also increased in thickness, the papillae enlarged, tmd 
 the epidermis thickened. There is also a certain amount of pigmenta- 
 tion. The skin may be smooth or rough from papillary enlargement 
 (,)r warts. Late in tlie disease the nervous substance is destroyed. 
 The lymjihatic glands are swollen, and the lymphatics greatly dilated 
 and distended with fluid, their walls thickened and of a light-yellow 
 color. In those cases where the lymphatics are not affected the veins 
 will be foiuid markedly dilated, with distinct hyperplasia of the ad- 
 ventitia.- 
 
 Sympfom.'<. — The disease is stated generally to begin with ervsipela- 
 toid inflammation of the parts, Avith fever, pain, heat, and swelling. 
 Such an attack is followed liy a slight enlargement, and is succeeded 
 by other attacks until eulargement becomes more marked and j)erma- 
 nent. At the end of about a year these attacks cease and the growth 
 from that time on is gradual. The parts of the vulva generally 
 attacked are the labia majora, clitoris, and labia minora. The growth 
 increases enormously, often reaching fortv to fiftv ])onnds in weight 
 and hanging down to the knees or ankles. Reyer^ has published a 
 large number of cases collected in Egy})t. The tumors, he states, are 
 often enormous and last twenty years or more. He describes these 
 tumors as having a small navel-like depression' in the upper third, 
 
 ' Fayrer, Lnnrrf, Feb., 1879. ^ Sclnvimmer, Handbook of Shin Dis., Zieinssen. 
 
 ^ Quoted in Zieinssen. 
 
526 DISEASES OF THE VULVA. 
 
 which reaches down to the entrance of the vagina. The surface may- 
 be smooth or rough, warty, fissured, and ulcerated. Eczematous erup- 
 tions are not uncommon on the aifected part. Maceration of the epi- 
 dermis takes place from the moisture of the parts, especially in the 
 folds of the skin. An oozing of lymph also occurs from minute open- 
 ings in the skin, as well as from the ulcerated surfaces. ExcejDt from 
 the weight and discomfort, and the impossibility of gratifying the sex- 
 ual desire, the tumors do not seem to aifect the general health of the 
 patients. The inguinal glands are always swollen and enlarged, and 
 occasionally form small tumors in the groin which sometimes admit of 
 the escape of lymph (Schwimmer). 
 
 Prognosis. — The prognosis as to recovery, once the disease is well 
 developed, is hopeless. It is stated that recovery occasionally occurs 
 in young subjects early in the disease. The affection runs an indef- 
 inite course, and while it does not ordinarily prove fatal, the wretched 
 condition of the victim is often worse than death. When fatal the 
 result is brought about by thrombosis and pysemia. 
 
 Diagnosis. — True elephantiasis arabum must not be confounded with 
 fibroid enlargements and hypertrophies of the parts, which are more 
 commonly met with in this country than the true disease. In these 
 cases the resemblance is often striking, but some of the conditions are 
 wanting — either the history of inflammatory attacks at the beginning, 
 or the enlarged glands in the groin, or the general diffusion of the 
 tumor, with thickening of the true skin over the growth. The absence 
 of these sio;ns will serve to distinguish it from fibroma diffusum or 
 from simple fibroma, with which it has often been confounded. Vir- 
 chow states that true elephantiasis never becomes pediculated, but 
 always involves the whole organ. It also contains yellow elastic 
 tissue, which is not true of fibroma in any form. 
 
 Treatment. — The principal hope lies in surgical interference, and, 
 fortunately, this can often be successfully offered. Before resorting to 
 the knife it might be well to try the effect of the galvanic current, 
 using galvano-puncture and very powerful currents, from fifty to one 
 hundred milliamperes. Some successful cases have been reported. 
 The treatment must be kept up for a long time — one or two years. 
 The most certain results have been obtained by amputating the 
 diseased mass. This does not seem to be either a very difficult or 
 dangerous operation,^ and is to be conducted on general surgical 
 principles. 
 
 Fibroma diffusum. — The disease which I wish to describe under 
 this head has been usually described either as elephantiasis, syphilis, 
 or lupus. Although it resembles all these affections in the hypertrophy 
 
 1 See p. 528. 
 
Plate I 
 
 .ui.ns nyi-LMli-ophions (ihintTan). Moi-.- pi-opr.i-ly !•.!.. <n,,i. DiCl'usiini 
 
 To rai;o page 527. 
 
m:\\' <;i:()]vtus of riii: vri.VA. 027 
 
 of tissiu', thciv is ccrdiiiily a (li>tiii<'t ctioloiiical (litlri-cncc, :is well as a 
 dillert'iicc in clinical hcliavioi-. 
 
 Ktiolo(j}i. — Tlic cause is very ohsciirc. Syphilis has hccii more j:eii- 
 erally assii;iie(l as a cause than anythiiij;- else, hut its i-elatioiis to the 
 ail'eetion are very uneertaiii. In two cases seen by the writer, venereal 
 disease was admitted, hnt iVuni the i)atient's descrij)tion, as well as 
 from the absence of" other marks of syphilis, the disease was most ])i'ol)- 
 ably ot" a chancroidal character. In cases reported by others there has 
 sometimes been a distinct syphilitic hist(»i'y, but this is not universal ; 
 and, even iirantino- it, the relation of cause and elfect is still unprove(l. 
 Dr. ^latthcws Duncan' describes a disease as lupus which froiu the 
 plates, as well as from his descriptions, corresponds with the di.sease 
 under consideration. He reports a nund)er of cases, but Dr. Thin, who 
 examined his specimens mioroseopieally, declares that they contained 
 no histological elements which would characterize them as either lupus, 
 gummata, cancer, or elephantiasis. In the same discussion ]Mr. Hutch- 
 inson was inclined to regard the cases as being syphilitic in character, 
 but Dr. Galabin reported that he had found in similar eases that, 
 although there might be some evidence of syphilis, the disease did 
 not yield to autisyphilitic treatment alone, but was cured by excision 
 followed by these remedies. Paget, Kaposi, and Vidal are quoted by 
 Duncan as being opposed to the syphilitic origin. Virehow has sug- 
 gested that the destruction of the inguinal glands by obstructing the 
 flow of lymph might result in a lymphatic oedema of the parts, with 
 dilatation of the lymph-vessels and hypertrophy of the connective tis- 
 sue. A considerable number of cases have been reported where this 
 has occurred, and a one-sided enlargement has followed the destruction 
 of the glands on the same side. In the two cases seen by the author 
 the glands were destroyed by buboes resulting from chancroidal ulcers. 
 INIayer, however, states that this condition is sometimes Avanting. There 
 is no evidence obtainable at the present time that any bacterial cause 
 for the disease has been observed. 
 
 With such conflictino- testimonv we must consider that the cause of 
 this disease is unknown, but that the gro\\'ths commonly follow some 
 local irritation seems to be probable. 
 
 C/inical Histoi'i/.—^The disease usually affects women during the 
 period of sexual activity. The parts affected are the labia majora, the 
 clitoris, and the labia minora, in the order named. Often the whole 
 rima vulvte is affected, the groAA-th forming a distinct collar around the 
 entrance to the vagina, which may thus be nearly closed and the sexual 
 act be entirely prohibited. The growths are usually largest near the 
 clitoris, becoming smaller as they approach the perineum. One side 
 alone may be affected, or the whole supra vulvar region be the seat of 
 
 ' Obstet. Trans. 
 
528 DISEASES OF THE VULVA. 
 
 the disease. The growths are very irregular, and are broken up into 
 lobes, and often portions form polypoid tumors with distinct pedicles. 
 In other cases the whole gro^^i:h assumes the shape of a polypus. The 
 surface is usually smooth, lobulated, and may be pink, nearly white, or 
 brownish in color. If covered by the skin, it may be warty and fis- 
 sured. Ulceration, simple in form and not typical of either syphilis 
 or lupus, often occurs, especially between opposing surfaces, from pres- 
 sure and friction. Cicatrices are frequently present from old ulcerations. 
 Unless inflamed, the growths are usually insensitive and painless, and 
 do not directly interfere with the general health of the patient. They 
 are, however, a hinderance to coitus, and if large to locomotion, and if 
 ulcerated or inflamed may be very sensitive and painful. They grow 
 slowly as a rule. 
 
 Pathological Anatomy. — The substance of the growths is connective 
 tissue in all stages of development. Around the vessels and under the 
 epithelium will be found more or less small cell-infiltration. The skin 
 or mucous membrane is not usually thickened, as in elephantiasis, nor 
 are the walls of the lymphatics or veins thickened and enlarged. There 
 is usually a distinct dilatation of the lymphatic spaces from contained 
 fluid, but without proliferation of the endothelium. 
 
 Prognosis. — If left to themselves, these growths last indefinitely, 
 growing slowly or remaining stationary, but do not kill, unless deep 
 ulceration and sloughing take place — a rare occurrence. 
 
 Treatment. — The only treatment which seems to oifer any chance of 
 success is surgical. In removing the gro^\i:hs several methods are open for 
 choice, the same methods being applicable to operations on elephantiasis. 
 Schroeder proposed to cut a small section at a time from below upward, 
 and to control the hemorrhage by bringing the parts together by deep 
 sutures before cutting farther. This is done a short distance at a time, 
 first on one side, and then on the other, until the whole mass is removed. 
 A number of cases have been successfully operated on by this method. 
 By the use of hsemostatic forceps in plenty, the whole mass, even if large, 
 might be excised at once, and the bleeding points secured as fast as cut. 
 The cautery, either the wire or the thermo-cautery, has also been used, 
 and is safer and prevents any serious loss of blood. In one case the 
 writer followed two plans — cutting and suturing on one side and cauter- 
 izing on the other. The result was the same on each side, as the cut 
 side did not unite by primary union, but both healed by granulation. 
 So low is the vitality of the parts that primary union cannot be con- 
 fidently expected. A good result may be obtained by the method pro- 
 posed by Munde, who safely removed a large tumor by passing three 
 needles through the face of the growth and tying an elastic ligature 
 around it. When the elastic ligature was loosened the vessels were seized 
 and tied with silk. Union took place except in the track of the silk 
 
\i:\v aiiowms or riii-: vi'lva. 521) 
 
 liiT'atnns. ICinnul liiis ()|)(i:i(((l liy [cissiiiji; silver Hiiturcs cntin-lv 
 Ix'liiiitl the <^i-(»\vlli, ami tlicii (wistiiiL! tlicm as fast as the incision was 
 uukIc, tliiis conti'ollinj;' the liciiKinliauic. SniMllcr tinnors have lu-cn 
 remove*! I'v the clastic li<;atiire alone, a Ciiitdw hciuf^ cut anjiiiid tlic 
 lUH'k of f.lit' tumor tlii-oiiu'li tin' skin or nuic<)ns iiienil)rane, and the 
 li«2,atiire placed in tli<' liiirow. This niij^ht he done in the case of 
 polypoid masses hy the aid of cocaine. The pos- ihiliiv of the removal 
 hv electrolysis is not to be forjj^otten. 
 
 FiHiioMA AND l'^iMi{()-MY()MA. — I'^'ihroid tumors arc quite rare, as 
 distintiiiishcd iVom elephantiasis and iihroma diffusum. They most 
 conunonly have their origin in the connective tissue of the labia 
 niajora, tIiou<jli other parts of the vulva may be their seat. They are 
 usually small, but have been known to grow to a great size. When 
 large and heavy, they stretch the point of origin, by dragging on it, 
 until they become pediculated. They are usually smooth and rounded, 
 but may be lobulated and irregular. They are com])osed entirely of 
 connective tissue, and covered by a thin but normal layer of skin or 
 mucous membrane. The skin is usually movable, while the mucous 
 membrane is more apt to be closely adherent to the tissue. In some 
 instances the covering has been converted into a dense capsule. 
 
 There are two varieties, the hard and soft — the latter is often called 
 fibroma molluscum — differing only in the amount of fluid contained in 
 the meshes of the connective tissue. There may be a greater or less 
 infiltration of round cells. The tumors often become oedematous during 
 menstruation and pregnancy. Ulceration of the surfaces from friction 
 is not uncommon ; inflammation may result and abscesses be formed. 
 As a rule, they grow slowly, and in time may attain a great size. 
 
 Myoma. — Tumors of this kind have been occasionally observed on 
 the vulva. They probably have their origin in the few smooth muscle- 
 fibres which are the remains of the round ligament. They differ in no 
 respect, except histologically, from fibromata, and from each other only 
 in the relative amount of smooth muscle-fibre and connective tissue. Dr. 
 Bedford Fenwick ' has reported a case of lipo-myoma of the left labium. 
 
 Si/mpfoins. — The symptoms are mostly due to the weight and size of 
 the mass. Incontinence of urine may occur if the origin is near the 
 meatus, but this is cured by the removal of the tumors. They may 
 hinder coitus and become a great source of annoyance in walking and 
 standing. 
 
 Treatment. — These tumors may be removed by the ecraseur, elastic 
 ligature, hot wire, knife, or scissors. The hemorrhage is usually slight 
 and the cure complete, as there is no tendency to return. 
 
 * Brit. GyitcECologicalJourn., Feb., 1887, p. 465. 
 Vol. I.— 34 
 
530 DISEASES OF THE VULVA. 
 
 Myxoma. — These tumors consist of a tissue which has for its type 
 the umbilical cord, and are therefore soft and yielding. They contain 
 spheroidal, stellate, and fusiform cells, often anastomosing. The inter- 
 cellular spaces are filled with a soft, gelatinous basement-substance. 
 They are generally mixed with fat, lipo-myxoma, or with fibrillary 
 connective tissue, fibro-myxoma. The tumors behave much like the 
 fibromata, with the soft variety of which they may be easily con- 
 founded. They are usually benign, but sometimes recur, and also 
 undergo sarcomatous degeneration, when of course they become malig- 
 nant. They seldom grow to any great size, and are very rare. 
 
 Lipoma (Fatty Tumoes). — These growths usually have their origin 
 in the fatty tissue of the labia majora, but have been found on the mons 
 Veneris and nymphse. They behave much like fibroids, becoming 
 pedunculated, but grow rapidly, and often reach a great size. Emmet 
 describes one reaching nearly to the knee, between six and seven inches 
 long. • The woman carried it in a bag attached to her waist. Stiegel§ 
 removed one which weighed ten pounds. Koch extirpated one entire 
 which reached the knees, the woman having already cut oif the lower 
 half herself. Goodell met with such a tumor of the left labium majus 
 reaching to the knees. 
 
 Diagnosis. — The diagnosis between lipoma and fibroma might ofPer 
 some difficulties, but this would be of no practical account, as the treat- 
 ment is the same in each case. In Goodell's case fluctuation seemed so 
 sure that he mistook it for a cyst. From their rapid growth they have 
 also been confounded with sarcomata. 
 
 Treatment. — These tumors can be readily removed by separating the 
 pedicle and closing the wound with sutures, or by a process of enuclea- 
 tion after having cut through the integument. 
 
 Papilloma. — There are three forms of gro^vth found on the vulva 
 which may be grouped under this head — viz. 1, simple papilloma ; 2, 
 pointed condyloma ; 3, syphilitic condyloma. The second and third 
 are probably due to certain specific poisons, while the first occurs Avith- 
 out assignable cause. 
 
 Papilloma Simplex. — Simple non-specific warts are a comparatively 
 rare form of groA\i:h on the vulva. They are, however, occasionally 
 met with. They may be multiple, as in a case described by Winckel, 
 where the whole vulvar region was covered with a multitude of small 
 warts, or they may be single, as large as a pea or much larger. They 
 are common on the mons, but are also occasionally found on the labia 
 majora or the nymphse. I have met wath a single example in the lat- 
 ter situation. The grov/th was low, broad-based, about one quarter of 
 an inch in diameter, and was on the outer edge of the left nympha. 
 
AKW CllOWTIIS OF THr. VCIA'A. 5;J1 
 
 Thciv was IK) history <»r siirn of vciicical (lismsc. It rosoinblod exactly 
 similar iirowths soiiu'timcs luimd on the toii<;ii<'. (jrillcttc' mot with a 
 <>;rowth as hiruc as two tists on tlic hil)iiim majiis ot" a \i\v\ nine years ot" 
 auc There was no history of syphiHs or of any inllammatorv affec- 
 tion. The yrowtli reseml^led a sy|)hiHtic condyloma, bnt was more 
 prominent. Her sister liad a simihir atfeeti(jn, and died of septiea'miu 
 followinj!; its removah 
 
 JIi.sfolof/i/. — These jjjrowths consist of an hypertrophy of tlie j)aj)ilUe 
 of the skin or mneous membrane, with a eorresi)onding thicUeninj^ of 
 the epithelial layer, and an incrca.se of connective tissue underneath. 
 They arc sometimes sessile or have short i)edieles ; the surface is not 
 dee[)ly divided as in the p(jinted condyhjmata. 
 
 In this division mu.st also be classed the so-called oozing tumor of the 
 labia, first descri])ed by Sir C. M. Clark. There is n(j puljlished account, 
 which I can find, of a microscopic examination of such a growth, but 
 descriptions, and a plate in Emmet's work, leave little doubt as to its 
 true histolotry. Clark describes one as growing on the outside of the 
 labium, which corresponds with Emmet's case. It was raised one-eighth 
 to one-third of an inch aljove the surface, and was lobulated and fis- 
 sured. Its peculiarity is that it discharges a great amount of Avatery 
 fluid from its surface, the amount varying with the weather and state 
 of the patient. It occurs mostly in weak, fat, middle-aged women. 
 Such tumors are very rare, and the name should be dropped, as being 
 biLsed on a peculiarity which is not confined to these gro"s\i:hs, and which 
 is not always present. More careful observation is needed on the 
 subject. 
 
 Treatment. — If small, the g^o^^i:hs may be destroyed by applications 
 of acetic acid, carbolic acid, or other caustics. But, undoubtedly, the 
 l)est method, when they are large and not vciy numerous, is to remove 
 them Vtith the scissors or knife imder cocaine, and then bring the edges 
 of the M'ound together with fine sutures. If the gro^iihs are quite 
 small and numerous, electrolysis may be used ; but if they are large 
 and hemorrhage is feared, the electro-cautery wire may be used, as was 
 successfully done in Gillette's case. The so-caUed oozing tumors have 
 been successfully removed by cutting, and no return noted. 
 
 Pointed Condyloma {C acuminata, Venereal Warts, Specific Veg- 
 etations). — It is only within comparatively recent times that the 
 true nature and relation of these groA\i:hs has been understood. 
 They may grow in all portions of the genital tract, from the cervix 
 uteri to the skin on the perineum and thighs. Their most common 
 seats are the inner surfiices of the labia majora, vestibule, and perineum. 
 They are always multiple, but cases have been seen where a nund^er 
 of groMiihs occurring near together have coalesced into one mass (Hil- 
 
 > Am. Journ. ObsteL, 1S79, p. 599. 
 
532 DISEASES OF THE VULVA. 
 
 debrandt), so as to appear like a single growth. They are usually 
 quite small, but masses have been observed as large as a man's liand.^ 
 When occurring on the skin or mucous surfaces, not subjected to pres- 
 sure and not too near together, they are found to have a very small 
 base, being polypoid in shape. They are covered with a thick layer 
 of epidermis, which gives them a yellowish or grayish appearance, but 
 when constantly moist they become semi-transparent, bearing, as Mc- 
 Clintock observes, a resemblance to the white muscular tissue of fish. 
 Often a number, springing from contiguous surfaces, seem to present 
 a large, broad-based growth, but on careful examination will show a 
 number of separated pedicles, and only an apparent coalescence. On 
 the skin they may be dry and hard, but when springing from a mucous 
 surface and constantly bathed in moisture, they are soft. Those occur- 
 ring within the vulva and vagina do not so much tend to assume the 
 polypoid form ; but the relative smallness of the base can always be 
 observed, and is quite characteristic. The surface of the growth is 
 always divided into small lobules with pointed ends, when not flattened 
 by pressure, like a cock's comb. Sometimes one pajDilla will be longer 
 than the others, giving a distinctly pointed shape to the whole growth. 
 The diiferences in appearance and shape are due only to environment. 
 
 If pregnancy coexist, the course of the disease is somewhat changed. 
 The w^arts then grow to a much greater size, and the number is also 
 greatly increased : the vagina is more likely to be affected. In the 
 vagina the warts are usually smaller and more rounded, resembling in 
 some cases granulations. They may cover the whole vaginal mucous 
 membrane, and even invade the cervix, covering its surface, though 
 there is no record of their having entered its cavity. With these 
 growths the discharge from the vagina is usually very profuse. It 
 is stated that after labor the growths rapidly diminish and disappear. 
 This observation we are unable to corroborate, never having seen such 
 a result, and Winckel states that it does not ahvays occur. Whether 
 the groAvths occur during pregnancy as a result of the irritation of the 
 increased discharge at that time, is unsettled ; but in my experience a 
 direct gonorrhoeal infection has ahvays been distinctly traceable. Given 
 the infection, the increased formative activity of pregnancy would be 
 enough to account for their rapid growth. 
 
 Etiology. — It is all but universally conceded that these growths are 
 due to the poison of gonorrhoea. They have incorrectly been attrib- 
 uted to syphilis, but clearly have not the slightest relationship with 
 that disease, though the two may undoubtedly coexist. Some author- 
 ities consider that other irritating discharges, besides those due to gon- 
 orrhcea, may be the exciting cause ; but this is rendered much less prob- 
 able now that the characteristics of chronic gonorrhoea are better under- 
 
 ^ Massot, De V Influence des Traumatismca sur les Grossesse, Paris, 1873. 
 
M-nv (niowTiis OF THE vriA'A. 533 
 
 httxid. That (lie i;iiii(irrli(r:il pnisoii may exist in tlic vagina, with an 
 aniitunt i>f (lis('liar;j;(' so small as to t'scapc notice, is certain (latent 
 «2;onoiTli(ea of \oeu<i'ei'titli) ; and, this being- the case, the poison (gei'in) 
 max l>c I'onnd in discharges chie primarily to cancel-, inflammation, or 
 other diseases. It is nearly certain that tiio presence of an irritating 
 <li.-cliarge withont the sju'cific cause of this disease is not en(»ngh to 
 eanse the Iniination of the gntwths. J'^irther ex|)ei-imentation and 
 ohservation is necessary to j)lace this among the acce]»ted facts, hnt 
 onongh has been done to render it all bnt settled, (jrernis, the gono- 
 c'occi of Xeissi'r, have been found in the growths themselves and in 
 the discharges accompanying them, and efforts liave been made at 
 transplantation ; but the results have been unsatisfactory and have 
 proved nothing. 
 
 lUdohx/ii. — The warts consist of a very delicate branching frame- 
 work of connective tissue, containing a few relatively large l)lood-ves- 
 sels, covered Avith a very thick layer of epidermis or epithelium. They 
 have not been observed on surfaces covered with cylindrical epithelium. 
 
 Trcat}nent. — Undoubtedly, the speediest mode of cure is to remove the 
 growths. This may be done with scissors, knife, or caustic. If simply 
 cut, a small pw'tion may be left, which will be the seed from which the 
 wart will grow again ; but if cut and the base cauterized, a certain cure 
 is arrived at. AVlien they are small, soft, and near together, the sharp 
 spoon mav be used with good effect, all bleeding points being afterAvard 
 touched with caustic or actual cautery. Numerous applications have 
 been advised which have for their object the drying up and gradual 
 (h^struction of the growths. Among these may be mentioned concen- 
 trated carbolic acid, chromic acid (gr. c-5J), Fowler's solution. Solu- 
 tions of corrosive sublimate in alcohol, and corrosive sublimate and 
 collodion (1 : 8), have been highly praised. Glacial acetic acid is 
 very effective, and lastly the tincture of Thuya occidentalis. This is 
 asserted to have a specific effect. The parts are to be kept constantly 
 moistened with it. It will be noticed that all these agents are para- 
 siticides. 
 
 In the pregnant state, if we accept the specific theory of causation, 
 it is certainly very necessary that the disease should be cured before 
 labor comes on. If the gonorrhoeal poison is left in the vagina, there 
 is danger of its extension during the puerperium, and also great danger 
 of ophthalmia for the newborn child. It is, however, impossible to 
 cure the gonorrhoea as long as the warts are left. The first step, then, 
 is to remove them, both from the vulva and from the vagina. In a 
 considerable number of cases the writer h;\.s done this at various stages 
 of pregnancy in the following manner : The patient being etherized, the 
 external warts were cut or scraped off, and their bases touched with a 
 point of silver nitrate or red-hot cautery, thus controlling all hemor- 
 
534 DISEASES OF THE VULVA. 
 
 rhao-e. In the vagina the growths were removed with the finger-nail 
 or sharp spoon. A very large cylindrical speculum was then intro- 
 duced, and after all blood-clots and discharges had been carefully 
 removed, an ounce of a solution of silver nitrate (3J to |j) was poured 
 in and the whole surface mopped over as the speculum was gradually 
 withdrawn. This application was repeated once in three days until 
 all discharge had ceased. Any remaining fragments of warts found 
 outside were treated with glacial acetic acid. If the urethra and other 
 passages were infected, they too were treated, as they might be a lurk- 
 ing-place for the poison and the source of a new infection. This method 
 will be found very eifective, and in no instance has the course of gesta- 
 tion been interrupted or hemorrhage at all severe. 
 
 Very large growths or masses may be removed by the galvano- 
 cautery wire. It is to be remembered, in all cases, that the mere 
 removal of the warts without curing the specific discharge will have 
 only a temporary effect. 
 
 Syphilitie condyloma, or mucous patches, are commonly found around 
 the vulva and vagina. They are flat, broad-based, and sometimes coa- 
 lesce, involving large surfaces. They are generally soft or spongy, and 
 are covered with a grayish secretion like mucus, which is said to con- 
 sist of softened and broken-down epidermic scales. They have no pedi- 
 cles, but are broadest at their bases. They are stated (Duhring) " to 
 sometimes take on action which results in the formation of luxuriant, 
 hypertrophic, warty, papillary growths," when they are easily con- 
 founded with the venereal wart. Local antisyphilitic treatment soon 
 causes them to disappear. 
 
 Cystoma. — Cystic groAvths are not very uncommonly met with in 
 the vulva. The majority undoubtedly have their origin in the vulvo- 
 vaginal gland ; but besides these there are cysts which possibly exist 
 as retention-cysts in Gartner's canal, and others which have their origin 
 in the capsule formed around old blood-clots. Another origin may be 
 found in the enlarged lymphatic spaces (Klob). Besides these, dermoid 
 cysts have been observed,^ but are extremely rare. 
 
 Cysts of the Vulvo-vaginal gland are true retention-cysts, and arise 
 from an obstruction in the duct of the gland, or from a stoppage of the 
 duct leading from a single acinus. They are found in the labia 
 majora in the region of the gland, and are usually round, smooth cysts 
 of varying size, but never reach any great magnitude. One observed 
 by the writer reached the size of an egg in seventeen years. When the 
 whole gland is involved they may be lobulated, corresponding to the 
 structure of the gland. 
 
 Cysts found in the upper part of the vulva near the meatus, and 
 ^ Kirmisson, An. de Gyn., 1874, p. 148. 
 
MJW (UIOWTIIS OF Till-: VIJIA'A. O.-Jo 
 
 sometimes exteiuliii;:; up tlu> anterior va<;inal wall, air tlioii<:lit to have 
 their ori;;in in (Jartiicr's canal, a lietal sti-iictiirc nsiially ohliicralcd, 
 Tlie othei" i'oiMiis ofcyst may l)c iuiind in any |i,iri dl'tlic vuKa, and are 
 sometimes veiy (leej\ extending;' intu the |)clvi>, uv arc lirnd\- attached 
 to till' hitne. 
 
 W'cn-likc tnniors I'onncd iVoin the oecliisioii of sebaceous {rJand.- have 
 been reported. 
 
 In a ease recently hroiiLiht to inc hy Dr. \\'. M. Hakcr (»l' Warren, 
 Pa., a eyst ot" the left hiMnin majus, nearly llmr inches long, jjrnjectintr 
 in such a way as to »;reatly resemble a ])enis, was c(»nnected throutih the 
 iniiuinal eanal witii a cyst ot" the abdomen reachinji' two-thirds of the 
 ^vay to the und)ilieus. The contents was a thin, watery fhiid with a 
 good many pus-eells. The cyst broke in the labium and emptied itself 
 entirely. I am not sure as to the nature of the eyst, but think it mav 
 be a hydrocele of the round ligament, which extended abo\'e the internal 
 abdominal ring and formed the tumor in the abdomen, as the point of 
 least resistance. When the sac in the vulva was open the finger could 
 be passed through the inguinal canal into the eyst al)ove. 
 
 The contents of labial cysts is usually a clear, watery fluid. Oeea- 
 sionally it is dark-brown, thick, or even purulent. The walls of the 
 sac are generally thin, but strong, and arc lined with epithelium and 
 firmly united with surrounding tissues. 
 
 Syiapfoms. — These cysts grow very slowdy, and at first cause no incon- 
 venience ; but occasionally they get large enough to interfere with coitus 
 and to cause discomfort, and even pain, in locomotion. Tliey may 
 become inflamed and suppurate, but usually only as the result of 
 mechanical violence. 
 
 Dinr/nosis. — Cyst of the vulva may be confounded with hydrocele, 
 hernia, abscess of the vulvo-vaginal gland, and hernia of the ovary. 
 The diagnosis can generally be made by the feel of the tumor, its situ- 
 ation and insensitiveness, and its long and slow growth. If doubt be 
 felt, tapping with a hypodermic needle is fully justifiable, and will 
 reveal the true nature of the disease. 
 
 Traifment. — We may extirpate the cyst by dissecting it carefully from 
 the surrounding tissues. If the cyst be superficial, this is undoubtedly 
 the most satisfactory method ; but if it is very deep and large, the ope- 
 ration is likely to be a difiicult, if not a severe one, as the hemorrhage is 
 apt to be consideraable. Great care should be taken daring the opera- 
 tion not to rupture the cyst. After it is removed the wound should 
 be lirought together with deep sutures, so as to get primary union. The 
 method of incising the cyst on its mucous surface, and then destroying 
 its lining membrane with caustic, Avill give good results; but the heal- 
 ing process is very sIoav, and the resulting scar quite large. .V lietter 
 plan is to pull up a portion of the sac-wall with a tenaculum, and cut 
 
536 DISEASES OF THE VULVA. 
 
 out a considerable portion with scissors. The interior of the sac can 
 then be painted with iodine and packed with gauze. Withdrawing 
 the fluid with an aspirator, and injecting a fe^v drops of iodine or 
 carbolic acid, will be enough to cause an adhesive inflammation and 
 destruction of the cyst, and is particularly applicable to small growths. 
 
 Gaseous Tumor. — Lusk^ has described a tumor of this kind. It 
 was an abscess of the vulvo-vaginal gland communicating with the 
 rectum. It is interesting from a diagnostic point of view. 
 
 Osteoma and Enchondroma. — These tumors have so seldom been 
 seen that they are simply surgical curiosities. Zweifel quotes a case from 
 Schneevogt of enchondroma of the clitoris as large as the fist. He also 
 mentions Beigel's case of ossification of the clitoris as belonging to the 
 same category, as Avell as a similar case mentioned by Bartolin. 
 
 Neuroma. — Simpson^ states that he has found neuromata or small 
 nodular tumors occurring under the mucous membrane around the 
 urethra, such as are found under the skin in other parts of the body. 
 He advises their extirpation, as the only hope of relief. Jackson^ 
 has described a similar case. 
 
 Kennedy* describes certain "sensitive papillse and warts" which, he 
 says, are exquisitely painful and often very small. They were found 
 on the labia minora and in the vestibule, and occurred after labor, from 
 imperfectly-cured ulcerations. He advises removal with the scissors. 
 
 Angioma. — Sanger^ reports a case of congenital angioma in a child 
 ten weeks old. The right labium majus was affected. The tumor was 
 like a cock's comb, 3 cm. high, 1.5 cm. broad, and 1 cm. thick. It 
 had grown rapidly since birth. Hennig met with a similar case in 
 a child two years old. Sanger's case was perfectly cured by excision 
 and suture. Some fibroids have a more or less angiomatous structure. 
 Thomas describes a disease affecting the urethro-vaginal tubercle to 
 which he gives the name of " urethral venous angioma." It closely 
 resembles irritable caruncle, but is to be distinguished from it by its 
 want of sensitiveness. 
 
 Melanoma. — Several cases ® of this kind have been reported, gen- 
 erally as melano-sarcoma. The tumor may be extirpated, but will be 
 
 1 Am. Journ. Obstet., 1880, p. 389. ^ Works, 1872, p. 784. 
 
 ^ See article on " Sterility. " * Med. Press and Circ, June 7, 1 874. 
 
 s Centralbl. /. Gyn., 1882, p. 175. 
 
 « H. Green, N. Y. Journ. of Med., 1844, ii. p. 323; Miiller (for Martin), Berl. klin. 
 Wochenschrifi, 1881, No. 31 ; Bull. Soc. Anal, de Nantes, 1878-79. 
 
m:w anoWTUs of 'iiir: vilva. .037 
 
 <|iiit(' llkclv to rcliini, tlioiii;li Marlin's m'coikI case is i-cportcd tu have 
 Ix'cii niiH'd. 
 
 Saucoma. — Sjircoinn (»(' tlic \iilva is furtmiatdy amoii^ tlic rarest 
 forms (if new i;i-o\\lli round in lliis siliiali(»n. Wiiickcl ' reports Itnt 
 2 anion^' 1 ()(>,()( )0 iixiiccolonical cax's. (Jiirlt's statistics show, aiiioiiir 
 4S;J easi's of sarcoma, 1 of the urethra, ."> of the reetutn, 1 of the 
 vainiiia, <S of the uterus and ovary, 150 in the lireast, and none in 
 the \nlva. His observations extended over twcntv-four vears, and 
 inehided 11,140 women with tumoi's. 
 
 'I'here are scarcely enonuh eases recorded to enable us to (h-aw a dear 
 picture of the (hsease. In some instances it seems to l)e oi-iuinall\' a 
 jH'iHeuhited tumor without nh-eration. Such Avas tlic ap])caranee in a 
 case seen hy the writer. The rate of j^rowth is often very slow, and the 
 tumor may he mistaken for a petliculated lipoma (Winckel) or fibroma. 
 In other cases the tumor breaks down and forms an nicer, which i-apidlv 
 <^xtcn<ls until the whole vulva may be involved (Hildebrandtj. There 
 is generally a marked tendency to hemorrhage, which reduces the pa- 
 tient very fast, even wlien the tumor is quite small. Soft and spongy 
 tumors are particularly apt to bleed. 
 
 The varieties of sarcoma which have been met with are the round 
 cell, spindle cell, melanotic, and myxo-sarcoma. 
 
 The prognosis is exceedingly bad, as in every case so far reported, 
 sooner or later, there has been a return and a fatal result. In the spin- 
 dle-cell variety early and complete extirpation might result in a cure. 
 
 Treatment. — The only thing to be done is to at once remove the 
 groAvth as completely as possible, either by the knife or the cautery. 
 The rules for operating are the same as for other tumors of the vulva. 
 
 Caxcer. — Frerjiienc}/. — Cancerous disease in the vulva is more fre- 
 quent than sarcoma. Meyer places the relative fre(piency of tumors 
 on the sexual organs as follows : Uterus first ; then brea.st, ovaries, 
 vagina, and vulva, in the order named. Gurlt^ found, among 16,G37 
 tumoi-s, 11,140 of the sexual organs; of these, 7479 were cancer, of 
 which 72 only were on the vulva. A large share of all malignant 
 tumors of the vulva are epitheliomata. 
 
 Varieties. — AYe commonly divide cancer into two forms — carcinoma 
 and epithelioma. These ditfer somew'hat in their anatomical structure, 
 and also in the mode of growth as well as in prognosis. 
 
 EpitheJioma (cancroid) is l>v far the commonest. The tumors are 
 ilistinguished microscopically by the peculiar arrangement of their 
 cells. Besides containing cells which resemble the normal epithelium 
 of the ]iart in which thev oriuinate, they also contain, in the alvivill of 
 
 ' I'dtltiilof/ir (I. ]Vcib. Sesmdonjanc. ' Quoted l>y Wiiu'kel, loc. cit. 
 
538 DISEASES OF THE VULVA. 
 
 the connective-tissue stroma, or within the lymph-spaces, numerous 
 nests or " epithelial pearls." These nests consist of collections of thin, 
 dry, horny cells resembling epidermic cells, and are often visible to the 
 naked eye, as they are of a yellowish color. The sebaceous glands are 
 usually implicated in the general proliferation, and show under the 
 microscope masses made up of their characteristic epithelium. These 
 tumors tend commonly to remain near the surface, and to extend above 
 it in the form of papillary masses, rather than to infiltrate the deeper 
 tissues. The surface is generally necrosed, forming ulcers. 
 
 Seat. — The most common seat is a question of dispute, but any por- 
 tion of the vulva or mons is liable to be affected ; the labia majora, 
 esj)ecially the upper third, and less often the clitoris, being quite com- 
 monly attacked. 
 
 Clinical History. — The growth begins usually with one or more nod- 
 ules, which are under the skin or mucous membrane, but to which the 
 overlying tissues are firmly attached. The epithelium over the tumor 
 is at first generally thickened, so as sometimes to form a sort of callos- 
 ity (Mayer), though it must not be forgotten that such a thickening of 
 the epidermis may occur independently of epithelioma. The nodules 
 may reach a considerable size and invade the deeper tissues before 
 ulceration begins ; but sooner or later this characteristic sign shows 
 itself. The growth now extends in every direction, the ulcerated sur- 
 face growing with it. jN^ew papillae appear through the ulcer, form- 
 ing fungating masses. The usual tendency to decomposition of the 
 discharges is not so marked as when the growth occurs within a closed 
 cavity, as the vagina. The disease remains as a local affection for a 
 comparatively long time, though portions lying against the diseased 
 surface may be infected (Zweifel). Enlargement of the inguinal 
 glands on the affected side occurs late in the disease. In the begin- 
 ning the growth attracts but little attention : there may be some burn- 
 ing and itching, or difficulty or pain in micturition, and the patient 
 may discover it only by accident, when scratching or washing her- 
 self. After ulceration has set in the course of the disease is more 
 rapid, and death follows usually within two years (Zweifel). Pain 
 may be entirely absent through the whole course, or it may be one of 
 the most prominent symptoms. Death occurs from exhaustion due to 
 septic infection ; severe hemorrhages are rare. 
 
 Cause. — Of this we know nothing. The age of the patient seems to 
 have a predisposing influence. The larger number of cases occur 
 between the fiftieth and sixtieth years, and about an equal number 
 in each of the decades immediately preceding and following. Local 
 irritation, as from a fall, a blow, or long-continued itching, has been 
 assigned as a cause. 
 
 Diagnosis. — The diseases most likely to be confounded with epithe- 
 
A7;H' alinWrilS OF Tin: 177. IM. 'ilW) 
 
 lloiici arc lupus ami s\|iliilis. 'I'lic history of" tlic ••asc will, liowcvcr, 
 ciiaMc us to (listin^uisli iM-twccu tliciu iti almost every iu-tauee. 
 S\|iliilis will lia\'e liceii preceded hy oilier iiiaiiire>talion> of the 
 (lisea>e ; whih' the lonjx ehroiiie eouix- ol' lu|»us, the ahsciU'c ol" paiu, 
 the eieatrization eoiueident with uh-eratiou, the ahseuee ol' the <'ha- 
 raeteristie watei'v, t'oul disehariic, and the ticiieral j^ood health ol" the 
 patient will serve to (list iiiifiiish that alleetion. In epithelioma the 
 ulei'r s|)rea(ls ra|)idly ; the vihj;v> are hard ami livid ; the base is sof'tei- 
 than the edo-es ; and the surfliee is covered by dirty, hroken-dowu 
 tissue, throUL:;h which projections and papilhe <•!' newly-t'ormed ti>sue 
 luav apjH'ar. There is no teiuleney to cicatrization ; later on the inirui- 
 nal irhiiids become atfectetl, M'hich is not the case in lupus, while in 
 sy[)hilis the enlarixement occurs very early or even antedates the ulcer- 
 ation. It" doubt exist, a microscopic examination of" a small piece will 
 settle the ([uestion. 
 
 P/w/((o.v/".s. — The pro<i;nosis is hopeless unless the tumor is completely 
 removed at a very early stage. The course of this affection is chronic, 
 ruiHiing as long as two or three years ; sometimes it is mucli more rapid. 
 Recurrence after removal may be delayed for a number of years or may 
 never happen. If the whole disease is not removed at the time of ope- 
 ration, it returns at an early date. 
 
 Treafmcnf. — There is but one plan which offers any hope of cure, 
 and that is complete and early removal. This may be done by caus- 
 tic, actual cautery, or the knife. The elastic ligature has also been 
 proposed. The knife, followed or not as the case may be by further 
 destruction of tissue, offers the best chance. The application of the 
 thermo-cautery to a large ulcerating surface has in my hands only 
 been followed by an increase of pain and a more rapid growth of the 
 tumor. It is impossible to thoroughly destroy the growth in this way. 
 If so situated that the knife cannot be used, a caustic paste would seem 
 to offer the best chance of deeply destroying the mass. AVhen the 
 inguinal glands are involved, Kustner^ advocates their removal, even 
 opening the ligamenta lata and dissecting out all the diseased structures. 
 If the primary affection can be entirely eradicated, thus giving hopes 
 of a cure, it would seem decidedly best to follow his suggestion ; but as 
 the enlargement of the glands usually takes place late in the disease, 
 when the chances of entire removal are small, the adoption of this jdan 
 will not often be likely to be followed by benefit. It adds to the diHi- 
 culties, but not much to the danger, of the operation. 
 
 Carcinoma. — Under this head we have two forms — medidlarv or 
 soft cancer, and scirrhus or hard cancer, also called atrophic cancer and 
 fibro-carcinoma. Melanotic cancer has also been observal (Klob and 
 others). All of these forms are very rare. They occur primarily on 
 
 ^ Zeilsch.j. GebnrL^. und Gyn., vol. vii., 1881. 
 
540 DISEASES OF THE VULVA. 
 
 the labia majora, and with relative frequency on the clitoris, and gener- 
 ally in women upward of sixty years of age. 
 
 In true cancer the epithelial cells fail of any special characteristic 
 shape, but may be of all sorts of irregular forms. The cells are packed 
 too-ether irregularly in follicles or cavities in the midst of a connective- 
 tissue stroma. It is the relative amount of connective tissue which 
 makes a hard or soft cancer. It begins deeper in the tissues than 
 cancroid, and extends widely and deeply before breaking down. It 
 always forms projecting masses. The ulcers are covered with foul 
 discharo;e and broken-down tissue. There is considerable tendency to 
 hemorrhage, especially in the soft variety, and pain is usually much 
 more severe than in epithelioma. 
 
 The prognosis is eminently unfavorable. Hildebrandt stated that he 
 was able to operate in two cases at a very early stage, but without suc- 
 cess. The disease returned in the scar. The lymphatic glands are 
 affected easily. Still, if seen in the beginning, an operation for the 
 complete reinoval is not only justifiable, but imperatively demanded. 
 
THE INFLAMMATORY AFFECTIONS OF THE 
 
 UTERUS. 
 
 Bv C'lIAUNCEV 1). I»AI..MK11. M. I)., 
 
 ClXClNXATI, (J. 
 
 Acute Endometritis. 
 
 Definition and Synonyms. — Acute endometritis sifinifie.s an acute 
 inflamniation of the mucous liuinii; of the uterus (endometrium). It 
 has been called acute uterine leucorrhoea, or catarrh, and acute inter- 
 nal metritis. 
 
 Pathological Anatomy. — There is a turgescenee of the vessels 
 of the nuicous membrane, with infiltration of serum, and even lymph- 
 cells, within its tissues, consequent oedema and softening. Accompany- 
 ing these there is more or less catarrh of the mucous surfaces, possess- 
 ing features of the secretion of (a) the cervical canal, which at first is 
 transparent and vitreous, afterward turbid and muco-purulent ; (6) of 
 the cavity of the uterine body, which is thinner, more serous, then pur- 
 ulent, and often streaked with blood. An abundant formation and 
 desquamation of epithelial cells, exfoliated pieces of mucous mem- 
 brane, casts of utricular glands, with an escape from the vessels of 
 lyni])h-cells and a few red blood-corpuscles, characterize the morpho- 
 logical elements of the catarrhal fluid. According to Scanzoni, the 
 surface is often, at portions corresponding to the openings of the utric- 
 ular glands, covered with bright red spots encom])assed by a network 
 of deeply-injected capillaries. In severer cases the submucous layers 
 of the parenchyma become hyperremic, softened, and pul]iy. The os ex- 
 ternum l)ecomcs tumid, the labia ]^utfv, de]irived of epithelium, and pre- 
 sent the appearance of erosion. The uterine cavity is increased in size. 
 
 The best opportunities for studying acute endometritis in the dead- 
 house occur in fatal cases of the acute exanthemata. The extent of 
 the surface involved varies considerably in different cases, and is nuich 
 modified by the causative influence. 
 
 The disease maybe limited to the cavity of the cervix and the ri'ginn 
 of the OS externum, to the cavity of the body, or it may extend through- 
 out the whole uterine canal. 
 
 541 
 
542 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 Frequency. — Concerning this point there is a wide difference of 
 opinion among prominent authorities. By some, Klob, Thomas, 
 Priestley, Edis, and Barnes, it is regarded as a frequent affection. By 
 others, Schroeder and Byford, it is thought to be rare. Without doubt, 
 it is not found prior to puberty, and probably the corporeal mucous 
 membrane is more often attacked than the cervical. When we con- 
 sider the accessibility of the endometrium to external agencies and 
 injuries, not only in parturition and in the lying-in, but also in the non- 
 gravid state, the liability to the upward extension of specific inflam- 
 mation of the vagina, together with the special physiological vascularity 
 of its tissues, oft recurring, it would seem a matter of surprise that any 
 one could doubt the frequent occurrence of endometritis as an acute 
 affection. There is every reason to believe that the disease is often 
 overlooked until it has subsided into the chronic stage. 
 
 Etiology.-^1. Traumatic Causes. — Under this head are included 
 direct injuries to the uterus by excessive coitus, the use of sounds, tents, 
 intra-uterine pessaries, the operation of incision of the cervix, removal 
 of intra-uterine growths, the use of the curette, and intra-uterine injec- 
 tions. Carelessness in the use of vaginal injections may likewise be so 
 classified. 
 
 2. Certain chemicals, as caustics, the local action of which is violent ; 
 for instance, the introduction of a crayon of pure nitrate of silver within 
 the uterine cavity is liable to excite inflammatory mischief of the endo- 
 metrium. 
 
 3. Extension of gonorrhoeal inflammation from the vulva and vagina 
 may be ranked as among the most frequent and serious of causes. This 
 form of the disease is too frequently not limited to this territory, but 
 extends farther, through the Fallopian tubes and to the pelvic peri- 
 toneum, producing what M. Bernutz so aptly called " female orchitis." 
 Vaginitis of a non-specific character does not possess this tendency to 
 extension. 
 
 4. Sudden suppression of the menstrual flux from cold or mental 
 excitement. 
 
 5. The progress of the exanthematous fevers, rubeola, scarlatina, 
 variola, also of typhoid fever, cholera, and phosphorus-poisoning, 
 sometimes so operates. Kiwisch has spoken of " metastatic constitu- 
 tional catarrh," referring to this class of cases. 
 
 6. The introduction of putrid materials from without, as well as the 
 decomposition of substances, solid and fluid, within the uterus, as the 
 products of conception, remains of tumors, retained menstrual fluid, 
 etc., is an active exciting cause. 
 
 In the puerperal form of the disease the. origin of the mischief is 
 probably the placental site. Aside from the local injury by contusion 
 and laceration received in parturition, the septic factor, whether auto- 
 
ACVTK i-:si)<)Mi:'ri:rris. rj4;j 
 
 JJOnctic nr llctCl'Oii'CIU'tii', is llic mo.-l illl|iiil-|;ili|. Aclilc |il|(|'|i(r;il cinlii- 
 
 m('trili-> i-- iisiuilly septic in clini.-utcr. 
 
 A slii(l\' (tf (he ctioliiLty iiiakv's it clc.-ii' tli;it in inu-t in~t;nic('s tin- 
 intl;innn;itnrv iictioii is lU'ct'ssai'ily extended t liroiiLilinnt tlie (ii'iian. 
 Acute enduiiK'tiMtis is, as a I'lllc, li-eiXTal. 
 
 SvM !• I'. )MA It »i.< )(i^■. — WHien arisinii" from tranniatic or septic causes 
 the disease nia\' l»e usliered in l)\" a rii^or, not so proiionnee(| a> in jn'ri- 
 iit(>rin(> inllainniatioiis, followed hy felirile plieiionieiia. The local symp- 
 toms are pain ol' a didl, aeliini;' kind, willi dra<i'<:in<;- seiisiitions within 
 the pelvis and hack; there is tenderness o\-er the hyp()i;astrie rej^ion ; 
 there ina\' he rectal and vesical tenesmus, liarely are the symptoms 
 of a violent character. Should the vesical irritation be prominent and 
 the other symptoms he ill defined, the affection may be taken for cysti- 
 tis. Sudden attacks of diarrhoea from reflex irritation of the n^etal 
 nerves are occasionally manifest. The diseharg-e per vaginam is at first 
 slight and serous ; in a day or two more free and nnieous ; then muco- 
 purulent or purulent, and sometimes bloody. It is offensive in septic 
 cases, and at times so acrid as to occasion excoriation of the vaginal 
 and vulvar surfaces, with an aggravating pruritus. 
 
 PiiYsu'AL Signs. — On digital examination the os will be found to 
 be more or less open, the cervix somewhat swollen, the uterus tender, 
 softened, and slightly enlarged. Its position is lower within the pelvis. 
 Bimanual exploration confirms these signs. Tlie sj^eculum shows the 
 cervix swollen, red or livid, oedematous, eroded. If the inflammation 
 is confined to the upper cavity, no special change in the cervix is notice- 
 able, save perhaps a slight alteration in the color of its mucous mem- 
 brane. In all cases the characteristic discharges will be seen pouring 
 from the cervical canal. 
 
 The above signs having been detected, the probe or sound ought not 
 to be emploved, for its introduction is attended with pain and an aggra- 
 vation of the existing disease. Nor should the speculum even be intro- 
 duced if the digital examination detects pronounced tenderness of the 
 uterus. 
 
 Diagnosis. — Acute endometritis is to be differentiated from acute 
 vaginitis, pelvic cellulitis, ])elvic peritonitis, and metritis proper. Any 
 or all of tliese may complicate it. From the first it is easily diagnosti- 
 cated by a greater general disturbance and pain, a different location of 
 tenderness, the character of the discharge, and the presence of the signs 
 referred to. 
 
 Pelvic cellulitis and peritonitis are each more frequently ushered in 
 Avith a rigor, f )ll()wed by a higher temperature, greater constitutional 
 disturbance, together with more severe loe:d pain and tenderness. Be- 
 sides, in these two jieriutcriue inflammations the presence of infiltrations 
 around the cervix above the vaginal vault, a consequent displacement 
 
544 THE I^^FLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 and diminished mobility of the uterus, are changes which in a few days 
 are so well defined that clearness in diagnosis is established. Both of 
 these affections uncomplicated are unaccompanied with any special 
 uterine catarrh, though menorrhagia or metrorrhagia is a frequent 
 attendant. 
 
 The diagnosis between acute endometritis and metritis proper will be 
 referred to hereafter. 
 
 PeoGi^OSIS. — Acute endometritis is, ordinarily, not an affection dan- 
 gerous to life. Mild cases are recovered from, the existence of which 
 has hardly been suspected. Prognosis is most grave in the septic and 
 traumatic varieties, the unfavorable elements being the supervention of 
 general septicaemia and the extension of the inflammation through the 
 Fallopian tubes to the pelvic and general peritoneum. When gonorrhoea 
 enters into the causation the disease is exceedingly prone to this exten- 
 sion and indefinite continuance. 
 
 A sound constitution, free from diathesis, favors a speedy recovery. 
 As the uterine mucous membrane is quickly degenerated, so with favor- 
 able general health it is actively regenerated. Therefore, the most 
 unfavorable aspect of acute endometritis is the marked tendency in 
 many constitutions for it to become a chronic disease. 
 
 A strumous, tubercular, or syphilitic diathesis, a condition of ansemia 
 or impaired general health at the time of the inception of the disease, 
 favor its perpetuation. Recovery is often only partial when it is sup- 
 jDOsed to be complete. Successive menstrual approaches tend to rekindle 
 the symptoms. We can be certain of the accomplishment of a cure only 
 when one or two such periods have been passed without relapses. 
 
 Treatmext. — The first and most important indication of treat- 
 ment is rest. In the recumbent posture the affected organ is placed 
 at rest, pain is mitigated, and the pelvic circulation favorably modi- 
 fied. The suggestion of rest becomes unnecessary in severe cases, 
 but in the milder forms of the disease, when the patients are going 
 about or on their feet, the injunction is imperative. Rest is to be main- 
 tained so long as there are pelvic pain and uterine tenderness. Precau- 
 tion is essential at the approach and during the first and second suc- 
 ceeding menstrual epochs. Rest and the absence of pain are likewise 
 secured by the administration of opium in some of its forms. For this 
 purpose a very desirable channel for medication is the rectum. Ordi- 
 narily, in this way it requires a quantity of the drug slightly in excess 
 of the dose by the stomach to obtain the desired effect. A suppository 
 of morphina sulphate (gr. |— ^) is to be introduced every few hours if 
 pain is present. The rectum should be unloaded of any fecal accumu- 
 lation by an enema or a mild saline cathartic. Active purgation is 
 ahvays to be avoided. 
 
 The febrile movement is controlled by the above-mentioned means 
 
Arm: j:.\i)')Mi:ii:rns. oi.j 
 
 ami the iiitonml adiniiiistratioii of tlu- tiiictun" of ac<»nitc' or vcratriim. 
 Norwoixl's tiiictiirc of vci'ati'iiiii vii-idc in small doses is a valuable 
 a>'eiit to re<:;iilate llic (irciilatioii and Hin-ilc -yinptonis in all the 
 aeiite nelvie iiiMaiuiiiati(tiis. Its use is euntraindicatcil <Mdy in cas*.'?: 
 of marked asthenia or al'ter septic absorption. 
 
 The diet should be easy of digestion l>ut supporting; concent rate<l 
 foods, as beef-juice and milk, are the best. 
 
 The local abstraction of blood by leeches or otherwise, the u.-c of 
 mercurials in anv stage of the disease, are not only unnecessary, but 
 prejudicial to a speedy recovery. Reference, of course, is not made to 
 those cases complicated with periuterine inflammations, in which one or 
 both of these agents may be especially indicated. 
 
 Fomentations are always grateful to the patient. There is n(^ more 
 convenient or efficacious means of ap])lying heat and moisture than by 
 a hot flaxseed poultice, the prepared material spread between thick 
 muslin and mosquito netting, covered with ttiled silk, the whole poul- 
 tice large enough to envelop the entire abdomen. 
 
 Vaginal injections, with water in large quantities, as h(jt as can be 
 borne (100°-12()° F.), projected against the cervix and the surround- 
 ing vaginal vault, with the patient on the back, the pelvis higher than 
 the shoulders, the current of water being received into a vessel at the 
 side of the bed by means of a rubber blanket, keep the cervix and 
 vagina clean, prevent secondary vaginitis and vulvar })ruritus, and act 
 as pcjultices to the interior of the pelvis. These injections should be 
 repeated from two to t\mr times a day. Beyond this n(» local treat- 
 ment is required. 
 
 Sept'iG en<Joiiietrifis, arising from a retained ovum, placenta, clots of 
 blood, or remains of disintegrating tissues, demands the local employ- 
 ment of antiseptics, as carbolic acid, boric acid, bicMoride of mercuiy, 
 or permanganate of potash. The bichloride (1 : 2000-8000) is the best 
 known parasiticide. In all eases with offensive discharges the injected 
 solution within the vagina should contain one of these remedies ; and 
 in those with symptoms of systemic absoqjtion, manifest or threatened, 
 the same kind of solution, though weaker, is to be carried within the 
 uterine cavity. It must be admitted that certain risks attend intra- 
 uterine injections, even under the circumstances of a large uterus, a 
 patulous canal, and a free exit for the fluid. But the risks are not 
 great. Compared with the dangers of septic absoqotion, or the 
 urgency for the removal and disinfection of septic matter, fresh 
 invoices of which by a continuous or intermittent imbibition into the 
 vascular system are being kept u]), these risks are very small indeed. 
 Fortunately, the uterus is in a condition less susceptible to these risks 
 of shocks, retention of the fluid and distension of the cavity, the pas- 
 sage of the same into the peritoneal cavity, etc., when the urgency for 
 Vol. I.— 35 
 
546 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 the employment of antiseptic injections is greatest. Nevertheless, the 
 utmost precaution ought to be instituted. The fluid is to be warmed, 
 injected slowly and without force, and the instrument conveying the 
 current so constructed as to permit a ready exit of the stream. The 
 canula of the author (Fig. 179) will be found useful. The frequency 
 
 Fig. 179. 
 
 Palmer's Reflex-current Canula, for washing out the uterus. 
 
 (one to four times per diem) of these injections is determined by the 
 amount of local sepsis, together with the general septicsemic phe- 
 nomena. 
 
 The general treatment also demands modification in septic cases. 
 Quinina in large doses (grs. xx-xxx), to reduce high temperatures, 
 to antagonize the poison after its absorption, and to support the vital 
 powers, is strongly recommended. Alcohol, acting in the same man- 
 ner,, is of immense value. It is to be given in large doses also. 
 Quinina in tonic doses is always beneficial in the stage of convales- 
 cence of all varieties of acute endometritis. 
 
 Acute Metritis. 
 
 Acute metritis, or acute parenchymatous metritis, signifies an acute 
 inflammation of the fibrous structure of the uterus. In speaking of 
 the subject of acute endometritis reference was made to the fact that 
 the uterine parenchyma sometimes becomes involved in the inflamma- 
 tory changes occurring in the endometrium. Unquestionably, these 
 changes in the contiguous layers always occur in severe endometritis. 
 Likewise, Avhen the serous envelope is afiected in acute pelvic perito- 
 nitis the inflammation dips down into the subperitoneal parenchyma. 
 
 Frequency. — It is a matter of disputation whether acute metritis 
 ever exists as an independent aflection. If we are to accept the testi- 
 mony of the dead-house, the only reliable witness, the question must 
 be decided in the negative. 
 
 Klob says : " Inflammation of the substance of the non-gravid uterus 
 seems to be one of the rarest affections to which this organ is liable. I 
 have not met with a single case which, with any degree of certainty, 
 I could pronounce to be one of genuine metritis." Rokitansky remarks 
 that "in acute inflammation of this organ generally the lining membrane 
 of the uterus is aflfected primarily, and that this is scarcely ever the 
 
ACUTE METRITIS. 547 
 
 case with llic iitci-Iiir tissue, :is l:ir :is can he (Iciiionsli'ad'd 1»\- the j)atli- 
 ()I()^•i(■al aiialoiiiist, with tiic exception ol" the reaction lolhtw inj;- traumatic 
 inHiiences, especially of th(! va«^inal poi'tion." Schroe<h'r, who contends 
 for its occnrrcnce, achnits that it is a very i-are «lisca.se, and always comph'- 
 cated with acute endometritis. Thomas no ioiiticr devotes an independent 
 i'hapter to the subject, a:ul regards metritis merely as a complication of 
 endometritis. As this author pertinently remarks, with the light of 
 the present state of knowledge acute ])arenchymat(»us metritis should 
 be placed in a subordinate instead of a j)rominent j)lace in uterine 
 pathology. The descriptions of most of the older authorities have 
 been transferred to us as matter of literary tradition, and not clin- 
 icid research. 
 
 What Virchow designated as " diffuse puerperal metritis " — a puer- 
 peral form of inflammation prevailing when certain epidemic influ- 
 ences are at work, possessing great resemblances to erysipelas on the 
 surface of the body — is in all probability endometritic, and not 
 metritic. 
 
 The following propositions, in the light of modern investigations 
 post-mortem and at the bedside, may be deduced : 
 
 1. IMost cases of supposed metritis are instances of inflammation of 
 the endometrium or the periuterine tissues. 
 
 2. Localized metritis, contiguous to the mucous layer, is resultant, 
 not unfrequently, on severe endometritis. 
 
 3. Parenchymatous metritis, complicated with and resultant on endo- 
 metritis, is more frequent and extended in the puerperal than the non- 
 gravid organ. 
 
 4. Pure and uncomplicated parenchymatous metritis rarely, if ever, 
 occurs. 
 
 Pathological Axatomy. — The changes which are noticeable are 
 h}'per£emia, tumefaction, and infiltration with serum. The uterine \valls 
 are succulent, sofltened, and at times ecchymosed. Small collections of 
 pus-corpuscles may be found between the muscular fasciculi and in the 
 uterine veins. Abscesses of any dimensions are extremely rare even 
 when puerperal. A uterine abscess may perforate, and, according to its 
 situation, open into the uterine or vaginal cavity, or outwardly into the 
 peritoneal cavity, or if proper adhesions are formed into the intestines. 
 Cases of perforating abscesses have been described by Kiwisch, Scan- 
 zoni, Bird, Rcinmann, and many others. These abscesses sometimes 
 depart from their usual course, and instead of evacuating in the sur- 
 rounding cavities the incarcerated pus undergoes caseous, fatty, or cal- 
 careous degeneration, then absorption, or becomes enclosed in a cavity 
 by a growth of the surrounding connective tissue. 
 
 Puerperal metritis is frequently associated with lymphangitis and 
 phlebitis and their sequelae. Sometimes the peritoneal envelope of the 
 
548 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 uterus is covered with fibrinous exudations. All the changes in the 
 uterine walls are most marked nearest the mucous membrane. 
 
 The disease may terminate (a) in resolution with absorption of the 
 exudation ; (6) in proliferation of the connective tissue with permanent 
 enlargement ; (c) in induration and atrophy. 
 
 It is most probable that the condition of the uterus called superinvo- 
 lution, first described by Simpson, is resultant on acute parenchymatous 
 metritis in the puerperal state. 
 
 Etiology. — Acute metrititis is developed either as an extension of 
 endometritis, or it arises from lesions in the puerperal bed. 
 
 Symptoms and Signs. — Though more severe, the symptoms are the 
 same as in acute endometritis, with which it is probably always asso- 
 ciated. To touch and bimanual examination the uterine body, espe- 
 cially in its antero-posterior diameter, is much enlarged, somewhat 
 doughy, and very tender. 
 
 Diagnosis. — The marked enlargement and sensitiveness of the uterus 
 are the reliable local evidences. They are associated with the general 
 febrile phenomena. Small collections of pus cannot be recognized. 
 Larger accumulations may be diagnosticated by the gradual increase 
 in the size of the organ, a localized elasticity of its tissues, if not fluc- 
 tuation. 
 
 Peognosis. — The prognosis is more grave than in j^ure endome- 
 tritis. 
 
 Treatment. — The same principles of treatment laid down for acute 
 endometritis are also applicable to acute metritis. 
 
 Bibliography. 
 
 Baknes, R. : Diseases of Women, 2d ed. 
 
 Berntjtz and Goupil: Diseases of Women, translated for New Sydenham Soc. 
 
 (1857). 
 Byford, W. H. : Medicine and Surgery Applied to Women, 3d ed. 
 Edis, a. W. : Diseases of Women (1882). 
 KiwisCH : Klinik Vortrdge. 
 
 Klob: Pathological Anatomy of Female Sexual Organs. 
 Priestley, W. O. : Reynold^s System of Medicine, vol. v. 
 BoKiTANSKY : Pathological Anatomy. 
 vScANZONi : Diseases of Females. 
 
 ScHROEDEK, C. : Diseases of Female Sexual Organs (Ziemssen's). 
 Simpson, Sir Jas. Y. : Works of, vol. iii. 
 Thomas, T. G.: Diseases of Women, 5th ed. (1880). 
 
 Chronic Endometritis. 
 As does acute, so chronic inflammation also may attack the diiferent 
 tissues and parts of the uterus. While acute inflammation is noted for 
 the suddenness of its inception, the rapidity of its progress, and its com- 
 
ciiRoxrc CKiiVicAL j:.\iK)Mi:Ti:fTis. 549 
 
 parativcly sluirt duration, cliivtiiic iiillaniiiialioiis, on the (ttlicr hand, 
 aiv inaniUstcd l>y tlicir insidious infcption, slow progress, lon^- dura- 
 tion, ami coiiiparatixcly mild s\ niplonis. 
 
 DKKiN'rnoN AM) SY^■()^"^■Ms. — ('ln-onic cndoinctriti.s sijrnilics ;i 
 clironic inflaiiiniation of the liiiinu- nnicous nicndiranc of tlic uterus, 
 and is known l)y llic name of clirctnic uterine Ieneoi*rlia;a or eatarrli. 
 Confined to tlie cervical canal, it lias been called hy the hyijrid tei in, 
 "chronic cndoccrvicitis," also "cervicitis," but inap})ropriately. The 
 term " cudotraeholitis " is proper, and that of "chronic cervical endo- 
 metritis " defines very correctly both the nature and the scat of the 
 atlection when the cervical canal alone is involved. Limited to the 
 corporeal cavity of the uterus, the disease has been entitled " chronic 
 internal metritis," also " fundal endometritis." But for reasons just 
 stated this form of the disease is best known by the appellation of 
 "chronic corporeal endometritis." 
 
 Divisions. — Three varieties of chronic endometritis are recf)":nized, 
 a division which clinical experience and post-mortem examination sanc- 
 tion. Thus : 
 
 1. Chronic cervical endometritis; 
 
 2. Chronic general endometritis ; 
 
 3. Chronic corporeal endometritis. 
 
 This is the order of frequency of the different varieties. 
 
 It has been observed for a long time — a pbint persistently held by 
 Bennet — that chronic inflammation very often confines itself to one por- 
 tion of the uterus, especially the cervix, without invading the other. 
 Various reasons have been assigned for this peculiarity of self-limita- 
 tion of the chronic type of the disease, which does not hold true in the 
 acute. For the most part, these reasons jiertain to the diiferences, both 
 anatomical and phvsiological, between the cervix and corpus uteri. 
 The decided distinction in the pathological proclivities of the two 
 parts is also evidenced by the frequent sharp limitation of tubercular 
 disease to the body, and cancerous disease to the neck, of the uterus. 
 
 The three forms of chronic endometritis will noAv be consideretl in 
 their order. 
 
 CHRONIC CERVICAL ENDOMETRITIS. 
 
 Frequency.- — It is more than probable that chronic inflammation 
 of the mucous membrane of the cervical canal and the exterior of the 
 infravaginal cervix is the most frequent disease of the female pelvic 
 organs. A vast majority of all women seeking advice for chronic pel- 
 vic disease have this aifection, either independently or complicating 
 some other. Considering the position of the cervix, its exposure to 
 injury in coitus and parturition, this statement excites no surprise. 
 Chronic catarrh of the cervical canal is infinitely more frequent than 
 of the upper uterine cavit}\ 
 
550 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 Pathological Anatomy. — Chronic cervical endometritis is essen- 
 tially a glandular disease. The first step in the pathology is a hyper- 
 emia of the peculiar follicles of the cervical canal, the glands of Naboth. 
 These become swollen, enlarged, elevated, with dilated mouths, and in 
 consequence there is a hypersecretion from them. Increased is soon fol- 
 lowed by an altered secretion. At first it is thin, glairy, alkaline, like 
 the white of an egg ; then it becomes thicker, more tenacious, and 
 adhesive ; later, decidedly albuminous, loaded with epithelial cells ; 
 and finally it may be yellow and tinged with blood. Within the 
 vagina, owing to an acid secretion, the discharge sometimes assumes 
 the appearance of coagulated white of egg. Another feature of its 
 altered character is its acridity, exercising a manifest erosive influence 
 on the surrounding cervical mucous membrane, already softened and 
 hypersemic. Thus, an increased and altered secretion jjroduces disin- 
 tegration of the epithelial layers, and creates what is known as abrasion 
 or erosion (Plate II. figs. 1, 2), the most superficial form of ulceration. 
 For the most part this erosive process is noticeable in the region of the 
 OS externum, but may extend up the cervical canal. 
 
 The disease progressing, it begins to effect changes in the mucous 
 membrane proper, already denuded of epithelium. In the papillae 
 a proliferative inflammation occurs. These papillae undergo hyper- 
 trophy, constituting a process known as granular degeneration or 
 the granular ulcer (Plate II. fig. 3). The labia uteri are now tumid, 
 pointing, the os externum patulous ; the whole cervical canal is larger, 
 and loses in a measure its natural fusiform shape. In some instances 
 the constant catarrh with an attendant tenesmus leads to eversion of 
 the cervical mucous membrane. Should the inflammatory action pro- 
 gress still farther, a well-defined or true inflammatory ulcer would be 
 formed. While such a result is possible, it is among the rarest of occur- 
 rences. 
 
 Localization of the disease in the muciparous follicles of the infra- 
 vaginal cervix creates enlargement in them, distension, bursting, a 
 follicular ulceration (Plate II. fig. 4) — a process which in its entirety 
 is called cystic degeneration. Hypertrophy of the Nabothian glands 
 may be carried to such an extent that, either singly or in aggregation, 
 they partake of the shape of polypi. In old cases hyperplasia of the 
 mucous membrane and adjacent fibrous tissue may be noticeable. 
 
 The steps, then, in the pathogenesis of the disease are — 
 
 1. Increased and altered secretion, incident to the changes in the 
 Nabothian glands. 
 
 2. Erosion of the epithelium. 
 
 3. Granular degeneration of the villi of the mucous membrane. 
 
 4. Dilatation of the os externum and lower cervical canal. 
 
 5. Eversion of the cervical mucous membrane. 
 
Fife 3 
 
 Fi^.4- 
 
 Fig.l . Ei-owicjiL of tlie Cei>\-ix (Meiji;s). 
 
 FMg.2. Follicvilar Erosion ^vith slight Jjacei-Mtioix (Muride). 
 Fig . :i . Gr-aTTiala-n De gerLt»r>Mlion of an Eloia^aled Cervix (Mei^s) 
 Fig. 4 . Krosiot-i.C'ystic! Enlargement ,C'al arrli of Cervix (Meigs). 
 
 To face page .550. 
 
ciiRoMf rjJin'JcAL KM)()Mj:rniTis. r,r,] 
 
 (). K<»lliciil:ir ulceration and dcj^ciu'ratioti. 
 
 It imist not Ih' inllrrt'd that all or most ol' tlicso changes are (•.\liil)itod 
 in every ease, for thev are not. Indeed, in a certain lew all that can 
 l)c noticiHl on the most <-aret'ul inspection throu;^h the speculum is the 
 chaiaiteristie «lis(har«ie issuing from the os externmn, the infravajrinal 
 cervix appearin«j; perfectly normal' 
 
 Etiolocy. — It is not only pn»per, hut necessary, in a lull considera- 
 tion of the etiolo<;y of this disease, to study the causes under two heads, 
 prtHJisposino; and exciting. The former are usually general or constitu- 
 tional, and the latter local. 
 
 A. Pi'cdlxpm'niff Ont.se.s. — Under this heading are include<l — 1. The 
 various diatheses and blood-disorders, as scrofula, tuberculosis, syphilis, 
 rheumatism, gout, rheumatic gout, antemia, chlorosis, leukaemia, chronic 
 albuminuria, malarial poisoning, etc. In most of these affections the 
 mucous membranes of the body in general show a special tendency 
 to local manifestations of the general state, that of the uterus being by 
 no means the only surface affected, chronic pharyngitis, br<jnchial or 
 gastric catarrh, granular eyelids) for instance, being present. Chronic 
 nterine catarrh is exceedingly common in phthisical and stnimous 
 subjects. 
 
 2. A Natural or Acquired Feebleness of Constitution. — Good general 
 health is, as a rule, essential for a healthy sexual system. A poor 
 inheritance, an arrested or imperfect physical development, tend to 
 make one liable to local affections. It is a matter of common obser- 
 vation that certain temperaments, notably the lymphatic, and females 
 of the blonde complexion, are the most frequent subjects of leucorrhoea. 
 
 All those diseases and modes of life which depreciate and undermine 
 the general health predispose to mucous inflammation of the uterus. A 
 cervical catarrh may first manifest itself during the convalescence of 
 some acute affection. This local disease too frequently insidiously 
 develops in women from bad hygiene, close confinement indoors, 
 indolent habits, insufficient and improper food, fiilse habits of dress, 
 fashionable dissipation, etc., through the impress these means make in 
 enfeebling the general health. Nutrition becomes faulty, the balance 
 between waste and repair is lost, the blood is impoverished, and func- 
 tion is disturbed. 
 
 In a like manner, on the nervous system the depressing effects of 
 grief, as well as the pernicious influence of our modern system of 
 schooling girls in their most important years of growth, may operate. 
 It is a lamentable fact that the health of thousands of our American 
 
 ' The forejroinjj represents the status of tlie patliological conditions as generally 
 accepted until some most recent investigations made hy Riige and Veil have taken 
 exceptions concerning part of them. The author has preferred to embody these views 
 in full under the heading of '' Degenerations of the Cervix." 
 
552 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 girls is broken during the last years of an arduous school-life, never to 
 be fully regained, and the seeds of some pelvic disease sown, never to 
 be entirely eradicated. 
 
 Prolonged and excessive lactation, frequent childbearing, favor the 
 development of chronic uterine disease, doubtless owing to the exhaust- 
 ing effects of the drain on the general health ^vhich an undue perform- 
 ance of these functions involves. 
 
 Many of the well-known exciting causes may utterly fail to bring 
 about local disease without some constitutional morbific force operative 
 in the background. In this way a discovery of one's actual standard 
 of general health is revealed. As Paget expresses it, " The intensity 
 or quantity of a constitutional disease or disposition to disease may be 
 estimated as in inverse proportion to the amount of disturbance requisite 
 to bring about a local manifestation." 
 
 Very many diseases and injuries severely test and accurately estimate 
 the degree of imperfection, so to speak, of constitutions. Local path- 
 ological changes in a constitution where the standard of health is at par 
 should be in proportion to the local exciting causes. Recoveries from 
 such should be regular in time and method. Deviations therefrom 
 exist only from some constitutional wrong. 
 
 B. Exciting Causes. — Chronic inflammation of the cervical mucous 
 membrane frequently follows the acute, puerperal or non-puerperal, 
 from which recovery is not complete, either on account of neglect, 
 bad management, or some vice of the general system. It may be an 
 extension downwardly of an inflammation within the upper uterine 
 cavity, or upwardly, from the vagina, especially in the specific forms 
 of the disease. 
 
 The newly-married, and more particularly prostitutes, often suifer 
 from this disease as a result of an abuse of the sexual function. The 
 use of cold-water vaginal injections and various other methods to pre- 
 vent impregnation and produce abortion are fruitful sources of the 
 disease. 
 
 Injuries to the cervix in parturition, and in the non-gravid state 
 from the use of sounds, tents, and pessaries, are prominent pathological 
 factors. Among them none are more potent than lacerations of the 
 cervix in parturition, especially if well defined, bilateral, multiple, or 
 stellate. Very often, indeed, lacerations of the cervix are not recog- 
 nized at the time of the accident, consequently no attention is directed 
 thereto to secure union. Healing is imperfect, and the cervix is left in 
 a condition of persistent irritation and inflammation. 
 
 Syimptoj^iatology. — Chronic cervical endometritis is often so slow 
 and insidious in its inception and progress that the disease may con- 
 tinue for some time without the presence of any special symptoms 
 denoting its existence. 
 
ciinosic cEiivicM. i:M>()Mi:rii!Tis. r,.-,.-. 
 
 The local symptoms will usually lu' tiist iiiaiiifot, Amoiiw- tlicst- 
 prominently stands Ictu'orrlui'a. Its r{'<'oi;nition by the patient dcjM'nds 
 hir<i-elv upon her hahits of juTsonal cleanliness. l*atient.s will some- 
 times say there is no lencori-lnea when a specnhim examinati«Mi reveals 
 its presence in «:;reat ahiuidancc. The dischari^c is thick, vis(;id, tena- 
 cious, hit;hly albuminous, and, in severe eases, nnjco-purulent or tin«i'ed 
 with blood. As it pours forth from the va<::ina it sometimes assumes a 
 coaiiulated appearance. It is always present, and ii.-ually the (piantity 
 is in proportion to the activity and extent of the local disease. 
 
 The next symptom is pain in the pelvic reij:i()n, the hind, de}j;ree, and 
 exact seat being subject to much variation. Ordinarily, the first mani- 
 festation of pain is backache in the sacral and hnnbar regions, and then 
 dragging sensations in the hypogastrium, inerea.sed by standing, walk- 
 ing, and during menstruation. Coitus becomes more or less painful, 
 urination more frequent than normal, and somewhat painful ; defeca- 
 tion, though less often, may also be attended with discomfort. Men- 
 struation may be deranged its to its frequency, duration, quantity, (pial- 
 ity, or the presence of pain, directly resultant on the local lesion, or 
 indirectly incident to the constitutional condition, especially the changed 
 state of the blood. 
 
 It is merely a question of time for the local disease to make its 
 impression on the general health. General symptoms arise with a 
 degree of rapidity proportioned to the vigor of the constitution, its 
 power of resistance, and as to Avhether the local disease has a general 
 or local origin. Sooner or later, the patient begins to look pale, loses 
 weight, is more easily fatigued, and lacks her accustomed energy. The 
 appetite is poor, digestion is slow, feeble, and disturbed, expressed by a 
 sense of heaviness after meals, acidity, flatulency, nausea, or vomiting. 
 The bowels are usually constipated, the stools often being hard, drv, 
 and insufficient. 
 
 Resultant (^n a depreciation of the general health from impaired 
 nutrition and from a direct sympathy of the various portions of the 
 body with the local disease, there are displayed various disturbances of 
 circulation, respiration, and secretion, and also in the nervous svstem 
 of motility and sensation. The latter rank most conspicuous among 
 these. The patient becomes nervous, irritable, excitable, and hyster- 
 ical. 
 
 It is in connection with the other inflammations of the uterus, es]ie- 
 cially of its body, that these reflex disorders will be more fully dis- 
 cussed, for it is with them that they are more commonly associated. 
 Local and general symptoms do not always hold a direct relationship 
 to the quantity of the local disease. In many cases they are out of all 
 proportion to it. 
 
 Physical Signs. — 1. By Touch. — In well-definetl cases a digital 
 
554 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 examination reveals the os externum and lower cervical canal more or 
 less patulous, somewhat roughened or irregular in shape, especially in 
 multiparse and if there has been laceration of the cervical walls. The 
 cervix may be slightly enlarged from infiltration, hyperplasia, and 
 granular degeneration. The ISTabothian glands as enlarged bodies 
 may be felt. 
 
 Any great tenderness in uncomplicated cases is not marked, nor is 
 the position of the uterus altered. 
 
 In the comparatively uncommon instances where the interior canal 
 is solely affected no dilatation of the os may be present, and touch may 
 elicit no evidence of the inflammation, 
 
 2. By Speculum. — The cervix well exjDOsed by the sj)eculum, the 
 regions of the os externum and cervical canal are generally found filled 
 with the characteristic albuminous discharge, so tenacious as to be diifi- 
 cult to remove. The cervix, once cleansed, displays the unmistakable 
 traces of the epithelial erosion, the granular degeneration, the patulous 
 OS, the enlarged Nabothian follicles, and the cervical eversion. The 
 speculum, carefully employed, enables one to detect the peculiar dis- 
 charge pouring from the os, and clearly establishes the diagnosis in 
 cases when touch has failed. 
 
 3.. By Sound. — It is unnecessary to make use of the sound when the 
 symptoms and signs as revealed by touch and the speculum point to a 
 limitation of the catarrh to the cervical canal ; but if employed not 
 nearer than a few days to the menstrual period the os internum will 
 be found unci dated. 
 
 Diagnosis. — The diagnosis between chronic cervical endometritis 
 and vaginitis is easy. Its differentiation from chronic endometritis 
 of the upper uterine cavity is much more difficult, and will receive 
 consideration in the description of that affection, 
 
 CoMPLiCATioisrs. — Chronic cervical endometritis, being the most fre- 
 quent uterine disease, may be associated with any other affection of the 
 organ. The most common complications are — (a) vaginitis, resulting 
 from the acridity of the cervical leucorrhoea ; (6) cervical metritis ; and 
 (c) corporeal endometritis, resulting in general mucous inflammation of 
 the uterus. Pruritus vulvae is sometimes a very annoying complication. , 
 
 Recent investigations and observations of Championniere, Leopold, 
 Courty, and Mund6 leave no doubt that a complication which, until of 
 late, has almost escaped detection or prope]- recognition is occasionally 
 present — ^viz, lymphadenitis and lymphangitis, diseases resulting from 
 direct extension of the inflammation to the parametritic lymphatic ves- 
 sels by absorption of infecting secretions from the cervix. 
 
 Duration. — The continuance may be indefinite, for it has no self- 
 limitation. Once well established and left to itself without medical 
 aid, it tends to progress and gradually bring into train various compli- 
 
c'JiiioMc ch'JiyicAL i:si)()Mi:ri:iris. TjOg 
 
 ■cations. D()iil)tk'ss, niild cases in <i;()0(l (•(iMstiliitii)iis ni:iv nndci'LTd .-|»(»n- 
 tanoons cure. 'Plicsc arc certainly tlie c\cc|»ti()n and not tlie rule. 
 
 IMaxJNosis. — This depends upon the eoudilion oi' llie ;:cneral health, 
 the severity and tlui-ation of the local disease, the extent of" de<icnerate 
 chani»es, and the amount, if any, of complications. In estimatlni! the 
 |)roiiiio,-is of any i;i\'en case there is no more \:dualilc Cactoi- than a 
 determination of the state of tlie <icneral health and whether the dis- 
 ease has ha<l a constitutional or local ori<;in. A seeminj;' small amoiuit 
 of local disease in a hrokeu-dowu constitution with a >trumous taiut is 
 very nnich more dilHcult to ei'adicate than a lai'^-er amoimt of cei-vical 
 chantje in <i;ood health and nutrition. 
 
 Appearances of the cervix to an inexperienced practitioner are very 
 deceitful in a ])rotinostic })oint of view. It is an observation borne 
 out by the experience of most gynecologists that cases with granidar 
 degeneration of the infravaginal cervix and patulous os arc more amen- 
 able to local treatment than those with no visible changes, but with 
 copious tenacious secretion of the canal. Cases of the latter descrip- 
 tion are not only more difficult of access, but require, generally, more 
 radical measures for relief. In the former topical aj)plications addressed, 
 in j^art, to the exterior of the cervix have a beneficial revulsive effect 
 on the glandular disease of the interior. 
 
 Treatment is often tedious, and relapses from a slight renewal of 
 causes liable to occur. 
 
 Treatment. — This is divided into constitutional and local. A con- 
 sideration of the former is omitted at this place, and deferred until the 
 subject of the management of both general and corporeal endometritis 
 is reached. To that section the reader is referred. 
 
 Local Trcaiment. — Cases requinng Local Treatment. — Reference has 
 been made to the fact that chronic cervical endometritis does, in excep- 
 tional cases, undergo spontaneous cure. The cause, generally a local 
 one, is removed, and Nature, aided perhaps by vaginal injections, is 
 competent to restore the integrity of the parts. Again, by an improve- 
 ment in the general health or a change in hygiene, the local disease is 
 benefited. Not only are such cases exceptional, but they must be mild 
 in character. Most women who have suffered for any considerable 
 period of time will not only be greatly benefited by local treatment of 
 a judicious nature, but absolutely require it. A seeming spontaneous 
 cure is usually only a temporary improvement. ]\luch controversy 
 has taken place as to whether local treatment is required — its extent 
 and kind. That it has been carried too far by some \y'\X\\ limited views 
 of the nature of the local lesions, and imperfect aj^preciation of their 
 pathological import, must be admitted. But this is not an argument 
 against this method of treatment ; it merely indicates an abuse. 
 
 Vaginal Lijections. — The use of injections of water, pure and medi- 
 
556 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 cated, within the vagina and against the vaginal face of the uterus, is. 
 a matter of history. from time almost immemorial. There is no agent 
 or means which has been used in a more uncertain or unscientific man- 
 ner, yet none, properly employed, capable of accomplishing in diseases 
 of the female pelvic viscera greater good. 
 
 Selection of an Instrument. — The old-fashioned pewter or glass 
 syringe has gone entirely into disuse, and is now mentioned only to 
 be condemned. The Davidson syringe (Fig, 180), well made, air- 
 tight, and in good working order, answers most purposes. Any 
 quantity of fluid can be injected with it. Its chief objection consists 
 in the fatigue jjroduced by working the bulb for a long time — a matter 
 of necessity where large quantities of water are used. Emmet has 
 claimed that there is a special advantage obtained from an interrupted 
 
 Fig. 180. 
 
 Fig. 181. 
 
 Davidson Syringe. 
 
 Vaginal Irrigator. 
 
 current in all cases where the stimulant and absorbent effects of hot water 
 are desired. The fountain syringe possesses many most excellent fea- 
 tures. The bag holding the water should have a capacity of from two 
 to four quarts. Any quantity of fluid may be injected without any 
 effort on the part of the patient ; the current is continuous and should 
 be small and without force. The vaginal irrigator (Fig. 181) answers 
 the same purpose as the above, and is admirably adapted for hospital use. 
 Whichever of these instruments is selected, special care should be 
 taken to close the central distal (uterine) opening, to avoid the possi- 
 bility of the accident of injection within the uterine cavity in cases 
 
cuiiosic cEiivicAL FSDnMiiinris. r,r,7 
 
 wIiciT tlu' OS is, iVoin ;iii\' <:msc, ]i:il iiloii-. All tiihcs sliuuM he iiKnlc 
 ot' liai"(l niljluT, which will not coriodc aii<l is least all('<-t<'(| by the 
 tciiUKTatun' ot" the iiot doiicln'. The >i/,t' should !«• siiniciciit to prc- 
 \fiit hreakiii}:;, and not too lar<;e for insertion, 'i'hc shank of the tiihc 
 should he straiuht, the extremity with small openin^^s, olive-shaix'd, and 
 the whole lenuth five inches, sniKeient to reach to the vaj^inal eul-de-sae 
 posterior to the cervix. 
 
 3Io<h' of l^siiif/. — The effects of vaginal injections are not fully 
 obtained in the ordinary erect or sitting ])osture, where the abdcjminal 
 and pelvic viscera are crowded down, the vagina shortene<l, and the 
 cervix made to a])j)roach the vnlvar orifice. The fluid more readily 
 escapes, failing to reach, as it should, every portion of the vagina; 
 tlierebv the special effect of the injection, whether detergent, absorbent, 
 anodyne, or astringent, is lost. Moreover, the uterus, from a c-hange in 
 its axis and its separated cervical lips, is more apt to be distended with 
 fluid. The dorsal recumbent position is worthy of the highest recom- 
 mendation. With hi])s elevated and shoulders depressed, the abdominal 
 viscera gravitate toward the diaphragm, the vagina lengthens, and its 
 whole cavity is flooded with fluid, a certain portion of which remains 
 around the cervix until the erect posture is assumed. This position, 
 with the quantity tjf water required, demands the use of some special 
 means as a receptacle for the fluid as it flows from the vulvar oi-ifice. 
 A round, flat be<l-pan, of large capacity — or, better still, one Avith an 
 outlet pipe and rubber tube attachment — or a rubber sheet suital)ly 
 folded over the side of the bed, hanging in a tub below, upon which 
 and over the edge of the bed the hips of the patient rest, with feet on 
 two chairs, fulfils the necessary indications. Sometimes a contrivance 
 which tightly fits to the vulva and prevents the escape of the fluid, 
 €xce})t through an efferent tulje, is very useful. By it the exterior 
 organs are protected from the irritating effects of the hot douche, and 
 the patient is kept dry, and a more thorough retention and distension 
 of the vaginal canal are secured. Dr. Frank P. Foster has introduced 
 such an instrument. 
 
 In addition to the dorsal decubitus, which is ordinarily resorted to 
 in the manner dest-ribecl, ]>atients may be ])laced in the knee-chest pos- 
 ture when it is thcjught best to further distend the vagina and ensure 
 longer retention of medicated — especially disinfecting and astringent 
 — hot- water injections. The position itself, through the influence of 
 gravitation, pov.erfully aids in diminishing pelvic congestion. The 
 proper administration of injections in ttese positions is best obtained 
 by the attendance of an assistant. 
 
 Temperature. — Vaginal injections are used cold, cool, tepid, warm, or 
 hot. If it is desirable to cleanse the infravaginal cervix and vaginal 
 tube of all discharges, a warm injection, ranging from 85° to 100° F., 
 
558 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 is indicated. If, on the other hand, in addition to the above it is neces- 
 sary to control pelvic circulation for the relief of venous congestion, the 
 temperature must be hot, commencing at about 100° F. and daily, 
 gradually, increasing it until it has reached 120° F. or more. The 
 primary effect of water at this high temperature is to produce a 
 dilatation of the blood-vessels, but of short duration. The secondary 
 effect, which more quickly follows and is more permanent, provided the 
 quantity is sufficient, is contraction. For a full understanding of the 
 beneficial effects of hot- water injections the profession is indebted to 
 Emmet. 
 
 Quantity. — A cleansing injection does not, generally, require more 
 than a quart of fluid. For astringent purposes less is needed ; for dis- 
 infection more will be advantageous. But when it is designed to obtain 
 the thermic qualities, the quantity ought to be very large, ranging from 
 half a gallon to several gallons at each sitting. The current should be 
 projected steadily or with interruptions for twenty to thirty minutes. 
 
 Frequency. — Under almost any circumstances when injections are 
 demanded to remove or control diseases of the cervix and vagina at 
 least two are needed daily, and they may with decided advantage, in 
 some cases, be administered oftener. 
 
 Indications. — (a) To cleanse with warm water the infravaginal cer- 
 vix and vaginal canal of morbid secretions, thereby favoring the heal- 
 ing processes in the former and preventing secondary inflammatory 
 action with its results in the latter ; (6) to medicate these surfaces with 
 emollients, anodynes, astringents, or antiseptics, according to special 
 local lesions; (c) to contract with hot water the blood-vessels and 
 diminish congestion of the cervix and its surroundings in the manner 
 detailed. A permanent restoration of the tone and calibre of the blood- 
 vessels is of paramount importance in the successful management of 
 these cases ; and this is a means to that end not to be neglected. As 
 one of the immediate effects of such injections is to diminish local pain 
 and soothe the irritable organs, thereby conducing to sleep, the best 
 time for such administration is on retiring. At this time also oppor- 
 tunity is obtained through bodily posture to maintain a more perma- 
 nent effect of capillary contraction. 
 
 The various astringents — plumbic acetate, zinc sulphate and chlo- 
 ride, tannin, alum — simply or in combination, are often efficacious 
 where the vaginal face of the cervix is eroded, granular, and there are 
 secondary vaginitis and pruritus. But milder agents, as pure castile 
 soap, glycerin, sodium chloride, sodium biborate, boric acid, are ordi- 
 narily not only more conducive to comfort than astringents, but answer 
 all the purposes of medicaments. 
 
 Contraindications. — Vaginal injections should not create any pain or 
 uneasiness. Reference has been made to the possible accident of the- 
 
ciH!().\/( • ( 'i:n i k -. i l hwno.y/rnnT/s. 
 
 •Oof) 
 
 Fig. 182. 
 
 injected lliiid i('achin<i; tlic niiiinc cavil y because of son n- liniliv <i(ii- 
 struotion or actit)ii of thv iiistriiiiiciit, carck'ssncss in its use, or <>rcat 
 patiiltnisne.ss of the cervical canal. This accident i-cally fi('<jncntlv lia|>- 
 peiis. Numerous instances of serious results, even deaths, have (icnir- 
 rcd and hccn rcportetl. With proper care such need rarciv take jdacc. 
 Occasionally there follows such a degree of pelvic discomfort after 
 injections, althoutih neither fluid nor air has entered the uterine eavitv, 
 that the jiractitioner may he obli<i;ed to recommend their discontinnaiice 
 or modification. l*rol)ai)ly these symptoms are explieahle on the <^i'ound 
 of special tenderness of the uterus or periuterine tissues, or that the 
 injections are administered at first at too high a tem|)erature. Gen- 
 erally, all that is required to meet such indications is to lower the tem- 
 perature of the water, and then slowly increase it. 
 
 Topical Applicdtion.s. — The propriety of direct topieal api)lications 
 of medicinal agents to the diseased cervix is the same as for any portion 
 of the body, and to a great extent the same prin- 
 ciples guide us. The medicaments are cukjI- 
 lients, anodynes, astringents, alteratives, and 
 caustics. 
 
 The following principles of local treatment 
 should always be held in view: 1. Thorouoh 
 cleanliness of the diseased surfaces ; 2. Proper 
 selection and adaptation of the medicinal ap- 
 plication to the individual case or condition ; 
 3. Thoroughness of application ; 4. Proper in- 
 tervals between applications ; 5. Careful atten- 
 tion to the approach of an oncoming menstrual 
 epoch and to that which has just closed. 
 
 The first is to be secured by a copious warm 
 or hot vaginal injection preceding the introduc- 
 tion of the speculum. The cervix uteri, now 
 being engaged Ijv a speculum, is cleansed with 
 small pieces of dry absorbent cotton, or by soft, 
 clean, fresh sponge squeezed out of hot water, 
 pure or medicated with sodium chloride, firmly 
 seized with the dressing-forceps. The cervical 
 canal requires particular attention. If it is much 
 dilated the above means answer, but if narrow 
 it is better managed with the cotton-wrapped 
 probe. Thomas recommends a syringe for the 
 purpose of removing the tenacious secretion 
 which plugs the cervical canal. Whatever 
 method is used, thoroughness is of the utmost importance, not only on 
 the exterior of the cervix, but in the interior canal, fi)r the medicament 
 
 Peaslee's Dilators fprraduated). 
 
560 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 is generally to be carried to within the latter. It is ever to be held in 
 mind that the disease on the vaginal face of the cervix is rarely the 
 whole affected surface. Usually, it is only pathognomonic of the glan- 
 dular inflammation within, which, if untouched and uncontrolled, will 
 surely cause a relapse of the erosion and granular degeneration, it 
 matters not how effectually they may have been removed. 
 
 The disease itself so often opens up the cervical canal that dilatation 
 by artificial means is comparatively rarely required. A successful issue, 
 hovv^ever, in cases of chronic catarrh of the cervical canal, where the 
 vaginal face remains healthy and the os externum is not rendered patu- 
 lous, makes dilatation necessary. We have for this purpose the metallic 
 dilators fashioned after the patterns of Peaslee (Fig. 182), or Ellinger, 
 or some of their modifications. Preference is given to those with expand- 
 ing blades. The author's (Fig. 183), which he has used since 1874, is 
 
 Fig. 183. 
 
 Palmer's Uterine Dilator. 
 
 simple in mechanism, easy of introduction, and if properly constructed 
 secures an absolute parallelism of dilatation, from out to out, of three- 
 fourths of an inch. A larger size also is now made when greater dila- 
 tation is desirable under other circumstances. 
 
 Ji free dilatation is sought in order to provide for a thorough applica- 
 tion of some caustic agent, the choice is given to tents of sponge, tangle- 
 weed, or tupelo. The superior advantages of the tupelo tent, introduced 
 to the profession by Dr. G. E. Sussedorff, over the other materials are 
 now generally recognized bv gynecologists. It possesses the better 
 qualities of both sponge and the tangle, without some of the disad- 
 vantages of either. By it the cervix can be 
 effectually expanded, at the same time softened, 
 and, being free from fetor and not tearing, the 
 mucous membrane, the clangers of septic^emic 
 inflammation are reduced to a minimum. 
 
 Incisions of the mucous membrane with a 
 knife before or in view of dilatation with tents, 
 as recommended by some, are unnecessary and 
 of doubtful propriety. 
 
 But there is a class of cases of chronic cer- 
 vical catarrh, for the greater part confined to nulliparous single women 
 or sterile married women, where thorough and permanent dilatation by 
 
 Fig. 184. 
 
 Conoid Cervix, Pinhole Os, 
 the canal seat of catarrh. 
 
( IinoXK ' CKR VICAL KMioMiynuris. 
 
 '>i;i 
 
 Fig. 185. 
 
 iiicisi(iii> ur the t'oi-ccps dilatnrs is ui' inijx'ral ixc ii<'<'i'>sity. 'I'Ik- calarrli 
 is due to a iiaiTnw, ••oii.-.trictrd os, jti'<'\ciitiiiL: a IVcc exit ot" iiurmal sc.-crc- 
 tiniis ot" iiiiicus ami iiiciistnial tltiid. The al)iii)riiiity is jiciH-rallv <-(iii- 
 gc'iiital, and nMd(iul)t('dly iii(»st ••((iiiiiioii at the <js cxtcniimi. TIk; 
 cervix is loiiii', narrow, conoid ; its canal, in con>c(|nciicc of pciit-uj) 
 fluids, dilated ( I'^i;^'. 1 -S 1). Ac<jnircd cases of stenosis are Ic.-s fre- 
 i^nent, and are r'esnltant on the vicious nse of caustics. .V thick plnji; of 
 mucii.s han>>inj; from the os, and its free flow after the withdrawal of 
 a sound, are proof of an accnnudation and retention. Tlie retention of 
 even normal secretion leads to acridity and its 
 results. Topical applications of medicine, the 
 curette, etc. caiuiot possibly he of any lastinu- 
 service. Dilatation by tents is insutticient, 
 for its effects are only temporary. Bilateral 
 or (juadri lateral incisions (Fi<r. 185) as rec- 
 ommended by Fritsch and Munde, made 
 deep enough to open uji the os as wide as 
 the canal above, with precautions to main- 
 tain the same, are attended with the greatest 
 benefit, and may be all-sufficient. Thorough 
 divulsion of the cervical walls by a strong 
 expanding dilator has also led to very good 
 results. 
 
 The frequency of applications depends 
 largely upon the choice of the agent. The 
 
 mistake is often made, and patients are in Dilated canai, from obstruction 
 numerous instances given unnecessary^ pain, 
 wiiile at the same time the healing processes 
 are delayed, by too frequent and uncalled-for applications. No agent 
 should be applied or reapplied until the effect of a former one has 
 passed away. 
 
 Another factor which should govern the frequency of topical appli- 
 cations is the special physical or mental susee]iti):)ility. Comparatively 
 mild agents, sometimes without any discernible contraindication, unex- 
 pectedly set up irritation and pain. Hence the interval must be length- 
 ened. Again, there are those Avho are profoundly disturbed in their 
 nervous system by any local treatment. The jjractitioner may be 
 forced to abandon, or at least to suspend for a while, such man- 
 agement. 
 
 It is always desirable that local examinations and treatment, even in 
 married women, be reduced to a minimum consistent with recovery. 
 In virgins only where constitutional measures, judiciously tried, have 
 failed, and there is some special urgency required, are they justifi- 
 able. 
 
 Vol. I.— 36 
 
 at Os Externum : lines for in- 
 cision (Munde). 
 
562 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 It is almost unnecessary to remind the reader that the greatest cau- 
 tion is to be indulged in whenever a digital examination bespeaks any 
 evidence of an old chronic perimetritic inflammation. 
 
 The physician should be watchful as to the time of the closing of the 
 last and the approach of the oncoming menstrual epoch. The more 
 potent the local agent in its effects, the farther removed it should be 
 from the dates of menstruation. As a rule, local treatment, even of a 
 mild character, ought to be suspended a few days prior to the approach- 
 ing period, and not resumed again until as many days after its close. A 
 disregard of these minor details tends to excite local pain, reflex disor- 
 ders, and to derange the time and quantity of the menstrual flow. 
 
 The choice of agent is of paramount importance. The experience of 
 the profession, after many years of trial, has now very fairly defined the 
 indications and range of utility of local uterine medication. The time 
 was, but fortunately has well passed, when gynecologists confined them- 
 selves almost wholly to the use of a single agent : nitrate of silver was 
 universally used — of course to be abused. 
 
 So far as practicable, the inauguration of local treatment should be 
 of a mild character, especially if the disease is not severe or its dura- 
 tion long. Emollients, anodynes, astringents, and alterative applica- 
 tions will cover the necessary indications for a large proportion of 
 cases. 
 
 When the mucous membrane of the cervix looks highly hypersemic 
 the use of mild means to deplete from the distended vessels is always 
 beneficial. These consist in the local abstraction of blood by super- 
 ficial scarification of the region of the os and cervical canal or by punc- 
 turing the vaginal face of the cervix. Either may be followed by the 
 application of a tampon of absorbent cotton saturated with pure anhy- 
 drous glycerin. If pain is a prominent feature of the local symptoms, 
 the glycerin may be medicated with morphina sulphate (gr. |-|-) or aque- 
 ous extract of opium (gr. j-ij) to each drachm. Belladonna may be 
 chosen with the same object in view, and is thought by some (Trous- 
 seau and Ringer) to possess properties to diminish the secretion of the 
 Nabothian follicles. The absorbing power of the vagina and cervix is 
 not considerable — probably not more than one-fifth of that of the stom- 
 ach — but it is materially increased by any superficial loss of tissue, as in 
 abrasions and erosions. 
 
 The tamponade with glycerin may be reapplied every second to 
 third day, each being permitted to remain some twenty-four hours. 
 The influence of pure glycerin thus applied to the congested cervix, 
 through its affinity for the watery elements of the blood — a power 
 most fully demonstrated in cases where the chronic inflammation has 
 involved the fibrous tissue as well as the mucous membrane — is 
 remarkable. 
 
cnnoMc cr.iivK'M. hwnoMirrniTfs. 5g;j 
 
 I r scai'irK-itiiiii di' |>iiiicliii'iiiLi is r<'|K':iti'(l, ii .-IkiiiM he at intervals 
 of three to live (la\s. Not all ea.ses ol' clii-diiic ceix ical <'ii(l()iiietritis 
 re(Hiire direct (le|)letioii. TIh' ^-lyeei-iii apiilieatiniis in some form 
 lia\'e a wider raiii;e ol" iiselidness, Ixit the joi'al iniproveiiient is very 
 lre(|iieiitly indeed laeiUtated l>y these pi-eliniinai-y ah.^traetioiis oC Mood. 
 'I'he adchtioM of horie acid to the t;lyeei-in — the l)oro-^lyeeri(h' (.")() per 
 eeiil. >nhi(ion)— is a xainahle one, especially il" in addition t<t th<! 
 h\j)er;cniia and catarrh there is sujx'rficial idcei'ation. Not only is 
 the tih'cerin ot" this cond)iiiatioii rendered more dense and anhydrous 
 hy heat, hut the horie acid is emollient and antiseptic. 
 
 Anion*:: tiie varions astrintients from which the selection may be 
 made, none is suj)eri()r to tannic acid. Its best vehicle is glycerin 
 — U'lycerite of tannin (tannin 3j-ij to glycerin sj). A tampon of cotton 
 of suitable si/e is saturated with one to two drachms of this solution, 
 and })acked thoroughlv against the cervix every two to three days. 
 Styptic colloid and concentrated ext. pinus Canadensis are other useful 
 agents of the astrintrent class. 
 
 Fluid hydrastis, though not an astringent, either pure or dilute<l 
 with boro-glyceride, is an excellent application, made with cotton, for 
 catarrhal states of the cervix. 
 
 The indications for astringents are hypersecretion, due to hypeneniia 
 and relaxation of, the blood-vessels and glands. By their use not only 
 are the secretions more or less checked, but erosions and granular 
 degeneration are made to disappear. 
 
 Such applications as above mentioned are made only to the vaginal 
 face of the cervix. Here they produce their best effect ; indirectly they 
 iuHuence the morbid conditions of the canal above. But one must not 
 be deluded with the idea that such treatment will often suffice to com- 
 plete a cure. A permanently good result, if the disease is of k>ng 
 standing and severe, is seldom secured unless the local treatment be 
 extended within the cervical canal. The agents which may be intro- 
 duced within the cervical canal arc> — astringents, as tannin, zinc chlo- 
 ride ; alteratives, as iodine and its combinations ; caustics, as silver 
 nitrate, carbolic acid, chromic acid, nitric acid, and the actual cautei-y. 
 There are many others, but these embrace those which the experience 
 of the author has found most useful. 
 
 For solids, the method by suppositories, gelatin-coated pencils, and 
 crayons ; for fluids, that by the cotton-wrapped probe, are used. Tannin 
 (grs. iij— v), zinc sulphate (grs. ij— iij), can be incoi-porated in an aj)pro- 
 priately sized suppository made of cocoa-l)uttcr or in a gelatin-coated 
 pencil. Either is inserted into the cervical canal every third dav, hehl 
 in position by a packing of cotton around the cervix, and allowed to 
 remain until well melted. 
 
 A certain amount of skill, ac(|uired only by ])ractice, is necessarv 
 
564 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 Fig. 186. 
 
 to prepare the cotton-wrapped applicator. The method is as follows : 
 A flexible hard-rubber probe (Fig. 186), nine inches long, 
 with a bulbous extremity and firm handle, one face of 
 which is roughened, is to be preferred to the silver instru- 
 ment, because more flexible and not aifected by the chem- 
 ical action of any agent. A thin film of prepared cotton 
 is wrapped around the distal extremity for three-fourths 
 of an inch, care being taken that it is not too thick to 
 pass readily within the canal or so loose that it may slide 
 off The parts now having been thoroughly cleansed of 
 secretions and dried with absorbent cotton, the cotton- 
 wrapped aj)plicator is dipjDed into the selected fluid and 
 pressed against the walls of the vial containing it to rid 
 the wrapping of any superfluous material. Then it is 
 gently introduced into the cervical canal to the os inter- 
 num, and allowed to remain a few seconds before with- 
 drawal. Any excess of fluid which possibly may be 
 squeezed from the applicator and run down around the 
 OS externum should now be removed with sponge or cot- 
 ton. There are those who prefer to make use of appli- 
 cations of this kind without the speculum, but accuracy, 
 as well as neatness, demands the aid of this instrument. 
 
 Iodine in alcoholic solution is one of the most efficacious 
 remedies we possess. Unless used too strong or too often, 
 it is not irritant, but stimulant, alterative, and antiseptic, 
 and is not altered by the secretions of the cervix as most 
 medicaments are. The ofl&cinal tincture is usually too 
 weak. GhurchilFs tincture (iodine, grs. Ixxv, potassic 
 iodide, sjss, to alcohol Ij), very much stronger, is often 
 to be preferred. A good tincture is one from Bijss-3j to 
 ^j, with a small quantity of potassic iodide to facilitate 
 solution. This can be applied to the exterior of the cervix 
 and the canal once per week and covers the indications 
 for a large number of cases. lodo-tannin (tannin dis- 
 solved to saturation in the foregoing tincture of iodine) answers a 
 similar purpose, and may at times be beneficially substituted. 
 
 Carbolic acid (liquefied crystals), used at the same intervals, is less 
 caustic than silver nitrate and possesses none of its disadvantages. 
 Locally, it is auEesthetic. Either in this form or as iodized phenol 
 (2 parts of iodine with 8 parts of carbolic acid) it is a favorite remedy 
 with many gynecologists. 
 
 Nitrate of silver, once so universally used for all cases and con- 
 ditions, has now fallen into undeserved disuse. Applied to the cervix, 
 its first effect is to produce more or less pain, which usually passes off* 
 
 Hard-rubber 
 Probe Applicator. 
 
ClinoSlC CI-JIVICAL KSnoMKTIlITlS. 565 
 
 within a lew hours, I'olldwcd <»ii the si'c<»ii(I aii<l thii-d chivs hv tnorc or 
 less hemorrhage from the caiiteri/.ed siiri'ace, with extoIiati«jii ot" a 
 superficial eseliai*. It therein- aets a.s a .stimulant of- the proa*s.ses of 
 jj^raiiiilatioii and cicatrization. Sooner or later, aeeordin<:; to the amount 
 and I'rcnueney of the cauterizations, excessive cicatrization at its .seat 
 and condensation of the sni round iiiu- fil)r(»us tissue follow. The cervix 
 thus becomes harder, den.ser, and the re<^ion of the o> externum c()n- 
 tractcd — a .stenosis, eausinj^ sterility and menstrual oljstrueti<jn. It is 
 also well known that cicatricial tis.sue, by inclusion within it of nerve- 
 filauKMits, may jjjive ri.^e to persistent local and <^eneral reflex neu- 
 ralgias. The pain and hemorrlia<;e, although po.-^sibly .severe, are not the 
 most serious objections to the use of the nitrate, but the foregoing 
 secondaiy morbid conditions produce effects wonse than the original 
 disea.se. There was a time, not many years since, when acquired 
 stenosis of the os and cervical canal from the vicious use of cau.stics, 
 the nitrate of silver in |)articular, necessitating dilatation by incision, 
 was quite common. Yet the very ill effects which have led to its 
 almost complete abandonment have also taught us its superior advan- 
 tages under proper indications. A cervix, which is .soft, flabby, eroded, 
 and granular, its canal patulous, pouring forth profuse muco-purulent 
 secretion — a condition found, for the most part, in multiparae — is greatly 
 benefited by the application of the crayon of silver nitrate (5 per cent, 
 chloride) to the whole diseased surface, at first about once per week, 
 afterward at longer intervals. The secretions diminish, the erosion 
 heals, the canal contracts, and the cervix — although perhaps slightly 
 lacerated, not so much as to require tracheloplasty — resumes its normal 
 shape. The intervals need no local interference save the use of the 
 vaginal douche. The number of applications is determined by the 
 progress in each individual ca.se, the utmost caution being observed to 
 discontinue their u.«e before the seeming necessary contraction has been 
 reached, for this effect is continued far beyond the last one. Further 
 treatment, if neces.saiy, may be continued with iodine, the glycerol of 
 tannin, or boro-glyceride. 
 
 A flexible silver probe of curve suitable to pass through the cervical 
 canal, dipped into the fused nitrate, after the manner of Sir Benjamin 
 Brodie, may be substituted for the crayon. 
 
 Solutions of the nitrate (grs. xx-lx to oj) are less injurious than 
 the solid, in mild ca.ses equally efficacious. The weak solutions 
 are adapted to more irritable forms of erosion, and the stronger to 
 the more sluggish. Solutions are to be preferred when granulations 
 are very vascular. 
 
 Solutions of the chloride of zinc (9j-9iij ad sj) will be found quite 
 efficacious at times. 
 
 Nitric acid, a more potent caustic than the silver nitrate, though not 
 
566 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 more painful, and less apt to be followed by hemorrhage, is adapted to 
 conditions similar to the above and the more rebellious forms of catarrh 
 of the Nabothian follicles. After its use with the cotton-wrapped appli- 
 cator the vagina needs to be protected by a tampon of cotton wet with 
 glycerin or oil placed against the cervix. The eschar formed separates 
 in from a week to ten days, and leaves a granulating surface. Nitric 
 acid ought not to be reapplied at intervals shorter than one month, the 
 choice of time being one week after the close of menstruation. 
 
 Acid nitrate of mercury has nothing to recommend it above nitric 
 acid, and its use is open to the grave objection of the possibility of 
 inducing salivation through its general absorption. 
 
 Chromic acid, deliquesced or with an equal part of water, is an 
 efficient caustic, comparatively painless, safe, and not liable to induce 
 secondary contraction and cicatrization. It too, in full strength, need 
 not be applied more often than once a month, although weaker solutions 
 (3j ad §j) can be used once a week. 
 
 All these more active caustics should generally be reserved for the 
 more severe forms of the disease which after long standing have resisted 
 a milder course of treatment. The tendency of the gynecological practice 
 of to-day is to restrict their use to the smaller number. The aim of 
 the physician should be to make the local management as mild and as 
 painless as practicable. As the disease is one depending upon or result- 
 ing in debility and nerv^ous derangement, the practitioner will avoid, if 
 possible, irritating agents and painful measures, which have a depress- 
 ing effect on the system at large. Caustics have heretofore been used 
 too extensively, and there has been a lack of j udgment in the selection 
 of agents of this kind which would not have been tolerated in local 
 treatment elsewhere. The best results are frequently obtained by an 
 occasional change in the choice of application. As no one agent 
 answers all cases, so no one can be depended upon during the whole 
 period of management. The local condition left after cauterization 
 may be much improved by astringents or stimulating alteratives. 
 Astringents in time lose their effect, and should be supplanted by 
 emollients, etc. 
 
 Many of these topical applications referred to do not require to be 
 followed by any special rest on the part of the patient. With perfect 
 safety they may be made, if convenient, at the physician's office. But 
 all caustics of the more active kind ought to be applied not only at 
 the patient's residence, where she can take the necessary rest, but cau- 
 tion demands that she maintain the same for several days in addition, 
 until all irritating effects have passed away. 
 
 Chronic cervical endometritis engrafted on a laceration of the cervix 
 may be bettered, but cannot be permanently relieved, by topical medi- 
 cation, if the rent is bilateral or multiple, and to within the fibrous 
 
CHRONIC CERVICAL hWDOM/.TlHTIS. r,t',7 
 
 tissue, ami there is ever>i<)ii. l'i(i;;ress in the iiii|)i-r)\-enieiit will eoii- 
 timie to a eertaiii jxiint, then cease, and as surely relapse ii|>i»ii >ii— 
 pension of the treatment. Traehelo[)lasty is tiic one ne<'essarv 
 
 Allusion has heen made to the utility and ne^'essitv ot" sueh eau.-ties 
 iLs nitric acid and chromic acid to tlu' <'ervical canal in old, rehellious 
 catarrhs dependent on exce-sive and persistent secretion of" the Nalxjtli- 
 ian follicles. Xot only do the mild caustics utterly fail to effect anv 
 favorahle chant:;e, but even these potential caustics freipiently prove 
 inadetjuate. Under tiiese circumstances the plan re<;ommende< 1 l)\- 
 Sims should be jiractised. After dilatation of the t"anal with a tent, 
 the follicles and irranulations are thor(Mi<ihly scraped down to healthv 
 tissue with the sharj) steel ctu'ette, after which the actual cautery or 
 Paquelin's thermo-cautery, a little above black heat, is run over the 
 whole surface. .V second application may be needed. The potential 
 caustics, after curettinj;, would answer much the same purpose as the 
 actual cautery. Dr. Isaac E. Taylor, from a considerable experience, 
 rejjorts favorably concerning this practice. Thomas gives the use of 
 the sharp curette in these cases his earnest indorsement. Although 
 the risk is small, the operation ought to be followed by necessarv 
 rest. The greatest objection that can be urged against it is the possi- 
 bility of subsequent constriction of the canal. But so eifectual are 
 these procechires that cases which hitherto have been considered incur- 
 able may be made perfectly amenable to treatment. Xot onlv Avill 
 good follow the excision by the knife or scissors of exuberant granula- 
 tions from around the os and cervical canal, but it is a j)roceflure calcu- 
 lated to abridge, to great degree, the course of other local treatment. 
 Excessive enlargement of the cervical glands — raucous polvpi — is to be 
 treate<l by abscission, and in certain cases exsection of hvpertrophied 
 and projecting tissue may be similarly dealt with. 
 
 May local treatment to the diseased cervix and canal l)e carried on 
 during pregnancy? "With proper precautions and due care avc answer 
 the question in the affirmative. Most of the accidents in the induction 
 of abortion by local interference have arisen from a neglect to investi- 
 gate and determine the condition of the body of the uterus, and ascertain 
 whether it may have been gravid. Pregnancy aggravates chronic cer- 
 vical endometritis, in that it increa.ses the catarrh, the granular degen- 
 erati<)n, the secondary vaginitis, and pruritus. By the gentle use 
 of warm vaginal injections of a uniform temperature, and bv the 
 topical use of astringents and emollients — in rarer ca.ses the nitrate 
 of silver in S(»lution — not only may the jiatient be made more com- 
 fortable through an improvement in the local disease and the arrest 
 of reflex disorders, as nausea and vomiting, but parturition itself be 
 made easier. 
 
568 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 Bibliography. 
 Battey, Robert : A m. Gynecolog. Transac, vol iv. p. 55 et seq. 
 Bennet, J. H. : Inflammations of the Uterus, 1861. 
 Championnieke, Courty, and Leopold: Am. Journ. Obsiet., vol. xvi. p. 1009 et seq.; 
 
 Non-Puerperal Pelvic Lymphadenitis and Lymphangitis, Paul F. Mxjnde. 
 Emmet, T. A.: Priiiciples and Practice of Gynecology, 1884. 
 Meigs, Charles D. : Diseases of the Neck of the Uterus, 1854. 
 MuNDE, Paul F. : Minor Surgical Gynecology, 1885. 
 Paget, Sir James : Clinical Lectures and. Esssys, 1875. 
 Ringer, Sidney : Handbook of Therapeutics, 1880. 
 Sims, J. Marion : Am. Gynecolog. Transac, vol. iv. jip. 63, 64. 
 SussENDORP, G. E. : American Journal Obstetrics, vol. vii. p. 473. 
 Taylor, Isaac E. : Am. Gynecolog. Transac, vol. iv. pp. 64, 65. 
 Thomas, T. Gaillard : Treatise on the Diseases of Women, 1880. 
 Trousseau et Pidoux : Traite de Therap. 
 West, Charles : Pathological Importance of Ulceration of the Os Uteri, 1854. 
 
 CHRONIC GENERAL ENDOMETRITIS AND CHRONIC CORPOREAL 
 ENDOMETRITIS. 
 
 Definitions and Synonyms. — Chronic corporeal endometritis 
 signifies a chronic inflammation of the mncous lining of the uterus above 
 the OS internum. General endometritis signifies that the cavity of the 
 cervix is also implicated. 
 
 Corporeal endometritis and general endometritis, localized for the 
 greater degree in the corporeal cavity, are recognized by the names of 
 chronic uterine catarrh, leucorrhoea or blenorrhcea, internal metritis, 
 fundal endometritis, etc. 
 
 Frequency. — Here there has been the greatest conflict of authority. 
 The utmost extremes of opinion have been, and are even now, enter- 
 tained. With the views of Bennet the profession is well acquainted. 
 With him the neck of the uterus was the favorite, the almost exclusive, 
 seat of chronic inflammation. Tyler Smith denied the existence of 
 chronic corporeal endometritis. On the other hand, Aran and West 
 contended that the mucous membrane of the uterine body is more fre- 
 quently the seat of disease than that of the neck. Hennig concurs in 
 this view, and also believes in the frequent existence of Fallopian 
 catarrh. Tilt, an authority equally good with Bennet, his associate 
 at one time in practice, radically dissents from the opinions of that 
 distinguished gynecological pioneer. Klob, whose expressions on such 
 matters are entitled to the greatest respect, describes the disease as of 
 frequent occurrence. 
 
 Most modern authorities — Bernutz, Courty, C. Braun, Scanzoni, 
 Schroeder, Fritsch, Atthill, Barnes, Eouth, Play fair, Simpson, Hart 
 and Barbour, Edis, Thomas, Goodell, and Byford — now recognize the 
 corporeal form of chronic endometritis, either as a distinct entity or in 
 the form of general endometritis. There is, however, a great variety 
 of opinions among these as to the relative frequency of the two diseases. 
 
ciiiiosic (ii:si:i:AL r.sDoMirnnris. 5C0 
 
 V\\v aiitlior (;ik('s tlic pusitimi tliiU Ixiili clinicMl mikI |iii-t-ni<>r(cin 
 cvidciKC prove tluit ('(ii-ixtifMl ciKloiiicli-itis may exist as a di^tiix't and 
 wi'lI-tU'liucd allc'ctioii, like thai kindred one of the eerviea! canal. If 
 CJirofiil search is made in Ixulies tliat ha\'e die(| fioni otlier diseases, 
 aeiite and chronic, it is believed that nnmistakalde evidences will he 
 lound ot' its existence. In onr [)resent state of knowledge of endomet- 
 rial diseiLses it is safe to tussunie — 
 
 1st. InHamination of the tvrvieal nuK-ons memhrane is hy far the 
 most fre(iuont of all the chronic forms of the disease. 
 
 2d. General endometritis stands second in the order of frequency, 
 and is laro-ely confined to the mnltiparie. 
 
 3d. Corporeal endometritis, the least frequent, is nevertheless a much 
 more common disease than has usually been accepted. Generally, it is 
 confined to the nnllij)arfe. Its recognition explains many cases of rebel- 
 lions IcucorrliLca, menorrliagia, dysmcnorrhcca, and sterility. 
 
 There seems no good reaiion for recognizing fundal endometritis a.s a 
 distinct form of the aifeetion. Its symptoms are not characteristic, and 
 it probably never exists independently of a similer condition of the 
 remaining corporeal and, it may be, the Fallopian mucous membrane. 
 
 Pathological Anatomy. — Like chronic inflammation of the cer- 
 vical mucous membrane, corporeal endometritis is essentially a glandu- 
 lar disease. In recent cases post-mortem appearances show the mucous 
 membrane hyjierremic, swollen, soft:, and succulent. Pigment-streaks, 
 brownish or blackish in color, resulting from blood-extravasations, are 
 found. At first the tissues are quite red, while later they become gray- 
 ish. The surfaces are either smooth, papillary, or uneven, especiallv 
 on the fundal and posterior walls, and covered with secretions. The 
 gland-t)penings are quite visible, the cavity dilated. The hypersecretion 
 is clear, in consistency thin and in reaction alkaline. It contains the 
 chlorides. It may be brownish and bloody, and after longer duration 
 muco-purulent or purulent. Granulations small in size or like villous 
 or pf)lypous masses are seen covering the surfaces. 
 
 In old cases still more important anatomical changes are noticeable. 
 The mucous membrane is eroded — a desquamation and destruction of 
 the peculiar ciliated epithelium. Its pi-esencc is replaced by polymor- 
 phous cells with a pavement-like epithelium. The whole membrane, 
 the utricular glands included, now becomes smooth, thin, and atrophied. 
 A layer of connective tissue lines the cavity, covered only, perliaps, by 
 polymorphous cells, or the membrane within which are minute cysts 
 of degenerated glands may be transformed into a callous structure of 
 varying thickness. The glands, however, before undergoing general 
 atrophy, quite commonly take on cystic degeneration from a constric- 
 tion or localized atrophy of their orifices, resulting in retention of tlieir 
 contents. Their ajipoarance is that of rounded, hemis]iherieal projec- 
 
570 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 tions or pedunculated tumors, varying in size from a pinhead to a large 
 pea, elastic to touch and with transparent contents. These glands may 
 likewise be greatly hypertrophied — cystic or glandular polypi. Asso- 
 ciated with the above conditions are the so-called vegetations, granula- 
 tions, or fungosities. They resemble somewhat papillary ejjithelioma, 
 and may degenerate into that condition. Also, there may be detected 
 pit-like depressions and elevations formed by a rujDture of or fall- 
 ing out of the glands. Their presence may lead to the formation of 
 adhesions and the subsequent development of hydrometra and hsemato- 
 metra. Chronic metritis is a frequent complication. 
 
 General endometritis presents more or less of the foregoing patholog- 
 ical lesions, in conjunction with those of the cervical canal already 
 described. 
 
 Etiology. — The causes are of two kinds — predisposing and ex- 
 citing. 
 
 A. Predisposing Causes. — Among these prominently rank the various 
 diatheses and cachexise — scrofula, tuberculosis, syphilis, aneemia, leu- 
 kaemia, haemophilia, malaria, rheumatism, gout, herpes, etc. The 
 strumous and phthisical diatheses are very common. Syphilis acts 
 as a cause by enfeebling the general health and impoverishing the 
 blood. 
 
 Corporeal endometritis occurs at all ages, from the beginning of 
 menstrual life to old age, and that, too, without any special local 
 exciting cause. Therefore, the best evidence of the operation of the 
 predisposing causes is afforded. So important a structure as that 
 of the interior of the uterus, subject periodically to changes of the high- 
 est physiological hypersemia, desquamation, and repair, is, above most 
 others, especially liable to receive the stamp of certain general morbid 
 states. Causes acting locally may be wholly inadequate to produce the 
 eifect without inherent or acquired predispositions. The local disease 
 is at times the only expression of the latent but existing constitutional 
 taint. 
 
 B. Exciting Causes. — Chronic endometritis is a very frequent sequela 
 of acute endometritis occurring from whatever cause, either in the par- 
 turient or non-gravid uterus. After parturition, as a result of the non- 
 recognition of the disease, want of proper or sufficient attention thereto, 
 some vice of constitution, or too early resumption of the erect posture, 
 a very large proportion of the cases of acute endometritis are imper- 
 fectly recovered from and the chronic aifection becomes established. 
 
 Endometritis originating within the area of the placental site must 
 be recognized. The return of this special area after parturition or 
 abortion to its original size and state is often delayed and imperfect. 
 Retention of hypertrophied decidua and young placental masses at or 
 about the third month of utero-gestation, with, it may be, partial 
 
CHRONIC GEyERAL EXnn.VirriHTfS. 571 
 
 «)i"i:;iiii/.at ii)ii ol' ilic siiinc, Icaxcs the interior of the nlcriis :i.< a roii^^li, 
 raw-like siirCaee, secret iiiii: iiuied-pus, and (he soiii-ee of a ])ersi>fent 
 saiiLi'uiiH'oiis (liscliaruc. The siirroiindiiiu- pareiichv iiia is thickened and 
 vascniar — iinpert'ecl iiixdhil ion. ( 'hi-onic eiiildiiicl ritis snper\'eiies. 
 
 IJennet hiniscll' expresses the jK)Ssihility ol" coi'poreal endometritis as 
 the result ol' the leniithened existence of inllaniniator\' disea>e of the 
 cervix. Chronic vaiiinitis may e\-enliiate in chi-onic endoniitritis. 
 (^hi'onic p(>lvic j)eritoiiitis and sal|)in<:itis may have a similar hnt 
 downward course. Wni specilic inllammation, startinti; in the vatiina, 
 is intlnitcK' a moi'e lre(|neiit cause of chi-onic cndoineti'itis. Xoeut^d'ath 
 lias drawn the attentit)n of the protession to the fre(|uency, insidious- 
 ness, and serious conse(][Ucnces of what he terms " latent ^'oiKtrrlujea 
 in the female." Although some of these views — secmintily exti'eme — 
 as to tlu> prevalence of clironie o;onori']ioca in women, taken from hus- 
 bands who previously — it may he many years — have had the disease, 
 are not substantiated by others, nevertheless Dr. Xoeuu'crath has invited 
 a jii'ofessional interest in a matter of the deepest concern, involving the 
 lu'alth of women and their fertility. This much, at least, seems con- 
 elusive : Chronic gonorrhoea in the male, supposed to have been cured, 
 often is not so. Its insidious lurking in the male is a fruitful source 
 of chronic uterine catarrh in women previously healthy. This catarrh 
 resides in the upper uterine cavity, is very stubborn, often incurable, 
 and is the cause of 2)ermanent sterility. 
 
 Anotlier cause of corporeal endometritis is enforced sterility. Xaturc 
 seems to have designed that the internal genitalia, through the influences 
 of pregnancy and lactation, should have stated periods of change and 
 rest. The ever-repeating periodical influxes of blood to these organs, 
 month after month for many years of married life, together with the 
 turgescence of the vessels inseparably incident to coitus, aggravated bv 
 such means as are employed to prevent impregnation and thwart gesta- 
 tion, are sooner or later inevitably folloAved by their evil consequences. 
 
 An important influence which produces this affection is obstruction 
 to the escape of the natural secretions, menstrual and otherwise. These 
 obstructions are formed (a) at the os externum from congenital mal- 
 formations of the cervix — the elongated and conoid cervix — and 
 ac(|uired strictures, usually following the vicious use of certain caus- 
 tics ; (6) at the os internum from flexion. The cavity above the 
 obstruction becomes dilated by distension from accunndation. The 
 uterus is provoked to j^ainful contractions to cmjity itself. The retained 
 secretions decompose and are transformed into irritating mattei"s. Thus, 
 in consequence of distension, septic accumulation, and abnormal con- 
 tractions, the mucous membrane above the point of obstruction becomes 
 inflamed. Finally, chronic uterine catarrh is provoked, aggravated, 
 and perpetuated by lacerations of the cervix, chronic congestions. 
 
672 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 displacements of the whole organ. The recognition of these causes^ 
 when existing, may be the keynote to the successfnl management of 
 the disease. 
 
 Symptomatology. — General Symptoms. — There is the greatest di- 
 versity of symptoms in diiFerent cases. The disease may continue for 
 several years with prominent local symptoms, yet the general health 
 seemingly remains good. Again, the greatest general disturbance in kind 
 and degree may be present. The. tendency of the aifection is to grad- 
 ually undermine the general health — for the patient to lose weight and 
 strength, to become ansemic and annoyed with sympathetic disorders 
 of digestion, circulation, and innervation. All the reflex symptoms 
 are more decidedly manifested than in cervical disease. Chief among 
 these are those of the nervous system — cerebral, spinal, and ganglionic. 
 
 Cephalalgia, especially on the crown of the head, of a burning cha- 
 racter, is one of the commonest of symptoms. Attacks of migraine at 
 or near each catamenial epoch are frequent. Then there is hysteria in 
 its protean forms, hystero-epilepsy, catalepsy, melancholia, insanity, etc. 
 In rarer instances there are paralyses, amaurosis, dyspnoea, palpitation, 
 cough, aphonia, and the various vaso-motor neuroses. Certain neur- 
 algias, facial, spinal, intercostal, etc., are very often experienced. Dis- 
 orders of the skin and its appendages, pigmentations on the forehead 
 and face like those seen in pregnant women, hypersesthesia or anaes- 
 thesia, loss of hair or change in its color, are also at times present. 
 
 The digestive system seldom escapes unaifected. The appetite is 
 impaired and capricious. There may be nausea and vomiting, espe- 
 cially at the approach of menstruation ; also gastralgia, flatulency, 
 diarrhoea, or constipation. The urine may be turbid, loaded with 
 urates or phosphates ; more often there is an abundance of clear, pale,, 
 limpid urine, deficient in salts. 
 
 Now and theu the general symptoms simulate very closely those of 
 pregnancy. Thus there are nausea and vomiting, enlargement of the 
 abdomen from flatulency, pain and tenderness in, and enlargement of, 
 the mammary glands. If, in addition, there should be menstrual irreg- 
 ularity of the form of amenorrhoea and the uterus be enlarged, an error 
 in diagnosis is easily committed. Tilt has regarded the presence of the 
 signs of pregnancy in young women without menstrual suspension as 
 prima facie evidence of internal metritis. 
 
 Various explanations have been oifered for the condition of meteor- 
 ism so often and prominently exhibited. Most probably it is a reflex 
 irritation leading to paresis of the nerves governing tonus of the intes- 
 tinal muscle, and consequent accumulation of gas. 
 
 Local Symptoms. — The first, most important, and most constant of 
 all the local symptoms is leucorrhoea. Arising solely from the corpo- 
 real cavity, it is glairy like starch-water, or is purulent and very com- 
 
ciiiioMc <:i:m:ii.\i. i:si>nMi:TiiiTis. r,i:\ 
 
 moiilv cominiiiLilctl with liluoil. It is iicvcf .-<» tlii<'i<, vi.-fid, m- tciia- 
 rioiis as is tlic product of tlic cervical <ilaii(ls. 
 
 BoiiiK't i'('L>,ai'(l('<l tlic riisty-coloi'cd Iciicori'lid'a — an adinixtiirc of 
 blond and nuiciis — "a diaractcristic of" iiitci-iial metritis, as the nisty- 
 colort'd I'xjK'ctoi'atioii is ul' jjuciiinoiiia." Tliis kind of'discliar<;(! mostly 
 follows tlio menstrual How, l)iit may coiitimie tliroiijili the month, con- 
 stitntinj; meti'offha^^ia. In old and fchelliou^ cases it may he j)urelv 
 ])urid('nt. The (|uantity is always increase<l alter iiieiistrnation. In 
 :uui?niic snhjects the menstrual How may consist almost entirely of 
 mncns and j)iis. While corporeal lencoirh(ea is g'enerally less abundant 
 than cervical, it is far more irritating in its ])roj)erties. It often pos- 
 sesses such acridity that the va<iinal and vidvar surfaces look red and 
 eroded — secondary va<2;initis and vulvitis. Thus there is aggravating 
 jM'uritus. 8nch effects are by no means in j)roportion to the amount 
 of the catarrhal discharge, for the smallest (juantity may be the source 
 of the greatest annf)vance. There is but little doid)t that such lencor- 
 rlnea is cajiable of producing urethritis in the male. 
 
 Notwithstanding the uterus at the close of menstruation is disposed 
 to take on senile involution or atrophy, terminating those pericMlical 
 congestions which tend to perpetuate any inflammatory action with its 
 catarrh, the morbid processes may remain indefinitely from the direct 
 force of the disease or some impediment to the pelvic venous circula- 
 tion. There may be apparent return of the menstrual flux many months 
 after its function has been supposed to cease. The cavity of the uterus 
 continues to throw off a creamy or Avatery discharge of special acridity. 
 This is chronic senile catarrh. Barnes states that in a considerable 
 number of such cases he has found more or less complete closure of 
 the cervical canal in some of its ]iarts, the walls having grown together 
 by a process comjDounded of inflammation and atrophy. The secretions 
 continuing, accumulate, and retention ensues. 
 
 Pain is a very uncertain symptom. Its seat may be the back, the 
 hip, or the uterine, or ovarian region. The extent of pain depends 
 more upon the amount and kind of complication, as chronic metritis 
 proper, displacements of the uterus, perimetritic inflannnation, than 
 upon the endometritis itself. 
 
 After leucorrhoea, the next most constant symptoms refer to the aber- 
 rations of menstruation. Menorrhagia, as to quantity, time, and dura- 
 tion, stands first in order. The flow appears at shortened intervals, is 
 too free, or prolonged. Menorrhagia may be merged into metrorrhagia. 
 Another feature of this form of menstrual disorder is an interruption in 
 the flow : thus, afitcr contiiuiing for a few days, it stops for a day or so, 
 to return again. Profuse and dangerous hemorrhages sometimes occur 
 from a fungoid condition of the endometrium. 
 
 The opposite menstrual state, amenorrhcea, is observable usually 
 
574 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 only after a long duration of the disease, when the mucous membrane 
 has become smooth, indurated, and atrophied. 
 
 Dysmenorrhoea in some variety — the congestive, from a hypersemic, 
 swollen endometrium ; the obstructive, from associated stenosis or flex- 
 ion ; the membranous, from an exfoliation of the entire lining — occurs. 
 By most authorities this shedding of the membrane in dysmenorrhoea 
 is regarded as an evidence of chronic corporeal endometritis. 
 
 Sterility is present in the majority of cases of endometritis of the cor- 
 poreal cavity, whether primary or secondary to stenosis or flexion, for 
 the following reasons: 1. The discharges are inimical to the vitality 
 of the spermatozoa. 2. There is frequently some obstruction to their 
 entrance within the cavity, because of stenosis or the quantity of mor- 
 bid secretions. 3. Should fecundation take place there is an inability 
 to retention and fixation of the fertilized product, because of the un- 
 healthy endometrium. It is easy to understand how a smooth surface 
 or one covered with unhealthy secretions, a dilated cavity, and a patulous 
 internal os may aflx»rd a poor resting-place for the ovum. Or, instead 
 of escaping altogether, the ovum is stopped only at the inner os. Con 
 cerning this point Klob has well remarked as to the predisposition to 
 the occurrence of placenta prsevia in females who have suffered for a 
 long time from blenorrhoea (uterine catarrh). Fertility is possible, but 
 not probable. Thus every function of the uterus is deranged in this 
 disease. 
 
 Physical Signs. — Patulousness of the os internum from a relaxa- 
 tion of the sphincter at the isthmus, increased length and capacity of 
 the corporeal cavity, tenderness of the corpus uteri to touch and biman- 
 ual examination, without at the same time any special enlargement, 
 great sensitiveness at the regions of the os internum and fundus on the 
 application of the sound, with a tendency to bleeding, — these are the 
 most reliable signs. 
 
 Diagnosis. — This is determined by a combination of the symptoms- 
 and signs. Localized pain and tenderness, the presence of the charac- 
 teristic leucorrhoea pouring forth from the uterus, menstrual disorders 
 and sterility, associated with a dilated internal os, enlarged corporeal 
 cavity, with special tenderness therein on sounding, are the evidences 
 of the disease. Not all of these are noticeable in every case. In many 
 certain symptoms or signs may be wanting, and in a few there is nothing 
 save the leucorrhoea to excite any suspicion of the nature and seat of 
 the trouble. 
 
 The differentiation between cervical and corporeal endometritis is 
 
 easily determined by the presence in the former of the characteristic 
 
 cervical discharge, and certain special local signs in the cervix as 
 
 revealed by touch and the speculum, and their absence in the latter. 
 
 General endometritis combines the symptoms and signs of both. 
 
cjmo.xic <!i:si:iiM. nsixiMiyniiTis. rj7,> 
 
 ()ii(' rca~"'ii \\\\\ iiillaiiimalinii ol" (lie i-avity of tlic titcriiic hotlv lias 
 so oitfii |)a»t'<l iiiirccdLiiiizcMl is tlial, In-in^ ('(unplicat*'*! witli ctTviral 
 disease in the liinii of" liciieral eiidoiiietritis, tiie jiraetitioiier lias satis- 
 fied liiiiiseli' with what he sees. Xoi |)(ilia|»s until he has failed to 
 relievi' his |)atieiil. allliiiii<:h the cervix l»y hical treatment presents an 
 iin|)foved appeaiaiiee, will he lie di>|K»se<l to exphtre Ijifther. 
 
 ( 'oMi'i.icAiioNs. — The iii(»t eoiiiiiioii e(»ni|ilieatio!is are vaginitis, 
 pruritus, metritis, iitei-iue displacements, and Hexioiis. Most utero- 
 ovarian diseases can he ti'aeed to the inflaminations of the endometrium. 
 
 Pk()(;N(»sis. — Prognosis depends upon the extent, duraticjn, and eoiu- 
 plications of the disease, as well as the state of the {general health. 
 A lonu-standiuii- j)urulent catarrh with metritie eonij)lieations and had 
 general health })resents a very unfavorable pro;^nosis. I3iJt there are 
 many eases, less severe, which are quite amenable to treatment. Gen- 
 eral endometritis yields more readily than pure corporeal. In the 
 multii)ane, caicris paribus, prognosis is more favorable than in the 
 nulliparre. Cases of gonorrhoeal origin are especially stubborn. 
 
 Some authorities are very dubious as to the curability of this disease. 
 Scanzoni is often quoteil as saying that he cannot remember a single 
 case cured. Althouo-h this statement convevs a more srloomv idea in 
 reference to the prognosis than the actual facts will admit of, yet it 
 must be acknowledged that chronic corporeal endometritis is one of the 
 most intractable affections we are called upon to treat, and, uncontrolled 
 by treatment, it has an indefinite continuance, manifesting no disposition 
 to abate, until at the menojiause, with the suspension of the menstrual 
 function, atrophy of the uterus ensues. Xature does not always bring 
 about relief even at this time, for senile catarrh may remain for nnun- 
 years longer to annoy the patient. 
 
 Local Treatment. — Having diagnosticated intracorporeal inflam- 
 mation, at first view it would seem wise and urgent that local treatment 
 be instituted here in the same manner that is found so beneficial for the 
 similar disease of the cervical canal. Further reflection on the function 
 and sensibility of the inner uterus, and especially a careful review of 
 recorded ex])eriences, lead one to undertake such treatment not only 
 with some hesitation, but certainly with much caution. Bennet has con- 
 tended that the cavity of the uterus proper bears surgical interference 
 less than any other part of the organ. Experience shows that this view 
 is correct. Surprise must therefore be expressed at the doctrine ad- 
 vanced by Miller, that treatment to this region could be maintained with 
 as much familiarity and as little ap]irehension as to the uterine neck. 
 
 As to the necessity of intra-uterine treatment, few gynecologists 
 doubt. It has the indorsement of most modern practitioners in this 
 field of labor. The chief questions are: AVhen? In what cases"? 
 How? and, What are the agents to be employed? 
 
576 THE INFLAMMATORY AFFECTIONS OF TtiE UTERUS. 
 
 Bennet has said : " Internal metritis is generally 'subdued by means 
 adapted to cure the inflammation of the cervical canal which accom- 
 panies it." There is a grade of truth in this statement. There can be 
 no doubt that corporeal endometritis of limited duration, mild in cha- 
 racter, coexisting with cervical, may be subdued by attention addressed 
 exclusively to the latter. It does not seem reasonable to suppose, how- 
 ever, that when the opposite conditions exist any material or lasting 
 benefit can be obtained in this manner. 
 
 The testimony of so acute, careful, and experienced an observer as 
 Thomas is worthy of note. He says : " Observation and experience 
 have so changed my own practice that I find myself very rarely, at 
 present, resorting to applications above the internal os." Their occa- 
 sional necessity, however, he does not deny. Emmet says he has 
 abandoned them since 1879. On the other hand, another prominent 
 and skilful observer, Goodell, always carries his application to the 
 fundus whenever the internal os permits it to pass. By so doing, he 
 says, he has obtained better results, without more hazard, than when 
 limiting the same to the cervical canal. 
 
 Selection of Cases. — Practically, in management three kinds of cases 
 may be recognized : 
 
 1st. Cases of chronic corporeal endometritis, dependent upon and 
 perpetuated by certain morbid constitutional conditions and diatheses. 
 Here local treatment accomplishes little at best — as a rule, signally 
 fails ; in fine, in many instances may be entirely dispensed with. 
 
 2d. Cases in which the corporeal coexists with the cervical disease, 
 both arising from a common cause, as is usual after abortions or partu- 
 rition at term. Such cases are limited, for the most part, to the multi- 
 parous organ, but almost always show a greater intensity in the cervical 
 region. Local medication, addressed solely to the cervix, will often 
 suffice, the disease of the corporeal cavity being arrested through the 
 derivative and depleting influences of the agents there applied. 
 
 3d. A class of cases, considerably less frequent than the last men- 
 tioned, in which the disease is not the outcropping of a diathesis, and 
 is localized to a point above the internal os, or if coexistent with cer- 
 vical disease the latter is secondary. Here cases of old, well-pro- 
 nounced menorrhagia, metrorrhagia, dysmenorrhoea, and metrorrhoea 
 are not influenced by cervical treatment. The indications are clear, 
 and the necessity for the execution is manifestly imperative, unless 
 some special contraindication presents itself, to direct the local treat- 
 ment to the seat of the disease. 
 
 From the foreffoina; classification the inference is that the number of 
 cases absolutely requiring intra-uterine medication is relatively small. 
 
 Under all circumstances it is important that the underlying general 
 and local condition be diagnosticated. Sometimes a comparatively 
 
cjiJioMc (;j:.\i:j:al I'.SDoMiyrniris. 
 
 'ill 
 
 iMG. 188. 
 
 small local Icsinii or almoniiity ol" llir (•( r\i\, wliidi i> at llic hMllnin 
 of the whole (lilliciilly, must (iist !»• icmcclicd. 
 
 The Mrllmil. — riici'f arc, in uciici'al, (wn iiictliods lor the iiitr<Mhic- 
 (ioii of mctliciiial aiiciits within the ntcnis — int;-estioii and injection. 
 
 A. I Ndl'.si'ioN. — {(i) llji flic A/tji/!<'(((nr. — I'l'ercrcnee is to he •riven 
 to the instrument ol' hard rnMier or \iri;in >il\er ( I'^itr. 1 •'^7 j, made 
 smooth, slim, tlcxihle, and with an olive-sha|)e<l extremity. 
 AI)S(»rl)ent cotton is carelhlly wrapped ai'onnd the extremity 
 in t|nantit\- siillielent to al)sorl> an adci|iiate amount of tiie 
 selected tliiid, and yet not so much as to interfere with its 
 passage thronj^h the uterine canal. 
 
 To secure tiiorouglinoss and elHcieu(T of application the 
 followinii' |)reliminary ste])s are needed, a dis- Fig. 187. 
 reu'ard of which is the chief source of failure 
 in intra-ntei-inc medication : 
 
 1st. Free exposure of the cervix by means 
 of the speculum, choice being- given to Sims's, 
 with the patient in the left-lateral semi-prone 
 position, the cervix being steadied with the 
 self- retaining tenaculum. 
 
 2d. A certain amount of dilatation of the 
 cervical canal, including the os internum. 
 The disease usually does this; if not, it 
 should be secured by a tent (tu]3elo) or ex- 
 panding forceps. The latter are to be used 
 gently, and never expanded to the full width 
 of the blades. Dilatation through disease or 
 artificially is not only necessary to facilitate 
 the introduction of the curved cotton-wrap- 
 ped applicator, Ijut also to prevent the medi- 
 cating fluid being squeezed from the cotton 
 by the contracting cervix. 
 
 3d. The diseased endometrium, which is to 
 receive the impress of the medicament, should, 
 so far as possible, l)e cleansed from all secre- 
 tions. Not only do these mechanically ])re- 
 vent contact, but chemicallv they impair the 
 
 activity of most agents. With the nitrate of Applicator. 'v — y 
 
 silver, nitric acid, tannin, iron salts, etc. there is formed an ^xenmul^m '".r 
 all>uminate. Iodine in aqueous (or even alcoholic) solution steadying the 
 undergoes no appreciable change — a feature which especially 
 recommends it for uterine purposes. The removal of these morbid albu- 
 minous secretions is effected by l)its of pure cotton or sponge squeezed out 
 of hot salt water, seized in a small jirobang, bent to a suitable curve. 
 Vol. I.— 37 
 
578 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 All gynecologists have experienced the difficulties and unsatisfactori- 
 ness of applications made even with the aforesaid precautions and care. 
 In spite of our best efforts a certain proportion of the ingested fluid will 
 likely be lost by the contractions of the uterine walls excited by contact 
 of the irritant introduced. Thus, surfaces which we desire to medicate 
 remain partially untouched, and portions of the canal not diseased, and 
 of course not requiring medication, receive the fluids. Accordingly, to 
 obviate these difficulties several contrivances, which keep the cervical 
 walls asunder, protect its canal, and afford free entrance to the corpo- 
 real cavity, have been introduced. Such are the instruments of Lombe 
 Atthill, Peaslee, Wylie, Stoops, and others. The author has made use 
 of one fashioned somewhat after the pattern of Atthill's, but with a 
 fixed flexible handle (Fig. 189). The canal is dilated, if necessary, for 
 the introduction of the canula ; the cavity above is mopped out with 
 sponge and probang; the rubber applicator, wrapped and saturated 
 with the selected fluid, is passed to the fundus and allowed to remain 
 a few seconds ; finally, the applicator is withdrawn to within the 
 canula, and both are then simultaneously removed. For the appli- 
 cation of the stronger fluid, caustics, nitric acid, chromic acid, etc., this 
 instrument is very valuable, but for the use of solutions of iodine and 
 carbolic acid, with moderate dilatation, it is ordinarily not required. 
 
 (6) By the Apjdicator Syringe. — This is a method obviating some 
 of the objections and difficulties of the wrapped applicator. It com- 
 bines the facility of injection, as well as the safety, for the most part, 
 of ingestion. It was first employed by Lente ; then, soon after, but 
 independently, by Munde. It consists in the use of a small, tightly- 
 fitting syringe, capacity of 3ss, with graduated piston, to which is 
 attached a long, slender, flexible rubber tube for introduction through 
 the speculum to the fundus of the uterus (Fig. 190). The syringe is 
 first filled with the fluid to be ingested ; then the tube at its extremity 
 is wrapped with cotton in a manner similar to the applicator, and is 
 next introduced within the uterus to the fundus, when the fluid from 
 the syringe is gently discharged into the cotton to saturation. It is 
 not necessary to discharge a quantity sufficifent to be seen oozing from 
 the OS externum. A saturation of the cotton (a matter which can be 
 accurately determined by previous experiment) implies the contact of 
 the medicament in an undiluted state to the endometrium. If care is 
 taken not to inject a surplus of fluid which may distend the uterine 
 cavity, no more unpleasant results need follow this method than with 
 the simple applicator. 
 
 This method is an excellent one for the application of tincture of 
 iodine and carbolic acid, but it ought not to take the place of the pro- 
 tecting canula for the fluid potential caustics. 
 
 Hegar and Kaltzenbach have made use of applications of medicated 
 
en IK IS ic <;!■:. \ /■:/:. I L nshoMKinrris. 579 
 
 Fi(i. 1.S!». 
 
 4 S 2 1 
 
 Palmer's Intra-uterine ^red^cato^ : 1, canula for protecting the cervical cannl : 2, plug to facili- 
 tate introductiou of cauula; 3, spunge-holder to cleanse uterine cavity: 4. flexible silver 
 applicator. 
 
580 THE INFLASniATOBY AFFECTIONS OF THE UTERUS. 
 
 lint, and Sims of cotton, by means of his slide applicator (Fig. 191). 
 Such applications are introduced and allo"\ved to remain within the 
 
 Fig. 190. 
 
 Applicator Syriuge. 
 
 uterus for from twelve to twenty-four hom's. Doubtless, thereby more 
 decided and permanent effects are secured, for not only is the medica- 
 ment left in contact with the diseased surface for a longer period of 
 
 Fig. 191. 
 
 Sims's Applicator, with slide. 
 
 time, but the uterus is made to contract by the presence of a foreign 
 body. 
 
 Fluids used by Ingestion. — These are solutions of iodine, chloride 
 of zinc, nitrate of silver, carbolic acid, chromic acid, and nitric acid. 
 Of these, iodine in the form of Churchill's tincture is one of the most 
 useful, and carbolic acid stands next. Iodine is stimulant, alterative, 
 antiseptic, and haemostatic. Carbolic acid, a feeble caustic, is one of 
 the most efficacious and safe agents, and is especially adapted to the 
 milder forms of the disease. Playfair, Thomas, and others hold it 
 in the highest esteem. 
 
 Iodized phenol, a combination of iodine and carbolic acid, first 
 recommended by Battey in 1877, in proper strength (1 part iodine in 
 4 parts by weight of carbolic acid), is a most excellent agent. Its chief 
 objection is its disagreeable odor. Solutions of nitrate of silver are 
 more irritant and less useful than in cervical disease. 
 
 Chromic and nitric acids are reserved for the severer forms of the 
 disease with patulous canal, granular degeneration, purulent discharge 
 — endometritis villosa, polyposa, hyperplastica, membranosa, hsemor- 
 rhagica — cases which probably will resist less active treatment. Nitric 
 acid in its pure state, so highly extolled by Atthill, Kidd, Kennedy, 
 and other British gynecologists, is not so painful or severe an applica- 
 tion as might appear ; nor is its use, within proper restrictions, more 
 dangerous than that of other agents, and in properly selected cases it 
 is certainly more efficacious. To protect the cervical canal and prevent 
 
ciiitoMc (!i:sEiiM. i:si><)Mi:rin'ns. o>ii 
 
 cicatricial contraction in the rc^iion ol" tlic o> cxlcrinini the cainila 
 should l)c cni|)loyc(l in the use ol" nitric aci<l. 
 
 (^irholic acid may i)c appliccl once in f«»nr t<t live days; ( 'Inircliill's 
 tincture and iodized phenol, ahoiit once a week din-in<r the menstrual 
 interval; the stronger acids rarely ol'tcncr than once a month. Too 
 fre([uent or inineeessary use ot" nitric acid may lead to cicatrization and 
 early induration of the endometrium. 
 
 Solids used by Ingestion. — Various astrintrents, alteratives, and caus- 
 tics niav l)e incorporates] with lard or cocoa-butter or vaseline in the 
 form of a plasma or ointment, and be ingested by means of a syringe 
 or tube with piston. This is a favorite method of intra-uterine medi- 
 cation with Robert Barnes of London, Fordyce Barker and F. D. 
 Lentc of New York. The application of all ointments is disagreeable, 
 and in point of efficaciousness they rank much inferior to fluids. 
 
 Instead of ointments, medicated crayons, pencils, suppositories, and 
 pastilles, containing carbolic acid (grs. ij), zinc sulphate (grs. j-ij), iodine 
 
 Fig. 192. 
 
 Applicator Syringe for fluids or ointments. 
 
 (grs. j-ij), and iodoform (grs. iij-v), have been used. The last-named 
 remedy is higlily recommended by Fordyce Barker for the menorrhagia 
 of the climacteric dependent upon endometrial congestion. Iodoform 
 pastilles make sometimes very useful applications for chronic catarrh. 
 These pastilles, properly prepared with gelatin coating, flexible for 
 introduction, yet firm enough to be seized with a speculum forceps, 
 possess all the advantages of this method. Sometimes, when slow in 
 melting, they produce symptoms of uterine colic. 
 
 Nitrate of silver, in the solid form as a crayon, has frequently been 
 aiiplied within the uterine cavity. Recamier first introduced the prac- 
 tice, and it has been followed by Lallemand, Bennet, Courty, Miller, 
 Byford, Lente, and others. At the present time the practice has gone 
 almost entirely into disuse. Aside from the danger of a portion of the 
 crayon being broken oif on account of the strong contractioas excited 
 in the uterus, the application itself is frequently followed by the most 
 intense pain. Profuse hemorrhage and peritonitis have likewise ensued. 
 Moreover, the practice of the introduction of a solid stick of the nitrate 
 within the uterus, allowing it to remain and melt, is too hazardous to be 
 countenanced. Occasionally, very little or no pain follows this treat- 
 ment, probably oAving to the fact that the stick, floating as it were in a 
 puddle of secretions of mucus, pus, or blood, is neutralized by them 
 
582 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 and does not come in contact with the endometrium. It is a well- 
 established fact that the greater the dilatation and disease of the corpo- 
 real cavity, the more tolerant, coeteris paribus, the organ is to irritant 
 medication and surgical interference. To say the least, the solid 
 nitrate is less safe than, and has nothing to recommend it before, 
 nitric acid. If used at all, the method of application of fusing it 
 on a flexible probe is to be preferred. 
 
 Byford states that he has frequently effected a cure in endometritis 
 complicated by stenosis and flexion by the introduction of tents of 
 slippery elm, which by dilatation overcome the constriction, and also 
 by pressure exercise a salutary influence over the diseased mucous mem- 
 brane. Each tent is from 1-|— If inches long, ^ inch in diameter — small 
 enough to pass through the narrow canal. 
 
 B. Intra-uterine Injections. — This is one of the most ancient of 
 gynecological usages, advised and practised by Hippocrates some twen- 
 ty-two hundred years ago, for medicating the interior of the uterus. 
 Subsequently, it was used by others among the ancients, and later on 
 by Ambrose Pare in the sixteenth century ; within the past twenty years 
 it has been quite extensively employed. There is scarcely a therapeutic 
 resort so old or one which has passed through so many phases of prac- 
 tice — ^to be forgotten, revived, then rejected, and finally reintroduced 
 and indorsed. 
 
 If the healthy uterus be injected with fluid, the following symptoms 
 will probably be noticed : Uterine pain and colic, abdominal tenderness, 
 feeble, frequent pulse, coldness of the extremities, nausea and vomiting, 
 and other indications of shock. The intensity of these symptoms will 
 vary according to the quantity and force of the injection, the character 
 of the fluid, and the special susceptibility of the person. That their 
 occurrence does not entirely depend upon the quantity or irritating 
 character of the fluid is evidenced by the fact that at times they are 
 manifested where its quantity is very small and it is most bland. If 
 the uterus is diseased with chronic inflammation, these symptoms are 
 apt to be provoked with less severity, or may be absent altogether, 
 according to the size of the cervical canal for exit of the fluid, the capa- 
 city of the uterine cavity for its reception, and the presence of various 
 secretions to neutralize the injection. 
 
 jSTumerous reasons, worthy of notice, have been advanced in explana- 
 tion of these morbid phenomena : 
 
 1. Penetration of the Injected Fluid through the Oviducts into the 
 Peritoneal Cavity. — Many experiments at difl^erent times have been 
 made to test the possibility of this accident. Vidal first operated upon 
 the cadaver, and found that with moderate pressure the fluid did not so 
 enter. Hennig's experiments coincided. Klemm could make the fluid 
 pass through the Fallopian tubes oidy on great pressure. The author 
 
ciiiiosK' (ii:si:n.\L i:\ix iMiyriiiris. 583 
 
 has r('|u'at('(lly iiiadc similar cxpciiiMciifs hy constricting; with a stout 
 cord the cervix around a tuhe (ilted to a stronj^' air-tight syrinj^e. No 
 fluid could l)c liirccd throu<;h the o\i(hicts uidoss tliey were dilatcch 
 
 1 (' >uch dilHcuhies are encountered in the dead suhject where then; 
 is no iustinetix'c contraction oi' the >|)hinctei' at the nieti'o-salj)ingian 
 orifice, how much lireater will he those met with in the li\inul Now, 
 do intra-uterine injectious over so penetrate in tlie liviujj; suhject ? A- 
 the iitorus wlieu injected is usually diseased in some way or eontaius 
 morbid materials, and a.s under these conditions the orifices of the 
 orji^an are f'reciuently dilated, it follows that in a cei-taiu rare j)roj)or- 
 tion of cases penetration of the fluids to within the abdcjminal cavity 
 does occur. Post-mortem examinations and Lawson Tait's opera- 
 tion prove the existence of })atulous and dilated tubes. Von Hasel- 
 berg, Barnes, and others report cases where, on autopsy, solutions of iron 
 salts were found at the fimbriae. But, notwithstanding these admis- 
 sions and provings, evidently the symptoms cannot be traced, except 
 possibly in rare instances, to such causes. 
 
 2. Penetration of the Uterine Veins. — An impossibility in the 
 healthy uterus, unless under the influence of the greatest force, but 
 an admitted possibility in certain morbid conditions of the organ. 
 
 3. Entrance of Air into the Veins and General Circulation. — Like- 
 wise possible when the mucous membrane is exfoliated, veins are en- 
 larged from disease, pregnancy, or after parturition or abortion. The 
 experiments of Klemm tend to confirm the possibility that injected 
 fluids w^ith a constricted cervical canal may be more easily driven into 
 the venous system than into the oviducts. 
 
 4. Acute Inflammations : Peritonitis, Phlebitis, Endometritis. — The 
 rapidity of the occurrence of the symptoms precludes the acceptance 
 of this explanation. These inflammations do often occur after intra- 
 uterine injections, and they are the most common immediate causes 
 of a fatal issue ; but such lesions are not the direct and immediate 
 cause of the first phenomena. 
 
 5. Rapidity of Absorption. — Certain medicines, as solutions of iodine, 
 carbolic acid, chromic acid, acid nitrate of mercury, etc., may be quickly 
 absorbed into the general circidation and produce evidences of poison- 
 ing. Iodine, applied to the uterine cavity even more than to the cervix, 
 is not uncommonly tasted by the patient, owing to its rapid absorption. 
 A denuded mucous surface, large and superficial blood-vessels, greatly 
 facilitate this action. But absorption does not always take place, and 
 if it did could not always do harm. Violent symptoms may supervene 
 on the injections of pure warm water. 
 
 6. Shock. — The uterine cavity in a healthy non-gravid organ at the 
 non-menstrual inter\ al is no cavity at all. In normal menstruation it 
 holds but a few drops of blood. Only wdien diseased by some morbid 
 
584 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 growth or accumulating secretions is there a real cavity. Injection of 
 a healthy organ is attended by an abrupt separation of the coaptating 
 myalls — a distension of the cavity. If the quantity is in excess of a 
 few minims, and a certain portion is retained, contractions are excited 
 to empty the uterus. The sudden entrance of a foreign substance, rapid 
 distension and contraction, imply irritation of the hypogastric plexus 
 of the sympathetic — shock. This is the most plausible theory, under all 
 the circumstances, that we have. It is the only tenable one to explain 
 the phenomena as presented in healthy subjects. It is satisfactory, too, 
 as showing why these phenomena are less severe or absent when the 
 injection enters a dilated cavity, mingles with morbid secretions, or 
 readily finds an exit. 
 
 In view of these facts various precautions can be observed which 
 tend to prevent the ill effects of intra-uterine injections : 
 
 1. Dilatation of the Cervical Canal. — Whether this is the result of 
 the disease or is accomplished artificially by tents, it matters not, so 
 that the injected fluid readily flows out of the uterus, retention and 
 distension thereby being prevented. For manifest reasons, it is more 
 dangerous to inject the uterus when flexed. 
 
 A ready exit of the current is also secured by the use of a double 
 canula. There are a number of devices, as ISTott's, Byrne's, Skene's, 
 and others. The one used by the author since 1870 readily permits of 
 a reflux current, and with it retention with distension is impossible. 
 The canula is fitted to an air-tight syringe with the capacity of half 
 an ounce. (See Fig. 179). 
 
 2. Shock is diminished by using fluids at a temperature of at least 
 
 95°-98° F. 
 
 3. Distension and shock are diminished by injections in small quan- 
 tities administered slowly, gently, drop by drop. 
 
 4. The possibility of injecting air is prevented by using a perfect 
 instrument and thoroughly filling it. 
 
 By an observance of these precautions are intra-uterine injections 
 safe ? Doubtless by them the dangers in a large degree are avoided ; 
 consequently, they should be complied with in all instances where 
 resort is had to this method of medication. But even then, with 
 the greatest possible care and precaution, occasionally uterine pain and 
 colic, symptoms of rapid absorption, with subsequent development of 
 metro-peritonitis, etc., will arise, terminating, it may be, fatally. There 
 are those who have been so fortunate and skilful as to have encountered 
 no such accidents in a large experience. Authorities in high position 
 still utilize this method of intra-uterine medication, but a verdict made 
 by a large majority of gynecologists of to-day, based upon accumulated 
 personal experience, is against the method except in rare cases. Chronic 
 endometritis is an affection not of danger, but largely one of incon- 
 
runoMc (:i:m:i:.\l h.MxiMi/rniris. r),sr> 
 
 veniciicc. In its inaiia<;('iiu'iit no pnictitioiuT is warranted in assiiniinj^ 
 iimu'ccssarv risks, wliicli tlu'si- iiijwtions imavoidahly imply. Mon;- 
 over, the method is ordinarily imneeessarv, iiiasmueli as, even if safe, 
 it is not snperior to that hy inj^estion. 
 
 What, then, are tiie eirenmstanees in w hidi intra-nterine injections 
 in the non-j^ravid state are jnstifiable and WeneHcial? 
 
 1. Cases of threatened or aetnal septiejemia the resnlt of deeonipos- 
 injj material Avithin the uterns, life being endangered]. Here the injec- 
 tions, because of a patulous canal, are less hazardous than usual. Even 
 if as dangerous they would be justifiable, for the reason that the prac- 
 tice is attended with less risk than is the disease unchecked. 
 
 2. Cases of uterine hemorrhage otherwise uncontrolled. 
 
 The agents used for septicaemia are solutions of carbolic acid, potassic 
 permanganate, and mercuric bichloride ; for hemorrhage, hot water, hot 
 vinegar, tincture of iodine pure or diluted one half. For the latter class 
 of cases the number of instances in which injectioas will be deemed 
 neeessarv must be very small, in view of other valuable and safe 
 resources at hand. 
 
 If untoward symptoms unavoidably arise, they are to be met by the 
 use of morphina hypodermatically, internal stimidation, and external 
 heat. 
 
 The curette, judiciously employed, is one of the most valuable of all 
 our therapeutic resources in the management of chronic endometritis. 
 Often, its use should precede local uterine medication ; it may render 
 the same entirely unnecessary, and not nnfrequently will it effectually 
 control conditions of the uterine cavity — endometrial thickening, soft- 
 ening, and granulations attended with hemorrhage — which topical treat- 
 ment of any kind fails to relieve. The indications for, and uses of, 
 this instrument will be referred to in flill under the subject of Uterine 
 Fungosities. 
 
 We must not fail to remember that chronic corporeal uterine catarrh 
 may be not only started, but maintained, by a cervical laceration or 
 uterine displacement, and to cure the catarrh we must remove the 
 cause. 
 
 , Contraindications, Dangers. — Intra-uterinc medication of any kind 
 by ingestion or injection is contraindieated when the uterus or the 
 perimetritic tissues are especially tender. Before such interference 
 is commenced all tenderness, due to acute congestion of the uterus, 
 or lurking inflammation in the surrounding cellular or [)eritoneal 
 tissues, should be removed by rest, the hot douche, saline purgation, 
 counter-irritation, and sedative medication. There is always increased 
 danger of exciting a new attack of jierimetritic inflammation — gener- 
 ally peritoneal — in every instance where this disease has previously 
 existed, although, seemingly, all evidences of it have become eflfiieed. 
 
586 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 Intra-uterine medication and curetting are most . decidedly contrain- 
 dicated when the uterus is more or less fixed from inflammatory exu- 
 dations and adhesions. 
 
 Intra-uterine treatment should, at the commencement, be mild and 
 tentative, in order to test special individual susceptibilities. For the 
 same reason such treatment is better initiated at the patient's house. 
 There is the greatest variation in point of sensitiveness in different 
 patients. With some the least interference for exploration and treat- 
 ment excites unexpected disturbance ; with others much manipulation is 
 borne without any unpleasant symptoms. When the menstrual period 
 is impending, the nervous and vascular systems being at the acme of 
 excitability and tension, then, above all other times, slight causes are 
 capable of provoking undue reactions. 
 
 Proper precautions as to the time of applications, exposure, and 
 exercise afterward should be observed in all cases. 
 
 The question of intra-uterine medication is one of the most import- 
 ant and serious within the domain of uterine therapeutics. The author 
 has endeavored to present a fair status of the subject in the face of 
 accumulated and sifted facts. Amid the great variety of opinions, 
 apparently based upon experiences, the beginner is put at a loss to 
 know what course to pursue. As will be inferred from the foregoing 
 pages, the author is not disposed to side with either extreme of prac- 
 tice — not with those who would altogether discard intra-uterine treat- 
 ment or with those who adopt it in all cases where the upper cavity 
 is seemingly diseased. Truth here, as elsewhere, lies in the middle 
 ground. Without doubt, immense harm has been done and many 
 valuable lives have been sacrificed by injudicious and uncalled-for 
 local treatment. That it has been used too frequently — used to be 
 abused — is freely admitted. That it can be omitted in not a few 
 cases in which formerly it was deemed necessary, and that in these 
 cases better results in a safer way can be obtained by other methods, 
 should not now be denied. But the reaction against intra-uterine 
 medication has probably gone too far. With a proper selection of 
 cases, and with due restrictions and precautions, intra-uterine medi- 
 cation is of great service in many cases — a service too valuable to 
 be laid aside and ignored. In this department of practice most 
 forcibly does it behoove us that in our efforts to do good we do no 
 harm. 
 
 Bibliography. 
 
 Aran : Malad. de F Uterus. 
 
 Atthill : British Med. Journ., Jan.. 1873. 
 
 BarkeK : Transac. Am. Gynecolog. Soc, vol. iv. p. 67 et seq. 
 
 Barnes : Diseases of Women. 
 
 Battey, Robert : " Intra-uterine Medication," Am. Gynecolog. Transac., vol. iv. 
 
ULCERATloys AM) l)i:<: IISEIIATIOSS OF CIHlVIX rTKIll. '>>*,! 
 
 Bennkt: Injlumiimtii)n of the UUtum. 
 
 Bkuni'TZ AN'i) (itHTPiL: '' Diseases of Winneii," Tnuuvictium uf Sijili-nhim Sur., 1807. 
 
 J^YKOKD: Di.ifM'x iif W'liinin, p. 1124 <'/ •'«■'/. 
 
 Coi'inv : Midnd. dr /' Utenin. 
 
 lOnis : />('.'<c((.s('.s o/' W'oiiwn. 
 
 Emmkt: PrinripliH (iiitl Prdclirr of Cii/nccolDi/i/, 1884. 
 
 FlllTscil : Dm-hxim i)f Woiin-iiy 1883. 
 
 (JooDKLL: Lri<.foii.t in Giimrolixjij, pp. 118, 11!). 
 
 IIakI' and Hakrouk: Munnd of (ji/iKrenlotfi/. 
 
 Kamkui:r: "Treatment of I'terine C'atarrli," Am. Jniirn. Obntetrinf, vol. ii. p. 18.5. 
 
 Klou: Piilliolo(/iral AiKtlomi/ <;/' J'Viiudf Sfxiud Ort/(ins. 
 
 MiLLKR: '' Ketrospei't of I'terine Pathology," Am. Journal (JhiilelriiM,vo\. iv. 
 
 MuNDE: 7';v(;(.-«c. Am. Gi/nicoloi/. Sue, vol. iv. p. 71, and Minor Siin/iad (itjnecoloijij, 1885. 
 
 NoKOGiCKATH : "Latent ( i(inonii<i';i in llii' I'enuile Sex," 187.3; also, Tranmc. Am. 
 
 Gynfcoloy. Soc, 1871), 
 Nott: "Treatment of Kndnnietiitis liy I'lerinu Injections," Amer. Jouriud Ob.sli:l.,viA. 
 
 ii. p. 470. 
 Playfair: London Lancet, Jan., 1873. 
 Peaslee: Xew York Med. Joniiud, July, 1870. 
 RouTH : " Fundal Endometritis," London Obstet. Transac., vol. xii. 
 ScANZoxi: Disease.'i of Femalt's. 
 ScHROEUER: Disease.'t of the Fenude Sej:ual Orgaiui. 
 SiMP.s(jN, Sir James Y. : i>/.sr((.s&s of Women. 
 Smith, Tyler: On Leiworrhoea. 
 Tait, Lawson: IJL^ea.ie.i of the Ovarie.s, 1883. 
 Tilt : Uterine and Orarian Inflanwudion. 
 
 Thomas: Transac. Amer. Gynecolog. Soc. vol. iv. p. 79 et seq., and Diseases of Women. 
 West : Dijseases of Women. 
 
 Ulcerations and Degenerations of the Cervix Uteri. 
 
 Intimately connected with the subject of chronic cervical endometritis 
 if< that of ulcerations and degenerations of the cervix. So much di.s- 
 putation and misunder.standing having occurred concerning the true 
 pathology of the affections of the cervix called ulcerations that it 
 .seems pr()])er to give a more full and distinct mention of them. 
 Within recent years new views of their pathogenesis, based upon 
 micro.scopical investigation, have been advanced \\liich seem destined 
 to revolutionize our previous ideas. 
 
 XoiiMAL Anatomy. — The vaginal portion of the cervix is covered 
 with layers of squamous epithelium resting upon papillte of connective 
 tissue. Slender blood-vessels ]iass into each and form vascidar loops 
 on their extremities; then, returning, pass into adjoining pa])illa\ 
 According to some, mucous ciypts are found, though this is denied 
 by De Sinety. Ruge and Veit also consider their existence as ])nth- 
 ological. 
 
 The cervical canal is lined with a single layer of epithelium, ciliated 
 on its free surface, folded so as to form shallow reccs.ses. There are 
 numerous racemose mucous glands with branching ducts. The sub- 
 stance of the cervix is made up largely of connective ti.s.sue. 
 
588 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 Pathological Anatomy. — The exact steps, according to the old 
 and generally accepted view, in the pathological processes of chronic 
 cervical catarrh by which, through the influences of increased and 
 altered secretion of the cervical follicles, the infravaginal mucous mem- 
 brane becomes macerated, exfoliates its epithelial layer, and proliferates 
 its papillae, etc., have been referred to. It becomes now our duty to 
 speak of the results of modern miscroscopical investigations, and to 
 show why the recently-advanced opinions may be accepted. 
 
 Much of the dispute among authorities as to whether these changes 
 are ulcerative or not, or whether " ulceration of the womb " is a com- 
 mon condition, is a contention about non-essentials, and arises from a 
 misunderstanding among the disputants as to what each considers 
 ulceration. Dunglison defines an ulcer as a solution of continuity 
 in the soft parts. The exact extent and depth of this solution of 
 continuity ought not to be the points at issue. Is there any solu- 
 tion at all? A simple destruction of the epithelial layer, from what- 
 ever cause, of whatever duration, is an ulcerative process, superficial 
 though it be. 
 
 Now, it appears that the acceptance of the doctrine of any destruction 
 of tissue is based upon naked-eye appearances during life and micro- 
 scopic examination of specimens taken from dead bodies, in which the 
 epithelium has been macerated and removed. 
 
 Careful investigations of Huge and Veit, who have examined speci- 
 mens freshly cut from the living subject, have demonstrated that the 
 apparently raw surface seen through the speculum is covered with 
 epithelium, and that the granular points supposed to be hypertrophied 
 papillae are not connected therewith, but are new formations. The 
 appearances, as described by them, are as follows : The seeming ero- 
 sions are covered with cylindrical cells, small, long, and narrow, 
 having a palisade-like arrangement. This layer of cells is thin, and 
 allows the subjacent vascular tissue to shine through ; hence the bright- 
 red color. The key to the discrepancy as to how pavement epithelium 
 is converted into cylindrical is furnished by recognizing the fact that 
 acinous glands are found in this portion of the cervix externally, and 
 especially internally. The glandular epithelium proliferates and covers 
 the parts denuded. The cylindrical epithelium may detach the pave- 
 ment epithelium, crowding between it and the underlying tissue. An 
 enlarged gland with spreading orifice displaces the pavement epithelium, 
 so that an area of protruding and proliferating glandular lumina is seen. 
 Thus, cylindrical epithelium seems to possess a much greater energy of 
 growth than pavement epithelium, displacing the latter and occupying 
 territory where not originally found. 
 
 Abrasions, M^osions. — The raw-looking surface called abrasion or 
 erosion is therefore only a newly-formed glandular secreting surface, 
 
l'lcj:j:atji).\s am) j>j:(;hsj:iuTiuss of ckiivix itfui. ,j.s'.) 
 
 ros('iiil»liiin' llic ccrvicMl imicoiis lucinhraiic. licin^ a practical additimi 
 to tlic extent (•! "area ol' scerclioii, it necessarily increases t lie Iciicorrlid'a. 
 Tliese so-called aliraded surfaces arc Wright wA, circular or i^-cuci'allv 
 in'eiiidar in slia|»c. situated around the cxtcrual os, more rr(M|ncnllv 
 the posterior eer\ical li|», with edtics sonictinics well deline(l, ;uid often 
 hlccdiiio- easil\- when toiielied. 
 
 (i nimihir / )((/ni<r(ili<)ii. — This is really no ideci'atioii at all. (ire;it 
 proliferation of the cylindrical e|)itheliiMn or of the uland.~ causes 
 j)r(>tul)erances to arise. The sui'face is furthci' thi'own into mnnerous 
 folds, produciuii- lilandular reces.ses and processes — j^landular luniina 
 which have proliferated outward. Such are j)aj)illonuitous ei'osions, 
 the surface of which has a ji'nuiular appearance. The condition pro- 
 vokes a persistency and intensity of th(^ inor])id action — hv])er;cniia and 
 increased secretions. 
 
 These granulations are soft to feel, of a vivid red color, show great 
 vascularity, and rise above the surrounding surfaces. They sjirout up 
 mostly around the external os, but may extend through the cervical 
 canal. At times they take on great luxuriance and look like raspberry 
 formations. Excessive development characterizes the so-called " fun- 
 goid ulcer," which when pressed upon and flattened down presents the 
 appearance of a cock's comb, called by the English writers " cocks- 
 comb granulations." ^' Varicose ulcers " are also spoken of. They are 
 distinct varicose venous plexuses ramifying over the hypcrtrophied 
 ])apillre. Phlyctsense (Lisfranc), aphthte and herpes (Lisfranc and 
 Rol)ert), pemphigus (Joulin), are mentioned. Thus, the great variety 
 of appearances in the color, extent, and degrees of intensity of the 
 morbid action found in these pseudo-ulcerative lesions has temjited 
 authors to classify them like surgical ulcers, but there is no practical 
 sionifieancc in such an arrany-ement. 
 
 Frequency, — Like the disease from which they ordinarily proceed, 
 these degenerations of the cervix are the most frequent of the uterine 
 afleetions. They attend a large proportion of the cases of chronic 
 uterine leucorrhoea, whether the discharge is cervical or corporeal. 
 They likewise complicate parenchymatous inflammation of the cervix, 
 and are almost invariable concomitants of laceration of the cervix. 
 
 Etiology and Syjiptoms, — Essentially, the same causes ]H'oduce 
 and the same symptoms attend erosions and granular degenei'ations as 
 attend cervical endometritis. 
 
 Physical Signs and Diagnosis. — To the touch, the cervix feels 
 softer, velvety-like, or granular, having lost its natural smoothness 
 and flrmness. Through the speculum the ])arts are .seen covered with 
 a thick, cream-colored pus, which after removal gives an ajipearance to 
 the cervix around the os of intense redness and vascularity, the velv(^tv 
 2:ranulations bcino; raised above the surroundinu: surliice. 
 
590 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 Such are the signs in nulliparae, and also multiparse, when the under- 
 structure of fibrous tissue is not diseased or lacerated. If, however, 
 these conditions named should be present, the cervix will be more or 
 less enlarged, thickened, and nodulated from hyperplasia and erosion. 
 
 The gross appearances are so characteristic that the diagnosis is easy ; 
 yet cervical laceration with ectropion is very liable to be mistaken for 
 granular degeneration, so nearly do they resemble each other. As on 
 a projaer diagnosis the results of treatment depend, the crucial test for 
 laceration should be made. 
 
 Granular degeneration is easily confounded with cervical epithelioma 
 in its earlier stages. 
 
 Prognosis. — Granular degeneration is one of the most amenable of 
 uterine affections. 
 
 Treatment. — The diagnosis having been clearly established 
 whether the degenerate changes of the cervix are primary or second- 
 ary, the indications for treatment become well defined. If the latter, 
 as the result of uterine displacement, a badly-adjustecl pessary, a per- 
 sistent acrid discharge from the uterine canal, a laceration with erosion 
 of the cervical lips, etc., these should be first corrected before any hope 
 can be indulged toward the accomplishment of a complete or permanent 
 cure. The effects will be repeated so long as the cause remains. The 
 benefits which accrue from a replacement of the uterus, the adjustment 
 of a well-fitting pessary, the repair of a laceration, rest from coitus, 
 etc., are examples of what can be done by a removal of the cause. While 
 the ulterior condition is receiving attention the granular degeneration 
 itself must not be neglected. To both cause and effect the treatment 
 is directed. 
 
 In all cases it is of paramount importance that the infravaginal cer- 
 vix and vaginal canal be kept clean, free from accumulating secretions. 
 The rules to be observed in the employment of vaginal injections have 
 been laid down. The medication of the water with various astringents, 
 tannic acid, zinc sulphate, lead acetate, with such emollients and anti- 
 septics as boric acid, sodic biborate, glycerin, etc., is highly advan- 
 tageous. 
 
 The morbid condition is often most speedily brought to a favorable 
 termination in initiating the local treatment, not by the use of astrin- 
 gents and caustics, but by depletion. This is especially true if the 
 srranular deffcneration is marked and the cervix shows signs of decided 
 hvpersemia. If the granulations extend throughout the cervical canal, 
 several scarifications with a narrow-bladed knife should be made over 
 each wall, from just below the os internum down to the os externum 
 and over such portions of the infravaginal face of the cervix as are 
 implicated. Congeries of superficial blood-vessels are thus divided, 
 the flow of blood is free, and the vessels are emptied. Congestion is 
 
CYSTK ' /)i:<;/:.\j:i!.i rios. r,!i i 
 
 (liiiiiiiislicd. Puncturing' luiiy he pnictiscd instciKl of" scarilication, or 
 hotli ni;i\' lie utilized at the same siltinii. Il'llic ^•i'anidation> arc lar^-c 
 and c\ul)crant and lill up tlicosand canal, tlic\' arc l)cs( treated 1»\- free 
 excision with the scissors and scra|)in«;- with u sliar|) cnrctle. Sncii 
 treatment may l>(' repeateil at ])ro))er intervals. When the htcai im- 
 |»ro\-ement is siitlicicnl ly advanced, further treatment may he Udlowed 
 n|) l)\' to|)ical a|)|)lications at ])roj)er intervals of emollients, as hismnth 
 siihnitrate, l)(»ro-<ilyceride ; of astringents, as taiino-j^lycerin, j^lyceride 
 of alum, or Richardson's styptic colloid ; hy alteratives, as tincture of 
 iodine, iodoform ; and hy canstics, as nitrate of silver in solution or 
 I'ravon, pure carholic acid, nitri(! acid, or chromic acid. 
 
 Mucous tissue, much hvpei-tro|)liied, [)roti'iidinL!,' and everted, is best 
 treated hv thorouirh excision. 
 
 Cystic Degeneration. 
 
 This is a degenerate change of the mucous follicles of the cervical 
 canal and the infravaginal face of the cervix. Granting that there are 
 no racemose glands on the vaginal portion beyond the limits of the os 
 externum, the degenerate follicles there found in this disease must be 
 produced from the mucous membrane of the cervical canal or from the 
 newly-formed glandular tissue. 
 
 Pathology. — The changes are variable, and indicate degrees of the 
 pathological processes. First, there are a number of vesicles, in size 
 from a millet-seed to a pea, filled with a thick gelatinous fluid due to 
 re[)letion from retention. The secretion becomes inspissated. The 
 efferent duct of the gland becomes compressed by the swollen peri- 
 glandular tissue, as well as by the neighboring glands. A retention- 
 cyst is formed called " ovulum Nabothi." The development of these 
 retention-cysts is hindered by the great resistance of the tissues ; hence 
 their formation is most readily effected at the surface. Second, the 
 cysts have opened, either spontaneously by internal pressure or l>y 
 trauma; the cylindrical epithelium is laid bare — follicular erosion; or 
 their contents may undergo suppuration and form mimite abscesses. 
 
 If the tissues are very firm the cysts elevate themselves from the 
 parenchyma. Hanging from the os, they assume the shajie of small 
 poh'pi. They may gradually acquire a long stem, and several sec- 
 tions of the gland may proliferate. 
 
 Thus, cystic degeneration is glandular hypertrophy, and the forma- 
 tion of ncAV glands is resultant on the epithelial proliferation ])reviously 
 described. The growth of the glands, whether from the internal sur- 
 faces of the cervix or from underneath the squamous epithelium, is 
 sometimes enormous. So great may be the glandular hyperphisia 
 involved that the entire vaginal cervix mav be converted into one 
 
592 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 cystic mass, a cavernous tumor, the connective tissue having been 
 eifaced. A section of the cervix, as in amputation, may thus cut 
 through innumerable retention-cysts filled with mucus. The whole 
 exterior surface secretes large quantities of mucus. 
 
 Fritsch describes this enormous hypertrophy which takes place in 
 the glands of the cervix, so that the part becomes almost an adeno- 
 matous structure. A persistency of this condition after the puer- 
 perium partly explains the frequency of chronic cervical catarrh in 
 multiparae. 
 
 Etiology. — The causes of cystic degeneration are chronic conges- 
 tion and hyperplasia of the cervix, chronic cervical endometritis, and 
 especially lacerations. 
 
 Diagnosis. — Touch may be sufficient to detect the enlarged follicles 
 on the exterior of the cervix or within the cervical canal. The spec- 
 ulum M'ill confirm the diagnosis. 
 
 All of the above-mentioned pathological changes may be revealed in 
 a single case. 
 
 The PROGNOSIS is favorable. 
 
 Treatment. — The first step consists in thoroughly emptying the 
 distended glands. This is best done by freely puncturing each cyst 
 with Buttle's scarificator or a knife with small-pointed blade. It is 
 useless to attempt to search for each individual cyst, for the whole 
 degenerated or Vcerated surface may be jiassed over by numerous little 
 stabs in all di^ etions at each sitting, and the process repeated from 
 once to twice each week until a radical improvement is effected. The 
 local bleeding is rarely free, and in itself is beneficial. Not only Avill 
 the cervix now present an improved color, but be reduced in size, and 
 the everted flaps from laceration assume a better shape. 
 
 Cauterization of each cyst-cavity with nitrate of silver or pure nitric 
 acid is rarely necessary, but may be reserved for the more rebellious 
 cases. 
 
 Applications of tanno-glycerin and strong tincture of iodine, as 
 described under the subject of Chronic Cervical Endometritis, are 
 very useful. 
 
 Failing to arrest the degeneration by these means, an eifort should 
 be made to extirpate the glands of the cervical canal by thorough 
 scraping with a sharp steel curette, followed by free cauterization with 
 the hot iron ; or, as a last resort, the infravaginal cervix may be ampu- 
 tated by scissors or the galvano-caustic wire. 
 
 The importance of a thorough eradication of the cystic degeneration 
 of the cervix following laceration before tracheloplasty is undertaken 
 cannot be over-estimated, since its continuance is very apt to endanger 
 an otherwise successful result of this operation. 
 
TRUE ULCKiiATinys OF Till-: ci'.nvix i'T/:/:f. ',u:i 
 
 True Ulcerations of the Cervix Uteri. 
 A true iilccrativi' process, with (Icstnictiini of the cpitlicliiiiii jiiid 
 iiii(l('rl\iti!i' tissues, docs sometimes, tlioiiH-li rarely, occur. (XCoiirsj* 
 rofei'euce is not li;t<l to uN'eratioiis coiisecjiieiit on mali^;iiaiit dixax — a 
 condition very common. 
 
 SYPHILITIC ULCERATIONS. 
 
 Tf there is any point in ntci-ine patliolot;y well settled, it is that 
 syphilitic uU-erations are e.\eci'dini!;ly rare in this rej^ion. Not (jnly is 
 this true iJS to the primary sore — ciiancrc or chaneidiil — but set^ondary 
 formations, as niucous patches, acknowledged to Ite tiie nio.st frequent 
 of all the manitestations of this stage of this disease, are very infre- 
 quent. The testimony of most observers agrees as to these points, and 
 ill substantiation such authorities as Rieord, Cullerier, Duparcque, and 
 liumstcad may be cited. But .some .statistics offered by Fournier would 
 indicate their greater frequency. 
 
 When present, true syphilitic ulcerations may be recognized by the 
 usual evidences of a well-defined border, which is indurated, surround- 
 ing a depressed area, manifesting a great tendency to be covered with 
 false membranes, as has been observed by Robert and Bernutz. Ac- 
 cording to Rieord, they are found more often on the anterior than the 
 po.sterior cervical lip. Commencing as a simple erosion, they quickly 
 become deep ulcers, and, according to Forster, may perforate the blad- 
 der and the rectum. Constitutional .symptoms rapidly develop. 
 
 The DIAGNOSIS rests upon the appearance of the ulcer, its rapid 
 progress in one previously free from local trouble, the quick develop- 
 ment of constitutional symptoms, and its inoculability. 
 
 Secondary eruptions, as mucous patches and vegetations, are recog- 
 nized by their rapid local development, associated with characteristic 
 constitutional .signs. 
 
 What, now, is the nature of the abrasions and granular degenerations 
 so frequently found in ])atients suffering wnth constitutional syphilis? 
 They are the same in kind and degree detected in women who have no 
 syphilis. They arise from common causes, local and general — sexual 
 abuses, dissipation, habits of uncleanliness, and impaired general health. 
 Treatment. — Xon-specific ulcerations may be treated like pseudo- 
 ulceration. Specific ulceration requires antisyphilitic medication. 
 
 Bihl'tography. 
 Barxks: Diseascit of Women, 1878. 
 BuMSTEAD : Venereal Diseases. 
 
 De Sinety: Practical Manual of Gynecologij, Paris, 1879. 
 Fritsch: Di.'<eases of Women, 1883. 
 Hart and Barbour : Manual nf Gyncrrolocm, 1886. 
 RuGE and Veit: Pathohgy nf Vaf/inol Cervix. 
 Thomas: Diseases of Women, IS80. 
 Vol. I.— 38 
 
594 THE INFLAMMATORY AFFECTIONS OF THE VTERUS. 
 
 Uterine Fungositibs. 
 
 Intimately associated with, and dependent upon, some of the varieties 
 of chronic endometritis of the corporeal cavity are fungosities or a 
 fungoid degeneration of the endometrium. It is a disease of great 
 frequency, and its recognition aifords a key to not a few cases of men- 
 orrhagia, metrorrhagia, and leucorrhoea. Fungosities proper are not 
 found in the cervical canal. 
 
 Pathology. — The conditions found are variable. At times (a) 
 there is a thickened, pulp-like state of the mucous membrane — a uni- 
 form general hyperplasia of the whole surface, without any projections. 
 Again, (6) there are found- sessile vegetations, in size from a millet-seed 
 to a pea, studding the mucous surface in patches or spread over the 
 whole area. They are red, gelatinous-like, and eroded by chronic 
 catarrh, and have an abundance of vascular supply. And (c) there 
 are numerous projections of fungoid material, polypoid-like, scattered 
 over a hyperplastic mucous membrane. 
 
 Olshausen termed this disease endometritis hyperplastica chronica, seu 
 polyposa. Microscopically, he describes these fungosities as hyper- 
 trophied mucous membrane, with an increase of all its histological 
 elements — dilated follicles, enlarged blood-vessels, and great cell-pro- 
 liferation. Slavjansky has styled the disease metritis interna villosa. 
 All these three neoplastic formations may be combined. 
 
 Placental villosities are very frequently detected in the uterus, espe- 
 cially after abortions at the second to the third month ; more rarely 
 after term. The symptoms of their presence are the same as from 
 uterine fungosities, and it is difficult to difPerentiate between them. 
 Retention of adherent placental villi is a common source of endo- 
 metritis hyperplastica. 
 
 Finally, diffuse or soft sarcoma of the corporeal mucosa, and adenoma, 
 a glandular disease, may be present. Both are rare affections, and both, 
 especially the former, manifest, even when seemingly wholly removed, 
 a strong tendency to return. The diffuse sarcoma shows soft, flabby, 
 villous groAvths, assuming an irregular polypoid shape, spreading over 
 the whole surface, rapidly proliferating. 
 
 Etiology. — Chronic endometritis is unquestionably the most com- 
 mon cause. Associated with endometritis, there may be a subinvolution 
 of the uterus. Displacements and flexions, either as the result or cause 
 of chronic hypersemia, are etiological factors. 
 
 These fungosities are noticeably frequent in marked retroflexion 
 and retroversion. Intra-uterine and interstitial fibroids, which enlarge 
 the uterus and augment its blood-supply, lead to similar changes in 
 the mucous membrane. 
 
 A neglected laceration of the cervix, if sufficient to produce gaping 
 of the cervical walls and eversion, is almost invariably thus complicated. 
 
UTEIUSK FVMJOSITIKS. r>!)5 
 
 Eiirorccd st<'rilitv, impls ill";- ;i disrc^^arcl (»t' Xat lire's laws, (Iciniiiidiiij^ 
 stati'tl pcriiHls of rest wliicli alone pregiiaiiey and laetatioii <'aii hciii;.'-, is 
 a eaii>e. In tine, pioloiiLicd uterine congestion, iVoiu whatever eaii.~e or 
 condition, is tlie chief" imderlyiiiii; causative iiiHiienee. 
 
 SvMP'roMATo Loci's'. — I'lie most si^nilicant syinptoin is utei-ine heni- 
 ori'ha^e, which hohls no |)ro|)ortioii either to the number or si/e ol" the 
 riinu'osities. The menstrual How may he i^reatly increased, prolonged, 
 or a|)|>ear with increasing- rre(jueii<y. Metrorrha<;ia or non-menstrual 
 uterine liemorrha<i,-e may supplement the menstrual How i»roj)er, the 
 hemorrhaiie thus hecoiniui;- contimial. More or less tiin<;-oid material 
 mav he cast oil' S[)outaneously, mixed with hlood. In the ahseiice of 
 hemorrha<!;e there is generally more or less mucous or muco-purulent 
 leiicorrlKca. The remaining symptoms are such as are present in (jrdi- 
 iiarv endometritis. Sterility is the rule. As a consequence of the local 
 drain the general health becomes greatly depreciated and anaemia may 
 be profound. 
 
 While uterine fungosities are a condition particularly of the child- 
 bearing years, it is occasionally perpetuated long after the climacteric. 
 
 Diagnosis. — The rational symptoms create a strong suspicion of the 
 nature of the disease. The uterus is somewhat enlarged, tender, and 
 the canal patulous, and there is catarrh. The entrance of the index 
 linger through the dilated canal may enable one to feel the soft, spongy 
 endometrium. 
 
 A confirmation of the diagnosis is reached by a physical exploration 
 of the uterine cavity made with the wire-looped curette gently passed 
 down over the walls and within the angles of the horns of the uterus. 
 To the touch a roughened sensation is communicated as the curette 
 glides over the diseased surfaces. Portions of the diseased membrane 
 or placental villosities, as the case may be, will be removed. This is 
 the only sure test of the existence of these fungosities. A gentle scrap- 
 ing will dislodge them if present ; if there are none, no harm is done. 
 
 To the experienced eye the appearance of the morbid material 
 removed is sufficient. Either it will be surfaces of thickened, soft- 
 ened, hyperplastic mucosa, patches of low soft granulations, polypoid 
 formations, placental villosities, if benign, or villous growths if sar- 
 comatous ; glandular formations if adenomatous. Any doubt as to tlie 
 exact nature of each may be solved by a careful microscopical exami- 
 nation, the histological features being characteristic. 
 
 The quantity removed may be very slight, up to one and several tea- 
 spoonfuls. The regions of the uterine cornua seem to ho flivorite seats 
 for their localization ; also, the site of the placental attachment in those 
 cases which have followed abortions and parturitions at term. 
 
 Prognosis. — Tliis is almost always favoral)le, provided a correct 
 diagnosis is made and a proper course of treatment is instituted. The 
 
596 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 prognosis is certainly favorable if the diagnosis settles the benignity of 
 the fungosities ; equally unfavorable if they should prove to be sar- 
 comatous. 
 
 It is always well to bear in mind that the disease is liable to return, 
 and treatment may have to be repeated from time to time in a certain 
 proportion of cases, especially when the uterine engorgement from any 
 cause cannot be effectually controlled. Where resultant on flexion or a 
 constricted cervical canal permanent relief cannot be expected until the 
 original aifection is remedied. 
 
 Treatment. — The one essential feature of the treatment of uterine 
 fnngosities is their radical removal. Constitutional treatment, except 
 for the purpose of improving the general health, is of no avail, and 
 intra-uterine cauterization is uncertain and unsatisfactory. The 
 stronger caustics may destroy these granulations, but, aside from the 
 danger arising from repeated cauterizations, and this tendency to the 
 formation of hard, cicatricial mucous membrane, the curette treatment 
 is less painful, more rapid, more safe, convenient, and eifectual. 
 
 Use of the Curette: Indications, Contraindications. — R^camier of 
 Paris in 1846 had the honor to introduce the curette, which original 
 instrument (Fig. 193) has largely gone into disuse. For a long time 
 
 Fig. 193. 
 
 K^camier's Curette. 
 
 its use met with much opposition, having been pronounced unscien*- 
 tific and barbarous by such men as Chassagnac, Scanzoni, and others. 
 AVithin recent years the instrument has been greatly modified and its 
 use rendered perfectly safe. Those at hand are the dull wire curette 
 of Thomas (Fig. 194) ; the sharp steel curette of Sims (Fig. 195), with 
 
 ^ 
 
 Fig. 194. 
 
 Thomas's Curette. 
 
 flexible handle; the sharp cutting spoon-curette of Simon (Fig. 196)^ 
 with a stiff shank; and the curette forceps of Emmet (Fig. 197). 
 
 Thomas's instrument of copper wire, without cutting edge, is now in 
 general use, and quite justly so, answering as it does not only for the 
 purpose of a thorough diagnosis, but in the great majority of cases 
 being all-sufficient to safely and effectually dislodge the fungosities. 
 Sims's sharp curette should be reserved for the destruction of hyper- 
 
UTER ISK FL'SU US 1 1 'IKS. 
 
 \)7 
 
 trophit'd «;l;m(ls ol' the cervical canal and those rait- instances of dis- 
 eased n|)|)er c-nd(tnieti'inni wiiere, after repeated I'ailm-e willi the didl 
 wiiH- instrunienl, a nmi'e jxiwiTlni inipressinn ami tlioronLili renioxa! nt" 
 liNiHTtnipliied nuici).-a are necessary. ^Sevi-r shonld it i)e .selected to 
 
 Imu. 195. 
 
 Sims's Sliari> Curette : a, h, showinj; the angles iit wliich it may l>e bent. 
 
 initiate cnrette treatment unless it be for the removal of sarcomatou.s 
 growths. Emmet is very severe in his denunciation of Sims's in.stru- 
 ment, stating that "the ingenuity of man has never devised one capa- 
 ble of doing more harm " — an expression doubtless true if it is 
 
 Fig. 196. 
 
 J.T/EM/iMJ &C0 
 
 Simon's Spoon. 
 
 employed by unskilful hands or as frequently as is the dull wire 
 curette. But the sharp curette is by no means to be laid aside and 
 abandoned. It has its place and power. 
 
 Emmet's curette forceps, introduced as a substitute for Sims's curette, 
 
 Fig. 197. 
 
 Emmet's Curette Forceps. 
 
 removes only such granulations as project above the common level of 
 the surrounding membrane. 
 
 Simon's spoon-curette was designed (1872) for the removal of malig- 
 nant growths. Motlifications of it with serrated edges possess special 
 advantages. 
 
 Any one of these curettes can be employed without the speculum, 
 
598 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 but the proper application is best obtained by the use of Sims's spec- 
 ukim in the left lateral semi-prone (or Simon's) position, the uterus 
 being steadied Avith a tenaculum. Artificial dilatation is seldom re- 
 quired. The curette is made to systematically scrape all the uterine 
 walls from fundus to os internum, not neglecting the regions of the 
 metro-salpingian orifices. Its withdrawal is followed by the fungoid 
 villous accumulations or the hyperplastic mucous tissue, and more or 
 less flow of blood. Rarely is the latter profuse, and it generally 
 quickly ceases. This loss of blood is not only protective, but is 
 directly beneficial in depleting from the congested endometrium. 
 Varicose vessels ramifying upon the surface are thus broken up, 
 and many others are emptied. 
 
 The vagina may now be irrigated with a stream of hot water, and, 
 if necessary, intra-uterine medication with iodine tincture, carbolic 
 acid, iodized phenol, or nitric acid may be inaugurated — always if 
 the growths are found to be malignant. Comparatively slight pain 
 usually attends this minor operation, an anaesthetic seldom being re- 
 quired. The dangers also are slight. Rarely does an attack of pelvic 
 peritonitis or cellulitis supervene. But the risks of curetting are con- 
 siderably increased if made to immediately follow tenting. Antiseptic 
 precautions should always be observed. As a matter of ordinary cau- 
 tion it is prudent that this operation be performed at the patient's resi- 
 dence, and that she remain in bed for several days thereafter — longer 
 if any unpleasant symptoms develop. 
 
 The effects of curetting are usually very prompt and decided in con- 
 trolling uterine hemorrhage arising from causes here before described. 
 Quite excellent effects also are produced on the congested mucous mem- 
 brane even when no fungosities are found. The forthcoming period is 
 at times considerably delayed; more often its first appearing at the 
 ordinary time is profuse, while subsequent ones become normal in 
 quantity. Repetition of the curetting may be necessitated from time 
 to time on account of relapses of the symptoms from re-forming of the 
 vegetations. Thorough removal of old, diseased mucosa favors the 
 regeneration of a new, better structure. 
 
 In these more stubborn cases the best results may be secured by 
 follo-^dna; each curetting with one to two intra-uterine treatments of 
 iodine, iodized phenol, or nitric acid. The use of the curette may 
 quite often not only initiate, but entirely supplant, intra-uterine medi- 
 cation. 
 
 So great are the benefits to be derived from the proper use of the 
 curette in judiciously selected cases of chronic corporeal disease that its 
 introduction is certainly one of the greatest advances in the manage- 
 ment of many conditions heretofore almost unmanageable. The con- 
 traindications to its use are the same as for intra-uterine medication. 
 
ciiJiusic MKTiwns, ETC. OF I'll I : rri-jii's. r>i)y 
 
 JiUtlioyraphy. 
 Couuty: Malttd. de r Ulrni.-<, 18S3. 
 K.MMET: Principles and I'raiiirr oj Gi/mroloffi/^ p. CA7. 
 GuDDKLL : //(wcd.s in (fi/mroloifif, 1.S80. 
 IIaut ani> IJAiMJoru: Mnunal nf ( hjuctcology, 1883. 
 MlNUli: Minor iSui(/irid (ii/necoliMji/, l8So, 
 Thomas: Diaeases oj' Women. 
 
 Chronic Metritis, Subinvolution, Hyperjemia, Hypertrophy, 
 Hyperplasia, Sclerosis, Atrophy of the Uterus. 
 
 Definitions, Synonyms, and NoMENCLATrni:. — Tlic term chroiiif' 
 metritis is used to ('.\])r(ss a morbid ])roc('ss, formei'ly iiiiivcr.^allv .•sup- 
 posed to bo iiiHammutory, involving the Hl)rous strnc-tnro ot" the nterus. 
 The term is retained, in the absence of a better one, to express its eor- 
 reet pathoh)uv. While it is not regarded by most authorities a.s a true 
 inHammation, it possesses many features like it. The various names 
 or sxiionvms bv whieh this ati'eetion is known are — ehronie con<»;estion, 
 hypenemia ; chronic infarctus (Kiwisch) ; engorgement (Lisfranc) ; 
 chronic parenchymatous inflammation of the womb (Scanzoni) ; diffuse 
 growth of the connective tissue (Klob) ; subinvolution; hvpertroj)hv ; 
 areolar h^-perplasia (Thomas) ; irritable uterus (Hodge) ; diffuse inter- 
 stitial metritis (Xoeggerath) ; sclerosis ; atrophy. Some of these terms 
 are inaj)plicable, convey most imperfect ideas of the nature of the 
 pathology, and exjjress merely certain symptoms or a single feature 
 of the disease. Strictly speaking, chronic meti'itis, as now understood, 
 is a complex morl)id process embracing diilcrent stages and varied con- 
 ditions. It is the most important disease of the female sexual organs. 
 
 Pathologicai> Anatomy. — Until within recent years it has been 
 supjioscd that the so-called chronic metritis was but the chronic stage 
 of the acute inflammation of the fibrous tissue of the uterus. The 
 error of such a view is now a]>]>arent when we consider the great raritv 
 of acute parenchymatous metritis, as shown by all auto})sic examina- 
 tions, and the clinical fact that most cases of chronic metritis have never 
 manifested any acute symptoms. To recent investigations, chiefly micro- 
 scopic, in pathology are we indebted for a correct understanding of the 
 morbid processes in this disease. 
 
 That chronic metritis can be engrafted u])on acute parcnchvmatous 
 metritis occurring in the puerperal bed is admitted. A uterus enlarged, 
 its muscular walls thickened, soft, ])ul])y, the cut surfoce of which would 
 show a bright-red color with engorged veins, the interstices yielding 
 on conijircssion a red exudation, and the muscular fibres infiltrated Mith 
 ])us-corpuscles, presents a condition which may become chronic or lead 
 to the pathological changes detected in chronic ]iarenchymatous metritis. 
 As stated, very few cases atlbrd any such antecedent history. Most 
 
coo THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 are ushered in so slowly and insidiously that it is difficult to determine 
 the date of inception. 
 
 It is to the condition of the uterus after parturition at term or after 
 an abortion that we are to look for an explanation of the processes 
 which lead to many of these cases of chronic parenchymatous disease. 
 The puerperal uterus is large, heavy, flabby, and usually anteverted. 
 The whole organ during gestation has undergone an enormous hyper- 
 trophy, its muscular fibres having assumed colossal proportions. It 
 weighs after delivery from twenty-two to twenty-four ounces (Heschl), 
 and measures in length from twelve to nineteen centimeters (four and 
 three-quarters to seven and a half inches) (Boerner). The interior of 
 the organ is bathed with a disintegrating fluid, and the placental site 
 shows large venous sinuses plugged with newly-formed thrombi. The 
 whole interior mucous membrane is not cast oflP, as was formerly sup- 
 posed, but a separation in the deciclua itself takes place, regeneration 
 commencing from the remaining portion. The new membrane is 
 usually formed during the third and fourth weeks. 
 
 The revolution by which this immensely hypertrophied organ is 
 reduced to almost its original size and weight before pregnancy is 
 called involution. It is accomplished partly through the drainage of 
 the lochial discharges, but largely through the action of fatty degene- 
 ration. The muscular fibres undergo a fatty metamorphosis, in conse- 
 quence of which they melt down and disappear, being absorbed as fat. 
 This fatty metamorphosis is easily discernible under the microscope in 
 each individual fibre a few days after delivery, commencing in those 
 near the mucous surface and extending outwardly. In a fortnight after 
 parturition the uterine length is reduced to some nine to twelve centi- 
 meters (three and a half to four and a half inches), and the weight to 
 ten or eleven ounces. The observations of Boerner, Heschl, and Sin- 
 clair go to show that the loss in weight and the diminution in size are 
 comparatively little at the end of the first week, but greatest during the 
 second week, and that at the end of the third the uterus is still three 
 to four times heavier than the non-puerperal organ (one ounce and a 
 half). This whole transformation — one of absorption and regeneration 
 — is ordinarily not completely accomplished short of the end of the 
 second month. It varies much in different subjects, both in the rapidity 
 and degree of its action, being influenced greatly by conditions local 
 and general. It is more rapid and perfect in the primiparee than the 
 multiparse. It is also delayed and made incomplete by a poor state of 
 the general health, inherited or acquired. Failure of suckling one's 
 own infant is a hinderance to its accomplishment. The local conditions 
 impeding involution are traumatic lesions of the cervix, retention of 
 portions of placenta, membranes, blood-clot, septic absorption, the super- 
 vention of endometritis, uterine phlebitis, pelvic cellulitis, etc. 
 
t^\ri{f- ..1 
 
 Fi§2 
 
 I''i'' . 1 . riiioiiii- I I\-|i< ■li.fjrn i n , f ■ Ji t iii-fK , n r \ (1 !•', 1 1 1 iar>^ em <■ i 1 1 
 
 P'iL;.!'. CliroMic Mi-liitiw i\ncl F] j u 1 fiin e li- i t i s (Mei^s). 
 
 To face pafao 001. 
 
CllROMC METlllTlS, KTC. OF THE ITLliL'^. (JUl 
 
 Arri'stiHl rctrot^nulc involution is calKMl ftiihlnvo/iition. 
 I'rct-isfly tlu' siuiu- process in kind, (liU'crinj; only in (iegrcc, occurs in 
 tlic uterus followint:; each menstrual perifnl. There i.s then menstrual 
 inv(»luti(»n, and there may he, in eonsefjiienee of imj)e<led circulation, 
 mvitf!lru(t/ suhinroliifioii. 
 
 Now, puerperal .subinvolution of the uterus is the ciiief underlying 
 condition or factor in the pnKluction of the so-callc<l chronic metritis. 
 Anythiiiir \vhich interferes with normal involution predispos<'s to chronic 
 metritis. The prominent feature of subinvolution is increascfl va.scu- 
 larity — ln/jjrrtnnia. The condition is a chronic one, and may have an 
 indefinite continuance. But its protraction for a Ictnj; peritxl of time 
 is followed sooner or later by certain changes in the ti.ssues of the 
 parenchyma. At the beginning hypertrophy of the muscular struc- 
 ture, eijually with the connective tissue, is found. As time advance.-^ — 
 it may be a few months or even yeans — microscopic section will show a 
 great preponderance of the connective tissue. As a result of the ])er- 
 sistent, habitual liyperffiniia this tissue takes on this increased growth 
 or proliferation. The same proliferation may follow in the muscular 
 structure, but it is always there limited, and usually absent. The mus- 
 cular structure is therefore relatively diminished, and it may be abso- 
 lutely, by the connective tissue supplanting it. 
 
 At first, then, the uterus is enlarged, heavy, flabliy, soft, and hvper- 
 jemic. Later on, as a preponderance of the connective tissue results 
 through its proliferation, the organ is found dense and indurated ; at 
 the same time it becomes less vascular. Diminished vascularitv is 
 brought about by the groA\'th of the intermediate az'eolar tissue espe- 
 cially surrounding the blood-vessels, compressing them and cutting off 
 the current of their supply. This, the second stage of the disease, is 
 called hyperplasia. 
 
 Still later on a further change becomes manifest, the result of the 
 former. Advancing proliferation and hyperplasia of the connective 
 tissue renders the parenchyma of the uterus more and more dense and 
 indurated, less and less vascular, until finally a condition is found as 
 descriijed by Klob. The parenchyma on section appears white or 
 whitish-red, deficient in blood-vessels, and its firmness is so increased 
 by contraction and condensation that it creaks under the knife, simu- 
 lating the hardness of cartilage. The uterus now g-rows smaller and 
 undergoes atrophy. This is the stage of sclerosis or cirrhosis. 
 
 We, then, may recognize three distinct stages of chronic parenchyma- 
 tous metritis: 1, hypenemia ; 2, hyperplasia; 3, sclerosis. The second 
 is a result of the first, and the third is a practical continuance of the 
 second. (Plate III.) 
 
 From a pathological point of \new the term " chronic metritis " has 
 been deemed incorrect, inasmuch as it implies an acute stage of an 
 
602 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 inflammation which rarely exists, and since a study of the morbid 
 anatomy has failed to demonstrate the evidences of a chronic inflamma- 
 tion. But, as Hart and Barbour state, the term is very convenient 
 from a clinical standpoint, because we possess none better to embrace a 
 variety of conditions presenting the same clinical features on examina- 
 tion. Very recently, Dr. Mary P. Jacobi has presented an elaborate 
 and strong argument in favor of the older view, that chronic metritis, 
 Avhether a chronic or the acute affection from the start, is an inflamma- 
 tory disease. There are, it is claimed, the subjective and objective 
 symptoms of inflammation — pain, hypersesthesia, heat, redness, and 
 swelling. There are enlarged and multiplied blood-vessels ; lowered 
 vascular tension ; venous stasis ; dilated lymph-vessels ; emigration of 
 the leucocytes ; transudation of nutritive plasma ; secretion, even pus,, 
 upon the free surfaces ; organization of connective tissue ; impaired 
 nutrition — conditions typical of chronic inflammation. 
 
 It is impossible to determine at the bedside exactly when the state 
 of subinvolution commences to merge into that of hyperplasia — a slow 
 and insidious development. The two affections, to clinical appearances,, 
 resemble each other, and, apart from the history, differentiation is 
 obscure. 
 
 Just as the hypersemia of subinvolution proves so potent a factor in 
 this disease, so may habitual hypersemia of the uterus from any cause 
 lead to the hyperplasia. To a very great extent hyperplasia is limited 
 to the parous uterus. The normally firm, resisting walls of the nullip- 
 arous organ afford a strong resistance to expansion, whether by vascu- 
 lar fulness or cellular proliferation. Still, it is not to be forgotten that 
 this disease may and does occur in the nulliparous organ. 
 
 Etiology. — The tendency of the uterus to fluxion^ and congestion^ 
 is obvious, and is due to — (a) excessive development of its vascular, 
 especially venous system, these veins having no valves ; (6) the erectile 
 character of its tissues, favoring stasis ; (c) the low position of the 
 organ; (d) pressure upon it by abdominal and pelvic viscera; (e) peri- 
 odical influxes of blood and hemorrhages ; (/) enormous hypertrophy 
 from pregnancy. 
 
 All the causes may be grouped under two heads : 1. Those which 
 interfere with the normal involution of the puerperal uterus at term or 
 after abortions ; 2. Those which produce repeated or habitual hyper- 
 semia of the uterus. 
 
 Under the first head are — contusions and lacerations of the cervix ; 
 retention of the products of conception, as placental masses, membranes,^ 
 or blood-clots ; various metritic and perimetritic inflammations after 
 
 ^ Fluxion is a temporary accumulation of blood, rapidly appearing and disappearing. 
 ^ Congestion is a more permanent accumulation of blood in the vessels, and may 
 result from fluxion often repeated or strong. 
 
L'liiiosic mj:ii:itis, ktc. of riii: rTr:i:rs: (in:; 
 
 |)ai"tiiriti(>ii ; too early I'isiiiiX nih'V laltur or alxiitimi ; iiiiii-la<tatiiiii ; 
 alxiit iiiii. 
 
 All ol' tlioc cair^'^ iiii|>lv (•oiitlitiKii'. wliicli arc liillowrd l)\- IocmI cmi- 
 ir«'>tii»iis. roil cariv r('siiiii|iti<iii of tlu- cri'ft po-liirr lead- to piL-.-ivo 
 col litest ion in an «'nlai";^('<l, tlal)l>y oiyan, arrcstinii; involution. Tlic 
 pliysiolojrjfnl tlotcrtnination of Mood to the Mianiniary L;land> in lacta- 
 tion cxiTciscs a derivative inHnence over tlie pelvic orjians. 'I'lic direct 
 application of" the cliild to the hreast rcHcxIy excites nterine contraction, 
 f'avoriiiu- involution. Involution is relatively more tardy alter ahonions, 
 in that patients do not aiterward ohsi-rve the same amount ol" i-e.-t, and 
 there is the absence of" the stimulus <tf lactation. 
 
 Under the second head are iucludetl — chronic endometritis, cervical, 
 C()rporeal, or *»;eneral ; versions and Hexions ot" the uterus ; pressure of 
 certain pelvic or alxlominal tumors; chronic cardiac, hepatic, and 
 nephritic diseases ; frequent and excessive coitus ; constipation ; faulty 
 Uodily postures; prolonged standing; wearing around tlie waist (jf 
 tight and heavy clothing, etc, 
 
 Chronic endometritis may be of long standing in the nullipara, and 
 not lead to any special hypertemia of the parenchyma. Not so if in 
 the multipara. The ditt'crcnce in results is owing to the difference in 
 the tissues of the parenchyma in the two — in the one firm and resist- 
 injr ; in the other more soft and vielding. 
 
 Versions and flexions almost always are secondary to increased bulk 
 and weight of the uterus, with its attendant chronic congestion. In 
 turn, these displacements so interfere with the venous flow that there is 
 conscfjuent passive hypersemia. Either wall or a portion of the uterus, 
 according to the kind and degree of displacement, may take on hyper- 
 plastic thickening and induration ; for instance, it is the upper and pos- 
 terior wall which is involved in retroflexion. 
 
 Any tumor within the walls or any outgrowth of the uterus or its 
 appendages may, by virtue of its size or position, so obstruct the venous 
 circulation as t(j produce great venous engorgement. The presence of 
 any tuin(jr directly invites and keeps up a developmental attraction of 
 blood. 
 
 Chronic valvular diseases of the heart, chronic interstitial changes in 
 the liver, impede the portal, then the pelvic circulation ; hence they are 
 attended by uterine hy]ierjemia of a passive kind. AVomen who are 
 suijjects of diabetes are particularly prone to chronic uterine congestion. 
 
 Congestion and inflammation of the ovaries provoke augmented 
 blood-accunudation in the uterus. Just as the initial physiohtgical 
 act of menstruation is commenced in the ovary, and thence propagate<l 
 to the uterus, so certain morbid .states of these organs lead ultimate- 
 ly to uterine congestion which may terminate in hemorrhage and 
 enlaro:emcnt. 
 
604 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 Every act of coitus is followed by some acute fluxion of blood to the 
 internal genitalia, which under normal restrictions soon passes away. 
 But if the act is excessive and often repeated the vascular flilness 
 becomes permanent and pathological. 
 
 Undue meddlesomeness of local treatment with the speculum or cau- 
 terization may perpetuate the very condition of chronic hypersemia 
 Avhich it is intended to remove. 
 
 The condition of the pelvic circulation, especially in women, is 
 modified in manifold ways by the general bodily condition. Imper- 
 fect general health, defective nutrition, and sluggish circulation in gen- 
 eral imply low arterial tension and favor pelvic venous stasis. The 
 female pelvis may thus be compared to a reservoir of great blood- 
 capacity, the quantity of its contents being subject to remarkable 
 fluctuations by virtue of various mental states, bodily conditions, 
 and positions. 
 
 In conclusion, as chronic metritis takes its origin in hypersemia from 
 any cause, it may be stated that whatever conduces toward the accumu- 
 lation and retardation in the uterine or utero-ovarian vessels leads 
 directly to the different stages of the disease in question. The proxi- 
 mate cause in all cases is an excess of venous blood in the endometrium 
 and parenchyma. 
 
 Frequency. — In view of the foregoing causative influences, pre- 
 disposing and direct, it is not a matter of surprise that this is an affec- 
 tion of great frequency. Probably more than 50 per cent, of all women 
 presenting themselves for local treatment show evidences of it in some 
 degree. Its importance, then, cannot be over-estimated. 
 
 Varieties. — Chronic metritis — chronic hypersemia and hyperplasia 
 — may involve any portion of the uterus, neck or body, or certain por- 
 tions thereof. For manifest reasons the neck of the uterus is the 
 favorite habitat. The extreme liability of this portion of the organ 
 to injury by contusion and laceration in parturition ; to friction in 
 coitus or by displacement; its dependency, favoring gravitation of 
 blood within its structures ; the relatively increased frequency of cer- 
 vical endometritis over the kindred affection of the body, — these may 
 be mentioned as among the more important reasons. Involution from 
 some of these causes may be incomplete in the neck, while perfected in 
 the body, of the uterus. 
 
 Hyperplasia may be localized largely within either wall of the neck 
 or body. If in the former, it is generally the anterior lip which is 
 affected ; if in the latter, it is the posterior wall which is more fre- 
 quently implicated, simulating fibroid infiltration. To the more fre- 
 quent implantation of the placenta on the hinder wall and consequent 
 increased risks of delayed involution, and to the fact that retroversion 
 
CHRONIC METRITIS, ETC. OF Till: UTERUS. G05 
 
 is one t>l" the iiiost (•(Hiiiiuni roiMiis (if tli>itl;icciii('iit alter |»:ir(m-it ioii, 
 iiiav 1)(' attriltiitcd this s|K'cial Incali/.atioii. 
 
 SvM I'roMAi'ol.ncN'. — 'PluTc art- no ^\ iii|)t<tiiis in clii'uiiic metritis 
 initliofiiioinonic of it, none that 1k'1()Ii<j; cxchisivcly to it, none hut what 
 arc found in othei- chronic pelvic (especially uterine) intlanunations. 
 Manvofthe sviu|)tonis arc dependent lart^ciy upon the degree of hypei- 
 teinia, with (he increased hulk and weight of the uterus. Others result 
 from certain complications, such as chronic endometritis, almost con- 
 stnntlv present. The nu)st common local symptoms, which in a great 
 pr(i])ortion of cases date hack to a confinement, are sensations of 
 iicaviness, weight, and dragging within the j)elvis, aggravated hy walk- 
 iiiir, standing, and the approach of menstruation. The performance of 
 this last-named function necessarily augments the local hlo()d-su])ply, 
 increases the uterine weight, and consequently the tension upon the 
 utei'ine ligaments. 
 
 Aside from these symptoms, resultant directly on excessive vascular 
 fulness, there is pain, traceable to the structural changes going on in 
 the parenchyma, leading to pressure upon the nerves. The uterus is 
 hyper£esthetic. Pains radiate to the back, loins, limbs, and distant 
 parts of the body. 
 
 Urination and defecation may now be made frequent and })ainful by 
 direct pressure of the enlarged uterus upon the bladder and rectum, by 
 congestion of these organs, or by a sympathetic irritation. Vesical 
 irritability is sometimes one of the most annoying of all symptoms. 
 Coccygodynia, usually a neurosis, is another sample of reflex uterine 
 irritation. There is often dyspareunia. Leucorrhoea is, as a rule, 
 present on account of coexisting endometritis. The menstrual func- 
 tion will be disturbed in time, duration, quantity, or quality according 
 to the stage of the disease, the degree of hyperoemia, and the portion of 
 the organ Avhich is especially involved. At the beginning, -when hypcr- 
 a^nia is the controlling pathological state, whether from subinvolution 
 or otherwise, menstruation will be profuse, ]irolonged, or too frequent. 
 Gradually, as hyperemia diminishes, resultant on the growth of the 
 connective tissue, the uterus becoming harder and denser, the menstrual 
 flow will be less free until it is scant, or may after years become very 
 irregular and cease altogether. A premature so-called "change of life" 
 is thus brought about. A dull aching pain through the uterine region 
 — congestive dvsmenorrhoea — is often experienced, conmiencing a few 
 days prior to the menstrual flow and increasing until it is well estab- 
 lished. It is usTially relieved by the depletion of the flow. 
 
 All of these local svmptoms are agirravated by the occurrence of any 
 serious amount of displacement. They are likewise more pronomiccd 
 Avhen the body of the uterus instead of its neck is the seat of the 
 disease. 
 
606 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 The reproductive functions are affected in various ways. Subinvo- 
 lution and early chronic metritis appear rather to favor pregnancy, 
 though abortions are more apt to follow. Each abortion adds to the 
 original difficulty, leaving the uterus larger, heavier, and more vascular 
 than before. Advanced stages of hyperplasia and sclerosis are attended 
 with sterility. Pregnancy completed, parturition normal, a prolonged, 
 careful attention during the lying-in state doubtless will do much to 
 improve the morbid condition of the uterus previously existing. 
 
 The general symptoms have reference to the disorders of digestion, 
 nutrition, and especially to disturbed functions of the nervous system. 
 There is dyspepsia; the bowels are constipated; the body loses weight; 
 there are feelings of languor and weakness. There are fretfulness, irri- 
 tability of temper, melancholia, and sleeplessness. The various reflex 
 or sympathetic disorders are more often manifest in chronic metritis 
 than in any endometrial disease. Thus, the stomach is quite often 
 made irritable in the form of nausea and vomiting. The mammary 
 glands are enlarged, nodulated, and tender, especially preceding and 
 during menstrual periods. The abdomen is flatulent, distended, and 
 the seat of various irregular muscular actions. It is in this disease, 
 after long continuance, more particularly approaching the climacteric 
 period, that we more commonly witness the symptoms of pseudo- 
 cyesis and phantom tumors. If prolonged into these years of cli- 
 macteric change, all the nervous disorders so characteristic of this 
 epoch are more early and strikingly displayed. 
 
 Hysterical symptoms are among the more important of the compli- 
 cations of the nervous system, and they are produced in every varying 
 degree and form. 
 
 Headaches of the nervous and congestive varieties are the source of 
 much suffering to many women. As the patient nears the menopause, 
 and especially when the menstrual flux is becoming irregular and scant, 
 the brain is prone to receive the impress of the undue vascular tension. 
 Each period is preceded or accompanied by a flushed face, throbbing 
 temples, and dull aching pain in the head. 
 
 Chloasma uterinum, a symptomatic pigmentation with broAvnish 
 spots or patches distributed over the face, is most pronounced in 
 brunettes and at the menstrual periods. These discolorations are 
 not confined to this disease, inasmuch as they may be present as a 
 result of various menstrual disturbances without any organic lesions. 
 
 Physical, Signs and Diagnosis. — The uterus will be found to be 
 enlarged, swollen, and sensitive. In the stage of subinvolution and 
 hypersemia these signs are apparent. The walls also are softer, flabby, 
 and on inspection present the appearance of increased vascularity, usu- 
 ally of the passive variety. The enlargement is uniform. 
 
 In the second stage (hyperplasia) the uterine walls are still sensitive, 
 
ciinosic MirrniTis, etc. of tiii: rrEiirs. (jo? 
 
 but hanl, (Iciise, (>iilar<rc<l, usually syiimictrirally, hut tiiavhc irrc;^!!- 
 larly, in either wall nf the iie<l< or hudy. Irrejxiihirities in .slia|M' an<l 
 iioihihitiuns tVoiii hy|)ei'|»hi>ia are iim-tly toiiiid where the parts are fis- 
 sured from iaet'i'atious. Owiu^i" to increased hulk and wei<;iit the uterus 
 is verv often (Us|)hieed downwardly, ■without, it may he, any elianjre in 
 its axis ; j)osteriorl\- with almost equal fre(|Ueney. The os is patulous, 
 adiuittini:: the tip of the index Hn^er. The sound shows increased 
 measurement, ."] to -'U or 4 inches, passes with *:;reat facility, and moves 
 freely in the roomy upper cavity. This exploration detects the decree 
 of sensitiveness, and is followed hy a dull acliin;:: pain. 
 
 As hyperplasia may be localized to the cervix, corpus uteri, or be 
 penoral, its exact seat is revealed by vaginal and rectal touch, specular, 
 bimanual, and sound explorations. 
 
 Chronic metritis may be confounded with early })re,L!;nancy, small 
 fibroid tumors, and scirrhus of the cervix. 
 
 Diti'erentiation between chronic hypcraemia with hyperj)l;L<ia and 
 prcirnaucy is sometimes obscure, on account of the marked resem- 
 blance in many of the general symptoms and physical signs. In the 
 former, however, menstruation very rarely ceases, though it may be 
 irregular, and the uterus is very sensitive to touch. 
 
 If conception should take place in a uterus previously the seat of 
 this disease while possibly the patient is under treatment, confusion is 
 further increased. In all cases of doubt the use of the sound as a 
 means of diagnosis, a.s well as all intra-uterine treatment, should l^e 
 omitted, until at least further developments settle the diagnosis. If 
 pregnancy exists, a few weeks will so alter the size, shape, and position 
 of the uterus that the real condition generally becomes clearly revealed. 
 
 Likewise, fibroid tumors of small size, developing within either ute- 
 rine wall or creating a symmetrical enlargement of the whole organ, pre- 
 sent physical signs calculated to mislead. Cimclusions may be based on 
 the menstrual history and such signs as are elicited by touch, the use 
 of tents, the sound, and conjoined manipulation. 
 
 Again, chronic hyperplasias with marke<l induration may offer sus- 
 ]iic-ious evidences of cancerous infiltration of the infravaginal cervix. 
 The imjiortance of a correct diagnosis is very great, but this is at times 
 \QTy difficult. If the general health is declining and there is cachexia, 
 the patient being advanced in years, and if there is menorrhagia, the 
 evidence leans toward cancer. If the history points back to ]>arturi- 
 tion, the local condition having been preceded by symptoms of chronic 
 uterine inflammation, and there is a tendency toward amenorrhcea, the 
 disease is probably not cancerous. 
 
 iSpiegelberg has offered a method of diagnosis wliich certainlv is val- 
 uable in the early stages of carcinoma, prior to destruction of any tissue 
 in the mucous membrane. Thus — 
 
608 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 1 . The mucous membrane in a cancerous gro-s^i:!! is firmly connected 
 with the underlying induration, and immovable over it, which is not 
 the case in mere hyperplastic thickening and induration. 
 
 2. The latter, under the pressure of compressed sponge in the cer- 
 vical canal, becomes regularly (even though at times inconsiderably) 
 looser, softer, and thinner ; the cancerous infiltration remains unalter- 
 ably hard and rigid, and cannot be stretched. 
 
 Localized hyperplasia of the anterior wall simulates anteflexion ; 
 of the posterior wall, retroflexion. The sound is the means of 
 diagnosis. 
 
 PROaxosiS. — This is for the most part favoraljle, but is influenced 
 to a great degree by the portion of the uterus, neck or body, which is 
 affected, and also by our opportunity to remove the causative hyper- 
 semia. Prognosis is much more favorable when the neck is the seat 
 of the disease and the body is not implicated, for the reason that the 
 svmptoms are less grave, the disease is more easily attacked by local 
 treatment, and, finally, the parts are much less sensitive to local inter- 
 ference. 
 
 If the cause cannot be removed, palliation alone is possible. Persist- 
 ent hvpersemia produced by an incurable chronic cardiac or hepatic dis- 
 ease or pelvic tumor is susceptible only of amelioration. 
 
 Recovery is commonly tedious, and the patience of both practitioner 
 and patient is sometimes severely taxed. It is not possible to directly 
 remove or create any absorption of the proliferating connective tissue. 
 The chronic congestion can generally be cured if its cause can be 
 removed ; always may it be diminished by local and constitutional 
 measures. Its abatement may be the means toward an arrest of the 
 hyperplastic changes. 
 
 The approach of the menopause is usually a favorable factor in prog- 
 nosis, for at this time the vitality and vascularity of the generative 
 organs gradually lessen. 
 
 The amount, kind, and degree of complications materially modify 
 results. Coexistent displacements, chronic cellulitis, ovaritis, and cys- 
 titis present important and serious barriers to a successful issue. 
 
 May the morbid tissues of chronic metritis be transformed in cancer- 
 ous formations? ISToeggerath has reported several instances favoring 
 this view. The experience of most gynecologists is to the contrary. 
 Klob expresses himself thus : " What has been said by various authors 
 on the relations of difPase growth of connective tissue to the develop- 
 ment of carcinoma must be considered a mere h^-ioothesis." But these 
 benign alterations in structure may, in such as are predisposed Ijy the 
 local irritation produced, indirectly conduce to the development of 
 malignancy of groAvth. Particularly is this so when the hyperplastic 
 formations are attendant on lacerations of the cervix. 
 
CJih'nMc Mjrnn'j'is, i:t<: of tii/-: rriiiiun. gou 
 
 TIk' pliysiciim is (it'tcii a-kcil, What iiilliiciicc will |(rc:^iiaii<-\' ami 
 parturition have on tin- local <'oii(litioii> of clironic nirtritis V In nianv 
 instances, donhtlcss, tlic inllncncc, il" any, is injnrions. Not onlv inav 
 tlic solt pails he lorn in (lie (Iclivny, lint the snlwipu-nt involntion 
 may !«' made more iniju'rlcct. 'V\\v. ntcrns rmiainin;^' larjx<'r, its snj)- 
 ports aic li'ss adcMpiati' to pcrlorin tiu-ir f'lniction, and the orj^an heconjes 
 iurtlicr disphu'cil. Siu'li is by no moans necessarily the case: pregnancy, 
 partnrition, and the lyin<»-in state may he so eonchicted that an nnnsnal 
 o|)|)ortnnily is atlorded to accomplish a degree of" good \\hi<'h can he 
 attained in no other niainicr. A natural deliyery, with tlu; integrity 
 oi' the parts unimpaired; a prolonged decubitus free from sepsis; the 
 ailminstration of yaginal injections to secure perfect cleanliness; ergot 
 and quinine to secure thorough tonic contractions of the uterus; the 
 suckling of the infant; careful return to ordinary exertion, etc., — 
 are some of the means which may bring about a complete transfor- 
 mation. 
 
 As interstitial fibroid tumors, if not of too large proportions, haye 
 undergone absorption, since their structure is homologous to the uterine 
 tissue proper, so, without question, there is reason to expect that hyper- 
 trophied cellular tissue from chronic metritis may likewise be cauuht 
 into the processes of absorption in normal inyolution after parturi- 
 tion, and be thus removed. 
 
 Complications. — The most common complications are chronic 
 endometritis, vaginitis, yersions and flexions, pelvic cellulitis and peri- 
 tonitis, and ovaritis. In point of frequency this is the order of occur- 
 rence. So frequently does chronic endometritis exist as a complication 
 that it is seldom, if ever, entirely absent. In Avhatever way or form 
 chronic metritis is developed, the starting-point of the disease is almost 
 invariably in the endometrium. 
 
 TuEATMENT. — It is evident at the start that a clear and correct 
 understanding of the etiology and pathology of chronic metritis is of 
 the utmost importance to comprehend the principles Mhich underlie its 
 management. H(jw misguiding such terms as " irritable uterus," 
 ^' chronic hypertrophy of the uterus," are is apparent. We must bear 
 in mind that chronic metritis, so called — except in rare instances, after 
 acute puerperal parenchymatous metritis — is not a chronic stage of an 
 antecedent acute inflammation. We must also endeavor to detect which 
 stage of the disease is present or predominant. 
 
 Treatment is both constitutional and local. As uterine congestion 
 complicates or plays a most important role in a large proportion of all 
 cases of chronic uterine disease, constituting the greatest and most serious 
 obstacle to cure, it follows that the chief aim and oliject of treatment in this 
 disease is to diminish and prevent the same. It may be laid down as 
 a cardinal principle that there can be no permanent improvement until 
 
 Vol. I.— 3U 
 
610 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 the pelvic circulation is improved by a restoration of the tone of the 
 blood-vessels. In various ways may this end be secured. 
 
 General Treatment. — Rest. — Such exercises as dancing, horseback 
 riding, much carriage and street-car riding, ascending stairs, prolonged 
 standing, the use of the sewing-machine, etc., which incite pelvic con- 
 gestion, should be avoided. The patient should be instructed to lie 
 down for a few hours in the middle of each day, the garments around, 
 the waist in the mean time being well loosened. The horizontal pos- 
 ture favors by gravity the partial emptying of the engorged blood- 
 vessels and diminishes pain. The necessity for such periods of rest is 
 most urgent as the menstrual epoch approaches and continues. Exacer- 
 bations of fluxion occur at these times ; hence much can be done by 
 judicious care in preventing relapses. But there is always danger that 
 the strict enjoining of rest may lead to its abuse. Rest becomes injurious 
 when unduly prolonged, as it interferes with digestion, circulation, and 
 nutrition. A certain amount of exercise — walking in the open air — 
 should therefore be carefully observed, 
 
 Xot only rest by posture, but rest in its general sense, should be 
 enforced. This implies freedom from excitement of all kinds, and the 
 avoidance, if possible, of all causes of mental depression. Sexual inter- 
 course is a frequent source of aggravation and perpetuation of uterine 
 congestion, Nothing can operate more injuriously in maintaining local 
 pain, interfering with the otherwise successful progress of a case, than 
 frequent coition. If not entirely abstained from, it should be indulged 
 in at long intervals only. 
 
 The beneficial eifects of rest in its fullest sense — physical and men- 
 tal — are at times well illustrated by a removal of the patient to, and a 
 sojourn at, the seaside, the mountains, or some well-selected mineral 
 springs. The change of air, diet, scenery, and associations, the pres- 
 ence of cheerful company, the absence of domestic care and anxiety, the 
 freedom from coition, are powerful means in the restoration of the gen- 
 eral health, and with it an improvement in the local conditions. The 
 influence of such forces durmg a sojourn at mineral springs has more 
 to do in restoring the health of many invalid women than the use of 
 the waters by drinking or bathing. Not that, however, the mineral 
 waters are to be ignored. Certain of them are most beneficial in 
 improving the appetite, correcting indigestion, and promoting secre- 
 tion and excretion. On the Continent the best are Kreuznach (iodo- 
 bromated), Schwalbach, INIarienbad, Carlsbad, Kissingen, Weisbaden, 
 and Baden-Baden ; in the United Sates, the Saratoga (N. Y.), White 
 Sulphur (W. Va.), Blue Lick (Ky.), Hot and Warm Springs (Va.), 
 and Rockbridge Alum Springs (Va.). 
 
 Weir Mitchell has introduced and practised a scientific system of 
 enforced rest in conjunction with full diet, massage, and electricity. 
 
cnnnsic MF/niiTis, irn: or riih: i"n:nrs. (ill 
 
 Tilt' Mit<'li<ll |>l;iii III inatiMciit i- »-|)('cially a(la|)tc(l to tiisi's (»f foii- 
 Hniicd lu'iirastlifiiia and l»yst«'ria in its inatiifnld loi-ni- (IcjH-ndcnt or 
 not n|)on chronic uterine diseases. 
 
 J),r.-<s. — 'i'lu' jrarinents should l)c \\oi-n loosely around the waist, and 
 their weight shoidd he as lij:ht as is consistent with warmth. Ti<rht- 
 tittinii" corsets and skirts, iniju'dinir as they do the alKloiuinal circulation 
 and de|)ressin<; the ahdoniinal and pelvic viscera, are to l)C discarded. 
 All uarnicuts hanuiuir from the waist should be suspendtKl by aj)i)roj)riate 
 ai)i)aratus from the shouhlcrs. Instead of a coi-set, a lifj:;ht, well-futed 
 waist answers for this purpose. The use of an abdominal bandage, which 
 will \'\i\ the abdominal viscera from below the und)ilicus, diminishes 
 intraj)elvic i)ressure from above, and is not unfrequently a source of 
 considerable comfort where the uterus is enlarged, heavy, and dis- 
 placed downward or forward. High-heeled shoes, which distort the 
 relations of the body, altering the natural inclination of the pelvis to 
 the trunk, should be rejected. 
 
 Posfinr. — Posture influences in a most marked manner the pelvic 
 circulation. As the blood-pressure is increased and venous stasis 
 brought about by faulty position of the bcxly in standing, sitting, and 
 lying-down, these should be corrected. 
 
 Attenfion to the Boweh. — Especial attention should be directed toward 
 acquiring a free alvine evacuation daily and the regulation of the func- 
 tions of the chylopoietic viscera, as constipation and obstruction in the 
 ])ortal circulation always hinder circulation in the pelvic blood-vessels. 
 The selection of the necessary medicine depends upon the condition and 
 constitution of the individual. An occasional mercurial, followed by 
 a saline purge, answers a good purpose in those sufficiently strong, when 
 the tongue is furred, the portal circulation torpid, and there is constipa- 
 tion. The salines, sulphate of magnesia, Carlsbad salts, etc., in small 
 quantities, well diluted, in the morning fasting, are well adapted to 
 many cases. The various mineral waters, Kissingen, Marienbad, 
 Hathorn, Congress. Hunyadi, are convenient agents for similar pur- 
 poses of promoting secretions and giving freer intestinal movements. 
 
 Others are best suited by the vegetable laxatives, podophyllin, colo- 
 cynth, aloes, etc., in small doses. Diet should not be neglectcxl. Fuller 
 directions for the relief of constipation will be given under the consti- 
 tutional treatment of chronic uterine diseases. 
 
 Special Medication. — Certain medicinal remedies are known to influ- 
 ence the uterine circulation and diminish its vascular fulness. X(»tably 
 among these stands ergot ; inferior to it, but not unimportant remedies, 
 are quinine, nux vomica, and the bromides. Ergot, in the form of the 
 fluid extract, or ergotin should be administere<l three times daily in 
 cases of subinvolution and in the stages of hyperaemia following ; in 
 fact, so long as increased vasc-ularity remains the chief local pathologi- 
 
612 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 cal factor of the disease. If the stomach becomes intolerant of its inges- 
 tion, suppositories per rectum may be substituted or the remedy may be 
 given hypodermatically. Ergot tends to contract the fibres of the uterine 
 wall, the unstriped fibres of the blood-vessels, and in this way dimin- 
 ishes congestion. Thus, its use is indicated during the menstrual period 
 if there is menorrhagia, and during the interval for its more permanent 
 efPects on the affected structure. The virtues of ergotin are enhanced 
 by a combination with quinine and nux vomica. A favorite pill with 
 the author is — 
 
 I^. Ergotinse, 9jss ; 
 
 Quininse sulphatis, Bjss ; 
 
 Extracti nucis vomicae, grs. viii. 
 M. Ft. mas. in pil. xxx. Div. 
 Sig. A pill three times a day. 
 
 When hyperplasia has well advanced ergot is useless. 
 
 The potassic and soclic bromides act with signal benefit in some men- 
 orrhagic conditions dependent upon uterine congestion. They are 
 equally useful to control certain reflex disorders. 
 
 Some practitioners have praised the virtues of the mercuric bichlo- 
 ride and the auric and sodic chloride, given in minute doses, continued 
 for a long time in chronic metritis. It is even claimed that they have 
 the power to check and diminish hyperplastic infiltrations. Probably 
 they are worthy of further trials in these directions. At any rate, the 
 potassic iodide and the mercuric bichloride are valuable remedies at times 
 in this disease prior to much hyperplastic change, remarkably improv- 
 ing the general health, although there is no specific constitutional taint. 
 The mercuric bichloride, in minute doses long continued, often proves 
 an excellent tonic, eveu increasing the number of red blood-corpuscles. 
 When parametritic inflammatory exudations are present these remedies 
 are especially indicated. 
 
 The prescribing of iron where there is early chronic metritis is a mis- 
 take too frequently made. All the chalybeate preparations promote 
 pelvic congestion in either sex. The objections to their use are founded 
 on experience. As a rule, iron is contraindicated ; certainly it should 
 rarely be given in the first stage and the first half of the second stage of 
 the disease, although there is ansemia. Under its use the author has very 
 often observed the menstrual periods made profuse, prolonged, and the 
 local conditions aggravated. Toward the stage of atroj)hy or sclerosis with 
 scant menstruation, iron is admissible if the general conditions indicate it. 
 
 Arsenicum (Fowler's solution), three drops, with water, after meals, 
 is frequently beneficial when there are contraindications for the use of 
 the chalybeate preparations. When the menstrual function is too fre- 
 quent, too long, and too free, these disorders may sometimes be corrected 
 by the persistent use of arsenic. 
 
ciinoMc M/rj/n'i'is, ETC. or rin: iii:i:rs. ci;; 
 
 Lociil Trt (ifiiiciil. — I iici'cascd locil liliiip(l->ii|)|)l\- to the iitcni- can In; 
 (limiiiislicd l)\ — 
 
 1. I fol-iralcr S'lK/iiKil Injcc/ioiis. — In addition to kcc|)iii^ the part.s 
 clean, tlicrcljv |)r('\('iitiii!j,' secondary vat;initis and vidvitis, vaj^iiial injec- 
 tions (tf liii;li tcni|K'ratnr(', n^vd in lariic qnantities, of lon^- din-atioii and 
 with steady |)ei-scvei-a nee while llie patient is in the dorsal p(^sition, are a 
 means second to nonc^ to contract the dilated blood-vessels and inijirove 
 the local circnlation. 
 
 2. IjOntl hcjtictioit. — Tliis can he pi'actised \)\ one ol' lonr methods — 
 leechino', pnnelin'inii;, scai'ilication, and eii|)|>iiiii'. 'he first i> thronuh 
 a cylindrical ti'lass specnluni larg-e c'lioniih to cn<2;a<i;e the whole vaginal 
 face of the cervix, which is first cleaned and then its canal plugtjed with 
 cotton to prevent the entrance of the leeches within the nterine cavity. 
 If the cervix is much vascular the necessary nuniher of leeches (two to 
 four) are pushed at once through the speculum against the cervix. On 
 suspicion that blood will not flow freely the cervix should be punctured 
 slightly before the leeches are placed in position. The leeches are per- 
 mitted to remain until filled, the cervix sponged with warm water, and 
 the speculum withdrawn. Leeching is expensive, troublesome, requires 
 much time if well done, is distasteful to the patient, and the bites now 
 and then bleed too freely and too long, and create much pain. In con- 
 sequence this method of depletion has very properly been almost entirely 
 superseded by puncturing and scarification. 
 
 Puncturing, if done thoroughly, will abstract all necessary quantities 
 of blood quickly and conveniently. It is best practised by a spear- 
 pointed instrument called Buttle's scarificator (Fig. 198). The point 
 
 Fig. 198. 
 
 Buttle's Spear-pointed Puncturing In.'^trumcnt. 
 
 of this little instrument is thrust into the cervix at its most vascular 
 points, care being taken not to wound a varicose vein. Each puncture 
 should be from one-sixteenth to one-fourth inch or more in depth, 
 according to the freedom of the flow of blood produced. The endeavor 
 should be to deplete at each sitting to the amount of one to two fluid- 
 ounces, each puncture depleting, on an average, one drachm. Bleeding 
 is facilitated by sponging the surfaces with warm water. It generallv 
 quickly ceases, rarely continuing beyond the withdrawal of the specu- 
 lum. The sitting can be rept^ated from once to twice each week, 
 and may be extended over a period of several weeks or months, the 
 indication being to continue until the cervix will no longer bleed freelv. 
 This little operation creates but slight pain, and may l)e j)i-aetised 
 
614 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 without the patient being acquainted with its nature, and at the physi- 
 cian's office. 
 
 Depletion from the interior of the cervical canal is best accomplished 
 by scarification, done by a long, very narrow-bladed knife (Fig. 199), 
 
 Fig. 199. 
 
 CTZTSESi'^ 
 
 Knife for Intra-uterine Scarilicatiou. 
 
 which on insertion to below the os internum is thrust into the mucous 
 membrane to sufficient depth to sever the superficial blood-vessels, the 
 incisions being extended downward over the rim of the os externum. 
 The number of scarifications will vary from two to six. Both punc- 
 turing of the vaginal face of the cervix and scarification of the cervical 
 canal may be done at the same sitting, the patient being directed to 
 remain quiet for at least twenty-four hours. 
 
 Cupping increases the flow of blood after puncturing, but it is ques- 
 tionable whether the suction efPect of this method does not draw blood 
 from above into the uterus. The same objection ma}^ be urged against 
 leeching. 
 
 As to the value of local depletion of the uterus, opinions are much 
 divided. A decade ago it was much in vogue, now it has largely gone 
 out of use. A great amount of this change in the methods of practice 
 is due to the fashion of the abandonment of local bloodletting in all 
 departments of medicine and surgery. It is still held in high repute, 
 however, by Freuch gynecologists. That local abstraction of blood accom- 
 plishes more than a mere temporary clisengorgement of the loaded blood- 
 vessels must be evident to any one who will judiciously and systemat- 
 ically follow the practice. The changed color for the better of the 
 uterus, the diminution in its size and tenderness, the healing of ero- 
 sions, the decrease in the discharge, the improvement in the local pain 
 and reflex disturbances, in the quantity and duration of the menstrual 
 disorders, — are the best evidences of its usefulness. Each abstraction 
 of blood relieves distension by partially emptying the vessels. For a 
 time the tone of the vessels is improved and the current within stim- 
 ulated. A repetition of the practice, aided by other means, gradually 
 enables the vessels to more permanently contract and recover them- 
 selves. Scarification not only empties the vessels, but a division of 
 their walls with the knife is the application of an irritant, provoking 
 contraction. 
 
 Another advantage of puncturing and scarification, besides the with- 
 drawal of blood, is the rupturing and emptying of the numerous dis- 
 tended muciparous follicles studding the surface of the hyperplastic 
 cervix, extending within the canal and imbedded within its walls. 
 
ciiiiosic Mii'inris, irrc. of tiii: rri'iius. oi") 
 
 Ovsti(^ (l(><;('iu'r:iti(>ii is a coiistaiil xiiiicr of irritation, iiiaiiitainiiij^ 
 livjH'rjpmia. I'lincdiriiiLi dl tli<>c ictciit inn-cysts rapidlv r<'licv»~ t<n- 
 sion ami reduces cerxiea! cnLinruciiicnl. Its lli(»i'(iiit;li and i'c|(catcd 
 a|)|>li("iti(>n is liic ui(i>t inijxirtant incans in the cniirc dotrnclinn nl' 
 their walls. 
 
 I jiical i)l(iiidlelt in^s arc I lici'd'ore cxtrcincK' \aliia Me adjuncts in treat- 
 ment. Indeed, tlie\' nia\' lie tlie keystone t(» the whole htcal nianaiic- 
 iiu'iit. \\\\\ tlicN are not e(|nally well adapted to every case. Tiie.se 
 features of" inipi-ovcnient (so I'ai' as the lociil abstraetion of blo(xl is 
 <'()iieeriu>d) can he obtained only in tiie early history of the disease. 
 When inthn-ation from hyj)er|)lasti(' inliltration lia.s comnieneed loeal 
 depletion is useless. 
 
 The eontraindieations to ])nnetiirin<:; and .searifieation are few. Tliese 
 are — tendtwicies to profuse hemorrliage from conditions of hrcinophilia ; 
 great varicosity of the parts; pregnancy; and finally, subacute and 
 chronic j)erimetritie inflammation. 
 
 3. Medicinal AppUcations. — Among these glycerin ranks first. Pure 
 anhydrous glycerin — a most active depletory agent on account of its 
 .strong affinity for the watery elements of the blood of the congested 
 vessels — should always be selected. If there is coexistent cervical endo 
 metritis, with erosion, etc., the glycerin may be medicated with boric 
 acid, tannin, etc. Such applications ought to be made every two to 
 three days on absorbent cotton, so packed against and around the cer- 
 vix as to freely drain it and to give support to the uterus if there is 
 any displacement. 
 
 The persistent application of tampons wet with the glycerite of 
 alum is most conspicuous for good in conditions of long-continued 
 chronic congestion with or without displacement. 
 
 Iodine, in the comjiound tincture or a stronger tincture^ is a most 
 valuable alterative and stimulant applied to a congested, hyperplastic, 
 and enlarged uterus. It will not take the place of direct depletion by 
 the local abstraction of blood or of the tamponade with glycerin. Its 
 special field of utility is after their use has ceased to be beneficial. 
 Applications of the mild tincture may be made twice weekly ; of the 
 stronger tincture, about once weekly ; carried to within the canal if 
 there is cervical catarrh, painted over the whole vaginal vault if there 
 are remaining indurations of old cellulitis or peritonitis, ])ut always 
 made to cover the whole infravaginal cervix. 
 
 Observation must have convinced most practitioners that chronic 
 metritis associated with erosion and granular degeneration is not unfre- 
 quently more amenable to local treatment than where no such compli- 
 cations exist. The recognition of this fact has led some to make use 
 of local irritants to produce similar conditions when they were not 
 present. The effects of counter-irritation have been held in view. 
 
616 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 Applications of a strong acetic vesicating collodion can be utilized for 
 this purpose. The cervix having been engaged in a large cylindrical 
 speculum, then dried with pledgets of absorbent cotton, is painted with 
 this solution. The mucous membrane is thoroughly blistered ; there is 
 a free discharge of serum, perhaps pus, wdiich flow clej^letes from the 
 tissue above, also acts as a revulsive in the relief of pain and tender- 
 ness, as a blister does to an inflamed joint. Similar applications may 
 be repeated from time to time according to the rapidity of the healing 
 process and the effects obtained. 
 
 Upon the same principle much more active agents, the strongest 
 caustics — acid nitrate of mercury, chloride of zinc, and caustic potash, 
 the actual and thermo-cautery — have been brought into use. Setons 
 through the cervix also have been employed. Fortunately, local treat- 
 ment so severe is seldom indeed required. All possible therapeutic 
 effects can be secured without these painful means and methods, and 
 their use too often indicates mistaken notions of the pathology of the 
 disease. 
 
 Medicinal injections of solutions of iodine, potassic iodide, ergotin, 
 have been carried within the parenchyma of the cervix for subinvolu- 
 tion, chronic metritis, and other diseases. The results obtained at 
 different times have for the most part not been satisfactory or devoid 
 of danger. There is a possible future, however, for these parenchy- 
 matous injections in cervical cancer. 
 
 The use of sponge tents under proper circumstances — where the 
 movements of patients can be controlled — to reduce the size of an 
 enlarged uterus has been found to be attended with excellent success. 
 Emmet, with whom the practice is original, speaks in the most satis- 
 factory terms of them as exerting by pressure an alterative effect on 
 the mucous membrane and indurated tissue, exciting the whole organ 
 to contraction, and depleting from the circulation by the profuse watery 
 discharge provoked. 
 
 Uterine massage was introduced into gynecological practice by 
 Brandt of Sweden. Dr. A. Reeves Jackson of Chicago read an 
 excellent paper on the subject before the American Gynecological 
 Society in 1880, stating that he had obtained good results in three 
 cases of subinvolution, areolar hyperplasia, with parametritic tender- 
 ness and fixation, after several months of treatment. Possibly, the 
 method of treatment has a limited field of utility in a few cases of the 
 above-mentioned diseases, but better results are obtainable by other 
 methods less tedious and much less objectionable. 
 
 The question frequently arises in practice as to the advisability of 
 the adjustment of a pessary in chronic metritis with an associated dis- 
 placement. When tenderness has been diminished and local interfer- 
 ence of an active kind is no longer required, the proper adjustment of 
 
CiiiioMc Mi:Ti:rri.\ irrr. of riir: fn:i:us. r,n 
 
 a wcll-fittiiii;' |>('ss:iry witli a bioad l):ir, hy sii|)|Hti'tiii^- tlic uterus at a 
 proper level and axis, will Taeilitale the i-etiini of llie Mood hy the veins, 
 relieve tension ot" the Ineal eirenlation, and piil a Inwdcd oipm ;it rest. 
 IC the displaeenieiit perpetnates a disordered eireidation, it is eertainlv 
 rational to eounleraet it, although it is seeondarv to nietrilie elian;i'es. 
 The applieatii>ii of an ahdoniinal l>andai;'e has likewise its j)lae<' in 
 certain eases. 
 
 Ampntatioii of the <'ei'\i\, when greatly hypertrophieil IVoni chronic 
 ii\"|)erplasia, has lVc(|nentl\' l)een |)erfornied. Since the da\.> of trach- 
 oloplastv and the rt'('OL;nilion of lacerations of" the cervix and their 
 results, the field for ainpntatiou has justly been <^rcutly narrowed. The 
 g;reatest liypertrophy may seemingly be present, when an apposition of 
 the everted cervical lips will dispel the delusion. Pro[)er repair and 
 restoration of the cervix to position by Emmet's operation will lead 
 to an effiicement of the enlargement of the cervix, and with it to a 
 structural improvement in the whole uterus. 
 
 Still, the question remains open : Is amputation ever desirable for 
 conditions resulting from chronic metritis other than lacerations ? The 
 answer, it seems to the author, should be made in the affirmative. 
 Removal of portions of the infravaginal cervix, it is wx'll known, 
 exercises a most -wholesome influence, like nnto the involution process on 
 the tissues of the uterus above. The effect is similar to that noticca])le 
 in the tonsils after a superficial section has been removed. Atrophic 
 changes follow'. The experiences of several German gynecologists, Mar- 
 tin, Schroeder, Kehrer, and Olshausen, also of American authorities, 
 Goodell, Noeggerath, Thomas, and many others, are favorable to it. 
 The methods of amputation after Hegar, with circular exsection, the 
 vaginal mucous membrane being stitched to the cervical, or that of 
 Simon and Marckward, of flap amputation by w'edge-shaped exsection 
 of the lips separately, the divided parts being stitched together, deserve 
 following. Some, however, prefer to leave the surface unstitched, to 
 heal slowly through suppuration by granulations, believing that the 
 secondary changes are better secured thereby. The class of cases 
 suitable to these methods is those with enormous, intractable, other- 
 wise incurable, cystic degeneration and great longitudinal hypertrophy, 
 especially of the supravaginal portions of the cervix. 
 
 In conclusion, the practitioner is ever to be on the alert in searching 
 for and treating complications Avhich exist or may arise. Some of 
 these, as laceration of the cervix and displacements, may have been 
 prime factors in the induction of the disease ; others, as fungosities 
 of the endometrium, cystic and granular degeneration of the cervix, 
 vaginitis, etc., are more often secondary. Anv one of either class 
 will aggra.vate and perpetuate the main affection. The relief of 
 chronic metritis with bad cervical laceration is improbable, if not 
 
618 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 impossible, save by tracheloplasty. Chronic hypersemia may be con- 
 tinued indefinitely, so long as there is version or flexion which needs 
 rectification. Fungosities of the uterine cavity provoke and repeat 
 menstrual disturbances, thus becoming a local irritation to constantly 
 invite vascular turgescence. Cystic degenerations keep the cervix 
 enlarged, tender, and the seat of profuse discharges. Vaginitis is 
 the source of an ever-present discomfort. 
 
 Eemove the complications and the metritic congestion and hyper- 
 plasia are placed in a most favorable condition for amelioration if not 
 cure. 
 
 When the third stage of the disease— sclerosis and atrophy — has 
 been reached, local treatment is useless except for the complications: 
 The uterus is hopelessly indurated and contracted. Very little can be 
 done for an increase or a return of the menstrual flux. Attention to 
 the general health is now the chief employment of the physician. The 
 local use of electricity, especially intra-uterine galvanization, may possi- 
 bly be of service. 
 
 Bibliography. 
 
 Barnes : Diseases of Women. 
 
 BoERNEE : Ueber den Piierperalen Uterus, Gray, 1875. 
 
 CouRTY : 3Mad. de /' Uterus, 1883. 
 
 Emmet : Principles and Practice of Gynecology. 
 
 Garrigues: "Eest after Delivery," Amer. Journal Obstetrics, vol. xiii. p. 845. 
 
 Hart and Barbour : Manual of Gyncecology. 
 
 Heschl: Zeitschrift der Wiener Aerzte, vol. viii., 1862. 
 
 Hodge : Diseases of Women. 
 
 Jacobi, Mary P. : " Chronic Metritis," Am. Journ. Obstet., vol. xviii. p. 802. 
 
 Jackson : " Uterine Massage in Treatment of Certain Forms of Uterine Enlarge- 
 ment," Transac. Am,. Oynecolog. Soc, vol. v. p. 80. 
 
 Kehrer : "Transac. German Gynecolog. Soc," Amer. Journal Obstet., vol. xii. p. 189. 
 
 Klob : Pathological Anatomy of the Female Sexual Organs. 
 
 Martin : " Transac. German Gynecolog. Soc," Amer. Journal Obstetrics, vol xii. p. 
 188. 
 
 Munde, Paul F. : Minor Surgical Gynecology, 1885. 
 
 Noeggerath : "Chronic Metritis in Relation to Malignant Disease of Uterus," 
 American Journal Obstetrics, vol. ii. pp. 505-610. 
 
 ScANZONi : Diseases of Females. 
 
 ScHROEDER : Diseases of the Female Sexual Organs. 
 
 Schucking: Bulletin general de Therapeutique, Oct. 30, 1883. 
 
 Simpson : Diseases of Women. 
 
 Sinclair : " Measurements of the Uterine Cavity in Childbed," Transac. Amer. Gyne- 
 colog. Soc, vol. iv. p. 231 ; vol. vi.. p. 325. 
 
 Spiegelberg : " Diagnosis of the Early Stages of Carcinoma Uteri," ArchivfUr Gyna- 
 kologie, vol. iii. S. 2, 1872. 
 
 Thomas : Diseases of Women. 
 
 Van de Wabker: "Use of the Seton in Chronic Afiections of the Womb," Amer- 
 ican Journal Obstet., vol. v. p. 226. 
 
cirnoMc Mi:ri:iris, iirc. of riii-: r runes. (iiit 
 
 C^ONKTITITIONAI. TlMOA TM HNT nl" (lIlJOMC UtKUINK InFI.AM- 
 
 MATFoxs. — 'V\\v coii-titiitloiuil Ircatiiiciit of" clirdnic ciKloiiiotritis and 
 nu'tritis in their (lilVciciit litniis admits of" hut little \ ariatioii, and its 
 cojisidcration has therefore until now heeii |)iir|)osely postjxtned. 
 
 A <i;ejieral siirvcn' of tlie siil)jeet l)i'ii)i;s lis to consider the e.-peeial 
 ada|)tal)ijit\' of local and p'neral ti'catnicnt to each individual case. 
 Kaeh case must be studied by itself. Individual teniperanioiits, idio- 
 syncrasii's, constitutional conditions and coinj)licati(jns, the amount and 
 kind of local disease, the de<2:ree of tolerance of local interference, etc., 
 must receive attention. 
 
 A local disease which is but a htcal manifestation of a constitutional 
 state especially re(|iiires constitutional treatment. Local diseases of 
 purely local origin, as trauma, when of short duration and in good 
 constitutions, need no constitutional treatment. Since, however, most 
 c^ses which come under observation are suttering not only from a local 
 disea-se, but also from depreciated general health — faulty nutrition, be- 
 sides reflex disorders manifested in a multitude of symptoms — there is 
 a call for both local and constitutional treatment. The reciprocal rela- 
 tions between constitutional conditions and local lesions are intimate, 
 never ceasing, and cannot be disregarded. In fine, in a majority of 
 cases encountered both plans of treatment are essential, a neglect of 
 either being a fruitful source of failure. 
 
 As no absolute rule is apjilicable to all, a comparison of the relative 
 values of constitutional and local treatment in chronic uterine diseases 
 cannot fairly be made. 
 
 The first point to be gained in general management is, so far as pos- 
 sible, to remove the cause or causes producing or aggravating the local 
 disease. Among these may be enumerated unnatural and unhealthful 
 modes of life, as close confinement within-doors, want of proper exer- 
 cise, faulty habits of dress, imperfect and insufficient food, prolonged 
 lactation, and sexual excesses. It is generally easy to remove or mod- 
 ify these evils, provided sufficient interest on the part of the patient is 
 enlisted. Numerous cases Ijy way of illustration in the jiractice of most 
 physicians can be called to mind. Witness, for instance, the rapid improve- 
 ment from a course of treatment in some patients who at the same time 
 live ahfique marito ; the marked response to medication after weaning, 
 following prolonged and excessive lactation ; the quick i-eturn of color, 
 weight, and strength after a change of diet, air, and exercise ; the relief 
 of pain, the abatement of leucorrhoea, by Avell-tiraed and judicious rest. 
 
 The general plan of management consists in the use of such means 
 and measures, hygienic, medical, mental, and moral, as tend to remove 
 disturbances of function, imj^rove nutrition, and elevate the standard 
 of the general health. 
 
 Rest. — AVith the body in the recumbent or horizontal j)osition venous 
 
620 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 distension of the pelvic organs is lessened and congestion is diminished. 
 Rest, then, is beneficial in hyperseniic conditions of the uterus, and its 
 advantages should always be made available, When there is much 
 local tenderness and motions of the body are attended with pain, rest 
 is doubly indicated. The presence of uterine hemorrhage and the 
 menstrual period are also indications for rest. Prolonged rest in the 
 recumbent posture, on account of the close confinement, the want of mus- 
 cular exertion, the sluggish circulation, and the general enfeebling of the 
 whole body which it entails, is ever, if possible, to be avoided. It is sel- 
 dom, indeed, called for, except in perimetritic complications, and then 
 only so long as exercise is painful. Prolonged confinement in its mental 
 and moral aspects is ecpially prejudicial to the welfare of many patients 
 by conducing to feelings of ennui, helplessness, irritabilit}' of temper, and 
 melancholy. Its whole tendency is tow^ard introspection, with a multi- 
 plication and exaggeration of symptoms purely subjective in character. 
 
 To every nervous impression such patients become unduly sensitive, 
 and when, after long rest, the upright posture is assumed the quick dis- 
 tension of the much-weakened vessels, through gravitation of the col- 
 umn of blood, produces a degree of actual suffering in itself discour- 
 aging to many. 
 
 As Emmet well remarks, there never was a greater fallacy in prac- 
 tice than to place in bed a woman suffering with chronic uterine" dis- 
 ease, under the expectation that she will recover by remaining there. 
 While all the benefits of rest may constantly be taken advantage of by 
 directing the patient to lie down for an hour or two each day, and to 
 observe the same with more vigilance at the menstrual epochs, all of its 
 disadvantages may be avoided by the observance of proj)er exercise. 
 
 Exercise. — Exercise promotes cutaneous exhalations, increases per- 
 ipheral circulation, and equalizes the same, so often distiu'bed by local 
 stasis mthin the pelvic viscera. By it the appetite is improved ; the 
 capacit}'' for the digestion of greater quantities of food increased ; the 
 bowels are made more active, the muscles firmer ; the body- weight is 
 augmented ; and sleep is favored. Therefore, as a rule, as much exercise 
 in the open air, and in cold weather within the direct rays of the sun, 
 should be taken as the strength and comfort of the patient will permit. 
 Exercise which creates pain, especially if persistent, should be discon- 
 tinued, but that which is followed by fatigue only, and which after a 
 few hours' or a night's rest passes away, is to be encouraged. Of all 
 the different methods of exercise, none is superior to walking, inasmuch 
 as it secures the aforesaid results to the greatest degree. Attention to 
 the manifold duties of domestic life give an occupation to both mind 
 and body in many ways most desiral^le. The reaction on, and the 
 dej^letion of, the general health from local pelvic diseases among women 
 in the middle and lower ranks of life, cceteris paribus, are usually less, 
 
cnnoMc MF/rnrns, rn: or riii: rrnncs. r,-2\ 
 
 Ix'caiisc of a <ii-cat('r Kodily activity aimniji- tlirm. Tlic piirsiiil of" |>lca>- 
 iirc and travelling: may atlnrd most excellent oppoi-tnnities t"or tlie ohscrv- 
 aiiccol a necessary j»liysi<al exercise. I'^or manifest reasons c'arriM<;e-i'i(l- 
 in<;- slionkl not supersede walUin;::, and oiiulit to he indnlticd in to the 
 exclusion (tf the latter only hy leehle jjersons. Florxltack exercise is 
 to l)e interdicted. Oalisthenic exerci.ses are often very vahial)]c. The 
 patient >liould he inihueil with the idea that exercise is essential to 
 health, and that, while it is pussihle to take hut the smallest amount at 
 first, it is to he «iiadually, day after day, increased; then, from a sen.se 
 of dutv, hetween proper periods of repose it is to he maintained in a 
 free, reuular, and systematic manner. 
 
 lidfhiiif/. — In the (li.sca.scs under consideration the action of the 
 cutaneous surfaces is livnondly defective; exhalations are often hinder- 
 ed and the peripheral circulation is inactive. A healthy action of the 
 skin should he .secured and maintainetk This can be.st be obtained by 
 aj)propriate hathiuii', friction, and exposure of the .surface of the body 
 to the light and the direct rays of the sun. 
 
 Batliing: once or twice a week, simply for purposes of cleanliness, is 
 iLsually insufficient. More frequent bathing (once daily), especially in 
 warm weather, may be ucce.s.sary. Warm and hot baths best augment 
 the exhalative proces.ses. Persons with weakly constitutions and feeble 
 reactive powers are bettered by warm or tepid baths. The Turkish 
 bath is most admirably adapted to those with torpid skins, cold extrem- 
 ities, and to rheumatic, gouty, and syphilitic constitutions. 
 
 Various mineral springs which possess thermal and medicinal quali- 
 ties atibrd bathing properties frequently beneficial. 
 
 The cold bath (sponge or .shower) is more tonic and exhilarant, and 
 is suitable to the more vigorous. The addition of sea-salt to the water 
 assists materially the remedial effects. Surf-bathing often proves to be 
 mo.st excellently tonic. 
 
 AVliatever temjierature or method of bathing is practised, there should 
 follow immediately the most vigorous friction with coarse towelling over 
 the whole surface of the body. The immediate effects may be some- 
 what fatiguing, but there ensues a rapid fluxion of blood to the per- 
 iphery, and Avith it a degree of warmth of the body. The pelvic vi.s- 
 cera are relieved, the appetite is sharpened, and all the recon.structive 
 processes arc quickened. 
 
 Light and sunshine arc of almost equal value. The human system 
 can no more thrive without these than can plants. The practice of 
 taking sun-baths under ])roper precautions, to those who possess fit 
 accommodations, is a good one. 
 
 Clothing. — The clothing should be liglit. easy, comfortable, and withal 
 sufficient to protect the body during all .-reasons. The climate through- 
 out much of the United States is cxceediuiilv trvinsx to manv of feeble 
 
622 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 health. The extremes of temperature are encountered and the changes 
 are sudden and great. Underwear of flannel or other woollen material, 
 or silk, covering the entire chest to the neck and the abdomen and the 
 arms, is needed during the greater portions of the year in this latitude, 
 and can be graded in weight according to the season. The corset, a 
 source of so much injury to women by impeding the thoracic move- 
 ments, weakening the imprisoned muscles, depressing the diaphragm, 
 and through it the abdominal and pelvic viscera, thereby deranging 
 their circulation, ought to be proscribed. To avoid, further, any 
 depression of the pelvic organs all clothing ordinarily suspended 
 around the waist should be supported in its entire weight (five to ten 
 pounds) from the shoulders. The burden of extra skirts can easily be 
 obviated by adopting thicker undenvear. Cold feet and extremities, 
 the source of pelvic discomfort and dysmenorrhoea, may be regulated 
 by friction, exercise, and suitable woollen coverings. 
 
 Air. — The importance of open-air exercise and the exposure of the 
 body to the light and the sun has already been suggested. Byford 
 recommends a plan for invalids who in cold weather are unable to 
 leave their rooms — viz. dress as for outdoors, and open freely all the 
 windows and doors to flood the room with fresh, cool air. 
 
 Diet. — The administration of food is one of the most essential parts 
 of the general treatment — to be successful requiring intelligent and 
 faithful care. A large number of diseases, especially those of a chronic 
 tvpe, proceed from errors in diet as to the quantity, the quality, and the 
 time of partaking of food. A healthy, vigorous physical constitution 
 can no more be built up and maintained by improper and insufficient 
 food than a steam-engine can be run on a defective supply of fuel — an 
 analogy which Pa\w has beautifully illustrated. The effects of an insuf- 
 ficiency of food are most apparent Y\-hen the deficiency is abrupt and 
 great — equally manifest, though longer developing, when the quantity 
 for a long period of time is seemingly not much below the average 
 required for normal nutrition. Denutrition may be a speedy or a very 
 slow process. As a cause in the production of chronic diseases it is 
 usually in the latter way. Digestion becomes difficult and otherwise 
 disordered ; there is constipation ; the secretions are diminished. The 
 blood is lessened in quantity, especially the red corpuscles ; the watery 
 element is increased ; it loses its plasticity, and a tendency to hemorrhagic 
 transudation arises. The subcutaneous fat disappears ; the muscular 
 tissues lose substance, becoming flabby ; and with the decline in the 
 assimilative process there is a fall in the bodily temperature. Func- 
 tional activity in all the organs is impaired, the nervous system being 
 seriously disordered. 
 
 Graily Hewitt has recently communicated some interesting factg 
 showing that a continued insufficiency of food — a chronic starvation — 
 
ciuiosic .y/rrnrns, etc. of tuk rr/:j:is. ci^'', 
 
 VJirviii<i' i;i decree, lie liad tniiiid aliiKtst conslaiit ly 1(» ('xi>( in the cliidnic 
 ilisi'Mscs (iC wnincii cniiiinti' hihIci" liis <il»s<'r\;iti<>ii. 'I'liis (|ii:iiitil:ilivc 
 (IfliciciicN' had cxlciidcd dvcr a loii^ jJciMod ol (iiiif, coiiinn'iiciM^ ;it 
 jUilxTtv. lie di-aws atlciilioii (u (lit- indirect cllccts (it* siidi in^nllicicnl 
 alimentation — meat in particnlar — in |»r(Mlii('inn- vascniar di>(»r(l(i-s dt" 
 tlic ntcrus, clironic catarrlis, and alterations in stnielnre and jto-ition. 
 Clironie ulcers of the le^' l)esj)eak a |>(»<»r regimen, and will not heal iC 
 the sn|)|)lv of food is dclective in (|nality and insnilieient in (jnantity. 
 W'\\\ not, also, some of the degenerations of the cervix? "Pain," 
 says Fothcruill, " is hniiiicr of the nerves for food." .... "Xenraljfia 
 is a prayer for healthy blood." The truth of these facts nnist he patent 
 to every praetitionor. Among- no class or race of \v(tnien are these 
 deleterious inHnenees more strikiuiilv observed than in the American. 
 AN'ith foods in quantities more abundant than elsewhere in the world, 
 and in (|uality inferior to none, a slow, insidious process of starvation 
 from false notions of diet has become a most potent factor in the cau- 
 sation of ])elvic diseases in our American o;irls and women. On the 
 other hand, a oenerous diet improves the hsematosis, increases func- 
 tional activity, augments the body-weight and heat, imparts tone and 
 tirmncss to the blood-vessels and tissues, and diminishes the sensibility 
 of the nervous system to pain and reflex irritation. A good diet is 
 su])erior to medicine in the renewal of the body. 
 
 Tlie diet of women suffering with chronic uterine disease should be 
 plain, simple, easy of digestion, but highly nutritious and taken at 
 regular intervals. It is necessary, therefore, that the attendant specify 
 what articles of food are to be eaten, how much, and at what intervals. 
 No inflexible rules can be laid down for all persons. The same foods 
 do not agree equally ^^■ith every one. Personal likes, idiosyncrasy, are 
 to be consulted and in a measure used as a guide. 
 
 Of all the alimentary principles — nitrogenous, hydro-carbons, and 
 carbo-hydrates — the first is the most valuable. Animal food ranks 
 very high among the elements of nutrition. Meat, especially beef, of good 
 quality and properly cooked (broiled and roasted), is ordinarily as easy 
 of digestion as are fluid foods, and for a constant diet is easier. Its free 
 use improves the quality of the blood, increasing the number of red cor- 
 puscles, and, as Liebig has shown, force in excess is developed. Fat is 
 not increased, but muscular activity is promoted. It is claimed also 
 that such diet diminishes the risk of the occurrence of phthisis, which, 
 if true, is a fact of the greatest importance in this relation. Meat in 
 some form — beef, lamb, or mutton, game, poultry, oysters and fish — 
 should be taken freely, and, as a rule, some one of these three times a 
 day. A too free or frequent use of soups is to be avoided : they are 
 adjuncts to, but not substitutes for, solid foods. ]\Iilk and eggs are 
 rich in nitrogenous matter. The former contains a considerable quan- 
 
624 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 tity of fat ; the latter possesses a maximum of nutrition in a minimum 
 of bulk. Their use, save in exceptional cases where they disagree, is 
 to be encouraged. A most excellent plan of dietary in cases of mal- 
 nutrition embraces the ingestion of a half to a whole pint of fresh, pure 
 milk from one to two hours after meals : if digestion is feeble, it may 
 be taken pejatonized. A cup of warm or hot concentrated beef-tea or 
 beef peptonoids in solution may advantageously be substituted once a 
 day for the milk. In conditions of marked feebleness of digestion the 
 diet should be restricted to milk, pure or peptonized, and beef pep- 
 tonoids, until the stomach can tolerate solid food. 
 
 Foods containing much starch and sugar — the carbo-hydrates — stand 
 lower in the nutritive rank and lowest in the strength-giving qualities. 
 Partaken of too freely to the exclusion of nitrogenous foods, they tend 
 to indigestion, acidity, and flatulency. They have their j)lace in our 
 dietary, and for variety are needed. The cereals, vegetables, and fruits 
 belong to this class. Bread, which stands first, possesses nutritive prop- 
 erties of the highest order. Wheaten bread should be prepared from 
 the entire grain. Vegetables may be taken in moderation, not more 
 than one to two at a single meal. The same holds true in reference to 
 fruits. 
 
 The fats — the hydro-carbons — though not the exclusive, are active 
 fat-, heat-, and strength-producing agents. Butter, cream, fats of meats, 
 oils, etc., articles of this class, are most valuable elements of alimenta- 
 tion when there is malnutrition, lack of adipose tissue, spansemia, etc, 
 — conditions in which there is always an increased susceptibility to 
 changes of temperature, to pain, and a diminished bodily resistance to 
 disease, Pavy expresses it thus : " Fat accumulated within the vesicles 
 and susceptible of reabsorption into the blood forms a store of force- 
 producing material to be drawn upon as circumstances may require," 
 Consistent with the ability to digest foods of this order, their use, under 
 proper indications, may be urged. Cream with oatmeal, abundance 
 of butter upon bread, and well-cooked meat-fats are selections which 
 may be made with the object in view. 
 
 Coffee, if taken, should always be in moderation, not to exceed once 
 daily (a, m,). On account of its tendency, with some persons, to 
 derange digestion, and being a most active stimulant, it will be found 
 well at times to discontinue it. Tea is less stimulant, and can generally 
 be taken. Cocoa and chocolate make excellent substitutes. 
 
 The use of alcoholic stimulants demands the greatest caution. An 
 invalid woman is even more prone than the sterner sex to contract 
 habits of excessive alcoholic drinking. The grateful effects quickly 
 expressed, the free relief to the sensations of languor and nervousness, 
 soon pave the way to their too-frequent and too-free use. Very rarely 
 ought alcohol to be prescribed under the plea of depression and exhaus- 
 
ciinoMc Mi:ri:i'ns, j-rn: of riii: rT/:i:rs. r,-2') 
 
 tioii. Wine or limit li<|ii<irs, in iiiodcratioii, taken with the more licarty 
 meal, iniidiicc to »li;icstii»n, arc (|iiickly assimilated, and in sek-eted eases 
 Im'coiiu' lieiiefieial. To tlntse wlin lalmr nmler li-eljle diLre>ti<in, are 
 aiiiPinic, and of" s|)are lialiit, and w lio can Ix- trusted with their ii-e, the 
 aroresaid alcoholic l)everai;cs may occasionally he prescrihcd. 
 
 Certain ai-ticles of diet, as pies, cakes, most puddiiifrs, nuts, and 
 candies, should he interdicted. 
 
 The great underlvin<; principles ol" alimentation are, to select -neh 
 foods as do not dcrantro djtjestion, but improve it if disordered, ancl, 
 ahove all, to introduce such (|uantities of the best nutriments as the 
 diji-estive oro;ans have capacity to incorporate. 
 
 The ingestion of foods at proper and regular intervals is of the next 
 importance — a rule of equal value where there is anorexia. It will not 
 do to wait for an appetite ; in the mean time the })atient may be starv- 
 ing. As is light to the eye, so is food the natural stimulant to the 
 stomach. A])petite can be created by its judicious ingestion. In the 
 foregoing j)lan and choice of diet the patient should be instructed and 
 held until habit and taste are created. 
 
 Attention to Functions of Digestion. — In addition to a systematic reg- 
 ulation of the dietary the employment of certain medicines plays a 
 most important role in aiding the functions of digestion. So frequently 
 are these functions disordered that it is seldom they do not require 
 some special attention, which, so far as medication is concerned, should 
 be the first step in general treatment. Appetite is to be promoted and 
 the various symptomatic disorders of the stomach are to be controlled. 
 For the first, such stomachics as the vegetable bitters — nux vomica in 
 tincture or its alkaloid strychnine ; cinchona in tincture or elixir, or its 
 chief alkaloid quinine; gentian, quassia, etc. — are the best. These act 
 most favorably when administered before meals, and besides improving 
 the appetite they give tone to the stomach, facilitating primary diges- 
 tion. To further aid in the solution of the food the artificial digesters, 
 ]iepsin, lacto-pcptin, and muriatic acid, may be prescribed after meals. 
 They are chiefly indicated where there are sensations of heaviness and 
 weight after eating, attended or not with acidity and flatulency. The 
 mineral acids, muriatic and nitro-muriatic, Avell diluted, frecjuently con- 
 trol acidity and flatulency better than the alkalies and more permanently. 
 In derangements of the secondary functions — imperfect digesti<»n of 
 the albuminoids, fats, and starches from some defect in the pancreatic 
 secretions, etc. — pancreatic powder, some time after meals, may artifi- 
 cially be substituted. Ipecacuanha powder, in small doses (gr. \-^) 
 after meals, is a remedy of no mean power in this direction, stimulating 
 the flow of gastric juice and bile. 
 
 The efficaciousness of most of these remetlies may be enhanced by 
 various combinations. Thus: 
 
 Vol. I.— 40 
 
626 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 ^. Strychninse, gr. ss ; 
 
 Acid, nitro-muriat. dilut., 3ij ; 
 Aquse destillatae, sij. S. et M. 
 
 Sig. Ten drops, with water, before meals, 
 
 ]^. Pepsinse (Fairchild's), Bj ; 
 Pulv. ipecacuanhse, grs. v ; 
 
 Extract, gentianse, Bj. ]\I. 
 
 Ft. in pil. XX. 
 Sig. One pill after each meal. 
 
 ^. Pepsinse (Fairchild's), Bj ; 
 Quininse sulphatis, yij ; 
 
 Strychninse, gr. ss. M. 
 
 Ft. in pil. XX. 
 Sig. One pill after each meal. 
 
 The addition of extract pancreatis (grs. ij) to either of the above 
 formulae, or ext. pancreatis with sodium bicarbonate (each gr. iij), given 
 alone after meals when this remedy is indicated, may be prescribed. 
 The peptonizing of food, a process of partial digestion before stomach 
 ingestion, first practically suggested by Wm. Roberts, F. R. S., of 
 London, has much to recommend it. While its field of utility, par 
 excellence, is intestinal indigestion, its use need not be thus limited. 
 Many cases of malnutrition needing full feeding have feeble digestion. 
 The artificial digestion of milk or beef so prepared is a great assistance. 
 
 For the symptoms of gastralgia no remedies act more promptly than 
 bismuth subnitrate (grs. x) or Fowler's solution (gtt. j-ij) before meals. 
 
 A teacupful of hot water from a half hour to an hour before meals- 
 has been found to be an excellent means to improve the digestion in 
 many cases of atonic dyspepsia and chronic gastric catarrh. The 
 stomach is washed of adherent mucus, the blood-supply is tempo- 
 rarily increased, the secretion of gastric glands promoted, and the 
 whole functional activity of the digestive organs facilitated. 
 
 The malt extracts, rich in diastase, assist the digestion of starchy 
 foods, besides possessing in small bulk valuable restorative principles. 
 They may be taken with or after meals. 
 
 Attention to the Functions of the Bon-els. — There is no more common 
 complication of chronic uterine diseases than constipation, none more 
 serious, none Avhich, for the want of proper attention thereto, is more 
 calculated to retard a progress to recovery. Considering the frequency 
 and the extent to which constipation exists in some women, it is no 
 longer a matter of surprise that it is a most fertile source of pelvic 
 disease. Not only does constipation impede venous flow within the 
 rectum, favoring congestion and hemorrhoids, but it directly influences. 
 
CHRONIC M/rriilTIS, ETC. OF THE UTERUS. iVll 
 
 In till' sMiiic maiuK r the \ rnoiis ciiciilMtiuii within iho uterus and remain- 
 ini;- |)cl\ic vi>('<'i-:i. The uterus is not nuly pressed upon or bent out of 
 position l»v H'cal accuuuilatious witliiu the colon and reetuui, hut hy 
 an iucrrased vaseidarity it is rendered heavier. Its lij^anientous attach- 
 ments are stretched, rehixed, and weaUeiied. Here are two lactors 
 ahine conducive to displaceinents. Indirectly coiniecte<l with the 
 pelvic eireiilation is the portal, which in turn inn-t he made slntr- 
 gish. Ap|)etite and di<j:estion are now impaired. 
 
 It is a sul)ject of" wonder wiiy i)Iood-poisonin<i;;, from an al)soi-j)tion 
 of the decomposing matter of large accumulations of feces long retainetl, 
 does not ofteiKM- manifest itself The aljsence of the more serious symj)- 
 toms, which might attract attention, only demonstrates the capacity and 
 endurance of the human sy.stem even under adverse circum.stances. A 
 slow, insidious, chronic toxremia, escaping notice, is doubtless sometimes 
 present. If the system sutlers from bad drainage and defective sewer- 
 age without, why not within, the body? Excrementitious matter, 
 long retainetl, must decompose and foul gases be generated ; these, 
 together with the liquid elements of the feces and products of w'a.ste 
 tissue, become absorbed, vitiate the blood, irritate the nervous centres, 
 and derange every function. 
 
 Free alvine evacuations can be secured daily by means hygienic and 
 medicinal. Among the first are exercise, diet, drink, and regular habits. 
 Bodily exercise, w^alking in particular, conduces to intestinal as well as 
 other muscular vigor and streno-th. The sedentarv habits of women 
 fiirnish one of the principal reasons for the much greater frequency of 
 constipation in their sex. Foods which contain a certain proportion 
 of refuse material stimulate intestinal peristaltic action. Such foods 
 are cracked wheat, coarse oatmeal, corn and Graham bread, and the suc- 
 culent vegetables, fruits, and berries. The former are otherwise exceed- 
 ingly valuable in view of their nutritive properties ; the latter, while 
 less nutritious, afford, on account of their different acids, a much-neetled 
 variety and promote gastric and intestinal secretions. If properly 
 selected as to time of eating, quantity, and quality, they need not 
 interfere witli digestion. Coffee, and particularly green tea, in excess 
 constipates. Water freely imbibed on an emjity stomach — above all, in 
 the morning fasting — favors intestinal action and liquefies the fecal accu- 
 mulations. Its virtues are materially enhanced by the addition of a 
 modicum of common table-salt. Congress, Hathorn, Blue Lick, and 
 various sulpho-saline waters act similarly, are most effective, but should 
 be regarded rather in the light of medication to be avoided if possible. 
 
 Constipation is a disease the cure of which can be obtained only bv 
 studying individual cases and causes. ]Mental attention directed to the 
 bowels in endeavoring to obtain an alvine movement at regular, stated 
 times is a matter of prime importance. Habit, albeit of slow develo])- 
 
628 THE I^'FLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 ment, can be established in this regard with perfect regularity, failures 
 largely resulting from a want of due patience and perseverance. A visi- 
 tation to the water-closet at a certain hour (after breakfast), interrupted 
 and prevented by naught else, be it friends, business, indisposition, or the 
 weather, and there remaining for it may be half an hour, rarely fails 
 after a few weeks to be successful. The posture should be easy, and no 
 straining allowed. The simple concentration of the mind upon the 
 present duty has its influence over the body. As a well-constructed 
 water-closet is one of the most important parts of house-building, it 
 should be accessible, convenient, comfortable, clean, and inviting. 
 Goodell has drawn attention in a most graphic manner to the baneful 
 influences of the old water-closet (privy) system in causing constipation. 
 
 Every effort should be made by the aforesaid means of diet, drinks, 
 exercise, and regularity of habits, to obtain free and regular alvine move- 
 ments before resorting to the use of any medication. Medicine is quite 
 generally needed, but it ought always be borne in mind that it gradu- 
 ally loses its eifect, and that the more taken the more will be required. 
 Drugs stand in a subordinate rank to hygienic measures. The various 
 laxatives and cathartics act by virtue either of promoting intestinal secre- 
 tions or of exciting muscular peristalsis. Constipation presents condi- 
 tions of defective secretion, in either the upper or the lower intestine, or 
 paresis of the muscular fibres of the intestinal tube. Defective secretion 
 in the upper intestine is evidenced by clay-colored, pasty, unhealthy- 
 looking, offensive stools ; in the lower intestine, by hard, dry, scyba- 
 lous formations. Obstructions to the alvine passages are encountered 
 within the pelvis on account of uterine enlargement and displacements 
 — notably retroversion and flexion. Thus, the various indications for 
 the use of the different remedies are obtained. 
 
 Defective secretion of the upper intestine calls for such remedies as 
 mercurials, podophyllin, euonymin, leptandrin, iridin, ipecac, aloes, 
 and rhubarb ; of the lower intestines, the salines. Muscular inactivity 
 of the intestines is met by nux vomica, belladonna, physostigma, aloes, 
 ' and faradization. Two or more of these indications — defective secre- 
 tion and muscular torpor — often present themselves. The practice 
 adopted by Emmet and Byford, of commencing the treatment of those 
 who have long suffered as chronic invalids by administering the mild 
 chloride of mercury as a cholagogue, and occasionally repeating the 
 same or mercury in the form of blue pill, folloAved by a saline as a 
 cathartic, is doubtless very efficient in stimulating the portal circulation 
 and secretions, dislodging fecal accumulations, and preparing the way for 
 stomachic tonics. These remedies have also a I'evulsive effect on the 
 congested pelvic viscera. This plan, although seemingly harsh, is not 
 always contraindicated even in states of debility and anaemia. 
 
 When the tongue is furred, the alvine movements small, hard, dry, 
 
vniiosic Miyniiris, etc o/- the cteui's. c>2'.) 
 
 ami paliiliil, llu- \;Minii> miiw r:il \\atn>, taktii in the iiidiiiiii;; lasting;, 
 ait' atla|)lf(|. Tlit- Idllowiiii;- mixture ol" siilpliatt' itl iiia;j:ii<'sia and siil- 
 plmric aii<l witli sulphate of intn, if indicated, answers well in many 
 eases, lieinu" Imtli la\ali\c ami tunic: 
 
 1^, .Ma^nesiie snipliatis, .sj ; 
 Acidi sidplnirici dilnti, ."j ; 
 Fcni >nlpljatis exsie., ^rs. xvj ; 
 A(|ii:e destillat. ad S^i'j- ^I- 
 
 iSiii-. A tal)le.-iH>onrnl or more in a wineu-lass ot'culd water before break- 
 flUst. 
 
 Or maiiiiesia sid])liate (SJ-oi.)), dissolved in a tiunblerfnl <A' water, to 
 be taken each morning before breakfast, gradnally diminishing the qnan- 
 tity of the medicine as habit is created, always, however, maintaining 
 the original (piantity of the water, may be preseribetl. Carlsbad salts 
 or sodinm phosphate may 1x3 substitnted for the magnesia snlphate. 
 The following forrauhie will be fonnd to meet many indications : 
 ^i. Resina? podo])hvlli, 
 Ext. nueis vomicoe, 
 Ext. belladonna, del, grs. ij. 
 M. Ft. in pil. xii. 
 Sii;. One at bedtime if no movement during the dav. 
 
 R, Aloein, grs. iv ; 
 
 Stryehnife, gr. ^ ; 
 
 Ext. belladonuse, grs. iij. 
 M. Ft. in pil. xx. 
 Sig. One at bedtime if necessary. 
 
 I^. Resinse podophylli, grs. iv ; 
 
 Pulv. ipeeacuauhte, grs. iv ; 
 Ext. eoloeynth. comp., grs. xxiv ; 
 
 Ext. nncis vomicae, grs, iv ; 
 
 Ext. belladonnse, grs. iv. 
 M. Ft. in pil. xxiv. 
 Sig. One pill at bedtime. 
 
 The Rhamnus Purshiana (Cascara sagrado), in the form of the fluid 
 extract (gtt. x— xxx), is quite usually an excellent laxative. 
 
 So soon as the proper dose of any laxative medicine has been deter- 
 mined, and the bowels by its aid have established regularit}- of evacua- 
 tion, the dose should be gradually diraiuishe<l until none is taken. 
 
 The colon, and especially the rectum, of women, after years of con- 
 stipation generally have become greatly dilated and have lost all con- 
 tracting power. Instead of a canal for the passage of fecal matter, they 
 are transformed into an immense sac for its accumvdation. The frefpient 
 administration of active resinoid cathartics onlv increases this diffieultv 
 
630 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 by leaving the parts in an increasingly weakened state. Manipulation 
 of the abdominal walls by kneading, especial attention being given the 
 whole track of the ascending, transverse, and descending colon, may be 
 resorted to with advantage. Direct faradization of the abdomen and 
 intestines (rectum included) may be useful. Both measures require to 
 be persevered in for a lengthened period. The injection of cold salt 
 water (about half a pint) within the rectum will not only empty it, but 
 tends to excite muscular contraction. But the frequent and long-con- 
 tinued use of enemata is to be discouraged, as calculated to induce the 
 condition referred to. The author has seen some excellent results after 
 perineorraphy and colporraphy for constipation dependent upon relaxed 
 vaffina and rectum. 
 
 As a dernier ressort in some cases paralyzation of the sphincter ani 
 by forcible dilatation may be tried. 
 
 General Medication. — The whole range of tonic medication becomes 
 more or less useful in the treatment of the chronic uterine diseases with 
 depreciations of the general health. For practical purposes, all tonic 
 and restorative measures might be limited to the following : quinine^ 
 nux vomica, iron, arsenic, phosphorus, cod-liver oil, electricity, and 
 massage. Each of these deserves special mention. 
 
 Quinine, the chief alkaloid of cinchona, is the best representative of 
 the whole list of bitter tonics. In moderate doses (grs. j-iij, ter die) it 
 is a stomachic tonic, a general restorative tonic, promoting constructive 
 metamorphosis and increasing mental and somatic activity. It is not a 
 special uterine stimulant, but indirectly by its use such an influence 
 may be exerted. These well-known effects of quinine enable the phy- 
 sician to utilize it in a large number of the chronic diseases of women. 
 
 Nux vomica, besides its field of usefulness in the atonic and nervous 
 forms of dyspepsia and torpid states of the intestines, is employed in 
 small doses for its stimulo-tonic effects, through the vaso-motor nerves 
 and centres in the spinal cord, to contract the arterioles and muscular 
 fibres, thereby increasing the arterial tension and improving the local 
 circulation. Quinine and iron have their virtues as tonics increased by 
 a combination with nux vomica or strychnia. 
 
 Iron is probably more frequently prescribed for the chronic diseases 
 of women than any other remedy, and no other is capable of doing 
 more good in properly selected cases. The common rules, that iron 
 should not be given when the temperature is elevated, the pulse fre- 
 quent in connection with increased temperature, the tongue furred and 
 foul, the liver inactive, and the urine scanty and thick, are ever to be 
 borne in mind. Local contraindications are equally important. Iron 
 increases pelvic congestion in either sex, provokes pain when the uterus 
 and ovaries are actively congested, and tends to excite menorrhagia. 
 Much harm is often actually done in these conditions by saturating 
 
riuioMc Mi:iniTi.\ j-nv. of tiih uterus. g.U 
 
 patients with the preparations of iron. Tlic ili<;estive iin<l alimentary 
 disorders tii^st need correcting, and the excretions shoidd he made free 
 before iion can |)roperly he assimihited. The general indications are — 
 anaMiiia, strnma, syj)hilis, and some nenroses (neural<xia.<) ; the IfK-al — 
 amenorrlKoa, dysmenorrhea, lencorrhwa, torpid and flahhy states of" the 
 uterus, espeeially in anjoiuie subjects and the ])hlegmatic temperament. 
 
 Quinia and strychnia are oflen ])rescril)ed together as a tonic, and 
 when there is no oi))ection t<) iron all these agents may be combined, as — 
 K. Puiv. I'crri redaeti, grs. xxx ; 
 Quiiiinie sulphatis, .^j ; 
 8trvchnina\ gi'- 1 j 
 
 Ext. gentianae, q. s. 
 INI. Ft. in pil. xxx. 
 Sig. One pill after each meal. 
 
 The best preparations of iron are — iron ]ier hydrogen, pill of the 
 carbonate, sulphate, tincture of the muriate, syrup of the iodide 
 (Creuse's formula), and the pyrophosphate. 
 
 Blaud's pill of the carbonate of iron (grs. ij-iij, ter die) has had a 
 deservedly high reputation for anaemic, chlorotic, and amenorrhoeic 
 females. Xo preparation of iron is so efficacious to rapidly furnish 
 the needed material to the blood as the muriated tincture. In those 
 exceptionally rare cases where uterine hemorrhage is prolonged by 
 extremely watery conditions of the blood, lacking all power of spon- 
 taneous hiiemostasis, this preparation of iron is xery serviceable. 
 Creuse's syrup of the iodide is well adapted for strumous, s^'philitic, 
 and tubercular cases. A light, agreeable, and efficacious preparation 
 of iron, which does not constipate the bowels, is the pyrophosphate. 
 The following is a favorite formula : 
 
 R. Ferri pyrophosphatis, 3] ; 
 Acidi phosphorici diluti, 3ij ; 
 Syrupi simplicis, 3xiv. 
 
 Sig. A half teaspoonful or more three times a day. 
 
 The officinal elixir ferri, quininae, et strychniae phosphatis, now made 
 by the best pharmacists, often produces effects most conspicuous for good. 
 As a rule, all preparations of iron are best omitted during menstruation. 
 
 Arsenic checks retrograde metamoq^hosis and improves nutrition. 
 It is a good remedy, given in minute doses (gtt. j-ij) before meals, in 
 irritative dyspepsia, and rather aids than otherwise movements of tlie 
 bowels in chronic constipation. In addition, it has an excellent adap- 
 tation to certain gynecological affections, being indicated in a class of 
 diseases in which iron is highly objectionable. Chronic uterine leucor- 
 rhfiea, cervical or corporeal, and menorrhagia de])endent upon chronic 
 hypcraemia and endometrial fungosities, are often much bencfitetl by 
 
632 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 arsenic. Next to ergot and quinine, arsenic stands as a remedy for the 
 so-called chronic metritis. It should be given in small doses (gtt. iij— 
 v) after meals for a long time. 
 
 Phosphorus, in the form of the phosphates, is a very important ele 
 ment in the nutritive processes. Eligible preparations are the officinal 
 syrup, hypophosphite comp., syrup, calcis lacto-phosphite, etc. Either 
 one of these preparations may be given where there is defective activity 
 of the nutritive functions, as in ansemia, malnutrition, morbid wake- 
 fulness, and melancholia the result of cerebral anaemia and exhaustion, 
 in neuralgia, spinal irritation, migraine, etc. The phosphide of zinc 
 (gr. -J^, ter die) is one of the best preparations to secure the influence 
 of pure phosphorus. All preparations of phosphorus tend to increase 
 the menstrual flux. 
 
 Cod-liver oil, on account of its power under proper circumstances to 
 facilitate gastric digestion, promoting the appetite, and, above all other 
 fats, forming the molecular basis of the chyle, is admirably adapted to 
 meet many of the morbid constitutional states found in women with 
 chronic pelvic disease. So soon as the stomach and bowels have been 
 regulated by a proper diet and medication, cod-liver oil should be given 
 where there are ansemia, certain diatheses and cachexise, the body-weight 
 below the normal standard, and the nutrition below par. Anstie and 
 RadclifFe have clearly pointed out that a diet of fats, especially cod- 
 liver oil, has a high degree of efficacy in many neurotic affections. 
 Through its influence in improving the general health it is very de- 
 servedly highly prized in chronic uterine diseases. A combination of 
 the hypophosphites of lime and sodium with cod-liver oil will meet 
 numerous indications. Further to increase the assimilation of fats, 
 cod-liver or olive oil or cocoa cream may be introduced into the 
 body by inunction after a Avarm bath at bedtime or after general mas- 
 sage. From one to two ounces daily may be incorporated in this way. 
 Such treatments soon begin to show their eifects in increased weight 
 and improved appearance. 
 
 Electricity,^ in the form of both the faradic and the galvanic currents, 
 is very often utilized for chronic uterine diseases. A marked physiolog- 
 ical effect of electricity is to promote and increase the menstrual flux, 
 irrespective of Avhether it is applied locally or generally. It is there- 
 fore doubtless to be withheld in some conditions of menorrhagia, while 
 indicated in the amenorrhoeic. Galvanization of the central sympa- 
 thetic, the cord, or the pelvic regions will at times very favorably 
 affect dysmenorrhoea of the neurotic t.Aqoe. 
 
 Systemic massage has been proven to be one of the best tonics. It 
 consists in a systematic exercise, by friction, kneading, tapping, and 
 passive motion, of all the muscles, of both the extremities and the 
 ' See article on " Electi'icity." 
 
CURU.SIV MKTniTIS, KIV. (jF TlIK irilllf^. (;;;;» 
 
 trunk, f'n)in h;ilf' an lutur to an lionr, once to twite daily. I"ii~t tlu' 
 t'xritation ol" tlic ciitanctMis circnlatitm is folhtwctl hv a j^cncial rise 
 of teinpciatiiic ; tlic iniisclcs arc l)r(iiiuli( into most active exercise with- 
 out the c\|>cn»litiirc »»1" ncrvc-force ; tlicn there is an acceleration in all 
 the organic functions and a <2;radual increase of weiuht. A most nuu'ke*! 
 ini|truvcmcnt in the \arious morbid plicndMicua of the nervous system 
 follt»ws. Local tenderness and pains <lisaj)j)car ; a pleasant sense <»f 
 exhaustion, and with it a refreshing sleep, is manifest. Faradization 
 and nuissage combined form the two most valuable means «jf exercisini^ 
 the nuiscles. The "ood effects of exercise are obtained with exertion. 
 Successful results with massairc or massatre and electricity require the 
 employment of a trained rubber — a ma^tseuse. 
 
 S. Weir Mitchell of Philadelphia has obtained some surprisin<rlv 
 good results from j::eneral nuissage, conjoined with exclusion, rest, diet, 
 and electricity. Each of these has been utilized by others, but to 
 Mitchell is due the credit of first scientifically com1)ining these differ- 
 ent means into one common therapeutic system of treatment. W. S. 
 Playfair of London has also published accounts of some ca.ses equally 
 wonderful, and many other ]>hysicians, instructed by ^litcheH's teach- 
 ings, have been able to confirm his results. 
 
 The typical cases most likely to be benefited by massage are those of 
 long standing, who are bedridden, wasted, hysterical, with a variety- of 
 simulated disorders. Such patients have ])rol)al)ly dragged out for years 
 a miserable existence in chronic invalidism. In many, though bv no 
 means all, as some might su]>]>ose, there is some local disease, and from 
 this starting-point the invalidism conuuenced ; but the resulting general 
 disturbance has at last become so great as to completely overshadow 
 the local. Every endeavor at an amelioration by further local treat- 
 ment or general medication is utterly useless. Playfair has Avell 
 remarked that the worse the case is, the more easy and certain it is 
 of cure by the Mitchell plan of treatment. 
 
 There are, however, not a few cases of neurasthenia, debility, and 
 wasting in women, consequent on some chronic uterine ailment, not 
 confined to bed or the house, Avhich may be much benefited by massage 
 or massage with electricity and a full diet, but with partial rest and 
 without seclusion. The different features of this plan of treatment may 
 be variefl to suit individual cases. In addition. th<»se who are fat, with 
 flal)by muscles, slugsrish circulation, are improved by massage. 
 
 The successful use of massage requires skill, otherwise it may be 
 hurtful. It is the principle of the rest-cure which should be aime<l 
 at in all cases ; the details are applied with many modifications. The 
 execution of these details to obtain successful results implies infinite 
 tact, great patience and perseverance, and gentleness combined with 
 firmness. 
 
634 THE INFLAMMATORY AFFECTIONS OF THE UTERUS. 
 
 A course of massage, electricity, and rest should always be followed 
 up by a well-regulated regimen, dietary, and exercise. Special symp- 
 toms seldom require special attention. The general and local treatment 
 is addressed to the underlying morbid states and the faulty habits pro- 
 ducing these symptoms. When the former are corrected the latter, in 
 turn, abate. The temptation is always strong, and the physician is too 
 often persuaded, to resort to the various anodynes to arrest pain. The 
 excessively frequent practice of the administration of opiates — morphia 
 hypodermatically in particular — because there is pain, without an inves- 
 tigation of its cause, is one of the crying evils of medical practice of 
 to-day. Except for acute pain due to inflammatory action or after a 
 surgical operation opiates are really seldom needed. They are danger- 
 ous remedies for the chronic uterine diseases, and their use, once com- 
 menced, soon begets a subjective erethism and neuralgia as difficult to 
 overcome as the original affection. Every discomfort is dwelt upon 
 and magnified ; the drug-intoxication is the only solace. But difficult 
 as it is to resist the imperious cravings, dependence upon these drugs 
 must be broken up, otherwise the case is ho23eless. 
 
 Almost equally pernicious is the habit of prescribing opiates, chloral, 
 and the bromides to produce sleep. The last named are the least objec- 
 tionable, but their use should never be depended upon for any length- 
 ened period. The bromides are vaso-constrictors and depressors of 
 reflex action ; hence they prove to be our most reliable remedies for 
 the reflex neuroses, psychical or physical. Sleep, of which an abun- 
 dance (eight to nine hours) is daily needed, should be obtained by reg- 
 ular habits, proper food, plentiful amount of exercise, massage, elec- 
 tricity, a cool and well-ventilated room, and self-control. 
 
 General nervousness or nervous excitability is gradually controlled 
 by a removal of the cause, proper hygienic measures, and such tonic 
 medication as the special indications call for. The use of the stronger 
 alcoholic stimulants under these circumstances is greatly to be deplored. 
 Save the lighter wines or malt liquors, and these only with food (the 
 heavier meal), and under conditions to which attention has been directed, 
 all alcoholic stimulants ought to be interdicted, for they, like the opiates, 
 are unsafe agents in the hands of invalids. 
 
 Headaches of the neurotic type are best treated by quinine, strychnia, 
 arsenic, phosphide of zinc, cannabis indica, and iron during the inter- 
 val, and by caffeine, the bromides, and galvanization in the attack; 
 'those of the congestive form, by the bromides, belladonna, etc. 
 
 Many of these suggestions in general management may seem com- 
 monplace and unnecessary, but to one who has had much personal con- 
 tact with such diseases in their manifold forms there is nothing in the 
 least promising which should be deemed unworthy of trial. The patient 
 must manifest an intelligent co-operation. The utmost regularity in all 
 
CUlioSlc MKTIUTIS, h'TC. OF THE UTIJU'S. (J.;') 
 
 lial)its and iliillil'iilncss in the obstTvance lA' all (lircction.s arc rcijuisito. 
 Kverv (U'tail is important, and lie wlu) j^lvcs most liced to fadi is tin* 
 one who, other thiiijis hein^- e(|iial, meets with the most j»romj)t and 
 best sneeess, ('hroni(! diseases reijuire a ehi'om'e treatment. There ran 
 be no restoration of" the local so lon;^ as tliT' ji'eneral health is deran;ied. 
 Tile reeij)roeal relations between the two are so stronjr and intimate 
 that a permanent improvement in the one can only be eoe.\tensi\c with 
 the other. 
 
 In no class of diseases is it more incinnbcnt n])()n the j»hysician to 
 brin<2.- to bear the inflncnces of" a moral treatment. His own maimer 
 shonld be eheerfnl, hopef'nl, and inspirinji;. A personal ma<^netism 
 counts in no small degree iu oreatino; a confidence so necessary to enlist 
 the proper interest and intelligent co-operation of one long sick. To 
 divert the invalid's mind from herself and her condition, to direct her 
 thonghts into new channels, to enable her to exercise the most health- 
 fnl discipline of self-control, is by no means ever an ea.sy task, b»it 
 when well done may accomplish more than medication in restoring 
 lost health. 
 
 So extended is the sphere of the application of remedial agents in the 
 constitutional management of the diseases under consideration that a 
 thorough knowledge of the whole field of medicine embraced is requi- 
 site. To survey the system at large, to recognize the true import and 
 significance of special symptoms, to detect disease in kind and degree 
 wherever found, must needs be the office of the gynecologist. Xo class 
 of affections, the body over, possess so many ramifications, assume so 
 many phases, induce such general disturbances as do the chronic dis- 
 eases of the female pelvic viscera. Therefore no one can be a compe- 
 tent and successful gynecologist who is not first a thorough physician. 
 
 Bibliography. 
 
 Anstie : Neuralgia, and the Diseases that Resemble it, 1871. 
 
 Beard and Rockwell : Treatise on Electricity, 1883. 
 
 Byford : Diseases of Women, p. 288. 
 
 Emmet : Diseases of Women. 
 
 Fothergill: Indigestion and Biliousness. 
 
 Goodell: "Lessons in Gynecology" and "Neurasthenia and AVonih Diseases," -Iwi. 
 
 Gyrwcolog. Soc. Transac, vol. iii. 
 Hewitt, Graily : "Chronic Starvation and Delicate Females," Ciu. Lancet, Oct. H, 
 
 1883. 
 Mitchell, S. Weir : Fat and Blood, 1884. 
 Pavy : On Food and Dietetics. 
 Playfair : Nerve-Prostration and Hi/steria. 
 KoBERTs;, William: Lumleian Lectures. 
 
SUBINVOLUTION OF THE UTERUS AND 
 
 VAGINA. 
 
 IJv TIIAI)I)i:rs A. liKAMV. A. M.. .M D.. 
 Cincinnati, <). 
 
 Subinvolution of the Uterus. 
 
 NoMExn.ATUUE. — MiU'Ii confiision lias existed, and still exists, 
 regardinjj:; the i-elatious of this aliection aud chroiiie metritis, aud the 
 nomenclature is faulty. 
 
 Some authorities helieve in subinvolution as an entirely distinct affec- 
 tion, while others believe it to be only the first step in chronic metritis. 
 Consequently, this latter class when treating of chronic metritis really 
 include what the former treat as a sejiarate ])atholo<2;ical condition. While 
 no name has been so universally apj)lied to defective reduction of the 
 uterus after parturition as " subinvolution," the condition has received 
 many other desiiiuations from the various writers u])on the sul^ject. 
 
 In Sir James Simpson's article on " ]\Iorbid Deficiency in the Invo- 
 lution of the Uterus after Delivery,"^ read in 1852, he makes use of 
 the term " subinvolution " in naming the condition of morbid deficiency, 
 which was probably the fii'st time the term was used. In a jjrevious 
 paper on the subject - he first called attention to such a condition, nam- 
 ing it " morbid permanence of the state of puerperal hy])ertroj)hy." 
 
 Klob, after a study of the pathological changes and conditions found 
 in the uterus which has not undergone perfect involution, in an endeavor 
 to more accurately describe both cause and condition calls it " habitual 
 hypertemia with profuse proliferation of connective tissue."^ 
 
 Scauzoni, holding the views of Sir James Simpson and many early 
 writers on the subject respecting the infiammatory cause of the disease, 
 styles it " chronic parenchymatous metritis." * 
 
 Most authors among the French believe the condition one of inflam- 
 mation, and have generally employed the same designation. 
 
 Edis" uses many of the terms employed by previous authors, and 
 
 ' Selected Obstet. and Gyn.Worh, 1871. 
 
 ^ Lomlon and Kdinbun/h Medical Journal, Nov., 1843. 
 
 ^ Path. Anat. of Female Sexual Organs, 1868, pp. 127 e( setj. 
 
 * Disease.^ of Female.^, pp. 175 et i>eq., 1881. 
 
 * Diseases of Women, p. 176, H. C. Lea'.s Son c*!: Co., Phila., 1S82. 
 
 6.37 
 
638 SUBINVOLUTION OF THE UTERUS AND VAGINA. 
 
 treats the aifection under the term *' chronic metritis," akhough dis- 
 claiming any belief in its inflammatory nature or origin. 
 
 Thomas ^ so firmly disbelieves in inflammation as a cause of the dis- 
 ease that he objects to any term which conveys the idea that it is in 
 any way inflammatory, and invents the term " areolar hyperplasia " as 
 most descriptive of the conditions marking the uterus in defective 
 reduction. 
 
 Hodge designates the condition " irritable uterus/' from its clinical 
 aspects. 
 
 Lisfranc calls it " engorgement/' to describe at least one step in its 
 etiology. 
 
 Kiwisch ^ uses " infarctus " as his designation, to show the vascular 
 condition when involution is imperfect. 
 
 Noeggerath, while a disbeliever in its correspondence to inflamma- 
 tion, thinks it should be called " diffuse interstitial metritis." 
 
 Hart and Barbour,^ after quoting much of the above nomenclature,, 
 although at the same time not believing it an inflammation in any sense, 
 adopt the old term " chronic metritis," assigning as their reason for so- 
 doing that " we are not yet in a position to propose a term resting on a 
 sure pathological basis." 
 
 Mary Putnam Jacobi,* who has written a very able and exhaustive 
 pa])er on the subject, calls this affection subinvolution, and makes both 
 a clinical and pathological distinction between it and chronic metritis. 
 The recognition of such a distinction, which is rationally sustained, will 
 probably prove a basis for enlightenment upon a subject hithertO' 
 obscure. 
 
 History. — The history of subinvolution of the uterus — or, prop- 
 erly, its existence as a- distinct affection treated in medical literature — is- 
 comprised in a little more than four decades. As a disease it has cer- 
 tainly existed as long as the uterus itself, but, like many other disaeses, 
 its recognition as a separate affection dates but a few years back. AV liile- 
 there are a few indistinct and general allusions to an enlarged condition 
 of the uterus remaining after delivery by others, it is to Sir James 
 Simpson that we are indebted for the first accurate and well-defined 
 information on the subject. It is an interesting fact that this distin- 
 guished observer almost immediately after he devised his uterine sound, 
 aud probably through this additional means of investigation and diag- 
 nosis, discovered the symmetrical hypertrophy of the uterus which is 
 so familiar to the profession to-day. 
 
 His first description of his sound — or uterine bougie, as he called it 
 
 1 Diseases of Women, pp. 307 et seg., H. C. Lea's vSon & Co., Phila., 1880. 
 
 2 Klinische Vortr., Prag, 1845, p. 104. 
 
 '^ Manual of OyncecoJogy, pp. 306 et seq., 1883. 
 ■* Amer. Journ. Obstet., Aug., 1885. 
 
suiifwoLrrioy of riii: rrr.iirs. 0,39 
 
 — appeared in llic Aiimist miiiilici- <•!' llic Lniidnn (iml IjHiilm rt/li 
 Mdiif/i/i/ JoKnui/ (A' 1<S};5. Ill the .\(>vciiil)cr miiiiiIki" of thai Joni-nnl 
 Cor the same year is a pa|)cr IVoni liis pen in wliicli lie first calls atten- 
 tion |() >iil)inv(>liiii()ii iiiMJcr till' lit le " Tlie Morltid I'eniiaiieiiee ol" tli(; 
 State (if I'nerpeial 1 1 \|)ertrnpliy." In tlie ahoN'e-inentioiied artiele lie 
 inndcstly asserts liiinselC as the first in\-estii:at<»r in this field in the fol- 
 low iiiii" words : " This |)c(iiliar eondition does not ap])ear to lia\'e as yet 
 attracted the attention of" obstetric patiiolo^ists as the cause of one of 
 those forms of chroiii(; hv])oiiastric tumors that ai'c occasionally met 
 with diiriiiLi' the first weeks and months after deliNcry.' Then, as an 
 apology for his predi'cessor.s in the field of gyneeolotiv not havinji' Ween 
 able to reeognizi^ and describe so patent a disease, he continues: "The 
 want of any decisive means of recoo-niziiiu- it has doubtless led to this 
 omissiou." Tlie decisive means here referred to was the sound of his 
 own device, to which he ascribes the honor of discoverinj^ the character 
 of these so-ealletl "chronic hypogastric tumors," which were so fre- 
 quently noticed, and whose mysterious disappearance was either a puz- 
 zle to gyuecologists or attributed to the various remedies which were 
 administered for their cure. However, there are few gynecologists at 
 the present day who would invoke the aid of the uterine sound in diag- 
 nosis of this condition. 
 
 Immediately after the publication of the article mentioned many 
 observers began to investigate the subject, but, so far as can be ascer- 
 tained, nothing new^ was offered, and the disease was simply accepted as 
 a morbid permanence of puerperal hypertrophy. 
 
 In 1851, Dr. Snow Beck described, microscopically, the same condi- 
 tion in a paper read before the ^Medical Society of London, A])ril 12, 
 1851, but made no reference to Simpson's discovery in 1843. He sim- 
 ply called it " a new disease of the uterus." His paper contained an 
 account of the microscopic examination of a uterus from a woman who 
 had died a considerable time after delivery, which was found post-mor- 
 tem to be greatly enlarged. He says the uterine tissue did notappear 
 to the microscope to contain any inflammatory or abnormal dej)osit. 
 The muscular tissue appeared to hold a medium, position between that 
 of the impregnated uterus and the muscular tissue of the gravid organ. 
 He concludes as follows : " These facts pointed to the conclusion that 
 this aflfeetion had its origin in an arrest of the due absoi-ption which 
 naturally follows parturition." These conclusions may be said to be 
 the same readied, as to the etiology of the affection, by Simpson and 
 most subsequent observers up to the time of Dr. Beck's paper.' Indeed, 
 the reduction of the uterus after delivery was ascribed to fattv d(>oen- 
 
 ^ Since tlie woman from wliom this uterus was obtained died of typlnis fever, and 
 since tlie microscopic details are very incomplete, it is doubtful whether the case throws, 
 any light upon the subject of subinvolution. 
 
640 SUBINVOLUTION OF THE UTERUS AND VAGINA. 
 
 eration before Simpson's discovery, aud the general belief, that the dis- 
 ease was due to a deficient absorption, was quite natural. 
 
 Dr. Lever' refers to cases of defective involution as a " morbid per- 
 manence of the state of puerperal hypertrophy," aud quotes as his 
 authority Sir James Simpson's paper of the preceding year. 
 
 Simpson, in a note appended to a later edition of the paper referred 
 to, says : " Long after the above was written I met the following passage 
 in Dr. Hooper's work, which showed that the diseased state I had 
 noticed during life was known to him as a post-mortem appearance : 
 '■ When a foetus has been recently expelled, it is, in some instances, a long 
 time before the uterus returns to its original state, and it is larger and 
 softer during the period. I have examined uteri four times their nat- 
 ural size from this cause two months and even more after the foetus was 
 expelled.' " " He also, in a note appended to the same article, asks the 
 following fjuestion : "Is this disease alluded to in Kleinert's Bepertorium, 
 Band ii., 1838, S. 51, as described by Kopp under the name of hys- 
 teranesis in the first volume of Denkwurdigkeiten, p. 1 68 ? I regret to 
 say I have no access to this work." Thus it seems that Simpson him- 
 self would endeavor to disclaim his right to priorit}^ in the description 
 of the disease, but to us there can appear little doubt that the honor 
 of discovery belongs to him; at least he was first to describe the con- 
 dition in the living subject. He described and laid down rules for the 
 treatment which have been very little modified in forty years. 
 
 Dr. Fleetwood Churchill,^ who wrote on the diseases of women before 
 Simpson's time, describes, as do most other gynecic authors of his and 
 former times, an inflammation of the uterus. He probably is describ- 
 ing what Simpson observed and named subinvolution when, in recount- 
 ing the terminations which inflammation of the uterus may undergo,- 
 he says : " H^^iertrophv or induration, which appears to consist either 
 in a temporary enlargement, probably from afflux of fluids, or in a per- 
 manent auo;meutation of the tissues of the womb itself, which may thus 
 be vastly increased in size." He describes further the appearance of 
 such a uterus as follows : " If a section be made, the texture will be 
 more or less fine according as the induration is temporary or permanent, 
 and of a reddish or grayish color, the surface being smooth and uniform." 
 From this I think we are without doubt to infer that he had under 
 observation the condition of subinvolution, but he nowhere assigns a 
 defective reduction of the uterus as a cause ; neither, indeed, do I find 
 any evidence that he understood in any way the process of uterine 
 reduction. 
 
 Still earlier than Churchill, and quoted by him, Dr. Burns* recorded 
 
 ^ Guy's Hospital Reports, vol. ii. p. 18, 1844. 
 
 "^Morbid Anatomy of the Human Uterus, p. 5. ^ Disease,^ of Females, 1844. 
 
 ■* Quoted by Churchill, op. cit. 
 
srni.woi.rTinx or nii: rrr.nrs. on 
 
 uiuli'i' the U\\v ntiiiolli.s.si iiiciil a i'(»iulili(iii nl'tlic ulcnis w Iiicli must have 
 Ik'OM siil)iiiv<iliitit>ii. TIk' CnllnwiiiLi' Mfc \\]> uords: " SdriK-tiiiics as a 
 C'onsiHjiK'iicc of iiltriiic iiillainiiialiiiii iihuc or li.-s (li.~l iiid l\- iiiarkiMl, 
 but occasional I \' wiilmiii aiiv \cry distinct iiidication ul' uterine diseubc, 
 we find pari tn' tlic whole ol' tlie woinl) soi'tened an<l its substance very 
 easily lorn." 
 
 l)u|)ai"c([ue' has observed a condition of" tilings (K'scribed as follows: 
 ''The auto|)sv ol" females who have died of metritis shows the tissue; 
 of the Ulei'US swollen, reddi>li-biaek, soflelicd, IVial^lc ; the bhiod with 
 which it is en«>;or<:;ed is mixed with a puriform or serous Ihiid." It is 
 probable that these wore eases of defective involution of the uterus. 
 
 It seems, however, that none of the observers uj) to Sir James 
 Simpson made out the cause of certain enlarged uteri ^\■]lich they sjiw. 
 Althouo-li in En<2;land tliis disease has been recognized as distinct from 
 what has usually been called '* puerperal metritis" by continental 
 Avriters, with the exception of Courty,^ yet it seems to differ from the 
 chronic parenchymatous metritis of Scanzoni^ and the post-puerperal 
 metritis of C'liomel only in etiology. jNIost authorities have treated the 
 enlarged condition of the uterus found some time after parturition as 
 subinvolution or chronic metritis, and whichever view they have sup- 
 ported has been advanced to the exclusion of the other. Some have 
 held that the chronic metritis which they sustain is almost if not 
 entirely identical with defective involution. Others maintain that 
 there is a morbid })roeoss engrafted upon and due to the })re-existing 
 subinvolution which they call chronic metritis. 
 
 Mary Putnam Jacobi is not an exclusive partisan of either view, but an 
 advocate of both. She claims that subinvolution and chronic metritis 
 both exist and ai'e capable of clinical differentiation, and arc the results 
 of markedly diverse pathological processes. 
 
 Thus it is seen that owing to the confusion of terms and the absence 
 of unanimity on the part of those who have been considered authority 
 regarding the relations of these affections, clear conception has not gen- 
 erally been reached. It is not improbable that more accurate know- 
 ledge, and therefore better agreement of opinion, await us in the near 
 future. 
 
 From all that has been written upon the subject, ]>robably the cor- 
 rect inference is that there is an enlarged condition of the uterus remain- 
 ing after jiarturition as a result of defective retrogression, which has not 
 usually been ditterentiated, either clinically or microsco]>ically, from 
 enlargement due to some morbid process subsequently added to this 
 defective involution. Since this couditiou of enlargement arises from 
 
 ^Quoted by C'liurchill, op. cif. 
 
 ^ Di.«en.«es: of Uterus, pp. 594 et seq.: "Ovaries ami Fallopian Tubes," 1883. 
 
 ^ Op cit. 
 
 yoL. I. — tl 
 
642 SUBINVOLUTION OF THE UTERUS AND VAGINA. 
 
 causes so dissimilar in character, it is fair to presume that there are 
 diiferences in the conditions which have as yet escaped observation, and 
 there seems to be thus good ground for assigning different names to the 
 condition based on its etiology. For instance, it is proper to call that 
 enlargement due to defective reduction subinvolution, Avhile it would 
 be certainly irrational to call such a condition due to other cause by the 
 same name, even though we were unable to make any other than an 
 etiological distinction. But since the possibility of a clinical distinction 
 appears to be demonstrated, it would be wise to confine the term sub- 
 involution to defective reduction pure and simple, and to employ some 
 other term for this superadded pathological process ; and w'e cannot at 
 present do better than to call this state chronic metritis, not retaining 
 the phrase simply in conformity to fashion, but because we believe the 
 condition to be one of chronic inflammation. 
 
 HiSTOLOaY. — In order to a better understanding of the pathology 
 of the changes in the uterus in both normal and abnormal involution, 
 a brief study of the histology of the organ is necessary. 
 
 While the main points in the histology of the uterus are agreed 
 upon by authors, some of the minuter structure is still sub judice. 
 As a whole, the uterine walls may be said to contain five distinct 
 classes of elements : 
 
 1. Unstriped muscle-fibres of the highest order and in the highest 
 state of development. These cells vary in length from y^S"*-'^ ^^ ^^ 
 inch in the unimpregnated uterus to ^th in the gravid state. They 
 are for the most part closely interlaced with each other, and are arranged 
 in bundles or layers, united and at the same time separated by areolar 
 tissue. This areolar type of connective tissue is more abundant at the 
 outer part of the muscular walls. The muscular structure of the uterus 
 may be divided into three layers wdth reference to arrangement : 
 
 a. The outer of these is a thin stratum lying immediately beneath 
 the serous covering of the organ. The bundles of this layer are said to 
 arch across the fundus in a longitudinal direction, beginning at the cer- 
 vix, some passing into the broad and others into the round ligaments. 
 
 b. Internal to this is found another thin stratum of muscular tissue, 
 w4iich is in the posterior wall, from which its fibres run over the fundus 
 and sides of the organ, and ramify among the blood-vessels, which are 
 here most numerous. It is also in this portion that the nerve-structures 
 are most plentiful. 
 
 e. The innermost layer of muscle is probably the part of the uterine 
 mucous membrane which corresponds to the muscularis mucosse of other 
 hollow organs. It is much thicker than the other layers, making the 
 greater part of the uterine wall. The muscular portion of this muscu- 
 laris mucosse is so well marked as to make it distinctly different from 
 that portion of other mucous membranes, and to class it properly as a 
 
si'iiLwoLcnoy OF TJIJ-: utj-jju's. Gi;i 
 
 ])()rti()n of" tlio iiuisciiliir wall. Its lihrcs ai'c |)('('iili:irly an"an<;c(l as two 
 S[)liiiict('rs surrouiidiiiti' the ciilraiicc of the I'^illopian tiilx's, wIkisc most 
 external lihrcs iiitci-lai'c with each oilier al the aiilei'i(»r and posterioi- of 
 the Ciindus, while (hey chanti-e direction at the eervix in sneh a manner 
 as to run almost transversi-ly, lorming sphineters at the os internmn and 
 OS extormini. 
 
 2. 1 Tomot^-cneous or amorphous eounc('tiv(! tissue, which forms tlie 
 areolar tissue of the muscular ])art of the walls, being i'ouiid also in the 
 mucous mend)rane. 
 
 3. Fibrillar connective tissue, wliich assists in formint^ the susten- 
 taculum of the lymphatics, accordinti; to Leopold.' 
 
 4. Round, spindlc-sha|)ed, and irregular cells imbedded in the homo- 
 geneous tissue, which, according- to Thomas, are supposed to be element- 
 arv fusiform fibre-cells. 
 
 5. Yellow clastic tissue is found in small quantity in the mueous 
 membrane. 
 
 In addition to these elementary constituents, it also has an envel- 
 oping serous membrane, nerves, bloodTvessels, and lymphatics, and a 
 lining mncons membrane. During the gestative process the princij)al 
 change consists in a simple hypertrophy whereby the mnscle-cells 
 enlarge from nine to eleven times their former size. A numerical 
 hypertrophy is said to occur in the innermost layer during the first six 
 mouths of gestation. The arteries, nerves, and veins also increase in 
 size, and the structures of the mucous membrane participate in the 
 increase. The artei'ies are extremely tortuous in their course through 
 the uterine wall, and frequently anastomose with each other. The 
 arterioles break up into a fine capillary network near the free sur- 
 face of the mucous membrane. These capillaries form arches siu'- 
 rounding the mouths of the uterine glands and lying immediatelv 
 beneath the surface epithelium of the endometrium. The veins, which 
 are very large and sinus-like, are exceedingly thin-walled, and lie 
 immediately in contact with the muscular structure. According to 
 Leopold, the veins are not nearly so numerous as the arterioles in the 
 mucous membrane, although this predominance does not persist in other 
 parts of the uterine tissues. According to Jacobi, this extensive arrange- 
 ment of surface capillaries, curling arterioles, and tortuous arteries, with 
 the large and dilatable veins, tends to prolong the abode of the blood in 
 the uterine mucosa, thus conducing to growth of the endometrium in 
 menstruation and pregnancy. There is a subepithelial stratum of embrv- 
 onic tissue, consisting of round cells and free nuclei, without anv definite 
 arrangement with reference to the surrounding or imbedded glands and 
 vessels. According to the Hoggans,^ the lymphatics begin within this 
 tissue, directly under the surface epithelium, like the lacteals of a villus. 
 
 ' Arch. f. Gi/n., vol. xii. * Obsict. Transactions, London, p. 4, 1881. 
 
644 SUBINVOLUTION OF THE UTERUS AND VAGINA. 
 
 Between these csecal lymphatics and the epithelium of the uterine glands 
 nothinsi; intervenes. 
 
 According to LeopokP and De Sinety/ the lymphatics begin in this 
 subepithelial embryonal tissue as endothelial lined connective-tissue 
 lymph-spaces. According to both views, these intercommunicate, and 
 ultimately enter the subserous and periuterine lymphatics, and accord- 
 ing to either view they are left lying patulous at the end of parturition, 
 and to a less extent also at the end of menstruation. 
 
 Pathology. — The condition of the pathology of this subject is so 
 crude that Thomas Mn his last edition says of it: " The literature is 
 scanty in the extreme as yet, and the subject awaits extended researches 
 before we can speak intelligently of it." It is now four years since 
 this distinguished authority wrote these words, and to-day there seems 
 very little to change the conclusion then reached. 
 
 Hart and Barbour in an edition only a year old, as already cited, 
 say, in referring to chronic metritis, " We are not yet in a condition to 
 select a name resting on a sure pathological basis." 
 
 Jacobi (in August, 1885) says: "It should not be too difficult to iind 
 specimens of chronically subinvqluted uteri .... without the second- 
 ary connective-tissue change. But, so far, these do not seem to be 
 reported, and we are reduced to inference from the appearance of the 
 accessible portions of the uterus and from the clinical symptoms." 
 
 Indeed, although it seems a libel on our boasted investigation of the 
 past forty years, not much has been added to the pathology of this 
 subject since the last paper on subinvolution by Sir James Simpson. 
 He made the declaration that " this retrograde metamorphosis of the 
 uterus has not taken place during the puerperal month, Or has taken 
 place only to such an imperfect degree that the uterus is of the size 
 we usually see it at the end of the first week or so after delivery." 
 Without attempting a minute description of the pathological changes 
 and conditions to be found in such an organ, he says : " Subinvolution 
 is due to any arrest of the fatty degeneration or subsequent absorption 
 from whatsoever cause;" from which we are to infer that his idea was 
 that the microscope would disclose a general fatty degeneration in a 
 subinvolution of the uterus at any time during the existence of the 
 condition. Schroeder says that " arrest of puerperal involution is rarely 
 a pure hypertrophy, but a change in which the fatty degeneration occurs 
 normally, but absorption fails and new muscular fibres are not formed. 
 The wails are thick, soft, and flabby. The uterine tissue is grayish- 
 yellow or yellowish-red in color, very friable, and delicate mucous 
 threads, like spider-webs, stretch across the laceration." These words 
 are in Schroeder's article,* but are quoted from Klob.' Thus it would 
 
 1 Archivfiir GyndL, Bd. vi. ' Quoted by Jacobi, loc. cit. {Mai. des Fern., p. 256). 
 3 Op. cit., p. sis. * Ziemssen, vol. x. p. 73, 1874. ^ Op. cit, p. 128. 
 
suiu.w'nij'Tiox or 'nil', rrmtrs. 645 
 
 ;i|t|t(:ir dial his |»atlin|(iMv afcnrds in llic main willi Simpson's in inal<- 
 in"' the cnndition one of I'atlv dci^cncralitm. Il i.-- dillicnll to liarmo- 
 iii/r till' above description widi sonic later ol)scr\atioiis ol" l\loli on this 
 conilidon, c.\cc[>t 1>\- supposing;- thai lie is descrihin;;- a later .sta<^e of the 
 disease correspoiidiiii;' to chroiiic metritis, lie says: " The whole ute- 
 rine c(miieeti\-e tissue sometimes proliferates, either with accompanyin}^ 
 iiKirease of" the nniscular siihstaiici', or, if this does occur, the eoiiiiec- 
 tive tissue predoiiiiuates to such an extent that the muscular substance 
 is comparativelv ot" not much account." Later on he says: "The 
 newlv-loiMucd connective tissue is chiefly c()m[)ose(l of thin lihi'ils <lc- 
 liciiMit in nuclei, which cross the uterus in lines of various breadth in 
 all directions, I'orming- a coiiiplicated felt-like ne[\v(;i-k and constitutin;^ 
 the greater substance of the uterus. In the first stjiges of the disease 
 the muscular fibres are broader and hypertrophied, but at a later period 
 may be conij)letely lost in the proliferation of connective tissue." 
 
 After parturition the uterus rapidly decreases in size, until in four to 
 six weeks it has reached its former weiti'ht, or as nearly so as it will ever 
 do. This change is agreed to be the result of the fatty degeneration of 
 the nniscular fibres, with the subsequent absorption of this fat and its 
 partial voidaiice, together with the degenerated mucous membrane, by 
 way of the lochia. These are the means by which involution is secured. 
 During the period of gestation the work of the uterus has been chiefly 
 one of growth, -which has brought about the general muscular hyper- 
 troi)liy. 
 
 When labor begins the process of "growth is charged to function"^ 
 for the expulsion of the uterine contents. The venous hyperjemia, 
 which was sufficient for growth, has given place to the increased blood- 
 supply, which constitutes the arterial hypersemia of function. The 
 muscular fibres, which have so enormously increased both in number 
 and size, have up to this time been supplied with only blood enough to 
 maintain their growth and life, and have lain comparatively dormant. 
 At the beginning of labor the increased nutrition furnished by the 
 copious afflux of arterial blood stimulates these cells to their proper 
 function of contraction until the uterus is emptied. The continued 
 contraction of the muscular fibres cuts off much of the arterial su]>jdy, 
 and veuoiLs stagnation ensues to such an extent that even the nutrition 
 neeessaiy to the integrity of the cells is removed. Fatty degeneration 
 consequently occurs as an expression of this impaired nutrition. Xot 
 only are the large muscle-cells broken down by the fatty degeneration 
 of imjKiired nutrition, but also by that cellular change which occurs 
 from the increased oxidation resulting from the contractions of labor. 
 
 Fatty degeneration begins, according to Heschl,- about the fourth 
 day. It is seen, however, from the above, that the processes leading to 
 
 ^ Jacobi, Am. Journ. Obst., 1885. ^ Review in Arch, ck Med., 1854. 
 
G46 SUBiyVOLUTION OF THE UTERUS AXB VAGINA. 
 
 this condition commence witli the inception of labor. The fat, the 
 product of this change, is partly absorbed bv the general cii'culation 
 and partly escapes from the mouths of the open lymphatics of the 
 endometrium as a contribution to the lochia. 
 
 It is a well-known clinical fact that subinvolution of the uterus to 
 a greater or less degree is prone to occur in women who have suffered 
 from jDuerperal metritis, perimetritis^ peritonitis, or some other mani- 
 festation of septicaemia. In most of these subjects the lochia was 
 greatly diminished or completely suppressed. It is legitimate to infer 
 that in these cases the lochial suppression may bear a causal relation to 
 the subsequent subinvolution^ since so much of the degenerated uterine 
 tissue as would have thus been disposed of must remain or be eliminated 
 by other channels. Since there is no authority for considering subin- 
 volution a permanent fatty degeneration of the uteruus, inasmuch as no 
 investigator finds fat in any considerable quantity in such a diseased 
 organ, we are to infer that fatty degeneration has not occurred, or that 
 it has occurred and subsequently been absorbed or changed into the class 
 of tissue found in the subinvoluted uterus. 
 
 As has already been noticed, Simpson and Schroeder seem to be of 
 the opinion that the enlargement is due to unabsorbed fat in the uterine 
 walls when they say that the affection is due to interference with the 
 absorption of fatty degenerated muscular tissue ; but there appears to 
 be no microscopic authority for such conclusion. 
 
 Dr. Snow Beck^ found that "the enlargement of the organ was due 
 to the great increase of the round and oval bodies, with amorphous tis- 
 sue in the uterine walls as well as at the inner surface, which form the 
 soft tissue of the uterus, aided by an enlargement of the vessels." He 
 also found no relative increase in the amount of muscular tissue ; or, in 
 other w^ords, agrees w'ith Klob in the absence of muscular hypertrophy. 
 
 There is indeed room to doubt whether this was a pure and simple 
 case of subinvolution, for the patient died of typhus fever and her pre- 
 vious clinical history is not given. Jacobi thinks it may have been " a 
 round-celled infilti'ation of the uterus under the influence of typhus 
 fever." According to Jacobi's method of differentiating subinvolution 
 from chronic metritis by the depth of the uterine cavit}=^, the presump- 
 tion is in favor of the latter, for the cavity in this case was but three 
 inches deep, and she states that in subinvolution the cavity measiu-es 
 from nine to fourteen centimeters (3.6 to 5.6 inches). 
 
 Finn's observations^ are diametrically opposed to Klob, Beck, Scan- 
 zoni, De Sinet}^,' and all others, and make the diseased state due to 
 muscular hypertrophy and hyijerjilasia, claiming that the muscle-cells 
 are both increased in size and number. He also states that the con- 
 
 ^ London Obst Trnns., vol-, xiii. ^ Amer. Journ. Obstet, vol. i. p. 264. 
 
 " Oyncecol, pp. 315, 351, 1879. 
 
sriiixvoij'Tioy or the rrrnus. <>47 
 
 iioctive tissue is ri'hitivi'iy (limiiiislicd. Finn's report is on elironie 
 metritis, and subinvolution is not eonsidered, altliou<^li, sinee liis i-esulls 
 ditJ'er so manifestly iVom those of otiiers wlio have made pathohjgical 
 investiji'ations of uteri alleeted witli chronic metritis, it may be i)re- 
 sumeil that his ease was not that disease, l)ut some condition (x-'cupying 
 a j)osition between the muscular hypertropliy of the gravid state and 
 the connective-tissue liyperplasia of well-marked ciiroiiic metritis. 
 
 Jacobi thinks this description coincides with what we may infer from 
 the clinical symj)toms and the pliysical condition of the uterus iu sub- 
 involution, or as ''a first form of chronic metritis entirely distinct from 
 inflammation." Thomas accounts for the great diiference between Finn's 
 views and those of others^ in the time after parturition when the inves- 
 tigations were made, and says that he who examines early will prol)ably 
 find a greater amount of muscular tissue than he who does so later. 
 
 De Sinety, in treating chronic metritis, compares its stages and micro- 
 scopic pictures to those observed in hepatic cirrhosis — an early soft, 
 large, hyperremic stage, and a later hard, small, anaemic stage. He 
 says : ^ " Iu the first stage the dominant lesion is the presence in great 
 numbers of embryonic elements throughout the whole thickne&s of the 
 muscular walls. These elements are met with specially round the blood- 
 vessels or form islands of variable dimensions which are more or less 
 apart. The second period is characterized by two changes: 1, marked 
 dilatation of the lymphatic spaces; 2, a localized hypertrophy of the 
 connective tissue. The sclerosis, for such it may be called, differs from 
 a similar change in the kidney and liver in the fact that the formation 
 of the connective tissue is localized round the blood-vessels." He is 
 unable to say whether the muscular tissue was normal or diminished in 
 quantity. 
 
 Mary Putnam Jacobi ^ has made a very careful study of the uterus 
 of a woman who died eight days after parturition, in which she found 
 the muscular fibres either hypertrophied with nuclei indefinable and 
 disappearing, or smaller fibres with indistinct central nuclei, others still 
 smaller Avitli nuclei distinct, while a fourth variety without nuclei were 
 granular and contained oil-globules. In all these the feeble manner in 
 which the extremities of the filires took up coloring matter seemed to 
 indicate that the wasting of the cell l^egan in the protoplasm and 
 attacked the nucleus last. Among these fibres were nucleated con- 
 nective-tissue cells and amor])hous tissue. The blood-vessels and lym- 
 phatics were much enlarged and in immediate contiguity with the nnis- 
 cular tissue, which is markedly different from the perivascular condition 
 observed by herself and De Sinety in cases of chronic metritis. 
 
 The same author also details her own results from the examination 
 of the uterus in a state of chronic metritis, and her observations in the 
 1 Op. cit., p. 312. 2 Op. cit. ' Loc. cit. 
 
648 SUBINVOLUTION OF THE UTERUS AND VAGINA. 
 
 main coincide with those of De Sin6ty. She says : " The three promi- 
 nent lesions found in either body or cervix of the uterus in metritis are 
 — enlargement and multiplications of blood-vessels, dilatations of lym- 
 phatics, proliferation of scantily-nucleated connective tissue, chiefly 
 around both sets of nutritive canals, but also, to some extent, between 
 bundles of muscular fibres, and even within these bundles. In the 
 hypertrophied cervix this tissue has been found even to replace mus- 
 cular fibre to a considerable extent." 
 
 For such appearances as these to be derived from those found in a 
 uterus eight days after delivery she infers — 
 
 "1. That from the subinvolved uterus the ribbon-shaped fibres, as 
 also those filled with fat-granules and all the intermediate forms, 
 together with the cells and granules, finally disaj^peared. 
 
 " 2. That the lymphatic spaces and blood-vessels remained abnor- 
 mally large. 
 
 " 3. That the walls of the enlarged blood-vessels finally suifered 
 some structural alteration, in virtue of which nutritive transudations 
 of an albuminous plasma took place, which gradually caused a local 
 development of connective tissue (perivascular sclerosis). It is this 
 perivascular sclerosis which constitutes the cardinal difference between 
 a pure subinvolution and a chronic metritis grafted upon it." 
 
 The question as to whether this process, chronic metritis, is an inflam- 
 mation or not is very old and much worn. The authority just quoted 
 believes that it is ; and it certainly seems clear that the results of the 
 disease, as shown in the latest researches of the microscope, manifestly 
 place it in the category of inflammations. While the phenomena 
 observed in a uterus aifected by this disease do not wholly concur with 
 chronic inflammations in other organs, they certainly as nearly approach 
 such concurrence as might be expected when we consider the marked 
 difference in the structure of the uterus as compared with other organs. 
 The presence of the perivascular deposit plainly indicates diapedesis, the 
 essential point of agreement in all inflammations. Some injury to the 
 cement-substance in the vessel-walls sufficient to allow the egress of the 
 white corpuscles from the vessels has occurred. These elements have 
 been found to assume the same conditions seen in transudation-products 
 in other organs, notably the liver. The hypersecretion observed clinic- 
 ally in this affection and the wide lymphatic spaces of the mucosa sug- 
 gest that these, lying patulous in the midst of the transuded cells and 
 plasma, are constantly busy in absorbing the infiltration and discharging 
 a portion at least into the uterine canal. The hypersesthesia noted in 
 chronic metritis is a clinical symptom of inflammation. Martin of Ber- 
 lin, in his textbook published in 1885, describes chronic metritis as a 
 chronic inflammation of the uterus, although admitting some slight dis- 
 agreement between this process in the uterus and chronic inflammations- 
 
suJuwdLrrmx nr riii: i-n:i:rs. 649 
 
 c'lscwljcro. IIl' :il.s(» adduces, as addilimial cxidciifi- (if its iiillaiMinatorv 
 charucter, the lac^t thai it is usually accumpaiiicd l)y iuilauiniation ol" the 
 nmcosu juul serosii ol" tln' ulciiis. 
 
 It is a matter of iiuicli regret that alth()u;;li suhinvolutioii has had a 
 more or less disliuct |»lace amonj^ uterine diseases loi' over lorty ye;irs, 
 no |)atlioloi!;ieal tc!stiniouy reoardinjr the eondition (»!" I lie uterus alfeeted 
 with this a|)i)areutly iiei;ative disease has been oilered. Its antecedent 
 ste|) or condition, the histology of the post-i)artum uterus durin<^ regres- 
 sion, is I'airlv understood, and th<' j)atlu)l()<jjical condition, chrouie metri- 
 tis, wliicli is sometiines in some way su[H;rinduee(l or eiiiiral'ted upon it, 
 is now (|uite clearlv demonstrated. Consequently, the real [)alhology 
 t)f pure and simi)le subinvolution, a eondition holding a j)lace some- 
 wheri' between the normal post-partuni uterus and chronic metritis, is 
 reduced to the uncertainty of inference. 
 
 E'ri()L()(;v. — Considering the etiology of subinvolution from a patho- 
 logical point of view, we are yet more in the dark than in the pathology 
 itself. A study of the morbid anatomy has enlightened us regarding 
 its existing conditions to some extent, but offers little or nothing con- 
 cerning the initial pathological causes. Klob' tells us it is due to a 
 " formative irritation ;" which means nothing so long as he is unable 
 to t(>ll us Avhat the irritation is. The word cause would mean about as 
 nmcli as " irritation " in his definition. It is a definition which does 
 not define. He also assigns " habitual hyperpemia " as the cause of this 
 condition, which is rather a result of the ambiguous " irritation," or at 
 best a secondary cause. Habitual hypersemia undoubtedly is the initial 
 stage of the affecti(Mi, and thus stands in a causative relation to the sec- 
 oudarv stase — infiltration of the walls with embrvonic elements. 
 
 Clinically examined, the etiology seems to be better understood, and 
 nearly all etiology classifications are clinical in character. As the term 
 subinvolution implies, there is an impeded or retarded involution after 
 parturition ; but, again, from our conclusions on the pathology of the 
 subject, the process is not actual arrest of involution, but a pathological 
 process engrafted upon or coincident with uterine involution. " Habit- 
 ual hypersemia," " engorgement," '' congestion," are recognized condi- 
 tions in this malady at the outset, and thus, clinically, any cause lead- 
 ing to such conditions is a cause indirectly for their ultimate result, 
 which we have seen to be subinvolution. 
 
 Conditions leading to hypernsmia, engorgement, or congestion of the 
 uterus may be divided into constitutional or predisposing and exciting 
 causes : 
 
 1. Any constitutional state which is characterized by non-resistant 
 tissues, as tuberculosis, serofulosis. In such women reconstructive ])ower 
 is much lessened, and their ability to resist and avert pathological con- 
 
 ' Op. cit., p. 127. 
 
650 SUBINVOLUTION OF THE UTERUS AND VAGINA. 
 
 ditions and processes is defective. lu such a patient there is a great 
 lack of muscular power and nerve-force,„\vhich is marked as well in the 
 involuntary muscles and nervous system of the uterus as throughout 
 the voluntary muscular and nervous apparatus. Such are the so-called 
 albuminous or gelatinous types of body, which are characterized by a 
 low vitality, feeble circulation, hypersesthesia of the nervous system, 
 ilabbiness of the muscles — which ordinarily recover but slow^ly from 
 the eifect of parturition, and are liable to the puerperal maladies, espe- 
 cially such as depend on the feeble and unhealthy contractions of the 
 uterus after delivery. Here also the exhausting effects of lactation are 
 much more marked, and while, as will be seen later, it acts in healthy 
 women as a stimulation to the reduction of the uterus, in such cases it 
 is such an extreme draft on the vital powers as to render the system less 
 able to combat the tendency to this pathological process. 
 
 2. The weakening eifect of frequent deliveries. No one can doubt 
 the fact that cases of subinvolution are much more frequent in multi- 
 parse, and that the number of cases increases with the number of pre- 
 vious parturitions through which the patients have passed. Klob says : 
 " Frequently this proliferation of connective tissue is developed after 
 repeated deliveries in rapid succession." Such being the case, the cause 
 must be sought for in habitual hyjDersemia. Certainly, no supposable 
 condition of the uterus more nearly fulfils the requirements of habitual 
 hypereemia, engorgement, and congestion, noted as causal conditions, 
 than the gravid condition frequently rejjeatecl. Under such conditions 
 the power for complete muscular contraction is lost : subinvolution 
 becomes inevitable. 
 
 3. Blood dyscrasise, among which may be classed such constitutions 
 as are marked by ausemia, which is really one of the sources of the 
 diminished vitality and want of resiliency in the reparative processes 
 which is often among the predisjDOsing causes of defective involution ; 
 also, conditions of spansemia where the recuperative powers are lessened 
 by the loss of the oxygenating and repairing influence of the fewer 
 number of red corpuscles. 
 
 Exciting Causes. — 1. Of the exciting causes connected with par- 
 turition, probably none is more prolific in promotion of the conditions 
 leading to subinvolution than the pernicious habit of allowing puerperal 
 woman to abandon the recumbent posture too soon after delivery. It 
 is granted that in this regard no absolute time can be fixed as the proper 
 limit for all cases, since it cannot be denied that involution of the uterus 
 'occurs in much shorter time with some subjects than with others. 
 
 Notwithstanding the discrej^ancy of authorities on this point, it may 
 be safely assumed that in most cases involution is not complete under 
 six weeks ; nevertheless it is in most cases so far advanced at the close 
 of the second week that leaving the recumbent posture for short periods 
 
sriii.wnij'Trox or the rricnus. GoI 
 
 ol" tiiiK' cacli tla\-, with luodoriite exeiviso, will latlu r proiiuttc than 
 I'ctaid this procL'ss, as such h coufso will add to the (hccrruliicss of the 
 j>atii'iit, c'lismv a In'ttcr atinosjdu'iv, a lu-ltcr (•iiv-ulatioii, better appetite 
 ami di<i('stioii. ( )ii tlu' other hand, leaxini; the reeiiinbeiit posture while 
 the veins are still enlari;ed aiitl the uterus liea\y with fat will tend 
 toward the niaintenanee of the venous congestion and defeat the absorp- 
 tion of the fattily-degenerated uterine tissue. Sueli venous congestion 
 and iK'Heient absor|)tion of involution-products are the iirst stei)S in tiie 
 process ot" sul)involiition. No canonieal law can be established as t(» the 
 exact time for which the recumbent posture slionld l)e ol>served. The 
 proper time varies with each case, and must be decided by the clinical 
 phenomena in each instance. It is a good rule to keep the j)atient in 
 bed so long as the lochia rubra continue, as advocated by Lusk.' The 
 (•ontinuance of the lochia rubra is a clinical exjiression of such active 
 involution as is not consonant with the uj)right posture. 
 
 There is also little doubt that involution is not far enough advanced 
 even at this time to permit getting up with safety. Fatty degeneration 
 and absorption are not well performed until after the sanguineous 
 elements from the uterine sinuses have ceased to give the red tinge 
 to the lochia. This fatty degeneration and its coincident absorption 
 and discharge are not -vvell under way until the lochia alba apjjcar. 
 Garrigues^ believes that involution is not so well established as to war- 
 rant the upright posture until the uterus has receded from the anterior 
 abdominal wall and again resumed its position in the pelvic cavity. 
 
 2. Lacerations of the cervix uteri are among the most important of 
 the exciting causes of subinvolution. When there is a lacerated tissue 
 more blood is required to institute i-epair. In the lacerated cervix the 
 increased quantity of blood needed for healing the breach answers the 
 great requirement in the etiology of this condition — engorgement, venous 
 hypera^mia. As a part of the re])arative ])rocess, here as elsewhere, we 
 have the exuded plasma recognized as essential to granulative repair in 
 soft ])arts. Such transudation-products are, by inference, a partial source 
 of the uterine enlargement in defective involution, and thus in Nature's 
 attempt to restore the broken continuitv' Ave have for a longer or shorter 
 time a literal local subinvolution. Again, considering the fatty degen- 
 eration which is taking place in the uterus during involution, the process 
 of repair is greatly hindered. Tissues in a state of fattv' degeneration 
 are not in a favorable condition for union by granulation, nmch less for 
 union by first intention. Such cases will always shoAv a tardy involu- 
 tion, and in most cases a general subinvolution superinduced upon the 
 local injury. AVhen the ]>atient leaves her couch, even though long 
 after parturition, and involution is apparently conq)lete, subinvolution 
 
 ' Science and Art of Midirifenj, p. 255, 1885. 
 ^ Am. Journ. Ob.-'t., vol. xiii. p. 861. 
 
652 SUBINVOLUTION OF THE UTERUS AND VAGINA. 
 
 may be caused by the weight of the uterus pressing apart the partially- 
 united lips of the laceration. This is especially prone to occur, as 
 pointed out by Hardon/ where the rent has extended through the 
 cro^vn of the cervix and the sides of the tear are drawn apart by the 
 uterine supports. This deformity causes the uterus to sink downward, 
 everts the mucous membrane of the cervical canal, and makes the lace- 
 rated cervix to rest upon the vaginal pillar. Xot only does this posi- 
 tion induce venous congestion in the whole organ, but the same end is 
 fostered by the irritation of the cicatricial tissue, which is thus brought 
 into prominence between the separated lips of the laceration. 
 
 3. Endometritis as a localized source of engorgement stands in a 
 causal relation to subinvolution. The purely inflammatory form of 
 endometritis, as described by De Sinety, is probably chiefly associated 
 with chronic metritis, and accounts for the clinical condition of excessive 
 endometrial tenderness wdiich Jacobi has pointed out in chronic metritis. 
 The glandular and fungous forms of endometritis, as described by 
 Olshausen and Ruge, are the most frequent concomitants of subinvolu- 
 tion. The exact relations of these forms to subinvolution has not been 
 demonstrated, but since many cases of subinvolution exist without coin- 
 cident endometritis, and neither glandular nor fungous endometritis is 
 found without more or less subinvolution, it may be inferred that the 
 disease w'hich w^as primarily localized in the endometrium has led to 
 the general engorgement of the whole uterus and a consequent sub- 
 involution. 
 
 4. Neoplasms of the uterus may, either by the irritation set up in 
 their locality by their presence or by pressure checking the return floAV 
 from the uterine veins, lead to a congestion which shall be followed by 
 subinvolution. Such is the tendency of these growths even in the 
 absence of parturition, but in the greatly enlarged, valveless, tortuous 
 veins of the gravid uterus the tendency is greatly increased. 
 
 5. Tumors above and distinct from the uterus may so press upon the 
 vena cava as to lead to such mechanical compression as will increase the 
 tendency to venous congestion and subinvolution. 
 
 6. Chronic constipation may lend some aid to uterine congestion by 
 mechanical compression, and thus enroll itself among the exciting 
 etiological factors. 
 
 7. Excessive sexual intercourse has been frequently mentioned by 
 authors as leading to enlargement of the uterus in the non-puerperal 
 state. This has been chiefly alluded to as a cause for the condition 
 called chronic metritis. Scanzoni says^ he has seen the afi'ection in 
 filles puhliques. Now, if such an habitual hypersemia may be induced 
 in the nulliparous uterus by excessive sexual intercourse, how much 
 more potent a factor might such a practice be in the recently impreg- 
 
 ^ Am. Journ. Obst., vol. xiv. p. 557. ^ Op. cit. 
 
sriH.WnLCTinX t,F Till-: I'TF.nUS. 653 
 
 ii;it<tl nrL;:iii, wIium- ti»ii«s ai'c yt-t sticciilciii :iii<l vessels oiilar<r«'(| — a 
 coiiilitii>ii iiivitiim coii^rstioii ami tiiliamiiiti the >ii><'<|»til)ility to 
 «'ii<;uriii'iii('nt I 
 
 8. KctaiiK'il niriiiln-aiio, jHti-tioiis ot" j)lac<'iita, nr (li>tcii~i(iii i»(" the 
 uteriiK' cavitv l>v clots is coiiccdeil to stand in a causative relation to 
 tlii^ disease. Any lorei^^n hody, as the al)ov(', will exert a dist«'ndin<^ 
 influence which ineclianieally increases the iiody of the nteiiis and pre- 
 vents the normal action of the nuiscniar walls, either of" which leaves 
 the vessels larj^e and inll. Aside from the mechanical inHncnce of such 
 bcxlies in the litems, the septic conditions often induced lead to a flahhy 
 condition of the origan conducive to enu-or<fement, 
 
 9. J\)st-partum hemorrhage is i)roi)erly iissigned as a cause of this 
 disease. A. II. Simpson ' has noticed that superinvolution often fol- 
 lows post-partnm hemorrhage. iSueli a serpience is not strange when 
 we consider superinvolution a last stage in the j)rocess which has sub- 
 involution for its earlier condition; and those who make post-i»artum 
 hemorrhage a cause of subinvolution, and tliose who make it a cause 
 for superinvolution, are doubtless both right, though at ditterent stages 
 in the process. 
 
 10. Abortions mav l)e followed by this disease. Indeed, Atthill 
 claims,- and we think Justly, that abortions are more likely to be fol- 
 lowed by this malady than delivery at full term. He assigns the fol- 
 lowing reasons for this fact : The fatty degeneration of the uterus is 
 alreadv under way at the time of delivery at term, and thus leads to a 
 more rapid involution of the uterus. Again, the uterus is not so well 
 ])rejxired to undergo fatty degeneration Avhen growing rapidly. Prob- 
 ably reason for the frequency of subinvolution after abortion is also 
 found in the fact that women are prone to attach less import to an 
 abortion than a full-time parturition, and by insufficient care and too 
 «arly getting up bring about this disease, so that the trouble is here 
 really to be traced to exciting cause Xo. 1. 
 
 Galabin^ assigns as a reason for this frequency the fact that the 
 uterine mucous membrane, being unprepared for the separation of the 
 decidua, and often having been previously diseased, is more apt to be 
 left in an al)normal condition or with portions of the placenta still 
 adhering. 
 
 11. Displacements of the uterus are among the most commonly 
 assigned rauses of uterine subinvolution, l)ut a rational examination 
 of the subject will call such causes in question. There is probably no 
 subject in gynecology which has given rise to keener controversy than 
 the etiology of displacements. Xoliody seems entirely clear on the sub- 
 
 ' Trnn.f. Edinbnrffh Oh-^f. .Sbc, vol. viii. p 91. 
 
 ^ LoniKe Atthill, -1/e^/. Pre.%< and Circular, London, vol. xxxiii. \>. 41. 
 
 3 Midniferii, p. 341, 1886. 
 
654 SUBINVOLUTION OF THE UTERUS AND VAGINA. 
 
 ject, and everybody seems to have a view remarkably well established, 
 considerinpj the scarcity of accurate investigation. 
 
 The uterus is a mobile organ within certain physiological limits. It 
 is pressed downward by a full meal and with each inspiration, and an 
 engorged rectum or distended bladder presses it forward or backward. 
 Such movements, however, are but temporary, and the removal of the 
 cause allows the organ to return to its normal position by means of the 
 resiliency of its supports. It is difficult to say just where uterine 
 movement ceases to be physiological and becomes pathological ; but it 
 is safe to assert that such movements are never pathological until there 
 is some permanent pathological weakening in some of the supports of 
 the organ, or a pathological increase jn the weight of the organ whicli 
 leads in time to a similar change in its supports ; and only after such 
 weakening of its supporting agencies can a displacement occur as a 
 pathological condition. Thus the conclusion is reached that as a very 
 general rule all displacements are secondary, and due to some other 
 change or process in the pelvic viscera. Such conclusion at once 
 greatly decreases the importance of displacements as a primary cause 
 of subinvolution. Subinvolution is certainly more frequent, for in- 
 stance, in a retroverted uterus, but the retroversion is generally caused 
 by. subinvolution or some other previous pathological process. 
 
 It is more rational and in accord with the facts to consider displace- 
 ments amono; the results of subinvolution. When subinvolution occurs 
 in an abnormally placed uterus as a result of the change of position, it 
 becomes then a cause for further displacement, though not a primary 
 cause, and is one of the class of causes assigned by all writers which 
 increase the weight of the organ. Graily Hewitt refers all flexions to 
 softness of the uterine tissue, which is markedly the condition of the 
 organ in this condition, but it is not easy to suppose the flexion alone as 
 the cause of softness. In respect to flexions, Schroeder finds the etiology 
 in retraction of the cervix by the adhesions of peritonitis ; and Schultz,. 
 in cellulitis of the ligaments, wliich produces cicatricial contractions and 
 retracts the cervix. Meigs ^ finds the etiology of most versions in patho- 
 logical lesions of the ligaments. An intelligent appreciation and adapta- 
 tion of the facts w^ould seem to warrant the conclusion that displacements 
 are rarely a primary cause of subinvolution, but oftener the result of 
 that process, and that such cases as are said to be due to displacement 
 are in reality due to some antecedent condition which caused the dis- 
 placement. 
 
 12. Among the causes which should be assigned are those conditions,, 
 generally inflammatory, which have their first pathological result in 
 some uterine displacement, as peritonitis, cellulitis, lacerated perineum^ 
 rectal and vesical lacerations, and fistulse. 
 
 ^ Diseases of Women, p. 237, 1859. 
 
srnixvni.rrioy nr riii: i-Ti:nrs. 655 
 
 13. Dt'Hciont al'tc'r-paiiis liave Ir-cii crcdiU'd with a ••aiisil i-('lati(»ii to 
 this disease, but such I'datioii Is |)r(»l)al)ly (tidy iUiieil'ul. An (•\li:iii~ti\<' 
 oxainiiiatioii of tlu- tiiiu' and causes iiiHiiencing invohition l)y Ar. S<|-- 
 did<()tl ' h'ads hiiii to the eoiiehisioii that " after-pains are not in any 
 wav necessary to invohition/' Tliis conchision was based on his tiwn 
 observations and \\\v c.\i»hination of I^azarewitch,- which accounts for 
 after-pains by siipposinsj; tliat " when violent after-j)ains occur they are 
 in many cases to be considered as the violent contraction of tlie whole 
 womb, particidarly of its middle layer, in which run the blood-vessels 
 and the sensitive nerves: compression of that middle layer is indicated 
 by the painfulness of some after-pains." Such explanation does not 
 warrant the inference that the absence of such painful impressions 
 indicates a tendency to engraft this new pathological process called 
 subinvolution upon the process of normal involution. Indeed, it 
 seems fair to presume from the above explanation that severe after- 
 pains are an expression of a hypersesthetic, if not of a pathological, 
 condition of the middle layer of the uterus, which would rather indi- 
 cate a susceptibility or tendency to subinvolution than the reverse. 
 
 Diagnosis. — Subinvolution, from the definition of the term, presup- 
 poses one partin-ition or abortion at least, and nulliparity is the only con- 
 dition which would exclude this form of enlargement, although a con- 
 ilition practically identical may occur in a uterus w-hich has never been 
 impregnated. The diagnosis here, as in nearly all pelvic and uterine 
 disorders, cannot safely be made from the subjective symptoms alone, 
 since all are vague and none in any sense pathognomonic. Our con- 
 clusions as to the presence or al:)sence of this condition is based here, as 
 elsewhere, upon a careful examination and comparison of the symptoms 
 and physical signs. 
 
 Symptoms. — In most cases the patient's own history indicates that 
 her troulile began from a previous confinement, and that she has never 
 been perfectly well since. AVeakness of the back is one of the most 
 generally present symptoms, and often the cause of the patient's seek- 
 ing relief of her medical adviser. 
 
 Leucorrhoea exists to a degree depending chiefly on the extent of the 
 affection of the endometrium. The menstrual functicMi is irregular. In 
 some cases there is menorrhagia, in others amenorrhnea exists. These 
 symptoms indicate such a diseased state of the endometrium as unfits 
 it for the proper reception and nourishment of the fructified ovum, and 
 as a consequence sterility is the rule. Painful defecation often exists 
 from the pressure of the fecal matter in the rectum upon the enlarged 
 and tender uterus, while the play of the abdominal muscles in the same 
 act tends to the same end. Vesical tenesmus may exist from the pres- 
 sure on the bladder or from dragging upon that organ by the enlarged 
 
 * Traruf. Edinburrjh Obgt. &r., vol. iv. p. 59. ^ London Lancet, Xo. 7, 1S67. 
 
656 SUBINVOLUTION OF THE UTERUS AND VAGINA. 
 
 and displaced uterus. Dyspareunia is a normal sequence of the irrita- 
 tion of the engorged and hypersesthetic cervix. The menstrual func- 
 tion is usually in a condition of menorrhagia, or at best the periods 
 are more prolonged and frequent than normal. Dysmenorrhoea often 
 occurs, the resul$pef the physiological engorgement of the already over- 
 sensitive uterus, ^vmch leads to pain of more or less severity. It should, 
 however, be remembered that all symptoms depending upon local uterine 
 tenderness are not so well marked in subinvolution as in chronic metritis. 
 A history of repeated abortions will, when many of the above symp- 
 toms are appended, always lead to a suspicion of this disease, for 
 although this condition tends to sterility, yet when the endometrium 
 is not so aifected as to preclude the possibility of the fertilized ovum 
 being established in the uterus, it is often so diseased as to fail to bring 
 the gestation to full term, and abortion or miscarriage occurs. Indeed, 
 as has been noticed in connection with the etiology, subinvolution is 
 more liable to follow an abortion than a full-term parturition, and thus 
 lead to subsequent and repeated abortions, where it is the result of the 
 first and the cause of those following. 
 
 There are also certain other symptoms which at times occur and tend 
 to increase the difficulties of diagnosis by leading to a suspicion of preg- 
 nancy. Among these are nausea arising from an enlarged uterus and 
 engorged rectum, the darkening of the areolse about the nipples, and 
 pain and enlargement of the breasts from sympathetic disturbances. 
 Hemorrhoids are at times a secondary result of the slowed circula- 
 tion and constipation. Many and ill-defined nervous disorders and 
 manifestations are apt to arise, depending on the temperament of the 
 patient and the duration of the disease. 
 
 Physical Signs.— While the symptoms are vague and without 
 accurate diagnostic significance, the physical signs are very much more 
 valuable, and are the chief dependence in arriving at a sound conclu- 
 sion as to the presence or absence of the disease. A vaginal examina- 
 tion in this affection discloses a large boggy cervix, often lower than 
 normal, Avith os patulous, mucous membrane pouting. Pressure of the 
 cervix in any direction by the examining finger causes pain, more 
 marked when pressure is made in the posterior surface from the poste- 
 rior cul-de-sac ; pain under pressure, however, is not so severe as in 
 chronic metritis. The whole organ, except in cases where subinvolu- 
 tion involves the cervix alone, will be found large and heavy, and as 
 a rule freely movable. Hypersesthesia of the uterus is a frequent con- 
 comitant. 
 
 An examination is also at times followed by some bleeding from the 
 congested vessels of the cervix so imperfectly covered by the diseased 
 mucous membrane. The speculum will bring into view an enlarged 
 cervix, patulous os, and a congested, eroded, granular, or ulcerated 
 
svnisvoLVTioy of tiie uterus. 667 
 
 (rare) (•<iii(litiiiii of the niucoii- iii(iiil)iaiic. Often its an excitin*^ (siuso 
 a niorr <>r Ic.-s t;aj)iiiir lac(i"atit»M is seoii. If the case be of l<»n<^ stand- 
 in<j; the field nt" the hiciTation is apt to be filled with new tissue. 
 
 Ill makiiiu- a diauiiosis the intimate relation between laeeration of the 
 cvrvix and sul)involiition must not be for<j:;otten. The im{)ortauce of 
 laeeration of the i-ervix as an ('tiolo«!:ieal iactor has already l>ef'U j)ointe<l 
 out ill till' proper j)lace, and here it may l)e remarked that if a laeera- 
 tion of the eervix is oi)served, the diajxnosis ot" m<»re or less subinvolu- 
 tion either of the whole uterus or of the eervix alone is almost absolutely 
 eertain. Conjoined manipulation discloses above the enlarged and dis- 
 eased eervix the body of the uterus, enlaro:ed, more globidar, and less 
 ])vriform than normal, and often disj)laeed. It' the Ijody of the uterus 
 is not fouml to partake in the enlargement, the case is one of cervical 
 subinvolution alone — a condition relatively less frequent than chronic 
 inflammation of the cervix. 
 
 Valuable information is to be gaine<l from the use of the uterine 
 probe or s(»iind, which will be found to enter the uterine canal a dis- 
 tance of three and a half inches or more, depending upon the severity 
 or duration of the disease. It is well here to point out a jjossible source 
 of error first mentioned by Matthews Duncan,' where the sound by 
 entering an inordinately patulous Fallopian tube might indicate a much 
 greater depth than is real. Not only does the sound pass to a greater 
 depth tlian normal, but it is much more freely movable at its point, and 
 its introduction and manipulation often provoke rather profuse hemor- 
 rhage from the fuugosities of the endometrium. 
 
 DiFFEREXTiATiox. — Since there are some conditions Avith Avhich 
 subinvolution might readily be confounded, a few remarks on its dif- 
 ferentiation may be useful. It has some points of semblance to — 
 
 1st. Pregnancy. — It may be especially difficult to diiferentiate sub- 
 involution from early pregnancy in lactating women, since the latter 
 may occur without the recurresice of the catamenia, and subinvolution 
 at this time does not exhibit itself in the character of the menstruation. 
 Under .such circumstances the only safe course is to wait one or two 
 months for the development of the usual signs of pregnancy in a sus- 
 pected case. Chief reliance must be placed upon the progressive 
 enlargement of the uterus in pregnancy, whereas the enlargement of 
 subinvolution is stationary. The well-recognized change in the form 
 and consistency of the uterus, even in the early stages of pregnancv, 
 as disclosed by bimanual examination, may be of great service in ar- 
 riving at a diagnosis, but cannot be conclusive earlier than the tenth 
 Mcek, especially in fat subjects. Where pregnancy is suspected it is 
 needless to say that the sound as a means of diagnosis is not to be 
 employed. 
 
 ^ Edinburgh Month. Journ., 1S56, p. 1057. 
 Vol. I. — 42 
 
658 SUBINVOLUTION OF THE UTERUS AND VAGINA. 
 
 2d. Periuterine inflammations, which are indeed amoDg the conditions 
 leading to this affection, cause sensitiveness to touch and many symp- 
 toms common to it, and when suspected also preclude the possibility of 
 employing the sound with safety. Careful manipulation will disclose 
 their localized tenderness and the asymmetry of their enlargement, 
 while usually the cervix will be found normal in size and leucorrhoea 
 absent. The fixedness of the uterus is a very general condition in these 
 inflammations not usually marking subinvolution. Such inflammations, 
 too, give rise, as a rule, to some systemic febrile action which in no way 
 characterizes subinvolution. Moreover, the history of the case often 
 points to the sudden inception of the trouble in these inflammations, 
 instead of the insidious beginnings of cases of subinvolution. 
 
 3d. Neoplasms of various types lead to enlargement of the uterus. 
 The most frequent of these are the fibromata and myo-fibromata. Such 
 tumors often produce dragging sensations, pain in the pelvis and back, 
 leucorrhoea, menorrhagia, and many constitutional symptoms observed 
 in subinvolution. A vaginal examination usually shows a low or 
 displaced uterus increased in size. Where the growth has attained 
 such size as to cause the uterus to ascend out of the pelvic cavity, 
 there is no difficulty in diiferentiation. Careful conjoined manipu- 
 lation, however, generally enables us to make out the chief differ- 
 ential point, the unsymmetrical enlargement of the organ. The 
 growth in such cases will usually be found localized in one of the 
 uterine walls. 
 
 In confirmation of this localization the sound is of much value. 
 There will be little if any tenderness on pressure, and scarcely any 
 pain will be elicited by manipulation. The history will rarely date the 
 beginning of the trouble at parturition. The cervix in these cases does 
 not often show any enlargement. Some cases there are where the 
 enlargement due to a neoplastic growth is so symmetrical as to render 
 the diagnosis very difficult. This is chiefly the case where the growth 
 is intra-uterine or submucous. In such cases mistakes in the recognition 
 of the true condition are by no means uncommon. It is here that the 
 dilatation of the cervix and the exploration of the uterine cavity by the 
 finger or sound find the greatest field of utility. 
 
 A scirrhous cancer of the cervix, with its enlargement, hemorrhage, 
 and other symptoms, may simulate for a short time the condition of 
 subinvolution. Confusion is all the more likely because in the early 
 stage of scirrhus of the cervix there is usually but little pain. The 
 history, the presence or absence of cachexia, metrorrhagia, etc., will 
 assist in clearing up the obscurity. The test originated by Spiegelberg 
 is in this instance a valuable means of differentiation. He introduces 
 a tent into the cervical canal, and if the dilatation is ready and regular 
 and the cervical tissue softens, the carcinomatous character of the aifec- 
 
sri:iwni.rri().\ of tui'. rrr.iirs. (;:,!! 
 
 tii)ii is ruled i>iil ; while if llie e.iiial (lil:ile> >lii\\ In, and on diie sido 
 more tliaii aiiotlier, leaxiii^i llie eer\i.\ liaid and den~e, iliedi.-ea>e is 
 prc'snnial)Iv eaneeroiis. 
 
 CoiiriN,' ill I real iiiL!,' Ill" I he dillrreiiliarniii orane-icd insdhil ion, savs : 
 "There art' two |)iiiiei|)al charaeteiMsties which will aid in niakinji' a 
 (lia«;"n()sis and ^listill^'llishin^■ the arresi <»!' in\dliilioii from other kinds 
 of livpertrophv : l''irsl, the niiilorni softness of the uterine ti>.-iie, eoin- 
 hiiied with tlie red color and other characteristics of oeslative eon^^cs- 
 tion ; second, the extreme hixity of the lij;uinents, and eoiise<|nent tend- 
 ency to prolapse, or at least the indili'erence of ])osition or direetion of 
 the uterus." 
 
 4tli. ( 'Iiroiiic Metritis {Arci)l(ir JIijjjcrjAa.sia). — The <j;reatest ditliculty 
 will be met in ditVerentiatin^ subinvolution from ehronic metritis, since 
 in both the svmptoms and [)hysieal sit>;ns differ chieHy in detiree. In siil)- 
 involution the uterus is larger, softer, and less tender than in cjiroiiie 
 metritis, where, although enlarged, it is smaller and eompaiativcly liini. 
 In subinvolution the uterine [)robe enters to a de])th of three and a 
 half inehes or inore and causes considerable hemorrhage, while in 
 ehronic metritis it enters to a depth only slightly greater than normal, 
 exciting intense pain and usually followed by less hemorrhage. In 
 subinvolution the endometritis is mostlv of the fungous or glandular 
 variety — hypertro})hy of the endometrium — and consequently men- 
 struation is usually ])rofuse, but not so painful. In chronic metritis 
 the endometritis is generally of the embiyonic type, the mucous mem- 
 brane having largely desquamated and the vegetations consisting of 
 embryonic tissue similar to the inflammatory granulations Avhich foi-m 
 upon exposed wounds. Menstruation will consequently be markedly 
 painful, but not so profuse as in subinvolution. In subinvolution the 
 heavy, slightly sensitive uterus produces dragging sensations, but not 
 always distinct pain. In chronic metritis the inflamed and hypersensi- 
 tive organ leads to more or less acute suffering with various irradiated 
 pelvic pains. 
 
 Course axd Resui/fs. — As has been indicated under Pathology, 
 the tendency of this disease, untreated and nncomj^licated. is to the 
 establishment of chronic metritis, and later sclerosis of the uterus, the 
 so-called snperinvolution. The scarcity of observed and recorded cases 
 of superinvolution until recently would indicate that the disease is often 
 arrested in the state of subinvolution or in chronic metritis, or that the 
 condition of sujierinvolution has escaped observation. Botli these snp- 
 ])ositions are probably true, and the great nundier of cases of super- 
 involution recorded recently evidences the truth of the latter, for only 
 recently has the condition received much attention. It is also prettv 
 well established from abundant clinical evidence that the disease sub- 
 
 ' Op. cit., p. 506. 
 
660 SUBINVOLUTION OF THE UTERUS AND VAGINA. 
 
 involution is often checked^ and that treatment has often brought about 
 a restitutio ad integrum. 
 
 As to chronic metritis — which, according to our belief, is one of the 
 results of subinvolution — it may be readily understood that the source 
 of the trouble, proliferation and growth of embryonic elements, may 
 be stopped ; but how these elements, when organized, may be made to 
 disappear is not so readily comprehended ; and although clinical evi- 
 dence to the fact in abundance is not wanting, yet we have no micro- 
 scopic pathological investigations to attest it. 
 
 Subinvolution runs a very slow course, as is shown by the lapse of 
 time after parturition which often occurs before it is detected. The 
 uterus is often found to be in this condition many months or even years 
 after a parturition or abortion, and the history clearly indicates the 
 beginning of the trouble at the last confiuement. Hence no approach 
 to definiteness can be attempted in describing the course of subinvolu- 
 tion. Certain it is that the course is not uniform. 
 
 Chronic metritis is probably the most frequent termination of 
 untreated subinvolution. Superinvolution has been mentioned, but 
 properly comes on rather in cursu than as a sequel to the chronic 
 metritis. Sterility often ensues from the incapability of the endomet- 
 rium to properly receive and nourish the fecundated ovum, or abortion 
 ensues from its inability to maintain and support a healthy placenta. 
 The menorrhagia, pain, and attendant weakness tend to that chronic 
 invalidism so often marked by numerous and fitful nervous symptoms. 
 Dysphoria, occasional dysmenorrhoea, dyspareunia, menorrhagia, consti- 
 pation, vesical tenesmus, enumerated among the symptoms, are results of 
 this disease, any one of which may be sufficiently aggravated to demand 
 treatment, and indeed be the feature which will lead the careful prac- 
 titioner to a diagnosis of the underlying trouble. Displacements are 
 chiefly related to subinvolution as a result rather than a cause. If a 
 small healthy uterus, weighing a little more than an ounce, is liable to 
 fall or be drawn from its position, how much more a bulky, cumbrous 
 organ weighing one or two pounds ! 
 
 The atony of the uterine walls caused by this condition of engorge- 
 ment, as shown in a case reported by Kaschkaroff, tends in the third 
 stage of labor to retention of the placenta. 
 
 The probability of subinvolution in its late stages passing into carci- 
 noma or epithelioma of the cervix has been warmly discussed pro and 
 con by gynecic writers. Klob considers the views of the affirmative 
 illusory, and Thomas never saw a case. Noeggerath has written a 
 paper to prove that the tissue of such a uterus tends to the formation 
 of epithelioma, but no other recent author, so far as I know, sustains 
 his views. My own clinical experience furnishes several cases in which, 
 to my own mind, the relation between cervical laceration and a subse- 
 
sriusvoi.rrios of tite rrEnj\^. g61 
 
 (|ll('lltly i|('\('lii|tc(| cpillicliDiii;! Wd-f iiiiii|ili\ ncil, lull I Ii;iv<' iicvf'i' seen 
 a sin<;"li' case of cpilliclioiiia wliitli I llniimlil due Id >iiliiii\(i|iiti<iii. 
 
 Ti:i:A'i'.Mi:N'r. — It is <i,iTaily t<i the ric<li( of Sii- .lamo Siniji.-on that 
 tho methods of trcatiiniil riii|)|o\ cd l)\- liim inniKdiatcIv on tlic disrov- 
 (TV of the disease arc ii-cil at the pivsciit lime, aii<l that hut t"e\v addi- 
 tions to the therapeutic uica>in'c> inaugurated l»y him have," heen made. 
 It is rather strauiie that while he believed the disease iiiHammatorv in 
 character, and addressed his ti-eatnient accord injijly, nearly all ^•yiHioolo- 
 ijists since have rejected his \ic\\s as to the cause, hut retain his inethods 
 and means of treatment, includiuii- <>eneral as well as local agents. 
 
 Thomas' does not call the tliseixse inflammation, hut he says: " Do I 
 myself not hlistci-, ;i|)ply leeches, and even am[)utate the cervix in these 
 cases? I blister lii^htly to exert an alterative influence on the nerves 
 for the relief of coincident congestion. I blister occasionally as I 
 would for hyperajmia elsewhere, and I amputate as I would for enlarged 
 tonsils." 80 woidd Sir James Simpson, .Scanzoni, Henry Bennett, and 
 Chomel ; and they considered it an inflammation, and indeed treated 
 other inflammations in the same way. Here as elsewhere we encounter 
 that incomj)rehensible " inflammation," which seems a veritable patho- 
 logical chameleon, taking its color peculiarly and faithfully from the 
 tissue wherein it rests — now forming the plastic bands of pleuritis, now 
 the white opacity of keratitis, now the pus of cellulitis, and again the 
 fibrous bands of hepatitis, and so on ad infinitum. 
 
 All treatment hjoking to the cure and cheek of this disease is, by the 
 agreement of most authors, addressed to the congestion or engorgement 
 of the uterus. This is admitted to be an underlying condition indi- 
 cating the course of treatment, and being at the same time its object. 
 
 For convenience the treatment is divided into prophylactic and 
 curative. 
 
 Prophylaxis comprehends such measures as tend to prevent the occur- 
 rence of the diseased condition. In this interest labor should not be 
 allowed to last so long, when it can be safely shortened, as to greatlv 
 weaken the recuperative powers of the system or bruise the parts into 
 a congested condition, since debility leads to feeble uterine contractions 
 after labor, and thus to deficient expulsion of blood from the Avails of 
 the organ and contraction of its vessels. The engorgement and atonv 
 of the j)arts from prolonged pressure and contusion are literally a begin- 
 ning of the disease which an enfeebled general condition may be unable 
 to thwart. 
 
 When conditions demand it, therefore, partial anaesthesia with forceps 
 delivery should be ado])ted. Zealous care and skill should ]»revent as 
 nearly as possible laceration of the cervix and pcrineiun, among Avhose 
 numerous sequelae subinvolution very often occurs. In short, everj- 
 
 ' Loc. cit., p. 317. 
 
662 SUBINVOLUTION OF THE UTERUS AND VAGINA. 
 
 thing which obstetric science and skill can afford for securing safe and 
 easy delivery should be employed. The binder is a useful means of 
 promoting and maintaining uterine contraction, but if too tightly applied 
 may cause retroversion of the yet engorged uterus, and thus indeed per- 
 manence of engorgement or subinvolution. The patient should not be 
 allowed to maintain pelvic congestion by leaving the lying-in couch too 
 soon, neither should she defer proper exercise so long as to discourage a 
 healthy pelvic circulation. After the fifth day she should move about 
 in bed and change posture frequently — change from dorsal to lateral 
 decubitus. Constipation will engorge the local pelvic circulation, and 
 its attendant tenesmus in defecation will aggravate the same condition, 
 and also cause too great a pressure on the enlarged uterus, and should 
 be avoided by the proper methods. The use of ergot for some days 
 after delivery to assist in securing and maintaining suitable uterine con- 
 tractions is generally approved. Quinine is also advised for the same 
 purpose. While much injury is often done and this disease established 
 by too early rising from the parturient couch, there is no doubt that the 
 opposite extreme is productive of evil consequences. After the proper 
 time (see remarks on Etiology) has elapsed, and the patient has had no 
 contraindicating symptoms, cautious and healthful exercise should be 
 advised to secure vigorous action of the general circulation and promote 
 tissue-change, with removal of waste material and a consequent demand 
 for food. There is little doubt that the prevalence of subinvolution 
 and other pelvic diseases may be partly traced to the indolent life led by 
 so many women in the wealthy classes. Sexual intercourse among such 
 is in no way abridged to concert with their general inactivity, and this, 
 with the monthly engorgement of the uterus by the catamenia, leads to 
 a pelvic congestion entirely out of proportion with the enfeebled general 
 circulation due to aimless indolence. Better rules as to exercise, with 
 moderation in sexual indulgence, should be enjoined. Galabin ascribes 
 much of pelvic congestion and its kindred ills to our modern sumptuous 
 upholstery, which conduces to this condition by making the pelvis 
 assume too low a position when sitting. 
 
 Retention of parts of placenta, membranes, or clots should be 
 avoided as an important preventive measure. It is especially import- 
 ant to guard against placental adhesions and retention, when we remem- 
 ber, as has been pointed out by Mary Putnam Jacobi, that the point 
 of adhesion or the irritation produced by a portion of retained placenta 
 may prove the site of a localized subinvolution. This localization of 
 the disease tends to induce general subinvolution of the whole uterus. 
 
 Antiseptic lotions and vaginal injections, as prophylactic to puerperal 
 diseases when indicated by special symptoms, will also be useful in pre- 
 venting subinvolution, since such diseases often pave the way for this 
 condition. Since subinvolution of the uterus is a disease of raalnutri- 
 
sri:i.\\(>i.rri(>.\ or riii: rii:i:rs. m:\ 
 
 tioii, allliDiiLih |)('i'li:i|)s ti( iicrallv (lc|)('ii(liiit upon local ('aiiscs, llicrc can 
 l)(' IK) (|iicstioii thai it is not un(Vc(|iicnti\' (lie rc-nll of ocncrallv lowered 
 vitality, an en feel) led state oj" the m(.|||.|-;i1 hcalt li, to w hidi certain w unien 
 arc |»articiilarly prone alter each partnrition. ( arefnl attention slionid 
 tliercloiH' l)c <;i\'en lo (he u'eneral health and proper conslil ntional meas- 
 ures enip|o\t(l. l'!.-pecial care is to lie enjoined ill WOliieii -iilijcct to 
 al)(>rtioiis ; which, I ly t lie w ay, ill I lew ill "> opinion, iiieaii> w omen alll'dcd 
 with uterine llexions. 
 
 C'uratix'c treatment is thai applii'd lo the di>ea>e when it is foiind 
 atK'ctinii; the uterus, and is chielly addressed, as has been said, to tla; 
 I'liH-orii-emeut of" tlie uterus. It cudjraws means, niechanical or thera- 
 peutical, whose near or remote effect is the decrease in tiie ainoiini ol' 
 blood in the uterine tissue. For the sake of clearness it is well to 
 divide these means into eoustitutional and local. 
 
 Constitutional treatiiieiit is liere, as in most pelvic diseases, of <i-reat 
 imj)()rtanet' at all times, hut the deg-ree of its importance ^vill dejieiid 
 largely upon the eoudition of each patient. A ease of subinvolution 
 in a healthy woman, due, for instance, to laceration of the cervix, will 
 not tiemanil mueii if any attention to the general health, while in u 
 weak, nervous woman with flabby, non-resistant tissues it becomes of 
 paramount importance, and is much more conducive to cure than is 
 local treatment. 
 
 First among the agents for coustitutiontd therapy are mineral and 
 vegetable tonics. Among these iron is especially indicated where there 
 is antemia, and menorrhagia is not an important symptom. Mercury in 
 the form of the bichloride is recommended in small doses over a lono; 
 period for its tonic effect. The mild chloride is also of great value. 
 The salts of iodine and bromine are very generally used by gynecol- 
 ogists. The iodide of potassium is indicated where there is an indica- 
 tion for promoting the absorbent system, while the bromide of potassium 
 is supposed to have an especial field of usefulness where it is desirable 
 to diminish the functional activity of the uterus. 
 
 Scanzoni recommended hip-baths containing combinations of bromine 
 and iodine, with vaginal injections of a similar character. .Vrscnic is 
 given as a stomach tonic here as in other diseases where such remedies 
 are indicated. Strychnia is much used from its supposed ability to 
 impart muscular tone to the abdominal and ]>clvic viscera. Ergot is 
 reconimcndcd for its action on unstriped muscular tissue. Theoret- 
 ically, it ought to do good, but after repeated trial I have but little con- 
 fidence in it for these cases. Quinia is given as a bitter tonic to "l)ring 
 about a better state of the mucous membrane of the stomach, whatever 
 that may include" (Xiekles), and thus increase the demand for food 
 and the assimilation of it. The mineral acids arc chiefly indicated from 
 the stomach symptoms, and thus are used as tonics to increase the gen- 
 
664 SUBINVOLUTION OF THE UTERUS AND VAGINA. 
 
 eral nutrition of the body. When the general nutrition is poor and 
 little food is taken or assimilated, cod-liver oil plays a useful role, act- 
 ing both as a food and as a tonic, leading to an increased demand and 
 absorption of other food. The various mineral waters are recommended 
 for use in their proper spheres, and baths of the same character are of 
 utility in this disease by building uj) the general health. The writer 
 has witnessed decided benefit from cold sponging of the entire body 
 every morning before the patient dresses. In most cases it is better 
 that the patient use the sponge without an assistant. Hewitt thinks 
 that the waters at Kreuznach have a special adaptation in the bromides 
 and iodides they contain. The same kind of waters are found at the 
 Triton and Union Springs, Saratoga. 
 
 It is probable, however, that the chief benefits obtained from such 
 waters consist in the change and rest for those who perform household 
 duties, and activity for those who lead lives of idleness at home. More- 
 over, absence from home avoids sexual excesses, of so much injury in 
 these cases. ' 
 
 Local treatment is divided into therapeutical and operative. 
 
 1st. Therafpeutical. — The therapeutic agents employed are mostly 
 irritants or caustics, and are either alterative, stimulant, or absorbent 
 in their effects. The cervix may be painted with iodine to secure the 
 alterative and absorbent effect of that drug. When the fundus of the 
 uterus reaches above the pelvic brim, Scanzoni suggests painting the 
 abdomen with tincture of iodine. Collodion and acetic acid for its 
 blistering effect on the cervix, as employed by Aran, is highly recom- 
 mended b\' Thomas, who uses it by applying several coats to the cervix 
 at stated intervals. It is followed in ten or twelve hours by a free dis- 
 charge of serum, which has the desired depleting effect on the engorged 
 organ. Scanzoni also employs for counter-irritation iodide of potassium 
 and glycerin. Simpson applied to the uterine canal, with his sound 
 wrapped with cotton, various irritants and caustics. Nitrate of silver 
 has been extensively used within the uterine cavity in these cases, and 
 has been followed by very satisfactory results. Carbolic acid, combined 
 with tincture of iodine, applied to the interior of the uterus, now has 
 greater favor among gynecic practitioners than any other agent. It 
 goes without saying that medication of the interior of the uterus is 
 not to be attempted unless the canal is sufficiently large to permit a 
 return flow and free discharge. 
 
 For severe cases Lombe Atthill^ carries ten grains of ciystallized 
 nitrate of silver into the uterus, and lets it dissolve in the cavity. The 
 same plan was carried out by Sir J. Simpson. In milder cases solutions 
 of tannic or gallic acid may be applied to the interior of the uterine 
 canal. Courty suggests that we may provoke the uterus to hypertrophy 
 
 ^ Diseases Peculiar to Women, p. 83 ei seq. 
 
si'JU.\V')LCTi'K\ OF Tin: riFiirs. Ofj-j 
 
 l)V means of local trcatiiiciit, and tlicn take advantage <)(" tin- tiiiilcncv 
 ot" [lie (»r«;an l<> nnih-i'LiK fatty dcuencratiftn and involntion. 
 
 To tlie };i"annlar ero>ion of the {ci-n i.\ wliidi is oiten seen in llii> 
 disease, and to nleeration, rarely seen, various means of aj)j>lieatioii are 
 in vo;jjiie. Vaginal injections of hot water at a temperatni'e of Irom 
 100° to 110° F. prove \'eiy \aUial)le in ijic treatment of tlii> condition. 
 To he availal)le, however, the nuilioil is important, 'i he injection 
 sh(»idd i)e _i;iven with the patient in the recnml)ent postm-e, with the 
 buttocks l)roui:;ht to the eilge of tlu; bed, and so placed that the outHow 
 will wet neither her clothinjj;- nor the beddin*^. At least three i;alIons 
 of water shoukl be used at each session. A fountain made by ase of a 
 wooden bucket and hose with faucet w ill answer every purpose. The 
 stream should not be lari:;e. The patient should invariably remain in 
 bed for at least an hour after the irrigatiou. Indeed, it would be better 
 that it be giveu at bedtime, so that she can remain in betl for the night. 
 This treatment should be employed once daily. In cases where vaginal 
 })acking is employed it is good [>ractice to place the packing in the morn- 
 ing before the patient arises from bed, allow it to remain during the 
 day, and its removal at night to be followed by the vaginal irrigation. 
 To Emmet will the profession be ever indebted for the emphasis he has 
 given to the use of hot water in treating pelvic congestions and inflam- 
 mations. Anhydrous glycerin in pledgets of cotton applied to the cervix 
 will, by abstracting water, greatly deplete the over-full vessels. Glycerin 
 with tannin or boric acid makes one of the most useful local applica- 
 tions, combining the dehydrating influence of the glycerin with the 
 astringent power of the acid. The vagina should be thoroughly 
 packed, especial care being taken to fill all the culs-de-sac. 
 
 A\'heu the cervix is much ulcerated or decidedly granular the caus- 
 tics are generally used. Ulceration, however, is extremely rare. Xitrate 
 of silver, caustic potash, potassa cum calce, or chromic or nitric acid 
 may be applied according to the severity- of the case, A general observ- 
 ance of the rule, to begin with the milder and use the stronger caustics 
 later, if necessaiy, is the best method of practice. In these cases, as in 
 all others, should nitrate of silver be employed, its well-known tendency 
 to harden and cicatrize the mucous membrane of the cervix and con- 
 tract the OS must be cautiously guarded against. Xo local applic-ation 
 will so speedily cure non-specific erosion or ulceration as the solid nitrate 
 of silver. But the conditions of induration, cicatrization, and contrac- 
 tion resulting from its indiscriminate use are deplorable, all the more so 
 because incurable. 
 
 The importance of electricity as a means of therajw in this disease is 
 at last well established. In simple subinvolution the faradic current is 
 to be emj^loyed alternately with the g-alvanic. In such cases " both the 
 muscular and vascular elements require contracting, and the circulation 
 
666 SUBINVOLUTION OF THE UTERUS AND VAGINA. 
 
 needs stimulation in order to hasten the normal retrograde metamor- 
 phosis. Therefore the faradic current is especially indicated." ^ When 
 the disease has passed into the second or inflammatory stage, chronic 
 metritis, electrolysis is indicated by means of the galvanic current." 
 The writer has had frequent opportunity of testing the value of this 
 method of treatment. 
 
 Mechanical Treatment. — When there is displacement aggravating the 
 disease the first step in treatment will always be its correction by the 
 proper manipulation and support by pessary or other device. 
 
 Local therapy is nearly useless when a marked version or flexion 
 exists which leads to a bending and compression of the vessels so as to 
 keep up the engorgement. When a pessary cannot be borne the patient 
 should rest in a suitable position as much as possible, while local treat- 
 ment is addressed to the engorgement and its consequent tenderness. 
 Tampons of cotton saturated with tanno- or boro-glyceride, so placed as 
 to assist in correcting the displacement, will also, by their dehydrating 
 and astringent influence at the same time, reduce congestion. Heavy 
 or tight clothing always tends to aggravate displacements and should be 
 avoided. The corset should be worn very loose, or, better, entirely 
 abandoned, while skirt-supporters should transfer the weight of the 
 skirts from the waist to the shoulders. 
 
 Operative Treatment. — When the cervix is large, tense, and congested, 
 scarification or the application of leeches is advised by all authors, though 
 now very rarely resorted to in actual practice — not because it is an irra- 
 tional means of depletion, but because it is not fashionable. Depletion 
 is the manifest object of all treatment, and certainly no means is a purer 
 depletion than this. We have already expressed the belief that lacera- 
 tion of the cervix is the most common cause of subinvolution. When- 
 ever, therefore, this condition of the cervix is found, it should be removed 
 by trachelorrhaphy at the earliest practicable moment. The influence 
 of the operation upon subinvolution is frequently very striking. The 
 writer has noted many cases where not only the subinvoluted uterus 
 and cervix have been reduced to normal size and form within a few 
 months, but the so-called reflex nervous symptoms, together with 
 uterine catarrh, metrorrhagia, etc., have vanished. 
 
 In this connection it is proper to state that it has been for many years 
 the writer's custom, should metrorrhagia, menorrhagia, or even marked 
 uterine catarrh coexist with laceration of the cervix, to use the blunt- 
 wire curette immediately preceding the trachelorrhaphy, usually after 
 the patient has been anaesthetized for this operation. There can be no 
 question that the influence of this procedure should be considered as 
 partly promoting the highly satisfactory'' results above referred to ; all, 
 
 1 MuBde, Am. Journ. Obst, 1885, p. 1252. 
 
 ^ Franklin H. Martin, Journ. Am. Med. Assoc, 1886, vol. vii. p. 67. 
 
scni.woi.rrioy of thi: r.i^/.v.i. 607 
 
 tliorcfbrc, should not he ;illi"il)Uti'«l t»» the li:i<'li(l<iiili:i|)|iy. The wi-itcr 
 has ill aiintlicr piihlicalinn ' expressed ilie opiiiioii, luuiided upon a l:ir;:;e 
 elinieal experience, lliat in a ease where eiirettinii is indicated it inav l»e 
 done at the same sittiii}^ with tiachelorrhaj>hy without in an\' dcjj;ree 
 increasing- its I'isks. This ininninitv iVoiii daiiLicr iiia\' l»i' parlK' <hie to 
 the deph'tion iVoni trachelorrhaphy. 
 
 \\ (• inn>t not he understood lus rccoinnieiidin^- the curette on I v in 
 cases where a (U'^ree of hicerati(»n of the cervix I'xists (U'inandinj; tra- 
 eliehtrrhaphy. The use ol" the etirctte is jnstitied wliero there is exten- 
 sive tk'ii'eneratinii of the eiidoiiictriiini a> c\iiice(I l)v inctrori'hagia, 
 inenorrhaiiia, or uterine catarrh. ( )l'ten tlie ch-ansiii!:; (»f the en(h)niet- 
 rinin hv the removal of villous or t"un<z:<>i<l <i'rowths, and the eonse(pient 
 irritation set ii]) l)y such an opei-ation, will had loan active process in 
 the uterus which soon eifects a cure of the underlyiuu- suhinvcjlution. 
 
 The practice of ami)Utatinn- the cervix in suiiinvolution and chronic 
 metritis, as extensively followed in (ici-many and to a limited extent in 
 this country, is to he mentioned only to he condemned. We fnllv 
 eiiiUn'se the foUowing language of Dr. Egbert PI. Grandin : " \\C have 
 yet to see the ease of subinvolution where amputation of the cer\ix for 
 the sole purpose of diminishing the size of the Ixxlv was in the least 
 called for."' This practice is also condemned in the .strongest possible 
 language by Emmet. 
 
 During the past eight years, both in hosj)ital and private practice, the 
 writer has demonstrated the value of removing a wedge-shaped piece 
 from the cervix and closing the rent with sutures, as in trachelorrhaphv, 
 both in sul)involutioii and chronic metritis (areolar hy])erplasia\ when 
 laceration of the cervix did not exist. If a sufficient amount of tissue 
 be removed and the sutures properly introduced, the results are fre- 
 quently quite satisfactory. I always allow the incised surfaces to bleed 
 freely before placing them in apposition, in order to produce as much 
 depletion as possible. This practice is strongly commended bv 
 Grandin.^ 
 
 An ingenious modification of this procedure, by which the same end 
 is securefl without incision of the vagiiial mucous membrane of the 
 cervix, is practised by Dr. Ellwood Wilson of Philadelphia. 
 
 Subinvolution of the Vagina. 
 
 Subinvolution of the vagina is that condition of the organ when 
 post-partum regression has failed and the canal remains much larger, 
 more flabby, and less contractile than normal. 
 
 NoMENCLATT'RE. — This condition as an entitv has no literature. It 
 
 > Tmm. Am. ^M. .Ix.sor., 188-1. 
 
 * Review " Handbuch der Frauenkrankheiten," Am. Journ. Obst., July, 1886. 
 
 ^ Loc. cit. 
 
668 SUBINVOLUTION OF THE UTERUS AND VAGINA. 
 
 has had but little recognition as an underlying or complicating condi- 
 tion in the affections of the vagina following and incident to partu- 
 rition. Such treatment as it has received at the hands of writers has 
 been directed to those accidental deformities which are either the causes 
 or the results of subinvolution of the vagina. Accordingly, it has been 
 called " rectocele " when the posterior vaginal walls became unduly lax 
 and pouted at the vulva. If that part of the vagina forming the floor 
 of Douglas's pouch gives way and the intestines descend into the sag- 
 ging pouch, it is called an " enterocele." When the anterior wall gives 
 way through lack of tonicity and support and presents at the vulvar 
 cleft, it is called a " cystocele." When the M'hole canal is in a condi- 
 tion of ectropion it is termed '^ prolapsus vaginee." When the exciting 
 cause is in the descent of the uterus through the lax and patulous vagi- 
 nal canal, the resulting condition of the vagina has been at times called 
 " inversion." 
 
 In whatever part of the organ the weakness of the canal is most 
 evident, as manifested by the deformity which gives a name to the 
 disease, the underlying pathological condition is subinvolution of the 
 vagina. 
 
 In addition to these expressions of the locus minoris resistentice, there 
 are. found cases where the whole canal is loose, flabby, and patulous, with 
 marked absence of normal tonicity, following a parturition, and usually 
 associated with subinvolution of the cervix or uterus, or both. These 
 cases are frequent. They have usually received no name, but are cer- 
 tainly typical examples of subinvolution of the vagina. Indeed, these 
 are the cases generally overlooked in the search for or treatment of 
 uterine disease. Most frequently the patient either does not realize 
 the condition, or neglects it until the condition declares itself more 
 distinctly in the form of cystocele, rectocele, or prolapsus vaginae. 
 
 Pathology. — The vagina partakes in great degree in the changes 
 which prepare the reproductive organs for parturition. Its muscular 
 tissue is largely increased by a physiological hypertrophy. Its blood- 
 supply is largely increased, as shown by the change in color which 
 occurs during pregnancy. The marked fulness of the circulation is 
 also shown in the " vaginal pulse " mentioned as a sign of pregnancy, 
 also distinctly recognized during attacks of acute cellulitis. The va- 
 ginal papillae become engorged and enlarged as a result of the nutrient 
 activity in the organ, and at times a papillary vaginitis is lighted up, 
 possibly from the venous congestion which ensues from pressure in 
 later gestation. Also, the connective tissue is increased in quantity 
 and its lymph-spaces are enlarged and engorged, making the whole 
 organ softer and more distensible. In the last weeks of pregnancy 
 the congestion renders the whole canal oedematous and stimulates the 
 mucous follicles to increased secretion. This secretion is sometimes so 
 
sr/.'/.vrn/. /'vvo.v or riii: r.u./.v.i. GG9 
 
 in-ol'iix' tlint ill.' |i:iti(iil, if >lic liiis licai'd the I nidilioii, savs slie is 
 losiiiii' her milk. 
 
 The siil)iMiicniis areolar tissue heeomes es|)eeiallv a'doiualous, and at 
 times the «edeina so diiiiiiiislies its tonicity that the deseeiidinj;- heail 
 |)iishes the iiiiieoiis iiieiiihraiie in front of it dnrln::- lalior l)\- de-irovin^- 
 tile areolar altaehnu'iit hetween the Jiiiieoiis nienihrane and the siihja- 
 eent stnietiires. WJien such an accident occurs siibiiivoliilirtn is almost 
 cortain to follow. It is |»roi)al)ly ti'ue that this injury is rarely detected 
 at the tiuie of its occurrence. 
 
 DiH'iuij; j)re«;-uancy there is a pure li\|)ertro|tli\- (tf all the vauiiial 
 tissues. The va>:-inal walls are leni;tliene<l, as >li(»\\n l)\' the fact that 
 while tlie uterus is higher than normal, and the ruj^te even more 
 marUed than usual, tlio nuiet)tis menil)ranc is often seen slijjjhtly jiro- 
 lapsed at the vul\:i duriiit;- latter pregnancy. That its calibre is 
 incivased is seen l)y the ease with Avhich the fiu<>;ers, or even the hand, 
 may be introduced, Still, its contractility is evinced by its ability to 
 expel the placenta when it has been discharged into the canal by the 
 uterus. 
 
 Felhnving pai'turitiou the vagina is reduced to its normal dimensions 
 by the i»roeess of involution. This process is probably similar to that 
 which reduces the uterus — a fatty degeneration of its hypertrophied 
 elements. When this regression fails or is only partly attained from 
 whatsoever cause, the vagina is left loose, flabby, and non-resistant. 
 This is the state of subinvolution. The particular result of this subin- 
 volution will depend chiefly upon the cause and extent of the condition. 
 
 No investigation has been made to show the pathological histology 
 of the relaxed vaginal walls in a ])ure subinvolution ; and here, again, 
 we are reduced to the uncertainty of inference. From the increased 
 amount of tissue in the organ, greater than normal and leas than at 
 parturition, we are to infer that the hypertrophied muscular fibres have 
 not all been removed. Like\vise, the lack of muscular tone or func- 
 tional ability of the muscular fibres lends color to the inference that 
 the sluggish circulation causes such inefficient nutrition that the fibres 
 are incapable of normal or functional activitv. 
 
 Etiology. — The causes of sul)involution of the vagina are mostlv 
 the same in kind, though differing in degree, as those producing sul)in- 
 volution of the uterus. 
 
 To those conditions wliich bring about sul)involution of the uterus 
 by maintaining ])clvic congestion directly or indirectly the origin of 
 subinvolution is chiefly to be referred. In addition to these causes, 
 already recited, may be added subinvolution of the uterus, which from 
 the intimate association with the uterus and vagina, cspeeiallv bv the 
 middle muscular coat, and the intimate relations of the blood-supplv, 
 will readilv induce a coincident congestion in the vai2:inal walls. 
 
670 SUBINVOLUTION OF THE UTERUS AND VAGINA. 
 
 The most importaut factor in etiology is injury to the perineum and 
 pelvic floor. These injuries may be divided into — 1. Simple lacera- 
 tions of the external perineum to the sphincter ani without injury to 
 the vagina. Such accidents are not so productive of vaginal relaxation 
 as is generally supposed. In feeble women these may lead to some 
 degree of congestion in the vagina, and thus act as an exciting cause 
 of subinvolution through enfeeblement of the general health. 
 
 2. Lacerations of the external perineum with the pelvic floor, in- 
 cluding the fascia and levator ani muscles in the median line. In such 
 injuries the subinvolution of the vagina is induced by the absence of 
 its chief supporting agency, the levator ani muscles with their strong 
 enveloping fascia. The vagina is a loose shut sac extending downward 
 and forward. Its chief support is the pair of levator ani muscles, with 
 their fascia, meeting behind and below, by which " drawstring " the 
 vagina is slung up to the anterior pelvic wall. These nmscles thus 
 directly support the posterior vaginal wall, and it in turn supports the 
 anterior wall and bladder. When this support is removed by lacera- 
 tion, the posterior wall relaxes and pouts forward as a rectocele, to be 
 followed at times by descent of the uterus, cystocele, and prolapsus 
 vaginse, in order as a result of the subinvolution produced primarily 
 by the injury to the pelvic floor. 
 
 3. When the laceration of the integumentary perineum reaches 
 through the sphincter without injury to the levators and their fascia, 
 more or less subinvolution is the result, although the amount of the 
 disease and the resulting deformity are not so rapid in their appearance 
 nor so marked in their extent. 
 
 4. When injuries No. 2 and 3 are combined, subinvolution of the 
 vagina occurs speedily, and is followed by the conditions noticed as 
 sequelae of No. 3. All that was said with reference to the arrest of 
 involution consequent upon the vascular hypersemia which is set up for 
 the purposes of normal repair of the uterine cervix after laceration is 
 equally applicable to lacerations of the vagina or perineum. 
 
 5. At times, and probably more frequently than is generally sup- 
 posed, there is separation of the opposite halves of the levator ani 
 muscle at their median raph6, without any integumentary or mucous 
 laceration. As a result, the attached ends of the. muscle on each side 
 are drawn forward, leaving the posterior vaginal wall unsupported, 
 except by the flabby mucous membrane and the sagging tissues of the 
 perineal body. In such cases the posterior vaginal wall drops forward 
 and downward, followed by the rectum, constituting a rectocele. The 
 same condition ensues when the levators suffer lateral submucous rup- 
 ture, except that when the lateral laceration occurs well forward, and 
 the median portions of the two muscles remain posteriorly to stiffen the 
 posterior vaginal wall, the anterior wall will suffer first, the cystocele 
 
srj:i.\\<>Lrri().\ or riii: r.u./.v.i. G71 
 
 talvinu' precedence miiiom^- the xa^inal defuniiilii s |)ni<liicetl 1)V lli<' 
 ivsultiiii;- siil)iiivitluli()ii. 
 
 Since each oiie <»(' the va^iiial ilefurniil ie< mhmiI ioiicd pi-exioii-lv ils a 
 sec()n«lar\' resull nf iiijurio to llie |icriiiiiiiii and pelvic lloorwill be 
 treated in their appr(»|)riale places hy other cdnlriluitors to this work, 
 thev will be disniisst-d from further consideration here, althonirh in our 
 discussion of the surt»ieal treatment ap[)roi)riate to subinvolution these 
 deformities must necessarily be fre(piently mentioned. 
 
 6. Those; cases where general subinvolution of tlie va}i;ina occurs :ts 
 a result of the traumatism done to the parts during labor, without 
 either rupture or laceration of any of the structures or supports of the 
 vagina. 
 
 Over-distension of the canal as a result of a long laboi' in (eel)le pa- 
 tients may so destroy the tone of the parts that the venous eongestion will 
 not be overcome by the process of involution. The fatty degeneration 
 will occur only to a limited extent, and by removing some of the mus- 
 cular fibres, whose loss will not be compensated by the new fibres which 
 should take theii ])laces in the process of re})air, will leave the canal 
 loose and flabby without contractile power. The relaxed vagina, desti- 
 tute of such muscular structure as by its contraction tends to drive out 
 congestion and promote fatty degeneration, is in a condition fiivoring 
 further congestion and maintaining its own relaxation. In time the 
 condition simulates atrophy of the vagina in the feeble functional power 
 of its muscular elements. 
 
 Not only may such a condition arise from over-distension of the canal 
 during parturition, but it may arise as a maintenance of congestion and 
 deficient involution, due to any of the causes recited under Subinvolu- 
 tion of the Uterus, although it does not always accompany the latter 
 condition. 
 
 Excessive sexual intercourse, indejiendent of parturition, will lead to 
 a condition of vaginal relaxation ])ractically the same as subinvolution 
 of the vagina following parturition. There is not here, however, the 
 antecedent element of nuiscular hvpertrojihy which marks changes in 
 the vagina as uniforndy as in the uterus during ])regnancy. The 
 vagina does not return to its normal size and tone until from eight 
 to twelve weeks after jxirturition, and sexual intercourse before this 
 time is always at the expense of proper involution. It should therefore 
 be positively forbidden. 
 
 Treatment. — Prophylactic measures are here important, cliief of 
 which is the ]n'evention of the traumatism of parturition. AVhat has 
 been said in this respect regarding ])ro])hvlaxis of subinvolution of the 
 uterus is equally true in regard to the same condition in the vagina. 
 Indeed, so ftir as relates to lacerations of the vagina and ]>elvic floor, it 
 is more important here than in subinvolution of the uterus, since in 
 
672 SUBINVOLUTION OF THE UTERUS AND VAGINA. 
 
 these injuries involution of the vagina is more directly impaired than 
 that of the uterus. 
 
 Every procedure indicated l)y the highest obstetric skill, lof>king to 
 the prevention of injuries to the cervix, vagina, or perineum, is prophy- 
 lactic of subinvolution of the vagina. When, however, injury, un- 
 avoidable or otherwise, does occur to the perineum, it should, receive 
 immediate surgical repair. 
 
 The same is true of the vagina. Immediate surgical repair of the 
 cervix has not yet received general sanction, although it has been pro- 
 posed in several quarters. In most instances such a procedure is, for 
 obvious reasons, impracticable. 
 
 Dr. Ellwood Wilson, in a paper read before the American Gynecolo- 
 gical Society in Sept., 1886, reports excellent results from the applica- 
 tion of nitrate of silver to the freshly-torn surfaces in cases of lacerated 
 cervix, the union being prompt, thus leaving no chronic processes favor- 
 ing subinvolution of the vagina. 
 
 In all cases of perineal traumatism where, from any cause, the pri- 
 mary operation for repair was not successful, the secondary operation 
 should be done within a few months, at farthest, belbre the necessary 
 influences inducing subinvolution have been operative to a permanent 
 degree. The same course should be followed in cases where the pri- 
 mary operation was neglected. The above remarks as to time apply 
 equally to operations for laceration of the cervix. 
 
 Not only are the same operations, above referred to, prophylactic of 
 subinvolution of the vagina, but the same procedures, done at a later 
 period when subinvolution already exists, are frequently more promptly 
 and efficiently curative than all other measures. 
 
 The constitutional treatment, including medicines, baths, exercise, air, 
 and diet, most appropriate in the treatment of subinvolution of the ute- 
 rus is equally applicable in the same condition of the vagina. The 
 reader is therefore referred to the foregoing remarks upon that subject. 
 
 Local treatment is of signal value, and should be employed in much 
 the same manner as detailed in the topical vaginal treatment of sub- 
 involution of the uterus. In using the depleting powers of glycerin 
 and the astringency of tannin and boric acid in this disease, not only 
 should the tampons be applied to the cervix in the upper part of the 
 canal, but the entire vagina should be loosely filled with pledgets of 
 cotton well saturated with anhydrous glycerin, boro-glyceride, or tanno- 
 glyceride. Topical application of tincture of iodine to the vaginal 
 walls and vault three or four times per Aveek is often very beneficial. 
 
 Electricity. — What has been said upon the use of electricity in sub- 
 involution of the uterus must be emphasized in the treatment of sub- 
 involution of the vagina. Indeed, it is the most important agent in 
 the treatment of cases not requiring surgical aid, and may sometimes 
 
suiiiwoi.rriox of the vacisa. 673 
 
 propt'i'lv siipplciMciit cnscs wliiili \\\\\v Ikch MiiLii<"illy trcMtcd. 'I'Ih- 
 i;-alvaiuc ciii'i'ciit al(»lH' sliniiM lie ii>t'(l wlicii the disease is coiiliiicd (o 
 till' vagina, with oiii- |)<»lt', tlic iiciiativc, in the va<;ina — the otlier, the 
 j)o.sitiv(.', in the (nrni of a Hat clcttrodc, ii|)iin the anterior alxluniiiial 
 wall. It is also well at tinie< to apply a ecntle enrrent tlirou^li the 
 posterior vaginal wall, plaeiiii;- one pole, the negative, in the vajxina, 
 and the other, the po,-iii\c, in the reetiun. The current should never 
 l)e so strong;- as to he j)ainl'nl, and the api)lieation should continue tor 
 \cn to fifteen ininules ahout three times ])er week. A current of low 
 intenslt\- and hiriic <|Uantity is always the most valnahle in such con- 
 ilirions. I'ropei'iv and patiently applied, no a^cnt is moi'e useful than 
 lialvanisni in stinudatin^- the ahsoi'hent process and hastening involution 
 in the slutiiiish circulation of a ilahhy vai2;ina. 
 
 In emplovino- ualvanism to the vagina in subinvolution the following 
 general rules shoidd he observed : 1, never use a current so strong as 
 to be painful ; 2, in the rare event that the organ is tender and i)ainful 
 use the positive pole, the anode, internally; 3, otherwise use the nega- 
 tive pole, the cathode, internally, since the catalysis induced by it best 
 promotes the absorbents ; 4, avoid the cauterization sometimes caused 
 by the negative electrode by having its metal exposure clothed Avith 
 chamois-skin. 
 
 During the employment of galvanism, as well as at all other times 
 in the treatment of this disease, the vagina should receive copious 
 irrigations of hot water daily, more especially just before the patient 
 retires. 
 
 The judicious use of a pessary is often valuable treatment, especially 
 when there is some uterine descent increasing the congestion of the 
 upper part of the vaginal canal and rendering the vessels more tor- 
 tuous. In such cases a pessary Avill sustain the uterus, removing its 
 pressure, and slightly stretch the vagina, straighteuiug its canal, thus 
 overcoming the congestion, which promotes subinvolution. 
 
 Surr/ical Treatment. — When the disease is due to vaginal traumatism 
 the only recourse lies in surgery. When the deformity of the anterior 
 wall amounts to a condition of cystocele, the integrity of the part may be 
 secured by Emmet's, Sims's, Stoltz's, Dieffenbach's, or Reamy's operation. 
 
 The writer has practised for several years an operation for this con- 
 dition which has given him better satisfaction than any other, a descrip- 
 tion of which was published in the Philadelphia Medical News for 
 Aug. 8, 1885. 
 
 In cases where there is a rectocele or prolapsus of the ])osterior vagi- 
 nal wall, some one of the operations for narrowing the vagina is indi- 
 cated. Prominent among these procedures are the operations of Eiumet 
 and Sims. 
 
 When the rectocele is associated with more or less laceration of the 
 
 Vol. I.— 43 
 
674 SUBINVOLUTION OF THE UTERUS AND VAGINA. 
 
 perineum, both conditions may be cured by the same operation. In 
 this field choice may be had among the procedures of Simon, Hegar, 
 Martin, and Fritsch, all of which combine the dual objects of repairing 
 the perineum and lessening the calibre of the vagina. In the injury 
 to the levators spoken of by Emmet as destruction to the " drawstring " 
 Emmet's operation should be performed. 
 
 When prolapsus of the uterus exists the operation resorted to for its 
 cure also corrects the subinvolution of the vagina. The operations pro- 
 posed for this condition are the same in kind as those devised for recto- 
 cele combined with perineal laceration. The writer in cases compli- 
 cated with prolapsus uteri has met with most success in an operation 
 upon the posterior wall similar to that already mentioned as performed 
 by him for cystocele.^ 
 
 This operation is especially useful in narrowing the vagina at its 
 upper part just below the cervix, at the same time thickening the pos- 
 terior wall in the same situation, and finally restoring the perineum. 
 
 In all the foregoing cases restoring the existing deformity proposes 
 involution secondarily in two ways : First, by restoring more nearly to 
 the norm the direction of the blood-vessels and lymphatics, and remov- 
 ing undue pressure which has resulted from changed relation of parts. 
 Second, depletion, removal of tissue, with union by first intention, pro- 
 mote lymphatic absorption, the removal of subinvolution-elements. 
 
 1 See Phila. Med. News, March, 1887. 
 
PERIUTERINE INFLAMMATION. 
 
 IJv laCIlAUl) \i. MAl'UV. M. I)., 
 Mkmi'His, Tknn. 
 
 Defixitiox. — This terra is used to designate the different forms of 
 inflammation which modern research has shown to originate in the soft 
 tissues of the true j)elvis in woman — the tissues lying outside the rec- 
 tum and bladder and adjoining the uterus, ovaries, and tubes. Inflam- 
 mation is often discovered in the tissues immediately adjacent to the 
 uterus as a result of some lesion of its structure, and may not extend 
 beyond this locality. On the other hand, from a greater lesion a more 
 destructive inflammation may arise, and extend into the broad liga- 
 ments, or even beyond the limits of the true pelvis, so that in conse- 
 quence of such extension there may result an abscess in the iliac fossa 
 or in the cellular tissue behind the pubes, or there may be a purulent 
 collectitMi in the peritoneum, the outlines of which will rise consider- 
 ably above the brim of the pelvis. To both these conditions it seems 
 quite proper to apply the term " periuterine." 
 
 Abundant auto])sical evidence can now be adduced to prove that two 
 distinct forms of periuterine inflammation may exist, each entirely inde- 
 pendent of, and separate from, the other. To these inflammations 
 have been given the names, according to the tissues involved, of pelvic 
 peritonitis and pelvic cellulitis. To those circumscribed inflammations 
 aifeeting the cellular tissue and the peritoneum immediately adjoining 
 the uterus Virchow gave the names of parametritis and perimetritis. 
 
 History. — It has been claimed by some distinguished antiquaries 
 that the ancients had a respectable knowledge of these affections. After 
 a careful review of wliat has been written, I know of nothing to prove 
 that the ancients had anv intelligent ideas concernino; the real nature 
 of pelvic inflammations. Acute observers as they were, it was impos- 
 sible that they could fail to see that the puerperal woman was often 
 attacked with an inflammation in the pelvis, that not unfrequently sup- 
 puration occurred, and that the abscess discharged itself through the 
 vagina, the rectum, or at some point on the cutaneous surface in the 
 neighborhood of the uterus. Yet when we read the work of him who 
 has always been cited as the foremost of the ancient gynecologists, 
 
 675 
 
676 PERIUTERINE INFLAMMATION. 
 
 Archigenes, whose teachings on " Abscess of the Uterus " have been 
 handed down to us by Oribasius and by Aetius, we are forced to the 
 conclusion that he had no knowledge of the tissues involved, or of the 
 cause or of the proper treatment of these inflammations. 
 
 It has been reserved for the physicians of modern times to truly 
 investigate and to elucidate this subject, as far as our positive know- 
 ledge of it goes. One of the first contributions which should attract 
 our attention is the work of Puzos of France, " Memoire sur les Depots 
 laiteux," published in 1743 as a chapter in his Traite des Accoiiche- 
 ments. His view of the nature of pelvic exudations Avas that they 
 were simply the result of a metastasis of the milk. He locates these 
 " milky deposits " in the iliac fossa, under the skin and the fat, and 
 between the muscles and the peritoneum. " The most important are 
 lodged in the cellular tissue of the peritoneum, in the broad ligaments, 
 or in the ovaries." ^ 
 
 JSFo important advance was then made until ] 843, M'hen Professors 
 Doherty of Galway and Churchill of Dublin published their view^s in 
 the Dublin Journal of MecUcal Science, the former under the title of 
 " Chronic Inflammation of the Uterine Appendages occurring after 
 Parturition ;" the latter under that of " Inflammation and Abscess of 
 the Uterine Appendages." Doherty pointed out some of the most 
 important signs of pelvic inflammation which are to be recognized by 
 vasfinal examination — "the hardness which is tender to the touch, and 
 as firm and inelastic as a deal board ;" also the fixation and displace- 
 ment of the uterus, which is bound down to the affected side. Both 
 these men clearly dedared the occurrence of exudations close to the 
 uterus and within the limits of the true pelvis. Both considered the 
 subject simply as pelvic inflammation. Neither undertook to discuss the 
 tissues involved in different forms of inflammation. 
 
 The next important contribution to which our attention is directed is 
 tlie work of Marchal (de Calvi), entitled Des Abees jihUgmoneux intra- 
 pelviens, in 1844. The chief advance made by Marchal is in showing 
 that puerperal and other abscesses are often located within the pelvis. 
 Yet he does not simply describe them as intrapelvic: he goes farther 
 and specifies the different tissues involved in the inflammation. Thus 
 from autopsical evidence he declares the existence of — 1, abscess of the 
 subperitoneal cellular tissue; 2, abscess of the subaponeurotic space; 3, 
 ovarian abscess; 4, intraperitoneal abscess. He also recognizes the dif- 
 ficulty of distinguishing during life abscess which is the result of a cellu- 
 litis from those purulent deposits which arise from inflammation of the 
 pelvic peritoneum. 
 
 As time advances we find arising differences of opinion in regard to 
 the tissue usually involved in pelvic inflammations. Thus a very able 
 ^ On Parametritis and Perimetritis, by, J. ]\Iatthews Duncan, 1869, p. 14. 
 
K'nofjx.y. 077 
 
 obsciAcr, Ail^ii-lf Ndii.Ml, ill l.S.">() insisted lli.it llic iii(l;iiiiiii;itin y >\\ill- 
 ino>4 ill tlif |)('1\ is were all located in iIh' cclliilai' tissue, and that tiie 
 |K'rit()Meiuii w.is iKil iiiNolved. To tlie>e swclliiiiis lie ai»[)licd the term 
 "periuterine |»hlei;iiii)n." M. IJernutz, on the nther hand, in a reniark- 
 al)le series of investioutions, to be noticed at leiiiitii in another j)Iuee, 
 demonsti-ati'd that the pelvic iuHaniniations coinin»i,- inulei- his observa- 
 tion occniTcd at the expense of the pelvic peritoneum, and that the 
 (H'lJnlai- tissue was usually not to auy degree invaded. He acknow- 
 ledi;-es the oxisteneo of phleijinons of the broad ligaments, but adds 
 that " they ought to be studied with plilegmons of the iliac fossa, of 
 wliicli they are a very interesting variety." 
 
 8ubse([uent writei-s have leaned to one or the other side of this con- 
 troversy, being influenced to some extent, perhaps, by the weight of 
 authority or else drawing their conclusions from the character of 
 the clinical material furnished by the limited field of their own 
 observations. 
 
 In 1868, in .1 Practical Treatise on the Diseases of Women, Dr. T. 
 Gail lard Thomas presented this subject in what I believe to be its true 
 light. From clinical and post-mortem observation Dr. Thomas accepted 
 the teachings of Bernutz. He moreover acknowledged the independent 
 existence of two distinct forms of pelvic inflammation, which he described 
 as periuterine cellulitis and pelvic peritonitis. He declared that while 
 they frequently coexist, they are entirely distinct from each other; that 
 they may usually be diiferentiated ; and that an effort at thorough diag- 
 nosis should ah\ays be made. He furthermore formulated rules for a 
 differential diagnosis. 
 
 During the same year this work was followed by the well- 
 known treatise of Dr. J. Matthews Duncan On Perimetritis and 
 Parametriflx. This author likewise recognized tAvo distinct forms of 
 periuterine inflammation, and also the importance of distinguishing 
 them ; and while he rejected the attempt at diagnosis made by Dr. 
 Thomas, he acknowledged our indebtedness to that writer " for even 
 attempting the difficult task." Since that time accumulated observa- 
 tion ha.s served to make perfectly clear the truth of the jn'opositions 
 stated by these writers. 
 
 Etiology. — As early as 1853, Dr. J. Matthews Duncan declared, in 
 substance, that periuterine inflammations were not to be regarded as 
 separate primaiy aifections, but that they were secondary in their nature 
 and dependent upon inflanunation of the uterus or its a]ipendages. 
 Prior to the date above mentioned medical opinion upon this subject 
 had scarcely taken definite form, although a number of writers — among 
 whoni may be mentioned Velj^eau, ^Nlarchal, ^NTcClintock, "West, and 
 Aran — had in a casual way expressed the belief that pelvic abscesses 
 were often traceable to diseases of the uterus. At the present time the 
 
678 PERIUTERINE INFLAMMATION. 
 
 general correctness of this doctriue is universally admitted by gyneco- 
 logical ^vriters. 
 
 According to Winckel/ it has been clearly shown, from the researches 
 of Virchow, Waldeyer, and others into the pathology of the puerperal 
 inflammations, that in pelvic cellulitis the lacerations and ulcers of the 
 cervix resulting from parturition produce at first tumefaction and albu- 
 minous infiltration of the intermuscular connective tissue of the uterus : 
 then follow enlargement and proliferation of the connective-tissue cor- 
 puscles. The same process extends to the connective tissue around the 
 uterus and the upper part of the vagina and at the base of the broad 
 ligaments and into the tissue between the folds of the broad ligaments. 
 At a later stage purulent deposits are formed in these and in other 
 ]oarts of the pelvis. 
 
 The same researches teach us that pelvic peritonitis may result from 
 direct injury to the peritoneum by laceration through the cervix uteri 
 or from contusion of this membrane in difficult instrumental labors. 
 Often it originates in an endometritis which extends through the inter- 
 muscular connective tissue of the uterus to the parametric tissue, and 
 from this to the peritoneum. ISTow and then the endometritis spreads 
 through the tubes and involves the peritoneum by continuity of tissue. 
 
 The non-puerperal inflammations recognize a similar etiology. Trau- 
 matism in the cervix and body of the uterus from the various surgical 
 procedures of gynecology, disease of the ovaries and Fallopian tubes, 
 and extension of inflammation from the endometrium through the 
 tubes, will, in the vast majority of cases, clearly account for them. 
 
 A study of the views of the foremost obstetrical writers of the pres- 
 ent age will show that they, with few exceptions, believe that the 
 puerperal inflammations are the res?ult of the introduction of septic 
 material into the blood, and that the avenue by which the poison gains 
 admission is furnished by the lesions of the genital canal. This is the 
 view now generally accepted by modern pathologists in explanation of 
 the phenomena of surgical inflammation wherever it may arise ; and to 
 set forth this important subject in clear language I quote the words 
 of the late Dr. William H. Van Bnren, a writer who was renowned 
 alike for his deep learning and his conservatism. According to this 
 author,^ "The terms infective and non-infective, introduced by Simon and 
 Sanderson, have been so generally adopted in treating of surgical inflam- 
 mations and fevers as to require special definition. 
 
 " ' An inflammation,' says Sanderson, ' which is more or less exactly 
 limited in duration and extent by the limits of the injuiy which has 
 caused it may, with scientific precision, be designated a simple or 
 normal inflammation ;' that is, non-infective. 
 
 1 The Pathology and Treatment of Childbed, translated by Jas. E. Chadwick. 1876. 
 ^ Internal. Encyclopaedia of Surgery, vol. i., " Inflammation," p. 105. 
 
ETIOIJXIY. (J7i) 
 
 "On (lie fiiiiti'ai'v, 'all iiillanmiatinii wliidi .-|>r('a<ls :iii<l ('iidurcs 
 Ix'voiitl the direct and pi'iiiiary ((piTatinn oi" its cause, wliicli induces 
 similar inllaninialions in other j)afts, and disorders the vital luiictifjus 
 of llie whole l>od\ , has in it soniethinj;- beyond the ellects ol" the injury, 
 and niav he projx'i'ly ti'i'nied ////rc//Vr.' 
 
 "In the latest lOn^lish systenialie woi-k on |)alholoMy ( hy T. ihnry 
 (Ireen, etc., London, 1 SS I ) this is s|»ok<'n ol" as one of the nio.-t iniporl- 
 anl divisions of inflaniniation ; and it is stateil that ' in all infective 
 iiifiatnniations the iorniation of the infective ,sul)stunee appears to he 
 due to the j)resenee of minute or}»anisms, these organisms in the or- 
 dinar\- iion-speeilic inflammations heing the common sej)tic bacteria.' " 
 
 Whilst eonsideiMng the etioloiiy of pelvic iiiHammations 1 would call 
 attention to an instructive ai-ticle by Dr. Paul Munde,' in \vhi<h he has 
 placed before the English reader the residt.s of the investigations of 
 Chanij)ionniere of Paris and Leopold of Leipzig into the minute 
 anatomy of the uterine lyniphatics. These authors have shown that 
 the Ivmphatie system of the female pelvis consists of a very luxuriant 
 and intricate system of vessels opening by multitudes of luinute orifices 
 upon the mucous surface of the uterus, and continuous with the lymph- 
 S])aces of the pelvic peritoneum. As these lymphatic canals coalesce to 
 form larger vessels, they are seen in places to form ganglion-like expan- 
 sions and to be interrupted here and there by glands, the most import- 
 ant and constant of which are situated in the cellular tissue on the sides 
 of the cervix. Leaving the walls of the uterus, they travel outwardly 
 between the layere of the broad ligament to empty their contents into 
 the general lymphatic system of the body. A more perfect mechanism 
 for taking up and conveying poisonous material from the lining mem- 
 brane of the genital passages to the periuterine tissues could scarcely be 
 designed. 
 
 ^^'hile the active part played by the lymphatics in the puerperal 
 inflammations has been fully recognized by obstetric writers of every 
 nation, as Dr. ^Munde says, "their influence in the transmission of sep- 
 tic matter and production of inflammation of the uterine adnexa in 
 the non-prer/nant state has by no means received the recognition it 
 deserves." In another connection he adds : "And thus, while all authors 
 on diseases of women speak of metritis and endometritis, of cellulitis and 
 peritonitis, and of ovaritis, scarcely one mentions the subject of peri- 
 uterine lymphangitis or lymphadenitis. What is considered and 
 described as one of the chief factors of jiuerperal disease is wholly 
 overlooked in the non-puerperal condition." 
 
 Notwithstanding all that has been said, it must be admitted that 
 there is a class of cases, few in number, the etiology of which, in the 
 
 ' Amer. Jonmal of Obstetrics, Oct., 1883, "Non-puerperal Pelvic Lymphadenitis and 
 Lymphangitis." 
 
680 PERIUTERINE INFLAMMATION. 
 
 present state of knowledge, is obscure. Thus in young girls and old 
 women pelvic inflammations now and then are met with, going on to 
 suppuration, in the absence of any discoverable uterine disease. 
 
 In this connection allusion should be made to the views of Dr. 
 Thomas Addis Emmet. This distinguished gynecologist says : ^ " My 
 convictions are that Avhile the primary cause of uterine disease lies, 
 through the influence of the sympathetic system, in impaired nutrition, 
 we must look to pathological changes in the connective tissue as the 
 immediate cause of the results we now regard as the original disease 
 in the uterus and ovaries. These views have no reference to the 
 puerperal state, for there I recognize the direct susceptibility of the 
 uterus to disease and mechanical injury. Pathological changes are 
 then brought about in the connective tissue of the pelvis as secondary 
 to the uterine condition, and may remain long after the original lesions 
 have disappeared. But these pathological changes may afterward so far 
 affect the circulation, either mechanically or through the nervous system, 
 as to become the cause of new and other forms of uterine disease." Dr. 
 Emmet classifies the causes of pelvic inflammations as puerperal and 
 accidental, and says : ^ " I am deeply impressed with the belief that 
 future observation will establish the fact that the point of origin of 
 
 inflammation in the pelvic cellular tissue is in the veins That 
 
 phlebitis in the pelvic cellular tissue does arise in the puerperal state 
 was taught by Trousseau, and I verified it in the earlier part of 
 my professional life, when my opportunities were better for studying 
 pathological changes ; but it must be left to future observation to 
 determine why and how it occurs in the non-puerperal condition, for 
 I have had no opportunity of establishing this point." 
 
 To the two forms of pelvic inflammation given above Prof. Courty 
 of Montpellier has added a third. To this he gives the name of peri- 
 uterine adenitis and angeioleucitis. From his description we learn ^ that 
 this affection " is often acute and the prognosis very serious when it is 
 puerperal ; more frequently it is chronic, and is then less important in 
 itself than from the ulceration of the uterine mucous membrane, of 
 which it is the certain sign." 
 
 The autopsies of Championniere, Leopold, and others have shown 
 that in the puerperal inflammations the lymphatics are commonly filled 
 with pus. 
 
 According to Courty, acute inflammation of the periuterine lymphatic 
 ganglia and vessels is observed as a result of traumatic causes, of endo- 
 metrial inflammation, or of the participation of these structures in an 
 acute periuterine inflammation. Most frequently, however, angeioleu- 
 
 ^ The Principles and Practice of Gynecology, 3cl ed. ^ Op. cit, p. 245. 
 
 ^ A Practical Treatise on the Diseases of the Uterus, Ovaries, and Fcdlopian Tube,?, trans- 
 lated from the 3d ed., p. 537. 
 
FRKQVEyaY. <).Sl 
 
 citis aiitl iitlciiilis dcciir in (lie clii'miii' Iniiii. I ln' <liH;i>c i- linn i-cc(»h^- 
 nizetl li\' llif occiirrciKH! ol" small rtniiulcd tiinioi'.s, smodlli at (•(■itaiii 
 points, irrciiular at others, situated l)eliin<l and to the sides ol' the cer- 
 vix, and h>oseIy connected with the nteiuis and va<i;inal cids-de-siic. 
 'riie^e liunors are smaller than the normal ovary, are less movalWe, and 
 usiiailv less ])ainf"ul on [)ressni'e than this or^an, hut in some eases are 
 very tender to the touch. 
 
 The uterus is ircnerally movable and often retroverted. " Apart 
 from the sym|)toms, either direct or sym[)ath{!tic, of the uterine malady 
 and of the ulcer which has caused it, jieriuterino adenitis has sp(!cial 
 symptoms characterizin<;- it: lumbar or lumbo-sacral pain, sometimes 
 cxtendini>; to the anus; continuance of the [)ains previously experienced 
 by the patient, which are increased by marital intercourse, evciu when 
 most of the apj)arent uterine symptoms have disappeared; pain elicited 
 by diii'ital touch, especially Avhen pressure is exercised by the finger 
 behind the uterus and laterally, and when an attempt is made to 
 depress the retro- or dextro-uterine cul-de-sac."^ This descrijjtion by 
 Prof. Courty is based not only on clinical observation, but also upon 
 autopsical evidence drawn from a woman at the age of forty who died 
 of [)neumonia after suffering a long time from leucorrhoea and ulcerous 
 endometritis. 
 
 Dr. J. S. Carreau " of New York and Dr. Paul Munde ■^ have each 
 reported a number of cases of this form of periuterine inflammation. 
 
 Fkequexcy. — It is impossible to give statistics which will fix with 
 accuracy the frequency of occurrence of these inflammations. It is 
 sufficient to state that they are the most common of all the disorders 
 of M'omen, and, in the language of Courty,^ " it is certain that out of 
 100 women there will be 55 with peritoneal adhesions and showing 
 traces more or less intense of pelvic peritonitis. Of this number there 
 are far more married women than virgins, and more nuiltipar;e than 
 primipara?." 
 
 Inasnuich as a thorough acquaintance with the peritoneum and cell- 
 ular tissue of the pelvis is essential to a correct interpretation of pelvic 
 exudations, an account of the most important anatomical features of 
 these structures is here presented. 
 
 * Courty, op. ciL, p. 539. 
 
 * "Adenitis and Angeioleucitis of the Pelvic Cellular Tissue," MixUml Record, July 
 2, 1881. 
 
 ' " Non-puerperal Pelvic Lvnaphadenitis and Lvmphan<^itis," Am. Journ. Obs(., Oct., 
 1883. 
 
 * Op. cit., p. 540. 
 
682 PERIUTERINE INFLAMMATION. 
 
 The Pelvic Peritoneum. 
 
 The peritoneum, after lining the walls of the abdomen, descends into 
 the true pelvis and throws itself as a covering over all of its viscera. 
 The floor of the pelvis, thus covered, is not a smooth surface, but pre- 
 sents many irregularities. Looking down into its cavity, we observe 
 that the pelvis is divided quite evenly into anterior and posterior spaces 
 by a prominent transverse fold which extends from one lateral wall 
 to the other. Within the two layers which constitute this fold lies 
 the uterus, and on each side of it are the ovary and Fallopian 
 tube. 
 
 That portion of the fold which extends from the uterus to the pelvic 
 wall and embraces the ovary and tube is the broad ligament. Accord- 
 ing to the statement of Hodge, which has recently been confirmed by 
 the investigations of Professor Polk,^ the broad ligament in the nullip- 
 arous woman is attached at its outer margin along a vertical line run- 
 ning between the sciatic notch behind and the obturator foramen in 
 front. The base of the broad ligament can be touched by the examin- 
 ing finger in the lateral fornix of the vagina, except during gestation, 
 and its outline can be distinctly felt whenever the ligament has been 
 indurated by inflammation. 
 
 In front of the transverse fold just mentioned is a convex surface 
 corresponding to the bladder, bounded on the sides by two curving 
 folcls — the round ligaments — which emanate from the anterior and 
 superior margins of the uterus, sweep around the sides of the bladder, 
 and seek attachment near the external abdominal ring. . 
 
 The reflection of the peritoneum upon the anterior surface of the 
 uterus after covering the bladder is called the vesico-uterine pouch. 
 Of this Dr. Hart ^ says : " It does not contain intestine when the 
 uterus is normal in position, and has therefore been unfortunately 
 named ' pouch.' " 
 
 That portion of the pelvic floor which lies behind the uterus and 
 broad ligaments presents three well-marked depressions or pouches. 
 These pouches are separated by two folds of peritoneum called the 
 folds of Douglas and also the utero-sacral ligaments. These ligaments 
 spring from the lower lateral part of the body of the uterus and pass 
 outward and backward to the second sacral vertebra. 
 
 The central depression between the utero-sacral ligaments, and imme- 
 diately behind the uterus, is the pouch of Douglas. Behind the pouch 
 of Douglas is the rectum. The two lateral depressions have been called 
 by Polk the " retro-ovarian shelves." ^ 
 
 ^ " The Topographical Eelations of the Female Pelvic Organs." by Ambrose L. 
 Ranney, Amer. Journ. of Obstetrics, April, 1883. 
 
 2 Atlas of Female Pelvic Anatomy, p. 43. ^ Eanney, loc. cit., p. 367. 
 
Till': rr.iAic I'lJirroNEUj^f. 
 
 (;.s;j 
 
 I'Ik' narts al><)V(' (Icsci'ilicd an- well >li(i\\ ii in llic a<'<-<>iii])aiiyiii;^ dia- 
 graiiiinatic viow of tlic pcKis, rioin llod^c (Fi^. 200j. 
 
 While stuclviiii;' the ixTitoiiciiin \\v. oWsci'vc that in its course down- 
 ward, alter t'overinu- (lie posterior wall of llie uterus, when on a lev(-l 
 with the OS iuternum, ii tiu-ns backward and a little upward in order 
 to cover the posterior fornix vai;in:e. it then descends alon«;- the |to— 
 terior wall of the va<iina a variable distance before it is relleeted upon 
 
 Fio. 2U0. 
 
 A Diagraiiimatic Superior Viow oi' the Fciuak' Pelvis, showing the reflections of the pelvic 
 
 peritnueuni (Hodgel. 
 
 the rectum. This variability in the point of reflection is one of the 
 most important peculiarities of Douglas's pouch. 
 
 Generally, the reflection occurs on a level with the os externum ; 
 occasionally, higher up, on a level with the posterior fornix ; rarely 
 and abnormally, as low down as one inch from the vaginal orifice. 
 Pirogoff has jirescnted a frozen section in which the peritoneum riuis 
 down to the very apex of the peritoneal body. 
 
 The boundaries of Douglas's pouch may be stated thus: in front, the 
 supravaginal portion of the cervix and the upper portion of the vagina; 
 behind, the rectum ; on the sides, the utero-saeral ligaments. Accord- 
 
684 PERIUTERINE INFLAMMATION. 
 
 ing to Hart, its depth is somewhat greater on the left of the uterus 
 than on the right. 
 
 It thus appears that all the depressions in the pelvic floor are poste- 
 rior to the uterus aud the broad ligaments. It is true, there is in the 
 anterior half of the pelvis what is called the utero-vesical pouch, but 
 it is shallow or does not exist at all when the bladder is distended, and 
 is of no clinical importance. 
 
 While the posterior pouches, especially that of Douglas, may become 
 the seat of encapsulated serous or purulent effusions in pelvic peritonitis, 
 anything like a mass of peritoneal exudation in the anterior half of the 
 pelvis is exceedingly rare. 
 
 When a vertical mesial section of the pelvis is made and the peri- 
 toneum shown in profile, it will be seen that the plane in which it lies 
 is considerably below the plane of the brim of the pelvis. 
 
 That portion of the pelvic cavity which lies above the peritoneum 
 has been denominated the peritoneal space, while that portion which lies 
 below it is called the subperitoneal space. The subperitoneal space is 
 one in which we are deeply interested, since it contains not only all the 
 pelvic viscera, but the pelvic connective tissue which binds them together, 
 and with them the blood-vessels, lymj)hatics, and nerves. 
 
 The Pelvic Connective Tissue. 
 
 The pathological anatomy of the subperitoneal pelvic space is per- 
 haps of more importance than any other one subject connected with 
 the diseases of women. In this space, underlying the peritoneum and 
 investing the viscera and blood-vessels throughout the pelvis, is found 
 the connective tissue. 
 
 The uterus, vagina, and their arterial and venous plexuses are all 
 enclosed in connective tissue, and, as Savage ^ remarks, " This uterine 
 cellular system is continuous at its periphery with every portion of the 
 subperitoneal cellular tissue at the lower part of the abdomen." 
 
 Although loose connective tissue is found everywhere throughout the 
 pelvis, lying between the different structures and binding them together, 
 it is in some places very scant and in others quite abundant. With 
 special reference to the clinical appreciation of inflammatory deposits 
 in the pelvis, T may mention those localities in which the connective 
 tissue is found in considerable quantity : 
 
 1. Behind the symphysis pubis and in the angle between the urethra 
 and the anterior wall of the bladder, continuous with the cellular tissue 
 of the abdominal wall — the retro-pubic fat deposit of Hart. 
 
 2. Between the posterior wall of the bladder and the anterior wall 
 of the cervix, on a level with the os internum, and between the posterior 
 
 ^ The Surgery of the Female Pelvic Organs, 2d ed., 18S0. 
 
Tin: PKLVIC CONNECTIVE TISSUE. 
 
 (iH.i 
 
 surthcc <t(" the su|>i';iv:it:iii:il |MHtiiiii nj" ilic cervix niul tin- fold ol" jm ri- 
 toiK'Uiii which turns duwii to cdvcr the jtostcrior wall of" the va<j;iiia in 
 its iij)|KT j)art. Indeed, this jxirtion oC the <'<'rvix, together with the 
 upper portion of the va<;ina, i> coniph-tely surrounded by a fold of" 
 loose, fatless ('oiineetivc tissue al)undaiitly supplietl witli blood-vessels 
 and lyniphatiis. 
 
 3. Alonir the line ul" junctiiHi of the broad ligaments with the uterus, 
 bi'twcon their folds, there is a large amount of coimeetive tissue with 
 numerous large blood-vessels. This tissue lessens in amount as the 
 
 Vu.. 201. 
 
 Lateral Sagittal Pection of Pelvis at junction of broad ligament and nteru:< (Hart) : D, vagina : 
 A, bladder; C, symphysis; F, broad ligament ; G, ovary; H, Fallopian tube. 
 
 broad ligaments leave the uterus. This is well shown in Fig. 201, 
 which is a lateral sagittal section of the ])elvis at the junction of the 
 broad ligament and uterus, taken from Plart.^ 
 
 Between the anterior rectal wall and the posterior wall of the vagina, 
 
 * Op. cit., plate xxii. fig. 4. 
 
686 PERIUTERINE INFLAMMATION. 
 
 from the lowest point of Douglas's pouch to the apex of the perineal 
 body, there is loose connective tissue. 
 
 The connective tissue lying between the peritoneum and the body of 
 the uterus on its anterior and posterior surfaces is too small in amount 
 to be of clinical importance. 
 
 In all the localities above mentioned inflammatory exudations occur, 
 and can be readily appreciated by the touch ; but that portion of the 
 connective tissue which overshadows all others in pathological import- 
 ance is the loose fatless layer, three-fourths of an inch in thickness, 
 which surrounds the supravaginal cervix and the upper portion of the 
 vagina. According to Spiegelberg,^ " It was especially for the puerperal 
 inflammations of these cellular sheaths that Virchow introduced the 
 word ' parametritis.' " 
 
 The very great importance of this tissue in the etiology of periuterine 
 inflammations arises from its intimate connection with the tissue of the 
 cervix, it being continuous with the intermuscular connective tissue of 
 the uterus ; from the facility with w^hich it becomes involved in the 
 puerperal lacerations of the cervix or the injuries which the neck may 
 sustain from gynecological operations; and lastly, from the readiness 
 with which its numerous lymphatics and blood-vessels take up and 
 carry into the system septic poisons. 
 
 These peculiarities of the circumuterine cellular tissue should remind 
 the gynecologist of the risks which attend and may follow the most 
 trifling injury of the cervix, and should make him ever cautious to 
 avoid the possibility of septic infection of these structures. 
 
 The Lymphatics of the Uterus. 
 
 A knowledge of the lymphatic vessels and ganglia in the uterus and 
 its appendages must necessarily throw much light upon the subject of 
 periuterine inflammation, inasmuch as these structures are closely related 
 to the connective tissue and constitute the principal avenues through 
 which poisons find entrance to the system. 
 
 According to Dr. Hart,^ " The lymphatics take their origin in con- 
 nective tissue. Thus, the lymphatics of the uterine mucous membrane 
 begin in the spaces between the bundles of fibrous connective tissue, 
 these said bundles being covered in part by endothelial cells ; that is, 
 the lymphatics begin in spaces bounded by the endothelial covering 
 of connective-tissue bundles. 
 
 " From these the lymphatic capillaries spring and merge into the 
 larger vessels, ultimately opening into the thoracic duct, which of 
 course pours into the venous system." 
 
 ^ German Clinical Lectures, 2d Series, New Sydenham Soc, 1877, p. 172. 
 ^ Op. cit, p. 29. 
 
I'h'iAic ri:i!ir<)srns. (;,h7 
 
 '' Ij('(i[)oI(1 ('(Hisidci's the iilcriiic iuiicdiis iiHMuhraiK! as a Iviiiiilialic 
 ij;laii(l, or lyiupliaticr surlacc iiilorsoctcd witli utcriiu; jrlaiid.- and Mood- 
 vi'sscls, tlio IyiM[)halics Ikmiih" not mere vosst'ls, hut .s[)a<'cs licfwccii (Ik; 
 connectivo-tissiie hundlcs." 
 
 Lymj)liatie vossels orininaliiiii; in diU'ci-cnt [xirtions of tlio jr(;nital canal 
 cany their contents to diilcrcntly .situated inlands. Thus the Ivniphatics 
 of tlie hibia, of the vai^inal orifice, and lower [)ortion of the va<i;ina o[)en 
 into the iuf^uinal <>huids. According to Le Bee, the lymphatics of the 
 upper portion of the vagina unite with those of the cervix uteri at the 
 level of the isthmus uteri. They then travel below the base of the 
 broad ligament and empty into the obturator ganglion. 
 
 From the investigations of Leopold it appears that the lymphatics 
 of the uterus originate in the lymph-spaces of the uterine mucous nuini- 
 brane. These lymph-spaces extend a little way into the funnel-shaped 
 hollows between two muscular bundles, and then into the intermuscular 
 spaces. When the external muscular layer of the uterus is reached, the 
 lymph- vessels, after surrounding all the bundles, run into large valved 
 canals at the sides of the uterus, and then pass into tubes in the broad 
 ligament. These vessels, along with those from the ovary and Fallo- 
 pian tube, empty into the lumbar glands. Lesions of the body of the 
 uterus and lesions of the cervix may therefore be expected to give rise 
 to differently situated periuterine inflammations. 
 
 All that is known upon this subject is admirably presented and beau- 
 tifullv illustrated in Hart's magnificent work. 
 
 Pelvic Peritonitis. 
 
 Synonym. — Perimetritis (Duncan, Fritz). 
 
 The term pelvic peritonitis is here applied to an inflammation, acute 
 or chronic, of the pelvic peritoneum. It often involves also the peri- 
 toneal covering of adjacent portions of the intestines. 
 
 The earliest scientific knowledge which we possess in regard to this 
 affection is derived from the labors of Bernutz. His in vesti stations 
 were first published in the Archives generales de JTedecine for 1857, and 
 subsequently, in niore complete form, in the CUnique medicale des 
 Femmcs in 1862 by Bernutz and Goupil. This great work of Bernutz^ 
 is based upon the study of 99 cases of non-puerperal pelvic peritonitis, 
 with 13 autopsies. The records of 7 of these cases, 6 of which were 
 his own and 1 that of his friend ]\I. Boucher, are in everv sense com- 
 plete and perfect histories. These histories present a full and minute 
 description of the clinical features of the disease. They also describe 
 with the greatest precision the pathological condition of the pelvic 
 tissues as observed after death. And, lastly, they demonstrate beyond 
 ' Clinical Manoirs on Diseases of Women, New Sydenham Soc, trans, by Meadows. 
 
688 PERIUTERINE INFLAMMATION. 
 
 cavil the existence of an inflammation of the pelvic peritoneum, pure 
 and simple, sufficiently extensive to destroy life and uncomplicated by 
 a trace of cellulitis. 
 
 It is only justice to Bernutz to say that his memoirs contain the fullest 
 exposition of this subject, and while, since his day, much has been done 
 to confirm what he has written, no very important additions have been 
 made to the stock of knowledge which we have derived from his inves- 
 tigations. 
 
 Referring to these investigations. Dr. T. Gaillard Thomas ^ wrote in 
 1868 : " Since the publication of these views I have directed my atten- 
 tion particularly to this point, and from careful observation, both clin- 
 ical and post-mortem, feel warranted in recording the conclusions at 
 which I have arrived in the following propositions : 
 
 "1. Periuterine cellulitis is very rare in the non parous woman, while 
 pelvic peritonitis is very common. 
 
 " 2. A very large proportion of the cases now regarded as instances 
 of cellulitis are really those of pelvic peritonitis. 
 
 '' 3. The two affections are eutirely cTistinct from each other, and 
 should not be confounded simply because they often complicate each 
 other. They may be compared to serous and parenchymatous inflam- 
 mation of the lungs, pleurisy, and pneumonia. Like them, they are 
 separate and distinct ; like them, affect different kinds of structure ; and 
 like them, often complicate each other. 
 
 " 4. They may usually be readily differentiated from each other, and 
 a neglect of the effort at such thorough diagnosis is as reprehensible as 
 a similar want of care in determining between pericarditis and endo- 
 carditis." 
 
 In 1869, Dr. Matthews Duncan said: "My adoption of Bernutz's 
 views is not founded on clinical observation merely, but on several 
 post-mortem investigations made by myself or for me by able path- 
 ologists." 
 
 Still more recently. Professors Spiegelberg of Breslau and Fritsch of 
 Halle, and Drs. Hart and Barbour of Edinburgh, have accepted these 
 views and have written in elucidation of the subject. But perhaps the 
 surgical work of Mr. Lawson Tait in the way of removing diseased 
 uterine appendages by abdominal section, begun about twelve or fifteen 
 vears ag-o, and carried on with such wonderful results as now to be 
 familiar to the entire medical world, has, more than all else, led to a 
 clear demonstration and a general acceptance of the views which were 
 promulgated by Bernutz. 
 
 One of the most valuable contributions which has recently been made 
 to this subject is a paper ^ by. Prof. William M. Polk, read before the 
 
 1 Op. cif., 1868, 1st ed. 
 
 ^"Periuterine Inflammation," Medical Record, New York, Sept. 18, 1886. 
 
I'ELVlc riCRITONITIS. GMO 
 
 Socii'ty of Pliysiciaiis and l':illin|(.Mi~t-, \\':isliiiit:toii, I). C'., June 18, 
 1886. In this pajx-r a rc<-ur»l of" Ki cjl^cs is ollln-d in wliidi alxloni- 
 inal section wils made ior tlie rcliel" oi" chronic pelvic inllanunatinn. 
 The lesions I'ouiul were sali)injj:;itis, |)eriovaritis, ami pelvic peritonitis. 
 To this important piil)lication reference will a<rain he made. 
 
 l*ATHOL<)(JV. — The memoir of liernut/, rich in anatomical material, 
 is well worth Ciireful study. It contains a report of 1.3 autopsies. After 
 a careful studv of symptoms and ])hysical sifi^ns duriiiir life, a physical 
 exploration of the pelvis was made at deatli by the bimanual, and then 
 the abdomen was opened. In some cases it is stated that the endomet- 
 rium was healthy ; in others, that it was inflamed, and in 1 it was 
 covered with pus. The pelvic viscera were covered by false mem- 
 branes. Adhesions bound them to each other — the uterus to the blad- 
 der or rectum, the broad ligament to the sigmoid flexure; the Fallopian 
 tube, bent upon itself, was adherent to the posterior wall of the uterus 
 or to Douglas's pouch. The tube was often adherent to the ovary, its 
 fimbriated extremity occluded, and the fimbria destroyed. In 9 of 
 these autopsies one or both of the tubes contained pus ; in 2 they con- 
 tained tubercular material. In 1 autopsy the peritonitis was found to 
 be due to cancer of the ovary. In 4 cases the ovaries were healthy. 
 As a result of these autopsies it may be said that the one constant fea- 
 ture in pelvic peritonitis is diseased tubes — salpingitis. 
 
 As a result of the condition here described there is fixation of the 
 uterus and the presence in the pelvis, at some point, of a tumor. The 
 tumor consists generally of the ovaries and tubes folded upon them- 
 selves, matted together by exudation, and adherent to the posterior sur- 
 face of the broad ligament or of the uterus. If the disease is chiefly 
 on one side, the uterus will be pushed to the other side. In some cases 
 the tumor is behind the uterus, and pushes it forward against the pelvic 
 bone. It then consists of an accumulation of serum or pas confined in 
 a cavity, the walls of which are the uterus and broad ligaments in front, 
 the posterior wall of the pelvis and the sigmoid flexure behind, coils of 
 intestines adherent by false membrane above, and Douglas's pouch and 
 the retro-uterine shelves l)elow. 
 
 The tubes are sometimes like hard fibrous cords, containing pus in 
 small quantities, one of their fimbriated extremities being occluded. 
 In other cases both extremities are closed and the tubes greatly dis- 
 tended, forming sausage-like tumors which can be recognized by the 
 bimanual. 
 
 These inflammatory processes are oftentimes entirely intraperitoneal. 
 In other cases the subperitoneal connective tissue is involved to a slight 
 extent ; and this is evidently secondary to the peritoneal inflammation. 
 
 Polk in the paper referred to says that in a large number of post- 
 mortem examinations made in the dead-house of Bellevue Hospital 
 
 Vol. I. — 14 
 
690 PERIUTERINE INFLAMMATION. 
 
 " nothing is more common than to find evidences of peritonitis about 
 the ends of the tubes ; and it is noticeable in such cases that the evi- . 
 dences of such inflammation diminish as you leave the extremities of 
 the tubes." 
 
 The same writer adds : " The ovary may be said to be always impli- 
 cated in this peritoneal inflammation, the fimbria which attaches it to 
 the tube forming a ready transmitter of the process from the tube ; but 
 the extent to which it is involved must depend upon its proximity to 
 the tubal opening and upon the degree of the inflammatory process." 
 Studying the inflammatory process more minutely as it occurs in the 
 peritoneum, it may be said that the serous membrane at first becomes 
 hyperfemic : its smooth, glistening surface disappears from loss of the 
 epithelium, and very soon exudation appears. 
 
 In the exudation material connective tissue rapidly forms, and if but 
 little free fluid is effused to separate the opposing surfaces, adhesion takes 
 place. 
 
 Very often there is an abundant exudation of fluid which separates 
 completely the opposing surfaces. In this fluid, which is of a clear^ 
 yellowish appearance, flakes or shreddy masses are seen floating, and 
 the inflamed surfaces themselves are covered with a yellowish or red- 
 dish friable substance composed in the main of connective tissue and 
 known as pseudo-membrane. 
 
 Resorption of fluid may now occur to some extent, and the opposing 
 surfaces, coming in contact here and there, become adherent. Thus 
 cavities are formed, within the walls of which fluid still remains, and 
 thus peritoneal tumors are produced. These tumors may undergo 
 enlargement by the addition of increased secretion. 
 
 In the severer forms of peritonitis, such as we see in the puerperal 
 woman, the fluid is almost from the beginning purulent. In other 
 cases the exudation may be sero-fibrinous for a time, but in con- 
 sequence of some reaccession of inflammation the cells floating in the 
 serum rapidly proliferate, and suppuration results as a secondary event. 
 We have, then, as clinical facts, adhesive peritonitis, sero-adhesive 
 peritonitis, and purulent peritonitis. 
 
 Etiology. — The occurrence of pelvic peritonitis in any given case 
 
 implies a pre-existing lesion of the uterus, ovaries, or tubes. In many 
 
 instances — indeed, usually — endometrial inflammation, salpingitis, and 
 
 pelvic peritonitis are simply stages of one and the same morbid process. 
 
 The causes which give rise to this disease are — 
 
 1. Traumatic Influences. — In certain unexplained conditions of the 
 sexual organs the slightest traumatism may produce a fatal peritonitis. 
 Such a result has happened from the application of nitrate of silver to 
 the cervix, from the use of a sponge tent, and from the passage of the 
 uterine sound. Sometimes this inflammation is traceable to blows over 
 
PELVIC PERirONITIS. (ill I 
 
 tlie alKlDiiu'ii, to venereal oxcossos, to the v:i<:inal doiielie, to the mh- of 
 steiu-pc'ssaries, and to siir^ieal o|)eratioiis on the eei'vix. 
 
 2. l^/ic h'iilr(i)icc of F()r(i(/)i ''^vf>sfaiiccs inio the IMr'ir ('(n-i/i/. — Intra- 
 uterine injei'tions may enter the peritoneum thi-ougli the tubes wlien the 
 eer\i.\ has not Ween well dilated, and they will be quite sure to produce 
 peritonitis. The sami' result will follow the rupture into the peritoneum 
 of an abscess of the ovary' or of an ovarian eyst, or any pelvic abscess, 
 rupture of a jnosalpinx, of a tubal pregnancy, or some one of the 
 branches of the ovarian venous pU'xns. 
 
 3. ^^r^^sfrl(al Di'<or<h'rs. — Of tiie 99 cases which formed the basis of 
 the nuMuoir of M. Bernutz, 20 were set down to disturbances of the 
 menstrual function. The circumstances under which menstrual pelvic 
 peritonitis occurred were as follows: lu 3 cases of incomplete menstru- 
 ation no cause was apparent ; twice it occurred after severe dysmenor- 
 rhfeal pains ; fifteen times after sudden suppression. Of these 15 cases, 
 the cause of the sui)pressi()n in 9 was cold ; severe mental emotion in 3 ; 
 a speculum examination in 1 ; cauterization of the cervix in 1 ; frequent 
 sexual intercourse during menstruation in 1. 
 
 I have frequently ol)scrved pelvic peritonitis in washerwomen, who 
 stand much with their feet in the wet, and in prostitutes as a result of 
 the application of cold water to the genitals during menstruation for the 
 purpose of stoppings the How and thereby enabling them to ply their 
 vocation. The eifect of cold in both instances is probably to first 
 induce an endometritis, which deranges the menstrual function. 
 
 4. Gonorrhoea. — There were 28 out of Beruutz's cases attributable to 
 gonorrhoea. This large proportion, he says, was due in part to the social 
 condition of the women who were admitted to the Lourcine, and in part 
 to some peculiarities in the management of the hospital. In his cases 
 the peritonitis never appeared before the eighth day of the disease, 
 rarely before the fourteenth, frequently at the end of the month, cor- 
 responding to the menstrual return. It was the result of a gonorrhoeal 
 endometritis extending by continuity of tissue along the Fallopian tubes 
 to the peritoneum. 
 
 Noeggerath has called attention to the pernicious influence of " latent 
 gonorrhoea in the male." In this form the gonorrhoeal inflammation is 
 supposed to have been long cured, but there exists in reality a granular 
 inflammation of the urethra at some one point producing scarcely anv 
 ap])reciable discharge or other symptoms. Proper exploration of the 
 urethra reveals a stricture of large calibre. This condition I have 
 
 ' Abscess of the ovary in the non-puerperal woman is of nniisiial occurrence, but 
 well-marked histories are narrated by Mr. J. C. Ciillinsrworth and Mr. Lawson Tait. 
 The abscess begins by suppuration of separate follicles; these subsequently coalesce, 
 and form an abscess of the entire gland. Rupture of such an accumulation would 
 cause a rapidly fatal peritonitis iTait on /)('.s. of the Omries, 4th ed., p. 127 j. 
 
692 PERIUTERINE INFLAMMATION. 
 
 repeatedly known to produce a vaginitis, endometritis, and salpingitis 
 very soon after marriage, when the cause of trouble was not suspected 
 by either husband or wife. 
 
 5. Parturition, Abortion. — Pelvic peritonitis often follows parturi- 
 tion, and its occurrence is frequently associated with a history of 
 repeated abortions. In many of these cases there will be found a 
 history of endometritis and salpingitis antedating the pregnancy ; and 
 during the period of confinement there is observed for the first time 
 an extension of inflammation from the endometrium to the pelvic 
 peritoneum. 
 
 Clinical observation leads me to believe that repeated abortions are 
 often the result of au endometritis, which probably operates in their 
 production by imjaairing the integrity of the fcetal attachments. Dur- 
 ing the abortion, from some inappreciable cause, the endometrial inflam- 
 mation extends along the tubes to the peritoneum. The parturient pro- 
 cesses seem to furnish the opportunity for propagation of an antecedent 
 inflammation. 
 
 This association of pelvic peritonitis with the puerperal state and 
 abortion was observed by Beruutz. Of his cases there were 43 follow- 
 ing the parturient act ; 35 of these occurred after delivery at terra, and 
 8 after abortion. In many of these cases there was admission to the 
 blood of poisonous material through lacerations of the uterine canal. 
 In others there was probably an endometritis, induced by special excit- 
 ing causes, such as venereal excess prior to and causing the abortion, 
 exertion too soon after labor, or cold. 
 
 Before the introduction of antiseptic methods rapidly fatal peritonitis 
 was often observed from septic poisoning. 
 
 Polk in his paper remarks : "An item of interest in many of the 
 cases is the appearance of abortions and miscarriages as etiological 
 factors." 
 
 After childbirth inflammation of the pelvic cellular tissue is the 
 lesion most commonly observed. It, as well as the accompanying 
 peritonitis, is of a septic character. According to Winckel,^ who has 
 made many autopsies, the trouble begins as a catarrhal endometritis, 
 and extends through the intermuscular connective tissue of the uterus 
 to the parametric tissue, and thence to the peritoneum. He says in 
 these cases it is 2'are for the inflammation to spread through the 
 tubes. 
 
 6. Tubercle, Cancer. — Tubercular pelvic peritonitis may supervene 
 slowly, as a diathetic manifestation, upon pre-existing pulmonary dis- 
 ease, and scarcely attract attention during life. It may develop simul- 
 taneously with the pulmonary disease, it may precede it, or it may run 
 its course without any pulmonary complications. Usually, tubercular 
 
 ^ On Childbirth, translated by Chadwick, 1876. 
 
ph'iA'fc rr.iurosiTis. ok;; 
 
 peritonitis has liccii picccdcd, at sumc [Miiod ninrc or |cs> rciiiolf, 1)V an 
 attack of sini|)lr pilvic jKTitonitis. 
 
 I'lu' canccroiis fofni of llic disease is (lie result of ext<.'nsi(»n <•(" nle- 
 rine cancer t(t the |)aranietric tissue, and thence to the peritonenni. 
 
 7. Ctiriitc F/c.rioiis (iiifl \'<rsi()iis. — An enlari;-e(l and (lisj)la<'ed nterns, 
 l»y dointi; injury to the neighl)orin<r peritoneiini, may give rise to a mild 
 lulhosive j)eritouitis. So also does a roughened, enlarged, ami di-placed 
 ovary. 
 
 <S. Piii'ic ('c/lii/iti.-<. — Pelvic peritonitis very <»t'ten — indeed, generally 
 — exists wlierever there is a pelvic cellulitis. The anatomical connections 
 hetwecn the two structures are very intimate, and hoth inflammations 
 are the result of a common cause. I do not think it strictly correct to 
 say that the pelvic cellulitis is the cause of the peritonitis. 
 
 While considering the influence of all the varying causes which have 
 been enumerated, it is important to remember a fact which is clearly 
 established by the auto[)sies of Bernutz; that is, the almost constant 
 association of diseased FallojMan tubes Avitli ])elvic peritonitis, and the 
 frequent existence of pelvic peritonitis unassociated with pelvic cellu- 
 litis. Abdominal sections and post-mortem observations by Polk and 
 others substantiate the truth of these conclusions. 
 
 Symptomatology. — Pain, severe and paroxysmal, is the most prom- 
 inent and the most constant symptom of acute pelvic peritonitis. This 
 pain, located in the hypogastric and iliac regions, may come on sud- 
 denly and without premonitory warnings, or it may be preceded for 
 days by feelings of weight and pelvic discomfort. The slightest move- 
 ment of the body intensifies the patient's suifering. Micturition and 
 defecation become painful. Great anxietj' is depicted in the counte- 
 nance, dark circles are seen beneath the eyes, and the patient clamors 
 for relief. The dorsal decubitus, with the thighs flexed, is the position 
 generally assumed. The abdomen in its lowest part is sensitive to the 
 lightest touch. It is somewhat swollen, and is resistant to pressure, l)ut 
 in the beginning of the attack, before exudation occurs, it is resonant 
 on percussion. In most of th^ cases gastric symptoms constitute a 
 marked feature, and nausea and vomiting occasion much distress. The 
 bowels are usually constipated, though occasionally there is diarrhcea. 
 The pulse is small and frequent or else feeble and depressed, not reach- 
 ing 100. The temperature in many severe cases will reach 105° ; in 
 most cases its range is moderate, yet, as will presently be shown, there 
 are many exceptions to this rule. 
 
 But the manner of invasion of pelvic peritonitis is variable. In 
 some instances it is abrupt and well marked, being introduced by a 
 chill. At other times it approaches slowly, there is no distinct rigor, 
 and several davs elapse bef<»re its character is established. These cases 
 are of the subacute or chronic form, and their real nature may at first 
 
694 PEBIVTERINE INFLAMMATION. 
 
 be easily overlooked. Instead of well-defined pain, there will be only- 
 soreness through the pelvic region. The patient perhaps does not go to 
 bed, but complains of languor and debility, and there is a slight febrile 
 movement in the evening. 
 
 One of the earliest symptoms of this disease is a moderate meti'or- 
 rhagia. 
 
 These are the conspicuous features of j)elvic peritonitis. It should, 
 however, be borne in mind that the symptoms will differ very greatly 
 in different cases. This will not be a matter of surprise when we 
 remember that a variety of pathological conditions underlie pelvic 
 peritonitis, or, in other words, that the peritoneal inflammation is in 
 itself only a symptom of several different morbid states. 
 
 Braxton Hicks ^ has stated that in some malignant cases of sep- 
 tic origin all the usual symptoms are wanting, " the rapid pulse 
 and pyrexia, coupled with a peculiar expression of countenance, being 
 almost our only guide," The abdomen in these cases is filled with a 
 purulent fluid, and vaginal examination discovers none of the usual 
 physical signs. 
 
 In reference to the symptom of pain, which is so characteristic of 
 peritoneal inflammation generally, it may be stated that sometimes, even 
 in extensive suppurating peritonitis, there is no pain whatever. Bernutz 
 emphasizes this fact, and Duncan^ says: "I might adduce cases of 
 gonorrhoeal ovaritis, commencing in healthy girls and ending in the 
 fusion of all the parts in the pelvis into a solid, immovable mass, with- 
 out the patient losing a cheerful, and even gay, visage, or making any 
 great complaint of pain, unless interrogated closely, and then alleging 
 the chief suffering to be from irritable bladder." 
 
 The range of the thermometer is also a feature which presents great 
 variations from the course described. Although very high temperatures 
 are often seen in peritonitis, the thermometer may be scarcely above 
 normal, or even below it, in the gravest cases. " Subnormal temper- 
 atures are especially common in peritonitis, and always suspicious: 
 death may follow these closely. High and rising temperatures do 
 not add, -per se, arguments for an unfavorable termination, although 
 adding another dangerous element to the case. It is not so much the 
 actual height as its constancy which must be feared, as must also great 
 and irregular fluctuations between very high and very low temperatures, 
 similar to pysemia, common in endocarditis, less frequent in inflamma- 
 tions of the pericardium, pleura, and peritoneum : these are always 
 highly dangerous."^ Very serious cases with a temperature never 
 2'oina- above 100° durins; their entire course are of common occurrence. 
 
 The progress of the disease varies greatly, and no precise hmit can be 
 
 1 Quain's Diet, of Medicine, 6th ed., " Pelvic Peritonitis." ^ Op. cit., p. 78. 
 
 ^ Medical Thermometry, Wimderlich, Seguin, p. 167. 
 
/ 'EL \ IC PKRITOMTIS. (J ! ) . j 
 
 assi«i;iu'<l to it> iliiialion. 1 1' the iiill;iiiiiii:itii»ii Ik- a >iiii|)Ic ;Klli(si\<- iicri- 
 toiiitis, the sviiipliiiii- may attract hut little attention, and no knnwledtre 
 l)e had of the atla<'k diuini:; life. Should the patient die IVoni .some 
 other cause, adiiesions attest its oeeiii-rence. If tiie jjoritoiiitis he due to 
 rupture of a tuhal ])re<inancy ahout the sixth oreii^hth week of gestation, 
 all inrianiniation may ilisappear in lour or live weeks, the ovum heeome 
 encysted, and eonvalescenee be slowly established. 
 
 ri' the morbid eonditif)n bi" diseased tubes, with ])erhaj»s hvdro- or 
 j)yosalj)inx, no limit can be Hxed to the duration of the consequent 
 peritonitis. It eontiiuies indeHnitely with frequent exacerbations, and 
 induces a condition of confirmed invalidism of the most pitiable kind. 
 The earliest period at which an attack of the sero-adhesive variety 
 may be expected to terminate is four oi- live weeks, and it will often 
 continue much longer. 
 
 One characteristic feature of the disease which has not yet been men- 
 tioned is a tendency to exacerbations. The patient may seem to be ap- 
 proaching convalescence, when all at once, without appreciable provo- 
 cation, there will be a return of pain, a rise of temperature, and an 
 increa.se of the exudation in the pelvis. The cause of this sudden 
 change may be some physical exertion on the part of the patient, or 
 else that determination of blood to the pelvic organs Avhich precedes 
 menstruation. A^ery often the exacerbation will be inexplicable except 
 upiMi the view suggested by ]Mr. Lawson Tait, that there has been ruj>- 
 ture of an occluded and distended tube, or that of Matthews Duncan, 
 the rupture of small follicular dropsies in the ovarv. Generallv, tliese 
 exacerbations are induced by the escape of the contents of the tubes into 
 the pelvic cavity. 
 
 In very protracted cases there will usually Ijc found purulent collec- 
 tions at some point in the pelvis. The occurrence of suppuration will 
 sometimes, but by nc^ meiius alwavs, be indicated bv rigors, fevei^ of 
 the hectic type, and night-sweats. After pus fjrms, unless it be com- 
 pletely evacuated by surgical or natural means, a cachectic condition 
 arises which sooner or later gives rise to certain secondarv affections of 
 grave importance. Bernutz has placed these in a very clear light before 
 us, and they are familiar to all who have studied this disease. 
 
 The first of these secondary affections is an extension of inflamma- 
 tion through continuity of tissue to the abdominal ])eritoneum. The 
 second is a catarrhal and often ulcerative inflammation of the mucous 
 membrane of the entire intestinal tract, giving rise to an intractable 
 diarrh(fa. About the time this affection arises a third is often added, 
 to w^hich Andral has previously directed attention ; that is, a form of 
 broncho-pneumonia with profuse jjurulcnt expectoration. The condition 
 of thi^ patient now closelv resembles that of one in an advanced staire 
 of jiulmonary con-umjnion. 
 
696 PERIUTERINE INFLAMMATION. 
 
 Chronic Pelvic Peritonitis. — There is much of truth in the remark 
 of Bernutz, that in chronic peritonitis " one only of the elements of 
 the affection is really chronic — viz. the uterine, the tubal, or the ova- 
 rian affection which originated the peritonitis, and which, with each 
 aggravation of the malady, sets up fresh peritoneal mischief, thereby 
 modifying the condition of the periuterine swelling." 
 
 It is very probable that many of the cases of chronic or recurrent 
 pelvic peritonitis owe their long continuance to the escape into the peri- 
 toneum of inflammatory products from a distended tube. This is espe- 
 cially true of gonorrhoeal cases. 
 
 While the chronic form is often the result of an inflammation which 
 was at first acute, very many cases are essentially chronic from the 
 beginning, the patient being for long more or less of an invalid, and 
 not taking to her bed except at the menstrual periods, when she is then 
 forced to do so from pain and slight febrile movement. In other cases 
 the chronicity appears to be due to the influence of some previously- 
 existing constitutional taint, such as syphilis or tuberculosis. 
 
 M. Aran said,^ ''At least two-thirds of the women who suffer from 
 chronic pelvic peritonitis are the subjects of tuberculosis." 
 
 Physical Signs. — In many cases an exploration of the pelvis will 
 reveal to the examining finger great tenderness over the entire pelvic 
 roof and resistance upon pressure on all sides of the uterus. At the 
 same time, the vaginal culs-de-sac are clear; no tumor can be any- 
 where felt; the inflammation is not localized. The position of the 
 uterus is that which it occupied in health, and any attempt to change 
 it produces pain. Fixation of the uterus is absolute — a degree not 
 attained in uncomplicated pelvic cellulitis. 
 
 In other cases to the physical signs just enumerated that of tumor 
 will be added. This tumor is close to the uterus, and yet distinct from 
 it, the two being separated by a groove. The tumor is composed of 
 false membranes binding together portions of the pelvic viscera, to 
 which a pyosalpinx is often added ; or it may consist of an encysted 
 serous or purulent effusion in addition to the above. 
 
 This tumor has many of the signs of a phlegmon, but may usually 
 be distinguished from it by the following characteristics : 
 
 I. Its Position. — (a) It occupies the latero-posterior part of the 
 uterine circumference, being situated in Douglas's pouch, and extends 
 at the same time into one of the retro-ovarian shelves. It then neces- 
 sarily pushes the uterus and one broad ligament forward in proximity 
 to the pelvic bone. 
 
 (6) It may be an encysted serous or purulent effusion, having for its 
 lower and lateral boundaries the walls of Douglas's pouch. It will 
 then carry the uterus and both broad ligaments upward and forward 
 
 ^ Legons diniques sur les Maladies de V Uterus, p. 716. 
 
VELVK' I'lJ'JTOSITIS. fi07 
 
 a<i;aiiist the [nihic hone, ami tlu; aiiatuiuical outlines of this poiirli will 
 he ck'arlv (li'liiicd on tlic postt'riur wall of the vuf^ina. The eiitin; 
 j)()sterior halt" of the pilx is i< then o((ii|)i((l hy the prodiici-. (.f iiiflaiii- 
 niation. 
 
 ((') Another |oi-ii» ot" tumor is a small, wcll-ddimd swcUin}^ the size 
 ot" a |)ii!,('oirs e<2:«:; or lar^t-r, occupying one of the lateral culs-de-sao 
 situatetl hehind the hroad ligament, separated from the side of the 
 uterus hy a groove, and extending; to ahout the level of the fundus. 
 Sueh a tumor may consist (»f a small serous or purulent eolleetion 
 enclosed hy false inemhrancs extendino; from the si«:;moid flexure to 
 tlie left hroad liirament, the ovary and Fallopian tube forminj^ part of 
 the mass. 
 
 A tumor of any size situated in the utero-vesical pouch is very rare, 
 because of the shallowness of this pouch ; hence we scarcely look for a 
 peritoneal accumulation in front of the uterus. 
 
 II. The Changeable Nature of the Tumor. — Bernutz called attention 
 to its disappearance, and reappearance in perhaps a different situation, 
 at short intervals. While I have repeatedly observed this, it has been 
 particularly noticeable in chronic cases which I would see at intervals 
 of one or two weeks. The change in position was often so marked that 
 I might have douI)ted the correctness of the previous examination had 
 I not made a careful record of the exact size and location of the 
 tumor. 
 
 III. Peritoneal Tumors are Extremely Sensitive to the Touch. — As a 
 rule, they rarely extend above the superior limits of the pelvis, and 
 can be explored only through the vagina. In cases of long standing, 
 however, the inflammation may gradually extend beyond the limits of 
 the pelvis, and the tumor then become abdominal. Occasionally, I 
 have seen abdominal tumor form in recent cases when there was no 
 ground for the suspicion of haematocele or rupture of an extra-uterine 
 pregnancy. 
 
 DiFFEREXTiAL DIAGNOSIS. — The diseases most likely to be con- 
 founded with pelvic peritonitis are pelvic cellulitis and intraperitoneal 
 hiematocele. That from which its differentiation is most difficult and 
 most frequently called for is pelvic cellulitis. In some cases this dif- 
 ferentiation is impossible: the two diseases coexist, all the structures of 
 the pelvis are involved, and the only diagnosis possible is pelvic inflam- 
 mation. In other cases the diagnosis can be satisfactorily made. It 
 should always be attempted, not only on the ground of scientific accu- 
 racy in the study of disease, but because of its practical bearing upon 
 prognosis and treatment. A careful study of the ca^ in all its aspects, 
 and an intimate acquaintance with the anatomy of the pelvic perito- 
 neum and cellular tissue, by enabling the observer to locate preciselv 
 the exudation, will often lead to the formation of a correct opinion. 
 
698 PERIUTERINE INFLAMMATION. 
 
 The etiology is of the first importance as an aid to diagnosis. Cel- 
 lulitis is an inflammation essentially acute in its character, generally 
 associated with a well-marked septicemia, and apt to eventuate rapidly 
 in suppuration. It commonly occurs after labor or abortion, and may 
 follow gynecological operations upon the cervix. In this form it is also 
 associated with salpingitis and pelvic peritonitis. 
 
 But pelvic peritonitis may also occur as a septic inflammation, and 
 terminate rapidly in death uncomplicated with cellulitis. Bouchut's 
 case, occurring after menstrual suppression from cold (reported by 
 Bernutz, Case III.), was evidently of this character. 
 
 Dr. H. C. Coe, the pathologist to the Woman's Hospital of the State 
 of New York, in a paper entitled " The Exaggerated Importance of 
 Minor Pelvic Inflammations," ' makes the following statement : " Of 
 half a dozen fatal cases of hystero-trachelorrhaphy and incision of the 
 cervix, in which I have enjoyed the rare opportunity of studying care- 
 fully the sequences, in every instance the cause of death was acute dif- 
 fuse peritonitis. The inflammation could be traced straight up from the 
 wound along the mucous membrane of the uterus as an endometritis, 
 along the tubes as a pyosalpinx, and then to the peritoneal cavity. In 
 none of these cases was there any evidence of acute cellulitis, although 
 old cicatrices were not wanting." 
 
 Peritonitis usually, however, is not of a septic character. The causes 
 which give rise to it are well known and have already been enumerated. 
 It is generally the result of disease beginning in the vagina or uterus, 
 giving rise to an endometritis, and spreading rapidly or slowly, in an 
 acute or chronic form, by continuity of tissue as a salpingitis, until the 
 peritoneum is reached. 
 
 The importance of differentiating peritonitis from cellulitis does not 
 attach to those pelvic inflammations which are associated with a M^ell- 
 marked septicsemia, for here both structures are usually involved; but to 
 the more chronic forms, and to those attacks of simple acute inflamma- 
 tion of which the memoir of Bernutz affords so many examples. 
 
 The chronic forms to which I refer have been fully described by 
 Polk in the paper spoken of. They have also been discussed by 
 Coe as " minor pelvic inflammations," and by Dr. Frank P. Foster^ 
 as "lesser pelvic inflammations." They are characterized by inflam- 
 matory masses in the pelvic roof, on the sides of or posterior to the 
 uterus, by the presence of circumscribed areas of periuterine inflam- 
 mation ; by areas of " induration," " resistance," or apparent " thick- 
 ening of the tisues " situated most commonly about the base of the 
 broad ligaments or near the utero-sacral ligaments ; and are painful 
 on pressure. 
 
 By some, these localized inflammations have been regarded as chronic 
 
 ' The New York Med. Journ., May 15, 1886. "^ Ibid., Jan., 1881. 
 
riCLVfC PERITONITIS. i\\)\) 
 
 cellulitis, hy otlicrs ;is |)crii()iii(is. ICmiiict ' laid jrrcjit -tress upon tlicm, 
 aiwl Ujxiii tlu' iiii|n>rtaiicc (tf their feednnition, aixl he has i-e<;anle(l theni 
 as the result (»r a limited cellulitis, lie deserihed them as jjcing most 
 tre(jiiently f'oiuid uiidiT tin' pn.-terior I'aee of the left hroad li'rauieut 
 in elose pi'oximity to the cervix or cxteiidiiiu hackward alon<:; the rjo-ht 
 utero-sacral liuament. He says: " If thickening ut any point can he 
 detected, or an unusual amount of pain he elicited by j)reH.sure of the 
 fiiiiicr, it will l)e inadmissil)le t(j institute any surjrical |)rocedin-(,' or to 
 attempt to reduce the uterus if it is retroverted, to introduce the sound, 
 or to make any application with in the uterine canal." 
 
 In many cases these tender j)oint.s or localized areas of inflammation 
 are easily overlooked in examining the pelvis, for they are not at the 
 base of the broad ligament, but are high up and require a far-reaching 
 finger to detect them. The opinion that these areas are the result of 
 cellulitis is held chiefly by those who have been guided bv clinical 
 observation alone. 
 
 Since Emmet's work was written the results of abdominal section, so 
 extensively practised during the past two years in Europe and America, 
 have contributed largely to the elucidation of this subject. In fact, they 
 have demonstrated that the exudations here described, and for so lons" 
 considered as cellulitic in character, are in reality the products of a 
 peritoneal inflammation. Thus, Polk in the paper referred to presents 
 a record of cases " in which the symptoms and signs present were those 
 of pelvic cellulitis and pelvic peritonitis, but in Mhich abdominal sec- 
 tion showed salpingitis, periovaritis, and peritonitis. In two of the 
 cases there Avas slight oedematous swelling of the cellular tissue in the 
 broad ligament just beneath the spot at which an inflamed tube had 
 rested ; in the remainder the most careful examination failed to detect 
 the slightest induration or swelling in any part of the cellular tissue 
 that lay about the uterus or between the peritoneal lavers of the 
 ligaments," 
 
 In these cases the bimanual exploration of the pelvic organs was 
 employed before and after the operation. After removing the diseased 
 uterine appendages, the swelling could not be found in a single case. 
 This is testimony of the most positive character. 
 
 The same conclusions in regard to the nature of these swell inir'=i have 
 been reached by those Avho have had opportunity to make post-mortem 
 examinations. Thus, Coe, in the paper referred to, states : " Peritonitis 
 is certainly the most prominent element in most of these cases, as far as 
 the post-mortem ap})earances afford any light." In a different connec- 
 tion he says: "By far the greatest number of these indurations are 
 situated high up in the broad ligaments, and consist of cicatricial 
 masses mostly confined to the peritoneum, of tubes or ovaries sur- 
 * Principles and Prac. of Gynecolo'jy, 1 884. 
 
700 PERIUTERINE INFLAMMATION. 
 
 rounded by old adhesions, or occasionally of an imprisoned knuckle 
 of intestine. 
 
 " The thickening of the utero-sacral ligaments so frequently alluded 
 to in works on gynecology has, when carefully dissected out, proved in 
 my experience to be due not so much to a disease of the connective tissue 
 of these ligaments as to a cicatricial condition of the peritoneum cover- 
 ing them." . ..." I confess that I have rarely (perhaps half a do2en 
 times) found such thickenings in the cadaver which could be referred to 
 a pure and straightforward cellulitis or inflammation of the connective 
 tissue; and this, too, where I have recognized by the vaginal touch 
 {before and after deathj what seemed to be an induration, a distinct 
 band extending outward from a deep laceration of the cervix, or a con- 
 dition of tension in or above one lateral cul-de-sac which did not exist 
 on the opposite side." 
 
 Polk makes the following statements : " In a large number of post- 
 mortem examinations made in the dead-house of Bellevue Hospital it 
 is noticed that, excepting those patients who have died of septicaemia, 
 it is the rarest thing to find pelvic cellulitis, unless the cellulitis be 
 clearly secondary to a previous inflammation of the pelvic peritoneum." 
 
 This evidence is adduced here in full in order to show that the common, 
 every-day form of chronic pelvic inflammation which attracts the atten- 
 tion of the gynecologist, as well as the simple acute pelvic inflammation 
 which is met with unconnected with septicoemia, is pelvic peritonitis asso- 
 ciated with diseased, appendages, and is not pelvic cellulitis. 
 
 Intraperitoneal hfematocele will be characterized by the following 
 history : Shock, anagmia, pain, and vomiting are the symptoms which, 
 all of a sudden, announce the occurrence of hsematocele if the hemor- 
 rhage be copious. Then, should the bleeding cease and reaction occur, 
 coagulation of the blood begins and peritonitis ensues. The effusion 
 being walled in by lymph, a tumor is formed which at first is soft and 
 fluctuating. As more lymph is effused and the coagulum becomes 
 firm, the tumor grows hard and resistant. This tumor, like that in 
 pelvic peritonitis, is usually retro-uterine, and pushes the uterus 
 upward and forward against the pubes. Unlike recent peritonitis, 
 there is usually in hsematocele an abdominal tumor. 
 
 But hsematocele often fails to make itself known by rational symp- 
 toms. Of 28 cases reported by Bernutz, the diagnosis being confirmed 
 in 20 either by puncture or autopsy, symptoms of hemorrhage were 
 present in 8 only. Symptoms indicating syncope or collapse are very 
 often absent even in large hsematoceles. 
 
 In these cases, inasmuch as the physical signs are identical with those 
 of peritonitis, a diagnosis may not be possible unless suppuration occurs. 
 When it becomes necessary to open the abscess, the discharge of coagula 
 with the pus will then reveal the true nature of the attack. 
 
PELVIC i'/:i:iTf).\iTis. 701 
 
 Occasionally liu'inaiitcflc tolldws iipun pi ritoiiitis, jls .shown hv 
 Viivliow, the litiM()rrliai;f hciiitr <lii<' to the ni|)tiir(' of new vesseisj 
 in the lalse nicinhrancs. 
 
 Thougli it l)c a digression fioiii the subject we are considering, yet, 
 as strictly relate<l to it, mention may here he made of a symj)tom which 
 has lont; l)een known as e(»lica seortorum. It is an interesting incident 
 in the history of jx-lvie peritonitis, and when [)resent may serve to 
 make clear a diagnosis which without it might be oljscurc. 
 
 This is an agoni/ing pain on one side of, and deep down in, the 
 ])elvis, coming on from time to time without provocation, and accom- 
 panied or followed by a purulent discharge from the uterus. During 
 the attack the \)uUii becomes depressed and feeble, the surface is cov- 
 ered by a cool perspiration, and the pain is often so severe that nothing 
 short of hypodermic doses of mor})hia will afford relief. 
 
 Exploration of the pelvic organs will in many cases reveal no tumor; 
 no evidences of inflammatory exudation may be appreciable, but there 
 will be tenderness over the pelvic roof. The patient suffering thus 
 gives the history of jirolonged invalidism, of fevers, emaciation, alxlom- 
 iual tenderness, w ith meteorism, painful and otherwise disordered men- 
 struation. The symptom most characteristic of these cases is a history 
 of repeated attacks of pelvic inflammatiou without appreciable cause. 
 
 Colica seortorum, though generally due to a gonorrhoeal endometritis, 
 is not always so. It signifies occlusion and distension of a Fallopian 
 tube — pyosalpinx — the uterine mouth of the tube being still open. The 
 attacks of pain are due to contractions of the muscular walls of the tube 
 in the endeavor to expel their contents through a small orifice into the 
 uterus. 
 
 This is Lawson Tait's ^ explanation of the symptom, and it accords 
 with my own observations. I have observed this svmptom in several 
 cases M-here there could be no doubt as to its true meaning or as to the 
 diagnosis, and yet a physical exploration of the pelvis would throw very 
 little if any light upon the subject. The tubes could not be felt, nor 
 would there be any trace of tumor. 
 
 Referring to this subject, Fritsch ^ remarks : " It is noteworthy that 
 there are cases of this nature in which, despite agonizing suffering for 
 years, neither distinct adhesions nor tumor appear." 
 
 Dr. Thomas Savage,^ speaking of disease of the tubes, states : " In 
 some instances I feel sure there is nothing to be felt in the pelvis before 
 operation, and we have nothing to guide us but the more or less con- 
 stant pain and recvu-ring attacks of inflammation." 
 
 Prognosis. — Simple adhesive pelvic peritonitis usually runs a mild 
 course, and complete recovery ensues. The uterus is often displaced 
 
 * " A Clinical Lecture." X Y. Med. Journ., Oct. 1?, 1884. * Op. eit., p. 285. 
 
 ' " Diseases of the Fallopian Tubes." 18S3, reprint from Birmingham Med. Bev. 
 
702 PERIUTEPdNE INFLAMMATION. 
 
 and fixed beyond remedy by adhesions to the rectum, to coils of intes- 
 tine^ and occasionally to the bladder. 
 
 Septic peritonitis is attended with a very grave prognosis as to life. 
 Peritonitis of gonorrhoeal origin usually implies sterility and invalid- 
 ism for years. Purulent peritonitis is a much more serious form than 
 the sero-adhesive variety. The puerperal state adds much to the grav- 
 ity of the case. In attacks of even moderate severity- the prognosis 
 should be guarded. 
 
 In view of the frequency of collections of pus in the tubes, grave 
 accidents are liable to happen in any case. 
 
 A high pulse and temperature indicate a severe attack, but, as before 
 shown, a low temperature does not necessarily imply a favorable prog- 
 nosis. A^underlich says : " Hyperpyretic temperatm-es in peritonitis 
 lead us to suspect an infectious origin, and indicate a speedy death with 
 a high temperature." 
 
 The extension of the disease beyond the limits of the pelvis adds 
 greatly to the danger. It may then be regarded as general peritonitis. 
 
 Although this form of pelvic inflammation often entails many 
 untoward results, such as atrophy of the ovaries, obliteration of the 
 tubes, and fixation of the uterus in a false position, and, in consequence 
 of these, disorders of menstruation and sterilit}^, yet it is not uncommon 
 after the severest attacks, in which life for a time hangs by a thread, to 
 see recovery complete and all the sexual functions re-established. Men- 
 struation again goes on normally, adhesions undergo aljsorption, the 
 -^vomb recovers its proper position, and conception occurs. 
 
 Treatmext. — The most important principle involved in the treat- 
 ment of acute pelvic peritonitis is the maintenance of absolute physical 
 rest. Every movement of the body should be prevented as far as pos- 
 sible, and the patient should not be allowed to rise or to leave the bed 
 for any purpose whatever until convalescence is established. In order 
 to put this principle in practice opium in some form must be freely 
 administered, and it must be continued to the verge of moderate 
 narcotism until the acute stage of the inflammation has subsided. 
 After this the doses should be diminished to the point of keeping the 
 patient quiet and free from pain. 
 
 In severe attacks the hypodermic use of morphia will be required to 
 bring the patient under the influence of the drug, and for a time this 
 method of continuing its use will be necessary. As soon as possible, 
 however, it is better to substitute for it the administration of opium 
 by the stomach. 
 
 At first no effort should be made to move the bowels, but after several 
 days have elapsed calomel may be given, in one-grain doses every three 
 hours until three or four grains have been taken. Tlien, with the aid 
 of an enema, a very gentle purgation will be the result, the gastric 
 
PELVIC I'h'nrroyfTrs. 7();i 
 
 symptoms will Ik- lessened, and tlic l)a([ <-llt'<'ts of opimn upon tlic 
 secretions will l>e diminislied. 
 
 \\ liilc |iiii<;ative medicines must he n-ed wilii extreme <^ution, or 
 not at ail, in peritonitis, wo must by such j^entle measures as these 
 throntrhout the diseitse take ("arc that fecal uccunudations do not w-cur. 
 
 In ilie very he<^inning the ai)pli("ation to the abdomen of hot turpen- 
 tine stupas or hot poultices aifords much relief to the pain. Heat 
 applied to the extremities will also be required in the state of dejues- 
 sion which often characterizes the early stages of peritonitis. Among 
 the remetlies which experience has shown to i)e of great value is a, 
 blister, which should be placed over the hypogjistrium. In con- 
 junction with this a poultice of cooked starch should i)e made to cover 
 the entire abdomen. When the blistered surface has healed the blister 
 mav from time to time be reapplied with great advantage; and as long 
 a-s the products of inflammatiou are appreciable, warm moist dressings, 
 in some form or other, should be w^orn ov^er the abdomen. 
 
 If the temperature runs high, reaching 104° or 105°, instead of the 
 measures just mentioned the rubber coil or some other device for the 
 continuous application of cold to the abdomen should be used. Anti- 
 pyrine also, either by stomach or enema, is of the greatest value in the 
 reduction of temperatm*e. 
 
 Throughout the acute stages of the disease the diet should be milk 
 and lime-water, pancreatized milk, buttermilk, and animal teas. But- 
 termilk is nearly a perfect diet, theoretically and practically, for fever 
 patients. 
 
 Chronic cases are to be treated by a repetition of blisters, the external 
 use of iodine, and the wet compress. At the same time, the utmost 
 attention should be paid to the improvement of the general health bv 
 sunlight, by the introduction of food and tonics into the svstem, and 
 in some cases by passive exercise in the open air and by a change of 
 climate. 
 
 In many of the chronic cases M-e shall find displacement of the uterus 
 backward, tenderness and fulness and resistance upon pressure in the 
 region of the tubes, and one or both ovaries enlarged, displaced, and 
 very sensitive to the touch. Uterine mobilitA' is also impaired. 
 
 One very important principle in the treatment of such cases is rest. 
 With this should be combined sunlight and good diet. The strictest 
 attention should be paid to the improvement of the digestion and to the 
 avoidance or relief of constipation. Iron, cod-liver oil, malt, and the 
 hypophosphites are the medicines usually found most beneficial in such 
 cases. 
 
 Much may be accomjilished for the relief of the inflammation by 
 local treatment also. The Preissnitz compress, or wet bandages covered 
 with rubber cloth, may be worn around the hips continuously, night and 
 
704 PEBIUTEEINE INFLAMMATION. 
 
 day, until the skin becomes tender and irritated. The hot vaginal 
 douche, used in large quantities twice a day, at a temperature 115° to 
 120° F., while the patient is in the recumbent position, is an agent of 
 great value, for the knowledge of which the profession is indebted to 
 Emmet. 
 
 The application of the strong tincture of iodine to the vaginal roof, 
 a,nd the filling of the upper part of the vagina with absorbent cotton 
 which has previously been saturated with pure glycerin, will do much 
 toward emptying congested tissues, relieving pain and soreness, and 
 promoting absorption of the exudation. 
 
 Cautious, gentle efforts by manual or other pressure should be made 
 to restore the uterus to its proper position if it has been displaced. But 
 the use of the sound or the probe or the repositor for this purpose will 
 be attended with very great danger of provoking a fresh endometritis, 
 a salpingitis, and a peritonitis. If the retroversion can be corrected, a 
 pessary may be watchfully used to keep the uterus in place, provided 
 the tenderness has been previously removed by the means just described. 
 
 In some cases, after the peritonitis has disappeared a most troublesome 
 feature will remain and baffle the most patient and persevering treat- 
 ment. One of the appendages, the ovary or the tube, will remain 
 displaced, tender, adherent in Douglas's pouch or in one of the retro- 
 uterine shelves, and we cannot dislodge it. The patient will suffer 
 much from this alone. She will experience nearly constant pain, inabil- 
 ity to stand or exercise — will be nervous and suifer from backache and 
 from irritable bladder. 
 
 After the appendages have been fixed by adhesions in the manner 
 and position here described, I know of no means which we possess for 
 dislodging them save by, removal through abdominal section. 
 
 While much of good can, as a rule, be accomplished by the plan of 
 treatment just described, cases are frequently met with in which no 
 improvement whatever follows. Kepeated attacks of inflammation 
 arise from time to time, exhausting the patient's strength, or else, at 
 some period in the history of a case which perhaps has been chronic 
 from the beginning, violent, acute symptoms are developed, indicating 
 general peritonitis. 
 
 The proper treatment for such cases is now generally admitted to be 
 that which has been made clear by Mr. Lawson Tait. His method 
 consists in opening the abdomen by an incision between the umbilicus 
 and pubes, removing the diseased ovaries and tubes which tend to per- 
 petuate the inflammation, evacuating accumulations of serum and pus, 
 carefully cleansing the peritoneum, and in proper cases making use of 
 drainage. This method is a rational deduction from the pathology of 
 pelvic peritonitis as it was given to us by Bernutz. It is also the appli- 
 cation of a surgical principle which has afforded the best results in the 
 
PELVIC ('KLIA'IJTIS. 705 
 
 treatiuciit of pniiilriii iiitl;iiiiiii:iti(iiis in otlwi- cavities of the \un\\- liiictl 
 bv serous iiR'iiil)iaiu's. 
 
 This surgeon, wlio has ublaineil sudi brilliant results I'roin abdominal 
 section, says: " By no means the least satisfactory groups in the above 
 list are those of acute and chronic i)eritonitis. In these c<Lses absolute 
 cures have been etiected, in every instance by the simple ])lan of open- 
 ing the peritoneal cavity, cleaning it out, and draining it for a short 
 time. That tluy were cases of an extreme kind might be shown by 
 their details, but probably one will suffice. I take the following descrip- 
 tion of the patient's condition from a letter written to me by Dr. Justin 
 McCarthy, who sent her to me : ' The condition in which I found her 
 was one of the greatest emaciation : seldom have I seen it greater, unless 
 in the last stage of phthisis. There was an enlargement of the abdomen 
 of rapid growth, and she had incessant vomiting and diarrlujia,' " 
 
 In addition to these, Mr. Tait published in the Briti-ih Med. Journ., 
 June 28, 1884, 5 cases of extra-uterine pregnancy operated on by 
 abdominal section shortly after rupture of the tube. In these cases 
 he was practically cidled upon to deal with a severe peritonitis, since 
 the condition was marked by rapid pulse and high temperature. Four 
 of these ca.ses were thus successfully treated. Very soon after he pub- 
 lishetl his results in 18 other cases, making 23 in all, with but a single 
 death. 
 
 The cases to which treatment by abdominal section is applicable may 
 be classified under the following heads : 
 
 1. Those chronic cases in which the sufferer has made full use of the 
 treatment discussed in this article without benefit, and has become a 
 helpless invalid. 
 
 2. Those cases in which the condition resembles the last stage of 
 phthisis, and the presence of pus is indicated by the symptoms of 
 hectic. 
 
 3. Chronic cases in which the symptoms have become suddenly and 
 urgently acute, and there are good grounds for the conclusion that ru[)- 
 ture of a pyosalpinx or an ovarian abscess has occurred. 
 
 4. Acute cases in which the pulse and temperature run high, and the 
 history justifies the presumption that the peritonitis is due to rupture of 
 the tube from a Fallopian pregnancy. 
 
 To-day there is nothing l)etter established in surgery than the treat- 
 ment, in jjroper cases, of peritonitis by abdominal section and drainage. 
 
 Pelvic Cellulitis. 
 
 SvNOXYMS. — 1. Periuterine phlegmon (XonatV, 2. Parametritis 
 (Yirchow, ^Matthews Duncan, Schroeder) ; 3. Periuterine cellulitis 
 (Thomas). 
 
 Vol. L — io 
 
706 PERIUTERINE INFLAMMATION. 
 
 The term " pelvic cellulitis " is here applied to an inflammation of 
 Virchovv's parametric tissue, which surrounds the cervix and upper 
 portion of the vagina ; and of the connective tissue which extends from 
 the sides of the uterus between the layers of the broad ligaments. Orig- 
 inating thus, the inflammation may extend to the connective tissue in 
 other parts of the pelvis. 
 
 Etiology. — Inflammation of tlie cellular tissue in any part • of the 
 body may arise from traumatism applied directly to the tissue itself; 
 or from extension of inflammation from some adjacent organ ; or else 
 from septic material introduced at a remote point and conveyed to it 
 by bacteria through the lymphatic and blood-vessels. 
 
 Pelvic cellulitis, pure and simple, is a rare disease. It is most com- 
 monly met with after parturition, and is associated with an evident 
 septicemia. The inflammation is not confined to the cellular tissue, 
 but usually involves also the endometrium, the membrane lining the 
 tubes, and the pelvic peritoneum. 
 
 In this, the puerperal form, the cellulitis has its origin in a septic 
 infection, the poison being introduced from without, and gains admis- 
 sion to the system through some one of the numerous abrasions to which 
 the genital passages are liable in parturition. Its occurrence is inti- 
 mately connected with the presence of bacteria ; and it is now quite 
 generally conceded that for the production of the cellulitis there must 
 be bacteria, which are introduced from without. There must also be 
 solution of continuity in the tissues of the vagina or the cervix, through 
 which the bacteria gain entrance to the blood. 
 
 Striking proof of the truth of this view is furnished by the experi- 
 ence of the New York Maternity Hospital. Since the adoption of 
 Garrigues's method of prophylaxis,^ the percentage of sepsis has been 
 reduced to .21 ; before its adoption the percentage of sepsis was 6.06. 
 The introduction of the same method into the Boston Lying-in Hos- 
 pital^ has reduced the percentage of sepsis to .0. 
 
 Steurer's microscopic investigations of the Strasbourg epidemic, under 
 the guidance of Yon Recklinghausen, showed that from the diphtheritic 
 patches on the vulva and the vaginal and uterine mucous membrane 
 " bacteria could be traced between the muscular fibres and deep down 
 into the canalicular spaces of the connective tissue, where their pres- 
 ence gave rise to cellulitis."^ 
 
 In the non- puerperal woman pelvic cellulitis is chiefly observed in 
 connection with surgical operations upon the cervix uteri, and is here 
 
 ^ Antiseptic Midwifery, by Dr. H. J. Garrigues, 1886. 
 
 ^ "Antiseptics in Obstetric Practice," by W. L. Eichardson, M. D., Boston Med. and 
 Surg. Journ., Jan. 27, j 887. 
 
 '^Science and Art of Midivifery, by W. T. Lusk, A. M., M. D., 1882, p. 617. 
 
PKLVIC Ci: LLC LITIS. 707 
 
 also of a s(>|)ti<' cliai'actcr. It is not a simple cellulitis, \n\{ is associated 
 willi peritonitis, as in the puerpei'al siiWjecls. 
 
 Tlie old method of treating' uterine poly|)us li\- deliiiation was not 
 iinl'ri'(|nenilv lollowed hy a >epiie intlammalion, which nj)on aiitopsv 
 was t'oiind to l)e pelvic ct'llidiiis with al)Uiidunt evidences (if perito- 
 nitis.' 
 
 Dilatation of the uterus hy tents, particidarly s))on<i:(' t<.'nts, has so 
 often lu'cn followed by severe and even fatal celliditis that the physi- 
 cian who uses them except for good reasons and after surroiuiding 
 his patient hy all known safeguards, lays himself justly o})en to 
 censiuv. 
 
 While, then, such is commonly the etiology of ])elvie eellulitis, to 
 use the words of Fritseh,' " it woidd be sacrificing truth to a principle 
 were we to assert that every parametritis is a traumatic aliection based 
 on infection." For in young girls and old women pelvic cellulitis 
 sometimes occurs without any recognizable lesion, and now and then 
 oin- attention is called to it in women in whom no uterine disease has 
 previously been suspected. 
 
 Circumscribed inflammations of the cellular tissue, non-septic in 
 character, probably arise froiu injury of the tissues of the cervical 
 canal, the process being propagated by continuity through the inter- 
 muscular connective tissue to the connective tissue on the sides of 
 the uterus or to that between the peritoneal folds constituting the 
 utero-sacral ligaments. This is Bandl's explanation of utero-sacral 
 celliditis. 
 
 Emmet ^ has met with two cases of cellulitis in children between 
 eight and ten years of age, and the records of his private hospital 
 contain the liistories of 15 cases of cellulitis after the menopause. 
 
 When we consider the change which our views have undergone 
 within the last few years in regard to the differentiation of pelvic 
 exudations, some doubt might naturally arise, in the absence of autop- 
 sies, concerning the true nature of these cases. But Aran * reported the 
 case of a woman eighty years of age whom he examined, and in whom 
 he found a swelling on the side of the uterus encroaching on the lateral 
 Avail of the vagina, which after death was found to consist of indurated 
 cellular tissue, presenting, under examination by Ch. Robin, numerous 
 fibro-plastic cells. 
 
 In some cases the cellulitis is due to a htematoma. In these the effu- 
 sion of blood takes place between the layers of one broad ligament by 
 rupture of its vessels or from the veins of the parametric tissue. 
 
 Pelvic cellulitis is essentially an acute disease. If at times it appears 
 
 ^ Diseases of WortuTt, by Alfred II. MoC'lintock. 
 
 ^ Di-^onses of Women, by Heinrich Fritseh. 
 
 ^ Op. cil.. p. 249. * Legons dinique^, p. 657. 
 
708 PERIUTERINE INFLAMMATION. 
 
 to be chronic, it is so because of its association with pelvic peritonitis, 
 to the continuance of which it owes its chronicity. 
 
 Professor Freuncl of Strassburg has described a chronic inflammation 
 of the pelvic connective tissue which has no acute stage. To this he 
 gave the name parametritis chronica atrophicans circumscripta et dif- 
 fusa. An account of his investigations has been presented to the 
 English reader in the admirable manual of Hart and Barbour/ and 
 from that source I derive my information. 
 
 The etiology of this form of cellulitis circumscripta is to be found 
 in ulcerative processes in the bladder, rectum, and uterus. Ulcerations 
 in the bladder and rectum produce inflammation in the connective tissue 
 surrounding those organs. Cicatricial formations with atrophy and con- 
 traction are the result, and the uterus is made to deviate from its nor- 
 mal position. Cicatricial tissue on the sides of the bladder gives rise to 
 right and left retroflexions of the uterus. 
 
 The result of dysenteric or simple follicular ulcers in the rectum is 
 cellulitis in the utero-sacral ligaments, which causes pathological ante- 
 flexion. 
 
 Laceration of the cervix is assigned as a cause of chronic cellulitis 
 at the base of the broad ligaments. This in time produces lateral 
 displacement of the uterus, compression of veins and nerve-filaments, 
 with cervical catarrh and reflex pains. 
 
 Pathology. — This form of pelvic inflammation is of very frequent 
 occurrence. Hart and Barbour remark : " Thus, split cervix, so com- 
 mon in women who have borne children, is almost always associated 
 with some cellulitis at the base of the broad ligaments." 
 
 The first result of inflammation of the cellular tissue is a sero-fibrin- 
 ous exudation from the blood-vessels. The tissue is then infiltrated by 
 young cells which arise from proliferation of the connective-tissue cor- 
 puscles. Their ranks are rapidly swollen by the emigration of white 
 blood-corpuscles from the capillaries. 
 
 As a result of pressure from this exudation and the crowding of 
 young cells, complete stasis of blood occurs in the capillaries ; necrosis 
 of the intercellular substance takes place; liquefaction follows, and 
 suppuration is the result. 
 
 If the inflammatory process stops short of the formation of pus, 
 resolution occurs, and the result is the production of a fibrous material 
 whose characteristic property is contractility. This is cicatricial tissue. 
 
 Cicatricial tissue in one of the broad ligaments causes a lateral ver- 
 sion of the uterus ; in the utero-sacral ligaments, traction upward and 
 backward of the cervix, which gives rise to pathological anteflexion 
 with its consequences, dysmenorrhoea and sterility. 
 
 Some writers allege that cellulitis never exists alone, but is alwavs 
 
 ^ Manual of Gyncecology, 3d ed., Edinburgh, 1886. 
 
PELVIC ci:LLri.n'is. 7<)i» 
 
 ass()ci:it('<l with iiiDfc ur Ic-s |)cl\ic |icrit<»iiili-. riitif is siitliriciil (-vi- 
 (Iciicc to sIkjnv that this npinidn is incorrect. 
 
 ('oiirtv' (U'clafcs tiiat hi- lias seen a |>iil('<i;iii<>ii ol' the rijilit hroad 
 li^-aiiKMit open into the roctuiu, and one of the left li<raineiit into tlie 
 va«^ina, without <2:ivin<>; rise to any symptoms of jxiritonitis; also, eases 
 of ehroni(^ cellulitis j^ivin<^ rise to cicatricial bands, with displacement 
 of the uterus, without a sym})tom of peritonitis durinj^; life, and leavinj^ 
 no trace whii'h could he discovered at death. He quotes Frarier's rase 
 of suj)puratiu<!: phlet!:inou of the ri<rlit broad lij^ament openinjr into the 
 bla(l(h'r, the autojjsy proviuo; that the })eritoneum did not participate in 
 the inllainniation. In Behier's case a suppurating; })hlegmon <jf the left 
 l)road iiuainciit extended to the iliac foasa after delivery, and terminated 
 fatally. There was no alteration of the })eritoneuni. Courty adds that 
 an equally conclusive case has come under his own observation. The 
 same author quotes the publisiied cases of Simon and Alph. Guerin as 
 coni'lusive examples of ante-uterine and retro-uterine cellulitis without 
 organic alteration of the serous membrane. 
 
 I have myself carefully observed in a non-puerperal woman an 
 extensive exudation going on to suppuration in the cellular tissue of 
 the left broad ligament and side of the pelvis. During the entire his- 
 tory of the case there was absence of pain and tenderness in the exu- 
 dation. After death, from double i^ueumouia, there were no signs of 
 peritonitis. 
 
 These cases must be considered as exceptional. Usually, autopsies 
 show^ all the pelvic viscera matted together by exudation, the cellular 
 tissue infiltrated with pits, the uterus, ovaries, and intestines adhering 
 by fibrinous bands, and the Fallopian tubes dilated by serum and pus. 
 
 Pelvic cellulitis may be general or localized. "When general, it begins 
 in the parametric tissue, extends thence to the broad ligament, involving 
 all the connective tissue between its folds. It then travels to the side 
 of the pelvis, perhaps going into the iliac fossa, or along the side of the 
 bladder to the retro-pubic cellular tissue and that of the anterior abdom- 
 inal wall. The most common seat of pelvic cellulitis is the connective 
 tissue of one of the broad ligaments. It is seldom that both broad 
 ligaments are involved at the same time. 
 
 As death is exceedingly rare in cases of simple circumscribed ]ielvic 
 cellulitis, we have to rely for the proof of its existence on clinical evi- 
 dence almost entirely. Fortunately, this evidence may be very satis- 
 factory, because of the ease with which the tissue around the cervix can 
 be reached by the examining finger. This is especially true in regard 
 to the small swellings in front of and behind the cervix. The swellings 
 which are formed on the sides of the uterus have long been the subject 
 of dispute, and involve much more difficulty in diagnosis. Xonat 
 
 ' Op. cit., p. 532. 
 
710 PERIUTERINE INFLAMMATION. 
 
 claimed that they were all due to phlegmons of the parametric tissue. 
 Bernutz, ou the other hand, showed by his autopsies that they are often 
 the result of pelvic peritonitis. 
 
 Dr. Thomas/ who has examined the post-mortem reports of a large 
 number of authorities, states " that, so far as his knowledge extends, 
 there are only two cases of such limited cellulitis substantiated by 
 autopsic evidence — one reported by Demarquay, the other by Simon." 
 He considers that " one of these, that of Simon, is conclusive of the 
 possibility of such disease ; that of Demarquay is doubtful, for with 
 the abscess in the cellular tissue there was also one in the cul-de-sac 
 of Douglas." 
 
 In addition to this unquestioned case of Simon's, Courty,^ quotes a 
 similar one by Alphonse Guerin resulting from direct traumatism in 
 the ablation of a polypus situated in the anterior wall of the cervix. 
 He also refers to an important autopsy by Naudier,^ which is quoted 
 here as not only conclusive of the possibility of such disease as we are 
 considering, but as demonstrating the occasional existence of large retro- 
 uterine cellulitic abscesses. 
 
 Naudier's patient suffered from hypertrophic elongation of the neck. 
 " The abscess which was evacuated through the anterior wall of the 
 rectum extended behind the whole of the vagina, the whole posterior 
 surface of the uterus, and laterally to the inferior border of the left 
 ovary ; pelvic peritonitis had only slowly followed the formation and 
 evacuation of this abscess ; the annexes of the uterus and the parts sur- 
 rounding Douglas's space could not be considered as the starting-point 
 of this retro-uterine cellulitis : the case proves these two points." 
 
 Lymphangitis and phlebitis are generally found coexisting with cel- 
 lulitis. We must regard the lymphangitis merely as the result of the 
 operation of the poison, which while travelling along the lymphatics has 
 caused the cellulitis. Phlebitis in the puerperal woman. Trousseau 
 taught, is the result of an extension of inflammation from the uterine 
 sinuses along the Avails of the veins. In the non-puerperal cases it is 
 probably at first a periphlebitis due to extension of the cellular inflam- 
 mation to the sheath primarily, and later to the inner coat of the vein. 
 
 Routes along Schick Pus Travels. — It is important to observe the 
 routes along which pus travels in the pelvic cellular tissue. 
 
 In puerperal cases, when pus forms in the iliac fossa it usually 
 works forward and points above Poupart's ligament. Very rarely it 
 behaves like a psoas abscess, and, making its way beneath Poupart's 
 ligament, forms a tumor on the inner aspect of the thigh. Puerperal 
 abscesses not unfrequently travel downward alongside the vagina and 
 open in the labium, or at some other point near the ostium vaginae, or 
 
 1 Op. ciL, p. 478, 5th ed. ' Op. ciL, p. 533. 
 
 ^ Annates de Gynecologic, vi. 293. 
 
i'i:i.vi<' CFLLr LITIS. 7; 1 
 
 tlii"iMit;li the intc-iuiiiriit near the anus. In dtlicr cases still llic |ins 
 makes a way tlii'niij^h the sciatif loranicn, and upcns lliion^ii llic t:lnt<i 
 iinisclcs nr tiirntiuli the ohturator loruiiicn. 
 
 Vvvv tVccjUcntiy these abscesses open into the \a;^ina, the iiieni-., the 
 hladtler, or the rectum. The iioii-jjiierperal cases nearly alwavs open 
 into one ol" these viscera. It is rare tor them to open into the perito- 
 neum, thoiii^h Di". McCIintoek ' siiys : "It is very rcmarkahle that 
 while three of the seven non-])iierperal cases of" ahscess were broiiirht 
 to a sucKK'ii and ahriipt termination by burstin<r of the sac into the 
 peritoneal cavity, no such accident ever occurred in all my experience 
 of pelvic abscess succeedinjj; to parturition." 
 
 Usually, the direction in which the intiammatory process travels will 
 depend on the route taken by the lymphatic vessels. But, a.s Lusk 
 remarks, it also "follows j)rearranged pathways in the connective 
 tissue." This has been shown by the experiments of Konig and 
 Schlesinger, who injected air, water, and liquefied glue at various 
 points in the pelvic connective tissue, and then studied the direction 
 taken by these substauces. 
 
 Symptoms. — Pelvic cellulitis in the puerperal woman may be cir- 
 cumscribed, or limited to the parametric tissue on the sides of the uterus, 
 and may not extend beyond the nearest lymphatic glands. This, how- 
 ever, is veiy rare, for in most cases the inflammation spreads from the 
 intermuscular connective tissue of the uterus along the lymphatics, 
 causing a lymphangitis, and involves the connective tissue of the broad 
 ligament, and often that of the iliac fossa also. 
 
 Under these circumstances the adjacent peritoneum is usually inflamed 
 also, so that, practically, Ave can seldom differentiate cellulitis from ])eri- 
 tonitis. Hence puerperal pelvic cellulitis can scarcely be considered 
 separately from pelvic peritonitis. 
 
 In the account of symptoms here given I have followed Dr. Lusk,- 
 who borrows from Olshausen. 
 
 Hardly ever later than the fourth day after labor, and most usually 
 on the second or third, the patient has chilly sensations or else a decided 
 chill, followed by rapid rise of temperature. On the second and third 
 days of the fever the thermometer in the axilla rises higher and higher, 
 so that there is often registered a temperature ranging from 103° to 
 105°. This fever then gradually subsides, ending in about 70 per cent, 
 of the cases in seven or eight days, in 20 per cent, in two weeks, and 
 prolonged beyond that period in only 10 per cent, of the cases. If the 
 fever continue into the fifth or sixth Aveek, it Avill probably be due to 
 the occurrence of suppuration. Suppuration may, however, occur in 
 severe c^ses within a week from the beginning of the attack. 
 
 The fever does not, however, always pursue the coui-se here described. 
 1 Op. ciL, p. 50. 2 Op. cil. 
 
712 PEEIUTEEINE INFLAMMATION. 
 
 Sometimes, after a few clays, the temperature will be normal in the 
 morning, but elevated in the evening, so as to lead to a suspicion of its 
 being malarial in character. Doubt about its nature can usually be re- 
 moved by a physical exploration of the pelvis, which in case of inflam- 
 mation will reveal an area of tenderness in close proximity to the uterus. 
 
 The pulse ranges from 120 to 140 per minute. It rarely goes above 
 120 in inflammations of moderate extent. Its persistence for twenty- 
 four hours in the neighborhood of 140 is indicative of septicaemia. 
 
 In many cases the chill is accompanied by severe lancinating pain, 
 coming in paroxysms like after-pains. This pain is due to the accom- 
 panying peritonitis. In the rare cases of pure cellulitis it is not a 
 noticeable feature. 
 
 Vomiting is not present to any marked degree unless the peritonitis 
 becomes general. 
 
 In portions of the country where malarial fevers are prevalent I 
 have been led into an error of diagnosis by supposing to be bilious 
 remittent what was really simple circumscribed pelvic cellulitis. By 
 way of illustration : A woman who has borne several children falls into 
 labor, and after two or three hours is delivered. Everything passes off 
 in the easiest manner conceivable, and there is nothing to suggest the 
 slightest injury to the genital canal. On the third or fourth day, how- 
 ever, there is a slight chill, followed by fever, which rises higher and 
 higher on the second and third days of the attack, and declines after- 
 Avard, under a treatment by quinine, to complete defervescence on the 
 fifth day, running a course which I have demonstrated elsewhere ^ to be 
 the typical course of bilious remittent fever, and which is almost iden- 
 tical with that of simple traumatic fever, whose thermometric range has 
 been drawn by Billroth.^ During such an attack the patient repeatedly 
 denies the existence of pain in the pelvis. There is no decided tender- 
 ness on pressure over the abdomen, and no evidence of inflammatory 
 exudation is at first observable on vaginal exploration. Three or four 
 days after tlie subsidence of these symptoms it is perhaps observed that 
 there is a return of fever in the evening, which declines toward morn- 
 ing and rises again in the evening, and is of decidedly remittent charac- 
 ter. Matters thus progress until some time during the second week 
 after delivery, when exudation becomes manifest in one of the broad 
 ligaments, and a dull pain is felt in the same region. It now becomes 
 clear that the attack was inflammatory in character from the beginning, 
 and examination Avill usually reveal a laceration of the cervix on the 
 side corresponding to the exudation. In many of the slight attacks 
 the fever subsides on the fifth day : in these there Avill seldom be an 
 appreciable exudation. 
 
 ' Amer. Journ. Med. Sciences, April, 1881. 
 
 ^ Surgical Pathology, 4th ed., p. 330, translated by Hackley. 
 
I'KiMc ci: LI. ('LITIS. 7i;; 
 
 Tlic ('\u<l:itiiiii tiiiiKiris ntimdrd in Innii, \;iii:il)l(' in size, stidutii 
 exci'ctliiii:,' an ;i|)|>lc in its dimensions, and sitnatcd iK'tuccn the lavcrsol' 
 till' Id-oad liiiaiuent. 'I'lir ntci'ns is soincwliat fixed, and pushed hy the 
 tnnmr to the opposite side of the pel\i>. In .-onic eases, after ilie hipsu 
 of a few weeks, the oxiuhition beeonies ot" ahuost stony har»hies~;, and 
 piTSLMits as nuieh resistance to the linger us would an exostosis growing 
 from the peKie wail. 
 
 Tlu' exudation need not he limited to the hi'oad ligament, hut niav 
 extend to the j)elvi(' walls, or even invade the iliac f'o.ssa, and I'oi'm a 
 large tumor casilv discerned through the ahdoininal waU. In I'cgard 
 to these tumors Lusk ' remarks that, " a.s the exudation between the 
 broad ligaments may have been slight from the beginning, or may have 
 subsequently disappeared by absorption, the iliac tumors have often 
 apparently a spontaneous origin." Sometimes the exudation within the 
 ])elvis is so extensive as to give to the examining hand the impression 
 that it has been freely poured, as it were, from above among all the 
 viscera, and lias solidified into one solid mass. 
 
 Some of these exudations are not sensitive at all, while others are 
 very painful upon the slightest pressure. The amount of discomfort 
 occasioned by the exudation will depend much on its situation. Tn 
 one ease the functions of the bladder will be greatly disturbed by the 
 tumor; in another the rectum \yill suffer most; while in a third, the 
 exudation being among the psoas and iliac muscles, extension of the 
 thigh will be painful. 
 
 When the fever subsides the exudation begins to undergo absorption, 
 and in a few weeks may entirely disappear. In other cases its removal 
 is slow, and it remains as an indurated mass for many months. 
 
 The continuance of fever for five or six weeks generallv means the 
 formation of pus. The occurrence of suppuration is marked bv acute 
 pain in the inflamed part, by great sensitiveness of the exudation, by 
 chills and evening fevers of high grade, and by night-sweats. Very 
 soon fluctuation will be detected in the tumor, and the precise location 
 of the pus can be fixed by exploration with the hyjiodermic needle. 
 
 According to Olshausen, the abscess, if left to itself, will generallv 
 discharge just above Poupart's ligament ; next in frequency ruptiu-e 
 takes place into the colon; rarely into the bladder, uterus, and vagina, 
 and most rarely of all into the peritoneal ctivity. 
 
 If we attempt a description of the clinical features of non-pucrpcral 
 ])elvic cellulitis, we shall find them diflering in no material respect from 
 those which characterize the puerperal form of the disease. Generally, 
 the symptoms of the former are less severe and the exudation confined 
 by more moderate limits. It must not be forgotten, however, that in 
 acute pelvic cellulitis, whether puerperal or not, pelvic peritonitis usually 
 
 1 Op. cit. 
 
714 PERIUTERINE INFLAMMATION. 
 
 exists also. In such eases there are present intraperitoneal as well as 
 extraperitoneal exudations. As stated by Lusk, " In suppuration of 
 parametritic exudations the pus commonly forms in small scattered 
 collections, and rarely gives rise to large abscesses." 
 
 In the non-puerperal form metrorrhagia is one of the earliest symp- 
 toms, yet, according to my observation, it is not peculiar to cellulitis, 
 but belongs to periuterine inflammation in general. 
 
 It is quite common to observe cases in which there is no chill and 
 little fever, but considerable pain. And, again, there is a class of cases 
 which give no history of any febrile movement and complain of no 
 pain. In these the patient is j^ale, weak, and somewhat emaciated. 
 There is failure of appetite and digestion, with a sense of pelvic uneasi- 
 ness and pressure, and a derangement of the functions of the bladder 
 and rectum. Exploration of the jDclvis tlien reveals a large mass of 
 exudation not sensitive upon pressure. 
 
 Emmet ^ has called attention to a very distressing symptom, hard to 
 relieve, which occurs as a secjuel after the acute symptoms have passed 
 away. This is irritation of the bladder, with a constant desire to urin- 
 ate. The cases in which this symptom is most prominent are those in 
 which the cellular tissue of the utero-sacral ligaments has been involved. 
 As the inflammation subsides and the ligaments undergo shortening, 
 the uterus necessarily becomes antevertecl to an abnormal degree, and 
 as the cervix is carried backward, direct traction is made on the neck 
 of the bladder ; hence the bladder symptoms. The phvsician, not 
 understanding the cause of this irritation, perhaps resorts to injections 
 into the bladder, which not only fail to afford relief, but hasten the 
 occurrence of a cystitis. 
 
 To relieve this distressing symptom, and to aid indirectly in relieving 
 the inflammation of the ligaments, Emmet has devised the now well- 
 known " buttonhole " operation on the urethra. 
 
 Diagnosis. — The clinical history of periuterine inflammation is so 
 variable that in a verv- large proportion of cases no conclusion as to 
 diagnosis can be reached except by a study of the physical signs 
 in connection with the circumstances under which the attack occurs. 
 This study involves a complete knowledge of the subject of pelvic 
 exudations. 
 
 The diseases which must be differentiated from pelvic cellulitis are 
 pelvic peritonitis, pelvic hsematocele, and uterine fibroids. 
 
 The differentiation from pelvic peritonitis is the most important and 
 most difiicult. I do not undertake to make a complete diagnosis 
 between these diseases, but simply endeavor to present here and in 
 the section on Pelvic Peritonitis such points as will aid us most mate- 
 rially in coming to correct conclusions. 
 
 1 Op. ciL, p. 275. 
 
ri:Lvrr cKLLri.iTis. 7ir> 
 
 We should boar in iiiiiid that as a resuk of exudation in tlic ninncc- 
 tive tissue there will In- at first merely a surface (jf rt-sistancc, and laicr 
 a firm, doughy, inelastic swelling of rounded outline dis<-overal>l(; in one 
 or more of the following; Iwalitics: 
 
 1. Between the cervix and bladder a small eircumscribed iuHamma- 
 tion or anti'-uterine j)ldegmon which is excessively tender to the touch, 
 of the same width as the cervix, and does not extend into the lateral 
 euls-de-sac. The uterus is partially fixed. A patient inider mv care, 
 while carrying an armful of wood, fell astride of a high doorsill in stej)- 
 ping over it, thus jarring, wrenehing, and straining hei*self through the 
 pelvis. She suffered severe pain, with retching and vomiting and dis- 
 tressing vesical tenesmus, and the exudation was as above described. 
 Termination in resolution. Suppuration very rarely occurs, and the 
 abscess, as in the case seen by Courty, empties into the bladder. This 
 is the most rare of the phlegmons. Traumatism is the cause. 
 
 2. Between the cervix and the rectum, retro-uterine phlegmon. A 
 circumscribcxl swelling, exquisitely sensitive on pressure, of ellips<^id 
 shape, lying transversely behind the cervix, differing from small eff\i- 
 sions into Dougla.s's pouch in its hardness and distinctness of outline, 
 and situated at a higher level than the floor of this pouch. The uterus, 
 not apprecialjly displaced, is in a manner fixed. There are pelvic j)aiu 
 and pain in defecation. Sujipurating phlegmons here are rare. The 
 two cases of Simon and A]])h. Guerin have been previously referred to, 
 and also that of Xaudier, the last illustrating the fact that quite large 
 abscesses may occur in this location. In the absence of an autopsy it 
 ■would be perhaps impossiljle in such a case as Xaudier's to sav whether 
 the effusion was in the cellular tissue or in the peritoneum. 
 
 3. Phlegmons of the parametrium proper, or of the lateral connec- 
 tive tissue at the junction of the broad ligaments with the uterus, form 
 tumors wdiich are of semilunar shape, extending from one side ai'ound 
 the cervix into the cellular tissue between it and the bladder, or to the 
 cellular tissue between the cervix and fossa of Douglas. These lateral 
 phlegmons are to be distinguished from the peritoneal tumors on the 
 sides of the uterus which have been demonstrated in the autopsies of 
 M. Bernutz. The peritoneal tumors, which consist of encvsterl serous 
 effusions and iuflammatorv adhesions behind the broad ligaments, from 
 my observation, usually seem to be attached to the womb on one of its 
 postero-lateral margins, and extend from about the level of theos inter- 
 num to the uterine fundus or a little above it. They are most easilv 
 explored through the rectum after throwing the womb into a position 
 of moderate retrovei-sion ; which can often be done, as its mobilitv is but 
 partially impairetl. 
 
 In addition to the above must be mentioned the exudations into the 
 connective tissue of the folds of Douglas or utero-sacral ligaments. 
 
716 PERIUTEBINE INFLAMMATION. 
 
 The peritoneal covering of these folds is usually involved also, and 
 the ligament sometimes becomes converted into a thick retro-uterine 
 tumor. 
 
 4. As a result of inflammation originating in the parametrium the 
 exudation may spread along the base of the broad ligament or along 
 its upper part, or may involve all the connective tissue between its 
 folds, thus forming in each instance a well-marked j)hlegmon ^ sepa- 
 rated from the uterus by a distinct furrow. In all these cases the uterus 
 is more or less fixed, and, if the tumor be of considerable size, is pushed 
 to the opposite side of the pelvis. It is often difficult to differentiate 
 this exudation from an encysted serous pelvic peritonitis behind the 
 broad ligament and pushing it forward. In some cases the connective 
 tissue of both broad ligaments, the entire parametrium, and the tissue 
 of the utero-sacral ligaments are completely infiltrated with exudation- 
 matter, forming a solid mass around the womb and rendering it abso- 
 lutely immovable. Under such circumstances it will be sometimes 
 observed that there is entire absence of fever and entire absence of pain 
 or tenderness in the swelling; and we may be certain that, as a rule, 
 where pain has been absent from the beginning there has been no 
 involvement of the peritoneum. Fritsch^ attaches great value for 
 diagnosis to the painless origin of these swellings. 
 
 5. The tumors described under the foregoing heads are small, con- 
 fined within the limits of the true pelvis, and do not rise above its 
 brim. The inflammatory process may, however, after travelling between 
 the folds of the broad ligaments, ascend into the iliac fossa and extend 
 forward underneath the peritoneum, to point, in the event of su2:)pura- 
 tion, above Poupart's ligament ; or, extending from the side of the 
 uterus around the latei'al margin of the bladder, it may invade the 
 retro-pubic tissue and ascend on the anterior abdominal wall, involving 
 the subperitoneal connective tissue as high as the umbilicus, and forming 
 an abdomino-pelvic tumor, This tumor is chiefly abdominal, but pre- 
 sents at the pelvic roof, and can be easily aspirated through the vagina 
 on the side of the bladder. It is not median in situation, but formed 
 rather on one side or the other of the middle line. 
 
 In these cases, though the tumor does not descend into the true pel- 
 
 ^ A description by Dr. West (Dis. of Women, 3d ed., p. 423) of an autopsy made by 
 him will assist the student in obtaining an idea of the composition and physical cha- 
 racteristics of phlegmons of the broad ligament. He says: "The appearances found 
 after death explained this thickening and accounted for the non-mobility of the womb, 
 for the folds of the broad ligament, from the upper part of the vagina to the lower 
 surface of the ligamentum ovarii, enclosed a mass of dense cellular tissue of almost 
 cartilaginous hardness, crying under the knife, dense white bands intersecting each 
 other in all directions and having a firm yellow fat between them. This mass was 
 closely adherent along the whole left side of the uterus, though the uterine tissue was 
 in no i"espect implicated in it." 
 
 2 Op. ciL, p. 272. 
 
rin.vic ci'.i.i.rLiTis. 717 
 
 vis, we will cxpccl lo liiid csidriiccs ol' iiill:iiiiiiiMl Ion nc.ir llic iitcni< — 
 that is, ('MKlalidii-iiKittcr— and some lixatimi nl'llial ortiaii, and in lia\X' 
 the aiid'cfdt'iit histdiy ol" lahttr or al>oi-lioii. 
 
 Ivai'cK', (lie phlcii'iuoiis run their conix' willmiil a .-Ninplnm <it' |)<ri- 
 toiiilis diii'inij,' lill' oi" a [\\\rv ol" il after death, as |»ii)\-en l)\' a lew 
 autopsies. Often |)ei"i(onitis, to a iiiodcralc c.rfciit, coexists with the 
 phlei;inon, hut to so slight a (le<;'ree that the attack is practically one of 
 cellnlitis. In sevei'c attacks the two din^ases nsnally pi'e\ail in nearlv 
 e(|iial intensity. 'J'hen the diai^nosis must he pei'iuterine inllannnalion. 
 Occasionally, a sejitic ])efitonitis destroys life in a few days without any 
 in\"olvcinciit of the ceilnlar tissne. 
 
 The sti'onLi; j)oints in favor of a tunioi' heino; dtio to cellnlitis are its 
 sequence npon lahor or ahortion or a snru'ical operation upon the cervix 
 uteri ; its appearance in one of the localities in which the cellular tissue 
 ahoiuids ; its unilateral position; its comparatively ])ainless ori^-in ; and 
 its freedom from tenderness on pressure. These may be termed proha- 
 bilities of diaii'nosis. In protracted cases there is a luarked tendency in 
 cellular tumors to suppurate; in peritoneal tumors, to monthly exacer- 
 bations. 
 
 Tumors which result from peritonitis alone occupy two })ositions. 
 One of these is in Douglas's pouch, where it can be felt encroaching 
 upon the vagina and rectum, and pushing the uterus forward and 
 upward against the pubic bone. The second position is in one of the 
 lateral ])ositions called by Polk the "retro-ovarian shelves." 
 
 Absolute immobility of the uterus is often observed in connection 
 with peritoneal tumors, while in cellulitis uterine mobility is less 
 impaired. 
 
 Courty says that peritoneal tumors are " never indolent ;" acute i)ain 
 accompanies their formation, and they are very sensitive upon pressure. 
 (For further remarks on diagnosis the reader is referred to the section 
 on Pelvic Peritonitis.) 
 
 Pelvic Hcematocek. — An intraperitoneal ha^matocele could scarcely be 
 confounded with ]ielvic cellulitis. It is difficult under some circum- 
 stances to differentiate a retro-uterine htematoccle from a pelvic ])eri- 
 tonitis in which there is an encysted effusion in Douglas's pouch ; but 
 the hist(M'y of the case usually removes all doubts of diagnosis. Aspira- 
 tion would not be advisable for diagnostic j)urposes. 
 
 It is only in the pelvic haematoma of Bernutz, or ha?matocele in 
 Avhich the bloody effusion has occurred in the connective tissue of 
 the broad ligament, that the physical signs resemble those of pelvic 
 cellulitis. 
 
 In this affection there is a history of abrupt invasion, sudden forma- 
 tion of tumor, without fever or symptoms of inflammation ; the tumor 
 is in the broad ligament, the anterior wall of which is bulging; the 
 
T18 PERIUTERINE INFLAMMATION. 
 
 tumor is at first jfluid, and in a few days becomes solid ; the uterus is 
 fixed. After a time, when absorption has occurred, the base of the 
 ligament is felt like a firm cord running out to the pelvic wall. 
 
 I have several times diagnosed such cases, and Emmet ^ has reported 
 one in which the wall of the hsematoma ruptured and blood was 
 extravasated into the peritoneum. 
 
 Uterine Fibroids. — The tumor formed by an interstitial fibroid is one 
 with the uterus, and cannot be separated from it by any line or furrow 
 of demarkation. A subperitoneal fibroid growing from the posterior 
 wall of the uterus, and pushing it against the pubic bone, might be 
 confounded with a parametritic exudation. Fritsch^ reports such a 
 case in which the diagnosis was very difficult. When the truth was 
 revealed by autopsy, instead of a parametritic suppurating exudation 
 there ^vas found a sloughing, incarcerated myoma of the posterior 
 cervical wall. It must be remembered that large parametritic exu- 
 dations behind the uterus are very rare, 
 
 Peogxosis, — In discussing prognosis reference is here made not only 
 to the probable course of the inflammation, but to its remote conse- 
 quences. Both recent and chronic inflammations of the cellular tissue 
 generally result in recovery. Both puerperal and non-puerperal cases 
 cause anxiety in proportion to the prominence of the septicsemic 
 symptoms. The inflammation may entirely disappear, and yet its 
 results may be of the most baneful character. 
 
 Pelvic cellulitis may give rise to the following morbid conditions, 
 which are oftentimes practically irremediable : 
 
 1. Pathological Anteflexion, the cervix being drawn upward and 
 backward, and the fundus thrown forward. The uterus itself is drawn 
 away from the pubes and' nearer to the sacrum. As shown by Schultze, 
 this is due, first, to inflammation ; then resolution with cicatrization and 
 contraction of the tissue between the peritoneal folds which constitute 
 the utero-sacral ligaments. Thickening and resistance of the structures 
 in the neighborhood of one or both of these ligaments are aj^preciable 
 by the finger. Dysmenorrhoea, sterility, and obstinate cystitis fre- 
 quently result from these changes in the ligaments. 
 
 2. Lateral Version is a result of cellulitis between the folds of one 
 broad ligament. After resolution, contraction follows and the uterus 
 is drawn to that side. 
 
 3. Disorders of Menstruation: Amenori'hoea and, 3Ienorr]iagia. — 
 Emmet has shown by analysis of his cases that menstruation remained 
 normal in about 16 per, cent, only. 
 
 Other consequences have been ascribed to cellulitis, but they are for 
 the most part attributable to the peritonitis which so often complicates it. 
 Treatment, — Prophylaxis. — The prophylactic treatment of a dis- 
 1 Op. cit., p. 233. ' Op. cit., p. 273. 
 
PKI.Vlc cELI.ri.lTIS. 7I<, 
 
 ejiso wliii'h is trcncrally coiisidci-cil in l)c lor ilw most part of septic 
 ori'^'iii must practically cinisist in the ri<;i»l adoption of" those measures 
 which ha\(' l)ccn i'onnd to he most efficient in preventin<r tlie admission, 
 of poisonous germs from without, to the tissues wjilcli liave been laid 
 o|)en l)v tlie injuries done to the genital canal ilnring parturition, or hv 
 the kiiit'c ot" the surgeon in the various procedun^s of gvnecologv. 
 
 Tlic strictest eleaidiness must therefore charaeterizo all obstetrical and 
 surgical manipulations — cleanliness of the entire person of the ojU'rator 
 and of his insti-uments and dressings; the av^oidanee of unnecessary 
 examinations of the genital passages during parturition; the frequent 
 ablution of the hands and bathing of the external genitals during labor 
 with antiseptic solutions; and antiseptic irrigation of the vagina in 
 gynecological oj)erations. 
 
 The most thorough, rational, and efficient system known to us for 
 obstetric cases is that Mhich was introduced into the Xew York ^Nlater- 
 nity H()S]>ital in 1883 by Dr. H. J. Garrigues/ and which is identical 
 Avith that adopted two years later by the staff of the Boston Lying-in 
 ll(>sj)ital.- This method is based upon the theory of the bacteriologists, 
 that the septic poison is not autogeuetic, but that the germs are intro- 
 duced from Avithout. Its great value may be inferred from the fjiet 
 that since its adoption the percentage of sepsis in the Xew York ^later- 
 nity has been reduced from 6 to .21 per cent., while in the Boston Hos- 
 pital a similar reduction has been obtained. A part of this system con- 
 sists in the careful and accurate closure of perineal lacerations. " Wlien 
 Ave have secured complete primary adhesion in a recent wound, as a rule 
 all danger from inflammation is at an end."^ While the application of 
 this principle is easy enough for lacerations of the lower portion of the 
 vagina, it is surrounded by some embarrassments where the cervix uteri 
 is involved. And yet in sjiecial cases Avliere extensive cervical lacera- 
 tion has occurred it should be repaired in the same manner very soon 
 after the termination of the labor. 
 
 This principle I have put to a practical test in a most conclusive case 
 of extensive laceration involving the entire cervix on one side, extend- 
 ing upward beyond the os internum and laterally into the vaginal 
 roof.^ 
 
 Gynecological operations up<^n the non-puerperal woman should be 
 conducted with the strictest antiseptic precautions. 
 
 Cnrnficr Treatment. — In the beginning of an attack of ]iclvic cellu- 
 litis the first indication of treatment is to relieve pain and bring about 
 
 ' Antiseptic Midwifery, by H. .T. Garrijjiies, ]886. 
 
 * " Antiseptics in Obstetric Practice," by W. L. Richardson, Boston Med. and Surg, 
 Journ., Jan. 27, 1887. 
 
 " Internat. Encyrlopfrd. of Surgery, "Inflammation," vol. i. p. 140. 
 
 * Mix!<. Valley ^[erl. Mnnthly. Dec, 1884, "An Important Point in the Prevention of 
 Pelvic Inflammation alter Delivery." 
 
720 PERIUTERINE INFLAMMATION. 
 
 reaction as quickly as possible. Both these objects will be accomplished 
 by the administration of opium and the external application of heat. 
 If the attack be of moderate severity, the opium may be given by the 
 mouth or rectum in doses sufficient to relieve pain ; and its use should 
 be judiciously continued as long as the patient's comfort actually requires 
 it. The good effects of heat are best obtained by the application to the 
 abdomen of flannels wrung out of hot water. These should be renewed 
 as often as they become cool, and at the same time copious hot-water 
 vaginal injections may be administered. 
 
 Absolute rest of body and mind should be secured from the begin- 
 ning, and should be continued until convalescence is established. 
 
 In cases of great severity there are usually decided chill, and, as the 
 peritoneum is involved, acute pain. The pulse rapidly rises to 120 and 
 upward, and the clinical thermometer registers 104° to 105° F. The 
 patient is in great distress. Under these circumstances prompt and 
 active treatment is demanded. The pain should be relieved by hypo- 
 dermic doses of morphia. The temperature should be reduced to near 
 the normal by proper doses of antipyrine. As the tendency in such 
 cases is to a continuance or to a return of high temperature, the two 
 other antipyretic agents, cold and quinine, may be required. After the 
 temperature has been reduced by antipyrine, quinine, in full doses by 
 the stomach or by the rectum, is of decided value, especially in those 
 cases marked by decided remissions. 
 
 The two objects to be aimed at are the relief of pain and the main- 
 tenance of a nearly normal temperature by the use of one or all of the 
 antipyretics combined. To accomplish these will require unremitting 
 attention for days. MeauAvhile, the patient should be nourished by 
 liquid food as well as the stomach will permit. 
 
 After the fever has subsided the most important work to be accom- 
 plished is removal of the exudation. The successful accomplishment 
 of this depends upon a proper performance of the nutritive functions ; 
 hence the condition of the digestive organs must be carefully observed. 
 From time to time, calomel in one-grain or half-grain doses, given once 
 in three hours to the extent of three or four grains, will be of great 
 value in modifying the secretions and in acting as a safe aperient. For 
 the relief of the gastric catarrh and other symptoms of impaired diges- 
 tion so common in febrile disorders, I have often used before meals a 
 teaspoouful or less of an alkaline powder composed of equal parts of 
 the phosphate of lime, subnitrate of bismuth, and magnesia. This aids 
 digestion and generally secures a daily movement of the bowels. Emmet 
 recommends five grains of inspissated ox-gall three times a day. 
 
 When convalescence begins the patient should be fed as liberally as 
 her digestive powers will alloAV, and these will be greatly aided by ton- 
 ics, among which the citrate of iron and quinia may be mentioned as 
 
PKLVrr AIISCESS. 7-2] 
 
 especially u-;(t"iil. < )|miiiii may \tv rc'(|tiirc(l in small doses f«»r a r-onsid- 
 craMc pt'iMfMl. It >ji()iil(l, however, be tliscon tinned as soon as tlie 
 patient's cnnditinn will allow ii. 
 
 l''or hiL-iteninj:; the al)sorj)tion of the exndation a blister across the 
 livpoi;iistriiim will be of" decided valne. This may be repeated in ten 
 ov twelvi- (lavs it' cireunistanees recpiire it. 
 
 The hot vajiinal douche, as recommended by Emmet, is of" great 
 valne in stimulating the removal of inflammatory products. 
 
 In cases which are disj)osed to a.ssume a chronic character repeated 
 blisters are called for ; and we may derive much benefit from the use 
 of the wet bandage around the hips and abdomen. It should be cov- 
 ered with rubber cloth and worn continuously day and night. It 
 lessens internal congestions and relieves pelvic pain and soreness. 
 
 Should the system fail in its efforts to accomplish removal of the exu- 
 dation, a new train of symptoms will arise, indicating the formation of 
 pus. 
 
 Pelvic Abscess. 
 
 Etiology. — Pelvic abscess in women is for the most part the result 
 of some one of the forms of periuterine inflammation which have been 
 described in the preceding pages. It is true that now and then a col- 
 lection of pus is found in the female pelvis, as in the male, in conse- 
 quence of an inflammation of the bones which enter into the formation 
 of the sacro-iliac sympliysis. Such a collection may also result from 
 the extension of a psoas abscess, or it may originate in the cellular tissue 
 between the rectum and sacrum in consequence of traumatism, or as a 
 result of those textural changes which are so ready to occur, in depraved 
 conditions of the blood, in the cellular tissue of anv portion of the 
 body. The collections of pus here alluded to are, however, of rare 
 (K'currence, and we shall not be far from right in declaring that, j)rac- 
 tically, pelvic absce-ss in the female is directly traceable to two causes — 
 1st, pelvic peritonitis; 2d, pelvic cellulitis, or else to both these inflam- 
 mations combined. 
 
 In any given case it will usually ])e an easy matter to prove that the 
 abscess has resulted from an inflammation which had its beginning in 
 or near the uterus. This will be made evident by the historv of the 
 case, by fixation of the uterus, and by the presence of exudation-matter 
 located near it and extending continuously to the seat of the abscess. 
 There need not be continuity of supj)uration from the uterus to the 
 abscess. The uterine lesion may originate an inflammation which will 
 be pro])agated along the lymphatics to the lymphatic gan<rlia remote 
 from the uterus. The connective tissue around these ganglia mav then 
 become inflamed, and thus the abscess is formed at some distance from 
 the uterus. 
 
 Vol. I. — 46 
 
722 PERIUTERINE INFLAMMATION. 
 
 In addition to these purulent accumulations in the pelvic cellular tis- 
 sue and peritoneum there are several others which require mention only 
 in this place. These are — 
 
 1st. Pyosalpinx, which sometimes forms a distinct tumor. 
 
 2d. Abscess of the ovary, which as a separate and distinct aifection 
 is occasionally met with in the non-puerperal woman. It is supposed 
 to be of very rare occurrence, and is probably caused by long-continued 
 ovarian irritation the result of some form of uterine disease, such, for 
 example, as fibroid growths. Mr. Henry Morris,^ Mr. C. J. Culling- 
 worth,^ Mr. Lawson Tait,^ and Dr. Emmet * have recorded cases. 
 
 3d. Abscess of the uterus or circumscribed abscess in the walls of 
 the uterus has been recorded by Scanzoni, Schroeder, and others. 
 
 In destructive puerperal inflammations which involve all the tissues 
 of the pelvis it is not very uncommon to find an abscess located in the 
 uterine parenchyma. Dr. Robert Barnes^ says the abscess does not 
 originate there, but may be traced to " foci foi^med in the venous tissues 
 or lymphatics, whose walls are first inflamed by the reception of septic 
 matter from the cavity of the uterus." Outside of this condition it is 
 questionable if abscess of the uterus is ever met with. Mr. Tait^ has, 
 however, described a case which he diagnosed as such in a non-puerperal 
 subject after exposure to cold. The purulent collection was at the base 
 of the bladder, intimately associated with the uterus and movable with 
 it. After the cervix had been dilated by a tent the uterine cavity was 
 found to be filled with pus, and the finger detected on the anterior 
 uterine wall, just within the cervix, a soft spot with an aperture in 
 its centre. The patient recovered. 
 
 Pathological Anatomy. — Intraperitoneal accumulations of pus ex- 
 ceed in pathological importance all other pelvic abscesses for the follow- 
 ing reasons : They are of common occurrence, often of large size, cause 
 profound disturbance of the nutritive functions, and, surgically con- 
 sidered, are usually very difficult of access. In some instances they 
 show but little tendency to empty themselves, and may be carried by 
 the patient for aii indefinite period. 
 
 If rupture occurs, it may be into the peritoneum, and give rise to a 
 rapidly-fatal peritonitis ; or else into the rectum, and cause an exhaust- 
 ing and uncontrollable diarrhoea ; or it may lead to the formation of 
 extensive fistulous tracts, which are always difficult to close and some- 
 times entirely beyond the reach of surgical art. Dr. Matthews Dun- 
 can said in 1 868 : " I regard intraperitoneal purulent collections as 
 forming the majority of the grave abscesses in this situation." 
 
 The intraperitoneal abscess has a cavity of indescribable shape, with 
 
 1 Bi-U. Med. Joum., May 21, 188L ' Lancet, Nov. 3 and 10, 1877. 
 
 3 Diseases of Ovaries, 4th ed., p. 125. ^ Op. cit., p. 651. 
 
 5 Med. and Surg. Bis. of Women, 1874, p. 439. ^ Diseases of Women, p. 64. 
 
ri:iA'l(' ABSCESS. 72:i 
 
 miiiu'nms |i(>ii<'lic,-, t>i- j»i(icc»(> riiiiiiiii|j,- in dilliTcnt dircclioiis. Its 
 walls are c*uiii[K)st'(l of false inciubraiies, of coils of intestine, of perhaps 
 the sit2;inoi(l Hexure and reetnni, and of the hroad li<jfain(;nt on one side. 
 In its centre, as Aran sttites, there is «2;enerally I'onnd one otthe uterine 
 appenda»!;es or the ovarv and tnl)e of one side. 
 
 Thi' most important feature of peritoneal al)S(!e.s-^es is that at some 
 point within the ahscess-cavity we are quite sure to have the I''allopian 
 tube ilistended with j)us. Here, then, is an abscess within an al)S((-s. 
 Althou>!;h the abscess [)roper may be evacuated by rupture or the knii'e, 
 a eiu'e is delayed : the foim et or'ir/o ina/i is not destiv)yed. This I 
 believe to be a great difficulty in the way of bringing about the closure 
 of these cavities. 
 
 Coming next to consider absc^^^scs of the cellular tissue, it may be 
 stated that wherever this tissue abounds suppuration may occur, and 
 may extend frohi its point of origin throughout the pelvis. Pas 
 will extend in the direction of the least resistance. The influences 
 which guide its extension are the planes of fasciae and the course 
 of the lymphatic vessels, which are the chief poison-carriei's. The 
 pus is often not confined in a single cavity, but the abscess is 
 multilocnlar. 
 
 Dr. Thomas Savage ^ states that these abscesses have burst or been 
 opened in order of frequency — 1, in the iliac region ; 2, above the pubes, 
 nearly as high as the navel ; 3, in the inguinal region ; 4, by the side 
 of the anus ; 5, by the vagina ; 6, by the rectum ; 7, into the bladder ; 
 8, into the peritoneum. 
 
 According to Winckel,^ from an analysis of 24 cases of puerperal 
 pelvic cellulitis of his own and 13 by Veit, suppuration occurred in 6. 
 He quotes Konig as saying that opening under Poupart's ligament Avas 
 the most frequent course ; sometimes through the abdominal wall above 
 Poupart's ligament ; then into the rectum ; then into the bladder and 
 vagina; while that into the uterus, through the perineum, greater 
 sciatic foramen, into the peritoneum, and alongside the quadratus lum- 
 borum muscle, are equally rare. 
 
 As to the frequency of abscess of the broad ligament discrepancy <jf 
 opinion exists. Thus, Courty ^ says that abscess of the broad ligament 
 is common. Dr. W. H. Byford * says : " The most frequent locality of 
 pelvic abscess is between the layers of the broad ligament." On the 
 other hand, Dr. ^latthews Duncan ' says that abscess of the broad 
 ligament "is very fir from common," and that " the broad ligaments 
 are not parts in which inflammation and abscess are likely to take their 
 origin." He alludes to the fact that the pus between the layers of the 
 
 » Op. cit., 1870. 2 Qp „7^ p 209. 
 
 ' Op. cit. * Tram. Amer. Gynecolog. Soc, vol. viii. p. 209. 
 
 5 Op. cU., p. 29. 
 
724 PERIUTERINE INFLAMMATION. 
 
 broad ligament, described in puerperal autopsies by old physicians, was 
 not in an abscess, but in the veins or lymphatics. 
 
 Dr. Thomas Savage, in his work on the Anatomy of the Female Pel- 
 vie Organs, whilst recording the forms and localities of 20 cases of pel- 
 vic abscess, mentions only 2 in which the broad ligament was the seat 
 of the abscess. In 1 of these there existed a uterine fibroid. Perito- 
 nitis and death resulted from rupture of a large abscess of the broad 
 ligament. In the second case a uterine polypus had been removed by 
 the ligature. Death followed rupture into the peritoneum of a large 
 abscess of the broad ligament. 
 
 Dr. D. Berry Hart ^ remarks : '' There is little doubt that we can 
 have a cellulitis of the broad ligament, and that it may go on to abscess 
 of the broad ligament. This I have seen in a case of abdominal section 
 by Prof. A. P. Simpson, where the existence of pus distending the 
 broad ligament was verified by the aspirator passed "in from above." 
 
 From my own observation I would say that abscesses of the broad 
 ligament are far from common. 
 
 Some pelvic abscesses have their origin in extraperitoneal hsemato- 
 celes or hsematomata in the cellular tissue of the broad ligaments. This 
 has been proven by Mr. Tait's operations, in which the abscess wall was 
 chiefly formed at the expense of the posterior layer of one of the broad 
 ligaments. The floor of the abscess-cavity was organized blood-clot ; 
 the contents were fetid pus and decomposing blood-clots. 
 
 The evacuation of the contents of an abscess frequently fails to result 
 in a cure. In the event of rupture into the rectum or bladder there 
 may be an almost uninterrupted discharge of pus through either of 
 these cavities for months. In a case under my care the purulent 
 accumulation was on the right side of the pelvis, and rupture occurred 
 into the rectum. The patient refused all manner of surgical assistance, 
 and the discharge of pus through the rectum continued with slight 
 interruptions for four years. 
 
 The explanation of such cases is to be found in the facts that the 
 opening is often oblique or indirect, and is not so situated as to com- 
 pletely empty the abscess-cavity ; the walls have become thickened and 
 otherwise changed ; granulations do not form and the adhesion of oppos- 
 ing surfaces fails ; moreover, one of the diseased uterine appendages 
 remains to keep up the inflammation. Fistulous canals result. This 
 leads us to consider — 
 
 The Structure of the Walls of Abscess- Cavities. — The lining mem- 
 brane of acute abscesses, Avherever they may exist, consists simply of 
 true granulation-tissue, such as we see covering the surface of a wound 
 Avhich is undergoing the process of healing. The abscess-cavity is 
 obliterated partly by the formation of granulation-tiasue, and partly 
 
 ' Atlas, plate xxii. 
 
ri'i.vic A!:sci-:ss. 7-J') 
 
 l)v the adlit'sloii ot" ()|»|)(i-iiiu' t:i'aiiiil;ili(iii-siii'l";iccs. 'To >cciirr ul»liicr:i- 
 tion of this cavitv coiiiplctt' cNafiiatioii and cf)!!!!!!!!!-!! tlniiiia<;o are 
 r('(|iiir('(l, and il' the cavitv is a lari^c one u licaltliy coiiditiKii of the 
 milfiti\t' fiiiictioiis is also essential. 
 
 According; to A_<;no\v/ the cncapsidatiiiti; wall of a chronie abscess 
 dilli'i's from that of the acute only " in tliicUiicss, stn'n<:th, and devel- 
 opment." .... " Mneh of the inllannnatorv ti"ansndati(tn is org-aiiized 
 into connective tissue, so that tiiis wall ix-comes a iihrons sac, sometimes 
 of ureat thickness." .... "The exterior of this wall or sac is 'wve^r- 
 idar, bristling- with prolongations which interj)enetrate the sin'ronndiii<; 
 parts, while the interior has a villous or irraiudar aj)pearance, the emi- 
 nences consistinj^ of h)()j)S of blood-vessels buried in transudation-cor- 
 puscles. These vessels are the source of the leucocytes which form the 
 pus of the abscess, the conne(^tive tissue, at least in several localities, 
 plavintji: a very subordinate part in its production." 
 
 Dr. William H. Byford" of Chicau;o has made a very interesting con- 
 tribution to our knowledge of the changes which take place in the walls 
 of the cavities of some chronic pelvic abscesses. Dr. Byford says: "At 
 first the inner wall of the cavity is covered with the healthy gramda- 
 tions of an ordinary ulcer, and in every respect resemble those observed 
 in external ulcerations. After an indefinite time they degenerate and 
 disappear, when patches of cicatrization residt, and in the end the whole 
 cavitv is lined with a cicatricial membrane. With the loss of the gran- 
 ular character of the inner surfiice no more pus is produced. The lin- 
 ing of the wall is no longer covered with granular eminences, but it is 
 a smooth, shining membrane of cicatricial organization. This membrane 
 is then of the simplest organization, and possesses the properties of ex- 
 osmosis and endosmosis. The cavity is kept in a state of repletion by 
 exosmosis, and sometimes grows by an excess of serum thus effused ; 
 generally, however, an equilibrium in these two processes maintains sta- 
 tionary dimensions in the tumor thus resulting." 
 
 Dr. Byford thinks the changes here described explain the origin of 
 some of the cvstic tumors of the abdomen and pelvis which have been 
 reported by Dr. George H. Bixby.^ lie was cognizant for a number 
 of years of the progress of two of the tumors alluded to in Dr. Bix- 
 by's article. 
 
 This author oroes on to state that "the linino; of the walls of the 
 chronic abscesses does not speedily undergo the changes thus describeil ; 
 but from it may be found dei)ending masses of granulations, giving 
 rise to tag-like projections in great numbers, from the twentieth of an 
 inch to half an inch or more in length. In all instances in Avhich I 
 have observed these projections they have proved too fragile to be con- 
 
 ' Principles and Practice of Sur(/ery, vol. i. p. 105. 
 
 * Trans. Am. Gyti. Soc, vol. viii. ' Ibid, vol. i. 
 
726 PERIUTERINE INFLAMMATION. 
 
 sidered fibrinous exudations, and have possessed all the properties of 
 aggregated granulation-masses. They are fungoid and easily broken 
 down and removed by the finger or dull curette." 
 
 Diagnosis. — The diagnosis of pelvic abscess involves the recognition, 
 first, of an inflammatory exudation in the pelvis, and secondly, of the 
 occurrence of suppuration. 
 
 Pelvic exudations are usually associated with a well-marked history 
 of periuterine inflammation. They have already been discussed in this 
 connection in the preceding sections. Sometimes, however, the exuda- 
 tion process is a cold one throughout its entire history; the usual symp- 
 toms of inflammation are absent ; the patient is at no time confined to 
 bed ; a large tumor fills the pelvic cavity ; and then for a time the 
 diagnosis may be obscured. In some instances the tumor thus formed 
 is easily confounded with a uterine fibroid. 
 
 The occurrence of suppuration in sthenic cases is marked by rigors 
 and fevers of the hectic type, the temperature rising high in the even- 
 ing and subsiding after midnight with a sweat. There are also added 
 increased pain in the swelling and fluctuation. 
 
 In other cases no such symptoms arise. Weeks pass by. The patient 
 suffers but little, yet convalescence does not occur. The exudation-mass, 
 instead of slowly melting away, remains unchanged or perhaps increases 
 in extent. Fixation of the uterus continues. The appetite does not 
 improve. Nutrition steadily fails. Careful examination with the ther- 
 mometer now reveals a slight increase of the bodily temperature above 
 the normal, and the physician is thus led to suspect the occurrence of 
 suppuration. Still, fluctuation may be inappreciable ; and this is espe- 
 cially apt to be so if the effusion is above the pelvic brim and intra- 
 peritoneal. Careful exploration by the finger of the roof of the vagina 
 will, however, in all probability, lead to the discovery soniewhere of a, 
 soft spot, through which the needle of a hypodermic syringe may be 
 carefully passed so as to explore the tissues beyond. Thus, the diag- 
 nosis will usually be made clear. 
 
 The hypodermic syringe, when intelligently used, furnishes us a per- 
 fectly safe means for the exploration of pelvic abscesses. 
 
 Abscess of the ovary is so rare, and so little is known of its clinical 
 history, that its recognition can scarcely be expected. 
 
 The diagnosis of pyosalpinx will be discussed in its proper place. 
 
 Prognosis. — Pelvic abscess in every case presents a situation more 
 or less grave. Intraperitoneal abscesses are usually high in the pelvis 
 — indeed, are partly abdominal in their location ; are difficult to reach 
 by surgical measures ; and even after their contents are evacuated a sac 
 may remain which, unless properly di^ained, will continue to discharge 
 pus for an indefinite period. 
 
 Abscesses of the cellular tissue, as a rule, admit of a more favorable 
 
PELVIC ABSCESS. I'll 
 
 proo"nosis. I I'sitiiati'd low tl<)\\ii,;is in the iiircrinr |»nriii)ii ol' (hk; of tln' 
 Itroad liuMinciils, or il" liM-atcd in tlu' iliac Ibssa <»r in (lie tissue ol' llic 
 anterior abdominal wall, a cure may readily be obtained by incision and 
 <lrainai2;e. 
 
 Ru|)tiu'e of tlie abscess uj)on a cutaneous surface or into the vaiiina, 
 with tree dischar<:;e, is favorable to speedy recovery, but i-n|)ture into the 
 bladder or rectum is not desirable. 
 
 Xonat di'clarcd that when the abscess "opens simultaneously into the 
 intestine and l)ladder, death is alm(jst inevitable." Dr. Thomas ha.s 
 emphasized this statement, and corroljoraled it by the results of a ca.se 
 under his care. 
 
 Tkeatmi-:nt. — .Vlthough sonu; modern gynecologi.sts, like Aran and 
 Becquerel, and very recently Prof. Fritsch of Halle, have taught that 
 these abscesses should not be interfered Avith, but left to Nature — that i.s, 
 to burst into the vagiua, the bladder, or the rectum — I know of uo good 
 reason why they should not be treated, like abscesses in other parts of the 
 bodv, in accordance with the general principles of surgery. 
 
 As stated by Howard Marsh,^ " it may be laid down as a general 
 rule that pus is to be removed as soon as it is formed. In cases of 
 acute abscesses this rule may be considered very nearly absolute. We 
 have now at our disposal the means by which the serious complications 
 that were formerly met with as the result of putrefactive changes may 
 be avoided, and the withdrawal of pus has a very beneficial effect in 
 abating the severity of acute inflammatory processes." 
 
 In the application of this principle to any given case our conduct will 
 be governed by the situation of the abscess, by its character whether 
 acute or chronic, and by the condition of the patient. 
 
 As has been clearly emphasized by Sir Jas. Y. Simpson and Prof. 
 T. Gaillard Thomas, no rule can be given which will hold good in 
 every case of pelvic absce&s. The safety of the patient may in one 
 instance demand early evacuation of the pus ; in another it may make 
 delay the proper course. Grave constitutional symptoms, high fevers 
 followed by heavy sweats, certainly justify, as Bernutz said, an almost 
 dangerous operation for the relief of the patient. 
 
 In most instances perhaps reasonable delay is the better course, 
 because the ahscess will then have an opportunity to become ripe ; the 
 separate accumulations of pus Avhich are often found in the connective 
 tissue M'ill then have coalesced, and a thinner wall will intervene 
 between the pus and the .surface to be incised. 
 
 It is true that while we wait the absce-ss may break in some disagree- 
 able direction ; but it is also true, as Aran declared, that there are cases 
 on record of spontaneous rupture into the peritoneum or intestine several 
 days after artificial puncture. 
 
 ' Inlernat. Encyclopcedia of Surg., vol. ii. p. 268. 
 
728 PERIUTERINE INFLAMMATION. 
 
 As illustrating the danger of leaving the disease to Nature, mention 
 may be made of the 24 cases of pelvic abscess reported by McClintock ^ 
 which were thus treated : 13 of these were puer|)eral and 11 were non- 
 puerperal. Four of the patients died from rupture of the abscess into 
 the bowel and an uncontrollable dysentery which followed ; 3 others 
 died of rupture into the peritoneum. A heavy mortality ! 
 
 Means for the Evacuation of Pus. — 1. Tlie Knife. — The 
 proper instrument for the evacuation of a pelvic abscess is the knife. 
 The presence of pus being ascertained, and its situation being favorable 
 for an incision through the roof of the vagina, the patient is to be ether- 
 ized and placed on her side. Sims's speculum having been then intro- 
 duced, a grooved director or exploriug-needle is pushed into the abscess- 
 cavity at some point as remote as possible from any pulsating vessels 
 which may be discovered. As soon as pus appears in the groove a tenot- 
 omy-knife is to be passed along the director, and the opening enlarged 
 by cutting in opposite directions until it is capable of admitting the 
 index finger. 
 
 After introducing the finger into the cavity any partitions which may 
 be felt are to be broken down. A full-sized drainage-tube should then 
 be introduced, and secured in position by stitching it to the vaginal wall. 
 Through this tube the cavity may be washed out every day or oftener 
 by a gentle stream of pure water, or the water may be made stimulating 
 and disinfectant by a solution of the bichloride of mercury, 1 : 4000, or 
 of Lugol's iodine somewhat diluted. 
 
 If exploration by the finger shows the presence within the abscess- 
 cavity of those fungoid masses which Dr. Byford has described, they 
 should be carefully and thoroughly removed, as recommended by him, 
 either with the finger-nail or by means of the dull curette. This measure 
 he found beneficial by lessening the amount of discharge, by destroying 
 the offensive odor which is present, and by hastening the closure of the 
 cavity. 
 
 The abscesses favorably situated for this plan of treatment are the 
 suppurating hsematoceles and other piu-ulent collections in Douglas's 
 pouch, the parametric abscesses behind the uterus, and those which point 
 at the base of the broad ligaments. Iliac and abdominal- wall abscesses 
 which seek an opening on the cutaneous surface are to be approached by 
 careful division of the tissues on a director, as in the operation for lap- 
 arotomy. 
 
 In using the knife for making incision through the roof of the vagina 
 the operator should bear in mind the dangers of wounding large venous 
 plexuses as well as arterial branches which ramify through the con- 
 nective tissue. He should also be mindful of a deplorable accident 
 which has sometimes occurred, and which can hardly be foreseen : the 
 
 1 Op. cii. 
 
PELVIC ABSCESS. 729 
 
 uivtcr iiKiv Ik- opened and a iireter(t-\a<:iiial fistula re~ult. 'J'wo >:i(h 
 t-ases have come iiiuler the oljservation of I )r. l^iiimet, who states that 
 ail abscess hetieath the folds of the broad li<rameiit may dia;^ the iii-eter 
 oi' that side up to the U'vel of the va<;iiia at a point one inch alioveand 
 the same distance beliind the point of entrance of tlie ureter into the 
 l)ladder, and niav attach it by adhesions to the vauiiia. It is then in a 
 position to be injured l)y tiie knife in o})ening- the al)scess. In one of 
 the cases referred to an operation for relief failed, and in tlie other it 
 Avas successful only throui;h the great skill of the operator and the Ibr- 
 tunate circunistance that the urine from the kidney on that side could 
 be turned into the l)ladtler through the tract of the old abscess. 
 
 raipieli n's cautery-knife may also be used for makin<j^ the incision 
 throuLih the roof of the vagina instead of the ordinary knife. 
 
 Many pelvic abscesses are so situated that the plan of treatment just 
 described is wholly inadmissible. Quite often the pus-cavity is high in 
 tlie pelvis, the vaginal roof is thickened by false membranes, and the 
 j)elvic organs are drawn so closely together by an adhesive i)eritonitis 
 that the abscess cannot be approached through the vagina at all. For 
 this class of cases the proper means of relief is to be found in the 
 operation of abdominal section, as proposed and successfully practised 
 by Mr. Lawson Tait. This method oifers a means of cure to a large 
 number of cases which cannot be successfully treated in any other way, 
 and which have hitherto resulted in death or hopeless invalidism. 
 
 Alluding to the history of chronic pelvic abscess as given Ijv Dr. 
 West, Mr. Tait says : ^ "In my own practice such disappointing cases 
 have occurred with but too great frequency, and though I have had 
 some successes by the employment of such means as the elastic ligature 
 and coimter-opening in the vagina, yet the progress toward recovery 
 has been so protracted as to contrast favorably only with those cases in 
 which there was no recovery at all. I have been therefore continually 
 on the outlook for some means of dealing with such cases Avhich would 
 bring them as satisfactorily Avithin our means of treatment as are col- 
 lections of matter in most other parts of the body. This has been fur- 
 nished by the wide, free, and successful application of abdominal sec- 
 tion for the trciitment of pelvic and al)dominal tumors, and I have now 
 to lay before the society six cases, which include the whole of my expe- 
 rience in this novel proceeding, and in which success has 1)cen obtained 
 far surpassing anything I have yet seen or heard of." 
 
 Mr. Tait oifers this as a means of treatment for all purulent accumu- 
 lations in the pelvis which cannot be safely opened from below, and he 
 recommends that in case of doubt an exploratory abdominal section be 
 first made. The cases which he has successfully treated thus are pyo- 
 salpinx, acute purulent peritonitis from rupture of distended tubes, 
 
 1 Diseases of the Oraries 4th ed., 1SS3, p. 346. 
 
730 PERIUTERINE INFLAMMATION. 
 
 abscess of the ovaiy, abscesses in the ujDper part of the broad ligament, 
 and suppurating hsematoceles. In his fifth case the cavity of the abscess 
 was formed bj the lifting up of the posterior layer of the left broad 
 ligament. The rectum was carried up in front of this, together with 
 the large vessels of both sides, as high as the bifurcation of the aorta, 
 whilst anteriorly the peritoneum dipped to such an unusual depth that 
 had he tapped through the vagina the trocar would have gone through 
 the peritoneal cavity to reach the abscess. 
 
 After the abdominal incision is made and the purulent accumulation 
 brought into view, it is aspirated ; then a free incision is made into the 
 abscess Avail, and its edges are carefully stitched to the edges of the 
 abdominal wound. A drainage-tube of glass or rubber is then inserted, 
 and the cavity is daily washed Avith plain water. 
 
 In some cases the abscess wall is adherent to the abdominal wall in 
 front. In such the treatment is more simple — evacuation of its con- 
 tents and drainage. In other cases the accumulation of pus is small 
 and is deep down in the pelvis. Here the work inside the abdomen 
 will consist in separating the attachments of adherent viscera and in 
 ligating and removing the diseased appendages. While doing this the 
 abscess-cavity may be ruptured and its contents discharged into the 
 peritoneum. The pus should then be carefully taken up by spong- 
 ing, and the pelvis washed scrupulously clean with warm water and 
 drained. 
 
 Mr. Tait has now operated in this way a great number of times, and 
 his example has been followed by other surgeons with varying success. 
 He says : ^ " My general conclusion from these cases is that the opening 
 of such abscesses by abdominal section is neither a difficult nor a dan- 
 gerous operation ; that recovery is made in this way more certain and 
 rapid than in any other ; and that in future I shall always advise an 
 exploratory incision where I am satisfied there is an abscess which can- 
 not be reached nor emptied satisfactorily from below." 
 
 Occasionally the disease we are considering assumes a form which in 
 all its clinical aspects very closely resembles the last stage of pulmonary 
 consumption. There is great emaciation, profound anaemia, and drop- 
 sical swelling of the lower extremities. Along with a rapid pulse and 
 fever of a remittent type and profuse sweating, there is constant pain, 
 which necessitates the daily and nightly use of opium. The pelvic 
 roof is hard and resistant, and in places greatly thickened. Though 
 no distinct tumor may have formed, the symptoms indicate that sup- 
 puration has long since occurred, and it is not difficult to find one or 
 more collections of pus. This may be evacuated by the trocar or aspi- 
 rator, but not even temporary improvement will follow, because the 
 relief is only partial, and the entire cellular and peritoneal tissues of 
 
 ^ Op. eit., p. 351. 
 
J'j:lvi(' AJiSCESS. 7:U 
 
 tilt' jK'lvis ai'c iiiv(»l\c(l in iiill;iiniii;iliHii. J-'or siu\\ cases alxluiiiinal 
 section and <li'aiiiai;c may lie j)r(»|)(»s('<l as a la>l I'tsort. 
 
 2. T/w ^[Kjtit'dtor. — 'riiis lu'aiitil'iil coiitrivaiicc lias hccii recoiniueiKlt'il 
 by some surucons as a safe and certain iiicaiis for llic ciii-c of alisccsses 
 wliicli are si-atcd \\\<j:\\ ii)) in the pelvis and so suri'oiinded that tlie\- 
 cannot he readilv rt-ached throniili the vai;inal rool" hy the knile. 
 
 J)r. (i. II. Lyman' lias pi-esentcd an interestini;- contril)nti<»n to this 
 sulyeet in the sha])e oi" a rc|)ort of 41 cases of pelvic ahscess treated hy 
 himself and collea<2;iies in the IJoston City Hospital. Jn some of these 
 eases the ahscess was evacnated by a troear, th( camila of which wa.s 
 left in as a <lrainai;-e-tnbe, or else some other Ji ans of di-aina^e was 
 used; but 17 casc-s were treated by aspiration alon* — that is, by sinij>Iy 
 emptying the cavity with the as})irator, without wa hing or injecting it 
 in anyway. Of this nnnd)er, 10 were reported cured; 4 were not 
 benefited; 1 was improved only; 2 were injured. In 4 eases serum, 
 clear or bloody, was removed by the as])irator. In 3 of these uo 
 improvement ibl lowed, while the fourtli was cured. 
 
 In regard to these cases I woidd remark that the results reported are 
 probably too favorable, for the following reasons : It is almost impos- 
 sible to learn the subsequent history of this class of patients. One of 
 these cases, as shown by the report, was discharged from the hospital 
 while remnants of exudation were still recognized in the pelvis. Some 
 remained only a few days after the operation, one being discharged five 
 days after aspiration, another thirteen, another fourteen davs. The 
 report cannot, therefore, be considered conclusive in regard to the 
 question of cure. 
 
 A knowledge of the pathology of absce&s, of the structure of the 
 walls of chronic abscesses, and of the almost invariable presence of 
 diseased uterine appendages in peritoneal collections, must convince us 
 that the cure of the disease is rarely to be obtained by aspiration. "SMien 
 the purulent accumulation has been withdrawn by the aspirator, clots 
 of blood, sloughs of connective tissue, and shreds of lymph too large 
 to pass through the canula are usually left behind, either to continue 
 the suppurative process, or else, in all probability, to furnish the excit- 
 ing cause for those " residual abscesses " -which Mr. Paget - has shown 
 are often "formed in or about the residues of former inflammations. 
 Most of them are formed when pus produced long j^reviously has been 
 wholly or in part retained and become dry or in some form obsolete." 
 
 In one of my cases treated by aspiration there was, in connection 
 with a large serous accumulation in Douglas's pouch, a collection of 
 pus in the cellular tissue of the pelvis and the anterior abdominal Avail. 
 The patient did well for many months, but a year afterward a large 
 accumulation suddenly formed in the pelvis without appreciable cause 
 
 ' Trans. Am. Gyn. Soc, vol. vi. - Clinical Lectures and Essays, 2d ed., p. 309. 
 
732 PERIUTERINE INFLAMMATION. 
 
 aud without complaint of pelvic symptoms, with all the signs of septi- 
 csemia, rapid pulse, high temperature, and delirium, and terminated 
 fatally in a few days. My conclusion w^as that this inflammation had 
 its origin in a residual abscess. Just before death a quart of fluid w^as- 
 withdrawn by aspiration, the first and far the greater portion of which 
 was deep straw-colored serum ; the last, thick, bad-smelling pus. 
 
 My own experience with aspiration in the treatment of pelvic abscess- 
 has been far from satisfactory as a curative measure, and in several 
 cases, though large amounts of pus were withdrawn, there has not fol- 
 lowed even temporary relief. 
 
 I believe that the use of the aspirator should be restricted almost 
 entu-ely to purposes of diagnosis and to the evacuation of those chronic 
 serous effusions which persist in spite of all other treatment. Safe as 
 aspiration may seem when properly performed, it is not devoid of 
 danger. If the needle be thrust into a hsematocele by mistake, 
 instead of an abscess, violent inflammation and death may ensue, as 
 in Case A^I. of Dr. Lyman's report ; and Dr. Thomas quotes a case 
 from the Boston Medical Journal in which air entered the veins dur- 
 ing aspiratiou and the patient died in ten minutes. 
 
 Whenever resorted to, aspiration should be practised with strict anti- 
 septic precautions. 
 
 Treatment of SixrsES. — It is not unfrequently the case, when the 
 patient first comes under observation, that the abscess has already dis- 
 charged itself through one or several openings, and as many separate 
 sinuses remain. If there be several openings, it is a matter of import- 
 ance to ascertain whether they all communicate with each other and 
 acknowledge a common source. To pass a probe from one of these 
 openings — on the cutaneous surface, for example — through a circuitous 
 route, and make it emerge at another, cannot often be done. But by 
 injecting iodine diluted, or some other colored fluid, into one of the 
 openings, it T^^ll appear at all the others if a communication exists. 
 
 Various expedients have been devised for the closure of these sinuses. 
 The principle which underlies them all was proposed by Sir James Y. 
 Simpson in his Clinical Lectures on the Diseases of Women, and his 
 remarks on the treatment of pelvic abscess are well worth a careful 
 study now. 
 
 The vagina is the most desirable channel for the evacuation of a 
 pelvic abscess. Simpson proposed, when the abscess has discharged 
 itself at some other point and a sinus remains, that a counter-opening 
 should be made in the vagina. His plan was to pass a large probe or 
 sound through some opening above the pelvic brim down into the pel- 
 vis, until its point was felt by the side of the womb in the upper part 
 of the vagina. Then, cutting upon this as a guide at the most depend- 
 ent point of the abscess-cavity, a counter-opening was made. The open- 
 
PF.IAIC AflSCESS. 7:V.) 
 
 inu" ill tlic va!i;iiia may (lien \h' ciilarticd l)y tlic kiiil'c m- a dilator, so as 
 to admit one or two liiiucrs loi- |)iirj)oscs of cxploratiftii. 
 
 1 1" tlu' abscess should have opened into llie bladder or i-eelimi, in-tead 
 ot" upon the entaneons surface, tiie pi'(i|)ei' means slmuld !)<• adnpicd for 
 Hudiui;" the openinj;- into these cavities and ])assini;- throuiih it th(; lar<^e 
 ])rol)e until the locality ibi- the; vaginal eouutei--opening is made clear. 
 If this is im|)ractical)le, we may, as Dr. IJyfbrd suggests, aspirate the 
 vaginal wall with a view of finding the old abscess-cavity, and then cut 
 with the bistoury upon the asj)irator as a guide. 
 
 A drainage-tube of glass or rubber being introduced, the daily wash- 
 ing out of the cavity with warm water, made stimulating and antiseptic 
 with iodine or Jjal)ari-a(pie's solution of chlorinated soda, will in some 
 ■cases bring about a cure. 
 
 In many cases no })lace can be found for making this counter-open- 
 ing. If the patient's condition is not bad, and the sinuses are small 
 and discharge but little pus, their closure may be accomplished now 
 and then by the application to their walls of a strong tincture of iodine. 
 In other cases, where the patient's health is seriously impaired and this 
 ])lan proves ineffectual, resort to abdominal section, removal of diseased 
 <ip])endages, and drainage will become necessarv. 
 
 Finally, during the surgical treatment of these conditions attention 
 must be paid to the general health, and we must invoke the aid of 
 tonics and stimulants, of fresh air and sunshine. These are the general 
 principles involved in the treatment of pelvic abscess. While many 
 cases will be thus successfully treated, others will tax to the utmost all 
 the resources of surgery, and some will prove entirely beyond the reach 
 of our art. 
 
PELVIC HyEMATOCELE AND HJiMATOMA. 
 
 By ELY VAN DK WARKEK, .M. 1)., 
 
 Syracuse, N. Y. 
 
 XoMENCT.ATiTRE. — Tlic term " hfcniatocele " is based by Bernutz, 
 the author of the word, upon the hypothetical resembhince of the 
 pentoueal cul-de-sac of the female pelvis to the tunica vaginalis of 
 the male, and is used to define a collection of blood in the pelvic 
 excavation within the peritoneiuii. Bernutz limited the term to 
 haematic collections due to hemorrhage from the internal genitalia, 
 
 Most authors exclude pelvic hemorrhage caused by rupture of extra- 
 uterine gestation-sacs, of aneurismal tumors, ovarian cysts, or blood- 
 eifusions due to accident or injury. Some exclusion is necessary, as 
 the term hematocele does not define a disease, but only a result that 
 may be the outcome of various conditions. In order to give the term 
 clinical significance, hnematoceles of pelvic origin, in the absence of a 
 better word, must be arbitrarily limited to certain well-defined sources 
 of hemorrhage. With this view the limits imposed upon the term by 
 Nelaton are adopted in this article. Nelaton restricted its meaning to 
 a definite pelvic location by the word retro-uterine. As the haematic 
 collection is not always located in the sac of Douglas, the term pelvic 
 haematocele, first used by McClintock, is by far the better one, and is 
 now in general use. 
 
 To be a true pelvic hematocele, to carry out the hypothetical anal- 
 ogy between pelvic peritoneal duplicatures and the tunica vaginalis, the 
 blood must become encysted within the pelvis. Although a true cyst 
 never enchases the effused blood, as good an authority as McClintock 
 divides pelvic hematocele into two groups — enci/stcd and non-enci/sted ; 
 which division has gained currency as defining the incarceration of the 
 blood-mass by adhesions of contiguous peritoneal surfaces. 
 
 Some of the terms qualifying pelvic hematocele have led to confu- 
 sion, which has resulted in confounding two distinct pelvic conditions. 
 Nelaton brought into use the terms ciiTumKfcrlnc and periuterine Jievma- 
 tocele, which are now frequently employed to designate a pelvic hema- 
 toma. As it is important to make a careful distinction between hema- 
 tocele and hematoma, the terms ought to be abandoned. Gallard, who 
 
 v:^5 
 
736 PELVIC HEMATOCELE AND HMMATOMA. 
 
 made frequent use of the terms, employed them without reference to 
 the peritoneal relations of the eifused blood. If we have made no 
 other advance since Gallard wrote (1857), we ought to have gained 
 precision in the use of terms. 
 
 While McClintock divided hsematoceles according to the condition 
 of the effusion, others have based the classification upon either the 
 source of the hemorrhage or its anatomical relations. Genouville 
 makes two groups — the catamenial and the accidental; but here, in 
 order to group a case, it is necessary to define the source of hemor- 
 rhage, which is in many cases impossible. Barnes makes an elaborate 
 classification of two groups and five sub-groups, and writes of it as 
 though it was a material addition to our knowledge of the subject. 
 Barnes has, however, added a very expressive word — cataclysmic — to 
 describe large and sudden effusions attended by alarming or fatal col- 
 lapse. Excluding rupture of the parturient uterus and of tubal gesta- 
 tion-cysts, which Barnes includes in this sub-group, hemorrhage of a 
 cataclysmic character belongs to a diseased ovary, rupture of the pam- 
 piniform plexus, or of the subovarian vessels. 
 
 Great confusion obscures the relations of hsematocele to hsematoma, 
 and, although the terms express two very different classes of pelvic 
 haematic tumors, the words have been used by good authors as synon- 
 ymous. Such terms as hsematocele ligamenti lati (Bandl) — and which, 
 according to Nelaton, are small blood-effusions in the broad ligaments 
 which are very common and mild in their course — Huguier's pseudo- 
 hsematocele, and Gallard's circumuterine and periuterine hsematocele, 
 have added useless confusion to the nomenclature of a difficult subject. 
 If we add to this confusion of terms the fact that writers who have 
 shaped opinion upon this phase of pelvic pathology have denied the 
 existence of extraperitoneal effusions of blood in the pelvis, except in 
 connection with gestation and the puerperal state (Bernutz), and when, 
 granting the possibility of such effusion, we have applied the terra 
 thrombus (Meadows), we are able to form an idea of the status of 
 hsematoma as a distinct symptom of a pelvic condition. Notwithstand- 
 ing the authority of Bernutz and Meadows, the term thrombus ought 
 never to be applied to an extraperitoneal effusion of blood, but restrict- 
 ed in its gynecic sense to blood-exudations of the external genitalia. 
 When upon the subject of hsematoma the term will be confined to 
 this condition. 
 
 By the term hsematoma we describe an effusion of blood between the 
 folds of the broad ligaments or in the connective tissue surrounding the 
 uterus and vagina, and which is now clearly recognized and differenti- 
 ated from hsematocele. Hsematoma is without the peritoneum; hsema- 
 tocele is within the peritoneum ; and upon this simple declaration this 
 article will be based. 
 
ILKMATOLKLl-:. T.'J 
 
 H-EMATOCELE. 
 
 HlSToiJ^'. — PoMcct states tli;ii in ilic works of I li|>|HMiaii> jMKic 
 luvinatocclo is ck-arly (Icscrilx'tl, Iml IVoiii that ])critMl ddwii to l(j71 
 IK) ivti'i-eiice is found to tlie disease until that year, wlien Knv.-eh ^A' 
 AiiLsterdain aeeunitely deseril)e<I the menstrual variety <.l" lut'iuatoeele, 
 proviufT the escape of blood outward throuiih the l''allo|»ian tuhes into 
 the peritoneal cavity, anticipating liernutz one hundred and seventv- 
 four yeai-s. In Hufeland's Journal (1818) another case of this variety 
 is described. P. Franck in 1823 added other facts to our kno\vled<re 
 of the subject, Init to Bourdon, a follower of Kecaniier, belongs the 
 honor of Hist describing the physical signs of liaeniatocele, demonstrat- 
 ing its en(ysted character and j)laci])g the lesion in the periuterine cel- 
 lular tissue, liernutz published his first memoir upon the subject in 
 1848, the beginning of a series of memorable papers. Vigu5s in 1850 
 based his (observations upon seven cuses, descriljed the effused blood its 
 extraj)eritoneal, and explained the source of the hemorrhage as ovarian. 
 Xelaton in LSol fii-st gave the-disease a status in literature, describing 
 the tumor, its signs, and treatment, from which, in its essential features, 
 there has been no departure to this day. In the French Academy in 
 the same year a memorable discussion took place upon a paper by 
 Monod descrii)ing a retro-uterine hsematocele. Xelaton, Robert, Hu- 
 guier, Denouviliers, Lenoir, took part in the discussion. Kobert 
 established the declaration of the pelvic regions involved in tlie effu- 
 sions, the most important of which "was the broad ligament, while 
 Huguier enunciated his anatomical classification of intra- and extra- 
 peritoneal "which endures to this day. Here, also, the treatment by 
 puncture was first proposed, and Mas twice made by Denouviliers. In 
 the thesis of Prost in 1854 the distinction of extra- and intraperitoneal 
 was firmly settled. He fii-st gave the physical signs of depression of 
 the uterus in intra- and its elevation in extraperitoneal blood-effusions. 
 To English literatiu-e Tilt has given the most elaborate contributions 
 (1853), but the condensed, graphic narrative of McClintock has had 
 more influence upon the coui'se of opinion. In 1855, Langier dem- 
 onstrated the ovary as the source of blood-escape Mith its histological 
 alterations. In the same year Gallard rendered a valuable service by 
 pas-ing in review the literature of the whole subject to liis date, and 
 reduced to order the fragmentary mass of facts. In this year also 
 Pencil (de Toulouse) made a material contribution by demonsti-ating 
 the several sources of hemorrhage, as lesions of the tul)es, the ovaries, 
 and the ovarian venous plexus. In 1858, Voisin published the most 
 complete monograph yet offered upon the subject, and may be said to 
 have concluded the period, one of the most brilliant in French medical 
 history. 
 
 Vol. I.— 47 
 
738 PELVIC H^EMATOCELE AND HJSMATOMA. 
 
 In Germany the period of literary activity coincided in date with 
 that in France. The first cases of note were described by Herzfelder 
 (1856), and by Crede (1857), Heyer, Breslau, Ukich, Braun (1860), 
 Krieger, and Ott (1863). In the works of Schroeder, Beigel and 
 Olshausen, and Klebs valuable references may be found. The views 
 of Virchow, that the hemorrhage is due to the rupture of neo-mem- 
 branes within the pelvis, have gained ascendency in Germany. Many 
 of the above notable papers are found in the files of the Monatschrift 
 fur Geburtskunde, so rich in gynecic literature during the formative 
 period in Germany. 
 
 In England, besides the important contributions of Tilt and Mc- 
 Clintock, we have those of Madge, Snow Beck, Meadows, Duncan, 
 Simpson, and in the works of Hewitt, Bennet, Churchill, Tait, and 
 others. 
 
 In America, although the subject has been well understood, but little 
 original work has been done. Bedford in 1855 was among the first 
 to make a material contribution; Byrne followed in 1862 with a very 
 valuable monograph ; C. C. Lee and Harrison are also later authors of 
 excellent papers ; while the more recent American textbooks — notably 
 those of Thomas and Emmet — have given liberal space to the subject. 
 From these beginnings the literature of hsematocele and hsematoma has 
 assumed grand jDroportions. An examination of the material upon 
 the subject in the library of the Surgeon-General's Office at Washing- 
 ton, as enumerated in the Index Catalogue, shows four hundred and 
 fifty-five titles. 
 
 Causes. — Hsematocele and heematoma are, for the purpose of de- 
 scription, regarded as diseased entities. They are, however, merely 
 symptoms, and as such must be studied in their causative relations. 
 
 There have been marked and intimate relations traced between hsema- 
 tocele and ovarian function, and in consequence age has a direct bearing 
 upon the liability. Voisin shows that the ages between twenty-five and 
 thirty-six years define the period of greatest frequency. The ratios of 
 those attacked at twenty-one years and at forty correspond. Schroeder's 
 observations, based upon forty -three cases, confirm those of Voisin. 
 
 Concerning the relative frequency of hsematocele authors differ so 
 widely that no conclusion can be reached. Thus — 
 
 Hugenberger reports 2 in 3801 cases. 
 Seyfort " 66 " 1272 " 
 
 Olshansen " 34 " 1145 " 
 
 The latter, again, " 29 " 769 " 
 Bandl " 5 " 1500 " 
 
 Scanzoni in twenty-eight years' practice met with hsematocele only eight 
 times. Barnes in his paper read before the Obstetrical Society of Lon- 
 
Il.KMA TiKELE. I'.V.) 
 
 (loll astuiiislii'tl his aiidicncc l)y the rri'(iii<'ri<v with \\hi<h he met with 
 the accident, and ii|)itn this assertion ahuie Mea(h)\\s (»[)enly attacked 
 the cnrrectness of his diagnosis. 
 
 This wide divergence in experieiiee may he e.\|»Iained hy the state- 
 ment that ()l)sei'vcrs wlio hase their ratios npon hospital records meet 
 wilh ha'matoccic los ot'tcii than those who are enjia^ed in consultation- 
 work. 1 hematocele is nsnaily \cry sndch-n and severe in its onn-t, and 
 is moi'c often a domiciHary than a hospital case. 
 
 The rcproihiclive ai;c at its period of greatest activity bcni}^ the period 
 most proiii' to attack, snl)stantiates the theory that many writers adhere 
 to, that the ovaries and their essential accessories, the tnhes, are the parts 
 commonlv conct'iMicd in the morl»id conditions that I'csnk in luematwele. 
 Voisin oixserves that the i;i-eater mnnher of htematoeeles occur near or 
 at the end of the menstrual period, and when the hicmatic accident 
 take.s place menstruation ceases or is lessened in amount. This 
 mav he true as a clinical observation, but is not made clear by Bandl's 
 explanation that the freipient develo|)ment of hiematoeele during men- 
 struation is due to the hiiili blood-pressure in the ovarian vessels, from 
 which, having been weakened by morbid changes, they give way. The 
 treneral hiirh-tension condition of the circulation that characterizes the 
 menstrual process is greater at the beginning of the function, and the 
 inference is clear that this ought to be the period of greater liability. 
 Tilt substantiates this idea, as ha?matocele presents itself in two opposite 
 conditions — namely, in the total absence of menstiniation, and when it 
 is morbidly j)rofuse (menorrhagia). In the absence of the discharge 
 the hemorrhagic loss attending the formation of the hsematocele would 
 sup})lant the menstrual discharge. 
 
 Bcrmitz and Tilt are the most determined advocates of the menstrual 
 origin of haematocele. Tilt concludes his book on Uterine and Ovarian 
 Inffammation by the rather dogmatic statement : " The occurrence of 
 hrematocele is one of the penalties of allowing the menstrual functitm 
 to be habitually morbid." Such positive statements must not lead to 
 the conclusion that haematocele is ever due to a functional derangement 
 of the ovaries. Such has been the theory advanced, but there is no evi- 
 dence to prove a vicarious origin, in the absence of organic lesion, of 
 the pelvic accumulation. Tyler Smith takes this view, and supports it 
 by the clinical fact that the ha^natocele is frequently augmented l)v 
 renewal of the hemorrhage at each menstrual period ; but, while the 
 fact must be admitted, its explanation is not a logical one. Bernutz's 
 theory is a better one, that it is a morbid excretion from the tube and 
 uterus, but only a portion of the discharge is so etfused, as in this 
 variety' (metrorrhagic hsematocele) there is always an external discharge 
 of blood at the same time. 
 
 Bernutz makes four clinical groups. The tirst is comprised of liama- 
 
740 PELVIC HEMATOCELE AND HEMATOMA. 
 
 tocele occurring in eruptive fevers and febrile conditions (purpura, black 
 jaundice) ; second, all those cases that attend flooding after childbirth or 
 abortion ; third, hsematoceles of metrorrhagic character symptomatic of 
 pelvic peritonitis : this last is purely a theoretical group, difficult if not 
 impossible to differentiate ; the fourth group is characterized by some 
 cachexia or observed in women subject to floodings. 
 
 Courty states that four sources of hemorrhage have been demonstrated 
 by autopsy. They are as follows, in the order of frequency : Apoplectic 
 hemorrhage from the ovaries ; hemorrhagic pachyperitonitis ; rupture 
 of one of the vessels of the ovarian plexus ; and, lastly, tubal hemor- 
 rhage (rupture). The latter source has given origin to the theory 
 expressed by Lee, Poncet, Raciborski, and others — and to the truth of 
 which a few demonstrations attest — that the inner surface of the tubes 
 will secrete blood at a menstrual period like the endometrium. If the 
 uterine extremity of the tube is closed, the blood will escape at the fim- 
 brise, and thus cause a retro-uterine hsematocele. If the abdominal 
 opening of the tube is also closed, a hematosalpinx is formed. In 
 case such a tube is ruptured, hsematoma, rather than hsematocele, is 
 formed. Barnes makes four sub-groups : 1, early Fallopian gestation 
 and escape of ovum into the peritoneal cavity ; 2, mechanical impedi- 
 ment to the escape of menstrual blood ; 3, interrupted or disturbed men- 
 struation from (a) cold, over-exertion, (6) emotion, (c) excessive sexual 
 intercourse ; 4, hemorrhagic tendency induced by disease, among which 
 may be mentioned jaundice in pregnancy and excited by strong emotion 
 or physical shock. 
 
 Bernutz says that a large and important class of hsematoceles is the 
 result of a defect in the relation of the tube to the ovary. If any such 
 source exists, it must be the result of pelvic peritonitis causing adhesions, 
 with distortion of either the tube or ovary in their relation to each other. 
 But there is no post-mortem evidence of the fact. Madge gives import- 
 ance to ovarian apoplexy as a cause of hsematocele. A small blood- 
 vessel gives way in the ovarian capsule, and a blood-extravasation 
 occurs, with a gradual augmentation m(mth by month until the ovarian 
 stroma is ulcerated (ulceration of ovary). At last the capsule ruptures, 
 and the blood escapes into the pelvic cavity. Monthly hemorrhages 
 then take place from the ovarian stroma, with a corresponding periodic 
 increase in the pelvic accumulation, with all of the attending signs — 
 pain and shock — of hsematocele. The case is nearly a hopeless one, but 
 at any of the periodic exacerbations does not present specially alarming 
 symptoms. This theory explains in a very perfect manner the case 
 reported by Madge. 
 
 Richet, D^valz, Scanzoni, and Winckel assign to a varicose condition 
 of the subperitoneal venous plexus of the ovary and tube an important 
 etiological relation to hsematocele. Scanzoni believes the condition is a 
 
JLKMATnchlj:. 7 JI 
 
 rare OIK- ; Winckcl, liowcvcr, li-iiuvs it vcrv licauliliilly in his J)i> J'nH,, 
 Wciblich. (//(/(iiir [[A. xxvii. li«rs. 2, 3), and staU's that this vaiiii.-i- cou- 
 (litinii (»r the t)vai-iaii venous plexus is rr((|ii(iil l\ iihi with in imisI- 
 niiii-t( Ml i-xaniinations. 
 
 r>aii(ll mentions rai'e eases of h;eniatoeeIe in whiiji aionnd ihe nteniH 
 and in the Ial»ia a varicose eondilion (dihe \-eins was ohsei-vcd. 'I'here 
 is no donht that a varicose condition ol" the parovarium hits hceii fomid 
 associated with the ae<i(h'nt. IJernutz also says that a varicose; dilata- 
 tion ot"lhe pamj)inirorm may occur in botli the [H'cj^nant and non-]ire<r- 
 uaiit, and w hen carried beyond a certain limit may rupture. A luema- 
 t(xvle due to this cause ought, iVoni the suddenness with wliich such a 
 rupture would occur and the ai)undant source of the hemorrhage, to 
 be catastrophic, as Barnes terms it. 
 
 It was first asserted by Virehow, and reaffirmed by Dolbeau, Huguier, 
 and Tardieu, that the blood-eftiision may be limited to the peritoneum 
 (peritonitis luemorrhagica), and explained by Virciiow as a process simi- 
 lar to that which occurs in pachymeningitis pseudo-mend)ranosa, in which 
 a liUe exudate is uoticeil. It is evidently the same process to which 
 Bandl gives the name of pelvi-peritonitis luemorrhagica. The same 
 idea has gained the good-will of Bernutz, who regards the exudate as 
 the homologue of that in the hemorrhagic pleurisy of Laennec. A 
 litematocele due to this cause ought to present some differential charac- 
 ters in marked contrast to those present in a ha?matocele due to sudden 
 rupture of a pelvic ve&sel. In the latter the pain and peritonitic symp- 
 toms follow, and in the former the peritonitis ought to precede the effu- 
 sion. This, clinically speaking, is just what does not occur. AVhile it 
 cannot be denied that effusions, such as are here described, may be the 
 residt of peritoneal inflammation of a certain grade in any situation 
 where the membrane may be met with — while, in fact, exudation mav 
 be said to be a general attendant of the inflammatory process in the ]iart 
 — still, we cannot regard it as a common cause of the hrematoceles that 
 concern the gynecologist. It is difficidt to conceive of a pelvic effusion 
 justly due to the latter cause that could reach such a point in its devel- 
 o])ment that it woidd be clinically proper to cease to regard it as a peri- 
 toin'tis, and become simply a hjcniatocelc. Exudative pelvic peritonitis, 
 in which the effusion is organized into vascular pelvic adhesions, may 
 lead to hR?matocele — not, however, as the result directly of the perito- 
 nitis, but as the outcome of the adhesions. The rupture of vascular 
 adhesions may take place and lead to a very active intra]iclvic hem- 
 orrhage. This accident is especially liable to happen if old uterine 
 displacements are replaced with the sound or with an instrument 
 known as a repositor, which has now, fortunately, gone nearly out of 
 use. It is a common matter, after a forcible re]ilaccment of a distorted 
 or displaced uterus, for a pelvic mass to quickly form, attended with 
 
742 PELVIC HMMATOCELE AND HEMATOMA. 
 
 severe paiu and rapidly-developiug peritoueal tenderness. In the course 
 of several weeks or months the mass is gradually absorbed, and the pain 
 and tenderness in like manner subside. Such a case is usually consid- 
 ered as a new, or as a relapse of an old, cellulitis. In our present 
 knowledge of the subject of hgematocele it is certain that many of 
 these cases ought to be considered instances of this accident. Abdominal 
 surgery teaches us that the rough handling of peritoneal surfaces adher- 
 ent with old adhesions is not specially liable to cause a renewal of 
 inflammation. With this experience before us it is philosophical to 
 class some cases of this character as hsematoceles. 
 
 Emmet holds that the theory of Bernutz, that menstrual blood may 
 regurgitate through the tube backward into the peritoneal cavity, worth 
 no more than a passing notice ; but he admits that Trousseau's theory, 
 that the source of the hemorrhage may be in an exhalation from the 
 mucous membrane of the tube, may be correct, the blood coming from 
 that portion near the fimbriated extremity. Meadows, in commenting 
 upon this theory, gives the opinion that in an ordinary state of the tube 
 such a thing is not possible, but that it must be granted that the tube 
 is dilated, and its contents forced toward the fimbriae, causing the spas- 
 modic pain characteristic of the menstrual variety of hsematocele. Tait, 
 without any qualification, says the theory is improbable. Very few 
 demonstrations bearing directly upon the subject are recorded, and in 
 both cases of undoubted regurgitation mentioned by Brodie and Pauly 
 there was occlusion of the os externum uteri. 
 
 Several cases have been recorded of dilatation of the tube in instances 
 of double uterus. Deces relates a case of double uterus and vagina, 
 with the left vagina imperforate, with accumulation of menstrual blood 
 in the left uterus and vagina. It resulted in over-distension, rupture, 
 and death. 
 
 Barnes has a group of heematocele due to the prevention of the escape 
 of uterine discharges during abortion. In these cases the blood is forced 
 along the tubes, and finds its outlet into the peritoneum. No cases have 
 been discovered which substantiate this theory. Such a condition may 
 be possible in traumatism due to forced abortion, but even here, from 
 the necessary condition of things, we can barely admit its possibility. 
 
 Spencer Wells states that blood may eflfiise from the stump of an 
 ovarian cyst when treated intraperitoneally. Small effusions from this 
 source are very common, and the symptoms slight. When the ped- 
 icle is secured externally, blood has been observed to percolate from its 
 exposed extremity at a menstrual period. By a parity of reasoning, we 
 may assume that the same condition may occur when the pedicle is 
 treated intraperitoneally, and thus small menstrual hsematoceles be 
 formed. It is doubtful if a hsematocele due to this cause would, 
 clinically, call for rigid diagnosis. 
 
II.KMATOCF.LI':. 74;j 
 
 l"'rc(|iii'iit iiinitioii is made 1»\ many aiMli<irs, c-iKTiallN' ol' tin- l''i-iiic|i 
 scliool (»r ^TiH'('t'li>uy, <»1" sexual iMici'coiiisc at a infii>lnial j»crit»»l as an 
 rti()U)j2;ical cDnditioii. Scncii cases nnl <il" ten nienti()ne<I l»v X'oisin had 
 the tiixt pains at tendinis' the aeeidcnt (teeiM- (hn'inu coitus. iSandl rec(»r<l.s 
 a case in which coitus lirst tooi< place at the ix-Liinnini: ol" menstruation, 
 attemh'd l)y the rapid I'ornialion ol luemalocclc. I'nech also cites a ease. 
 W c can readily admit what a potent I'actoi- sexual iiitefconrse at a inen- 
 sti'iial pefiod may lie as a cause of fuptufc i»t' inij)aifed |iel\ic hlood- 
 vessels. Too rre(|uciit of too violent a sexutd act is also mentioned a.s 
 an excitinii' cause; hut il" any eases are directly ref'crahlc to this cause, 
 they havi' escapetl demonstration. 
 
 Severe hodily eiliirt durint;' menstruation has heen known to ])recipi- 
 tate an attack of pel\ic heni()rrlia«»:e. Heavy liftinj^:, daneiufr, or long 
 jH'destiian excursions ou^ht to he carefully avoided by one at this 
 })eriod who has ever been subject to a menstrual hiematocele. Sudden 
 ehillino; during menstruation, especially of the extremities, may act as 
 an exciting; cause. Bathing the feet in cold water at such a time has 
 been known to be the a]>pai'eut cause of an attack. 
 
 Changes in the constitution of the blood or in the walls of blood- 
 vessels after acute exanthenis are sometimes the cause of pelvic accu- 
 nmlations of altered blood. Bandl names purpura, icterus gravis, scar- 
 latina, and variola as the diseases in which pelvic j)eritoneal affusions 
 are the more liable to occur. Trousseau calls the hrematocele thus 
 jissociated the cachectic. In a strict classification of etiological condi- 
 tions this cause ought to be excluded. The morbid condition may, and 
 probably docs, extend to the general peritoneal cavity of the abdomen, 
 and the blood accunudates in the pelvic spaces by gravitation. Clini- 
 cally, a ha-Muatocele due to this cause would rarely claim the attention 
 of the gynecologist. 
 
 We have thus gone over all the j>elvic and general conditions which 
 may act as near or remote causes of this serious accident : a great many 
 are rarely acting factoi-s ; others, however, are so frequently observed 
 that ordinarily, without going into any method of rigid exclusion, we 
 may say that the lesion exists in the circulatory plexuses of the ovaries 
 and tubes. AVe are justified in saying that the ovaries are periodically 
 in a condition favorable to the accident. As Rokitansky states from 
 actual demonstration, a source of ovarian hemorrhage may exist in a 
 bui-sting of cysts of the ovary formed of distended follicles in which 
 l)lo(xl has been extravasated — a condition, minus the ru])ture, observed 
 with great frequency in the cadaver. It is not difiicult to undei-stand 
 why the menstrual group of pelvic haematoceles is the one with Avhich 
 the gynecologist has most frequently to contend. 
 
 Pathology. — Since retro-uterine and anteuterine hteraatoceles 
 rarely terminate fatally, many of the early pathological conditions 
 
744 PELVIC HEMATOCELE AND HuEMATOMA. 
 
 are obscure and are largely obtained from clinical study. Time is 
 not measured by its ordinary periods in gynecology, and the year 
 1859, when Simpson wrote upon hseraatocele, while near in the matter 
 of years, is remote in view of the rapid advance of a great science; 
 and yet, crowded as is the intervening time with facts, nothing has 
 been added to the truth as he expressed it, that " there is almost no 
 limit to the variety of the situations in which a pelvic thrombus or a 
 hsematoma may be found, for the veins may give way in any part of 
 the pelvis, and the blood which escapes may fill sometimes one facial 
 loculament only of the pelvis, at other times several at once." Snow 
 Beck says that the arrangement of the fascia in the pelvis covering the 
 various muscles, and converging to a central part at the neck of the 
 uterus, is very complicated, and often presents a weak point behind the 
 OS internum, into which the finger can be pressed and through which 
 a hernial protrusion of the veins may occur. This was the seat of an 
 effusion observed by him. There are other and less complicated rea- 
 sons why the hsematic affusion is generally noticed in the recto-uterine 
 pouch. The Fallopian tubes are always directed backward, never for- 
 ward, so that a blood-effusion naturally takes the direction downward 
 and backward. Periuterine and anteuterine hsematoceles are usually 
 secondary to retro-uterine hsematocele, or when anteuterine hematocele 
 exists without the retro-, it is because Douglas's space is obliterated by 
 adhesions and fibrous bands, so as to prevent the accumulation at this 
 point. A case recorded by Schroeder demonstrates this fact. While, 
 however, the ovaries and tubes lie mostly in the posterior wings of the 
 broad ligaments, and the escaping blood most easily finds its way into 
 the recto-uterine duplicature of the peritoneum, it is a mistake to sup- 
 pose that all blood so effused will do this if this cavity is free. Small 
 blood-masses will become entangled in the vesico-uterine pouch or even 
 lie above the broad ligament. These are marked exceptions to the rule, 
 which may be said to hold true when Douglas's space is free. 
 
 Courty says that if the hemorrhage comes from the tubes or ovarian 
 venous plexus, the resulting hematocele may be limited to the folds 
 of the broad ligament, or under the peritoneum covering the uterus, 
 in periuterine cellular tissue, not only behind and in the broad ligament 
 of the other side, but also in front under the peritoneal fold covering 
 the uterus and bladder. These limits of the haematic tumor define the 
 hsematoma rather than the hematocele, and the disposition of the blood 
 affused into one broad ligament to pass over to the other develops the 
 central constriction in the tumor, to which considerable importance is 
 given in the differentiation of the two forms of pelvic effusions. 
 
 Emmet defines three sources of hemorrhage. The first is from the 
 mass of vessels known as the bulb of the ovary, from which the blood 
 would pass into the peritoneal cavity ; second, from the pampiniform 
 
ILEMAToci.U:. 71,-, 
 
 plt'Xiis Mini iHluork of vosH'ls iiii(l< r tlir tiilxs aii<l Ixf wtM-n tin- folds 
 ui" the l)i-u;i«l liirMlilcllts, :ill<l llilis tlir «'sr;ijM- wuiild (K-ciir ill tin- <«lliilar 
 tissue (»r, l)y niptiir.- of the |Hi-itoiii'Uin, jkuvs into the ^-avity of the alwlo- 
 nu'ii ; tliinl, fn»in the vatj^iiial jmictioii at l)ottoiii «tf Doufrhis's s|>a<f, 
 at the point (Icscrihcd by Snow !i«c|<, or from sonic point in front of 
 tlic iitcnis, l)iit out.sidf ol" the jx ritoiu iim, from wliidi point tiic cHii.sion 
 would be fonfincHl to the (cIlMlar tis-iic The tir-t sourrc of hcmorrlijijje 
 would, LT^'uerally speak i nir, uivc oi-itrin to tin- menstrual variety of liuMii- 
 atoeele, and the seeoud and third to the forms usiiallv found iLss«KMat(xl 
 with eliildhirth or abortion. Most frequently the extravasation of blood' 
 into the pelvic cellular tissue, known as luematoma, results from ru])ture 
 of the pamj)iniforni plexus or the venous auiLstomoses of the broad 
 litrameuts, and not from the ovaries. Rupture of the vessels in the 
 vaginal roof is irenerally due to traumatism, such as foreed abortion 
 or j>elvie operations. 
 
 The ovaries have been found degenerated and ])artially converte<l into 
 soft, dark-red capsules capable of pouring out considerable quantities of 
 blood, and in this form associated with retro-uterine luematcxele. In 
 the section upon Cause a varicose condition of the venous plexus of the 
 ovary or broad ligament has been noticed — a condition found in child- 
 bearing women, and of which a varicose condition of the labia majora 
 may be taken as a type. If in these cases the peritoneum were to give 
 way a haematocele woidd result ; and, on the contrary-, such rupture 
 of the vessels has been observe<l with the peritoneum intact, with 
 haematoma as the result. Xelaton believed that blood might escape 
 spontaneously from the ovaries during menstruation. 
 
 In over-exertion during menstruation blood can esca})e from the cor- 
 pus luteuni in certain morbid states of the organ. Ajioplexy of the 
 ovary, mentioned by Scanzoni, may possibly be a condition that would 
 favor hemorrhage from the organ in the condition last mentioned. The 
 case on which his theory of apoplexy is based is not of that character. 
 In the instance of an eighteen-year-old girl Avho died from a rapid 
 pelvic hemorrhage, the section showed the right ovary the size of a hen's 
 egg, with a large bloml-cyst in the posterior wall, in Avhich was a rup- 
 ture one inch long, through which the blood had escaped. Blorxl- 
 thrombi in the connective-ti.ssue stroma, usually quite small, or small 
 cysts, are not rarely observed. Bandl gives to these imjwrtant patho- 
 logical value. 
 
 The tubes, aside from rujiture due to over-distension, are sometimes 
 sul)ject to changes which may result in hemorrhage. Occlusion of the 
 uterine extremity of the tube has been observe<l. Barlow reports such 
 a case where the tube was distendetl with the clot protruding from the 
 ovarian extremity. Scanzoni mentions a like case, with the tube dis- 
 tended to the size of the finger, holdinir two ounces of bloo<l. mIhIc 
 
746 PELVIC HEMATOCELE AND HEMATOMA. 
 
 sixteen ounces had escaped into the peritoneal cavity. Bandl roughly 
 generalizes that when the ovary is normal the pathological change is 
 located in the tube. The reader is now prepared to realize that no such 
 broad generalization can be made — that^ as a matter of fact, if the ovary 
 is normal the source of hemorrhage is usually found in some of the 
 numerous venous congeries of the uterus or broad ligament. Vigues 
 has stated that every hsematocele is caused by a tubal pregnancy. Gal- 
 lard also adheres to this theory. Hsematocele very frequently follows 
 a two months' lapse of menstruation, and often after a recent delivery. 
 Frequent childbearing is associated, either as a cause or a result, with 
 narrowed and dilated tubes. As a further proof of this theory, tubal 
 moles or blighted ovum have been noticed. In some cases a decidua 
 has been found. There are several cases of extra-uterine mole preg- 
 nancies on record. Prof. Heschl placed a typical instance of this at 
 Bandl's disposal, preserved at the Vienna Pathological Museum. Two 
 other cases of like nature have been preserved, while Duverney also 
 described a case. The fact that tubal pregnancy can cause, and unfor- 
 tunately has caused, pelvic haematocele of a catastrophic character jDer- 
 mits no kind of doubt, and, from possessing altogether another kind of 
 interest to the gynecologist foreign to this subject, has been excluded as 
 a cause from this article. It is a matter of direct interest to the sub- 
 ject that this form of pregnancy may result in a mole and be a source 
 of danger for an indefinite time. We must regard it as placed beyond 
 a doubt that this termination has taken place, and has not placed the 
 subject exempt from dangers which are regarded as the direct and cer- 
 tain outcome of tubal pregnancy with normal development of the ovum. 
 Destruction of the ovum by electricity, with a mole degeneration of the 
 bliglited product, may be a result of the use of this very certain way 
 of arresting foetal growth. 
 
 Courty considers the anteuterine variety of haematocele secondary to 
 the retro-uterine. If the recto-uterine pouch is too small to contain the 
 effusion, both varieties will form. G. Braun notes a case in which a 
 tumor 15 cm. long developed in the utero- vesical space. The bladder 
 was forced doAvnward and backward in the vagina. On examination 
 after death peritonitis was marked ; a sac as large as a child's head 
 occupied the anteuterine space ; behind and below it was bounded by 
 the ligamentum latum and the uterus, on the left by the mesentery and 
 sigmoid flexure, in front and above by the adherent small intestines, 
 mesentery, and the greater omentum. Braun remarks that after adhe- 
 sions of the extent and character noted a large space was left in the 
 region of the utero-vesical space that could be occupied by a haemato- 
 cele. Schroeder examined a like instance in which the rupture of a 
 tubal pregnancy gave origin to an anteuterine haematocele. Douglas's 
 space was obliterated by strong adhesions which confined the uterus 
 
ILKMArocilLE. 7 17 
 
 haclvward. Sclirocdcr's idea was tliat llic atllirsiuiis <»!' (lie iitcni> wiih 
 the rectum, aii<l tlu' resulting displaeement backward of tlir orj^an, 
 were primary t<» tlie I'ormatiun ol' the ha'matdceh', tliiis (•aii>iiin; a large 
 space to he occupied hy the exlravasated hlood in tlie aiilcutci-ine region. 
 Reiusouing from the great Imjueney with wliidi adhc-ions and conse- 
 quent obliteration of Doughus's sac are observed, we must admit that 
 it is a very })rol)ablc antecedent of h.ematocele. (ii\-cn this condition, 
 tliere is but one other pelvic space that c(ndd be occupied bv anv con- 
 siderable blood-accumulation. While we achnit a perinteiine jxritoni- 
 tis may be jtrimary to any pelvic effusion, it certainly does not afford 
 grounds for the broad generalization that the extensive adhesions that 
 encaj)sulate the haematic tiniior, and give origin to the name of h:ema- 
 toeele, are always a condition that exists jn'ior to the jielvic hemorrhage. 
 Schroeder is inclined to this view of the matter, while Braun also 
 expresses the same (^pinio.n in the case quoted from Iiim. Xelaton says 
 that the formation of the blood-tumor is the j)rimarv, and the perito- 
 nitis with pseudo-membrane and adhesion of near parts the secondary, 
 steps in the process. The argument, on the other hand, tliat experi- 
 ments with animals by injecting blood into the ])eritoneal sac do not 
 result in exciting peritonitis and encapsulation of the foreign blood-clot 
 by adhesions, is not valid, and furnishes no grounds for a like conclu- 
 sion in the human subject, in Mhich mc have to deal with a morbid 
 process from the beginning to the end of a pelvic htematocele. In the 
 human subject we have not alone the l)lood-clot, l)ut an altered state of 
 the secretions, a lowered vital tone incident to the hemorrhao-e, and the 
 primary tissue-changes which made the entire series of morbid events 
 poasible. These conditions can never ol)tain in animal experiments. 
 We must come to the conclusion that the ])entonitis and adhesions 
 which form such a striking phenomenon in true pelvic haematocele are 
 the results of the pathological conditions which have their origin in the 
 pelvic blood-accumulation with its primary morbid tissue-alterations. 
 This conclusion must, however, be modified to the extent of admitting 
 that a pelvic peritonitis Avith adhesions and distortion of the pelvic 
 organs may precede the occurrence of pelvic blood-accunudation, but 
 that such a condition is a coincident, and not in any ^vay a link, in the 
 chain of diseased sequences related to the h;emat(X'ele, except as the 
 previous existence of the pelvic inflammatory process may favor the 
 occurrence of rupture of some pelvic blood-vessel. A more careful 
 study of the haematic sac affords additional evidence of the truth of 
 this argument. 
 
 Generally, quite rapidly after the formation of the pelvic clot, symp- 
 toms of peritonitis develop. If, in a week to three weeks after, a post- 
 mortem examination is made, the clot is found surrounded by a false 
 membrane, which has been mistaken for jieritoneum. This pseudo- 
 
748 PELVIC H.EMATOCELE AND HJEMATOMA. 
 
 membrane throws out filamentous prolongations which pass through the 
 mass, while other extensions from it resemble bands of connective tissue 
 and pass through the clot like partitions. In other instances no fibrin- 
 ous bands of adhesions are formed, but a membranous-like covering 
 spreads over the blood-mass. In other cases the enveloping process 
 consists in a welding together of intestinal loops. An instance of this 
 has been described above in relation to a case of anteuterine haematocele. 
 
 In retro-uterine blood-collections the following boundaries are usually- 
 noticed : The broad ligaments and the uterus are above and in front, 
 behind is the rectum with the contiguous peritoneum, below the utero- 
 rectal pouch, and above it is bounded by agglutinated loops of small 
 intestine. In cases of retro-uterine haematocele with a well-defined his- 
 tory of antecedent pelvic inflammation the following boundaries were 
 observed by Voisin : Below the recto-uterine pouch, above the broad 
 ligament and the sigmoid flexure, and sometimes the small intestine. 
 These cavities are of a great variety of forms — sometimes winding, 
 sometimes ovoid Avith inter-opening spaces — and have a capacity of 
 one-half pint to five pints. 
 
 The contents of the sac of the hsematocele present quite a uniform 
 character, according to the stage at which it is observed. In its early 
 history it is simply blood, which rapidly undergoes changes. At first 
 it acquires a greater consistency, due probably to a loss of a portion of 
 its serum by absorption, and of a tar-like color. At a later stage 
 Huertaux found (1) drops like oil of a brow^n or yellow color; (2) 
 spherical cells, entire or reduced to fragments, abounding in adipose 
 nucleoli ; (3) amorphous fragments of hsematoidin ; (4) quadrilateral 
 crystals resembling ammonio-magnesian phosphate; (5) some blood- 
 globules darkly stained; and (6) a great quantity of blackish corpuscles 
 resulting from altered blood. In other instances the tar-like blood is 
 largely mixed with pus and sanies. Rindfleisch found in the contents 
 serrated and shrunken blood-corpuscles, rarely any fresh, numerous 
 white blood-corpuscles or pus-globules, with epithelial and granular 
 cells. 
 
 The pelvic hsematoma differs totally in its surroundings from the 
 hsematocele. In some instances the peritoneum is stripped off from the 
 underlying parts and the space occupied by the extravasated blood ; in 
 others, as in the duplicatures of the broad ligament, two peritoneal sur- 
 faces are wedged apart by the blood-mass ; while, again, the cellular 
 tissue affords space for the extravasation. From the nature of these 
 surroundings the hsematoma is always of less extent than the hsemato- 
 cele, and as a rule unattended with adhesive peritonitis and the agglu- 
 tination of the near parts. If found associated with obliteration of 
 pelvic peritoneal spaces by adhesions, that condition is probably a prior 
 matter to the development of the hsematoma. The displacement exerted 
 
JLr.MAroCF.I.K. 
 
 7I!> 
 
 l)y the hii'inatic tumor upon (•»»iitiiiiiuus (ir<r;iii.s also (litters from that of" 
 tlu' hiomatocek', wliidi will l)e luttici-d later when upon the snliject ot" 
 (litl'erentiatioii of" the two (•on(liti<»ns. 
 
 ( 'haiiiic's in the contents of " a hiematoma are less rapid than in ha-nia- 
 toeele. It is dillienlt to ex})lain this, unless it is done by the assiini|ition 
 that the hlood is more elfeetually sealed from sej)tic inHuenees external 
 than internal to the peritoneal sac Of course the marked jx-ritonitis 
 that attends the luematocele may atld both raj)idity and mali<:nancv to 
 the changes that take place in the contents of the latter. Altered hlood, 
 simies, j)us, are found that do not materially differ from those already 
 described. M'hen the extravasiition is situated between the folds of the 
 broad ligament, adhesion to near ])arts has been observed, but not to the 
 same extent as in hienuitocele. Silvestre found in the rio-ht liffamentum 
 lata a cavity filled with blood which communicated with the cavitv of 
 a thrombus behind the uterus. The jieritoneal surfaces were changed 
 by the deposit of lymph and injected vessels. This example shows 
 that these jielvic blood-tumors may coexist, and probably have their 
 origin at the same time, while their cavities may communicate. Clinic- 
 ally, it would be impossible to form any opinion as to this coexistence. 
 Such a condition may occiu' more frequently than the isolated case of 
 Silvestre Avoukl give grounds to believe, as the extensive massing 
 together and alteration of the tissues would render the recognition of 
 the complication difficult if not impossible. 
 
 An instance of hsematoma of the ovary was submitted to the writer 
 by Dr. C. E. Billington, a coroner, for opinion. The si^ecimen was 
 taken from a woman thirty years old, who had died after a suspected 
 criminal abortion. The uterus was about four inches long, its walls 
 thickened, soft, and the inner layers of its parenchyma deejily injected, 
 with evidences of fatty degeneration. The right ovarv had upon its 
 upper surface a cyst as large as a pigeon's qo^q:, covered by the perito- 
 neum on the outer one-third of its surface, and the remainder of the 
 circiunference embraced by the structure of the organ. It was filled 
 with dark coagulated blood. There were evidences of general jierito- 
 nitis, but no mention was made of pelvic adhesions. The affusion was 
 but a few days old, judging from the appearance of the l)lood-clot, 
 which was quite fresh. While, in our present knowledge of the sub- 
 ject, we could not regard the hsematoma as an evidence of forced alior- 
 tion, the assumption is projier that it was the result of violence to the 
 pelvic organs. If this sac had ruptured Avhile the hemorrhage was in 
 progress, it would have been an examjile of a hsematoma passing into 
 a haMnatocele. 
 
 Poncet states that in old sacs the contents become jiartly organized 
 with bands of false membranes and strata of fibi-in, resembling the 
 condition of old aueurismal sacs. This condition is rare. 
 
750 PELVIC HEMATOCELE AND HEMATOMA. 
 
 Emmet says that if the term is confined to blood -accumulations in 
 the peritoneal cavity, the disease is a rare one, but if held to embrace 
 all blood-accumulations in the pelvis, the disease is more common than 
 is generally supposed. It is frequently mistaken for a pelvic cellulitis. 
 Escape of blood in small amount into the connective tissue may be 
 like an attack of cellulitis in suddenness of symptoms ; and, on the 
 other hand, such small cellular effusions may exist without symptoms. 
 Emmet has detected large accumulations going on in the peritoneum 
 without causing the patient any discomfort. Cellular effusions of this 
 minor character are more frequent midway in the menstrual life, espe- 
 cially in those who have borne a number of childi'en in rapid succession. 
 That the hsematocele may exist without marked symptoms and without 
 pathological traces is not to be doubted. Barnes says that the remains 
 of slight pigmentation in Douglas's sac are very frequent, assuming, 
 of course, that such appearances indicate the presence of old effu- 
 sions. 
 
 There is yet a wide field for study in the pathology of these interesting 
 accidents. On many points we are yet in doubt. There has been too 
 much theory and too little demonstration of actual conditions. Upon no 
 subject have there been more voluminous contributions made of learned 
 speculations, and yet so little actually settled. 
 
 Symptoms ajstd Course. — McClintock makes three symptomatic 
 groups : First, the severe, the cataclysmic of Barnes ; second, the more 
 moderate seizures, though plainly marked; and third, the chronic form 
 — the symptoms being developed gradually and in succession, and being 
 liable to be confounded with pelvic abscess or ovarian tumors. The 
 marked symptoms belong to the initiative stages and attend the extrav- 
 asation of blood. The symptoms of the first group are, first, the shock 
 of pain and blood-loss ; second, the reaction ; third, the inflammation. 
 The attack opens with a severe and sharp pelvic pain, generally well 
 localized, but sometimes diffused over the abdomen. Associated with 
 it is a more or less profound shock, the features pinched and blanched, 
 the expression anxious, the pulse rapid and thread-like, the surface 
 bedewed with cold sweat. In this condition the patient is found. For 
 the first day, about in the following order, we would notice that the 
 abdomen was distended ; the least movement would cause more or less 
 violent pain ; vague shiverings or absolute chill ; fever to 102° to 104°; 
 pulse small and concentrated, from 100, 120, to 140 per minute; nau- 
 sea, at times vomiting, sometimes uncoercible; the face continues pallid, 
 expression anxious ; the flesh soft and flabby. She rarely loses intelli- 
 gence, and coma is extremely rare. The position is dorsal, avoiding all 
 movement. After about the first twenty-four hours, these extreme 
 evidences amend ; the nausea and vomiting cease ; the pulse loses its 
 frequency, but is still above the normal ; the face is less pinched, but 
 
Il.h.MATOCh'LK 701 
 
 is still tliin, ami has a caclu'ctic look, like llmi in iiinli^iiiint (iinior. 
 Tlu' pain is t"r('»|ii('ntly of a neuralgic diaractcr, anil sonictinics <»1" 
 (li'sjK-nitr iiitfiisity. In one casi! mentioned hv I'oncct the jiain was 
 in the ri<;ht side, the anus, the thi^h, the heel, and would then transfer 
 itself without apparent cause to the; opposite side, and then a<i:ain shift 
 in sueeessitin to its former points, as is sometimes seen in the evanescint 
 pain of hysteria. Ju sjjite of most active treatment the pain will per- 
 sist for two, three, (M- four days. The bad general condition, the pro- 
 found antemia, and the excited mental state tend to prolong the neur- 
 algia, and render it resistant to all treatment. As this neuralgic con- 
 dition is a feature of the attack prior to the introduction of the pain 
 that is characteristic of the inflammatory stage, it is probably due to 
 the blood-loss and the intrapelvic pressure, and gradually subsides a.s 
 the system becomes adjusted to the loss of blood and the nerves habit- 
 uated to the pressure of the pelvic mass. Due imj)ortance will be 
 given to intrapelvic pressure when we reflect that in no other accident 
 to which woman is liable can such a pelvic mass Ije developed so rap- 
 idly. This profound nervous disturbance causes yet further phenom- 
 ena which prove its far-reaching character. The intestinal strangula- 
 tion M-hicli has been noticed has by some been explained by the com- 
 pression of the tumor upon the intestines; but it has been observed, 
 too, soon after the effusion, before the coagulation of the blood and 
 before the onset of inflammation, to be explained as the result of 
 pressure. Poncet has for it a better explanation, regarding it as due 
 to paralysis of the muscular layer of the intestines, and calling it 
 pseudo-sti'angulation. 
 
 A very common form is attended with a monthly exacerbation of the 
 symptoms. There are increase in size of the abdomen, tenderness on 
 pressure, pain, and febrile reaction, defecation difficult and very pain- 
 ful. This periodical renewal of the attack has been explained by a 
 return of the hemorrhage at each period, and defines the menstrual 
 variety- of ]>elvic hrematocele. AVhen the tumor is large we generally 
 have vesical tenesmus or micturition is difficult, so that the catheter is 
 necessar}\ Hart and Barbour say that actual retention is rare in the 
 retro-uterine variety. This symptom is quite common in the ante- 
 uterine form, and is probably due to mechanical causes, as the 1)ladder 
 is forced downward and backward, doubled upon itself. Vesical catarrh 
 is frequently noted, Voisin has observed in a number of cases a dysen- 
 tery occur at irregular intervals, and considers it of utility in favoring 
 absorption. This description defines the acute form of pelvic haeraato- 
 cele. In its more chronic development the first feature to attract atten- 
 tion would be the attack of more or less severe pain, severe abdominal 
 tenderness, not much if any distension, with possibly a normal tem- 
 perature, and possibly difficult defecation and sense of fulness in the 
 
752 PELVIC HEMATOCELE AND HMMATOMA. 
 
 pelvis, with the detection of a tumor in Douglas's sac if an examina- 
 tion is made. 
 
 The jjatient may be upon her feet before the exjiiration of a mouth, 
 but at the next menstrual period the attack recurs, it may be with 
 greater severity. If the pelvis is again examined, the retro-uterine 
 tumor is again observed, increased in size over that first detected, and 
 with more marked general disturbance. Thus, month after month 
 there are repeated attacks until the patient is brought into an exceed- 
 ingly dangerous condition. This train of periodic symptoms simply 
 defines a repeated pelvic hemorrhage. 
 
 One of the most remarkable features of an attack of pelvic hsema- 
 tocele is the tumor itself. Speaking of this in its early development, 
 McClintock says : " We may satisfy ourselves that it contains fluid, but 
 whether this fluid be blood, serum, or pus cannot be determined by the 
 most delicate sense of touch." The sudden filling ujd of the pelvis, the 
 rapid distension of the abdomen, the vesical and rectal symptoms mark- 
 ing the great displacement of the pelvic viscera, are traits that in the acute 
 hsematocele define it from nearly every pelvic accident. Strange to say, 
 however, even in this marked form the pelvic tumor may afford matter 
 for serious doubt. Nearly every writer upon the subject agrees that 
 the pelvic tumor can be felt from the earliest moment in the history of 
 the case. Instances by Sireday, Aran, and Bernutz show that this may 
 not be so, and McClintock first, and Tait later, have shown that it can- 
 not be so. Blood when it is first efiiised does not coagulate, and with- 
 out coagulation we cannot have an intrapelvic or abdominal mass. A 
 fluid free in the abdominal cavity cannot give the defined limits of a 
 tumor. A small collection would give doubtful evidences of fluctua- 
 tion. There is, therefore, a pause in the stage of development when 
 the attack is free from the local evidences of pelvic tumor. This 
 embraces the period from the beginning of the attack until the coagu- 
 lation of the effused blood. The rapid distension of the abdomen 
 observed in some cases is probably due to meteorism, which has its 
 origin in the profound nervous disturbance, as when the more acute 
 symptoms subside on the second day this general abdominal distension 
 is much less. We are to look independently of this for the tumor, 
 Avhich will be found occupying the Douglas space toward the end of 
 the first day. This matter has now been so positively stated by the 
 excellent authority of McClintock and Tait that this error should be 
 eliminated from the textbooks. 
 
 A consideration of the tumor naturally brings us to a study of the 
 subject of physical exploration, which, in view of the exhausted and 
 threatening condition of the woman, has to be practised with peculiar 
 care. When the retro-uterine mass is small, Tait's method of pelvic 
 exploration is an excellent one, as the abdominal rectal or vaginal 
 
HEMATOCELE. 753 
 
 (loiiMc touch, wliicli is ('>|)('ci;ill\- iKiiiiliil, iii:i\' l)c avoided. W iili the 
 woman ii|toii her Ictl side tlic li-t'i index tin;;('r is iiiii-odnccd into tlic 
 rtH'tiini, and tlu' tliiinil) ol" (lie same liand into tlie vagina, or with the 
 woman upon her hack tiie rii;ht index may ix' \\>(-i\ I'oi' the I'ectal exjilo- 
 ratioii and the riiiht tliiimi) for tlie va^inah In this way tlie thickness 
 and density ol" the tumor in the Douglas sj)aee may he eiearlv made 
 out more reailiiv than 1)\' anv other method, as well as its non-connec- 
 tiou with the uterine hody and ei'rvix. By the vaij;inal touch we show 
 the marked forward displacement of" the uterine hodv. Jn the instance 
 of lai'u'cr j)i'l\'ic masses the ahdomcn is eidari^cd and rfinnde<l, and the 
 tumor may be i'elt approach ini;- the umhilieus and spreading- towai'd the 
 ilia. ]iy vaginal exploration we discover a condition closely resembling 
 a retroversion of" tlu' gravid uterus at thi-ce oi- I'onr months (Barnes). 
 The finger cannot enter the hollow of the sacrum, because it is occupied 
 by the retro-uterine mass. The posterior vaginal wall is dis])laced for- 
 ward and the direction of the canal altered ; following the vagina, the 
 finger passes forward and enters the anterior vaginal fornix, Avhich is 
 diminished to a narrow space behind and above the symphysis pubis, 
 where we find the cervix uteri closely compressed against it, some- 
 times even flattened. With some care the finger can be passed in front 
 of the cervix and somewhat laterally, in which movement of the finger 
 the forward limits of the tumor are detected, blending w'ith the cervical 
 wall so closely that the margins of the latter are defined with difficulty. 
 With the posterior margins of the cervix the tumor is blended in a 
 peculiarly deceptive way, very much as the posterior cervical wall dis- 
 apjiears in the uterine body in retroversion of the gravid uterus. At 
 first the mass is soft, with a sense of elastic fluctuation. After two or 
 three days it becomes firmer and more tense, or quite solid, caused by 
 advancing coagulation and inflammation with plastic affusion, Avhich 
 more securely walls in the mass. 
 
 In these large effusions the uterus can be defined from the mass only 
 by aid of the sound. It is needless to add to the cautious reader that 
 this instrument must be used with the greatest gentleness and care. The 
 way is first cleared by emptying the bladder with the catheter, and the 
 sound guided by the fingers forced forward, and some considerable 
 manipulation may be necessary. The curve enters forward and upward, 
 and the point may be felt through the abdominal wall directly over the 
 symphysis. By external manipulation the uterus may be felt u]ion the 
 point of the sound, its lateral walls defined, and the tumor moved with- 
 out imparting any motion to the uterus. This shows that the tumor is 
 unconnected with the uterus. Leaving the sound in the uterine cavity, 
 the finger may be introduced into the rectum, where it detects a 
 rounded, more or less yielding tumor, to which no movement can be 
 imparted by manipulating the sound within the uterus. An exam- 
 
 VOL. I. iS 
 
754 PELVIC HEMATOCELE AND HEMATOMA. 
 
 ination carried out in this way demonstrates that this quickly-develop- 
 ing tumor, attended with pain, shock, and anaemia, is not uterine or an 
 ovarian tumor or a fibroid, as nothing will give this rational and phys- 
 ical symptom but a pelvic effusion of blood. At a very early period 
 it may be impossible to make this careful local exploration, as the 
 patient's condition will not permit the least excitement; and if this 
 holds true, it is prudent to wait several days befoj-e undertaking it, 
 as the physician will find enough to do without going into elaborate 
 methods of examination. 
 
 The tumor is often felt through the vagina before it is above the 
 brim of the pelvis. The extent of swelling in the vagina depends 
 upon the depth of the Douglas space. Voisin states that early in the 
 history of the effusion the tumor is slightly movable. This might 
 hold true of very small effusions after firm coagulation and before it 
 is enclosed by plastic effusion. It is a doubtful sign, and had better 
 not be relied upon. The tumor often does not at once attain its max- 
 imum size, but advances, not continuously, but by a series of starts 
 which correspond with the menstrual periods. In some cases a small 
 tumor may be detected in front of the large tumor just above the 
 pubes, which is the uterus, as may be proven by the employment of 
 the sound. The hemorrhagic tumor varies in consistence at different 
 parts, fluctuating in one region, elastic in another, or soft or resistant 
 at another. At some points it gives the sensation of a solid tumor, 
 but for the first week usually the tumor over its general surface gives 
 the peculiar feel of a blood-clot (Poncet). 
 
 In Poncet's monograph Bouchacourt is stated to have observed 
 bloody urine. In some cases the tumor has pressed upon the ureters, 
 throwing the urine back upon the kidneys, causing uraemia, with fatal 
 results. The pressure exerted by the mass upon the lumbar or sacral 
 plexus of nerves causes severe neuralgia within the limits of these 
 nervous areas. Under some circumstances the tumor compresses the 
 large venous trunks and causes oedema of the lower extremities, being 
 greater upon that side which corresponds to the greatest bulk of the 
 mass. Cases of phlebitis of the side exposed to greatest pressure have 
 been also noted, in some instances too early for the condition to be due 
 to blood-poisoning ; or possibly one ought to say, rather, that no evi- 
 dence of blood-poisoning other than this had appeared. And in other 
 instances traces of general infection developed long afterward. It is 
 difficult to regard the phlebitis as due simply to pressure, unless, as we 
 have noted above, it is the sudden development of the mass, which 
 causes its presence to be so much more actively resented by the near 
 parts than is usually the case in pelvic tumors of more gradual devel- 
 opment. Extensive oedema of the vulva and vagina has been noted 
 and explained as due to the pressure. In an instance of oedema of 
 
ll.KMATOCF.U:. 7.-,.-, 
 
 (lie \;ii:iii;i tlic purl (oi'iiicd ;i sort ol" cii.-liiini wliidi prujtctrd ((trward 
 bctwcfii the l:il)i:i. 'i'lic latlcr is a foiiiinon fcatiii'c that attends lame 
 (.'ll'iisious, and is assut'iatcd with a-deinu ot" the i-xtreniity ; hut the 
 phlegmasia dolens is rare, hut two cases observed by iSIadj^e and one 
 by IJerniitz havini^ been n(»tiee<L 
 
 In the nietrorrhajiie hicniatoeele a ihtu oi" bhiod is noticed externally 
 from the vagina durinj^ the attack, 'J'he peritonitis is very slight as a 
 rule, and a eaeheetie appearance rapidly develoj)s. The periodic exac- 
 erbations so marked in the menstrual variety are absent. Another 
 feature of this form is a frequently-recurring metrorrhagia a few 
 hours or days after the attack, and continuing until al)sorption of the 
 pelvic eti'usion. This variety is quite prone to be attended with nausea 
 and vomiting. Snow Beck notes an instance of marked exception to the 
 rule in which the j)ain ceased on the appearance of the tumor, or, as he 
 ought to have said, when coagulation of the effused blood was complete. 
 
 In the cataclysmic cases of Barnes only that portion of the blood 
 settling in the pelvic cavity coagulates, and that imperfectly. Peri- 
 tonitis does not take place ; the l)lood does not therefore become 
 encysted, and thus no tumor forms. Collapse and death intervene 
 too quickly for the usual train of symptoms to form. Notwithstand- 
 ing the fact that the loss of blood is the cause of death — in fact, may 
 be called the disease itself — yet the most active feature of the attack 
 is the great preponderance of shock over anaemia. 
 
 The symptoms of pelvic hsematocele due to cachexia are the more 
 gradual advance of the haematic accumulation, the pain gradually gain- 
 ing intensity, a lowering of the temperature partly due to blood- loss and 
 in part to shock. A well-defined pelvic tumor is in some cases absent, 
 especially in a lowered and vitiated state. A fatal ending is common. 
 Pelvic haematocele attending typhoid fever is needless to refer to, as 
 the accident is necessarily fatal. 
 
 The course and termination of a pelvic haematocele are very uncer- 
 tain factors, in our estimation, of the disease. While it may be said 
 that hematocele, except in most severe forms, always terminates with- 
 out destroying life, yet it is very difficult to estimate to what extent the 
 subject's future may be affected. As the local condition advances to a 
 favorable termination, the tumor grows smaller and firmer. This is the 
 first act in the absorptive process. In twentA--four cases observed by 
 Carl Braun absorption was complete in fi-om two to six months. In 
 twenty-five cases noted by Voisiu fifteen terminated in absorption. Bandl 
 noted the following periods in which this termination was completed : 
 
 In 2 oases in \l months. 
 In .1 " " -1" " 
 In 1 case " 6 " 
 In 1 " "8 
 
756 PELVIC HEMATOCELE AND HEMATOMA. 
 
 In whatever way health is restored, the process is a slow one. The 
 progress toward recovery is subject to so many interruptions, owing to 
 the intimate relations of the tumor to the menstrual function, that 
 the natural termination is indefinitely prolonged. In some instances 
 no marked change occurs after several years, the tumor maintaining its 
 same relative size and density. Delore has recorded a case that pre- 
 sented the same appearance for five years. Such a case is exceptional 
 (Poncet). Dr. Barnes says that many cases supposed to terminate by 
 absorption gradually diminish in size as their contents escape through 
 a small opening, but so slowly as to elude notice. In the minor forms 
 of hsematocele, with a moderate eifusion, in some cases so small as 
 almost to escape notice, and with all the general symptoms moderate to 
 a like extent, absorption is the rule, and in a few days, or at most a 
 few weeks, the mass disappears as quietly as it came. Barnes asserts 
 that these cases are very common ; but if so, their true nature is not 
 yet commonly understood by medical men. We may know when a 
 hematic tumor of the pelvis is terminating by absorption, as the mass 
 grows smaller and firmer to the touch. The latter sign is a point in 
 spontaneous absorption, for if the tumor becomes soft and fluctuating it 
 indicates that the contents are breaking down and it is seeking an 
 external opening. The amount of extravasation, the age, and the gen- 
 eral condition of the subject are the circumstances that modify the 
 duration of the absorption process. Poncet states that when the mass 
 has kindly relations with the menstrual function, resolution advances 
 by successive amendments coincident with menstrual epochs, and conse- 
 quently having a duration of several months. He is emphatic in the 
 opinion that termination in health is the rule, especially when all sur- 
 gical treatment is abstained from. 
 
 When the contents of the hseraatocele escape externally, the outlet is 
 formed by ulceration of the cyst-wall outward, by the rectum, by the 
 vao-ina, or through the encapsulating membrane into the abdominal 
 cavity. Bandl states that the most frequent exit is into the rectum. 
 In twenty-seven cases Voisin noticed escape into the rectum six times, 
 and in a like number of cases it gained an outlet by the vagina in three. 
 Escape into the peritoneal cavity is alwavs a fatal channel of exit, and 
 fortunately occurs but rarely. Escape by the rectum is liable to be 
 attended with dangerous result. Fecal matter may find entrance into 
 the sac of the haematocele, and gas from the rectum is quite sure to. 
 The consequence is rapid changes in the contents of the cyst with 
 quickly-developing evidences of blood-poisoning. The fetor generated 
 in the cyst under these circumstances is sui generis. Septic intoxication, 
 is rare after opening by the vagina, but the vaginal walls offer greater 
 resistance to the ulcerative process than those of the rectum. Some- 
 times a double perforation by rectum and vagina is met with, and rare 
 
HJEMATocr.Li-:. 757 
 
 cnscs arc on i-ccocd in wliicli triple (ij)('iiiiijj,s occui'ixil, by rceluiu, va<;iiia, 
 and alulniiiiiial wall. Instead ol" <;ainin}>; exit (jiiictly by tin; rcctinn, a 
 sort of crisis is observed. Tlic pain becomes severe, exaspei'atcd by 
 prcs'^nre or movement, chills with niarUcd liiuli temperature, vomitinji:, 
 si<in dry, pulse small and fVc(pient, with ccili*- and t(!iicsnuis. Ai"tcr 
 some days, and lullowino- an abnndant diarrh(ca, tliei'c is a jrcneral and 
 sudilen amendment, attended by escape oC black and olTcnsive disehart^e 
 by the rectum. 'I'liere is at once a ra])id diminiiiion in the size of the 
 abdomen, but the tumor, instead of entirely (lisa|)pearinu-, residts in a 
 small induratiou Avhicii persists indetiuitely. A (quantity of fluid as 
 large as four quarts has been known to escape by the anus. 
 
 The dcijeneratiou of cyst contents into pus is an infre([uent termina- 
 tion, and attended with alarming symptoms. Chills, fever, dry skin, 
 rapid and shrinking pulse, severe pain in the loins extending to the 
 Ws, are the most marked evidences of this dano-erous chancre. The 
 symptoms resemble those of perforation of the cyst into the abdominal 
 cavity, but ai'e of longer duration. When the cyst contents find their 
 way into the peritoneal cavity the termination is nearly certain death. 
 AV'lien death results in the usual course of the disease, it is caused by 
 wearing the patient out. Profound alterations of nutrition, prostrating 
 high temperature, exhaustion, death, are the fatal chain of events. 
 
 Diagnosis. — The positive recognition of pelvic hematocele at its 
 various stages offers one of the great problems of pelvic diagnosis. It 
 is sometimes very easy and at others exceedingly difficult. The period 
 at which the disease is brought under observation has much to do with 
 its easy recognition. Dolbeau says that while pelvic hematocele is not 
 the only pelvic disease that begins suddenly, fever, sudden and severe 
 pain, and abdominal distension may occur in pelvic peritonitis and in 
 intense ovarian congestion. Pelvic hiTematocele is never ushered in 
 with fever, nor is ovarian congestion : to guard against error he trusts 
 to one unfailing sign — namely, the direction in which the cervix is dis- 
 placed forward behind the symphysis. 
 
 Intraperitoneal effusion makes its appearance without premonitoiy 
 signs, and in general terms the symptoms are those which characterize 
 hemorrhage. In the menstrual group there is defect in menstrual 
 excretion which precedes the outbreak ; and in the hemorrhagic group 
 there is a profuse discharge of blood from the genitals before and dur- 
 ing the act of intraperitoneal effusion. In the first there is severe ]ieri- 
 tonitis with less anaemia and prostration, and in the second less peri- 
 tonitis with greater prostration and evidences of hemorrhage. The 
 degree of collapse in ha?raatocele is quite out of proportion to the 
 amount of blood lost, as a rule. In the hematocele of menstrual 
 retention there is what one may call the secondary shock, due to the 
 quickly supervening peritonitis. In rupture of the ovary the effusion 
 
758 PELVIC HJEMATOCELE AND HuEMATOMA. 
 
 is sudden and profuse; the rupture of ovarian varix is improbable 
 when there are no signs of venous stasis in the lower extremities, 
 and especially on the external genitals, either past or present. 
 
 In case of small ovarian tumors yet in the pelvis suddenly taking on 
 inflammatory action, the pain is sudden and severe, the cyst not mova- 
 ble, with rectal or bladder symptoms. The diagnosis is made yet more 
 difficult by pelvic effusion being sometimes one-sided and cyst-like, as 
 in a specimen exhibited by Phillips at the London Obstetrical Society 
 (1868). It is safe to say in ordinary cases that the ovarian cyst dis- 
 places the uterus to one side, while the hsematocele forces the uterus for- 
 ward without obliquity. Expectation would clear up the atmosphere 
 of doubt that obscures this condition, or a careful aspiration would at 
 once expose the character of the retro-uterine mass. In the case of 
 small ovarian tumors becoming ruptured, Winckel makes the point 
 that while the pain and collapse would resemble that of hsematocele, 
 the cyst contents would diffuse themselves and the tumor grow smaller 
 and softer, notwithstanding the peritonitis, while the haematic tumor 
 would grow larger and firmer. Ovarian tumors occupying Douglas's 
 space present a history of considerable duration, have uniform density 
 of surface, fluctuate on palpation, with no peritonitis or variation in 
 volume as in hsematocele. The symptoms of compression of rectum 
 and bladder gradually intensify in the cyst, but in hsematocele these 
 symptoms present themselves early and gradually abate. Between an 
 incarcerated, inflamed retro-uterine cyst and a hsematocele with a like 
 history and symptoms, the difficulties of differentiation are sometimes 
 insuperable. Nothing but aspiration with a small needle can prove the 
 difference. McCormick gives an instance in which even this failed. 
 
 A retroflexion of a gravid uterus at three months is very difficult to 
 distinguish from a retro-uterine hgematocele. A hseraatocele has, in fact, 
 been so mistaken in several instances. In the gravid uterus there are 
 softening 'of the neck, absence of menstruation, the characteristic dis- 
 coloration of cervix and vagina, a smooth, uniform, and elastic tumor, 
 giving consistency of surface at all points, with marked line of flexion 
 between the cervix uteri and body. Pain in this condition is functional 
 and due to disturbance of near parts. Contrast with this a tumor of 
 uneven surface, with points of varying consistency, the peculiar dis- 
 placement of the uterine cervix, and absence of the flexion line, while 
 the pain of hsematocele is persistent, with the tumor itself as a point 
 of radiation. A very difficult problem to solve is presented in this 
 case, and if an anaesthetic affords any advantage it ought to be employed. 
 Expectancy furnishes a clue to the real nature of the pelvic disturbance. 
 In hsematocele the tumor shows a disposition to shrink and the pain to 
 abate; in retroflexion of the gravid uterus the tumor grows firmer, 
 larger, with an increase of functional disturbance of near parts. 
 
lI.KMATOCKLi:. 75!) 
 
 (lallartl says llial Wf may .-I'ai'cli in \aiii lnr dillliNiiiial si^ns 
 lu'twccn I'Xti-a-iitci-inc |»r('iiiiaii<'y and lia'nialocclc. ll is well to 
 notice what l"f\v we liavr. TIk' Ininor of cxtfa-iilci'inc I'o'iMiion is 
 rare in the rctro-ntcrinc space; li;enialoeek' is <'oniinon. In llielirst 
 tlie tumor is of slow growth, willi the rational si<;iis of pre^naiicv — 
 iu'tal movonieiits, breast-chaniros, anienorrha'a, soinotinu's meiioi-rha- 
 ui;i, hut not metrorrhagia as in hscmatocele. If not called in until the 
 rupture of the i'a^tal sac, it is douhtfid if a dilVeivntial (lia<i;nosis can be 
 inacK'. If one had a chance to deliberately study the case before the 
 catastroi)he of rupture, it is probable that a mistake wduld not be 
 made. 
 
 In a paper on perimetritis by J)r. John Williams in the London 
 Obstetrical Society, Dr. Graily Hewitt said that it and ha3matocele 
 were very ditticult to distino-uish. At the outbreak of the attack the 
 local conditions afford but little evidence of value. Both diseases are 
 attended with rapid accumulations in the Douglas space — in the one 
 with chill at the opening of the attack usually, inflammation always; 
 and in hematocele we have shock. In pelvic peritonitis the chill is 
 the beginning of a continued fever, while in hsematocele it is frequently- 
 repeated. In the latter the pelvic mass antedates the chill, and in the 
 former the chill precedes the pelvic tumor. In cellulitis the tumor 
 presents itself slowly, and is not severe or sudden, and is usually sit- 
 uated to one side in the broad ligament, and the tumor is not so large 
 as in hfematocele ; further, the board-like induration of cellulitis is not 
 detected in the hsematic tumor. If the attack follows labor or abortion, 
 the evidence will favor pelvic peritonitis. If the symptoms begin 
 during menstruation, and the discharge suddenly stops, and the ces- 
 sation is coincident with pain, attended with chill, followed by fever, it 
 is jirobably peritonitis. If menstruation w'ere due, but did not appear, 
 but sudden and severe pain came on with collapse, it is more likely to 
 be liiematocele. If the attack is not associated with delivery or abor- 
 tion, the diagnosis inclines more to hrematocele than to pelvic peritoni- 
 tis or cellulitis. The mistake of confounding a periuterine phlegmon 
 with hfematocele might easily be made, but the remarks already made 
 would apply. 
 
 Dr. Rasch states that there is low tem]->erature for twenty-four hours 
 after an attack of hfematoeelc — 96° to 97° F. — and the uterus is more 
 movable than in cellulitis. 
 
 In cases of adeno-lym])hangitis in the post-pubic region, mentioned 
 by Guerin, the mass is well defined by the double touch, and is small 
 and nodular. The small tumors attending this disease posterior to the 
 cerxnx could hardlv be mistaken for a hoematocele. 
 
 Dr. Smyly has detected urobilin in the urine in cases of pe]\-ic lurma- 
 tocele, and gives it diagnostic value. When the urine is alkaline, the 
 
760 PELVIC HuEMATOCELE AND HEMATOMA. 
 
 pigment has the usual color ; and when acid, it is red. A drop of zinc 
 chloride in an ammoniacal solution shows the characteristic green 
 fluorescence. In the spectrum a band between the green and blue 
 absorption-lines is observed to attend the presence of urobilin. Urine 
 containing the pigment has a clear to a dull-brown color. Dr. Wilt- 
 sliire has noticed that cases of hsematocele were attended by a peculiar 
 jaundice, which is symptomatic and due to the absorption of the biliary 
 coloring matter of blood when the effusion is large. 
 
 Bernutz formulates the following as a guide to the diagnosis of ova- 
 rian hsematocele : " There is absence of menstruation or of any bloody 
 discharge from the vulva at the time the symptoms developed ; the 
 coexistence at the commencement of the attack of two distinct groups 
 of symptoms — one referable to internal hemorrhage, the other to inflam- 
 mation of the peritoneum ; lastly, the absence of dysmenorrhoea at the 
 time or at the preceding menstrual period. Such a concurrence of 
 symptoms is strongly confirmatory of ovarian lesion." In explanation 
 of the above it may be proper to say that the absence of dysmenorrhoea 
 demonstrates that no retention existed, and the absence of blood-dis- 
 charge from the vulva shows that menstruation was not present. 
 
 The diagnosis between menstrual retention and hsematocele depends 
 on the relation of menstrual pain to the tumor. The pain in metror- 
 rhagia occurs considerably before or at the discharge, while the periodic 
 pain in menstrual retention occurs in the absence of discharge, with 
 coincident distension of the pelvic tumor — a condition never observed 
 in the tumor of metrorrhagic hsematocele. The periodic increase of size 
 in the menstrual hsematocele is always attended by discharge from the 
 vulva. Equally so in hsematoceles from menstrual defect the effusion 
 is preceded by absence of menstruation. 
 
 The diagnosis between sources of hemorrhage has been regarded as 
 impossible. In rupture of the tube from over-distension and hsema- 
 tocele from menstrual retention the following doubtful distinction may 
 be made : distension of the tube is a gradual process, and one attended 
 at no stage by pain, while dysmenorrhoea is a leading trait of menstrual 
 retention, especially the month previous to attack (Bernutz). 
 
 In the matter of the minute distinctions enumerated in the most 
 difficult field of diagnosis, the pelvis, but little has been said about the 
 history afforded by the patient. This is indeed the medium through 
 which all the objective and subjective symptoms have to be viewed. 
 Without this element in the study of a case no local exploration can be 
 relied upon to furnish differences broad enough to rest a positive opin- 
 ion upon. This remark is made in this connection because it applies 
 with peculiar force to the differentiation of menstrual and metrorrhagic 
 hsematoceles from the deposits of inflammatory origin peculiar to the 
 female pelvis. 
 
HA'JMA TOVKLK. 70 I 
 
 IkiikII iiiciif ions the (icciiirciicc of l:iltr:il li:i'iii:i(<)iii(tr:i in (liiplicalc 
 Uterus. riu' (Ic'i'p and lateral relations ol' the niitss, tiji; periodie pain, 
 the monthly increase and snpervenin<;- deerea.se in size, the absence of 
 fever and peritoneal inHaniniatorv symptoms, p(jint to a dilTicnltv other 
 tlian hiematocele. The early aji;e, a period nearly cxenij)! IVorn h;i nia- 
 toeele, «:;ives additional <2;roiinds for distinction. 
 
 It is hardly possible that a iihroid uterine tumor can he mistaken for 
 hjomatocele, hut Gusserow has ^iven some traits of th(! latter in this 
 relation that may be worth meutioning. In fibroma the tumor is lim- 
 ited on all sides, uniform density, its mobility more or less, but clearly 
 related to the uterus, absence of peritoneal tenderness in isolated fibrf)ma 
 — none of mIucIi characteristics belong to hsDmatocele, Mhich shows a 
 tendency to ditfuse itself, to dissect, as it were, into the surrounding ti.s- 
 sue, whicJi is sometimes observed in a marked degree on the vaginal 
 wall. 
 
 Hart and Barbour assume in their diagnosis that inflammatory adhe- 
 sions occur previous to the effusion. They say : " It is often said that 
 effused blood naturally gravitates into Douglas's space. It is not so. 
 It is there because it is affused near it and causes Douglas's pouc^h to 
 bulge only w'lien it is affiised beloM' adhesions which prevent its spread- 
 ing." AVhen in any given case, as above, on vaginal examination a 
 firm convex tumor is felt, and the cervix so closely pressed behind the 
 symphysis as to be almost inaccessible, and by the bimanual exam- 
 ination the uterine fundus is distinctly felt just below the abdomi- 
 nal Avail, and generally to one side, we have a condition of affairs that, 
 in connection w' ith its histoiy, establishes the existence of a pelvic effu- 
 sion. Meadows gives great importance to the vaginal tumor coincident 
 with the attack, as no mass can be produced so rapidly with such symp- 
 toms from other causes. The idea that a pelvic blood-collection gives 
 no evidence of tumor prior to coagulation must be admitted ; but Hart 
 and Barlwur, in order to be consistent with their opinion, as mentioned 
 above, of antecedent adhesions, assert that a hemorrhagic accumulation 
 in the pelvis gives no physical signs more palpable than flatus or 
 ascites unless enclosed, and these can be recognized only by puncture 
 or aspiration. 
 
 It must be rare that a cancer of the pelvic organs would give 
 occasion to a mistake in diagnosis; but Gallard gives one case in which 
 hsematocele was believed to exist, but which on post-mortem examina- 
 tion turned out to be a cancer htematodes of the ovary which occupied 
 a position behind the uterus. ]\Iarrotte recorded a case in which an 
 accumulation of feces gave cause to suspect a hsematocele. A purga- 
 tive cleared up the doubt. 
 
 The -same difficulties that attend the diagnosis of hsematocele follow 
 us in an examination of haematoraa. Hart and Barbour sav that when 
 
762 PELVIC HjEMATOCELE AND HEMATOMA. 
 
 the eifiision is in the broad ligament it is difficnlt to recognize, and 
 is usually found on post-mortem examination. The physical signs in 
 typical cases differ in essential points from those of hsematocele. The 
 tumor occurs suddenly, with absence of inflammation for a longer period 
 than in the intraperitoneal effusion. The tumor is not in the pouch of 
 Douglas, but bulges around the uterus. The hsematoma is especially 
 liable to be mistaken for a cellulitic deposit. The situation of the ute- 
 rus in the two classes of effusions gives but little evidence. When the 
 uterus is forced above the pubes it is probable that the blood is extra- 
 peritoneal, and is effused between the folds of the broad ligament, which 
 usually displaces the organ in the direction named (Madge). Unilat- 
 eral hsematoma is more frequent upon the left side, and in such a case 
 the uterus is displaced laterally and appears to rest upon the tumor, 
 while in hematocele the mass displaces the uterus upward and forward 
 in the retro-uterine and downward and backward in the anteuterine 
 groups. The uterus is more mobile in hsematoma, which is probably 
 due to the fact that peritonitis is less quickly developed, and not so 
 severe as in the intraperitoneal effusions. Tait says that if the febrile 
 symptoms have set in and the clot broken clown, the diagnosis is mere 
 guesswork, and any operative interference hardly justifiable. The fol- 
 lowing manipulation is suggested by Frankenhauser and followed by 
 Bandl : Before the blood is encapsulated — and we ought also to say 
 before it is coagulated — if the patient is placed in the knee-chest posi- 
 tion the blood will flow out of the Douglas space, and return again to 
 the pelvis when the patient assumes the dorsal posture. In hsematoma 
 the tumor must keep its situation and form, no matter what position 
 the patient may be in. Early in the attack — and it must be practised 
 early to be of any value — when the patient is suffering pain and col- 
 lapse, it must be difficult to practise this manipulation. If Hart and 
 Barbour's theory is correct also in regard to the antecedent adhesions in 
 Douglas's space being the cause of the hsematic tumor in this region, 
 the posture test would prove useless. This remark is thrown in for the 
 benefit of the younger readers, in order to show the difficulties in har- 
 monizing the conflicting statements of authors. 
 
 The form of the tumor may'be to a certain extent a diagnostic sign 
 of hsematoma. If a tumor lateral to the uterus is quickly developed 
 and connected with the uterus by an isthmus, it is probably in the 
 broad ligament and extraperitoneal. It may be that there are two 
 tumors laterally situated on the same level and connected by an isth- 
 mus : this condition is characteristic of hsematoma. The surface of 
 the tumor also affords evidence. In hsematoma it is uneven, knobbed, 
 and rough, owing to the unequal cellular spaces filled with blood. This 
 is especially true of the lower surface of the tumor situated deep in the 
 vagina. In hsematocele the lower (vaginal) surface of the tumor is 
 
JLEMATOCIJLK 
 
 lii-.i 
 
 smootli. Tlic al)(l<»iniii:il siirliicc of tlir lia'iiuiloina is >li:ir|tl\- (l<-rui((l ; 
 in liieinalocclc it is ditliised from \Vfl(Iin<»; tojj^ctluT ol" .suiTouiiding 
 parts. The fact just spoken of, tlii' vaginal prolongation of tlic 
 tumor, is vci-y characteristic of lucmatoma. In lueniatocclc the tuiiMjr 
 cannot invatle the vagina farther than tlie extent to which Doughis's 
 j)ouch descends heh)\v the uterus, Jt is true that this varies gr<'atlv in 
 indivichials, l)ut the bulging of the vaginal wall in hiematoma is more 
 usually lound lateral or antero-latcral ; and, fiu'ther, in ha^inatonia the 
 vaginal tumor gives the peculiar feel of having dissected its wav into 
 the cellular spaces of the part. 
 
 The following table of ditterential diagnosis is condensed from Courtv, 
 and may j)rove of value to the reader: 
 
 Phlegmon of the Broad Ligament and 
 Suppurative Periton it is. 
 
 Connected with delivery, abortion, or 
 inflammaiion of pelvic organs. 
 
 Phlegmon, a tumor of moderate size, 
 not displacing cervix, often at the side, 
 formed after the commencement of 
 symptoms, hard at first and very sen- 
 sitive, gradually softening and becom- 
 ing fluctuating. 
 
 Pelvic peritonitis rises above the 
 brim, not displacing the fixed uterus 
 to any great extent. 
 
 General symptoms continuing till the 
 pus gains an outlet. 
 
 Extra-uterine Pregnancy. 
 
 Develops slowly. 
 
 At first no functional disorder (?) : 
 afterward those of normal pregnancy. 
 
 Foetal sounds and movements. 
 
 Sometimes amenorrha?a, at others 
 regular menstruation, but no metror- 
 rhagia. 
 
 Retroflexion and Retroversion. 
 
 "When non-gravid : slow develop- 
 ment, no diminution in size. 
 
 When gravid : symptoms of preg- 
 nancy. 
 
 Fibroid Tumor. 
 
 Development slow and continuous. 
 Sometimes occur at menopause. 
 
 Hcematocele. 
 
 Unconnected with any of these con- 
 ditions, and manifested at other peri- 
 ods than those of delivery. 
 
 Large tumor pushing forward the 
 cervix, behind which it is situated, 
 formed at the commencement of the 
 disease, soft at first, not sensitive, hard- 
 ening with time, and losing the cha- 
 racter of fluctuating, descending to the 
 lowest portion of Douglas's space, and 
 displacing the fixed uterus to a great 
 extent. 
 
 General symptoms diminishing after 
 a few days, long before the disappear- 
 ance of the tumor. 
 
 Begins suddenly. 
 
 General symptoms more or less seri- 
 ous from the beginning. 
 
 Auscultation negative. 
 
 Menstrual disorders coinciding with 
 metrorrhagia. 
 
 Uterus and tumor distinct. 
 
 Development rapid, subsequent dim- 
 inution, always in period of sexual 
 activitv. 
 
764 
 
 PELVIC HEMATOCELE AND HEMATOMA. 
 
 Fibroid Tumor {continued). 
 Amenorrhcea, leucorrhcea, or metror- 
 rbagia. 
 
 Nodulations, density unequal. 
 Softening rare. 
 
 Ovarian Cysts. 
 Develoj^ment slow, but unlimited. 
 
 No symptomatic disorders. 
 
 Tumor always (?) fluid and fluctu- 
 ating. 
 
 Hcp.matoma. 
 
 Tumor descending into recto-vaginal 
 septum. 
 
 Uterus puslied upward and forward, 
 more distinct from the abdominal 
 tumor. 
 
 Violet color of vaginal cul-de-sac. 
 
 Hcematocele [continued). 
 Menstruation and metrorrhagia. 
 
 Regularity of outline, equal density. 
 Softening frequent. 
 
 Rapid development, followed by de- 
 crease. 
 
 General symptoms more or less se- 
 rious. 
 
 Tumor at first fluctuating, and then 
 hard. 
 
 Tumor higher up, projecting at the 
 sides and behind uterus. 
 
 Uterus fixed in varying directions. 
 
 No disc'oloration ; frequent paleness 
 of mucous membranes. ' 
 
 In conclusion, we may quote from Hart and Barbour : " Hsematocele 
 and hsematoma are symptoms, but the diagnoses of the conditions caus- 
 ing the hemorrhage, unless in cases of extra-uterine pregnancy, are 
 beyond our clinical knowledge." 
 
 Pelvic Hematoma. 
 
 Wherever possible in our study of hsematocele, we have thrown it 
 into contrast in all its relations of cause, effect, and symptoms with 
 hsematoma. The field has thus been very much narrowed in all that 
 relates to the unstudied part of hsematoma. So important are the dis- 
 tinctions to be made between these different pelvic conditions, and so 
 frequently are they confounded by authors and practitioners, that hem- 
 atoma deserves a separate study. 
 
 Anatomy. — Blood effused within the pelvis, but external to the 
 peritoneum, takes certain directions more or less definite. Tripier has 
 made experiments to determine the resistance of the peritoneum. He 
 first injected colored fluid into the broad ligament from the direction of 
 the ovary. A pyramidal tumor was formed in the ligament as the first 
 result. A larger quantity of fluid with greater force caused an exten- 
 sion of the fluid behind the rectum, forcing it forward. The fluid dis- 
 colored the mucous membrane of the vagina. This discoloration of the 
 peritoneum did not extend beyond the junction of the neck with the 
 body of the uterus, and that organ was not discolored. When the 
 cauula was placed at the posterior border of the broad ligament, the 
 
I'KLVIC II.V.MATnMA. 7(j.j 
 
 fluid filled, first, the V( si<(>-iit(iin<' riil-d<-.-;i<', niid sccoiully, tlie poste- 
 ri»»r ful-(U'-s;u', both .-ides at <iii<r. Jlc made tlir rcinarkablo cxjHTi- 
 lueiit ol" using a jUTs^^urc' syringe connected with a manometer, and 
 mcasuroil the f'oi'ce necessary to niptni'e the Itrnad ligament l)v disten- 
 sion. It equalled two atmosj)lieres. Poneet exj)lains this gi-eat .-tr( nglh 
 by the character and distrii)Uti(tn ot" the connective tis-ue ot" the liga- 
 ment. These experiments, further than testing the resistance of the 
 peritoneum and the channels of connection through the connective-ti— 
 sue spaces when distended hy fluid under j)ressin-e, prove nothing. 'Jhe 
 ditferenee between the living and the dead subject is too great, ^\"e 
 may also observe that the fluid in Tripier's ex})eriments was distributed 
 in a manner never recorded in j)elvic htematoma. Beigel verified by 
 post-mortem examination a large haematoina in the folds of that j)ortion 
 of the broad ligament known as the ala vesj)erti]ionis. The subject 
 died from pneiunonia, and tlie discovery of the hiematoma was acci- 
 dental. Nona says that the effused blood is generally covered by false 
 membrane, but this is not so, and in the carefully-made dissections by 
 Ball, so frequently referred to by Poneet, no covering of this character 
 "Was observed. 
 
 As already referred to, there is great difference of opinion as to the 
 frequency of hiematoma. Bandl asserts that it is I'arely met with out- 
 side of the puerperal condition. All those who follow Bernutz hold 
 that hiematocele is very frequent and luTeniatoma veiy rare. Tait on 
 his individual experience believes that hsematoma is ten or twelve times 
 more frequent than the intraperitoneal effusion. 
 
 Causes. — Olshausen relates a case of auteuterine hiematoma follow- 
 ing acute dysmenorrhoea. The anterior lip of the cervix was shortened, 
 and the anterior vaginal vault driven backward by a tumor of half-soft 
 consistency. ]\Iany cases of htematoma attend forced abortion at the 
 €arly weeks and rough manipulation in gynecological operations. These 
 cases are frequently mistaken for cellulitis. Careful attention to the 
 order of morbid events will define it from the latter condition. In 
 ha?matoma the local lesion precedes pain and fever. In inflammatory 
 deposits fever and pain are preludes to the development of the jielvic 
 mass. Further, the induration in cellulitis is detected in regions in 
 "which the minor forms of htematocele are rarely observed. AVe find 
 the latter developing, as it were, in the vaginal wall, forming small, 
 well-defined masses, usually posterior to the vaginal portion, rarely 
 lateral, with a slight degree of uterine immobility, Avhile cellulitis is dif- 
 fused and generally lateral. The termination is the same in both cases, 
 and unless the distinction is made early it may l)e difficult, if not impos- 
 sible, to recognize the difference. It may be said that we have passed 
 through the period of cellulitis in pelvic pathology, and other condi- 
 tions will now come to the front that were formerlv confounded with it. 
 
766 PELVIC H^EMATOCELE AND HJEMATOMA. 
 
 Diagnosis. — It is important to make a clear diagnosis between 
 hsematocele and hematoma. Both are sadden in their development. 
 If the patient is menstruating at the time, the probabilities favor the 
 catamenial variety of hsematoma. If the subject has not menstruated 
 for eight or ten Aveeks, rupture of an extra-uterine foetal sac must be 
 considered. If menstruating at the time of attack, with arrest of the 
 flow from exposure to cold or chill, it is probably hsematoma. The symp- 
 toms are more intense in intraperitoneal than in extraperitoneal. Tait 
 says that he never saAV anything alarming in the first onset of the latter 
 form. The limitations of the tumor to the Douglas space, not being 
 felt above the brim, are characteristic of hematocele. When beyond 
 the peritoneum the tumor is clearly distinct from the uterus, but closely 
 connected with it, is felt above the pelvic brim, and is soft or indis- 
 tinctly fluctuating. Examination by the rectum shows that the tumor 
 disappears to the right or left of the passage, or, in other words, the 
 tumor is sharply defined. Tait says that he has seen the extraperitoneal 
 effusion (hematoma) contain pints of clots and reach not far short of 
 the umbilicus. In doubtful cases if the aspirator is used and pus 
 escapes, it is parametritis ; and if blood-debris and pus, it is a suppura- 
 ting hematoma. The diagnosis is very difficult when small blood-clots, 
 form within the folds of the broad ligaments. 
 
 Prognosis. — In the case of the small clots last noted above^ the ter- 
 mination is, with scarcely an exception, favorable. In the more severe 
 form serious differences of opinion exist. Poncet claims tliat hsematoma 
 is more grave than hematocele, as it is more liable to rupture the peri- 
 toneum, but so far as clinical records are known this opinion has no value. 
 Kuhne believes the outcome is favorable. Bernutz views it in a very 
 serious light. Courty states that the periuterine hematoma generally 
 terminates in recovery by absorption, and qualifies his opinion by the 
 statement that the outlook is not so favorable as in hematocele, as 
 rupture of the peritoneal covering and escape of blood-clots into the 
 abdominal cavity usually cause death. Tait, on the other hand, says 
 that the hematoma is rarely fatal, while the intraperitoneal is generally 
 fatal. When the eff'usion is into the cellular tissue, the natural tendency 
 is toward spontaneous arrest ; if into the peritoneum, the hemorrhage 
 is excessive and irritation of the peritoneum very great. However, out 
 of a large number of cases Tait never saw but one fatal. It is undoubt- 
 edly the fact that the more generally approved idea of the prognosis of 
 liematoma is expressed by the latter author. Those cases of hema- 
 toma that occur in the latter part of pregnancy or in childbirth or 
 the lying-in are much more serious than those that are noticed at 
 other periods, and, as a rule, are the only cases concerning which any 
 anxiety need be felt. 
 
 Symptoms. — The eff'usion is more gradual than in hematocele — less. 
 
VKLVlc ILKMAIOMA. 707 
 
 pain and less shock. Kiiliiic siiys lliat (lie ])aiii is diU" to the remliiij^ 
 of the coniu'c'tivt'-ti.ssuc clciiiciifs. TIk." pain is intermittent, caused hv 
 the suct'cssive escapes of MihkI. WC may note the ahsenee of peritonitis, 
 meteorism, and ihc dear deliniiioii of tlic line of (hdness if the mass 
 ]>resents above ihe ju'lvic ImIiii. Id examinalion l»v the vajjina tlie 
 tumor is found just within tln' \idva, nearly always Ix-N.w (he noi-mal 
 limits of I)oui;-las's sac. TxTnut/. reports cases of lateral tunutr at the 
 Junction of the middle and lower third, and existini;- in the re<-to-\a<ii- 
 nal cells. The lateral situati(»n is rare, hut when found it is character- 
 istic of a hivniatoma only. Poncet says that he has never seen luenia- 
 tonia develop in the vaginal wall anterior to the cervix ; while Nona 
 has rarely seen them in this situation. Prost assigns great importance 
 to the fact that h:ematoma will displace the uterus upward, just as 
 hieuiatocele will displace the organ downward and forward, while the 
 cervix is displaced sometimes to the right or left. The uterus does not 
 lose its mobility as in ha?matoeele. Kuhne calls attention to the bridge 
 uniting two lateral tumors, which has been already described. Through 
 the speculum the vagina presents a violet color in those portions con- 
 tiguous to the tumor. Nona gives this appearance high diagnostic 
 value, but according to Bernutz it is not alwavs constant. The lucm- 
 atoma has a doughy consistency, a false fluctuation, and maintains its 
 characteristics longer than hsematocele, as its contents change less rap- 
 idly. Absorption is more prolonged in hfematocele, Avhile the latter is 
 more disposed t(i rupture into the rectum or the vagina. 
 
 Treatment. — The primary indications are, first, to arrest hemor- 
 rhage and avert or mitigate the shock ; secondly, to treat the inflamma- 
 tory complications, and lastly, the blood-poisoning that mav result from 
 septic changes in the effused blood. 
 
 To arrest hemorrhage we may employ cold irrigation of the vagina 
 or rectum — three to five minim doses of the liquor sesquichloride of 
 iron, sulphuric acid, tannin, alum, or acetate of lead and opium, avoid- 
 ing hot baths and hot ajiplications, sitz-baths especially, as favoring hem- 
 orrhage. Shock closely follows the blood-loss. The head should be 
 placed lower than the body by removing pillows and I'aising the foot 
 of the bed. Vomiting should be checked l»y pounded ice, Avhile pain 
 may be subdued as well as the system stimulated by ether or Hoff- 
 mann's anodyne. Moderate use may be made of stimulants or cor- 
 dials, if retained l)y the stomach, without fear of renewing the hem- 
 orrhage. Sinaiiisms to the arms or inside of the thio;hs mav be 
 employed, as the pain of the application retards shock. 
 
 The cataclysmic cases are treated on the same principle as rupture 
 of the uterus or of the cyst of extra-uterine pregnancy, or other great 
 pelvic lesion ; when peritonitis is present, with opium and the hori- 
 zontal position. Purgatives should be avoided, as breaking the law 
 
768 PELVIC HEMATOCELE AND H.EMATOMA. 
 
 of rest. The bowels will probably act, as in other cases of obstruc- 
 tion, under the use of opium. 
 
 In from twenty-four to thirty-six hours the evidences of peritoni- 
 tis present themselves. The tonic treatment is to be kept up. While 
 excessive tenderness exists, warm poultices or fomentations ; after that 
 stage has passed blisters may be applied to the abdomen, as the perito- 
 nitis has a tendency to assume a chronic form. Bernutz advises us 
 at the approach of a menstrual period, provided the local tenderness 
 has abated to a sufficient extent, to apply leeches through a speculum 
 to the cervix uteri and to promote the flow by warm-water injections. 
 This treatment applies to the menstrual variety of ha3matocele. Mc- 
 Cormick suggests mercurial plaster to the abdomen or friction with 
 mercurial ointment, with iodide of potash internally ; tonics after the 
 subsidence of fever. 
 
 Emmet's treatment is hot-water irrigation to control inflammation, 
 careful nursing, rest in bed with light covering. As in all cases of 
 pelvic or abdominal inflammation, one should abstain from repeated 
 vaginal and pelvic examinations. Make one as complete and thor- 
 ough as possible, if necessary under ether, for diagnostic purposes; 
 then stop. 
 
 The surgical treatment of pelvic hsematocele may now be regarded 
 as placed upon a firm basis. Emmet expresses the voice of the period 
 in the emphatic assertion that surgical interference is rarely required. 
 Bandl has formulated two rules : First, if the hematocele is, after a 
 week, undiminished in size, with no amendment of symptoms, evacu- 
 ate its contents ; second, if pus or sanies appears to have developed, as 
 proved by aspiration, open the sac. The first rule does not conform to 
 the practice of English or American surgeons, and cannot be approved. 
 We may suspect the degeneration of the cyst contents into pus by the 
 presence of hectic and chills; and, having proved its existence, the only 
 treatment that can afford relief is to apply the second rule of Bandl. 
 Barnes's rules have in a large measure settled the practice. When 
 the tumor softens and moderately enlarges, with high pulse and tem- 
 perature, septicsemia is present, and the proper time for operation 
 has arrived. The cyst should be punctured in the bulging part, behind 
 the cervix, in the vaginal roof, with a moderate-sized trocar or bistoury. 
 The instrument should be inserted in the direction of the axis of the 
 pelvic brim, parallel with the posterior uterine wall. A sound inserted 
 into the uterine cavity will aid in defining the direction in which the 
 trocar should be inserted. If directed too much backward, it is liable 
 to wound the rectum or enter the sac too obliquely for free evacuation. 
 The opening may be further enlarged by dilatation if necessary, so that 
 clots may have free escape. The cavity should be Avashed out daily 
 with carbolic-acid solution or solution of mercuric bichloride. Sir 
 
i'i:i.vic ii.KMA'ioMA. 7G9 
 
 .1. Sim|)-()ii iiisislcd nil ;i I'lci' ii|iciiiiiL;- in pdvic li;iiii;itiic(|f : " 1 iicmkc 
 with a l('ii(it<nii\ -kiiilc and ciilaiLii' il"' opmini;' wiili llic liniii'i', hrcak- 
 iiiii' (low n septa and l)ln(Kl-('<)at;iila."' Meadows I'eeoniineiids t lie very 
 (loiil)tl'id |»ra('tiee of |)nneliire tlii'oiii;li the reeliini. It i> onl\ neccs- 
 sar\' to remark that e\aeiiation ol" the sac ihrouuh tln' reetuni exposes 
 the palieiil to the same danLi'ei' that attends .--pontaneoiis cNaeiiatioti 
 thron^ii the same eliannel. In i'a>es (»!" old luemaloceles thiit have 
 sii|)puiate(| ;nid iii|tlnred into the reetnm, a I'nrtJier daii<2;cr is that 
 thev will u'o on diseliar^iinL;,- |)ns for years, exhan.-t in^;' the patient. 
 Sneh ea>es nnisl lie treated l)V a IVee eonnter-(»peninii into the vaii'ina, 
 " w liieli is a |>erleelly snecessful operation " (Tait). The last anlhority 
 Sii\s that ])nneliire throiio-h tlie va<i;ina rarely Llives relief. ()p(,'nin<i; 
 1)\- the ahdomen is not justiliable, and tjie one ride to he observed is, 
 that all cases of intraperitoneal hseraatocele out2;ht to be left to Nature, 
 unless it is exceptional. Cases are upon reeord (Aran) in which after 
 openinix rapid decomposition took place within the cyst, due to the 
 entrance of air. In modern practice, with antiseptic precautions, this 
 dauLicr ouu'ht ro be remote. 
 
 The treatment of hematoma is based upon the same general plan. 
 Snriiical interference is rarely required. 
 
 DIULIOGHAPHICAL NOTE TO ARTICLE OS '• MENSTRUATION, AND ITS 
 
 DISOnUERS." 
 
 As an explanation for tlie absence of any reference to several papers and discnssions 
 
 on Menstruation that have appeared in the journals in the past eighteen months* 1 
 
 will say that my article on Menstruation, and its Disorders, was written in the tall 
 
 and winter of 1885, and was ready for the press Feb. 1, 1886. When tiie proof-sheets 
 
 were retin-ned to me, I found it impracticable to change it without rewriting most 
 
 of it. and it was left in its original state. Selected parts were read before the meeting 
 
 of tlie Alumni Association of tlie New York State Woman's Hospital, Jan., 1S86, 
 
 but, at llie request of l)r. Mann, they were not published. 
 
 W. Gill Wylie. 
 June 17, 1SS7. 
 
 Vol. I.— 49 
 
AUTHORS' INDEX. 
 
 [See also lists of Lilenttmr ivlonvd to on pp. 03, 278, 548, 568, 586, 593, 599, 618, 635.] 
 
 A. 
 
 .\ili>l(>n, 445 
 
 AjiiKw, I). H., 28, 41, 725 
 
 Aikinim. John, 252 
 
 Alhuc.isis, 22 
 
 Aiulral, 09") 
 
 Apnstoli, 387, 399, 400, 403 
 
 Appletoii, 22 
 
 Aran, 377. 568, 664, 677, 696, 707, 723, 727 
 
 752, 7()9 
 Arcliigenes, 676 
 Ai'tiiis, 20, 676 
 Atiee, J. L., 27 
 Atlee, W. L., 27, 28, 64 
 Atthill, 568, 580, 653, 664 
 
 B. 
 
 Bainl, 60 
 
 Baker, W. II.. 02, 261 
 
 Balfour, 86, 176 
 
 Ball, John, 41, 433, 765 
 
 Bandl, 163, 219, 707, 736, 739, 
 
 755, 756, 760, 761, 762, 705, 
 Barl)oiir, 101 
 
 Barker. Fonlvce. 38, 395, 484, 58 
 Barnes, Eobert, 568, 581, 583, 
 
 738, 740, 742, 750, 755, 756, 
 P>ai"stellbero;ef, 203 
 Battey, Robert. 36, 3S, 39, 49 
 Bear<l and Rockwell, 385 
 Beck, Jos. E., 43, 433, 705 
 Beck, Snow. 039, 640, 738, 745, 755 
 Becqnerel, 727 
 Bedford. G. D., 30, 03, 738 
 Behier, 709 
 
 Bei<i;el, 70, 167, 738, 765 
 Bell, 24 
 Bennet, 377, 568, 571, 573, 576, 581, 661, 
 
 738 
 Bernutz, 508, 677, 687. 688. 089, 
 
 694, 695, 696, 700, 704, 715, 
 
 735, 730, 737, 739. 740, 742, 
 
 760. 70). 760, 767, 768 
 Bigelow, Henry J., 52 
 Bi<;elow, H. R.. 57 
 Bi Hinder, J., 27 
 Billroth, 712 
 Bird, 547 
 Bisciioff, 409 
 Bixby, G. H., 03, 725 
 
 741, 
 768 
 
 >1 
 
 722, 
 
 768 
 
 745, 
 
 736, 
 
 691, 
 
 693, 
 
 717, 
 
 727. 
 
 752, 
 
 755, 
 
 Boehni, C, 93 
 
 Boerner, 000 
 
 Boisin and Diifjcs. 447 
 
 Boisin, Mad., 157 
 
 Bouchnt, 698 
 
 Boynhain, Wm., 28 
 
 Bozenian, Natlian, 34, 36, 445 
 
 Brandt, 616 
 
 Braun, C, 508, 738, 755 
 
 Breiskv, 20O 
 
 Brickell, 4(5, 49 
 
 Briddon. Charles K., 56 
 
 Broca, 100 
 
 Browne, B. Bernard, 57 
 
 Budin, P.. 93, 119 
 
 Bumstead, 593 
 
 Burns, 640 
 
 Buttles, M. S., 39 
 
 Byford, W. II.. 36, 45, 56, 63, 66, 542, 568, 
 
 581, 723, 725, 728, 733 
 Byrne, Joiin, 38, 62, 64, 738 
 
 c. 
 
 Cadiat, 124 
 Campbell. H. F., 45 
 ' Carrard, 477 
 Carreau, J. D., 681 
 Carrington, 224, 225 
 Chadwick, J. R., 45, 46. 53, 198, 199, 480, 
 
 692 
 Cliampionniere. 554. 679, 080 
 Channing, AValter, 30 
 Chajiman, E. X., 63 
 Chauvau, 93 
 Chrobak. 135. 141 
 Chroniel, 041. 601 
 
 Cluirchill, Fleetwood, 040, 670. 738 
 Clark, 29 
 Clark. Alonzo. 30 
 Clark. C. M.. 531 
 Clark, Edward H.. 45 
 Coe, H. C, 01, 330, 69S. 699 
 Coen, 242 
 
 Coleman. J. D., 259 
 Cooper, Astlev, 483 
 Cornil, 91, 519 
 Couriv, A., 91, 93. 445, 554, 568, 581, 641, 
 
 604, 680, 681, 709, 715, 723, 740, 746, 
 
 703. 766 
 Crede, 738 
 
 771 
 
772 
 
 AUTHORS' INDEX. 
 
 Creighton, 178 
 Cruveilhier, 252 
 Cnllerier, 593 
 Cuilingworth, C. J., 691, 722 
 
 D. 
 
 Dal ton, 178 
 
 Davies, Gomer, 258 
 
 Davis, E. Y., 515 
 
 Dawson, B. F., 63 
 
 Deces, 742 
 
 Delore, 756 
 
 Del rand, 515 
 
 Denouviliers, 737 
 
 Deralz, 740 
 
 Dewees, Wm. P., 63 
 
 Dohrn, E., 72, 93, 262 
 
 Dolbeau, 741, 757 
 
 Doran, 180 
 
 Douglass, 22 
 
 Doutrelepont, 519, 523 
 
 Drysdale, Thomas M., 43, 64 
 
 Duhring, 534 
 
 Duncan, Matthews, 252, 465, 519, 
 
 657. 677, 688, 694, 695, 705, 
 
 73S' 
 Dunglison, 588 
 Dunlap, A., 27 
 Duparque, 593, 641 
 Duverney, 746 
 
 E. 
 
 520, 527, 
 722, 723, 
 
 Frey, 121 
 Friedlander, 141 
 
 Fritsch, 154, 354, 561, 568, 688, 701, 707, 
 716,727- 
 
 G. 
 
 Galabin, 527, 653, 662 
 
 Gallard, 735, 736, 737, 759, 761 
 
 Gantillon, 377 
 
 Garrigues, 56, 140, 192, 210, 228, 706, 719 
 
 Gartner, Herman T., 70, 93 
 
 Geigel, K.,J0, 93 
 
 Gendrin, 377 
 
 Gillette, 531 
 
 Gilmour, 38 
 
 Giraldez, 75 
 
 Giranlt, 475 
 
 Goodell, Wm., 36, 40, 42, 50, 54, 58, 66, 
 
 359, 433, 517, 530, 568, 617 
 Goodman, 46 
 Goupil, 687 
 Graaf, Regnier de, 80 
 Grandin, Egbert H., 667 
 Green, T. Henry, 536, 679 
 Greenhalgh, 356 
 Grobe, 236 
 Gross, 26,431 
 
 Guerin, Alph., 217, 709, 715 
 Gussenbauer, 109 
 Gusserow, 155, 761 
 Gurlt, 537 
 
 Edis, 542, 568, 637 
 
 Elischer, 175 
 
 Ellinger, 433 
 
 Ellis, 189,198,224,231 
 
 Emmet, T. A., 34, 35, 36, 37, 41, 42, 43, 44, 
 50 54, 55, 63, 65, 199, 234, 252, 337, 
 338, 530, 597, 667, 680, 699, 704, 707, 
 714, 718, 720, 721, 722, 729, 738, 742, 
 743,750,768 
 
 Engelmann, 50, 141, 331, 387, 400, 403, 
 409 
 
 Erich, 499 
 
 Eustache, 476 
 
 F. 
 
 Fallopio, Gabriele, 87 
 
 Far re, 169 
 
 Fayrer, 525 
 
 Fenger, Christian, 55 
 
 Fenwick, Bedford, 529 
 
 Finn, 646 
 
 Fischel, W., 93 
 
 Forstei', 593 
 
 Fort, C. H., 263 
 
 Foster, Frank P., 102, 118, 228, 233, 234, 
 
 362, 554, 698 
 Foulis, 84, 93 
 Franck, 737 
 
 Frankenhilnser, 146, 762 
 Frarier, 709 
 Freund, 708 
 
 H. 
 
 Hadra, B. E., 59 
 Hagemann, 93 
 Harrison, 738 
 
 Hart, D. Berrv, 682, 686, 724 
 Hart and Barbour, 101, 106, 109, 112, 125, 
 131, 132, 154,167,168, 188,212,222, 
 2'?7 228, 229, 233, 568, 602, 638, 644, 
 688', 708, 751, 761, 762, 764 
 
 Heath, 224, 229 
 
 Heath, W. H., 483 
 
 Hedenius, P., 93 
 
 Heo-ar, 149, 578,617 
 
 He'lie, 135, 137 
 
 Henle, 121, 142, 172. 187, 188, 189, 230 
 
 Hening, 137, 163, 169 
 
 Hennig, 536, 568, 582 
 
 Heppner, 269 
 
 Hermann, 107 
 
 Herrick, O. E., 56 
 
 Herzfelder, 738 
 
 Heschl, 600, 645, 746 
 
 Hewitt, Graily, 622, 654, 663, 738, /o9 
 
 Heyer, 738 
 
 Hey wood, 478 
 
 Hicks, Braxton, 694 
 
 Hildebrandt, 498, 499, 515, 537, 539 
 
 His, W., 94 
 
 Hodge, H. L., 29, 63, 599 
 
 Hodgen, 487 
 
 Hoggan, 643 
 
 Holden, 187, 497 
 
 . Holyoke, 22 
 
.1 rrimiis- f\in:x. 
 
 lis 
 
 FI<i\vnrd. Win. T., '>X 
 
 H.i-iiier, ii:i. .'.11. ::'.<■' 
 
 Iliiiiior, "Jo 
 IliiiUfr, J. H.. •'>•'- 
 lliitrliiiison, ii'l'i, 't'Si 
 llvatt. II.O.. iM 
 
 11 "v 111, l'.»s. -jiw;. .■)!(; 
 
 111..}, i:.. 414. 
 
 Imbeit, G.. 94 
 
 I. 
 
 J. 
 
 .linkson. A. K.-oves, 39, 53, 536, 616 
 
 .Jtuolii, 64 :;. 644. ()46. 647, 652 
 
 Jaiulii. Marv Putnam, 59, 41U, 437, 602, 
 
 (13S, tMl". 647, 662 
 Jacobsoii. L.. 94 
 Jenks, Ivlwanl W., 52. 55, 513 
 
 K. 
 
 Kaltzenbach, 578 
 
 Kam merer, 377, 454, 462 
 
 Kaposi, 527 
 
 Kasciikaroff, 660 
 
 Kehrer. 421,441, 462,617 
 
 Kelly, H. A., 58 
 
 Keiinedv, 536, 580 
 
 KerkrinV, 239 
 
 Ki.M, 5S0 
 
 Kimball, Oilman, 45, 61 
 
 Kiiia, John. 28 
 
 Kirmisson, 534 
 
 Kiwisch, 511, 542, 547, 599, 638 
 
 Klehs, 268, 271, 738 
 
 Klein. 121, 139, 142, 164, 172, 176, 190 
 
 Klemni, 5S2 
 
 Klob, 534, 539, 542, 546, 574, 599, 601, 
 
 608, 637, 645, 649, 650, 660 
 Kobelt, 104, 109, 112 
 K<.eh, 519,523, 530 
 Kocks, J., 71, 94 
 Kulliker, A., 69, 73. 79, 83, 84, 85, 91. 94, 
 
 237 
 Konig, 219, 723 
 Krause, 104 
 Kreiger, 738 
 Kiiluie, 766, 767 
 Kmulrat, 409 ' 
 Kiissmaiil. 247 
 Kustner, 539 
 
 L. 
 
 Lallemand, 581 
 
 Lamballe, J. de, 377 
 
 Lani^enbeck, 242 
 
 Langier. 737 
 
 Langlade and Cum men, 239 
 
 Lazarewilch, 655 
 
 Le P.ee, 123, 131. 146, 687 
 
 Lebeeleff, 261 
 
 Lee, C. C, 55, 738, 740 
 
 Lefort, 243 
 
 Lenoir, 737 
 
 Lente, I". D., 39, 57H, 581. 
 
 Leopidd, 129, 140,141,172,409,554,643, 
 
 644, 679, 680, 687 
 Lever, 640 
 Lew, 454 
 Lewi.s, \V.. 63 
 Lindgien, 142 
 LislVani-, 599, 638 
 Lister, 165, 339 
 Litzman, 443 
 iMtt. 141 
 Louis, 261 
 Lowenthal, 309 
 Luschka, 102, 121, 132, 169, 186, 188. 19.3, 
 
 221 
 Lusk, 101, 107, 142, 492, 536, 651, 711, 713 
 Lyraan, Geo. H., 28, 48, 731 
 
 I M. 
 
 Mct'arthv, Justin, 705 
 'McClintock, A., 532, 677, 707, 711,728, 
 I 735. 736, 738, 750, 752 
 
 McCormick, 758. 768 
 
 McDowell, 23, 29, 30 
 I Madge. 738, 740, 755, 762 
 
 Mann, Matthew D., 56, 127, 131, 334, 339 
 
 Mapother. 447 
 
 Marchal, 676, 677 
 
 Marrotte. 761 
 
 Marsh, Howard, 727 
 t Martin, t)48 
 
 Martin, Franklin H., 365, 617, 666 
 
 Mason, 477 
 
 Massot, 532 
 
 Maver. 243, 527, 538 
 
 Meadows. 736. 738, 739, 742, 761, 769 
 
 Meigs, C. D., 29, 63, 502, 654 
 
 Meniere, 405 
 
 Meyer, H., 77, 94, 271 
 
 Mever. Leopold. 236 
 
 Miller, Henrv. .377, 581 
 
 Milne, Edwaixls H.. 70, 94 
 
 Minor, Julius F., 38 
 
 Mitchell, Weir, 610, 633 
 
 Monod, 737 
 
 Morel, 237 
 
 Morris. 722 
 I Muller. J., 85 
 
 Munde. 50. 53, 66, 250, 327, 398, 405. 443, 
 444, 480, 528, 554, 561, 578, 666, 679, 
 I 681 
 
 ! X. 
 
 Nandier. 710, 715 
 
 Nega, 242 
 
 Nelaton, 735, 736, 737, 745, 747 
 
 Newman, Robert, 61 
 
 Xickles. 663 
 
 iNoeggerath. E., 37, 38, 45, 48, 431. 459. 
 1 460, 571, 599, 608, 617, 638, 660, 691 
 
 Nona, 767 
 ( Nonat, 627, 677 
 
774 
 
 AUTHORS' INDEX. 
 
 Nott, J. C, 30, 377, 516, 518 
 Nylander, 141 
 
 o. 
 
 Olshausen, 209, 23G, 617, 652, 713, 738, 765 
 Oribasius, 676 
 Orne, 22 
 Osgood, 22 
 Ott, 737 
 
 P. 
 
 Paget, 527, 552, 731 
 
 Palfyn, 261 
 
 Fallen, Montrose A., 45, 443 
 
 Palmer, C. D., 35, 57 
 
 Pare, Ambroise, 22 
 
 Parry, John S., 39 
 
 Parvin, Theophilus, 38 
 
 Pattee, A. F., 62 
 
 Pauliis JEgineta, 21 
 
 Pauly, 742 
 
 Peaslee, 36, 37, 64, 243, 245, ;;77 
 
 Peuch, 737 
 
 Peuch, A., 94, 236, 237, 255, 743 
 
 Pfluger, 176, 409 
 
 Phillips, 758 
 
 Physick, 26 
 
 Pick, 524 
 
 Pirogoff, 212, 488, 683 
 
 Playiair, 568, 580, 633 
 
 Polk, Wm. M., 56, 60, 192, 193, 210, 212, 
 
 215, 682, 688, 698, 699, 717 
 Poolev, J. H., 261 
 Post, Alfred C, 58 
 Post, Sarah E., 60 
 Poncet, 737, 740, 749, 751, 754. 756, 765, 
 
 766 
 Priestley, 542 
 Prochownick, 239 
 Prost, 737 
 Puzos, 676 
 
 Q. 
 
 Quain, 94, 105, 107, 112, 136, 224 
 
 R. 
 
 Raciborski, 740 
 
 Paine}', 159 
 
 Eannev, 101, 102, 105, 108, 113, 131, 141, 
 
 218, 228, 233 
 Rasch, 759 
 Eecamier, 22, 30, 581 
 Eeinmann, 547 
 Reyer, 525 
 Richard, 476 
 Richardson, W. L., 719 
 Richet, 740 
 Ricard, 593 
 Rieder, Carl, 72, 94 
 Rindfleisch, 748 
 Ringer, Sidney, 365, 662 
 Robert, 737 
 Robin, C. H., 124, 707 
 Rogers, D. L., 27 
 Ro'kitansky, 248, 546, 743 
 Rose, Cooper, 245 
 
 Rosenmiiller, 75 
 Ronget, 139 
 Routh, 477, 568 
 Ruge and Veit, 143, 587 
 Ruysch, 737 
 
 S. 
 
 Sanderson, 678 
 
 Sanger, 536 
 
 Savage, 98, 99, 108, 109, 121, 135, 140, 157, 
 
 183, 186, 188, 189, 210, 226, 229, 684, 
 
 701, 723, 724 
 Scanzoni, 377, 516, 541, 547, 568, 599, 637, 
 
 641, 652, 661, 664, 722, 738, 740, 745 
 Schafer, 216 
 Schroeder, 118, 354, 477, 480, 528, 542, 
 
 568, 617, 644, 646, 654, 705, 722, 738, 
 
 746 
 Schiiller, 180 
 Schultz, 654 
 Schultze, 718 
 Sch upper t, M.. 38 
 Schuregius, 515 
 Schwimmer, 524 
 Scott, John, 59 
 Scultetus, 22 
 Sedgwick, 86 
 Sei'dukopf, Ar., 655 
 Shatz, F., 94 
 Silvestre, 749 
 
 Simon, 29, 187, 617, 709, 710, 715 
 Simpson, A. R., 653, 724 
 Simpson, Jas., 377, 511, 516, 536, 568, 637, 
 - 638, 640, 641, 644, 646, C61, 664, 727, 
 
 732, 738, 769 
 Sims, J. Marion, 30, 34, 36, 37, 39, 45, 60, 
 
 63, 475, 514 
 Sinclair, 600 
 Sinety, L. de, 91, 94, 116, 117, 124, 125, 
 
 140, 143, 167, 475, 587, 644, 647, 652 
 Sireday, 752 
 
 Skene, Alex., 46, 48, 65, 71, 94, 185, 188 
 Smellie, 23 
 Smith, A. G., 27 
 Smith, N., 27 
 Smith, Tyler, 568, 739 
 Smyly, 759 
 
 Spiegelberg, 607, 686, 688 
 Stearns, 26 
 Steurer, 706 
 
 Storer, H. R., 36, 38, 63, 450 
 Strieker, 140 
 Stroinsky, O., 55 
 Snrgus, Damien, 496 
 SussdorfF, 322 
 
 T. 
 
 Tait, Lawson, 169, 172, 180, 267, 409, 503, 
 505, 509, 519, 688, 691, 695, 701, 704, 
 705, 722, 724, 729, 730, 738, 74:-, 752, 
 766, 769 
 
 Taliaferro, V. A., 38 
 
 Tardieu, 262, 741 
 
 Tavlor, I. E., 28, 57, 241, 259, 519, 567 
 
 Thin, 520, 527, 
 
Al'TlinliS' IXDh'X. 
 
 Thomas, T. G., '2S. M, 38, 49, "j1, .'.4, .")•.», 
 
 (;:;. 118, ;5')6, 4S(), 510, ois, o4'_', r.iiT, 
 o(js, ")S(), .")Wit, (>17, (i.'Js, (ii:!, (ic.o, ()(;i. 
 
 «i(i4, ()77, 70.'), 710, 7U7, 7;{li, 738 
 Tilt. 7:58, 7.'5'.» 
 Tripier, .SIMI, 7(i4, 7(1"> 
 Tnmssi'iiii, o()"J, 710, 74'. 
 TiinuT, 141 
 Tiiniipsei'd, Iv !!., 'J<!.'> 
 
 w 
 
 74:! 
 
 ririi'ii, 7;;8 
 
 u. 
 
 V. 
 
 \';in lliinu, \\ in. II., (>78 
 
 \ai> .lo \V:uk.i-, Iv, ol, 53, 132 
 
 Veil, 72:'. 
 
 \'el|)eau, 077 
 
 Vi<lal, 527, 582 
 
 Vifliiis, 7:37 
 
 Vireiiow, 2:57, 520, 527, 547, 075, 678, 701, 
 
 705, 7:iS, 741 
 Voisin, 7:^7, 738, 7:^9, 743, 748, 751, 755 
 Von Haselberg, 583 
 Von i'reuscliin, 124 
 Von Kecklinghausen, 706 
 
 ■, 270, 
 
 Wal.lrv.T, W., 08, 81, 80,94, 17 
 
 (i78 
 WalkcT, II. v., 252 
 Wanvii, .1. ('., 27,51 
 \Va.s.sili(.-(r, M., 72, 94 
 Walts, R.. 72 
 Wi-l,stor, 10. II., :540 
 Wells, SponctT, KW, 480, 742 
 Wernick, AVA 
 West, 508, 077, 710 
 Wiiitc, J. C, 523 
 White, J. P., 30, 37 
 Whiltaker, J. T., 242 
 Williams, 141, 144, 155, 400. 759 
 Wilson. ICllwood, 067, 672 
 Wiltshire. 700 
 Winekel, T., 94, 186, 230, 415. 401, 488, 
 
 491, 497, 530, 5:W. 078, 723, 740 
 Wolf!" Casper Friediieh, 08 
 Wun(lerliL4i, 694, 702 
 Wylie, G., L35 
 
 Z. 
 
 Zweilel, 515, 536, 538 
 
INDEX TO N'OLIIME I 
 
 A. 
 
 Abdomen, exnininatinn of, 30(3 
 
 inspei'lioii dt', 'MM 
 
 ineiisuratioii of, .'iOT 
 
 palpation of, 307 
 Aljcloniinal section in pelvic pcritunilis, in- 
 dications for, 704 
 Abdomino-rectal exaniinatinn. ;;i)l 
 Abortion, treatment of hemorrhage after, 
 
 Abscess, chronic ]ielvic, o6, 60 
 pelvic, 7"J1 
 
 asjjirating sac, 731 
 diagnosis of, 726 
 opening sac, 7'2S 
 pathological anatomy, 722 
 sinuses, 73.! 
 treatment of, 727 
 Acute eczema of vnlva, 503 
 
 metritis, 546 
 Adenitis, periuterine, 680, 759 
 Aileno-lymphangitis. 680, 759 
 Adhesions, pelvic, treatment of, 51-54 
 Air, fresh, iniportaiu-e of, 622 
 Alcoholics, use of, 624 
 Alexander's operation, 160 
 Alopecia of vnlva, 500, 501 
 Amenorrhoea, 411 
 electricity in, 3;il 
 treatment of, 364, 413 
 Amputation of cervix, high, 150 
 
 in metritis, 617 
 Ana\stl)esia in operations, 338 
 Angeioleucitis, ()80 
 Angioma of vulva, 536 
 Anteflexion, cause of dysmenorrhoea, 423 
 
 of uterus, 256 
 Antisepsis, agents for, 329 
 
 in gynecological operations. 328 
 Antiseptic injections in childbed, 662 
 Aiuisciitit's in lupus, 523 
 Anus, lissure of, causing dyspareunia, 453 
 Apoplexy of ovary, 745 
 Appendages, uterine, 161 
 
 disease of, complicating dvsmenor- 
 rhrea, 420 
 Applications, intra-uterine. agents, 381 
 by applicator syringe, 578 
 bv ingestion. 577 
 
 Api>lications, intrauterine method, 380 
 
 topical, in endometritis, 559 
 Applicator, cotton-wrapped, 577 
 
 hard rubber, 564 
 
 Sims's. 580 
 .\|iplicator .syringe, 578, 581 
 Arlior vitiu ntcrina, 134, 137 
 Arsenic, use ol', in metritis, 612 
 
 value of, 372 
 Arteries of ovaries, 179 
 
 uterus, 143 
 Artificial im[)regnation, 475 
 Aspermatism, 453 
 Aspiration for diaguusLs, 326 
 Aspirators, 326 
 Assistants in operations, 340 
 Astringents in congestion, 563 
 Atresia ani vaginalis, 261 
 
 of hymen. 262 
 
 of uterus, 253 
 
 of vagina, 257, 458 
 
 of vulva, 267 
 
 treatment of, 478 
 .^.trophy of uterus, 599 
 
 treatment of, 618 
 Auscultation and percussion of abdomen, 
 306 
 
 B. 
 
 Bacillus tuberculosis in lupus, 519 
 Bartholin, glandsof, 113. (SeeVulvo-vaginat 
 
 Guind.) 
 Bathing in uterine disease. 621 
 Baths, hip, in subinvolution, 663 
 
 stni, 621 
 Battey's operation, 39-49 
 Battey on removal of ovaries. 39, 49 
 Belladonna, action of, 370, 373 
 Bimanual examination, method, 298 
 Bladder, anatomy of, gross, 188 
 minute. 190 
 
 diseases of, works on, 65 
 
 ligaments of, 207 
 
 relations and attachments, 191 
 
 sphincter of. 189 
 
 supports of 225 
 
 symptoms, importance of, 29] 
 Bleeding, local, in chronic metritis, 613 
 Boils on vulva, 494 
 Bowels, atteniidu to lunction of. .370, 62f6 
 
778 
 
 INDEX TO VOLUME I. 
 
 Broad ligaments, 207 
 
 contents of, 209 
 
 in pregnancy, 208 
 Bromides, value of, 365, 374 
 Bulb of ovary, 180 
 Bulbs of vagina, 112 
 
 of vestibule, 112 
 Bursting cysts of abdomen, 54 
 Buttle's spear, 613 
 Buttonhole incision of urethra, 54 
 
 C. 
 
 Cancer as a cause of metrorrhagia, 417 
 of cervix, excision for, 62 
 of vulva, 537 
 
 pelvic, diagnosis from hajmatocele, 761 
 Carbolic acid in dj'smenorrhoea, 428 
 Carcinoma of vulva, 539 
 Caruncles of urethra causing dyspareunia, 
 451 
 electricity in, 404 
 Carunculse myrtitbrmes, 118 
 Cases, rational history of, 284 
 Catgut for sutures, 339 
 Catheter, passing the, 115, 197 
 Cedron as tonic, 369 
 Cellulitis, pelvic, 705 
 diagnosis, 714 
 from fibroids, 718 
 from hsematocele, 717 
 electricity in, 404. 
 etiology, 706 
 exudation, seat of, 715 
 pathology, 708 
 prognosis, 718 
 pus in, 710 
 symptoms, 710 
 
 non-puerperal, 713 
 puerperal, 711 
 treatment of, 60 
 curative, 719 
 prophylactic, 718 
 remarks on treatment of, 220 
 Centennial year, 46, 49 
 Cervical protector, Wylie's, 428 
 Cervix, amputation of, in metritis, 617 
 anatomy of, 587 
 
 appearances of, in Sims's speculum, 314 
 congestion of, glycerin and boro-giy- 
 
 cerides in, 562 
 cystic degeneration of, 591 
 false ulceration of, 587 
 forcible dilatation of, 41. (See also 
 
 Dilatation.) 
 granular degeneration of, 589 
 high amputation of, 150 
 in laceration, 149 
 in old age, 149 
 
 lacerations of, causing subinvolution, 651 
 operation for lacerated, 58 
 
 history of, 37 
 pathological anatomy of, 588 
 pelvic peritonitis following operations 
 
 upon, 698 
 shape and size of, 133 
 
 Cervix, stenosis, dangers of incision for, 
 151 
 syphilitic ulceration of, 593 
 true ulceration of, 593 
 Chadwick's table, 295 
 Change of life, 436. (See Menopause.) 
 Chloral, use of, 374 
 Chromic acid as application, 566, 580 
 Chronic eczema of vulva, 514 
 metritis, 602 
 
 hot douche in, 613 
 quinine in, 630 
 sponge tents in, 616 
 pelvic abscess, 56, 60 
 peritonitis, 696 
 Clinic, first gynecological, 30 
 Clitoris, anatomy of. 106 
 attention to, necessary, 621 
 hypertrophy of, 447 
 
 treatment, 477 
 malformations of, 266 
 Cocaine, use of, 381 
 Coccyodynia, 516 
 
 causing dyspareunia, 452 
 Nott on, 30 
 Coccyx, neuralgia of, 516 
 
 removal of, 518 
 Cofiee, use of, 624 
 
 Coitus during menstruation, effects of, 743 
 excessive, as cause of subinvolution, 652 
 hindrances to, from malformations, 446 
 impossible, causes of, 446 
 painful, 448 
 
 spasm in, from vaginismus, 515 
 Colica scortorum, 701 
 Columbia Hospital, report of, 41 
 Condyloma, examination, 298 
 syphilitic, of vulva, 531, 534 
 venereal, of vulva, 537 
 Congestion, use of astringents in, 563 
 Conjoined examination, 298 
 Connective tissue, pelvic, 215, 684 
 continuity of, 219 
 
 practical deductions on anatomy of, 
 219 
 Constipation, treatment of, 390, 627 
 Constitutional treatment of chronic uterine 
 
 disease, 363, 619 
 Constriction at os internum, 152, 421 
 Contraction of os, 561 
 Corpus luteum, hemorrhage from, 745 
 Counter-indications of hot douche, 559 
 Course of chronic metritis, 601 
 
 of subinvolution of uterus, 659 
 Cowper's glands, analogues of, 113 
 Cumulus ovigerus, 83 
 Cupping the uterus, 614 
 Curette, in endometritis, 596 
 forceps, of Emmet, 597 
 Eecamier's, 596 
 sharp, use of, 567 
 Simon's spoon, 361, 597 
 Sims's, latest form of, 418 
 Thomas's, 360, 596 
 used for diagnosis, 324 
 varieties of, 324 
 
IMUX TO VOLT Ml-: I. 
 
 CiircttiiiLr, mc'tliiMl of, odS 
 
 tlie ccivital raiial, 'iliT 
 Ciini'iit, olfftriral, sliciintli, .'!S7 
 Cyst 1)1" [larovariimi, 7") 
 
 i>l' rtiuiid li^^aiiK'Ht, case of, 4SS, 'V,\'j 
 Cystic (k'lii'iK'iatiiMi of cervix, o'Jl 
 Cystocclc, (Icliiiiiiiiii of, -jS7 
 Cystntoiiiy, rj(> 
 Cysts, Itiirstiiiji, of ali(iniiicii, ')4 
 
 of (riirtiiers canal, 72, hob 
 
 of rouiiil lif^aiiiL'iit, 4S8 
 Ciise of, i).'i") 
 
 of vulva, b'.W 
 
 of viilvo-vajjiiial f:;lan(l, 034 
 
 sebaceous, of vulva, ')ib 
 
 D. 
 
 Da.sjijjet's oxarniniug-table, 29G 
 
 Decidua, uterine. 140 
 
 Detecation. importance of, as a svinptom, 
 
 Denuilation in plastic operations, 340 
 Depletion, local, o<j"2 
 
 in chronic metritis, 613 
 uterine, value of, 37!) 
 Depressor, Sims's, 311 
 Diagnosis, artilicial prolapse of uterus in, 
 325 
 gynecoloiiical, 2S3 
 of chronic metritis, H06 
 of early pregnancy, 149, 151 
 of endometritis, chronic cervical, 554 
 
 corporeal, 574 
 of masturbation, 478 
 of pelvic cellulitis, 705 
 ha?matocele, 757 
 ditierential, 763 
 from cellulitis, 717 
 from liffimatoma, 761 
 htematoma, 766 
 peritonitis, 697 
 
 from hiematocele, 759 
 of periuterine inllamniation, 658 
 of phlegmon of broad ligament from 
 
 pelvic hiematocele, 7(j;> 
 of retroflexion of gravid uterus, 758 
 of sterility, 464 
 
 of subinvolution of uterus, 655, 659 
 of tumors from subinvolution, 658 
 position of uterus in, 300 
 use of microscope in, 327 
 Diaphragm, pelvic, 223 
 Diet, importance of, in disease, 622 
 Dietetics, directions for, 368 
 Digestion, attention to, 625 
 Digital examination in left lateral position, 
 310,315 
 method, 298 
 Dilatation of cervix, advantages of dili'er- 
 ent methods, 357 
 by sounds. 359 
 dans;ei"s of, 359 
 for diagnosis, 319 
 for surgical purposes, 354 
 forcible, 41. 153 
 
 Dilalatiiin of cervix, in dvsiiiciiorrhii-a, 
 
 427, 433 
 Dilatr)rs, uterine, l^mmei's, .'521 
 Frit.sch's, 358 
 (ioodell's, :;i9 
 H:uiks'>, 320 
 Molesworth'.s, 320, 322 
 Nott's, 358 
 Palmer's, .".20, 560 
 Peaslee's, 559 
 Schultze's, 358 
 Sims's, 427 
 Dimensions of uterus, 132, 152 
 Diphtheritic vulvitis, 4!»2 
 Discharge, vaginal, as a symidom. 292 
 Discus proligeru.s, 83 
 Disorders of menstruation, electricitv in, 
 
 388 
 Displacements cause sul)involiition, ii53 
 geuu-[)ectoral position in, 46, 129 
 uterine, electricity in, 390 
 Dividsion in dysmenorrluea. 429 
 Dorsal position in examination. 297 
 Double uterus, preiinancy in, 252 
 relation to superf(etatiou, 253 
 va<^iua, 259 
 Douche, hot-water, 379, 414 
 counter-indications, 559 
 in cervical endometritis, 556 
 in chronic metritis, 613 • 
 
 in endometritis, 545 
 in pelvic peritonitis, 754 
 indications, 558 
 mode of use. 557 
 Douglas, folds of, 210 
 Douglas's pouch, anatomy of. 211 
 boundaries of, 683 
 dangers of wounding, 127 
 depth of, 214 
 
 intestines in, 147, 212. 488 
 Drainage in ovariotomy, 45 
 Drainage-tubes, Wylie's intra-uterine. 429 
 Dress, importance of attention to, 621 
 
 rules for, 610 
 Ducts. ( nirtner's, 70 
 Miillerian. 85 
 Skene's, 71 
 Wolffian, 68 
 Duverney, glands of. 113. (See Vulva- 
 vaginal. ) 
 Dysmenorrhcea, 419 
 
 caused by retroflexion, 423 
 causes of, 421 
 classes most liable to, 424 
 complications of, 420 
 divulsion in. 429 
 electricity in. 390 
 forcible dilatation in. 433 
 glycerin and boro-glycerides in, 426 
 membranous, 434 
 pessaries in. 434 
 treatment of. 425 
 by dilatation, 427 
 by divulsion. 429 
 by soinids, 4'>3 
 by sponge tents, 433 
 
780 
 
 INDEX TO VOLUME I. 
 
 Dyspareunia, causes of, 448-452 
 
 caused bv lacerations of cervix, 458 
 
 E. 
 
 Eczema of vulva, 503 
 
 chronic, 514 
 Electrical current, dangers from, in extra- 
 uterine pregnancy, 406 
 strength of, 387 
 
 in extra-uterine pregnancy, 406 
 in uterine fibroitls, 4()2 
 Electricity, in amenorrhcea, 391, 414 
 in chronic pelvic inflammation, 404 
 in diseases of menstruation, 388 
 in dysmenorrhoea, 390 
 in exti-a-uteriue pregnancy, 405, 406 
 in fibroid tumors, 399 
 in hyperplasia uteri, 404 
 in menorrliagia, 391 
 in ovarian tumors, 398 
 in ovaritis and ovarian neuralgia, 393 
 in periuterine hsematocele, 397 
 in subinvolution of uterus, 393 
 in subinvolution of vagina. 672 
 in siiperinvolution of uterus, 395 
 in uterine displacements, 396 
 in uterine stenosis, 405 
 note on use of, 632 
 use ofV in gynecology, 373, 383 
 Electrization, localized, method of, 385 
 Electrodes, covering of, 387 
 
 size of, 388 
 Electrolysis in fibroids, 399 
 electrodes in, 404 
 in ovarian cysts, 50 
 pain in, 401 
 results in, 403 
 strength of current in, 402 
 Elephantiasis Arabum, 524 
 
 distinguished from fibroma diffusum, 527 
 Emmenagogues, 366, 414 
 Emmet's needle-holder, 348 
 ojjeration, invention of, 37 
 Enchondroma of vulva, 536 
 Endocervicitis, silver nitrate in, 564* 
 
 use of zinc in, 565 
 Endometritis, acute, 541 
 
 as a cause of subinvolution, 652 
 caused by gonoiThoea, 542 
 chronic, 548 
 cervical, 549 
 cause, 551 
 complications, 554 
 diagnosis, 554 
 frequency, 549 
 hot douche in, 556 
 pathology, 550 
 phj'sical signs, 553 
 prognosis, 555 
 symptoms, 552 
 treatment, 555, 560 
 corporeal, 568 
 cause, 570 
 diagnosis, 574 
 frequency, 568 
 
 Endometritis, chronic corporeal, pathol- 
 ogy, 569 
 prognosis, 575 
 symptoms, 572 
 treatment, 575 
 ingestion, 577 
 local method, 577 
 general, 568 
 fungoid, 574 
 
 curette in, 596 
 hot douche in, 545, 556 
 septic, 545 
 silver nitrate in, 581 
 Enucleation of fibroids, 44, 45 
 
 of pedicle, 38 
 Epispadias, 265 
 
 treatment of, 477 
 Epithelioma of vulva, 537 
 Erectile organs of female, 108 
 Ergot, action of, on sexual organs, 371 
 discovery of 26 
 in uterine fibroids, 45 
 Erysipelas of vulva, 504 
 Erythema of vulva, 503 
 Esthiomene, 518 
 
 Etiology of chronic metritis, 602 
 of dysmenorrhoea, 421 
 of dyspareunia, 448. 
 of pelvic cellulitis, 706 
 hfematocele, 738 
 hematoma, 765 
 peritonitis, 690 
 of periuterine inflammation, 677 
 of sterility, 467 
 of subinvolution of uterus, 649 
 of vagina, 609 
 Examination, bimanual, 298 
 digital in dorsal position, 298 
 in erect position, 316 
 in genu-pectoral position, 316 
 in left lateral position, 310, 315 
 in Sims's position, 310 
 dorsal position in, 297 
 in diagnosis, 296 
 in sterility, 466 
 of abdomen, 306 
 of rectum, 318 
 rectal, 301 
 
 recto-abdominal, 301 
 specular, 304, 313 
 vaginal, method of, 298 
 vesico-rectal, 302 
 Examining-tables, 294 
 Excision of cervix for cancer, 62 
 Exercise, importance of, 620 
 Exploration, rectal, 29 
 External genitals, anatomy of, 96 
 
 OS, 133 
 Extra-uterine pregnancy, cause of hsema- 
 tocele, 746 
 dangers from electrical current in, 406 
 distinguished from hsematocele, 759, 
 
 763 
 electricity in, 405, 406 
 operations for, 28 
 Exudation in pelvic cellulitis, 715 
 
lyphx m voLi'Mi'. I. 
 
 7H1 
 
 Falliipian tiilies, aiiatnmy nf, |(il 
 catarrh ol", Itl.'J 
 (k'vi'li>|>iiR'iit of, S7 
 hoiimrrliai^'i' from, CA'l, 746 
 inall'iirmalions of 'J.'iT 
 iiMU'oiis iiioinliraiie of, Itil 
 porinealtility l>y lluids, 582 
 liy prolie, I52 
 Fiiradi/.ation, tfoiK-ral. ."Wt 
 Ki-riiinlaiiciii, I'oiKlilioii.s of, 441 
 Fil>roitl tumors canso liemorrlia^e, 410 
 of uterus, t'leriric'hy in, .'ilJK 
 uteriiK'. removed througli anterior vag- 
 inal wail, •")(! 
 Fibroids diagnosed from celliditis, 71S 
 Irom luematocele, 7G1, 703 
 electricity in, (iO 
 of uterus, enucleation of, 44 
 removed l>v lapamtouiy. 57 
 Fii'roma and tiliro-myoma of vulva, 529 
 
 ditl'usinu of vulva, 520 
 Fibrous tinnors of uterus, Atlee on, 28 
 Fissure of vulva, 494 
 
 of anus, causing dyspareimia, 453 
 Fistula, artificial vesico-vairinal, liistorv 
 of. 31 
 in ano, operation for, 55 
 uretliro-vaginal, Parvin's operation for, 
 
 3S 
 vesico-vaginal, history of, 30 
 operation for, 30, 50 
 Floor, pelvic, anatomy of, 222 
 Follicular vidvitis, 492 
 Food, care in diet, 022 
 
 value of, in pelvic disease, 369 
 Forceps, tissue, 345 
 twisting, for wire, 352 
 vulsellum, 342, 349 
 Forcible dilatation in dysmenorrhcea, 433 
 Formula? for constipation, 029 
 for pruritus vulv:e, 51.18 
 for tonics, 626, 031 
 Fonrchette, anatomy of, 102, 105 
 Fungoid degeneration of endometrium, 594 
 Fungosities, uterine, 594 
 Furunculosis vulva^, 494 
 
 G. 
 
 Galvanometer, necessity for, 387 
 
 Gangrene of vulva, 496 
 
 Gartner's ducts, 70, 181 
 
 Gaseous tumor of vulva, 536 
 
 Genu-pectoral position for displacements, 
 46, 129 
 
 Geodes, 139 
 
 Gestation, incapacity for, 461 
 treatment, 472 
 
 (iiraldez's body, 75 
 
 (iland, Skene's, of uretlira, 71, 180, 185, 
 796 
 of Bartholin. (See Vidvo-vaf/inal Gland.) 
 vnlvo-vaginal.. catarrh of, 499 
 
 Glands, titricular, 140 
 
 (ilycerin and boro-;;ly(eri<les in <lysmeiior- 
 rhoa, 420 
 to vagina, 414 
 as a depleting agent, 3s() 
 in chronic metritis, (il5 
 in congestion of cervix, 502 
 Gohl, chloride of, action of, 372 
 GonorrJKi'a, cause of enilomelriti.s, 542 
 pelvic infhimmatioii, 091 
 warts of vulva, 53(J 
 latent, 48, 091 
 
 cause of sterility, 400 
 Cionorrlio'al vulvitis, 492 
 Graafian follicles, anatomy of, 170 
 
 develo|)meul of, 82 
 CJravid \iterus, injuries of, 55 
 Gramdar <legeneration. like cancer, 590 
 ' Greek gynecology, review of, 18 
 Gutheri.s's nniscle, 186 
 ' Gymnastic exercises, value of, 376 
 : Gynecological diagnosis, 283 
 i examining-table, 294 
 Society, American, 40, 64 
 Gynecology, chairs of 66 
 j first American article on, 22 
 history of, 17 
 works on, 63, 65, C6 
 
 H. 
 
 I Hematocele and h;ematoma. 736 
 
 caiLsed liy extra-uterine pregnancy, 746 
 distinguished from extra-uterine preg- 
 nancy, 759 
 first essays on, 38 
 pelvic, 735 
 
 bloody urine in, 754 
 boundaries of sac, 748 
 causes, 738 
 contents of sac, 749 
 contrast with hrematoma, 748 
 diagno.sis, 757 
 
 from cellulitis, 717 
 from htematouia, 761 
 of source of blood, 760 
 difl'erential diagnosis, table, 763 
 liistorv, 737 
 
 mobility of uterus in, 759 
 pathology, 743 
 symptoms, 750 
 temperature in. 750 
 termination of, 755 
 tumor in, 754 
 
 ulceration of cyst-wall. 756 
 peritonitis following, 747 
 periuterine, electricity in, 397 
 Haematoma of ovarv. case of, 749 
 
 of vulva, 497 
 . pelvic, 764 
 
 anatomy, 764 
 causes, 765 
 diagnosis. 766 
 prognosis, 766 
 symptoms. 766 
 treatment. 767 
 Hiemostaiics, 418 
 
782 
 
 INDEX TO VOLUME I. 
 
 Hair, inversion of, on labia, 502 
 Headache, treatment of, 634 
 Hemorrhage after abortion, treatment of, 
 419 
 
 from corpus luteum, 745 
 
 from Fallopian tubes, 642, 746 
 
 from vulva, 115 
 Heredity, importance of, 286 
 Hermaphrodism, 267 
 
 case of Carl Hohmann, 273 
 
 spurious, 277 
 Hernia, inguinal, 482 
 
 labial, anterior, 482 
 
 perineal, 487 
 
 pudendal, 486 
 
 uterine, 257 
 
 vaginal, 483 
 
 ventral, 60 
 Herpes of vulva, 502 
 History of gynecology, 17 
 
 rational, of cases, 284 
 Hohmann, C, the hermaphrodite, 273 
 Hook, counter-pressure, 349 
 Hot- water douche. (See Dovche.) 
 Hot water, history of use of, 61 
 Hottentot apron, 267 
 Houston, valve of, 267 
 Hvdatids of Morgagni, 288 
 Hydrocele, 488 
 
 case of forming large cyst, 535 
 Hymen, anatomy of, 117 
 
 atresia of, 262 
 
 development of, 92 
 
 examination of, 125 
 
 forms of, 118 
 
 malformations of, 262 
 
 medico-legal importance of, 118 
 
 of negro race, 263 
 
 resisting. 447 
 Hyoscine, hydrobromate of, 373 
 Hyperaemia, uterine, 599 
 Hyperaesthesia of vulva, caufee of dyspa- 
 
 reunia, 450 
 Hyperplasia, areolar, of uterus, 599 
 
 electricity in, 404 
 Hypertrophy, uterine, 599 
 
 of clitoris, 447 
 ' treatment, 477 
 Hypospadias, 265 
 
 treatment of, 477 
 Hysterectomy, vaginal, position for, 128 
 Hystero-neurosis, 50 
 
 I. 
 
 Ice, use of, after operations, 333 
 Impregnation, artificial, 475 
 Incontinence of urine after dilatation of 
 
 urethra, 196 
 Induration, pelvic treatment of, 51 
 Inflammation of vulvo- vaginal gland, 500 
 Inflammatory exudations, cause of dyspa- 
 
 reunia, 451 
 Inguinal hernia, 482 
 Injections, intra-uterine, 582 
 of hot water. (See Douche.) 
 
 Injections, parenchymatous, 616 
 Injuries and wounds of vulva, 479 
 Insemination, incajaacity for, 442 
 Inspection of abdomen, 306 
 
 of vulva, 297 
 Instruments, mode of cleaning, 330 
 
 operating, 340 
 Intercourse, sexual. (See Coitus.) 
 Internal os, 134 
 Inti'a-uterine applications, 381 
 injections, 582 
 
 counter-indications, 585 
 to prevent dangers of, 584 
 medication, 578. (See also Applications.) 
 Lente on, 39 
 value of, 377 
 medicator. Palmer's, 579 
 
 Wylie's, 428 
 scarification, knife for, 614 
 Inversion of inverted uterus, operation 
 
 for, 57, 62 
 Inverted uterus, reduction of, by White 
 
 and others, 37 
 Iodine, Churchill's tincture of, 564 
 
 in chronic metritis, 615 
 Iodized plienol, 580 
 lodo-tannin, 564 
 Iron as a tonic, 364 
 
 in chronic metritis, 612 
 Irrigation, antiseptic, in operations, 330, 
 331 
 of uterus, 332 
 
 J. 
 
 Journal of Obstetrics, American, 63 
 
 K. 
 
 Knife, Emmet's ball-and-socket, 345 
 
 for scai'ification, 614 
 Kolpo-hysterectomy, first case of, 55 
 
 Labia, hvpertrophv of, obstacle to coitus, 
 447 
 inversion of hair of, 502 
 majora, anatomy of, 98 
 anatomy, gross, of, 100 
 minute, of, 101 
 minora, anatomy of, 101 
 arteries of, 104 
 malformations of, 266 
 treatment of hypertrophy of, 477 
 oozing tumor of, 531 
 Labial hernia, anterior, 482 
 Lacerations of cervix, cause of dyspareu- 
 niu, 450 
 cause of subinvolution, 651 
 operation for, 43 
 Laparo-elytrotomy, 46, 56 
 Latent gonorrhoea, 48, 691 
 Lateral displacement of uterus, 148 
 Left lateral position, description of, 308 
 digital examination in, 310 
 
!.\j>j:.\ to Vol.1 mi-: i. 
 
 r«;i 
 
 Ja-I'I l;itcr:il po.-ilicin, <ilijiTti(His 
 
 ;;(»!» 
 
 spociiliiin in, iUO 
 Leptotlirix vaj^iualis, oOO 
 Levator aiii iiiusik-, U'JlJ 
 
 spasm of, ')1;') 
 Liiiaiiu'iit, infmiililiulo-pL'lvif, 79 
 Litiameiits, romid, 107 
 of MadtltT, •J07 
 sari'd-iiteriiH', feci of, 1-7 
 
 lltlTilU", lil.'J 
 
 aiiaioMiy of, 'J()7 
 support tliu uterus, 221 
 Li.Lraturea, silk, luoiie of cleaning, 330 
 Lipoma of vulva, 53U 
 Literature, lists of, 93, 278. (See note 
 Jiiflrx of Aiit/iorx for other pages. 
 Local treatment of uterine disease, 37G 
 Lupus, antiseptics in, 523 
 
 bacilius tulierculosis in, 519 
 
 of vulva, 51S 
 
 perforans, 521 
 
 prominens, 521 
 
 serpiginosus, 521 
 
 ti'eatment of. 523 
 Lymphangitis, adeno-, 680, 759 
 Lymphatics of uterus, anatomy of, 139, 
 
 686 
 
 31. 
 
 Maltormations, hindrances to coitus, 446 
 
 of clitoris, 2()(» 
 
 of hymen, 262 
 
 of ovaries, 235 
 
 of uterus, 238 
 
 of vagina, 257 
 
 of vulva, 264 
 Massage, general, 632 
 
 uterine, 53, 616 
 
 value of, 375 
 Masturliation, diagnosis of, 478 
 ^Melanoma of vulva, 536 
 Memhrana granulosa, formation of, 84 
 Memiiranous dysraenorrlicea, 434 
 pathology, 435 
 treatment, 435 
 Menopause, 436 
 
 symptoms referred to, 293 
 
 treatment of, 437 
 Menorrhagia, electricity in, 391 
 
 theory of, 48 
 Menstruation, absence of, 411 
 
 disorders of, electricity in, 388 
 
 excessive, 415 
 
 normal, 408 / 
 
 theories of, 409 
 
 paint'nl, 419 
 
 questioning about, 287 
 
 scanty, 413 
 
 theory of, 59 
 
 vicarious, 415 
 Mensuration of abdomen, 307 
 Mental disease due to sexual disease, 50 
 Mercury, action of, on disease of sexual 
 
 organs. 372 
 Mesosalpinx, development of, 79 
 
 Mesovariuin, development of, 77 
 Metritis, acute, 516 
 chronic, causes. <)()2 
 diagnosis, 606 
 glvceriii and bonj-glvceride in, 
 
 "615 
 iron in, 1)12 
 parenchynuitous, 599 
 (piinine in, 6.'i() 
 .sponge tents in, (il6 
 stages of, 601 
 symptoms, 605 
 treatment, 609 
 general, 610 
 special medication, Oil 
 varieties, 604 
 Metrorrhagia, cancer as cause of, 417 
 curetting in, 41.S 
 fibroids as cause of, 416 
 treatment of, 417 
 Microscope in diagnosis, 327 
 Mineral waters, value of, 610, 627 
 Mitchell's, Weir, treatment, 610, 633 
 Mons Veneris, anatomy of, 97 
 Moral treatment, 635 
 Morgagni, cohunns of, 198 
 
 hydatids of, 23S 
 Mucous membrane, uterine, 140 
 of cervix, 142 
 of the ne\v-l)orn, 91 
 of uterus, 136, 140 
 Miillerian ducts, development of, 85 
 Muscles, levator ani, 226 
 of pelvic floor, 225 
 of perineum, 230 
 Myoma of vulva, 529 
 Myrtiform ciruncles, 118 
 Mvxoma of vulva, 530 
 
 X. 
 
 Needle-holder, Enuuet's, 348 
 Needles, mode of use, 347 
 
 varieties of, 347 
 Negro race, hymen of, 263 
 Nerve-sedatives, 372 
 Nerve-tonics, 364, 372 
 Nerves of clitoris, 109 
 
 and ve.ssels of perineum, 232 
 of uterus, 143. 155 
 
 of uterus. 140, 142, 146 
 
 of vagina, 124 
 
 of vulva, 100 
 Nervousness, treatment of, 634 
 Neuralgia of coccyx, 516 
 
 ovarian, electricity in, 393 
 Neuronui, case of, causing dvspareunia, 
 452 
 
 of vulva, 536 
 New growths of vulva, 518 
 Nitrate of silver within tlie uterus, 581 
 Nitric acid as application, 565, 580 
 Nuck, canal of, 158, 160, 236 
 
 cyst in, 488 
 Nymphs?, anatomy of, 101. (See Labia 
 Minora. ) 
 
784 
 
 INDEX TO VOLUME I. 
 
 O. 
 
 Obsletrie Gazette, 65 
 
 (Edema of vulva, 75, 495 
 
 Oidium albicans, cause of pruritus, 506 
 
 Ointments for intra-uterine use, 581 
 
 Oozing tumor of labia, 531 
 
 Operation for lacerated cervix, 58 
 
 for perineal rupture, 54, 55, 59, 234 
 
 for retroversion, 56 
 Operations during pregnancy, 334 
 
 plastic, 346 
 
 preparatory treatment, 336 
 
 two at once safe, 385 
 
 when to be done, 333 
 Opium in pelvic inflammation, 374 
 
 use of, in operations, 333 
 Oi'gasm, efiPect on uterus, 443 
 Os, contraction of, 661 
 
 external os tincse, 133 
 
 internum, 134 
 Osteoma of vulva, 536 
 Ova, formation of, 80 
 
 number of, -84 
 Ovarial tubes, 174 
 Ovarian corpuscle, Drysdale's, 43 
 
 disease and dysmenorrhoea, 419 
 
 neuralgia, electricity in, 393 
 
 tumors, diagnosis from hsematocele, 758 
 electricity in, 398 
 works, writers on, 64 
 Ovaries, absence of, 236 
 
 anatomy of, 107 
 gross, 169 
 minute, 172 
 
 blood-supply of, 179 
 
 color of, 169 
 
 descent of, 78 
 
 development of, 76 
 
 indications for removal of, 40 
 
 malformations of, 236 
 
 position of, 167 
 
 practical deductions from anatomy of, 
 181 
 
 prolapse of, 53 
 
 relations and attachments of, 168 
 to the tubes, 79 
 
 removal of, Battey on, 39, 49 
 
 rudimentary, 237 
 
 size of, in children, 85, 169 
 
 supernumerary, 236 
 Ovariotomist, McDowell the first, 24 
 Ovariotomists, early American, 27 
 Ovariotomy, drainage in, 45 
 
 euncleating the pedicle in, 38 
 
 high temperature after, 5 1 
 
 Lyman on, 28 
 
 septicaemia following, 37 
 
 vaoinal, 40, 50 
 Thomas on, 38 
 Ovaritis, electricity in, 393 
 Ovarv, apoplexy of, 745 
 
 bulb of, 180 
 
 epithelium covering, 172 
 
 hsematoma of, 749 
 
 prolapse of, 37, 181 
 
 Ovary, prolapse of, in dyspareunia, 451 
 Oviducts. (See Fallopian Tuben.) 
 Ovula Nabothii, 143 
 Ovule, non-maturation of, 459 
 
 obstruction to passage of, 461 
 Ovulation, incapacity for, 458 
 Ovum, anatomy of, 177 
 
 primordial, 84 
 
 P. 
 
 Pachydermia of vulva, 524 
 
 Pachysalpingitis, 167 
 
 Packing the vagina, 53 
 
 Pain as symptom of uterine disease, 259 
 
 Palpation of abdomen, 307 
 
 Papilliform plexus, 180 
 
 hemorrhage from, 745 
 Papilloma of vulva, 530 
 Paradidymis, 76 
 Parametritis (see Cellulitis), 705 
 Parenchymatous metritis, chronic, 599 
 Parotitis following operations on genitals, 
 
 58 
 Parovarian cyst, cause of, 75 
 Parovarium, 75, 180 
 
 Pathology of endometritis, chronic cer- 
 vical, 550 
 chronic corporeal, 569 
 of membranous dysmenorrhea, 435 
 of pelvic cellulitis, 708 
 hsematocele, 743 
 peritonitis, 689 
 of subinvolution of vagina, 668 
 Pedicle, enucleating the, 38 
 Pediculosis pubis, 505 
 Pelvic abscess. (See Abscess.) 
 chronic, 56, 60 
 cellulitis, electricity in, 404 
 pus in, 710 
 exudation in, 715 
 connective tissue, anatomy of, 215 
 disease, jDhysical signs of, 293 
 effusions, Brickell on, 49 
 floor, anatomy of, 222 
 muscles of, 225 
 physics of, 233 
 projection of, 234 
 spasm of muscles of, 511 
 hfematoma, 764 
 induration, treatment of, 51 
 inflammation caused by gonorrhoea, 691 
 
 use of opium in, 374 
 peritoneum, anatomy of, 204, 682 
 peritonitis, 687 
 
 complicating dysmenorrhosa, 420 
 electricity in, 404 
 hot douche in, 754 
 sinuses from abscess, 732 
 vessels, enlargement of, 156 
 obstructions in, 155 
 Pencils, gelatin, 563 
 Perimetritis (see Peritonitis, Pelvic), 687 
 Perineal body, anatomy of, 228 
 function of, 233 
 hernia, 487 
 
lM>hX TO VOU'Mh' f. 
 
 7X5 
 
 I'l riiual niptiiro, (i[)er:iti(>ii for, ;")1, 55, 59, 
 
 •J.iJ 
 IVriiR'i)ri'li;i|iliy, .)i'iiks ciii, o'J 
 IVriiieiiiii, "Jli',) 
 
 failmo ill upt-ratioiis lor riiptiire i)f, 4'J 
 
 imisi'k's of, 'SM 
 
 nerves juul vessels of, 'J.>2 
 
 j)rim;irv openilioii tor rupture of, 481 
 
 rupture of, o|ier:itiou for, 42, 54, 55, 59, 
 
 2:54 
 veins of, 1015 
 Peritoneum, jielvic. GS2 
 anatomy of, 2U4, (5>S2 
 
 elianges in prei,'nancy, 206 
 folds of; 207 
 Peritonitis, encysted tubercular, 58 
 ha'morrhanica, 741 
 followinj;; hannatocele, 747 
 pelvic, (>87 
 
 alidoininal section in, 704 
 
 cause of, (Jilil 
 
 clironic form, GOG 
 
 common form of pelvic inflammation, 
 
 700 
 complicatin<r dysmenorrhfsa, 420 
 diagnosed from iKcmatocele, 759 
 diagnosis, ()97 
 electricity in, 404 
 exacerbations in, 695 
 following operations on cervix, 698 
 minor forms, 698 
 pathology of, 689 
 physical signs, 696 
 prognosis, 7ul 
 septic form of, 694 
 symptomatology, 693 
 treatment, 702 
 tumors in, GOG 
 tubercular, oS, G92 
 Periuterine adenitis and angeioleucitis, 680 
 htematocele, electricity in, 397 
 inflammation, 675 
 delinition, G75 
 diagnosis, 653 
 etiology, 677 
 history, 675 
 Permanganate of potash, 365 
 Pessaries, invention of. G2 
 
 in dysmenorrha?a, 434 
 Pessary, Hodge's invention of, 27 
 Phenol, iodized, 580 
 
 Phlegmon of broad ligament. (See Cel- 
 luUtis.) 
 diagnosed from pelvic haematocele, 
 7 Go 
 Phlegmonous vulvitis, 493 
 Phosphates as nerve-tonics, 364 
 Phosphorus, use of, 373 
 Physical signs of pelvic disease, 293 
 Pityriasis versicolor of vulva. 5>)4 
 Placenta, retained, causing subinvolution, 
 
 653 
 Plicae palmatae, 137 
 Plica urogenitalis, 6S 
 Position, doi-sal, 297 
 erect, examination in, 316 
 Vol. I.— ;0 
 
 Position, genn-pectoral, cxiimination in, 
 315 
 in gynecological diagnosis, 29G 
 left lateral, examination in, 310 
 of uierus in diagnosis, 3U0 
 Post-partum hemorrhage, causing subinvo- 
 lution, G53 
 Practical deductions on anatomv of ovarie«, 
 181 
 of pelvic connective tissue, 219 
 of pelvic peritoneum, 213 
 of rectum, 2(t2 
 (jf urinary organ.s, 193 
 of uterus, 147 
 of tubes, 165 
 of vagina, 125 
 of vulva, 114 
 Precocity, 239 
 
 Pregnancy, early diagnosis of, 149, 151 
 in double uterus, 252 
 operations during, 334 
 treatment of cervix during, 567 
 tubal, 56 
 Preparatory treatment to operations, 336 
 Primordial ovum, 84 
 Probe, Emmet's flexible, 315 
 
 introduction of, 315 
 Prognosis of endometritis, chronic cervi- 
 cal, 555 
 chronic corporeal, 575 
 of pelvic cellulitis, 718 
 haMiiatoma, 766 
 peritonitis, 701 
 of sterility, 4G8 
 Prolapse, anificial, of uterus for diagnosis, 
 325 
 of ovary, 53, 181 
 
 Sims's operation for, 37 
 Prurigo of vulva, 503 
 Pruritus of vulva, 505 
 treatment of, o07 
 caused by o'Mium albicans, 506 
 Pudendal hernia, 486 
 
 sac, 230 
 Pudendum. (See Vulva.) 
 Pus in pelvic cellulitis, 710 
 
 Q. 
 
 Quinine, use of, 373 
 
 after operations, 333 
 in chronic metritis, 630 
 in menstrual disorders, 367 
 
 R. 
 
 Rectal examination, methods of, 301 
 Simon's method of, 302 
 exploration. 29 
 by eversion, 38 
 Rectocele, definition of, 487 
 Rectum, anatomy ol", 197 
 gross, 198 
 minute, 250 
 examination of, 318 
 practical deductions on anatomy of, 202 
 
786 
 
 INDEX TO VOLUME I. 
 
 Rectum, relations and attachments of, 201 
 sphincter of, 199 
 symptoms, importance of, 291 
 Remedies acting on pelvic organs, classifi- 
 cation of, 368 
 Rest as a therapeutic agent, 619 
 Retroflexion as cause of dvsmenorrhoea, 
 423 
 of gravid uterus, diagnosis, 756 
 Retroversion, operation for, 56 
 Roman gynecology, history of, 20 
 Rosenmiiller's organ, 75 
 Round ligaments, cyst of, 488, 535 
 
 of uterus, 157 
 Rudimentary uterus, 242 
 Rupture. (See Hernia.) 
 
 of perineum, failure in operation for, 42 
 operation for, 54, 55, 59, 234 
 
 S. 
 
 Sarcoma of vulva, 537 
 Scarification, knife for, 614 
 Scissors, Emmet's, 344 
 Sclerosis, uterine, 599 
 Sebaceous cysts of vulva, 535 
 Sedatives, nerve, 372 
 Semen without spermatozoa, 453 
 Senile changes in vagina, 120 
 Septic wounds, treatment of, 332 
 
 pelvic peritonitis, 694 
 Septicsemia following ovariotomy, 37 
 Serpiginous vascular degeneration, 509 
 Sexual sense in women, 444 
 Shield, Sims's, 352 
 
 for twisting sutures, 352 
 Silk for sutures, 339 
 
 ligatures, mode of cleaning, 330 
 Silver nitrate in endocervicitis, 564 
 in endometritis, 581 
 
 suture, invention of, 33 
 
 sutures, 339 
 
 application of, 348 
 shouldering of, 351 
 twisting of, 351, 352 
 Simon's speculum, 341 
 
 spoon curette, 361, 597 
 Simpson's sound, 302 
 
 use of, 303 
 Sims's depressor, 311 
 
 position, description of, 308, 340 
 
 sharp curette, old model, 597 
 
 shield, 352 
 
 speculum, objections to, 310 
 
 tenaculum, 314 
 Sinus, urogenital, 69, 88, 89 
 Sinuses, pelvic, from abscess, 732 
 Skene, glands of, in urethra, 71, 180, 185, 
 
 796 
 Skin diseases of vulva, 501 
 Societies, gynecological, 66 
 Solid uterus, 242 
 Sound, best form of, 302 
 
 care in use of, in pelvic haematocele, 753 
 
 Simpson's, 302 
 
 the uterine, 302 
 
 Sounds, graduated, 357 
 Spasm of muscles of pelvic floor, 511 
 Spear, Buttle' s, for cervix, 613 
 Specula, cylindrical and plurivalve, 304 
 Speculum, Brewer's, 305 
 Fergusson's, 305 
 Hunter-Erich's, 310 
 invention of, 20-22 
 Mann's, 312 
 Munde's, 313 
 Nott's, 306 
 Simon's, 341 
 
 Sims's, advantages of, 306, 311, 340 
 invention of, 31 
 mode of use, 313, 340 
 Spermatozoa, absence of, in semen, 453 
 destruction of, in cervix, 454 
 impediments to jDrogress of, 455 
 mode of entry into uterus, 43 
 progress of, 445 
 Sphincter recti, 199 
 of bladder, 189 
 of urethra, 186 
 third, 198 
 uteri, 135 
 Sponge-holder, Sims's, 343 
 Sponges, mode of cleaning, 330 
 Spoon, Simon's sharp, 361, 597 
 Spurious hermaphrodisra, 277 
 Stem, intra-uterine, for drainage, AVylie's, 
 
 429 
 Stenosis of cervix, dangers of incision for, 
 151 
 uteri, electricitv in, 405 
 Sterility, 441 
 
 abnormal conditions of, 463 
 caused by latent gonorrhoea, 460 
 diagnosis of, 464 
 examination in, 466 
 hidden causes of, 467 
 prognosis, 468 
 subjective symptoms of, 462 
 table of abnormal conditions in, 463 
 treatment, 468 
 Strychnia, value of, as a tonic, 364 
 Subinvolution, electricity in, 393 
 non-puerperal, 601 
 operations on vagina in, 673 
 of uterus, 599, 637 
 
 caused by tumors, 652 
 course and results, 659 
 diagnosis, 655 
 
 diagnosis from chronic metritis, 659 
 differentiation, 657 
 etiology, 649, 653 
 exciting causes of, 650 
 histologv, 642 
 history of, 638 
 local treatment, 664 
 mechanical treatment, 666 
 operative treatment, 666 
 physical signs 656 
 symptoms of, 655 
 treatment, 661 
 of vagina, 667 
 cause, 669 
 
L\nh'.\ TO voi.iMr: i. 
 
 787 
 
 SiiliiiiVdliition of vagina, pallioloj^y, (>(iS 
 ireatmi'iit, (>7 1 
 
 p(>st-|iarUiiu hi-iiiorrliagu cuiming, 653 
 Sun-l.atlis, (i-il 
 Superra'taliou, relation of, to double uterus, 
 
 •J53 
 Siiperiiivolutiou, electricity in, 3D'> 
 Supports of ilie uterus, 221, 6."j4 
 
 of l.la.Uler, 22.') 
 Sutures, nuiterials for, 338, 339 
 
 removal of, 353 
 SyuiploMis, iniportauce of, 288 
 
 of elirouic metritis, ()()5 
 
 of pelvir ]ierit()iiitis, ()93 
 
 of sterility, subjective, 462 
 
 of subinvolution of uterus, 655 
 Sypliilitic ulceration of cervix, 593 
 
 condyloma of vulva, 534 
 
 warts of vidva, 534 
 Syringe, applicator, 581 
 
 T. 
 
 Table of abnormal I'onditions in sterilitv, 
 463 
 of dilll-'rential diagnosis of pelvic ba^na- 
 
 tocele, 763 
 operation, 337 
 Tables, gynecological examining-, 294 
 Tampon, latiipwick for, 362 
 
 vaginal, 361 
 Temperature, Ivigb, after ovariotomy, 51 
 Tenaculum, Emmet's, 314 
 double, 342 
 Mann's, 312 
 operating, 345 
 self-retaining, 577 
 Sims's, 314 
 Tents in treatment of endometritis, 560 
 laminaria, 321, 356 
 mode of use, 323, 356 
 sponge, 321, 355 
 sponge in chronic metritis, 616 
 tupelo, 322, 356 
 Therapeutics, general uterine, 363, 619 
 Thrombus of the vulva, 497 
 Tissue-forceps, 345 
 Tonic, strychnia, value of, 364 
 Tonics, use of, 630 
 
 Touch, vesico-vaginal and vesico-rectal, 45 
 Treatment, constitutional, of chronic ute- 
 rine disease, 363, 619 
 moral, 635 
 of atresia vulvtp, 478 
 of atrophy of uterus, 618 
 of cervix during pregnancy, 567 
 of chronic metritis, 609, 610, 611 
 of constipation, 390, 627 
 of disorders of menopause, 437 
 of dysmenorrha?a, 425 
 of endometritis, chronic cervical, 555 
 
 corporeal, 575 
 of epispadias, 477 
 of lieadache, 634 
 
 of hypertrophy of labia minora, 477 
 of hypospadias, 477 
 
 Treatment of lupus, 523 
 
 of mend)ranous dysmcnorrlura, 4.35 
 of metrorrhagia, 417 
 of nervousness, 634 
 of pelvic abscess, 727 
 a<llK'si()ns, 51- 54 
 amennrrhiea, 364, 413 
 celliditis, (iO 
 ha'iuatoma, 767 
 induration, 51 
 peritonitis, 702 
 of pruritus vulva-, 507 
 of septic vulva, 332 
 
 wounds, 332 
 of sterility, 468 
 of subinvolution of vagina, <)71 
 
 of uterus, 661, 664, 666 
 preparatorv to operations, 33(i 
 Weir Mitchell's, (ilO, 633 
 Tubal pregnancy, operation in rupture of 
 
 sac, 56 
 Tube, Fallopian. (See Fallopian Tube.\ 
 anatomy of, 161 
 anatomy of, minute, 164 
 development of, 87 
 malformation of, 237 
 practical deductions from anatomv of, 
 
 165 
 surgical relations of, 167 
 Tubercular peritonitis, 58, 692 
 Tubes, ovarial, 174 
 Tumor of labia, oozing, 531 
 Tumors, diagnosis from subinvolution. 658 
 in pelvic peritonitis, 606 
 of uterus, causing subinvolution, t)52 
 ovarian, diagnosis from hsematocele, 758 
 Twisting forceps for wire, 352 
 
 u. 
 
 Ulceration of cervix, 587 
 syphilitic, 593 
 of vulva, 494 
 Urachus, 88 
 
 Ureter, malfoi-mation of, 261 
 Ureters, anatomy, 192 
 catlieterization of, 195 
 surgical relations of, 196 
 Urethra, anatomy of, 183 
 gross, 185 
 minute, 186 
 button-hole of, 54 
 Skene's glands of, 70 
 sphincter muscle of, 186 
 vesical opening of, 187 
 Urethral caruncles as a cause of dyspareu- 
 
 nia, 451 
 Urethrovaginal fistula, Parvin's opera- 
 tion, 38 
 Urinary organs, anatomv of, 183 
 
 practical deductions from anatomv of, 
 in pregnancy, 193 
 Urogenital sinus, 69, 88, 89 
 Uterine appendages, 161 
 
 disease of, complicating dysmenor- 
 rhea, 420 
 
788 
 
 INDEX TO VOLUME I. 
 
 Uterine decidua, 140 
 depletion, value of, 379 
 disease, pain as a symptom of, 259 
 displacements, electricity in, 390 
 fibroids removed through anterior va- 
 ginal wall, 56 
 fungosities, 594 
 hyperaemia, 599 
 hypertrophy, 599 
 massage, 53, 616 
 sclerosis, 599 
 sound, 302 
 subinvolution, 599 
 therapeutics, 363, 619 
 Uterus, abnormal communication, 257 
 anatomy, gross, 134 
 
 minute, 137 
 anteflexion as malformation, 256 
 arcuatus acordiformis, 247 
 arrest of development of, early, 240 
 
 later, 254 
 artificial prolapse for diagnosis, 325 
 atresia of, 253 
 atrophy of, 599 
 attachment' to vagina, 150 
 bicornis acollis, 244 
 bipartitus, 243 
 
 bleeding from external coat, 153 
 cavity of, 134 
 development of, 87 
 didelphys, 245 
 dimensions, 132, 152 
 double, in pregnancy, 252 
 
 relation to superfostation, 353 
 duplex separatus, 244 
 excessive development of, 239 
 fcetalis or infantilis, 254 
 gravid, injuries of, 55 
 hernia of, 257 
 
 hyperplasia of, electricity in, 404 
 incudiformis, 255 
 lymphatics of, 139, 686 
 malformations of, 238 
 
 in development, 256 
 massage 53, 616 
 mobility, 147 
 
 in pelvic hsematocele, 759 
 
 of mucous membrane of, 136, 140 
 of cervix, 142 
 nerves of, 140, 142, 146 
 obliquity of, 256 
 OS internum, construction of, 152 
 parts of, 133 
 
 parvicollis and acollis, 256 
 position, 131 
 
 as regards symptoms, 351 
 
 in diagnosis, 300 
 practical deductions from anatomy of, 
 147 
 in pregnancy, 193 
 pubescens, 255 
 
 relations to surrounding parts, 147 
 round ligament of, 157 
 rudimentary, 242 
 septus, 248 
 softening of tissues, 151 
 
 solid, 242 
 sphincter of, 135 
 stenosis, electricity in, 405 
 subinvolution of, 637 
 subseptus, 249 
 unifolis, 250 
 supports of, 221, 534 
 ulceration of cervix, 154 
 unicoUis, 246 
 
 vaginal extirpation of, 156 
 vessels and nerves, 143, 155 
 Utricular glands, 140 
 
 V. 
 
 Vagina, arteries and veins of, 122 
 
 atresia of, 257 
 
 as obsti'uction to coitus, 458 
 
 blind canals of, 260 
 
 development of, 87, 92 
 
 double, 259 
 
 faulty communications, 260 
 
 malformations of, 257 
 
 nerves of, 124 
 
 operations on, in subinvolution, 673 
 
 packing the, 53 
 
 practical deductions from anatomy of, 
 125 
 
 relations of, 124, 128 
 
 senile changes in, 120 
 
 shortness as cause of dyspareunia, 450 
 
 stenosis as cause of dyspareunia, 449 
 
 subinvolution of, 667 
 
 veins of, 105 
 
 walls of, 119 
 Vaginal discharge as symptom, 292 
 
 examination, method of, 298 
 
 extirpation of uterus, 156 
 
 hernia, 483 
 
 hysterectomy, position for, 128 
 
 ovariotomy, 40, 60 
 
 tampon, 361 
 Vaginismus, 511 
 
 as cause of dyspareunia, 449 
 
 superior, 515 
 Valve of Houston, 198 
 Varicose veins of vulva, 497 
 Vascular degeneration, serpiginous, 509 
 Veins, air in, from injections, 583 
 
 of perineum, 103 
 
 of vagina, 105 
 Venereal condyloma of vulva, 537 
 
 warts of vulva, 531 
 Ventral hernia, 60 
 Vesico-rectal examination, 302 
 
 touch, 45 
 Vesico-uterine pouch, 214 
 Vesico-vaginal fistulse, operation for, 30, 50 
 
 touch, 45 
 Vessels of the uterus, 143 
 
 pelvic, enlargement of, 156 
 obstructions in, 155 
 
 of vagina, 122 
 
 and nerves of perineum, 232 
 of uterus, 143, 155 
 Vestibule, anatomy of, 110 
 
l.\nj:.\ TO VOIAMF. I. 
 
 im 
 
 Vi-stiWiiiiN i>uii>s..r, irj 
 
 VilmiiuiiM iinmiruliiiin, 40^ 
 Vit-iritnis monslriiarK'ii, H') 
 ViilM'lliim I'lvrceps, ill-, :>J'.> 
 Vulva, alopi'i-ia ol', oUU, .')Ul 
 analnmy of. il(> 
 antjc'ioiua, ").'i(> 
 utre.sia of, 'HSl 
 
 treatiut'iit. 178 
 caiHvr, rarcinoma, •'):59 
 
 epitlielionia, •"):57 
 camvr of, V.M 
 rysts of, "):54 
 development of, '.)2 
 eczema, aeiite, 503 
 
 eh roll ii". -Jl-i 
 enchoiidroina, oMt) 
 erysi[)ela.s of, 504 
 erythema, -iO^ 
 
 tihroma and Jibro-niyoina oi, 529 
 lihroma difllisuni of, 520 
 gani::reiie ol', 49i) 
 gitseoiis tumors of, 536 
 hiematoiiia of, 497 
 heinorr]ia<re from. 115 
 herjies of, 512 
 
 injuries and wounds of, 479 
 from coitus, 480 
 labor. 480 
 lipoma of, 530 
 lupus ot", 518 
 malformations of, 204 
 melanoma, 536 
 myoma of. 529 
 myxoma of, 530 
 nerves of, 100 
 neuroma, 452, 536 
 new growths of, 518 
 oedema, 75, 495 
 osteoma of, 536 
 papilloma of, 530 
 pediculosis pubis of, 505 
 pityriasis versicolor of. 504 
 pointed condyloma of, 531 
 
 Vulva, |»ra(ti<al deduclions from aiialomy 
 of, 114 
 
 prurigo of, 503 
 
 prurltiiH of, 505 
 
 Harconiu, 537 
 
 skin disea.ses of, 501 
 
 syphilitic warts of, 534 
 
 thrombus of, 497 
 
 tdceration and li.-ssure, 494 
 
 varicose veins of, 497 
 
 warts of, 530, 5:51, 5:')4 
 Vulvitis as cause of dyspareunia, 449 
 
 diphtheritic, 492 
 
 follicular, 492 
 
 gonorrho-al, 492 
 
 phlegmonous, 493 
 
 simple, 490 
 Vnlvo-vaginal glands, anatomy ol", 116 
 cysts of, 534 
 
 gland, catarrh of, 499 
 inflammation of. 500 
 of duct, 499 
 
 w. 
 
 Warts of vulva, 530, 531, 534 
 
 vulva caused by gonorrhrea, 536 
 Water, hot-, douche. (See iJouche.) 
 
 mineral, value of, 610 
 Weir Mitchell treatment, 610, 633 
 White line in pelvis, 226 
 Wolffian bodies, development of, 73 
 
 ducts, development of, 68 
 Wounds of vulva, 479 
 
 septic, treatment of, 332 
 Woman's lio.-^pital of Stale of New York, 
 Alumni Association of, 60 
 foundation of, 35 
 
 Z. 
 
 Zinc as nerve-tonic, 373 ^ 
 
 chloride in endocervicitis, 565 
 Zona pellucida, 84, 177 
 
 END OF VOLFME I. 
 

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